Late Facial Swelling After Implant Placement?

Dr. R. asks:
I placed 6 post-extraction 3i Osseotite dental implants on a 60 year-old lady. The implants are submerged and the area has healed well without any exposure of the implants. I also placed 3 transitional IMTEC implants in order to retain a temporary upper denture. The healing was normal. Sutures were removed after 7 days and the denture was placed with a soft liner on that same date.

The patient had the denture for the whole weekend and she presented three days later with a swelling under her nose and seems to extend from the left central incisor area to the left canine area. No pus nor any exudate. She has been under taking antibiotics (clindamycin and metronidazole) for 10 days already. I do not think it is infection. I have taken radiographs and the implants look fine without any radiolucent areas around them. What disturbs me, is why this late swelling? Any advice or ideas? I am stumped and very worried. Thanks for any ideas.

33 thoughts on “Late Facial Swelling After Implant Placement?

  1. R, if you have an implant in that area it will probably be lost. I have had a delayed onset inflammatory reaction a few times and the ultimate result was loss of the implant. It happens, work around it. If you MUST have that spot for an implant then graft it and re-implant if you lose it. If you are placing 6 immediates and 3 MDI’s, you should be fairly advanced in your implant journey. Good luck amigo.

  2. Dr. R. You did not mention the condition of the teeth prior to extraction. From what it written, I assume that the teeth were extracted and the implants laced immediately.

    You did not mention how the extractions went…were they simple, or were they traumatic? What was the condition of the periodontium prior to extraction? Was there existing pathosis in the area at the time of the extractions? Was this a closed procedure, or did you open a well defined flap that allowed you good visibility of the area to be implanted?

    You placed six conventional and three mini implants into a localized area all at one time……this can be quite traumatic, and cause swelling and discomfort.

    It is difficult to try to give advice from previous experiences, when the facts are not clear.

    Give it some time, perhaps the Metronidazole is too irritating to the underlying tissues if it is creeping in.

    Best advice is to wait, apply warm compresses, and let nature take its course……it just may work out. Good luck

  3. It’s possible that the patient is having an allergic reaction. Did you use a membrane? Membrane manufacturing process leaves chemical residue that can cause hypersensitivity reaction. If that’s the case then membrane should come out.

  4. Dear Dr.R , although the clinical data about the case is not enough concerning the condition of the teeth prior to extraction and the distrubation of the implants , the problem could be related to perforation for the outer cortical plate during insertion of one of the fixtures which leads to involvement of one of the facial space , or related to allergy to the denture material , try to ask the patient to put the denture a side and give him antihistaminic with follow up , if you can send me the x-ray before and after implant placement.
    good luck
    Dr.ossama Ghorab

  5. I think this can be very normal response to your surgery. Patients in general have delayed swelling post operatively, specially when you extract several teeth, lay a long flap and place 6 implants. You should note that we follow our implant patients much more than our extraction cases. If you follow your hard surgical extractions, I bet you will see this kind of swelling. I would suggest placing the patient on 4mg decodron if you have not already.

    Good Luck and just wait and see. I would also place the patient on augmentin and metronidazole just to cover both aerobic and anaerobic bacteria

  6. It may be too soon to show anything on the x-ray. Placing implants in to infected extraction sites is a high risk even if you bone graft and you did get total closure. It is not worth the risk. There are too many unknown factors that we can not control.

  7. I also agree this sounds more to be an allergic reaction based on the facts provided…think of all the materials you used and review the patient profile…could be the membrane (which I have seen) or even the denture material…

    Good luck

  8. in acute infections you cant too see nothing in X-ray .You must wait wat can you doo on next step you ordinair 2 antibiotk in the good sinergation .

  9. Dear Dr. R,
    There are two possible problems with this kind of late swelling:
    1. over-extension of the denture
    2. necrosis (as a result of overheating or dull burs), infective lesion (because of periapical lesion of the pre-existed tooth), or undisclosed and advanced fenestrationof the bone in apical part of implants.
    Fortunately, both of these problems are containable:
    For first condition you should adjust the borders of the denture and check its fitness as soon as possible.
    For second condition you should open an extended flap and remove the granulation tissue, then augment the area, if possible.
    Please tell us the results,
    Waiting to hearing from you about your new findings and treatment results,
    Good luck
    Neda Moslemi

  10. Dr. Niznick and the other Docs. have brought up good points. Did you take her vital signs along with her temp? Were you in and out quickly with the implant burs and did you irrigate. Increased temp of bone may be an issus, but it mostlikely is from a residual infection from the teeth or bone about the teeth.

