Dental Implants: Unpredictable Problems

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While practicing implant dentistry, no matter how careful we are in performing procedures, unpredictable events and problems occur.

A real life example: While performing a procedure, the assitant knocks the driver out of my hand and the patient thinks they swallowed the driver. Actually, the patient is sure they swallowed the driver. What would you do? Would you send the patient for a chest XRay? Would you wait for something else? Would it be appropriate to have the patient check their stool?

Another interesting simple problem, and yet difficult to deal with, is when a cover screw strips so you can not remove it with the appropriate driver. On occasion, I have had to use an ultrasonic tip to loosen a cover screw. I have also had to create a slot and use a regular screw driver.

Do you have an interesting problem to share? Let´s talk about some of these unpredictable situations that rear their ugly head and post some solutions (including how I can deal with the patient who may have swallowed the driver). Furthermore, what are some of the steps people may take to avoid these these small complications?

12 Comments on Dental Implants: Unpredictable Problems

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daniel c. samaniego
9/27/2005
with regards to the "swallowed driver", it is absolutely imperative that you do send the patient for a Gastro-intestinal x-ray series to verify the presence, or absence, of the hand diver. to fail to do it may expose you to unnecessary mitigating factors that will be to your detriment in case your patient decides to seek legal action if any problem arises due to this incident. from a complications standpoint, the risk of a gastro-intestinal perforation, and an ensuing abcess formation, is very real. and it only shows your real concern for your parient's welfare by doing the above.
Chia-MingLee
9/27/2005
I think you are right, I would send for both the GI survey and CXR, although I cannot see that the FB could go down the larynx that fast to bypass the gag and cough reflex center. We had a case in the school before and it is extremely difficult to convince the patients until they see the films for themselves. Another reason to make your assistants take the time to pass the floss through the holes in the driver as recommended. As for the cover screw issue, it is interesting because I wonder how the case is resolved since coverscrews are typically placed by the surgeon and it looks like it is now your responsibility. Hope you had good documentation and interesting how you dealt with the surgeon, unless you were the surgeon. LCM
alvaro ordonez
9/27/2005
We have had a few interesting "unexpected" situations, I remember a patient that wanted sedation for a sinus elevation procedure (we don't sedate patients in our office, only intraoral sedation), the surgeon called us a few month later and told me the patient was ready for the implants and that he had used a "super product" (I still wonder what that was, never told me), while doing the drill sequence, I felt it was super soft and felt something mushy on the buccal side (the flap was very small) we decided to look and noticed the graft material (super product)was coming out of the lateral window which actually never got to form bone, I had to finish placing the implants (thanks god I had the height) and went in to the mandible, got some bone and mixed it and placed it in the sinus area, with good results, it wasnt fun! The case has been stable for three years now (when referring a patient make sure you discuss what is going to be used, testing a product can have an impact in the results) Another one was a bar overdenture that got stuck 2 times, we cutted it the first time and had to re do it! the second time we were very carefull and happened again, the natural desire is to put force on it, DON'T DO IT, I already know of a case in litigation for implant fracture during an attempt to separate an overdenture that got stuck! anyway, the second time we decided to open an access hole in the lingual area and recover the overdenture and reline it with permission of the patient (he was nice to accept), I am more carefull now with my pick up and block out techniques, I spend a lot of time blocking out while picking the hader clips and always lubricate the areas.
Anon
9/28/2005
Hi - there is a generally accepted protocol for swallowing bridges and crowns which basically involves the patient checking stools for one to two weeks - if there is no discovery of the instrument, then the pt. should be sent for a GI series, to make sure the instrument hasn't lodged in a bowel fold.It is highly unlikely (as in nearly impossible) that an instrument this large could fall down the trachea w/o causing symptoms. One way to handle this is simply to inform the pt. and send them for a consultation w/ a gastroenterologist - let them make all further decisions. Among other things, it assures that correct x-ray study will be ordered.
russell
9/28/2005
Dr. Ordonez, Please note: the oral surgeon must have mixed the "super product" with Prp.
Marc Goldman
9/28/2005
I was once uncovering several implants in the mandible. I had the patient with bilateral mandibular blocks plus she was on Nitrous oxide. I was placing the healing abutment and it feel off the hex tool. I turned to get the college pliers off the bracket tray. My assistant and I looked down and in a matter of miliseconds, it disappeared. I pushed up the tongue and searched into the muco-buccal folds but it was no where. I took the nitrous off and pushed the patient's head forward. Nothing came out. Here is the kicker, the patient is a malpractice PLAINTIFF lawyer. I explained that a "little screw" had fallen into her mouth and she may have swallowed it or she may have aspirated it into her lung. Considering that she had no gag reflex, I was concerned. "Do me a favor and go to the hospital and get a chest x-ray. It's on me." She wasn't the least bit excited and asked if there was a "rush". I said in about a day or two would be fine. A couple days later the radiologist calls me, "I don't see any metallic object but I am concerned that the patient is a smoker and there are some spots on her lungs." The radiologist compared this chest x-ray to the one about a year ago and there were no changes. You would expect the patient to be upset for the inconvenince but she even thanked me for helping her stop smoking. So, yes have the patient get a chest x-ray and pay for it. Don't be a putz and tell the patient to have their insurance company pay.
Jeffrey Hoos
10/1/2005
I am wondering how often these things happen and we never openingly discuss them. Of course the floss idea is a good one. The use of a throat pack is the best one for managing the cover screw problem. Complications are alwayed managed by prevention.
Dr.Ejaz Khawer khawaja
10/3/2005
it is absolutely imperative that you do send the patient for a Gastro-intestinal x-ray series to verify the presence.
Dr Marielle Pariseau
10/4/2005
I use what I call a safety net: an unfolded 2x2 gauze that I simply drape directly behind the most posterior implant fixture creating a safety net in front of the pharynx. This way, anything that comes loose falls into the gauze and is easily retrieved. Since I doubt very much that the healing abutment was aspirated, I don't see the need for any chest x-ray. However, I would refer this patient to a gastroenterologist.
sue smith
11/13/2007
has anyone heard about something foreign floating around sinus after implant surgery. all x rays are showing a white mass, we think it is something other than implant. patient needs surgery to remove.
satish joshi
11/13/2007
Why do you think it is foreign? Did you loose any part during surgery? Why it is floating? Does it change position in different angles in X rays?Or does patient feel it? Why don't you just advise CT scan? Wouldn't it be easier to identify and locate that white mass with CT scan and then decide for surgery? Just a thought.
sue smith
11/14/2007
patient is scheduled for surgery. dentist claims it has nothing to do with his work. 4 implants, 2 removed, 3 extractions, and 1 more placed. plastic temps with only the above as far as teeth in the upper. a lot of trauma with bruxism and tmj, with only implants to support one connected bridge. ct has been done. white shape has caused inflammation and sinus infection. patient has swollen cheek.white object is constant and not moving. 2 dentists and 2 ent dr. have no idea as to the origin. do you think it is dental related? was not there before surgery.