Numbness and Nerve Injuries after Implant Placement?
I placed 4 implants in a fully edentulous mandibular arch in sites 46, 43, 33, 36 on 18 oct 2019. During the implant osteotomy at site 36, there likely was less dense bone surrounding the superior roof of the IAN canal. The implant sank in 3mm subcrestal. The next day post op I called patient for review and was informed about numbness and heaviness on lower left lip and chin, limited to extraoral region only.
Around 28 hours post op from the first surgery, I removed the Nobel Active fixture 4.3x 10mm RP and replaced with Nobel Active 5mm x 8.5mm RP with GBR. 6 hours post op I also prescribed prednisolone, Neurobion and ibuprofen for the patient after the nerve injury. After the second surgery, I called the patient for post op review. Patient told me that she can feel the lower left lip almost completely now. But still feeling numbness and heaviness on lower left chin. What do you think of the chance of nerve injuries and usually how long it takes for recovery?
31 Comments on Numbness and Nerve Injuries after Implant Placement?
New comments are currently closed for this post.
Neil Zachs
10/29/2019
Hi...your question is super hard to answer as nerve injuries are all so incredibly unpredictable. This patient obviously has an injury of some sort to the mental nerve or a branch off of this. How long and if this is permanent depends on so many factors. Did you just traumatize the nerve or was there permanent damage...time will tell. It can take up to a year to gain full sensation back if it comes back at all. Not a bad idea to refer to a really good OMFS for assessment. They will probably want to give it some time...but there is a window that is crucial if nerve grafting is recommended. This is a tough one cause how these play out can be so different. My hope for you is that this was just a pressure injury from the implant sinking and the nerve just needs time to heal. Best of luck
Neil Zachs
Periodontist, Scottsdale AZ
Dr Bruce
10/29/2019
Howdy Neil, excuse my ignorance, how common is nerve graft repairs in your view? https://www.ncbi.nlm.nih.gov/m/pubmed/26059454/?i=6&from=/21705245/related Obviously Lit Rev are not real world experiences... just curious, thx
Dr. Neil Zachs
12/10/2019
Hi! so sorry I didn't see your question. Not really common. Few do them. There is an MD, DMD (OMFS) in my area that does them. The problem has to be caught at the right time and NOT too far post nerve injury. Obviously, like this case, most resolve on there own after time since most are caused by stretching the nerve or pressure on it. I really think the grafting situation comes into play when the nerve has been severely traumatized.
Carlos Boudet, DDS DICOI
10/29/2019
If you are not going to refer the patient to an experienced surgeon, then you need to become familiar with the whole process involved in the evaluation and treatment of these complications. Have you done any mapping of the affected area so you can compare and evaluate any changes? Here is a protocol for the evaluation (PDF File link). I may not be the most current, but it is a start.
Consider referring to an experienced surgeon.
Carlos Boudet, DDS DICOI
10/29/2019
Correction: "It" may not be...
purpleaquarius
10/29/2019
thank you for sharing the document. it is helpful. I have been calling patient every alternate day to check on patient. today she mentioned she feels less heaviness. tomorrow will be seeing her for post op review. hope for more improvement on her nerve recovery.
Crisantos G
7/30/2020
Hello Carlos Boudet
I can´t find the pdf link
Thank you
DreamDDS
10/29/2019
Both responses are very good. Thank You Dr. Boudet for the nerve injury protocol.
I am assuming that the osteotomy drill was controlled and did not go down to depth shown and that it was only on implant placement pressure that the implant went down further? Good CT follow up. It is unpredictable but my feeling is the numbness/paresthesia will go away and may be weeks to months. The symptoms may not even be from the implant in question. Many times I have had paresthesia with the full arch bone and implant surgery and I have not entered any zone of concern. An appropriate highly reflected flap that identifies the mental nerve and foreman can cause what you are describing. Usually one month and feeling is back to normal. You have done what you can. The more experience with surgery, the more confident you can guide the patient. Consent forms always contain the language needed for this.
