55 yo female presented for implant placement on tooth #30. Tooth lost over 10 years ago and quality of bone poor, type III. Undersized osteotomy and placed a 5/10 mm fixture and HA. 3 days post op patient developed a lot of pain and swelling. Saw patient for post op and buccal tissue red and swollen. Implant stable with no mobility or discomfort. 5 days post op ....pain in not manageable and patient is stating she has numbness in her chin and lip. I am seeing her today to remove the fixture can't figure out what is going on. Please help.
Matt,dmd comments:
Remove, graft and replace at 4 months. When you place at 4 months don’t undersize osteotomy.
Dr B comments:
In correct abutment selection and crown does not fit abutment.
vperio comments:
Update: removed implant last night and patient said anesthesia wore off. Woke up this morning in severe pain and now feels numb again in chin and lip?!?? What’s going on
Faisal comments:
Don’t worry she’ll be fine. Prednisolone (prednisone) 5mg start with 3 times a day and then taper off in 4 days.
Map the paresthesia, it will go in a few days.
I’m glad you removed the fixture before it bonded.
Pain on second day after fixture removal is normal.
Wolves comments:
Hi, did you take a repeat CT scan of the area before removing the implant? It might have been really useful / smart depending on how things progress
vperio comments:
I didn’t. Patient didn’t develop numbness till 5 days post op ...then went away and started again today. Could this be permanent damage
Wolves comments:
Most people are saying that they had a case where the numbness subsided after a few days etc. some prescribed steroids etc. How will your patient respond to being placed on steroids etc? For every case that subsides there are a similar number that don't. You need to have all the information you can possibly record at hand to defend against litigation / possible litigation. Ask yourself one question - was this an avoidable complication? If the answer is "yes" and your patient decides to seek alternative advice then can you defend? It's more than just a clinical complication that we can all wish would just go away.
vperio comments:
I agree! It’s been 3 days and has not subsided. I am worried that I may have been too close to IAN and internal swelling affected the nerve. No real literature out there to support this but I can not think of another reason this is happening.
Drsmith comments:
I had same situation about 10 years ago. I presumed it was sub periosteal swelling or hemorrhage. Prescribed Medrol and numbness and swelling subsided in about 24 hrs. Nothing permanent and implant was restored and still functional.
MIke comments:
Hi,
Most definitely too close to the ID.Pressure on the ID from internal swelling.
Yes take it out and put a much shorter. one in 3months time.
Stay 2mm clear.
Don’t worry,shit happens..Will come back.
Tim comments:
I have had probably 10-12 patients over the years experience numbness exactly like you described and it has always returned to normal within 12 weeks. You most likely traumatized, not damaged, the mental nerve at its exit point near the foramina. As far as removing the implant I would say that may or may not have been necessary. Another possibility is the particular implant design that you chose that being one with aggressive threads. You mentioned that the bone quality was poor so you undersized the osteotomy. It is possible that you underestimated the actual bone quality and caused some additional local inflamation via pressure necrosis. I am not really really sure why you felt it necessary to graft this site at the time of placement but in doing so you had to extend your incision and release the periostium in the area of the mental foramina and probably bruised the nerve.
vperio comments:
no grafting was done. the flap was minimal and patient had normal sensation with anesthesia wearing off that night. Pain got worse at day 3 then at day 5 i removed the implant (reversed with a torque driver) and no graft was placed in the osteotomy site. Anesthesia wore off that night (patinet called and said she was comfortable and feeling better)and numbness returned the next morning after implant was removed
Jawfixer comments:
Always best to do these guided and buried. I would have taken off the healing abutment and prescribed Medrol dose pack. Swelling peaks on the third day, probably had some bleeding. The neurapraxia will take some time to resolve. Doubtful that the nerve was injured in surgery. Do you have an experienced Oral Surgeon who can help you with this post op sequela for the patient’s best interest vs getting advice from a website? Always best to have real time clinical help with a trusted colleague. I would not have removed the implant but given it time, but I was not present. If you damaged the nerve the numbness would have been immediate.
vperio comments:
yes.... I had an OS colleague take a look at it her today and suggested opening up the site and placing a drain. She is very SWOLLEN. no suppuration or fluctuance just swollen. Also suggested that the swelling is probably causing the paresthesia and he does believe it will resolve in time. I am praying it will
otis comments:
these are scary. always use cases like this as a learning experience
Dr Pravin patel comments:
Hi
You are on a right path..better u removed fixtures..mostly such incidents commonly happen in mandibular arch.bone necrosis due to excessive pressure in under osteotomy most probably the reason..avoid under osteotomy in mandibular arch
.if less than 30 torque than submerged fully..steroid will help in fast recovery of nerve inflammation under antibiotics coverage... Now you can put implants again after 45 days..when bone is soft and in healing stage with full of osteoblast...submerged fully. Hope it helps.
Dr pravin patel mumbai india