  11. A 60 year old female, well is she on oral biophosphonates like Fosamax or Actonel? Something to consider. I would continue with antibiotic therapy and wait for further developpments. Tell her not to wear the denture, and you may want to use a chlorhexidene mouth rinse. If there is a wound dehiscence and continued pain then you have more than a local issue but probably a systemic one. Good luck.

  12. I’m going to try and not to be to harsh here, I think its time you refer this case to your local specialist and you need to review the types of cases you are doing to see if you are qualified to handle them. Based on what you have presented you clearly need to take some more CE and stick to the easy cases. There are several problems but Ill point to one that could really hurt you in a court case.

    You said
    “No pus nor any exudate. She has been under taking antibiotics (clindamycin and metronidazole) for 10 days already. I do not think it is infection.”

    So basically there is no indicating factors for an infection yet you have the patient on a combo of Clindamycin and flagyl. HMMMMMMMMMM…..Ok well first off what are you basing that regimen on? Did you do a culture and sensitivity? Wait there was no pus so you couldnt of cultured. So why did you put the patient on Clindamycin and Flagyl???????????????????????? And if you didnt think there was an infection why put the patient on antibiotics at all.

    First off you should never put a patient on a combo like that. Clindamycin is bacteriostatic and Flagyl is bacteriocidal so they are counter acting each other. This clearing shows you dont understand the basics of treating a complications. Plus consult with your local internal medicine docs, they will tell you there is an epidemic of Clostridium difficile due to misuse of antibiotics.

    If you think my questions are harsh, these would be the same questions any peer review group or lawyer would ask you and you would be finished.

    You need to review the types of cases your doing, work with you local specialist to advance your knowledge and advance your case work as you get more educated.

    Good Luck.

  13. Insufficient information to clinch a diagnosis. A thorough systemic and localised history and localised examination is necessary. Site of implants, pain, swelling etc. is essential. Anything is possible from sarcoma to just a simple delayed hematoma…. and even a blocked salivary gland. Having said that, it is usually just something common and local like infection or denture trauma or part of the healing process since it is an immediate post extraction placement of implants. Maybe a loose screw on the fixture? We need to approach with a comprehensive overview, considering all the details before zeroing on the diagnosis. Thoroughness is essential

    Cheers

  14. To dr. Mehdi jafari:A metastatic malignancy would always appear on an x-ray as an ill defined lucent area, would rarely cause a swelling and are more commonly found in the mandible.This is either an inflammatory or a reactive process. I agree with other opinions about a possible allergic reaction(delayed hypersenstivity) if a membrane was used, An acute infection would not give any signs on the x-ray. Ask the patient to use warm saline mouth rinses/pack over the area and look for any signs of localization/pus oozing through the swelling.

  15. When it comes to think about a metastatic seeding of a far-sited malignancy, the most frequent localizations would be in maxilla.Sometimes, even a minor surgical intervention may lead to the deconstruction of the natural local defense infrastructures and make the micro- environment more optimal for malignant seeders to settle down and proliferate.The most common tumors that metastasize in oral cavity are breast and pulmonary cancer; even if in literature, several cases of oral metastasis from primitive hepatic, gastric, bone and sometimes colon-rectal neoplasies are reported. The sites of oral metastasis can be palatine tonsils, larynx, tongue, and most of all the hard palate.Moreover metastatic lesions in oral cavity could clinically mimic benign formations, such as fibromas, large cells granulomas or a periodontal abscess. However, local relapses and distant metastasis, may take a while to be quite visible or even diagnosed on ordinary radiographic images.

  16. will remove temporal prosthetic appliance,estimate the state of gum,it is possible overload which provokes traumatic inflammation and mikromovments in the area of implants. In bone D 3-D-4 physiological line of postoperative necrosis is more expressed,especially if buccal cortical plate is thin,collateral travmatic inflamation from mikromovments and residual infection from periapical sites do that they mast do. After few days-1 week if clinicaly reduce inflamation, change design of provisional restavration and take in place. Hope this will help you. Best regards

  17. Well as mainoralsurgeryman mentioned above,your antibiotics regimen is not an appropriate one.This case can be a superinfection because of misusage of antibiotics.It is a serious condition.

    This case can be an allergic reaction.Prosthetic material or liner are more likely to be responsible for this.

    Also this case can be a late inflammatory process,if you used corticosteroids for avoiding early swelling and inflammation.Corticosteroids can alter healing and can cause late inflammations like this.

    I hope second or third possibility had been ocurred.If it is a superinfection,you should refer your patient to a clinical microbiologist.

