Patient Complains of Numbness after Implant Surgery with Graft: Is this a Complication from the Graft Material?

Impossible to be the graft material as it is completely bio-compatible and no where near the IDN , pressure from the implants more likely , how long ago were they placed if recently can un-screw the implant ( even a mm) in the second premolar area ASAP.

PLot numb area on chin take photos and note if its fine or brush parasthesia - take a PA measure end of implant / osteotomy to mental foramen - if you have come within 2mm of it - remove the implant - otherwise wait things tend to get better if its haematoma above the mental foramen. The ID nerve turns up through the mandible to the mental formen about 2mm superior to the IDB canal at the point of on laws of average the lower second premolar - therefore usually if implants are placed beyond the apex of the lower 2nd premolar u can get parasthesia of the lip. My advice if you didnt take a CT scan - or measure correctly prior to placement remove the implant !! give low dose steroids and hope for the best - good luck - ps its happened to most implantologists in their practicing careers - we just have to manage the situation and patient with care and explain why this has happened carefully.

obviously the second premolar has cut through the anterior loop of Henley. Unscrew the second implant a bit. Add steroids to prescriptions and start praying.

This is a general comment, which I am sure most out there understand. Numbness will occure with nerve insult of any kind. This can arise from the local anesthesia, osteotomy, laying the flap in certain locations, incision not long enough, anything touching the nerve that may be irritation to said nerve. So it's not always the implant.

agree with all the above comments. P:S- dear sdj could you pls enlighten me on the loop of Henley you mention? The loop of Henley / Ansa Nephroni Is a unit of the kidney !! Is there something I'm missing?

It's' Loop of Henle' and is part of the Renal System!

I beg of you. Please go get some more hands on education. It would appear you don't know what you don't know.

Dr. A should not be too harsh with himself.CT scans are not done routinely with placement of every implant...excessive radiation....unless there was reason to suspect something in the irregular in the anatomy of the region before surgery.He sounds responsible and was careful I believe. In 14% of the population there is an anterior loop of the mental foramen which cannot be picked up in conventional radiographs, and can be nicked...this does not mean it has to be a lifetime of paresthesia..nerve damage takes time to repair. What Dr. A did not specify when the patient returned and is whether the paresthesia occurred immediately after the surgery... so that the lower lip on the side of the surgery never "awoke" or did it occur after the freezing wore off.If the numbness occured after the anaesthetic completely wore off, it could be because of an inflamation in the manibular canal or inflamation in the area around the anterior loop...in which case, with time the nerve will come around. Pins and needles, burning, and itching sensations are indications that the nerve is coming around.... and what about the chin....is it also numb ( not specified) Mapping out the numb region with a sharp explorer on the skin and/or lip and recorded with a felt pen, and then photographed ...and repeated every few weeks to see if the area is getting smaller is a good idea and will give encouragement to the dentist and the patient. The grafting material was added to the top of the implants, and should not be a consideration. Usually when there is nerve damage because of the insult to the nerve exiting the mandibular canal, the chin is affected as well....... I have another thought, in that since he only mentions the lower lip and not the chin, there is a possibility that the patient damaged herself by biting the lip while under the local anaesthetic......this is why I ask when did the paresthesia take place... whole different ball game!! Gerald Rudick Montreal Assoc. Fellow AAID Fellow & Diplomate ICOI

Could be one of several issues. Some of what is posted above is just plain wrong, sorry. 1)It could be the local anesthetic injection. Did you give a mandibular block or mental block with Septocaine? Septocaine is notorious for causing long lasting (sometimes permanent) nerve injury (especially of the lingual nerve) when used in this fashion. If you didn't use Septocaine, you might have nicked the mandibular nerve, or the artery (causing pressure on the nerve from a hematoma) or the injury could have been caused by fluid pressure from the anesthetic itself if you injected too fast. In any case I recommend placing the patient on a Medrol dosepak, with regular followups to see if it resolves. This cause can be presumed if all other causes are ruled out first. 2) It absolutely could be caused by migration of the particulate graft material into the nerve sheath, whether it is biocompatible or not is irrelevant. Whether this should be suspected as the cause or not only you know, as you can recall the technical aspects of the surgery. In the future, I'd recommend using one of the paste type products, such as DynaBlast paste from Keystone Dental, as an example. If you have any doubt, I'd take the graft out. When I want to graft, and I'm near the mental foramen, I will always put some kind of barrier (usually a collagen plug) between the nerve and my graft bed. 3) I have seen perfectly well placed implants (usually those with more aggressive thread patterns) create fluid pressure within the marrow space which compresses the nerve and creates temporary paresthesia which typically resolves by the time the implant is ready to be restored. Again, I treat these with a Medrol dosepak. 4) Less commonly will it be the actual implant position. Of course, you'll need to determine this by looking at the post placement radiographs. If it's close, or you're not sure, get a cone beam CT. I don't generally recommend removing the implant, unless you are certain that you're compressing the nerve badly. The reason for this is that if you have indeed physically traumatized the nerve (say with a drill bit), and then you remove the implant, now you've created a void superiorly that a neuroma can expand into. Neuromas can create perplexing and disturbing and painful symptoms for a patient that are far worse than a simple paresthesia. If you are really uncertain as to what to do after reading the above, always consider referring the patient to specialist for a second opinion and/or treatment. Remember, what gets you into trouble is not causing a complication, but failing to properly manage a complication after you are aware that it has arisen. You will be held to the standard of care that a specialist would deliver; you can stave off a lot of personal hand wringing and grief by referring patients out early, which the complication may still be reversible. Good luck, let us know how this case turns out.

