Managing Implant Complications, Flapless Surgery and much more…

Dr. Anthony G. Sclar is considered a leader around the world in reconstructive and esthetic dental implant surgery. In private practice at South Florida OMS since 1989, he is the founder of Integrated Seminars and Director of Education at the Sclar Center for Empowered Dental Implant Learning. In addition to publishing numerous journal articles and textbook chapters pertaining to dental implant surgery, Dr. Sclar authored a hallmark, multilanguage textbook entitled; Soft Tissue and Esthetic Considerations in Implant Therapy (Quintessence2003).

A dedicated professional, Dr. Sclar serves as an editor for the dental implant surgery section of the Journal of Oral and Maxillofacial Surgery and is the Director of Clinical Research and Post Graduate Dental Implant Surgery in the department of Oral and Maxillofacial Surgery at Nova Southeastern University School of Dentistry.

In February 2008, Dr. Sclar will be hosting a Comprehensive Implant Surgery Training Conference in Florida. Click Here to Learn More about this exceptional program.

Osseonews: Before we ask you discuss how you would manage some common implant complications, as well as your approach to managing esthetic complications and failures, please tell us about your professional background and discuss the focus of your dental implant practice and teaching efforts.

Dr. Sclar:
I am a board certified oral and maxillofacial surgeon who practices the full scope of dental implant surgery including related hard tissue reconstruction, oral plastic surgery and immediate function. Although I am very involved in teaching, I maintain a extremely active practice performing between 15-20 implant related and oral plastic surgery procedures each week. This allows me to unite my extensive clinical experience with current science in my teaching efforts with our residents and course participants.

The initial focus of my implant practice from 1989-1992 was esthetics. I applied the principles of plastic and reconstructive maxillofacial surgery toward developing a site preservation protocol and towards achieving predictability with hard and soft tissue site development. We assembled a team that allowed us to provide a comprehensive multidisciplinary approach to esthetic implant therapy. I shared our extensive experience in a textbook entitled; Soft Tissue and Esthetic Considerations in Implant Therapy (Quintessence 2003).

I also focused my efforts toward learning how to avoid and manage implant complications. As a result of analyzing our experience with complications and an escalating opportunity to treat a large number of implant related complications referred to my practice, I gained considerable knowledge and experience concerning the factors that needed to be recognized in order to avoid such complications as well as the treatment planning concepts and techniques required to manage patients who had experienced a wide variety of implant complications. Although, most implant complications have multifactorial etiologies, for education and research purposes I organized the material into complication categories.

We have incorporated this information into our didactic program for our residents and developed a full day course dedicated to avoiding and managing implant complications as part of our 10^th ISTM Comprehensive Implant Surgery Training Conference for doctors who want to gain in depth knowledge on this very important topic.

Osseonews: You mentioned that you are seeing an increasing number of patients referred to your practice for management of implant complications. In your opinion, why are the numbers of implant complications on the rise and what can be done to avoid these complications?

Dr. Sclar:
First of all, implant dentistry remains one of the most successful and long lasting options for patients who desire tooth replacement. With greater awareness of the tremendous benefits that dental implant therapy provides, an increasing number of general practitioners and specialists are now providing surgical and restorative implant care.

With the increasing numbers of patients receiving dental implant care, it is natural to experience an increased number of complications. Nevertheless, the increasing numbers of avoidable complications is of great concern and may jeopardize the excellent status that dental implant therapy currently enjoys. A similar phenomenon occurred during the boom of cosmetic surgery when many physicians began to perform surgical and non surgical cosmetic procedures without making a commitment to obtain the prerequisite education and clinical experience prior to providing care.

Thus, in order minimize the number of avoidable complications; it is imperative that dental professionals who want to provide implant care qualify themselves by obtaining additional education and experience specific to this treatment modality.

Osseonews: What progress has been made in terms of educational opportunities for dentists who wish to qualify themselves to provide restorative or surgical implant care for their patients?

