Good day. Welcome to this session on "When Implants Go BAD!" We're not here to scare you but, yes, we are here to scare you! Things can go bad if you do it for long enough and you do it enough times. This is a very big topic, so today, we're really going to be only concentrating on some of the more common surgical complications. Now, what is a complication? Well, it's defined as an unanticipated problem that arises following, and is a result of, a procedure, a treatment, or illness. Well, if you look at surgical complications, I guess, probably the worst thing is the patient can actually die from it, from what you do, and, believe me, that has actually happened a number of times around the world, but we won't go into that because they are certainly fairly rare occurrences, so we're not going to cover that today. Then, of course, the next most distressful situation for surgeons, as well as, patients alike, is, generally, haemorrhage. I mean, to a patient, bleeding is something that is very, very distressing, and something that we should know about. Now, we are certainly not talking about bleeding, like in this situation here, where you can actually see the blood squirting out: "This is an action shot!" That is really an intraoperative inconvenience and it'd probably just slow us down, maybe 10, 15 minutes, we have to stop the bleeding before we get back to what we have to do. We're also not talking about this sort of scenario. These are, basically, just severe bruising, and that can happen to a perfectly healthy patient. It can also happen to just any normal, totally uneventful surgical procedures. So as long as you warn the patient beforehand, this is really not a complication here, in any shape or form. Now, this is, perhaps, the kind of scenario where we create dangerous situations. When you pick up an OPG and you say, "Nope, might be a bone, I can put some implants in there and that's easy." That's exactly the kind of situation where we end up with these sorts of problems. Life threatening haemorrhage, haemorrhage of the mouth, severe haemorrhage, emergency tracheostomy, near fatal airway obstruction, this is serious haemorrhage we are dealing with here. And as you can see, the list goes on and on and on, and fortunately not too many of these patients actually end up dying, but certainly, they come close to it. So, what actually happens here? So, if you didn't expose the surgical site properly, and you just placed the implant, you think you're very good, and there's haemorrhage of the floor of the mouth from perhaps just even very small lingual perforation during implant placement. And that's exactly what the problem is, because there's very little bit of bleeding and that's why you don't realize it's there. You suture up, send the patient home, and the problem is identifying the problem. The patient goes home, it's slow progressive post-operative haemorrhage, and generally the patient won't be, because you already told them they're going to get some swelling, so they do not contact you for a day or two, and slowly, with the haemorrhage with the haematoma building up, the floor of the mouth is lifted up, and it causes an elevation of the tongue, and very quickly, it can obstruct a patient's airway. And that very quickly becomes life threatening. The fact that it is undiagnosed, the further it is undiagnosed, the more dangerous that becomes. Obviously, a thorough understanding of the anatomy of this area will reduce the incidence of these sorts of problems. This is why we conduct cadaver workshops. Now, how to manage this is certainly way beyond the scope of these types of sessions here. I'll refer you to a chart provided by a good friend of mine, Dr. Lydia Lim. You know, if you really want to learn this, you would have to attend a proper training course. In fact, that's what the oral surgeons are trained to do. So, if you're going to do these sorts of procedures, I suggest you have a very good working relationship with your oral surgeon, because one day you might just need them to help you get out of trouble. Well, you haven't killed your patient, your patient hasn't bled to death, probably the next most distressing thing would be if you injured a nerve. The patient rings you up and says, "I got a numb lip" or a numb cheek or whatever. Now, if you look up these statistics on some of these publications here, this is a publication that covers well over 200 publications on implant complications, if you look at the figures, 7% incidence of neurosensory disturbance, that's actually very high. I've certainly never seen that in my practice. Now, when we talk about trigeminal nerve injury, the first thing we tend to think of is injury to the inferior alveolar dental nerve. But, one thing we also forget is the infraorbital nerve, that can also be quite easily injured if you are perhaps just doing a releasing incision, when you're doing soft tissue grafting or guided bone regeneration procedures. When we look at the inferior alveolar nerve injury, the most common, of course, we are talking about actually direct injury to the nerve and usually it's with the drilling during the osteotomy preparation. Of course, the severity of that depends on how much you actually traumatize the nerve. Unfortunately, that's often, it can certainly be permanent. It can also have a haematoma formation and that leads to, fortunately, in most cases, a transient neurosensory disturbance. These next two, the down fracture and bone formation are certainly less common causes of neurosensory disturbance. Now, this is a pre-operative CT scan of a patient that was treated by a very caring, and certainly very meticulous general practitioner who was going to operate in the right mandible area. The purple dots were the areas identified by the radiology center as where the inferior alveolar nerve is. Now, post-operatively, when the problem happened, I was asked to look at this case and I actually plotted where I think the actual nerve is, which is a somewhat different position. So, unfortunately, this particular clinician actually went ahead and used the radiologist's measurements and actually placed the implants. Well, unfortunately, both of those implants ended up partially or almost completely in the nerve. Now, surprisingly, the first question this clinician asked me was, "Shouldn't the radiologist be responsible in some way?" I said, my answer was, "Excuse me, Doc, who did the drilling?" So, I think it's pretty obvious that the lesson here is never trust anyone but yourself. If you are the one drilling, you are the one responsible for what happens. So, next time, before you tackle your next case, particularly if it's a complex case, ask yourself these questions: Are you aware of the potential complications? And are you capable of managing these complications if they occur? The honest answer from yourself to these questions will probably determine how soon or when you get your next complication. Good luck, and let's see. Hopefully you have a lot of happy patients! See you next time!
