Paresthesia After Implant Placement: What Should I Do?

Possibly should have removed both implants the next day if any parasthesia was present as better safe than sorry . Now best call your dental defence lawyer and discuss the case , when you refer to a IDN injury specialist they will paint a poor prognosis for your patient so be prepared. I always tell all patients with mandibular placement even if 3 or 4 mm from the IDN to call me immediately if the sensation in the lower lip area is affected 5 hours after surgery as pressure can be the issue . Have heard it said by an IDN injury specialist that if the there is excessive bleeding in the lower molar osteotomies htat you should not place !

Did you block the IA nerve during placement? I had similar case, removed implants the next day, placed patient on steroids, patient regained sensation and I came back six weeks and placed with no problem. Now I ONLY use infiltration anesthesia when placing my implants. Havent had any problems doing it this way.

When did the paraesthesia commence? If it occurred immediately after surgery, the prognosis certainly isn't good. If it occurred some time after, then it is better. It's now 2 months + after the event so there is no real point in going in and removing the implants. You'll probably make it worse now that they are integrating.Furthermore the patient is better off with a numb lip and implants, than having been through the whole experience and then having to have the implants removed-they will be doubly p...ed off! If the nerve damage is from pressure following surgery and the nerve hasn't been severed then there is a pretty good chance that recovery will occur, although it make take many months.The fact that she has some sensation is positive, so I would be giving encouraging advice to the patient and leave the implants in situ. I agree with Dr C about using infiltration for posterior mandibular implants. If you use infiltration and you get near the mandibular nerve, the patient usually will let you know. It's not guaranteed but it's better than having nil feedback as when a block is used.

2 months post op is a long time. Is the paresthesia improving or staying the same? Is there radiographic evidence of impingement on the canal by either the fixture or the drill? Remember due to the rake angle of the drill bit, you are preparing a depth of at least 1 mm more, particularily as you get into larger diameter drills. At this point your fixture are integrated so you do not have many options. If this occurs immediately post op I'd verify if the canal was violated. If not, could consider course of steroids, but need to map out the area of paresthesia and critically determine if improving. If not improving quickly, then removal of the fixture is probaly the best course. I personally do not subscribe to the theory of not giving a block and seeing if the patient responds to pain. You can still get diffusion through the bone. Careful case workup is more likely to reduce this risk. As the other post noted, pressure can cause paresthesia and also need to consider acute infection if it shows up 3-5 day postop (and again treat aggressively with high consideration for removal of the fixture vs. just backing it up)

This is the problem..."what should I do?". I have no problem with people doing procedures but when there is a lack of knowledge to properly treat complications it becomes a huge liability! This should have been asked immediately when the parathesia commenced. Referral should have already been started (especially since it was known immediately after as the implant was "rotated a full 360 degrees). This pretty much a defenseless situation.

Get a good lawyer or pray that the person does not sue. Not much you can do at this point as it is too late. It should have been dealt with at the time of paresthesia. Good luck, I think you may need it as you will be held to the standard of a periodontist or OMFS on this one for their training and I think you will be in trouble.

dr k, i personaly think theres no problem in removing the implant.as the patient complains of numbness after 2mnths means its placed on the mandibular canal or in a very close vicinity to it, better to refer to a oral surgeon to remove it if u r not confident about it, any to remove implant in the 2nd mnth is not a problem as the bone is still remoulding in implant can be easily unwinded,the fact there is numbness suggest the nerve is injured ,but it will heal (regenerate) eventually after removal of the implant and few doses of steroids for a period of time , and yes never do implant srgries under a block. and dont worry u have not done with the intention to hurt or damage someones life it happens by the best of the surgeons ,have faith and do the right steps ,act immediately

It's seems that the paraesthesia happened immediately after you put the implant. Well the implant should have been immediately removed. You will never know if it was , from drilling, or only when the implant was inserted , or maybe if block given,rarely, from needle trauma, or even more rarely from L.A solution.