Dr. Sclar:
Significant progress towards obtaining a consensus on the educational requirements has been made within dental school curriculums and dental specialty training programs. Progress also has also been made in the area of pre-treatment risk assessment and providing the information needed for doctors to be able to distinguish entry level cases from those cases that require advanced knowledge and clinical experience.

I believe that doctors seeking dental implant knowledge should first become acquainted with the many professional journals and textbooks dedicated to fundamental sciences, clinical research, and clinical practice of dental implant therapy.

Comprehensive courses given by experienced clinicians or experts that combine fundamental sciences, risk assessment, case selection and treatment planning information and didactic programs with opportunities for hands on training have proven to be invaluable for doctors at various stages of their learning curve. In response to this, we expanded our courses and added a flexible format to allow participants to customize their experience according to their level of experience and educational needs.

Doctors should also consider the topic focused courses regularly offered by implant and specialty organizations. Finally, while there is no substitute for clinical experience, clinical observation courses and mentorship programs are a very important component of dental implant education. As such, we will be offering such opportunities at the Sclar Center for Empowered Dental Implant Learning in Miami, Florida early in 2008.

Osseonews: What technological advancements have the greatest potential to help doctors avoid or reduce implant complications?

Dr. Sclar:
Improvements in implant surface technologies, surgical instrumentation, and prosthetic connections and restorative materials have greatly reduced hardware associated complications. In addition, implant designs which incorporate a “superior shift” of the implant abutment junction such as the Straumann ITI implant or more recently a “central shift” of the implant abutment junction such as the Prevail ™implant from BioMet 3i, the Ankylose® implant from Dentsply Tulsa Dental, and the OsseoSpeed™ implant from Astra Tech Dental, provide the opportunity for improved management of biologic width thus enhancing “soft tissue integration” and stability of underlying crestal bone levels. The potential benefits include improved esthetics and reduced incidence of peri-implant mucositis or peri-implantitis.

Nevertheless, I believe that Cone Beam CT technology and treatment planning software have the greatest potential for helping doctors avoid or reducing the numbers of implant complications. Our in office I-Cat cone beam CT (Imaging Sciences International) scanner allows us to evaluate the patient’s anatomy in 3 D and accurately identify the location and course of vital structures such as the inferior alveolar nerve. In addition, dental pathology not seen on plain films occasionally becomes readily apparent with this technology. When combined with a scan guide derived from a diagnostic wax up that duplicates the proposed final restoration, we are able to perform 3D treatment planning as we evaluate all of the restorative and surgical information on the screen. We can then convert the scan guide into a conventional surgical guide to prepare our sites for implant placement or to guide our 3D hard tissue site development procedures. The 3D diagnostics provides greater information allowing us to make better treatment planning and intra-operative decisions. Taking it a step further, we can order a computer generated surgical guide that incorporates a master cylinder and drill sleeves to allow precise 3D osteotomy preparation or even guided implant placement.

As with any technology, there is a learning curve and nuances which must be understood in order to avoid complications related to the technology itself. Some examples include misinterpretation of CT data or misfit or movement of a guide during surgery which can lead to irreversible complications. The bottom line for doctors is to make a commitment to learn all that they can about the technology and apply it at an entry level before proceeding into advanced applications such as guided surgery.

Osseonews: In your opinion, what are the indications for taking a CBVT scan (Cone Beam Volumetric Tomography) as an aid in treatment planning for the placement of implants?

Dr. Sclar:
In my practice we obtain an I-Cat scan when we need additional information following the completion of the patient’s clinical examination, and our evaluation of standard dental peri-apical and panoramic radiographs and other diagnostics.

Typically, we evaluate the patient information and radiographs provided by the referring dentist prior to the patient consultation. Then we perform our clinical examination. Whenever there is an alveolar ridge defect, an abnormality in skeletal or dental relationships, or we are unable to locate vital structures with the existing radiographs, then we obtain an I-Cat scan. Ideally the scan should be taken with the aid of an anatomically correct scan guide that replicates the proposed final restoration. This allows us to evaluate both the restorative and surgical information in three dimensions.