    Good Luck with your work…

  18. Too many unknowns in this case to answer but how about eliminating some of the unknows by: 1) another ct to rule out fenestration and adhesence 2) removal of the denture for few days 3) Peridex mouth rises few times a day 4) give it some more time for healing late inflammatory action is a possibility.

    Good luck

  19. Mainoralsurgeryman,
    u r the totally annoying guy that knows half and thinks he knows everything. Firstly and most importantly Metronidazole is the best choice ( Vancomycine is the second best ) for treating C. difficile. Secondly there is no need to culture before prescribin antibiotics if there is infection. Swelling under the nose is the first CLEAR sigin of infection. Just in the first cyttaric stage it doesnt yet give us pus.If the swelling gets worse u do a culture and change ur treatment.

    Be sure of yourselves before judjing others who admit their mistakes.

    Dear Dr . R DO NOT prescribe corticosteroids.Its the worst choice…u supress the immune system and do a lot of damage to bone remodelling. Stick to NSAIDS
    and better combine FLAGYL with amoxixillin plus clavulanic acid or Clarithromycin.

  20. Coxsakie, Bully for you! Taking time for a culture to yield results prior to placing a patient on the proper antibiotic tx is folly. You can always change the treatment. However, take the culture and gram stain specimen prior to starting antibiotics. Also culture aerobic and anaerobic. I to take cultures from time to time, but I get the specimen first.

  21. ok, let me get this straight.
    After taking out full or partial bony impacted wisdom teeth, oral surgeons place their patients on antibiotics( ALL the oral surgeons I know do ). Why? Because those teeth were infected? Im sure some had pericoronitis but why put patients on antibiotics on every case? I know about potential to introduce bacteria when flap is laid and all.Doesn’t cuture have to be done before prescribing those? My question is why are some people here giving hard time to Dr.R about prescribing the antibiotics? Sure, I think it was overkill to bring out combination regimen with Clinda and Flagyl. But when a patient walks into your office with noticable extra and intraoral swelling, do you tell that patine let’s do culture test first? or put on antibiotics for whatever the reason( medicolegal as one of them) you may have? MAinoralsurgeryguy and everyone else here, I like to ask you to consider, there are many different ways to reach the same result. When a patient has swelling under eye and on theceek, there will be a surgeon who want to drain the area right away and take out offending tooth or some others who will want the patient to go to hospital for check of cavernous sinus thrombosis. I observed this answer differs from even some of most well trained clinicians. Point is, if you don’t have an answer, let’s not blame the guy to be inexperianced? Does that question answer the question Dr.R is asking? It gets really frusrating from time to time reading some of the comments here specially like the harshly unproductive one. By the way, local interal medicine doctors might tell you there is rising numbers of case about C.Difficle but most over prescribed meds in united states right now is antidepressants and antibiotics. Do they culture everything before putting patients on antibiotics? DOn’t think so. Any tesy they do to find out if patient is depressed in scientific way? Nope. Think about it..

  22. To Coxsakie, I will be honest with you. I only culture about 1% of the time. Most physicians do not culture, when patients present to them with various infections. I use to be a microbiologist. I know the value of C&S, but I am not going to take 24 to 48 hours to yield results. Time is of essence! So in a word you are doing the correct thing.

  23. I am 57yrs old an stopped the fosamax for the implant.
    I had my implant 48hrs ago on my two last teeth on the bottom left. The swelling I have is huge and reaches to under my nose to include the left half of my lip.

    I am using ice and rinsing…my question is how much
    swelling is normal? This is over an 1 1/2″ petrusian.

    Please advise
    “worried”

  24. Dear Dr R,
    Permit me to make my observations -
    A 60 yr old pt who has had Immediate post extraction Implants done would heal rather slowly as one is expected to take into account the following facts

    (I AM PRESUMING AS ALL OTHERS HAVE SO FAR THAT YOU ARE DOING A FULL ARCH REHAB OF THE MAXILLA)

    1.Extractions and accompanying Inflammatory phase (Amler et al 1969)would result in an initial negative tissue response. Add to it the bone response to drilling (in a significantly more cortical bone with less Spongiosa – as in a 60yr old maxilla)it would add to the insult.