Dear Dr K, This is a case of nerve injury where timing is of vital importance. The implants should have been removed at the first indication of continued numbness after implantation. The nerve injury will rapidly heal provided it is not a neurometsis, i.e. a complete severance of the nerve. But the opportunity was missed and now after 2 months, the patient presents with parasthesia and the increasing of "funny feeling" on the site. With such a history and current presentation, the best course seems to be to wait and pray for the nerve to recover. Since there is this feeling coming on, it is a good sign of recovery. However, nerve injuries and its healing are notoriously difficult to predict. The suggestions to be prepared to face legal action is good. It is always good to confront the worst case scenario and to be prepared. Well and good if no legal action results..... and it will have been a telling and useful learning exercise that will also convince us deeply not to repeat such a mistake again. Thank you for sharing the case with us and all the best in your successful management of a difficult situation.

Dear Dr.K I think first you should take a radiography (OPG-PA)and if it shows any proximity to the inferior alveolar nerve the gold standard is (cone beam CT)to visualize nerve damage exactly.You have done your best to unscrew 360 degree but without any documents about impingment of your implant or drilling injuries .This condition may happen in nerve damage by needle during block anesthesia that it may have a recovery time more than 6 months.She has paresthesia it may indicate a neuropraxia or axenothemesis But be sure not a neurothemesis. It can evaluate by two point disremination and other kinds of nerve damage tests.In the case of nerve damage using of dexametazone and corticoesteroid are recommended and in my experience it is extremly useful.I personally agree with Dr.Vishal and also I appreciate him to support you.Don't worry it may happen during surgeries for any great sugeons, we should be honest to all of our patients at any situation. Best Regards Dr.Ali Hossein Mesgarzadeh Tabriz oral and maxillofacial surgery department Tabriz / Iran

If you are placing implants and you don't know how to manage nerve injuries you are commiting malpractice. Your situation is non-defendable, regardless of what the outcome is. Luckily, the human body is pretty resilient. Always, when in doubt, or faced with a situation you are unsure of, REFER!! Failure to diagnose and failure to refer are the biggest problems here. The act itself is defendable, nerve injuries happen. It's part of surgery. It's what you do afterwards that counts.

sb oms, point really well made.

Please refer to an article written by Misch CE,Resnik R. Mandibular Nerve Neurosensory Impairment After Dental Implant Surgery: Management and Protocol. Implant Dentistry. 2010;19:378-384. I think you will find your questions answered in this article as it describes different nerve injuries and the protocols regarding the course of action to take. I think the best protection against IAN injuries is the diagnosis enhanced by the use of tomograms and the selection of an implant size(lenthgwise) that ensures that no risk of injury is allowed. I believe the use of tomograms in implant dentistry to be the standard of care and would likely be your best protection should a legal complaint arises. Hopefully your patient will fully recover and good luck.

If an implant is potentially violating the canal, its depth should be decreased in bone and left short of the canal or removed. Since the altered sensation may be due to an inflammatory reaction, a course of steroid treatment or a high dose of non-steroidal anti-inflammatory medication (such as ibuprofen [400 milligrams] three times per day) should be prescribed for three weeks. If improvement is noted at three weeks based on a repeated neurosensory examination, the clinician can prescribe an additional three weeks of anti-inflammatory drug treatment. If, however, sensation has not improved by two months, the prognosis will be poor, and I recommend referral to a microneurosurgeon. If the clinician notes improvement at two months, he or she should re-examine the patient at three and four months after the injury occurred. If the patient’s nerve function has not returned to the baseline level by four months, again, I recommend referral to a microneurosurgeon. The need for repair before Wallerian degeneration of the distal portion of the inferior alveolar nerve has occurred is vehimently emphasized. Since this degeneration is a slow process, repair can be possible four to six months after the injury.

remove the implant first and place new implant wider in diameter and short in length .do all this after one week.