Nevertheless, periapical radiographs of the adjacent dentition are always necessary even when a scan is obtained. Together with periodontal probing information, peri-apical radiographs are critical in identifying compromised bone volumes on the dentition adjacent to the proposed implant site. This recognized risk factor has been associated with site development and esthetic complications and failures as detailed in my textbook.

Osseonews: What software program do you recommend for analyzing CBVT scans and developing a treatment plan for implant placement and restoration?

Dr. Sclar:
We use three programs for analyzing our scans. First of all, I quickly review the surgical anatomy and restorative information using the I-Cat Vision Software (Imaging Sciences International) immediately following the acquisition. Subsequently, if needed we further analyze the 3D anatomy using the Anatomage program (InVivoDental) and perform virtual treatment planning using SimPlant 11 software (Materialise Dental). We also have a maxillofacial radiologist review all of our scans.

Osseonews: What are the indications for flapless surgery for implant placement? What are some contraindications? What kinds of complications can occur?

Dr. Sclar:
While flapless implant surgery has several advantages including: preservation of circulation, preservation of soft tissue architecture and hard tissue volume at the site, decreased surgical time, improved patient comfort and accelerated recuperation there are drawbacks. These disadvantages include: inability to visualize anatomic landmarks and vital structures, thermal damage secondary to reduced access for external irrigation during osteotomy, increased risk of malposed angle or depth of implant placement, decreased ability to contour osseous topography when needed to facilitate restorative procedures and the inability manipulate soft tissues to ensure circumferential adaptation of adequate dimensions of keratinized gingival tissues around emerging implant structures.

The flapless approach for implant placement is indicated when the surgeon has confidence that the underlying osseous anatomy is ideal relative to the planned implant diameter and three dimensional placement in the alveolus. Typically, this is determined by clinical and radiographic evaluation aided by analysis of articulated dental study models and in certain cases interactive CT treatment planning is required for further evaluation of osseous ridge morphology and for fabrication of computer generated surgical guides.

The surgeon should verify that an adequate volume of good quality non mobile soft tissues will remain surrounding the emerging implant for optimal function and esthetics. In order to avoid soft tissue complications, the quantity and position of the existing keratinized tissues relative to the planned implant emergence should be evaluated by a pre-operative try in of the surgical template allowing the surgeon to determine whether adequate apicocoronal width of keratinized tissue (~ 3.0 mm) will remain following the tissue punch procedure. When this criterion is not met, the flapless approach is contraindicated.

A common complication of “Flapless” tissue punch approaches is related to inadequate irrigation during osteotomy preparation leading to bone necrosis and implant failure. Typically this scenario becomes apparent between the second and fourth postoperative week with patients complaining of pain, swelling, and on occasion secondary infection.

Finally when intra-operative findings necessitate additional access or visualization, the surgeon must be experienced and prepared to proceed with surgery performed via an open flap approach. Consequently, although the flapless approach has been suggested for and embraced by novice implant surgeons, successful use of this approach often requires advanced clinical experience and surgical judgment.

Osseonews: One of the most common complications that our readers have discussed is what to do when you perforate the maxillary sinus when doing a sinus lift or placing implants in that area. Could you discuss how you would manage a complication like this?

Dr. Sclar:
Typically, perforations can be avoided by using a diamond bur or Piezo electric instrumentation (Piezotome, Salvin Dental Specialties) for lateral window sinus lift procedures. In addition a cone beam CT scan will aid in the identification of sinus septae which when unrecognized can be a cause of sinus membrane perforations during surgery. An inadvertent perforation that occurs during the preparation of the window for a sinus lift performed via a lateral approach, is easily managed by enlarging the preparation approximately 5 mm’s in all directions beyond the perforation and proceeding with the lift in a standard fashion. Once the sinus membrane is elevated, a resorbable collagen membrane or CollaTape® (Zimmer Dental) is used to repair the perforation or tear. This type of repair is greatly facilitated by the use of Platelet Rich Plasma (PRP) (Harvest Technologies) which is used to ensure immobilization of the collagen barrier to the surrounding sinus membrane.

