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Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 62-66

Surgical considerations and related complications in oral implantology: A comprehensive review

Department of Prosthodontics, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh, India

Date of Submission15-Feb-2022
Date of Decision26-Mar-2022
Date of Acceptance26-Mar-2022
Date of Web Publication20-Jun-2022

Correspondence Address:
Prince Kumar
Department of Prosthodontics, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcdoh.jpcdoh_6_22

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Dental implants have become a remarkable face of modern dentistry and are considered to be one of the several treatment options that can be used to replace missing teeth, which is considered to be an advanced procedure for oral health. The biologic basis of hard- and soft-tissue interfaces between the implant and the surrounding tissues and their clinical relevance plays a major role in the success of implant. Further, it is very crucial to explore the best suited approach for implant treatment planning. Numerous surgical protocols are required to cover the standard sets of steps for placing implant in complex as well as noncomplex situations for implant-supported dental prosthetics. However, dental implants may fail as a result of mechanical complications, such as screw loosening or due to biological causes such as periimplant diseases. As a result, dental personnel should be able to recognize these complications and the factors that have negative effects on the success of such implant-supported restorations or prostheses. Therefore, it is required to have an appropriate knowledge of dental implants for every dental student, hygienist, and dentist. Maintenance of implant-supported restorations and prostheses requires long-term follow-ups, so it is the responsibility of the patient to maintain good oral hygiene.

Keywords: Dentistry, implant, implant-supported, PubMed, surgery

How to cite this article:
Omar S, Jaiswal H, Kumar P, Mishra SK. Surgical considerations and related complications in oral implantology: A comprehensive review. J Prim Care Dent Oral Health 2022;3:62-6

How to cite this URL:
Omar S, Jaiswal H, Kumar P, Mishra SK. Surgical considerations and related complications in oral implantology: A comprehensive review. J Prim Care Dent Oral Health [serial online] 2022 [cited 2023 Jan 30];3:62-6. Available from: http://www.jpcdoh.org/text.asp?2022/3/3/62/347802

  Introduction Top

Dentistry has experienced immense advancements in dental restorative materials, techniques, and strategies that are effective for the long-term management of tooth loss. The objective of modern dentistry is to restore the patient's normal contour, function, comfort, esthetics, speech, and periodontal health of a tooth.[1] Recently, the choice of treatment plan for the replacement of missing tooth is dental implants. The aim of implant-supported prosthesis is to achieve optimal esthetics and function. Implant surgery is similar to many other oral surgical procedures as it starts with appropriate preparation for the surgery. Sterilization protocols are mandatory in implant placement like other oral surgical interventions.[2] Dental implants (also known as oral or endosseous implants) are considered a gift to dentistry as they have revolutionized the way by which missing teeth are replaced with a high success rate. This success rate depends on the potential of the implant material to integrate with the surrounding tissue. Implant placement protocol requires raising a soft-tissue flap, preparing the implant bed by drilling the alveolar bone, placement of the implant, and healing cap or healing abutment, followed by adequate closure of the wound.[3] Furthermore, today's clinicians have a better understanding of the loading principles, which allows immediate loading of implant-retained and/or implant-supported restorations in selected patients.[1] Good planning and meticulous techniques are responsible for successful implant surgery. Previously, appreciation of the restorative requirements and visualization of the desired end result of treatment was required, whereas later on, it requires adequate surgical training and experience of the selected implant system.[4] Therefore, the primary goal of this review is to explore the different aspects of surgical considerations in implant.

  Methods of Literature Search Top

In this modern era of technological advancements, various internet-based means are available that can legitimately retrieve biomedical information. Some of the popular internet-based popular search engines (Google, Yahoo), scholarly search bibliographic databases (PubMed, PubMed Central, MedlinePlus, Cochrane, Medknow, EBSCO, ScienceDirect, HINARI, WebMD, IndMED, and Embase), and textbooks were searched until January 2022 using MeSH (Medical Subject Headings; PubMed) keywords such as “implant,” “surgery,” “implant-supported,” “Dentistry.” The search was limited to reviews, systematic researches, and meta-analyses in different dental journals published over the past 40 years in English and in Spanish. A total of 98 articles were identified; however, after investigating the titles and abstracts, this number was finally reduced to 19 articles.