Sincerely
Leonard
Paul
10/29/2019
There is a lesson to be learned. Don't mean to editorialize but dentistry is a whole is guilty to allow any and every dentist (the day after graduating from dental school) to place implants. Nobody needs to explain that and other shortcomings in dental education and the governing laws. Liability insurance and the legal system are not the cure for errors or lack of training a dentist. We owe the public a responsible approach to dental care without risks coming from inadequate education and lack of protective laws. The theory of a sinking implant does not stick well as a defense. Sooner or later this will become an issue on a big scale.
DrT
10/29/2019
Good info...Lip paresthesia seems to be almost a common report by most patients
who have had AO4 therapy
Doc B
10/29/2019
I don’t think that referring to another “experienced surgeon” at this point is the answer. You have done everything and maybe more than an OMFS would do by now. Your removal of the implant and replacement with a shorter fixture and GBR is a great start. I think that the improvements in symptoms already suggest a repairing injury. This will continue to be a slow process as the feeling returns and it is often accompanied by an occasional stinging or burning sensation as the nerve tries to rejuvenate The best thing you can do is to prepare the patient for the worst but expect the best. There may be some residual tingling or partial numbness in the chin even after a year. Document the area by position , size, and degree of pain perception. This does not need to be done weekly but as time passes the recalls will be further apart because the change in symptoms will not be as rapid as the first three or four weeks. This is not a big failure on your part and you are to be commended on your rapid response These things happen in flap surgery, 3rd molars , and implants regardless of experience level of the surgeons. Nearly 40 years of experience has not made me immune to problems but has given me a little understanding of this complex problem Had the patient not responded to your remedial treatment as fast as he or she did then I would be more concerned. Just relax a little and let the healing take its course. We need more dentists like you that actively respond to problems with knowledgeable treatments rather than throwing their hands in the air and not taking responsibility. Hang in there
purpleaquarius
10/30/2019
Thank you Dr for being encourging.
Dok
10/29/2019
Since you cannot see exactly what happened, you don't know what happened exactly. The patient should understand this. In this case, probability suggests that an implant that approximated the nerve somehow affected it. Probability that the nerve will "heal itself" is an unknown. Nerve tissue by its nature doesn't heal well because it was not designed to do so in humans. These are risks that surgery presents and that patients should fully understand BEFORE the surgery.
DrA
10/30/2019
Hi, I was wondering if someone could share information on how does this situation presents . Does it occurs because implant was inserted with motor and by accident it went too far upon insertion or simply with hand pressure upon torquing healing abutment down or even implant. How often does this situation presents on the lower arch when taper implant is displaced downward on the lower arch. Thank you
Cpkw
10/29/2019
What is going on in our industry ?
Is this really the standard we hold ourselves to ?
Clearly inadequate training is seen by this case
The other implants and grafting appear very poorly done
If implants are to be used to improve the quality of life then they must be done properly
If we do not start doing things to a much higher standard the lawyers will take us on for sure
I suggest you refer to adequately trained OMS to take care and of this patient ASAP
Neil Zachs
10/29/2019
Whoa....take it easy. I am a board certified periodontist and have been in practice for almost 30 years. And have done well over 12,000 implants. Although I do feel as if surgery should be done by surgical specialists...that is not the reality of the world we live in. We all make mistakes. I most definitely still do...and I learn from them. Maybe an issue like this will make this practitioner think twice about taking on a case of this magnitude. But he should be commended for coming to this forum and asking for help.
Dr Mahendra Bagur. BDS MD
10/29/2019
Agreed... Mistakes do happen.. rectify and move forward....
and ..Thanks Mr Boudet for the Protocol document...
Paul
10/29/2019
To Cpkw
I agree with most of your comment but when you say "adequately" trained OMS, I have some objections. Nobody has a crystal ball to know who is the adequately trained OMS and who is not. It is not an issue of a specialist being the only one competent in placement of implants. It is a matter of training not a matter of specialty. In addition OMS is not the one and only that has the skills to place implants if we focus just on specialties in general. I say that based on experience of seeing people with implants signed by various specialists and general dentists.
