Numbness after Aborted Implant Surgery

Dr. J. It sounds like you are in over your head. First of all, you should be able to manage the bleeding & complications. Otherwise you shouldn't be doing the surgery. To manage bleeding you need items like gelfoam, colaplug, bone-wax etc etc... If you have "unmanageable" bleeding you could have a few different scenarios going on... a Bad Medullary Bleed, coagulation problems with the patient or you violated the inferior alveolar canal/artery. The fact you state the patient is having numbness/paresthesia also points to possibly having violated the infeior alveolar canal/nerve. Placing Coe Soft in the osteotomy site also sounds very suspicious. Another possibility (although rare) could be a mandibular fracture. Finally your choice of antibiotics is very poor (unless she is allergic to all the other first-line, second-line, third-line choices). Now you have possible issues with Nerve Injury, Infection, and additional bone-loss. I hope you obtained proper informed consent. Bad things happen to us and our patients from time to time, but honestly it sounds like you need to refer this patient to an oral surgeon. Good luck. Dr. T 3rd Molar Slayer

Do not waste more time.Just refer the patient to OMFS as soon as you can for patient's welfare (Think about litigation later on). You should have done that right away. YOU DO NEED PROPER TRAINING.(Anatomy,pharmacology of antibiotics, management of operative and post operative complications,D&T for bar over denture why would you place implants in no.18 and 31 for bar over denture? What happened to other locations?

Refer ASAP! If there is still bleeding after 10 days the patient needs attention NOW. If you were placing implants in sites 18 and 31 for a bar overdenture, that tells me that you are not aware of how a bar from 18 to 31 is contraindicated and therefore you have not sought out the proper training. Take care of your patient and then go out and get the proper training, don't let this discourage you. Anybody can have a complication, but you should be able to handle most of them. From time to time even an oral surgeon will refer out to another oral surgeon or physician when they can't handle a complication. PS- The longer you wait the worst things will get.

I agree. Even the best dentists, surgeons, and physicians have to refer. This is where the art of being a good clinician comes in... "knowing your limitations, your short-comings, and when to ask for help." Please comment back and tell us how things are going for you and your patient. Back to the grind-stone...

Kinda Ditto here. Second molar sites are poor choices. Bar retained is best done in the anterior if you only plan to use 2 implants. The second molar area is just above the submandibular fossa. The facial artery comes off the ext carotid loops through this area and laterally inferior to the facial notch. Drilling the osteotomy and suddenly piercing through this area can cause profuse bleeding if the facial A. is cut, requiring ligation by an ENT ASAP! Sounds like you however may have had a mandibular canal invasion. Perio pack to stop bleeding? WTF??Always keep colla plugs and gelfoam packing them in under pressure can stop spurters(platelet aggregation and arterial occlusion).Give this a try in this case. Superficial arterial bleeds: coag w electro surg or ligate w gut suture. The nerve paresthesia/ anesthesia I would have investigated by a Neurosurgeon MD. He'll just repair it and keep his YAP SHUT! An Oral surgeon will just bash you to the patient to instigate a lawsuit especially if you're not one of his referral DDS's In the absence of infection antibiotics won't help here but you can cover your ass w/ augmentin, clindamycin, keflex. Look into the implant programs by Misch Institute, Med College of Georgia, Brookdale Hospital NY they're all good,just apply , bring$$$$$$ and show up sober. Hope I helped.

The only thing that I would ad is that 18 and 31 are poor location choices for implant placement (there are 2 full pages in Misch's book that argue the fact that most of the patients don't even need a tooth in these locations); many times the risks (the proximity of IAN, submand. fossa) in these areas are greater than the benefits. Don't beat up yourself, keep your spirit high and consult with an OMS you trust ASAP.

...for a Class I occlusion there is only 1/2 of the occlusal table of 2nd mandibular molars participating in mastication.

