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Fig. 3.15. Open reduction with internal fixation of the mandible fracture.

POST‐OPERATIVE COMPLICATIONS

       Infection

Wound infections after dentoalveolar and dental implant surgery are not unusual due to the clean‐contaminated nature of the surgical procedure, and in most instances are managed fairly simply with local wound care, possibly incision and drainage, and systemic antibiotics [32]. Infections become more complicated when a foreign body such as a dental implant is associated with this infectious process. Infectious complications can be divided into early‐stage and late‐stage infections. Early‐stage dental implant infections arise in the immediate postoperative phase, usually within days to weeks after implant placement. The presenting signs and symptoms are consistent with an acute infectious process (cellulitis), including pain, edema, erythema, and often purulent drainage. The best method to avoid early‐stage dental implant infections is with the use of aseptic surgical techniques with meticulous sterile handling of all implant components and instrumentation. Although the need for an entirely sterile field is not required, the clinician should make concerted efforts to decrease bacterial load and site contamination. This includes the handling of implanted materials with only sterile instruments and manipulation of the dental implant with only titanium forceps. All efforts should be made to decrease any local debris or other potential contaminants from entering the prepared osteotomy site prior to dental implant placement. Copious and repeated irrigation is an ideal way to decrease potential bacteria and dental material settling within the surgical site. All osteotomies should be prepared according to the selected implant manufacturer recommendations and implant drills should not be used beyond their recommended life spans. Attention should also be given to the osteotomy during and after preparation, since certain indicators of poor bone healing or compromised vascularity may present themselves during surgery. Extremely porous and extremely dense bone may lead to issues after placement and should be noted in the surgical operative report. After placement of a dental implant for a two‐stage protocol, all efforts should be made to ensure a tension‐free primary soft tissue closure over the implant. It should be noted that two‐stage implant protocols are performed much less often today. Tension on the repair site or a soft tissue dehiscence will allow food debris and bacteria to harbor on the exposed cover screw or implant surfaces. This may compromise the osseointegration process and may form a localized parulis or submucosal abscess in the soft tissue over the implant. The treatment is incision and drainage and possible early healing abutment placement to assist in soft tissue healing and improved oral hygiene in the area. If early implant uncovery is not an option, resuturing of the area should not be attempted. If there is a large dehiscence and soft tissue coverage is desired, complete re‐exposure and local flap mobilization with freshened tissue margins should be performed, but this is rarely necessary. As mentioned, one‐stage implant surgery (with placement of either a healing abutment or provisional crown or prosthesis) is performed more commonly today than two‐stage surgery, so if the implant is placed with adequate primary implant stability and it appears that there will be no compromise to the restorative plan, all efforts should be made to perform one‐stage implant placement and avoid some of the issues with two‐stage surgery [33]. The placement of a healing abutment or provisional prosthesis during the initial implant surgery not only spares the patient an additional surgery, but also allows for soft tissue healing around the cuff of the implant/healing abutment interface, thereby decreasing bacterial migration along the implant/bone interface.

The evaluation of a patient with an infection following dental implant placement should include a review of their comorbidities and an evaluation of the presence of systemic sepsis with imaging and laboratory analysis depending upon the severity of the infection. A localized gingival infection or vestibular abscess can be managed with incision and drainage with local anesthesia and intravenous sedation, if necessary. The status of the dental implant should also be addressed with a periapical film or CBCT. If an area of circumferential radiolucency exists around the implant, and there is clinical implant mobility, and this coincides with the signs and symptoms of an odontogenic infection, then the prudent next step would be implant removal and debridement of the surgical site. If the implant and osseous structures appear stable, then it may be possible to treat the localized soft tissue infection and retain the implant, with close follow‐up to ensure no recurrence of infection that would then require implant removal. Late‐stage infections can present in multiple different ways, and the complication of peri‐implantitis is complex, and will be discussed separately from other late‐stage dental implant infections. Although rare, severe infections involving the deep fascial spaces of the head and neck, sinus, and other regional areas must be treated aggressively and often in an inpatient hospital setting. The location of the infection and involvement of adjacent anatomical spaces/cavities will guide the treatment algorithm. An infected maxillary implant with sinus involvement will necessitate the use of systemic antibiotics not only aimed at odontogenic organisms, but also for typical maxillary sinus flora (e.g., Streptococcus pneumoniae , Haemophilus influenzae, Moraxella catarrhalis) [34]. Removal of the infected implant can also be complicated by the creation or persistence of an oroantral fistula, which may eventually require closure, possibly with a loco‐regional mucosal or muscle flap, or the use of the buccal fat pad for a layered repair. For severe secondary fascial space involvement, appropriate evaluation with a medical‐grade CT scan and open surgical exploration in the operating room with the use of culture and sensitivity‐guided intravenous antibiotics (and possibly an infectious disease consultation) are standard protocols. In these instances, although the implant may appear stable or healing, appropriately consideration should be given toward implant removal, in order to eliminate a bacterial‐colonized foreign body that could lead to a refractory or recurrent infection. Prior to replacement of the implant, consideration must be given to the identification and correction of all possible contributing factors that led to the initial infection (Algorithm 3.6).

       Peri‐implantitis

The phenomenon of peri‐implantitis is a well‐recognized and frustrating clinical problem for dental implant surgeons and patients. Part of this frustration lies in the fact that unlike periodontal disease, which is well defined and organized into categories, peri‐implantitis remains a rather ambiguous and debated term with variable clinical presentation. Some surgeons prefer the term “peri‐implantosis” since there are instances where there is bone loss surrounding an implant, but an absence of inflammation, so the term “peri‐implantitis” would not technically apply [35]. Most surgeons agree that for a diagnosis of peri‐implantitis to exist the presence of gingival recession and implant exposure and bone loss should be present. The distinguishing factor between peri‐implantitis and peri‐implant mucositis is that peri‐implantitis has bone loss around the implant (Figure 3.16), while peri‐implant mucositis does not exhibit bone loss since the inflammation is confined to the mucosa (Table 3.5). The bone loss in peri‐implantitis has been referred to as a “saucer‐shaped” bone defect around the implant on clinical examination and a peri‐implant radiolucency on radiographic imaging (Figure 3.17). Peri‐implantitis often presents itself years after initial dental implant placement, and for this reason is included in the late‐stage infection category. Often, the peri‐implant bone loss is discovered incidentally on routine dental radiographs, and in the posterior region of the jaws, the presence of gingival inflammation, pain, BOP, purulence, and recession may go unrecognized by the patient for some time. Peri‐implantitis is believed to be due to

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