Perforations that inadvertently occur while placing a maxillary implant rarely cause a problem unless primary implant stability is in question or this occurs during tooth extraction followed by immediate implant placement. In these cases, I recommend delaying implant placement and proceeding with a site preservation procedure such as the Bio-Col technique which can also serve as a repair procedure for the perforated sinus.

Osseonews: Another complication that our readers have discussed is what to do after you place the implants and the patient experiences paresthesia. Sometimes this has been attributed to infection compressing a nerve trunk or the apical terminus of the implant fixture being too close to a nerve trunk. How would you recommend managing complications like this?

Dr.Sclar:
Nerve injuries occurring during implant surgery can be from multiple causes. Mandibular block anesthesia and infiltration, especially in the area surrounding the mental foramen can cause an altered sensation involving the lip, chin, and the tongue. Retraction injuries can also present with similar symptoms. In the majority of these cases the resultant paresthesia will eventually resolve. Nerve injury may also inadvertently occur during osteotomy preparation especially when the surgeon does not realize that the system drills are longer than the planned implant. As a general rule a safe zone of 3 mm’s should be respected in terms of distance from the inferior alveolar nerve and the apical extent of the osteotomy preparation. Increased distances may be indicated when the cancellous marrow is sparse and poor bone density is encountered. Again, a cone beam CT scan can avoid or reduce nerve injuries by facilitating precise localization of the nerve position at the implant site during treatment planning and by also providing an estimate of the density of the cancellous marrow.

Initial management of nerve injuries during dental implant surgery is largely dependant on identifying the etiology of the injury and the resultant patient symptomotology. A neurosensory examination should always be performed to document the initial extent and distribution of the resultant anesthesia, paresthesia, or dysesthesia.

If the nerve is known to be severed during surgery, then microsurgical exploration and repair is usually indicated. If the injury is caused by impingement of the nerve by a deeply placed implant, backing out or removing the implant may be indicated. If the patient regains normal sensation postoperatively and then experiences a delayed onset of altered nerve sensation, the surgeon must first rule out a fracture of the mandible. Having done so, an assumption can be made that marrow space edema or hematoma, or infection has caused nerve compression. The treatment in these cases is to prescribe a course of antibiotics and anti-inflammatory medications such as prednisolone. The patient should then be closely monitored with repeated neurosensory examinations at regular intervals. Again, a cone beam CT scan will aid in the diagnosis and provide accurate information that will allow improved decision making in the management of nerve injuries related to dental implant surgery implant surgery.

Osseonews: One vexing problems for our readers is how to perform predictably successful bone grafts to create a more suitable implant site. What are your recommendations to maximize success? Could you discuss complications that the dentist might encounter?

Dr. Sclar:

Achieving predictable results with intra-oral bone grafting and oral soft tissue grafting procedures require advanced training and experience. To begin with, the implant surgeon must fully comprehend the biology, principles, and material science related to bone grafting and guided bone regeneration procedures. The surgeon must also understand the importance soft tissue management and the important role that the quality and volume of the reconstructive soft tissue envelope plays in the long term maintenance of bone graft volumes. Possessing knowledge about bone grafting biotechnologies including instrumentation that facilitate site preparation, graft harvest, graft immobilization and biomaterials that enhance grafting success is also a prerequisite to achieving predictable success with Intraoral bone grafting.

Case selection is a very important factor. Guided bone regeneration procedures can be accomplished simultaneous with implant placement with predictability only when the implant is paced within the alveolar housing. These procedures become less predictable when the implant will be placed outside the alveolar housing. Thus, when restorative driven placement dictates implant placement outside the alveolar housing, staged reconstruction using block grafts or supported membrane procedures are indicated prior to implant placement.