  Biological Consideration Top

The main objective in implant placement is to achieve and maintain osseointegration. Osseointegration for dental implant is defined clinically as the asymptomatic rigid fixation of an alloplastic material (the implant) in bone with the ability to withstand occlusal forces. Key factors responsible for successful osseointegration include biocompatibility of the implant material, design characteristics of the implant, surface characteristics of the implant, state of implantation bed, surgical considerations, undisturbed healing phase, and prosthetic design and loading characteristics.[3] The dentogingival junction, or area where the soft oral tissues join the hard dental tissues, protects the root of the tooth, periodontal ligament, and alveolar bone against chemical and bacterial invasion. It consists of two elements: a dense resilient connective tissue, the lamina propria, and a thick, mostly parakeratinized or keratinized epithelium. The soft tissue attached to the teeth is comprised of two parts that are fibrous tissue and attachment of the epithelium. The biological width of the attachment varied between about 2.5 mm in the normal case and 1.8 mm in the advanced disease case.[5]

  Presurgical Consideration Top

After treatment planning, the surgical execution of implant placement is the next critical procedure in attaining successful osseointegrated implants. The most important factors to control in implant surgery include sterile technique, i.e., avoiding the contamination of the implant surface and avoiding damage to the bone by thermal injury during the drilling process. Furthermore, carefully preparing the bone site is also important so as to make implant stable at placement. Placing the implant in an esthetically and functionally acceptable position is equally important as avoiding excessive loading in the healing period. The former protocols do not allow loading before 3–6 months. The latter protocols that allow immediate loading of dental implant require careful control of the magnitude of loading.[6] Poor control of these factors can lead to failure of osseointegration, which may be demonstrated as infection at the implant site, implant mobility or the implant may be rotated when attempting to detach or attach a component, and pain from inflammation in the bone surrounding the implant. This may be manifested as pain on pressure on the implant and a radiolucent space surrounding the implant, which is consistent with fibrous encapsulation. However, a failed implant may have a normal roentgenographic appearance. There are some of the basic preoperative cares which include, antiseptic rinsing of the oral cavity such as chlorhexidine gluconate (2% or 1.2% proprietary rinses for 1 min). Administrations of analgesics such as oral analgesics (ibuprofen 200 mg or 400 mg or paracetamol 1 g) are usually sufficient in most outpatient cases. Control of pain is more effective if analgesics are given prior to surgery. There are some manifestations to suggest that preoperative antibiotics may reduce implant failure.[7]

  Surgical Preparation and Site Development Top

Preparation for implant surgery requires complete guide of the patient's medical records, including medical and dental histories, radiographs, as well as restorative fabricated surgical guides. There should be a proper planning for surgical sequencing and strategy, anesthesia, operating time, instrumentation, and postoperative management. The operator should also have a clear understanding of the restorative and treatment plans. Prior to surgery, the implant handpieces, motor, and irrigation equipment should be checked to ensure proper function.[4] Preoperative prophylactic antibiotic administration is sometimes recommended. Exposure of the implant site can be accomplished by several methods, including flapless surgery or tissue elevation, and can include sulcular, midcrestal, and vertical-releasing incisions.

In flap reflection, reflection at the papilla is initiated with a periosteal elevator, using gentle, well-directed, and controlled pressure. During osteotomy, the speed should be set at 1000–1500 revolutions/min (rpm) for the initial set of drilling steps. All osteotomy drills should be copiously irrigated, internally or externally, or both, during bone preparation. The initial drilling with the 2-mm twist-drill at full speed should be done. Once the drill has been well positioned, drilling is initiated at full speed with a gentle pumping motion to the final depth of the intended implant.[7] The implant is inserted into the prepared osteotomy site with appropriate position and angulations. After completion of implant surgery, healing abutments are placed in a 1-stage surgical approach or after uncovering in a 2-stage surgical approach. The abutments can be parallel walled or tapered and range from 2 mm to 10 mm in height and it is determined by the thickness of tissue present. At last, suture is done using some type of resorbable suture (chromic gut or polyglactin 910) or nonresorbable sutures such as black silk.[8]