Brad
10/29/2019
I have used septocaine for a mandibular nerve block and remove a really criuddy # 18 with no surgical flap etc. The patient had numbness out to midline and after Z pack, Vit B complex and NSAIDs the patient was still numb out to 6 mos. Maybe the last poster would have had a neurologist give the block. I have 37 years experience and never had this happen. Thank God I had a comprehensive patient release form. Stuff happens. Just Pray and yes science has shown that to be effective for bodily healing. I think all will be well with you and the patient. It can take up to 3 years according to the lawyers.
Brad
10/29/2019
I have used septocaine for a mandibular nerve block and remove a really criuddy # 18 with no surgical flap etc. The patient had numbness out to midline and after Z pack, Vit B complex and NSAIDs the patient was still numb out to 6 mos. Maybe the last (CK) poster would have had a neurologist give the block. I have 37 years experience and never had this happen. Thank God I had a comprehensive patient release form. Stuff happens. Just Pray and yes science has shown that to be effective for bodily healing. I think all will be well with you and the patient. It can take up to 3 years according to the lawyers.
Brad
10/29/2019
Meant to say CPKW would recommend aneurologist to give a block. Sorrry don't want to impugn the Periodontist.
Neil Zachs
10/29/2019
Thanks!!! Appreciate it! And I agree...stuff happens. Welcome to Private Practice!
Paul
10/29/2019
Brad,
Trying to be funny? Nothing wrong with that. How do you feel about a dental student receiving about 10 hours of trining in conscious sedation being considered ready to provide the service the day after graduation. That is the way it use to be until not too long ago in California.
Joseph Kim, DDS, JD
10/29/2019
My only suggestion would be that anytime a nerve injury happens, for whatever reason, it should be mapped as soon as possible, and photographed. In my experience, some improvement is a very good sign, and usually a small parasthesia of an area of the chin if far better than an area on the lip. Just inform the patient, document you informed them, and offer a referral to a nearby micronuerosurgeon. Document the referral, as well.
For those who are offended by this case, this is exactly what malpractice insurance is for. The risk of permanent damage versus the reward of being able to function more normally again if for the patient to decide. It goes without saying, that you should review your systems to avoid this type of mishap in the future.
Aref Natour
10/30/2019
The cbct showes implant in close proximity to mental nerve . Another slice showing the mental foramen vs implant might be more diagnostic . I would remove the implant and put patient on Neurobion(vit B complex) once a day for one month and hope for the numbness to go away. This situation can happen to any dentist who places implants and the more you place the more chances your will encounter this situation. Once patient’s symptoms are gone I would go back and place a shorter implant or at a different orientation. Good luck!
purpleaquarius
10/30/2019
Thank you dear all for your taking the time to comment.
Today i just reviewed the patient with our visiting oral surgeon and did the nerve injury mapping. Today patient reported of feeling less heaviness on left chin (not so tight) and she reported everytime after neurobion consumption she feels some mild sensation on her chin. Today we increase her neurobion dose from twice daily to three time daily for additional 2 weeks. We will see her again and keep everyone updated.
Ed Dergosits
10/30/2019
Short implants work. Why take unnecessary risk?
purpleaquarius
12/10/2019
Good news to share.. My patient has recovered completely at 8th week post implant surgery. thank you everyone who spend your valuable time in this platform.
Dreamdds
12/10/2019
Great news Doctor. Thanks for update which is as valuable as your first post
Continue your implant journey. Take courses
Join one of the large implant societies
Sincerely
Leonard
Ed
12/10/2019
I am happy for you and your patient. What plans do you have to expose the implant in site 36?
Wally Hui DDS. FAAID. DAB
1/7/2020
Time frame is critical, the best care time is first 2 months. Perceptions of pain and temperature are usually recovery first, other sensations take longer. Anyway keep recording weekly. If fails improved within 2 months. Referral to microneurosurgeon. Early management before distant degeration of the nerve usually occurs within 4-6 months of nerve injury.
Strauss et al concluded 50% under repair with improvement. Referal ASAP as NEED!