In addition to the above, the surgeon must understand the principles for successful bone grafting including*: proper aseptic technique, appropriate flap design to allow passive closure over the graft and barrier membrane complex, site preparation to expose marrow elements in order to facilitate graft integration, use of autogenous cancellous marrow grafts because they provide the highest cellular density and osteogenic potential of all autogenous sources, achieving intimate adaptation and immobilization of particulate and block grafts at the prepared recipient sites, isolation of the graft with a barrier membrane, use of platelet rich plasma as an aid to immobilizing particulate grafts and barrier membranes and to improve cellular conduction within the graft during healing and for theoretical positive effects of native growth factors contained in PRP, and to protect the site from micro-motion in the postoperative healing period*.

Whenever any of the above principles are ignored or violated; wound dehiscence, graft exposure, infection, partial resorption of the graft, or complete graft failure are likely to occur. Consequently, I recommend that doctors who desire to achieve predictable results with bone grafting procedures seek advanced training that includes a detailed didactic program enhanced by video surgery presentations and hand-on training that will allow the doctor the opportunity to develop the necessary psychomotor skill required for successful implementation of these procedures within their practice.

With this teaching methodology in mind, we have dedicated a full day program during the ISTM 2008 conference for doctors seeking to gain knowledge and surgical skills related to intra-oral bone grafting and other bone augmentation techniques such as “ridge expansion” and “ridge splitting”

Osseonews: What kind of graft materials do you recommend?

Dr. Sclar:
I recommend using autogenous particulate cancellous marrow and coticocancellous block grafts. I also use slow substitution Xenograft materials such as BioOss® cancellous bone graft (Osteohealth) mixed in a 1:1 ratio when performing hard tissue implant site development procedures. I also have achieved predictable results using block Allografts (J-Block, Zimmer Dental) combined with autogenous particulate marrow grafts for staged reconstruction of deficient alveolar ridges in preparation for implant placement.

Osseonews: What are some of the complications that may occur when placing and restoring implants in the anterior aesthetic zone?

Dr. Sclar:
Esthetic implant complications and failures can be devastating for a patient. Although the course of action required to deliver an esthetic implant restoration may, in certain instances, seem straightforward it has been rightfully suggested that the delivery of esthetic implant restorations be considered a complex treatment modality requiring advanced training and experience.

Providing acceptable esthetics for patients who desire implant replacements requires in depth knowledge of biologic mechanisms, superior patient management skills, and highly developed diagnostic acumen. Therefore, it is imperative that clinicians who want to provide esthetic implant therapy qualify themselves by obtaining additional education and experience specific to this advanced treatment modality. Clinicians who desire to provide esthetic implant replacements must posses; a level of expertise in smile esthetics, specific patient evaluation and interview skills, and a sense of artistry not typically required when dental implant therapy is performed in areas of low esthetic concern. Clinicians must also be able to perform an esthetic risk assessment and identify factors that are known to contribute to esthetic complications and failures. When the above prerequisites are not met, patients not only suffer esthetic deformities, but also suffer from speech impediments and psychological impairments. I have been fortunate to have the opportunity to treat a significant number of patients who were referred to me after suffering reversible and irreversible esthetic implant complication many of which could have been avoided. We have carefully catalogued these cases for teaching our residents and for use in our new full day complications program included in the ISTM 2008 conference.
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Osseonews: Dr. Sclar, could you describe the Bio-Col technique for preserving alveolar ridge anatomy following tooth extraction. What advantage does this technique have over other comparable techniques?

Dr. Sclar:
The development of the Bio-Col site preservation technique was based upon my understanding of the mechanisms involved in initial extraction site healing and the subsequent seemingly unavoidable alveolar ridge resorption. The technique was initially developed between1989-1991 solely for use in esthetic areas but with some modifications has expanded applications in non esthetic areas.