  Implant Placement Surgical Protocol Top

The heat generated during an implant osteotomy is related to the presence and temperature of irrigation, amount of bone being prepared, drill sharpness and design, time of preparation, depth of the osteotomy, pressure on the drill, drill speed, and variation in cortical thickness. To minimize heat generation, at least 50 mL/min of cooled irrigation of sterile saline (0.9% NaCl) should be used as a profuse irrigant and is a critical factor in the osteotomy process. The amount of heat produced in the bone is related to the amount of bone removed by each drill and later causes necrosis. In a similar fashion, the amount of heat generated by successive drills is also directly related to the increase in drill diameter. The gradual increase in drill diameter also maintains the sharpness of each drill for a longer period, which also reduces the heat generation.[9] Sharma et al. recommends drilling speeds of 1500–2000 rotations/min (rpm) with irrigation. Sharma reported bone cell death when a temperature of 40°C was applied for 7 min, or when a temperature of 47°C was applied for 1 min.[3] Sufficient pressure should be used on the drill to proceed at least 2 mm every 5 s. The amount of torque is expressed in units of newton centimeters (N/cm), which ultimately determines the loading protocol. Insertion torque is the most important factor in determining primary stability, with higher torque values leading to higher primary stability. Lower values of insertion torque have been shown to be associated with implant failures.[6]

  Generic Drilling Sequence Top

The sequence of drilling is pilot drilling which is followed by position drilling and then second twist drill is done again followed by final shaping drills and bone tap drills.[10]

  • Step 1: Pilot drill: With most surgical systems, a 1.5-mm or 2.0-mm surgical pilot drill is used to initiate the osteotomy
  • Step 2: Position verification: Once the initial osteotomy is prepared, it is assessed for ideal position. If incorrect, the osteotomy location may be “stretched” to the proper location by a side-cutting Lindemann bur. This will prevent the second surgical bur from entering the first nonideal implant osteotomy
  • Step 3: Second twist-drill: The second drill used is approximately 2.5 mm in diameter, and is an end-cutting twist-drill required for the initial osteotomy to the required depth
  • Step 4: Final shaping drills: Depending on the surgical system used, most shaping drills are used to sequentially widen the osteotomy to the matching diameter of the implant being placed
  • Step 5: Crest module and bone tap drills: Most implant crest modules (implant neck) are larger in diameter than the implant body. The larger diameter often requires a side-cutting crest module drill in D1 (and some D2). This drill is inconsiderable when the bone density is poor (D3 and D4).

One-stage surgery

A one-stage surgical protocol involves the placement of a healing abutment that extends slightly above the crest of the tissue. The soft tissue is then sutured around the healing abutment to form a soft-tissue drape during the healing period. There are innumerable advantages to the one-stage surgery technique [Table 1].[10]
Table 1: Advantages, disadvantages, and indications of one-stage surgery

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Two-stage surgery

The two-stage surgery technique involves the placement of the implant and a low-profile cover screw, which is inserted into the implant body. When the cover screw is in the final position, it may be tightened and no tissue, blood coagulants, or bone particles should prevent the complete seating of the cover screw [Table 2].
Table 2: Advantages, disadvantages, and indications of two-stage surgery

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  Ideal Implant Positioning Top

Ideal implant distances between implant and tooth are 1.5 mm (apical) and 2.0 mm (coronal) while implant-to-implant distances is 3.0 mm. The thickness of bone (after implant placement) for buccal is 2.0 mm and for lingual is 1.0 mm. Ideal implant positioning for apicocoronal is 2.0–3.0 mm apical to free gingival margin, anteriorly for cement-retained prosthesis which is slightly lingual to the incisal edge and for screw-retained prosthesis, it is cingulum area. Posteriorly, in both cement and screw-retained prosthesis, it is the central fossa. The minimum interocclusal space required for cement-retained prosthesis is 7–8.0 mm (zirconia), 8–10.0 mm (porcelain fused metal) and for screw-retained prosthesis, it is 5.0–6.0 mm (zirconia/porcelain fused to metal (PFM)). In case of overdenture for bar retained, it is 14–16 mm (depending on attachment) and for independent attachment, it is 9 mm (e.g., locator).[11]

