ask a question Discussing the Latest in Implant Dentistry
Dental Implant Perforation
Dr. Steinberg asks:
I just started placing dental implants. I took courses for 5 years before I felt confident to place an dental implant on my own. The only area I feel I really need to master is using CT scans for treatment planning since I had the following disaster.
Here is what happened: I was placing a dental implant in the maxillary lateral incisor position and I perforated through the buccal cortical plate when I torqued down the dental implant. I thought about placing a mineralized freeze dried bone graft and repositioning the flap. But I panicked and sent my patient over to the oral surgeon. Did I do the right thing? What would you have done? Thanks for any comments.
July 11, 2006 in Treatment Planning & Complications | Permalink
Advertisement
Comments
Dear Dr. Steinberg:
Panic is normal when you meet an unexpected complication.
Your idea of grafting was the right one. Hopefully this was a flapless surgery and if so you just needed to make a pocket by lifting the gum and periostium and using that as your membrane(that is the best there is) and making a really tight packing of material like PUROS or the one of your choice.If this was an open surgery, decortication, graft, membrane and multipoint clossure.
Then protect the area with a fixed temporary,maybe even a temporary over the implant if you had one loger than 13mm.
If the oral surgeon is a decent guy you wont have problems at all.
As a recomendation you should allways have a contingency plan for this and all other problems that you will face if you keep doing surgery, they are a fact of life.
So just relax and plan ahead
Posted by: Alejandro Berg | Jul 11, 2006 3:10:48 PM
What I would do?
If I can not handle such a minor problem,
before placing next implant I would get more training.
Posted by: satish joshi | Jul 11, 2006 5:18:48 PM
Sometimes the problem can be solved by placing shorter implant as long as you can get primary stability. Any kind of bone graft will be more effective if it is contained within the perforation (you get the blood supply from every wall except the buccal) than try to gain bone width outside the perforation( you get the blood supply ONLY from the buccal wall). A good way to get your bone craft is by using Mx- grafter or something similar and get it from the adjacent area but of course there are more ways to do that. I definitely agree that this is a minor problem and you should consider some additional training before you do your next case. Of course the CT-scan will make you avoid this error most of the time but not always. Either way it is an excellent diagnostic aid for implant treatment plan. An easy case to start your implant surgical exposure is an upper premolar. I hope that helps
Posted by: yianni | Jul 11, 2006 6:17:24 PM
In response to Dr. Berg, the periostium is not better than a GBR membrane. Studies have proven that. Otherwise, why GBR at all?
The questions you would ask yourself are:
Did I consider the possibility of perforation?
Did I do all I could to prevent it?
Did I truely know the local anatomy of this area?
Did I have the surgical skills to control the drilling and placment to avoid this complication?
Was I prepared to manage the complication?
Did I know how to detect the drills coming too close to the buccal surface?
Without a CT, did I really know the bone width along the path of the implant and the angulation of the planned path in regards to this potential complication?
If your answer is Yes to any of this, I would suggest that you need more training and experience. I am not saying that you have to stop placing implants, and this complication could happen to the best of us.
Posted by: TW | Jul 11, 2006 6:18:52 PM
Dear Dr.steinberg
This is a problem that arise from an anatomoc limitation and badtraining in implant dentistry.the buccal bone concavity in the lateral incisors of maxilla dictate a more palatally drilling of fixture site,the second problem is the path of insertion fixture in the area .I have heard from many speakers in the implant course to go prependicular to crest and do not afraid from perforation in the buccal aspect and then use GBR technique!I want to answer this is only true when we ought to use a screw type superstructure because of the height of gingiva or restriction in height<7mm.But why we should go prependicular and straight in the cemented superstructure,so in cemented case we can follow parallel to buccal bone curve and insert our fixture without damaging the buccal plate.
Posted by: Dr.Hajiheshmati | Jul 11, 2006 9:47:50 PM
Even an experienced surgeon can get a perforation, and even he will feel some anxiety under the circumstances. The difference is that for the surgeon, clinical experience allows them to deal with the situation with more confidence. It sounds like you were insecure due to this unexpected event, but did the proper thing by making the referal. Perhaps taking more hands on surgical courses will enable you to develop more comfort. Regardless, you need to do more supervised surgeries to achieve the skill nesessary to treat your patients. Good luck.