The technique combines a surgical and prosthetic treatment protocol. To start, minimally traumatic tooth removal is accomplished with the use of a periotomes or by sectioning the tooth. Next the socket is degranulated and prepared to ensure active bleeding. The intra-osseous portion of the socket is grafted with BioOss cancellous bone graft (Osteohealth) condensed in the socket to eliminate voids. The supra-osseous soft tissue socket is filed with CollaPlug absorbable collagen dressing (Zimmer Dental) and sealed with IsoDent tissue Cement (Ellman International, Inc.) to isolate the site and render it impervious to the deleterious effect of oral liquids and debris. A tooth or tissue borne ovate pontic is modified to provide shallow but broad circumferential support to the surrounding soft tissue and adjacent papilla. Fixed provisional restorations are preferred, but removable restorations are worn by the patient without removal for 72 hours after which they are removed for hygiene and immediately replaced.

The perceived disadvantage of the BioOss material is actually its greatest strength. The slow substitution rate ensures long term maintenance of alveolar ridge contours. Although some of the material may persist at the site indefinitely, studies demonstrate vital bone growth through the porous mineral structure and equivalent percentages of bone to implant contact compared to control site implants placed in non grafted alveolar ridges. The greatest advantage of this technique is our long term documentation and excellent clinical results in a private practice setting since 1989.

Osseonews: You have developed an innovative approach to enhance soft tissue aesthetics in implant dentistry called the Vascularized Interpositional Periosteal-Connective Tissue Flap (VIP-CT Flap) procedure. Could you describe this technique for our readers? What are the advantages of this technique compared to comparable techniques?

Dr. Sclar:
Between 1989 and 1991 I was a novice periodontal plastic surgeon. Nevertheless, because of my background and training in reconstructive maxillofacial surgery, I was interested in developing a vascularized pedicle flap that could be rotated or transposed into the maxillary anterior area with the goal of improving local circulation and providing a large volume soft tissue augmentation with a single procedure. In addition, I understood that such a flap would provide mesenchymal tissues that enhance the maintenance of autogenous graft volumes during second stage bone graft healing and might allow for synchronous hard and soft tissue site development at sites compromised by previous trauma, infections, and surgical endodontic procedures.

By 1992, we had numerous successful cases which demonstrated enhanced results compared to conventional oral soft tissue grafting techniques. We noticed superiority with vertical soft tissue augmentation which allowed for enhanced soft tissue profiles around implants and increased volume and height of inter-implant papilla. As my practice grew, we gained considerable experienced and made refinements to the procedure. I began to share the procedure and our results with my colleagues in 1994 through lecture presentations. Many doctors related the positive results they obtained after performing the procedure.

The VIP-CT flap is a random pattern periosteal-connective tissue flap that is developed in the bicuspid region of the palate via subepithelial and subperiosteal dissections. The design of the flap allows rotation to the maxillary midline where it can be secured underneath an open flap or within a pouch. The VIP-CT flap is a transpositional flap as the donor and recipient sites are closed by primary intension. The flap depends upon the periosteal-connective tissue plexus that emanates from the greater palatine vessels as they course towards the incisive canal. In the development phase, we used Doppler flow technology to document that perfusion pressures were sufficient to support flap length to width ratios of 4:1 and greater. This procedure changed my practice as we were able to accomplish esthetic implant reconstructions with greater predictability. In addition, this procedure became an indispensable tool in the management of esthetic implant complications. I dedicated a chapter in my textbook on the VIP-CT procedure and after many years produced and educational DVD with surgical footage and graphic animations to demonstrate the technique. Readers can learn more at www.drsclar.com

Osseonews: On behalf of Osseonews.com I would like to thank you for taking time out of your busy schedule for this interview. The insights and recommendations you have made will be of value to our readers.

Interview conducted by:

Gary J. Kaplowitz, DDS, MA , M Ed, ABGD

Editor-in-Chief, Osseonews.com