Direct injury to the facial artery seems unlikely. If anything, an implant surgery related injury would be to the submental artery (a branch of the facial artery). As far as having a Neurosurgeon evaluate the patient's paresthesia... I couldn't disagree more! Your best friend and advocate in such situations should be an oral & maxillofacial surgeon. Now you may not have maxillofacial surgeons in your area that are proficient in microneurosurgery, but MANY are, and those that aren't KNOW WHO TO SEND YOUR PATIENT TO. You sure seem to speak very confidently about the neurosurgeon repairing the trigeminal nerve... almost as if you have personally done some trigeminal nerve repairs. I guess they are teaching those in the Implant Continuing Ed Courses or Periodontal Residencies nowadays... As far as throwing antibiotics at the patient in the absence of infection... BIG MISTAKE. This places the patient at risk for allergic reaction, microbial resistance or even a severe colitis that could result in resection of the patient's colon. And please don't go sticking an electrosurgery tip down a deep dark osteotomy site ("fire in the hole!") to try to stop the bleeding. That is unless you want to necrose the bone and risk further nerve injury.

This post will make me question my placement in this location. However, if the placement is in the location of a lost tooth next to a 1st molar in place, is the risk reduced provided the anatomy is thoroughly scoped out?

I can agree with most of the above but why has the lip been tingling for so long and then gradually got number? I would guess from this than the nerve has possibly not been damaged enough for the neurosurgeon to need to repair it. My guess is that either the Coe-pak or the fact that there has been prolonged bleeding and therefore inflamation is the problem. More likely it is a result of pressure or chemical insult than direct cutting of the nerve.

ASK YOURSELF IF YOU REALLY THINK YOU WERE THE MOST QUALIFIED PERSON TO DO THE SURGERY.WAS THE CASE WORKED UP WITH A CT SCAN AND APPROPRIATE XRAYS. THE USE OF COMPUTER SOFTWARE SIMULATION IS OFTEN VERY HELPFULL IN AVOIDING VITAL STRUCTURES. IF THIS WAS ONLY YOUR SECOND IMPLANT CASE IT SHOULD REALLY HAVE BEEN IN A TEACHING HOSPITAL UNDER EXPERIENCED SUPERVISION. FURTHERMORE CONTROL OF HAEMORRHAGE IS BASIC SURGICAL CARE AND SHOULD RARELY POSE A PROBLEM. I THINK IT IS IN THE BEST INTEREST OF THE PATIENT THAT THE SURGEON HAS ADEQUATE SURGICAL TRAINING OTHERWISE EACH CASE IS EXPERIMENTAL. WHILE COMPLICATIONS HAPPEN TO ALL OF US IT IS ONLY THROUGH THOROUGH TRAINING AND SUPERVISION THAT SUCH PROBLEMS CAN BE AVOIDED OR KEPT TO A MINIMUM. IF YOU ARE SERIOUS ABOUT THIS TYPE OF SURGERY INVEST SOME TIME AND EFFORT AND GET A QUALIFICATION IN A SOUND DENTAL SCHOOL. OFTEN THE IMPLANT COMPANIES MAKE THIS TYPE OF TREATMENT SEEM SIMPLE. THIS IS A GROSS OVER-SIGHT .THIS IS NOT MEANT IN A PERSONAL WAY BUT IS SURELY THE MOST ETHICAL WAY TO PROCEED.

Dr. J, You have been hit pretty hard only for your benefit. We have not heard from you and would like to know if any of what has been written make any sense to you. We would also like to know what has been your course of action and how is your patient. I hope you have not been intimidated by your colleges and that we hear from you soon. Good Luck

My only additional comment would be to ask what type of anesthetic was used? Septocaine has been noted in the literature to cause temporary parathesias, in some cases up to 6 months. I've had a few of these unrelated to imlant surgery.

I know the Oral Surgeons that have responded to you seem very pompous. Infact they often place implants in the most inappropriate positions. However, It appears you have no training or business placing implants. Do what you know how to do i.e., restorative dentistry. Your other option is to go back to school for several years. Weekend courses in implants will only get you in a bad place. By the way, nerve parasthesia and or bleeding have nothing to do with infection and the need to prescribe antibiotics.

