Patient numb 2 days after implant placement: thoughts?

It is unfortunate. However since you have indicated that there is a hematoma in the area, it is quite possible for the same hematoma to create pressure within the bone over the inferior mandibular Canal which can result in numbness. Since it has only been two days following implant placement, take a CBCT for the record and remove the implant. Place the patient on anti-inflammatory medication and refer the patient immediately to an oral surgeon for a second opinion. Map the area of numbness and follow up weekly and hopefully natural healing will take place. Since you have indicated there was no physical trauma to the nerve, once the pressure releases, the nerve should go back to normal. Best of luck.

"I placed a 10mm implant in site #30 . The CBCT showed that it was 14mm away from IAN canal, but there was some radiolucency in the area. The patient is still numb 2 days after placing the implant. He also has a bluish discoloration in the chin area where the implant was placed. No nerve block was used, only local infiltration. What could have caused this? Any recommendations for follow-up or treatment?" There is a lot of information that you are not giving. Are you referring to the anterior implant that shows the radiolucency or to the posterior one that does not show the apical part of the implant? and did you place both at the same time.? Can you post an image of the area that measured 14 mm? To me it looks like the implant was placed 8mm in the bone, close to 3 mm is outside the bone and I cannot see the inferior alveolar canal in the radiograph. Did your patient give you any signs that you hit a nerve? Where is the numbness, and did you map it? Removing the implant and anti inflammatory meds are warranted, but consult with a local experienced oral surgeon. Good luck!

I would agree with the previous comments, however I would remove both implants in addition to the steroid regiment. It’s difficult to evaluate with the images presented but the posterior plant may be more problematic. Also, I don’t believe that you mapped the nerve properly in the CT scan and you are likely much closer than you think. Which implant is supposed to be 10mm and is there a reason why you did not place the anterior implant to its full length?

1st. There two implants one placed not all way, must be removed. Another implant no apex visible 2nd. Your marking or measurements mproperly made. Treatment: remove implant and let it heal on its own. Next time use guided surgery.

All the above comments are very valid. I cannot see the positioning of the distal implant, it is not clear in the radiograph...….since you did not give a mandibular block, only infiltration injections on the buccal and lingual , and the patient did not experience any noticeable pain while you were preparing your osteotomies and screwing in the implants …..I am led to believe that the inferior alveolar canal was not perforated, and there is no physical damage to the nerve. The preoperative panorex show a much less mineralized section of bone coming off the canal, and perhaps this is where the inflammation into the canal has settled. Dexamethazon is a good anti-inflammatory drug to use in this situation, and I would not remove the mesial implant ( I cannot see the final position of the distal implant......but give it some time, and it will probably resolve itself without removing the implant (s)

I don't think I've ever seen 14 mm of distance between a 10mm implant and the nerve in the posterior mandible. Take a new scan and make sure it gets read properly. Best of luck.

All the previous comments are relevant but we need more information. Firstly we need another cone beam radiograph or we are all just guessing. The PA is simply not enough in this situation. Secondly we need a more accurate description from you about the procedure. When did the numbing start – straight after or during surgery or 1-2 days later? You also mentioned the implant was 10 mm in length but then you say it was 14 mm away from the canal. So are you saying there should be 14 mm between the apex of the implant and the canal or do you mean there was 14 mm from the crest of the bone? If the latter, then where did you measure the 14 mm from (the ridge slopes away considerably – ie there is probably 3-4 mm length difference from the crest to the canal – depending on your point of entry). Did you use a surgical guide? What was the canal position – you have indicated 2 circles in one of your radiographs – was this similar the entire length of the mandible? We need to see the full trace. What was the radiolucent area above the canal in your initial radiograph – artefact or less dense bone or something else? Did you trace the path of the mental nerve through the bone from the canal – the mental nerve can have a very different pathway to what you might expect (ie up or down or sideways from the exit point)? What was the sensory reaction during surgery in regards to the anterior and posterior implant placements – ie was there any indication which implant might be causing the problem? What is the relevant affected sensory distribution post operatively? Clearly this needs to be known in order to decide which implant is the most likely offender. What is the radiolucent area apical of the anterior implant in the post-operative PA? Did you prep this for the full implant length and not place the implant the full distance into the bone (the implant seems to be 3 mm short of what I would expect) or is there some other explanation in regards to this particular radiolucency? So you can understand that there are really many answers required before an accurate diagnosis and treatment can be given. With all this in mind, and considering your uncertainty, I think it is best for the patient and wisest for you to refer to a competent oral surgeon quickly. Obviously there is an issue, and it is in your interest and most importantly the best interest of your patient to mitigate the potential damage suffered (both at this time and in the future).