Posted by: | Jul 12, 2006 10:38:49 PM
Next time you graft.Panic is normal.Do not forget to update the patient about the complication.
When you will not be anymore friend with the Surgeon , he will say you are a beast!That is the way we are!
Posted by: Albert Hall | Jul 13, 2006 3:08:11 PM
Placing implants in the maxillary anterior is probably the most challenging aspect of implant surgery anywhere. You are always fighting for adequate width - even with ridge preservation you will still get resorption.
In my humble opinion, grafting for small perforations in the cortical plate may be best characterized as "the enemy of good enough is better". Small little pieces of membrane are difficult to stabilize, raising a flap will strip periosteum from the cortical plate - raising the spectre of resorption - best summed up "no good deed goes unpunished".
My approach to small perforations are - and many of you will be aghast - do nothing. Of course it depends on where the perf is, how thick/translucent the tissue is, etc; but I find no difference in implant integration and it avoids the pitfall of resorption with flap elevation.
As an OMS who does alot of DA surgery, osseous dehiscences are very common in the natural dentition. Why would you flip out when witnessing the same in an artificial dentition.
Remember - patient has the disease - not the patient.
Just my 0.02, FWIW. I trust many of you will not agree with this approach.
Posted by: David Lambert | Jul 24, 2006 6:14:23 AM
Ooops....sorry....
I ment to say "patient has the disease, not the doctor"...
Best
DML
Posted by: David Lambert | Jul 24, 2006 6:19:39 AM
In response to T.W.
In flapless surgey as I stated yes periostium is best, read some Petrungaro work
Posted by: Alejandro Berg | Aug 1, 2006 4:21:51 PM
Sorry (bout my english, I´m out of training) In my experience this kind of complications may happen to everyone. I´m maxillofac surgeon and have a master in prosthetics, I think this things don´t happen if you use osteotomes, it´s obvious that every rotation may fracture bone when you approach with drills. Derivation is ok! I think you have to put more implants!!! good luck
Posted by: Pablo | Sep 20, 2006 8:58:01 AM
I realize that this is after the fact, but just a helpful idea for the next time, CT scan have it read, do you have simplant planner? if not you may want to purchase, use a drill stent, very helpful. best of luck
Posted by: | Oct 22, 2006 3:16:37 PM
As a dental patient, when you read these letters, you think to yourself, the best advice to anybody is: Stay Away from the Dentist, if at all possible. What a quote: "the patient has the disease, not the doctor." This is what passes for "integrity" on this blog.
Dentists, who are undertrained, doing implants.
Other dentists supporting the man - who probably did permanent damage to another human being. For me, it is too late. I have several crowns, two root canals, some gum recession, and am facing an implant myself now, on molar #19, because my dentist said the crown I had on it, which was causing no real trouble, was "leaking" and needed to be replaced. I did -and after undergoing crown lengethening surgery, there was not enough healthy tooth remaining to fit a crown - hence, extraction - and an implant set for September. For my three year old nephew, I am telling my sister to do everything PREVENTIVE she can so he doesn't have to face the kind of outright fraud that is evident from reading these messages. Dentists can do much more damage than good - because they don't stress preventative measures or proper nutrition, etc. I know these statements will not win me any fans - but they state some truth. I do not know if I should trust the implant process or not. Or if I should choose an oral surgeon or a periodontist - there is so much bewildering information out there. I AM going to do it, because I need to have that molar, and am not a good candidate for a bridge, but after reading some of these postings, I am not only alarmed, but shocked at the level of discourse by so called "professionals." Do you realize you are operating on fellow human beings? If an oral surgeon or peridontist is reading this, PLEASE guide me with integrity about what to expect about having a dental implant on my lower left molar, #19. I am so anxious about this procedure -so confused as to its success - not to mention its safety - and hope that someone out there will read this and respond. But PLEASE look over some of these postings and understand how they would alarm innocent patients reading them. It's not right.
Posted by: Matthew | Jul 31, 2007 6:09:51 PM
Browse by:
In The News