Dr. J... we still haven't heard from you. I hate the suspense (its a slow day in the office). This forum exists to share cases, ask questions, give and get opinions etc... While some people on here may come across as "pompous pricks" I truly believe the vast majority of us aren't (even if our posts come across that way). Although some of my comments may seem harsh (and perhaps a little sarcastic), they quite possibly are being read out of context. When I respond to posts, I do so merely to share information, give a different perspective and give my honest "non sugar-coated" opinion. Sometimes you just gotta read between the lines. Open discussions, honest opinions, and a reality check from time to time is what we all need. I would also like to reitterate something that was said in another message thread a while back. This website is for discussion and for debate. BUT IT SHOULD NEVER BE A SUBSTITUTE FOR Legitimate Science, and Supervised Mentorship. I too fear that when we give online advice, it has the potential to be utilized incorrectly...further endangering patients. There is NO SUBSTITUTE FOR PROPER TRAINING, SUPERVISION, MENTORSHIP and PEER REVIEWED SCIENTIFIC LITERATURE. This website should be used only as a compass to point you in the right direction. I encourage you to look into the Bigger (probably More Expensive) and More Extensive Implant Training programs and to avoid the quick weekend or short implant training programs. Now write back to us and tell us what is going on... Cheers, Dr T 3rd Molar Slayer

Dr. J, You have to be kidding us. 1. aborted surgical procedure due to bleeding 2. coe pack into an osteotomy 3. parasthesia as a symptom of infection 4. bar overdenture on implants on 18 and 31 5. inappropriate selection of antibiotic If you are not kidding, then you dont know what the hell you are doing. This is simply fact and not a pompous statement.

Why are general dentists even allowed to place dental implants? Would you go see an optometrist for LASIK surgery? No you would go to a qualified opthamologist because they have been properly trained to do this type of procedure. They both know a lot about occular science and procedures, but only the opthamologist has the proper training. Why do we have to avoid this subject? Weekend courses and mini residency's in implant dentistry are ridiculous and should be banned. ADA accredited residency's from ADA recognized specialties not only teach the science and research behind these procedures, but they are long enough to actually see cases through to completion and deal with complications as they arise with experienced faculty members overlooking each case. Oral surgeons and periodontists often butt heads on who should be placing dental implants, but at least both have been properly trained to deal with complications related to dental implant placement and the majority of OMFS and perio residents leave their respective programs placing a couple of hundred implants and assisting on hundreds more. I know in perio, most residents now are actually mandated to observe the restoration of all of their placed implants so that they will have a better understanding about proper angulation and depth of placement, so they are not just placing implants to place implants. Just "sinking" a few implants in a pig's jaw is not proper training and is an unethical way to practice dentistry. Sorry for being so harsh, but the facts are the facts. Do you what you do best, i.e., single rooted endo, simple extractions, crown and bridge, removable appliances, etc, your life will actually be more profitable and less stressful in the long run.

Excessive hemorrhage occurring from an osteotomy preparation in the mandible, may be from the involvement of three major arteries supplying the mandible, including inferior alveolar, facial, and lingual artery. Deep concavities as in the sublingual fossa and lingual cortex of the posterior mandible serve as potential danger zones. It has been estimated that ruptured artery may lose blood at a rate of 14 ml/min, equivalent to 420 ml of blood loss within 30 minutes. If the operation is being done under local anesthesia, the patient is asked to stick out and raise his/her tongue arbitrarily to bring up the floor of the mouth and to compress vessels against the medial aspect of the mandible. Sometimes extraoral pressure applied to the submental or submandibular arteries against the body of the mandible for twenty minutes would be very helpful before taking the patient under general anesthesia to ligate the major vessel which is responsible for the bleeding. In our facilities, these arterial ligations are always being done by oral and maxillofacial surgeons and not the ENTs. Nerve trauma and neurosensory disturbance may result from the damages to inferior alveolar, mental, or lingual nerve during osteotomy preparation or flap incisions. A minor injury usually heals spontaneously within days or months. However, prolonged pressure from the Coe Pack plunged into the drilled cavity and in direct contact with nerve fibers may lead to a permanent degeneration of the inferior alveolar nerve. Although with the combination of symptoms like bleeding and neurosensory disorder, one is directed towards the diagnosis of entering mandibular canal, but the sustained course of active bleeding may also be an indicative of perforating the lingual cortex and severing the (e.g. lingual artery) and formation of a pseudoaneurysm.