Did you score the flap in order to get primary closure? Nerve injury can occur from this also. On the other hand, temporary numbness can result from manipulating the nerve (as in surgically isolating and protecting the nerve during surgery), but feeling comes back within 2 weeks. Good luck.

Get an CBVT scan to see where the implant is relative to the IAN.

Dear Dr. Numbness always may happen special after sugery around the sensory nerves,but the important points the it need to have a consideration : 1/ was there a traumatic surgery 2/ pressure of the retractor during surgery by you or dental assistant may be main cause 3 /dislocation of graft materials around the mental nerve 4/ trauma by implant fixture if there is some proximity 5/ trauma by dental needle during anesthesia that it may happen even during dental extraction or dental procedures Recommendation :A/ take a preapical radiography or cone beam CT to reassure about perforation of nerve or pressure by it B/If you can not find a logical cause please wait and see and in recall sessions you should check the nerve sensation by two point discrimination and other test and i point you to reveiw of fonseca oral and maxillo facial surgery text book or peterson oral and maxillofacial surgery text book( chapter of neurosensry disorders -neuropraxia and axenothmesis )and it's tests C/ if it happened 1 or 2 weeks after surgery and you cannot find a logical cause it is a good idea to use dexametasone for a short times and NSADI for a week. Best Regards Dr.Mesgarzadeh DDS- MS- OMFS Tabriz /Iran

I seriously cannot believe some of these questions. Get some education people!

Paul: I have to agree with you!

paul, you feel my pain!!

I agree with most of the above assessments, but ESPECIALLY with the last 3! THIS is the issue with a lack of regulation and strict standard of care in implant placement. I personally have NO problem with any practitioner that has an interest getting the proper education and training. IF you are going to be placing implants, however, you have the responsibility to know the complications of the procedures you are undertaking, the differential diagnosis of those complications to treat your patients accordingly, and the training and ability to be able to manage them. THIS is the kind of issue, that unmanaged, will give implants in general a bad name and poor perception to the public.

I, think that if we could do surgeries with our egos like some surgeons do....we'll all be Einstains!!!!

jg...nevermind

There is a right way and a wrong way to criticize. I believe these pleople leaving hard comments need to step back and remember when they were starting and did not know it all. Forums like this are a great place to learn by your own mistakes and those of others, and we have all made many. I believe you can be critical and encourage individuals to increase their knowledge in a nice manner. If you cannot do that, and your comments are derrogatory, they contribute nothing good.

It's a tough call of criticism. I did 5 yrs of residency and messed up lots of times and lots of patients. Am I better for it now? Of course. Those that roll their eyes at other people trying implants need to remember they too messed up lots of patients in their residency. Was it any better that you messed them up as a "resident"? They're still patients and people. On the other hand, when you "practice" procedures in an academic center you have the advantage of backup and others' skills and experience from which to call. I have had to bail resident myself now out of floor of mouth hematomas, sinus perfs, nerve involvement, bony fracture, bla bla bla ... The problem with facing these complications for the first time in practice is a) lack of immediate/delayed help, b) unwillingness/unable to get help. This leaves the patient in a vacuum of possible inadequate treatment which is dangerous. I think when contemplating the more advanced procedures like encroaching on nerves, sinuses it is important to ask yourself first: "what's my fall back?". Do I have an experienced colleague who can bail me out? Does the patient know what they're getting into? Have I been honest with them and myself about my experience? When a patient is treated in the dental school/teaching hospital they know or are made to know that the 3rd year resident is a relative noobie at some procedures? How do they know? By the the attending hovering over them... At least the patient knows what they are in for. I worry somewhat about the patient who is lulled into believing the person about to do a sinus lift like it's old hat has really only done it on paper. This is not fair to the patient or to the profession.

I find this particular forum, fascinating! A candid, unrehearsed portrayal of human nature... It is touching to know that in times of trouble, when one is uncertain, there would be people, practically strangers who would stand behind you, support and encourage you, through it.There still may be hope for humanity, afterall. On the other hand, one has to learn to handle criticisms, good or bad.They will always be part of life, stepping-stones to improve oneself. It is comforting to realize that I would find mentors, and friends who would be willing to be there with me when it's my turn to be concerned and uncertain... Thank you

I must second Dr. Colbys' comments. This is a fabulous forum with very few unsensitive responses. Dr. A don't overthink this. You placed an implant in the second bi area and it is very likely that the implant is causing the paresthesia. During the second to fourth week after placement it will unscrew with less torque than it was placed with. If a c-scan, and it is time to take one, reveals that it is actually in the mental foramen remove it. If it is less than 6 mm anterior to the mental foramen but apical to it by more than a mm or two, back it out a couple of threads. As this is a tapered implant watch your torque. If you back it out a couple of threads and have less than 15 ncm remove it. Do not graft. Go back in two months and place another implant. Next time only use infiltration on lower implants distal to the cuspid. I have a c-scan in the office and even with the detail it offers I never block the lower arch for posterior implants unless I feel compelled to do an immediate implant and It tkes a lot to compel me to do that. Good Luck