I agree with Sean above I think You mapped IAN wrong on the CBCT. It's blood supply and some nerve bundle is actually more coronal, dark area, on the right side of the scan in the CBCT. Right above the two circles that you have drawn. Also the PAN shows some extra marrow space, or large cancellous, areas on the apical areas of the extracted teeth. I presume, and I can be wrong that, the Hematoma on the same side is from extra bleeding, (again I am assuming that's what happened), and that impinging on the nerve. I would follow excellent advice provided above by other Docs here about, mapping it, placing the patient on Mederol dose pack, and sending them to an O.S. to work in a multi-disciplinary fashion. Mistakes happen so, I wouldn't worry my self sick (this is what malpractice ins. is for, errors happen and hopefully you have informed consent), but how quickly you respond to alleviate the issue will determine how happy or mad the patient gets. Good luck!! My $0.02

I have had this happen a couple of times and it seems to be related to pressure most likely from the inflamatory response. When it has happens it has always resolved within 8 weeks. I have found it to start gradually disappearing and fully resolve in that amount of time. Don't remove the implants but rather let nature take its course.

Lots of good advice about the hematoma. The anterior implant has a threaded collar which should be submerged in bone. The soft tissue is not meant to be in contact with this surface. Should be removed.

I can't tell on the CT scan where the nerve is usually have to trace it to be sure by scrolling from the lingula. Anyway on the Panorex the nerve looks high. Was the implant backed off since it's not all the way in on the periapical. Looks like the nerve was damaged, take the implant out and follow for resolution of the paresthesia. If this surgery was not done guided with a restorative plan for the implant spacing and depth control there may be a future lawsuit.

The bluish area around the chin indicates that there is a hematoma around the mental foramen.You have not damage the inferior alveolar nerve. The fluid within the hematoma will create pressure around the mental nerve and resulted in a temporary paresthesia which will subside Within 10 days. Please keep us informed of the results in this matter.

Great comments and advice. One more question is flap design. Was that a full thickness reflection or split? If split then that could cause both the hematoma and paresthesia your patient is experiencing. In my opinion you MUST remove both implants, place the patient on steroids and map the paresthesia as well. If you leave an implant in and this leads to a legal discussion, there will be no defense of that. An afterthought...If you by any chance used Articaine I can see the possibility of paresthesia from that if it was coached into the canal. Very good advice given above by others... Bill

It seems that the IAN has a variant configuration. Although rare, it has been reported that sometimes there can be a double IAN, or bifid canals. Check this case report: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3692193/

-Take the implant out. Inflammatory response around nerve. Implant is poorly placed , with threads exposed. -anti-inflammatories - map out parethesia - follow up frequently - should resolve -

I would consider backing the implant out and see if you get recovery

Doesn’t look like either implant even approximates the IAN. Anterior one isn’t close to being seated and needs to be removed for that reason . Did your flap extend towards the mental foreamen ? Did you inject 4% Articaine ? Is it anesthesia or paresthesia ?

Consider too: Where did the anterior aspect of your incision go? Hopefully away from the mental nerve. I have done countless All on 4 cases that simply stretching the mental nerve caused par aesthesia. Think back during surgery: did the patient have any pain? A CBCT would help you see if the radiolucent areas are violated with either implant. I agree with removal of the anterior implant. Those micro threads should be in bone or you will have mucositis > peri-implantitis quickly. With over 5000 implants placed, I've seen less than a handful that didn't have a simple explanation for paraesthesia. The anti-inflamatories are a good idea too: Medrol dose pack and an NSAID taken regularly. If the problem persists, with no significant improvement by 2 weeks, then I would remove both implants at the same time.