I think the comments are self evident that this case was not a proper effort at implant dentistry. In referring for nerve repair, there are surgeons that do nothing but repair nerve damage and graft t reestablish sensation. refer immediately when necessary. I beg to differ with Gums and Roses on the general dentist placing implants. We can be (and I was) adequately trained at the MCG maxicourse to place and restore implants which I have been doing 2004 with great success - and a few failures. I have taken many courses and while I will never possibly know everything there is to implantology, neither will the best specialist. And the best specialist in the country has had failures of his or her own making. We GP's have had impossible restorative situations arising from specialists placing implants without regard for the restorative parameters following placement. The inadequate clinical situations arise. We all have failures, and we can all look through our retrospectroscope and see what we should have done or could have done differently. Hindsight is 20/20. Let's please keep this forum going in a grand rounds professional manner as equal colleagues and offer each other sound clinical advice instead of criticism. JMHO Bill

anyone who has not placed implants in a poor position or had a complication has either not placed implants at all or is in denial. whether a gp perio or max fac it is obviously important to appreciate a prosthetically driven approach.the more solid the background the more likely to have a happy outcome.thus case selection and pre operative work-up is probably the most important aspect of the case. a sound training is the initial part of the work-up. there is a not-so subtle difference between an inadequately trained gp doing a weekend course and a person who has had formal surg training doing the same weekend course. next time you find yourself in an airliner in iffy weather ask yourself if you have as much confidence in pilot on his second ever landing following a weekend course or if a properly trained expert is your safer choice. it is really much the same thing.

Fascinating. I'm not a dentist (I'm a nurse practitioner) but I found this site because I'm still having pain and bleeding from an extraction with bioss (?) two weeks ago. I want an implant...I think the site is #19...I could be wrong, but I think that was the number. I saw my oral surgeon once for this and was told all was well, but this site tells me implants may be more complicated than I thought! Is bioss good? I love the screen names--Gums and Roses??? Man of Steel? Great!

Dear Laura You are indeed correct that implants are quite complicated. They are very technically demanding in all aspects... Patient Selection Site Selection and Development Presurgical Treatment Planning The Surgical Placement The Restorative Aspects Implant Hygiene and Maintenance Implant Esthetics And all of that has to work in one of the harshest environments on earth... the human mouth! There are a million and one approaches to the ever evolving science of oral implantology. As you can see on this site, there countless personalities, opinions, and treatment options available. If you read further on this site you will also see a number of dental professionals from general practitioners, prosthodontists, periodontists and oral & maxillofacial surgeons posting their opinions. Implants are traditionally surgically placed by either Oral & Maxillofacial Surgeons or Periodontists and typically restored by Prosthodontists or General Dentists. However there is no official implant specialty, and the surgical/restorative boundaries are crossed by a number of individuals who provide complete/comprehensive implant therapy (as you can see there are many opinions about these "boundaries"). Its all about case selection and proper treatment planning. Some cases belong in the hands of specialists while other cases can be fully treated by general dentists with "proper training." As a nurse, I am sure you understand and appreciate that no procedure (even in the most capable hands) is 100% safe/effective. With that said, I will say that bio-oss is an excellent grafting material (used by many generalists and specialists)with very good results. Pain and discomfort at your graft site could be from a number of reasons. If you have continued pain/discomfort/bleeding I would recommend you continue to follow up with your general dentist and your oral surgeon. Although I wouldn't expect you to have continued bleeding this far out from your surgery... this is something that should be addressed ASAP.

re: 3Mslayer comment You seem to have your facts and possibly your ego misplaced. "Traditionally," the pioneering work with implants was in large part due to the contributions of general dentists. In fact many of the leaders in the surgical aspects of implant dentistry today are general dentists. We as a profession should be past this petty arguement. The issue is training and experience. Neither of which is dependent upon a specialty degree. I receive surgical referrals from two oral surgeons and I am happy to refer to specialists when it is appropriate. If we want to debate the issue of establishing an implant specialty, that is another matter. Obviously this dentist did not have the proper training to perform this surgery. For his and his patient's benefit that is the best message.

