Implant may have perforated lingual cortical plate: options?

Hi Everyone, A colleague here is asking for help. Comments like "you should have stopped and not place an implant" or "mouth opening is a relative contraindication", is not helpful. If you have all placed implants perfectly without ever having a complication then congratulations - you have my vote for sainthood. If not then why don't we give our colleague, who has entrusted this forum, left his ego at the door, asking for expertise and mentorship of his fellows, something meaningful to work with? The purpose of the forum is to troubleshoot and not be a sitting duck for legal wannabes. In my years of being a moderator of groups of people, including dentists, the etiquette is never to say "you" but instead say"if it were me this is what I would do" or "If I may offer this I would approach it this way...". In the end its all about respecting the other individual in any dialogue, and bedside manners, whether in the clinic or on a forum is, with all due respect, appreciated under all circumstances. Thank you. As for a solution, I am still thinking about a meaningful reply as I have not had this experience before.

Sometimes it is difficult to give advice when having to weigh ones words and be concerned about how the advice will be taken and whether or not the persons feelings will be hurt. If the individual does not like the answer then perhaps the question should not be posed. Based on the information given here, limited opening,20 degree distal tilt, copious bleeding, possible lingual perforation and 20% the case is going south for many reasons and the operator is not seeing that. Now I see a post on how my comments should be more considerate. Quite frankly over the year and a half I have been reading this blog I am shocked at how many times the same errors are being posted and how it us okay to be learning on patients. There are many people out there placing implants who are not adequately trained and are getting into trouble but this seems to be okay also. Often extraneous material gets mentioned about how another person would also make a mistake as this which I don't see how that has anything to do with this set of facts. Then I see defensive reactions about how we should be kind to each other. Honest advice by someone who knows what they are doing I feel is much more helpful then a feelings check and being politically correct. Giving the hard advice and educating seems to be frowned upon. The bottom line is that these complications are becoming more common in the literature as more poorly trained people are placing implants, so keep taking the courses, buying the gadgets and posting the close calls. It's okay as long as I don't hurt the doctors feelings and don't educate anyone especially if it keeps them from harming a patient. So let's just keep patting ourselves on the back even when a doctor is venturing into trouble it's okay no one is perfect! If one wants to truly be a surgeon then hard criticism needs to be heard and learned from. So I guess one has to learn the hard way unfortunately for the trusting patient. Fools ignore sage advice. Good luck you will most likely hear very little from me in the future since my honest advice is not appreciated and I get a lecture about his it us given so logically the value us being missed.

Dear John, I would be very careful in case selection and only do straight forward cases with a lot of bone. Work closely with a trusted colleague on more complex cases. This is probably not worth the thrill of playing surgeon. More time could be wisely spent on treatment planning and restoring these cases. It will also be more profitable for your practice unless you are charging extra for all the post op visits and complications. One big mistake or lawsuit will ruin your practice. It is not easy placing implants but well placed implants are easy and profitable to restore, everybody including the patient wins. I do hear your sincerity and conscience. Good Luck I hope you take my advice and benefit from it, good luck.

Lots of tough love in the above. John gets props for posting and good follow-up. CRS tells it like it is, but nobody is born knowing all this stuff. I perfed two out of 6 posterior mandibular implants on my first case in 1989. Fortune smiled and restoration was uneventful. Consider a simple "periapical" radiograph for diagnosis of perf (you can't always get a CBVT image). If you see a "periapical" (deep end of the implant) radiolucency that looks like an abcess around a tooth, then you perfed the plate. I've seen many perfed cases over the years (including mine, as I said) and no restorative problems, so don't be too quick to throw in the towel on the reconstruction just because you have a small perf. John - you are keeping your eyes open, and as a result you have a bright future. Keep posting and don't lose any stomach lining over what you read here - we all take a beating now and then and in the long run it is good for us - there really is no other way to learn (someone will disagree, but that is my experience).

Thank you so much for your advice, CRS. I do value your opinion, and it's good to remember that it's Ok to say "no" to certain cases too.

You are very welcome. I think the most critical part is the restoration and I respect your restorative skills. It truly is restoratively driven surgery, we can help each other!

Hi George, Thank you so much for your advice and for sharing your experience. Hopefully with more experience, something like this will not happen again. It's a good "scare" for me actually so I will be more careful in the future. Again, just really thankful there was no actual perf....