  Surgical Complications of Implant Top

Intraoperative complications

  1. Lack of primary stability: On rare occasions, the surgeon will over prepare the implant site, resulting in a so-called “spinner,” or an implant that has not achieved the desired level of initial anchorage, especially when preparing an osteotomy site in poor-quality bone
  2. Implants placed too close together: If this occurs and the preparation of the osteotomy sites is especially traumatic, osseointegration may be compromised between the two implants. If implants are too close together, the contours of the periimplant soft tissues, especially the interdental papilla, will be compromised[12]
  3. Perforation of the facial plate of bone: When preparing osteotomy sites or placing implants in areas with minimal facial plate thickness, or if the implant is placed too far to the facial, a fenestration or dehiscence may occur
  4. Perforation of the lingual plate of the mandible and bleeding: Perforations of the lingual plate of the bone in the mandible can lead to laceration of the branches of the lingual artery. If not detected and treated, the resultant hemorrhage can lead to airway obstruction and be life-threatening[10]
  5. Perforation of the inferior border of the mandible: Slight perforations of the inferior border of the mandible are generally inconsequential. However, on occasion, a subperiosteal hematoma develops, and the hematoma may be contaminated with blood-borne pathogens. An infection and a submental cutaneous fistula can develop that can lead to loss of bone around the offending implant, placing the mandible at risk of fracture[13]
  6. Injury to the inferior alveolar nerve, mental nerve, or lingual nerve: The morbidities associated with injury to the inferior alveolar nerve include paresthesia, hyperesthesia, and dysesthesia; these may be severe, particularly dysesthesia. Possible causes of nerve injury include improper flap design, traumatic flap reflection, accidental intraneural injection, traction on the mental nerve in an elevated flap, penetration of the nerve canal during preparation of the osteotomy, and compression of the nerve within the canal by the implant body.[11]
  7. Fracture of the mandible: This is a relatively rare occurrence. It occurs most often in patients with severe resorption of the mandible and when implants of excessive diameter (5 mm or more) and/or tapered, self-tapping implant designs are used.
  8. Damage to the implant platform during placement: Damage to the implant platform during insertion appears to be quite rare. However, if excessive force is used to insert the implant, the hex can be damaged, or if an internal interlocking design is used, the neck of the platform can split. The frequency of this complication is highest with narrow diameter implants (3.0 mm or 3.5 mm)[14]
  9. Damage to the internal threads of the implant: On rare occasions, the internal threads of the implant can be damaged. This can occur when a cover screw, healing abutment, or provisional prosthesis is inserted at the time of implant surgery. The internal threads of the implant can also be damaged when an abutment screw fractures[10]
  10. Penetration of the apex of an implant into the maxillary sinus: Perforation of the sinus membrane with the apical portion of dental implants does not appear to compromise sinus health or impair osseointegration or the long-term success of implants according to both retrospective clinical reports and animal studies[15]
  11. Tearing the sinus membrane during sinus augmentation: Perforation of the sinus membrane frequently occurs during elevation of the sinus membrane. Very thin or very thick maxillary sinus walls and the angulation between the medial and lateral walls of the sinus also appear to influence the incidence of membrane perforation during surgery. Sinus membrane perforation appears to occur most frequently in patients with little remaining alveolar bone and a flat palatal vault[7]
  12. Excessive bleeding during sinus augmentation: Excessive hemorrhage during sinus augmentation is unusual because the primary blood supply is relatively distant from the surgical site[9]
  13. Postoperative maxillary sinusitis: Maxillary sinusitis can occur as a result of contamination during the surgical procedure or by obstruction of the ostia secondary to postoperative swelling of the maxillary mucosa, hematoma, and seroma. To minimize the risk, possible causes of sinus infection should be addressed prior to sinus augmentation.[16]

Postoperative complications

  1. Excessive facial placement or inclination: This outcome can result when the diagnostic workup is not adequate or the surgeon fails to use a surgical template. If an implant-assisted overdenture is planned, facial inclinations or excessive facial positioning can be mitigated with an implant-connecting bar[12]
  2. Bisphosphonate-related osteonecrosis: Bisphosphonates are widely used for the treatment of osteoporosis, multiple myeloma, and skeletal complications of bone metastases[10]
  3. Devitalization of adjacent dentition: If implants are placed too close to the adjacent natural dentition, there is a risk of perforating the periodontal ligament or devitalizing the teeth, which could lead to failure of the implants secondary to periapical infection associated with the loss of vitality
  4. Improper apicocoronal positioning: In the esthetic zone, improper apicocoronal positioning may have significant consequences. If the implant platform is not positioned sufficiently apically, it will be difficult to achieve normal emergence profiles with the restoration. If the implant is excessively subcrestal, the periimplant pockets will be excessively deep, predisposing to periimplant mucositis and periimplantitis[17]
  5. Exposure of titanium mesh: If the titanium mesh housing a graft becomes exposed, the area must be kept as clean as possible during the healing period. Brushing with a soft-bristle toothbrush and swabbing the area of exposure with chlorhexidine immediately after meals is recommended[18]
  6. Periimplant mucositis: Periimplant mucositis is similar to gingivitis associated with natural dentition. Hygiene instructions include modification of oral hygiene, nonsurgical debridement with scaling/root planing, and reevaluation typically in 1 month
  7. Periimplantitis: The currently accepted definition for periimplantitis is an inflammatory process affecting the tissues around an osseointegrated implant in function, resulting in loss of the supporting bone. However, it must be pointed out that bone loss may be precipitated by a variety of factors (e.g., implant overload, improper surgical handling, an excessively thin layer of cortical bone overlying the implant, and at initial surgical placement) and in and of itself does not imply periimplantitis.[19],[20]