Laura, you need to get an examination and follow up as previously recommended. There could be several reasons for the bleeding, which isnt related to the implant you are considering. When I remove that tooth on a patient and graft, there is very rarely any bleeding whatsoever when the patient is dismissed. as far as implants are concerned, implant placement does not require a specialist, but it does require special training most concerned dentists or specialists receive to do so. Implants are a reliable, predictable treatment. Although we cant see what your clinical circumstance is, if everything heals with normal limits, replacing that single tooth following an extraction should be pretty straight-forward for any conscientous, well trained dentist or specialist. After the initial problem you have is solved, talk to your dentist. Implants are the treatment of choice for a missing tooth instead of a bridge. You regain the support you lost, save teeth on each side of the space created by the extraction and preserve the bone there as well. It will feel and function just like your own tooth and can last 10-20 years. You will lose bone rapidly by not doing anything, up to 20-30% in jst the first two years alone. Be confident that implants are rapidly becoming a routine treatment in today's dentistry. Its a great choice. Hope that helps. Bill

Dear Andy... I believe that my above comment to Laura was pretty honest and factual. But let me set the record straight if I wasn't clear about my position on "general dentists." I was a general dentist in private practice (and hospital dentist) for a number of years before I went back to become an oral & maxillofacial surgeon. During my time as a general dentist, I too successfully placed implants, performed bone grafts and soft tissue grafts. I have never once in any of my posts (on this thread or other threads)said that general dentists are not capable of surgically placing implants. In fact if you read my other posts you will see that I have always advocated for the rights of general dentists to peform implant surgery (especially given my former general dentist background). The only thing I ever stressed was "PROPER TRAINING AND CASE SELECTION." I also am aware that many general dentists were instrumental in the development and progression of the science of implantology. But Andy, what I hate to see happen is the specialist be marginalized by the generalist(especially because some weekend corporate sponsored course gives the practitioner a "false sense of security"). You can't deny that in today's day and age the vast majority of implants are STILL being placed by specialists and restored by general dentists. This number may be changing, and no doubt the number of general dentist that surgically place implants will continue to grow. That doesn't bother me one bit because there is plenty of work out there for ALL OF US. And it doesn't bother me because when it comes to the "big stuff" its still in my realm (General Anesthesia,Tibial Grafts, Anterior/Posterior Iliac Crest Hip Grafts, Calvarial Grafts, Zygomatic Implants, Distraction Osteogenesis etc etc). Finally, as far as ego... we all have some. And I believe that I tend to channel mine properly. That's why my referring general dentists aren't "affraid" or "ashamed" to call me when they need help. They know I always bail them out (especially at 5pm on a Friday). Too many people that post on this site are "ashamed and affraid" and let their "egos" get in the way of properly treating their patients (i.e referral, or not calling their specialist when they need help). Instead they seek critical information online instead of picking up the phone and calling their local specialist.

Sharing opinions , cases and mistakes , and negotiating the hints and pitfalls in implant dentistry is the main goal of this forum. being sometimes agressive in our judgments ,opinions does not really mean to be rude with the person who did the mistake or had the complication regardless of the causes ,every opinion is highly appreciated and should be taken in a friendly manner .I really encourage Dr.J and ask him sincerely to post again to the forum and inform us what had lately happened with his case and what was the opinion of the OMS who saw the patient and keep us informed of the details and the sequence of the sugested treatment so we can share opinions for the benefit of all the colleagues especially for the newly practicing doctors ,

Well said 3rd Molar and Dr E.S. I continue to learn from everyone willing to share, and I certainly try to keep things within my surgical comfort level and taining. I will never hesitate to call my specialists when necessary. I AM dependent on them for many things beyond my scope of care. I do believe things go well when working together, turf battles and egos aside. Bill