Agree with previous comments. Take CBCT and see proximity to IAC. I would like to add: In order to evaluate bone dimensions at the implant site, the pre-op cross-section should be parallel to the axis of the implant and perpendicular to the occlusal plane, otherwise it might show more bone than what is really the case. The cover screws are also switched. The wider one (placed on the mesial implant) should be for the posterior implant and vice versa

"What could have caused this?" 1. CT-slice posted indicates you measured 10mm from crest of soft tissue ridge. No info on where the IDN is measured from, but presumably same soft tissue ridge because measurement made during the same simulation session. 2. Where was osteotomy measured from? Flapless surgery , and measured from crest of soft tissue ridge - might explain why the 10mm fixture is only 7.79mm in bone. If it is flap surgery - possible osteotomy was measure from crest of bony ridge - hence osteotomy deeper by soft tissue thickness. 3. Implant systems differ, the system I am using, osteotomy drills for 10mm fixture preps to 10.91 mm - 0.91 mm deeper, 0.5mm for the subcrestal placement of fisture, and the rest to facilitate self-tapping of fixture. Earlier small diameter implant I was using, osteotomy preps bone 2mm deeper than fixture . 4. Errors from 2 and 3 means you might not have the safety margin 4.0mm you have judiciously planned. 5. CT-slice is 2D only, without a guide, it is pure luck if can locate the 3rd D/exact anteroposterior point/"slice" on the ridge.

i follow a practice of calling the patient in the evening; same day, after a period of time of which the local anesthetic should be metabolized - if they report numbness they are required to come into ofc for radiographic ( pax, cbct) imaging and probable implant removal. There may be a bifid mandibular canal present and the implant has impacted the coronal aspect. As the other replies, lots of variables here. TY

Numb where? Diagnosis first.

Conceivably you could have over drilled with the 2.0 guide drill and perforated the cortical plate either buccal or lingually. This would explain the hematoma and the paresthesia. I would definitely explant both at this time and I would give the patient a Medrol dose pack and cover with antibiotics. Then I would graft and retake a new CT scan 3 months later and place the subsequent implants guided.

Most probably hematoma and inflammation Place on Dexamethasone Remove implant (threads showing on anterior implant) Take CBCT to see the position of implant and nerve. Get a second opinion for a colleague

>From your comment I assume 14 mm is the distance is from the top of the alveolar crest to the IAE canal Your implant is 10 mm and the PA X-ray clearly shows osteotomy was done up to 10 mm length but implant inserted is 3 to 4 mm above the bone. >M y observation So from the end point of your osteotomy, IAE is only 4 mm away, now look at the PA, PAN, CBCT there is a large radiolucent area indicating 'BONE MARROW DEFECT'whis is seating on the top of IAE canal. My conclusion is the Bleeding from the bone marrow defect created the Hydraulic pressure causing the numbness. My advice> is to remove the implant stat and then place the patient on Antinflammatory meds and Steroid. Map the area of numbness so you can monitor the improvement. Refer patient to OMFS asap. Refer the patient to OMFS

>From your comment I assume 14 mm is the distance is from the top of the alveolar crest to the IAE canal Your implant is 10 mm and the PA X-ray clearly shows osteotomy was done up to 10 mm length but implant inserted is 3 to 4 mm above the bone. >M y observation So from the end point of your osteotomy, IAE is only 4 mm away, now look at the PA, PAN, CBCT there is a large radiolucent area indicating 'BONE MARROW DEFECT'whis is seating on the top of IAE canal. My conclusion is the Bleeding from the bone marrow defect created the Hydraulic pressure causing the numbness. My advice> is to remove the implant stat and then place the patient on Antinflammatory meds and Steroid. Map the area of numbness so you can monitor the improvement. Refer patient to OMFS asap.

>From your comment I assume 14 mm is the distance is from the top of the alveolar crest to the IAE canal Your implant is 10 mm and the PA X-ray clearly shows osteotomy was done up to 10 mm length but implant inserted is 3 to 4 mm above the bone. >M y observation So from the end point of your osteotomy, IAE is only 4 mm away, now look at the PA, PAN, CBCT there is a large radiolucent area indicating 'BONE MARROW DEFECT'whis is seating on the top of IAE canal. My conclusion> 1)is the Bleeding from the bone marrow defect created the Hydraulic pressure causing the numbness. Also, lingual plate perforation is likely to cause bruises and numbness. My advice> is to remove the implant stat and then place the patient on Antinflammatory meds and Steroid. Map the area of numbness so you can monitor the improvement. Refer patient to OMFS asap.