I have a patient with paresthesia after only drilling the osteotomy site. I did not manage to get primary stability in region of #29 [mandinular right second premolar; 45], just distally from the mental foramen. On post-oerativep CBVT scan [cone beam volumetric tomographic scan] the osteotomy site does not contact the mandibular canal. There was some bleeding during drilling, and the patient reported some pain during the drilling. Three weeks have passed since the operation, and there is some numbness in the lower lip right and lower right chin . Is there a chance that sensation will normalize? Do I need to prescribe some steroids right now? If yes, which dosage I should use?

drm: refer to the article by Misch et al as described on my previous comment. You'll find the answers there

drm, You bagged the nerve. Do the steroid and vit b13 and niacin thing.

Dear Dr.K, I have reviewed all the suggestion posted and best advice is given by Dr.Mehdi Jafari.I would differ with him by increasing Ibuprofen 800mg three times for two weeks then 600mg for two more weeks.I would include physiotherapy also. Do not get scarred by the Halloween Doctors.Things happen even in the best circumstances.

Stop doing implant or any other surgery unless you pursue proper traiing.

Dear Dr. K: the comments here are in fact a composite of how the dental community will feel. They are only "opinions" as is mine. First: did the patient sign an informed consent that possible and permanent numbness can occur? Second: do you have a treatment plan documented that shows you had a scientific approach to the surgery ie: Px using 5mm marker ball for calibration, PAs, hopefully CBCT, mounted casts with markings of sites, expected width and lengths of implants, diagnostic wax up and surgical stent/guide?. Third: surgically, did you start off with progress xrays of the surgical depth/directional marker, did you probe the osteotomy and doument that there was or was not a perforation (stop) at the apex? Torque of implant/quality of bone all need documenting even if not pertinent to the numbness. If all these things are documented you should feel better because it will support your case. Things happen, its just that if there is no scientific trail then the case will go against you. I tell new implant dentists, it is the single implant that will cause the most trouble: get a CT , the cost of $300 at this point in time will never be an issue but we make it an issue before the case starts. I can sympathize with how you may feel, I have had this happen. The reality of numbness IS significant and can ruin your attitude for a long time depending on the reaction of the patient. Some patients will take this to the limit and others will understand. Say to them: did you read that part on numbness, how do you feel about that? Good Luck

dear DR K, whats happened does not leave you wit any option well i would suggest u mandibular nerve repostioning will do the trick as when the implant doesnt move we ll move the nerve. with proper care and a good consultant it could be taken care of.... i would love to hear from you..

I realize at this point, it is too late to answer the question for Dr. K, but I feel my two cents is necessary. First off, just because she has a "funny feeling" DOES not necessarily mean that it's a good sign. It could be, yes. But it could also be dysesthesia, which would not be such a great sign. Second, on the decision to instruct your patient to more or less overdose on NSAIDs, it is not one that I personally would be comfortable with. A short, low dose course of prednisilone would be for better tolerated, more effective, and has less potential to cause devastation to the GI tract if only used for a short time. If the goal is to reduce inflammation, which I assume it is, to reduce possible compression of the nerve, the corticosteroids will do a far better job. You might also consider CBCT if there is any question that the nerve has been injured. It may seem a bit excessive, but the cost is far less than paying for legal defense. More important, it is minuscule compared to the cost paid by your patient, not only financially, but also in reduction of quality of life. As to your question of what you should be doing at this point? I will say it as politely as possible. Number one, REFER. Better late than never does NOT apply here. If you are uncomfortable or unsure of what to do or what is causing this, refer to someone who can help. It is not a sign of weakness, it is a sign of strength to be able to admit that you do not know. A patient deserves to be treated by someone who knows what to look for and how to treat it. If I were this patient, I would far prefer a referral and honest "I don't know" than to be used as a guinea pig. And please, to any of you out there, if you don't have the knowledge or experience to be placing implants, including the complications that can arise in the practice, don't put a patient through the unnecessary pain and possibly permanent suffering. It is never too late to admit that you don't know everything and refer. Any patient with complications will thank you for this. Wasting too much time deciding can lead to permanent nerve damage, if the nerve is in fact damaged. Please do provide an update. A few of us are curious to know what the outcome was.

dear dr k, i completely agree with dr vishal.and advise for some stop acting superhuman we all commit mistakes