  Conclusion Top

Implant surgery is highly technique sensitive and requires adequate training and an understanding of the restorative requirement of the proposed treatment. An understanding of the basic surgical principles is necessary to ensure successful osseointegration of implant in correct location which allows good esthetics and prognosis. The goal of every treatment with dental implants, regardless of how the protocol is devised, is to create a functional and esthetic outcome, which is similar to that of natural dentition. Sterilization of instrument also plays a very important role in osseointegration. Careful treatment planning and surgery result in ideal placement of the implants.

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There are no conflicts of interest.

  References Top

Hupp JR, Ellis E 3rd, Tucker MR. Contemporary Oral and Maxillofacial Surgery. 6th ed. St. Louis, MO: Elsevier; 2014.  Back to cited text no. 1
Rathee M, Bhoria M. Basics of clinical diagnosis in implant dentistry. J Int Clin Dent Res Organ 2015;7:13-8.  Back to cited text no. 2
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Sharma MS, Pandey V, Vartak V, Bondekar V. Prosthetic driven implantology – A review. Int J Res Health Allied Sci 2016;2:21-5.  Back to cited text no. 3
Palmer R, Palmer P, Floyd P. Basic implant surgery. Indian J Dent Res 1999;18:190-5.  Back to cited text no. 4
Talwar N, Singh BP, Chand P, Pal US. Use of diagnostic and surgical stent: A simplified approach for implant placement. J Indian Prosthodont Soc 2010;10:234-9.  Back to cited text no. 5
Bhargava D, Thomas S, Pandey A, Deshpande A, Mishra SK. Comparative study to evaluate bone loss during osteotomy using standard drill, bone trephine, and alveolar expanders for implant placement. J Indian Prosthodont Soc 2018;18:226-30.  Back to cited text no. 6
[PUBMED]  [Full text]  
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Mijiritsky E, Ben Zaken H, Shacham M, Cinar IC, Tore C, Nagy K, et al. Variety of surgical guides and protocols for bone reduction prior to implant placement: A narrative review. Int J Environ Res Public Health 2021;18:2341.  Back to cited text no. 8
Govindaraj S, Muthuraman MS. Systematic review on sterilization methods of implants and medical devices. Int J ChemTech Res 2015;8:897-911.  Back to cited text no. 9
Misch CE. Contemporary Implant Dentistry. 2nd ed. St Louis: Elsevier; 2008.  Back to cited text no. 10
Sanz I, Garcia-Gargallo M, Herrera D, Martin C, Figuero E, Sanz M. Surgical protocols for early implant placement in post-extraction sockets: A systematic review. Clin Oral Implants Res 2012;23 Suppl 5:67-79.  Back to cited text no. 11
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Elsayed MD. Biomechanical factors that influence the bone-implant-interface. Res Rep Oral Maxillofac Surg 2019;3:67-72.  Back to cited text no. 14
Bonfante EA, Jimbo R, Witek L, Tovar N, Neiva R, Coelho PG. Biomaterial and biomechanical considerations to prevent risks in implant therapy. Int J Oral Maxillofac Implants 2019;8:139-51.  Back to cited text no. 15
Clokie CM, Warshawsky H. Morphological and radioautographic studies of bone formation in relation to titanium implants using the rat tibia as a model. Int J Oral Maxillofac Implants 1995;10:155-65.  Back to cited text no. 16
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  [Table 1], [Table 2]


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