    2. If the canine Implant was placed in an extraction socket and the adjacent (Lateral and Premolar) areas were previously edentulous already, it is likely that the Canine alveolar ridge was protruding out of the confines of the arch of form in the residual Maxilla. Making it quite likely that the Implant in its most apical position was actually positioned with a portion of its apical threads out of the confines of bone or with a thin sliver of recipient bone around it at the time of insertion.
    (RADIOGRAPHS BEING 2-D WOULD NOT DISCLOSE THE PERFORATION OF THE BUCCAL CORTEX IN THE CANINE REGION)

    3)If you did manage to get a few MDIs like you mentioned, then you may have had situation as the MDI’s were probably inserted in the adjacent edentulous areas.
    As a result you probably were required to raise a considerable amount of soft tissue (both attached gingiva and alveolar mucosa) off its attachment during surgery.
    As Dr Hughes / Dr Moslemi and others pointed out (and you you have probably already noted) there is the possibility of the denture flange extending well into the Canine fossa region which would cause the swelling to be clinically contained within the precincts of the Central Incisor – Canine areas.
    So after the initial wound healing took place, the perforation in the Canine region (or even the Nasal floor if you had less vertical height there and did violate the floor inadvertently during Implant placement)starting playing up and began to manifest as a swelling in the localised region.
    5) I would however, strongly be inclined to believe that residual periodontal infections are one of the chief perpetrators of the “Early-delayed” swelling situations.
    They have a way of sprouting sometime after the aftermath of the surgery has settled down.

    Do we then discount the probabilities of Bisphosphonate therapy as Dr Emil Shiri points out, or Malignancies as Prof Jafari mentions ?As Dr Chow rightly says, it could be one of a gamut of causes which are usually considered the ‘RARE’ causes in literature (if you and the patient have been unlucky enough to have encountered them in this case !)
    Well, would be really good from the Medico-legal standpoint to have them be discounted off straigthaway with appropriate investigative modalities – A CT and some Lab work would do the trick I am sure).

    Having gotten these seemingly rare causes out of the way , you obviously would be wanting to get the swelling “Out-of-the-way” and get on with it !

    ANTIBIOTICS – ??
    I don’t know too many folks in my fraternity ( I am a practicing OMFSurgeon since 17 years) or outside who would see a clinically presenting swelling with no reasonable cause and think twice to prescribe antibiotics.
    We all do that I guess. The back up to rationalize the choice of Antibiotic therapy (which is usually empirical initially) would be the C&S result which would be a good 48 to 72 hrs later.
    In your case, the choice of CLINDAMYCIN + METROGYL seems justified, as the combination covers the the range of micriobota very well.
    Clindamycin is proven to be effective against Stretococci (from pyogenes to pneumoniae) including those which are usually resistant to Macrolides and some Quinolone derivatives . An Imidazole derivative such as Metrogyl as every dentist who has seen enough Odontogenic infections in the Head and neck region also is know is invaluable in quelling any microbiota suggestive of an Anaerobic infection. Although I must admit Antibiotic abuse is rampant, the line between Use and Abuse can at times get a little thin.

    PLAN ?
    I would follow the paths suggested by Drs Harpaz and Shamray.
    1)Relieve the region of the prosthesis for a while
    2)Get suitable investigations done to rule out the fringe possibilities (shud I say Impossibilities ?? )
    3)Raise flap if it gets bad, revisit the wound for a more accurate visual assessment – debride , irrigate if necessary clear devitalized tissue debris)
    4)Redraw the plan for provisionalization
    5) Perform second stage grafting if necessary after subsidence of the acute phase.
    Good luck doc
    Cheers
    Jeevan

    So,

  25. Go for a CT SCAN and pay the bill for it yourself. The faster you do it the quicker will be the diagnosis . Mostly it is buccal plate perforation and/or apical portion of your implant might be in soft tissue. In the two dimensional scan you will not get the exact position of imlant and condition of the bone.

  26. From the hip. I suspect perforation of buccal plate. I have seen swelling the size of half a golf ball under lip a week after implant placement. Placed pateint on antibiotics without success and removed implant at end of second week. Let heal a couple months. Took new i-CAT and replaced implant at different trajectory with sucess. I have seen this a couple of times.

  27. unless denture is way overextended rule out. penn vk is drug of choice so must be allergic.Don’t think culturing is useful as something else is going on. I am not a surgeon but my feelings on implants remain mixed. They are dangerous if things don’t go right even if everything done perfectly. if everything works out everything is great.I think that dentistry is getting a bit too high tech and major problems arising. The longterm outcome of these implants are not known as they are so new. 10 years ago a great deal of prostesis were coming lose from screws not working in about 405 of the cases. I don’t want to choke on an implant tooth.Certainly surgeons who only do this are the key. Too many drs. getting involved. I find when i restore an implant the surgeons are not that familiar with crown and bridge difficulties. I think conservative is prudent and hope the swelling described is from something easily resolved.

Comments are closed.