CHAPTER 14
Complications
14.1 INTRODUCTION
As with any medical treatment, there is a risk of potential complications with dental implant treatment. These complications can be minor or major, early or late and reversible or irreversible.
There are current studies on the frequency of complications. Defining success as ‘free of complications’, two literature reviews reported that 39% of patients have problems in the first 5 years [1]. It is important to highlight that in addition to this, the number of complications associated with implants and implant‐related treatment procedures is increasing. This is due to a number of factors. To begin with, the number of implants placed is increasing, so even if the complication rate stays the same, the greater number of procedures will result in an increase in adverse events. In addition, more dentists with a varying level of experience undertake the procedures, more aggressive protocols (such as immediate placement and loading) are implemented and placements are being performed on more compromised patients. The lack of formal and continuous education and training in dental implantology by the dental team is also a contributing factor (Figure 14.1).
Knowledge and experience are therefore paramount in reducing the severity and frequency of complications in implant dentistry, as is ensuring that the whole team are working within their competence and subscribing to the principle of non‐malfeasance.
14.2 PATIENT MANAGEMENT
As clinicians, we have a responsibility to provide safe, effective and predictable treatment for our patients. However, it is accepted that complications happen (B).
Our main responsibility is to ensure that we minimise the risk of error and the frequency of complications. For this to happen, the whole team needs to have adequate training, experience and ability to carry out the implant procedure and classify the case complexity, as well as the ability to predict, recognise and treat complications that may arise (B).
FIGURE 14.1 Outline of common complications during implant surgery.
| Aspirational | Basic | Conditional |
|---|---|---|
| Ensure that the patient has as accurate expectation of the outcome of treatment and the likelihood of complications. (ii) | In the event of a complication, ensure that the patient is advised at the first possible opportunity. (i) | If appropriate, refer the patient to resolve the complication. (i) |
| In the event of a complication, ensure that the patient is aware of the consequences and possible outcomes. (ii) | Report adverse incidences to the appropriate body. (i) | |
| Appropriate protocols, procedures and aids are implemented to minimise complications. (ii) | ||
| Ensure that an appropriate maintenance and monitoring protocol is in place to reduce the risk and severity of complications. (i) |
When complications occur, we need to act in the patient’s best interest. It is important to understand that our standard of care does not require perfection, nor does it require ideal dentistry. However, it does require reasonably careful and prudent treatment, i.e. scientifically motivated care (C).
If any part of the treatment falls beyond the skill of the practitioner, it is appropriate to refer the patient to a specialist or more experienced colleague (C).
14.3 DOCUMENTATION
In the event that a complication escalates to involve litigation, the best defence for a clinician is maintained, complete, accurate and contemporaneous records. It is also prudent to document the original treatment, options, risks and costing, as well as all modifications to treatment in writing to the patient (A).
| Aspirational | Basic | Conditional |
|---|---|---|
| Document and outline the possible complications, their consequences, incidence and management, and share this with the patient at the start of treatment. (ii) | Demonstrate appropriate level of indemnity for dental implant procedures and the management of complications. (i) | |
| In the event of a complication, inform the patient, ideally in writing, of the treatment plan for managing the adverse event. (ii) | In the event of a complication, ensure that any additional costs are explicit at the start of treatment. (i) | |
| Keep accurate, complete and contemporaneous notes. (i) |
14.4 DIAGNOSIS
The lack of an internationally agreed objective criteria and clinical parameters for defining implant success and failure has made it challenging to diagnose and categorise complications.
The correlation between immune reactions and dental implant failure is a complex phenomenon that involves various immune cells and factors. Figure 14.2 depicts the influence of macrophages, complement activation, B cells and T cells on the correlation between immune reactions and dental implant failure. Macrophages are important cells of the immune system that play a role in inflammation and tissue repair. Complement activation is a cascade of biochemical reactions that help to eliminate pathogens and damaged cells. B cells and T cells are two types of immune cells that play a crucial role in the adaptive immune response. The interplay between these immune cells and factors can lead to either a positive or negative outcome in terms of dental implant success. Understanding the role of the immune system in dental implant failure is crucial for developing effective strategies to prevent and treat implant complications.
The International Congress of Oral Implantologists have classified the health of an implant into success, satisfactory survival, compromised survival and failure, and have defined a set of parameters to aid clinical diagnosis. Additionally, failures are commonly divided into early or primary failures (those relating to osseointegration), and late or secondary failures (relating to complications that occur after osseointegration).
FIGURE 14.2 The correlation between immune reactions and dental implant failure is influenced by various factors, including macrophages (M), complement activation (C), B cells (B) and T cells (T).
Reproduced with permission from Albrektsson et al.
| Aspirational | Basic | Conditional |
|---|---|---|
| Have a screening and surveillance protocol for the early detection of complications, including peri‐implant probing and radiographs. (ii) | Document a differential and definitive diagnosis and develop an appropriate treatment plan. (i) | Carry out the appropriate diagnostics for assessing complications, including cone‐beam computed tomography. (i) |
Implant complications can be caused by a number of factors broadly divided into:
- host factors
- iatrogenic factors
- infection
- bone quality and quantity
- overload
- trauma.
It is essential that a differential diagnosis is reached and communicated to the patient (B). In the event of atypical symptoms, it is appropriate to seek expert advice (C). (Figure 14.3).
14.5 SURGICAL COMPLICATIONS
The correct surgical technique, combined with the technical skill and experience of the operating team is essential for preventing surgical complications.
FIGURE 14.3 Periodontal and peri‐implant interfaces. The implant interface consists of supracrestal collagen fibres oriented in a parallel rather than a perpendicular configuration, and has a weaker mechanical attachment compared to natural teeth.
| Aspirational | Basic | Conditional |
|---|---|---|
| Determine and remove any aetiological factors. (i) | Manage appropriately uncontrollable bleeding, nerve damage, pain, ingestion/aspiration and infection. (ii) | If appropriate refer the patient to resolve the complication. (i) |
| In the context of the best available evidence, design surgical protocols and perform corrective procedures to optimise the prognosis of the implant fixtures. (iii) | Appropriately manage wound dehiscence and/or graft exposure. (ii) | Have protocols in place for prescribing antibiotics and, when appropriate, use them to treat surgical complications. (iii) |
The surgical procedures involve preoperative and postoperative care, flap design and site preparation, bone augmentation and membrane positioning, implant placement and suturing. Each individual stage requires a thorough knowledge of the essential principles and management of clinical complications.
14.6 RESTORATIVE COMPLICATIONS
As more and more dentists of all levels of experience are restoring dental implants, there is a need to understand and manage the factors governing the degree of complexity of dental implant restoration (Tables 14.1–14.3).
| Aspirational | Basic | Conditional |
|---|---|---|
| Determine and remove any aetiological factors. (i) | If appropriate refer the patient to resolve the complication. (i) | |
| In the context of the best available evidence, design restorative protocols and perform corrective procedures to optimise the prognosis of the implant‐retained restoration. (iii) |
TABLE 14.1 Patient factors in dental implant restoration
| Patient factor | Guidance to reduce complexity level and complications |
|---|---|
| Expectation |
|
| Communication |
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