Implants are tooth-root like structure place beneath the jaw-bone. although it is best replacement of natural teeth, complications are still there, surgical complications like hemorrhage and hematoma neurosensory disturbance and damages of adjacent teeth which occurs due to in-proficient surgical exercise. Biologic complication like inflammation dehiscence and recession periimplantitis and bone loss occurs due to patient's ignorance of hygiene. Technical Complication like implants fracture, screw loosening, prosthesis fracture. and some miscellaneous complication, which occurs and should care as soon as possible. An impeccable procedure is needed to perform a perfect Implants procedure. For more details, go to our links:-Google link: https://business.google.com/dashboard/l/04970356233769420071 Facebook link for Dental Courses: https://www.facebook.com/dentalcoursesdelhi/ Facebook link for Dental Treatments: https://www.facebook.com/sachdevadental/ You tube Link: https://www.youtube.com/user/drrajatsachdeva Linkedin link: https://www.linkedin.com/in/drrajatsachdeva/ Slideshare: https://www.slideshare.net/drrajatsachdeva Twitter Page : https://twitter.com/drrajatsachdeva Call us to know more:- +919818894041,01142464041 #rajatsachdeva #dentistdelhi #dentaldelhi #smiledelhi #dentalclinicindelhi #dentistinashokvihar #dentalimplantologist #dentalimplantsclinic #dentalimplantcost #dentalimplanttreatment #dentalimplantprocedure #dentalimplantspecialist

1. COMPLICATIONS OF LOWER
ANTERIOR IMPLANTS

2. Dental implants are tooth root like structure place beneath the
gums in the jawbone.
It is the only replacement option for replacement of missing teeth
that are naturally looking and preserve the original bone and
maintain the overall oral health.

3. Complications are events that occurs during or after the surgery.
It can be further classified as-
Surgical complications
Hemorrhage and hematoma
Neurosensory disturbances
Damage to adjacent teeth

4. Biologic complications
Inflammation
Dehiscence and recession
Periimplantitis and bone loss
Implant loss or failure

5. Technical Complications
Screws loosening and fracture
Implant fracture
Fracture of restorative materials
Esthetic And Phonetic Complications
Esthetic complications
Phonetic completions

6. The most serious complications during implant surgery is Nerve injury
Inferior alveolar nerve injury-IAN injury is most commonly
encountered.
The IAN terminates and give rise to mental branch and incisive
branch to supply the lower anterior teeth and are located in the
interforaminal area.

7. This interforaminal region is involve in many surgical
procedures like bone harvesting, orthognathic surgery,
dental implant surgery, etc. The nerves involve are inferior
alveolar nerve, lingual nerve, mental nerve and incisive
nerve.

8. Causes
Direct - compression, stretch, cut, overheating , accidental
puncture, etc.
Indirect - postoperative edema or hematoma especially inside
the mandibular canal.

9. Neurosensory disturbances, pain, etc can occur after implant
placement in the interforaminal region due to the perforation of
the incisive canal and nerve or due to IAN injury during implant
placement in the posterior mandible.

10. Bleeding is the most common complications in implant surgery

11. The most common reason for bleeding
during implant procedure is from the
sublingual artery or branches which is
observe during bone osteotomy due to
lingual cortex perforation.
According to some studies, the canine
region is at greatest risk for perforation
as the sublingual artery follows a
horizontal course to the direction of drill
at this region.

12. Moreover, as the lingual periosteum contain rich arterial plexus,
any flap tear, mishandling increases the chances of bleeding or
improper instrumentations in the deep muscle layers of the
floor of the mouth could also lead to life threatening
hemorrhage.

13. Several arterial anastomosis in the lower anterior region of
the mandible.
Anastomosis between sublingual and submental arteries in
the mylohyoid muscle is also reported in literature. However,
their anatomical variations were highly debated.

14. In a study by Bavitz et al., in 53% of cases sublingual artery
was either small, unimportant or absent.
In another study by Hofschneider et al., 29% of cases has
missing sublingual artery and 41% has large submental
branch in sublingual region.
Despite the differences, these arteries may lie superficially in
atrophic cases and can be a reason for hemorrhage during
implant surgery.

15. Accessory mandibular foramen
Few studies shows presence of multiple foramina in both the buccal
and lingual surface of mandible with varying in size, position,
distribution, etc.
The median lingual foramen is more commonly found and located
10 to 13.7mm away from the inferior alveolar border.

16. The lateral lingual foramen is 6mm away from the inferior alveolar
border.
The arteries associated with the accessory lingual foramina are
sufficient enough to cause severe hemorrhage during implant
surgery in inter-foraminal region of the mandible.

17. Preventive Measures
Proper Imaging
Due to anatomical variations in lower
anterior region, proper imaging is
necessary before implant placement to
prevent any possible injury or trauma.
Most commonly use imaging are:
IOPA
Occlusal view
OPG
CBCT

18. Implant Length
Implant length and angulations to be consider before implant
surgery in inter-foraminal region.
A distance of 2mm from the roof of the canal and a distance of
10-13.5mm from lower border of mandible (due to presence of
accessory lingual foramina) to be maintain as a safety margin.

19. According to some studies, most of the hemorrhagic
incidents were reported in the canine region with
osteotomy preparation of ≥15 mm depth.
Besides, digital palpation also help in anticipating the
occurrence of bony perforation during osteotomy
preparation.

20. Management
Airway management
Observation – observe any signs
and symptoms of airway
obstruction.
Nasotracheal intubation – intubation
either by blind or fibre optic assisted
within a limited time period.

21. Cricothyroidotomy — surgical cricothyroidotomy is
contraindicated and needle cricothyroidotomy is
indicated in children below 12 years of age.
Tracheostomy — most effective procedure in
preventing asphyxia and also indicated when
cricothyroidotomy is not possible.

23. Sometimes pulling the tongue out can reduce bleeding as
it may compress lingual artery against the hyoid bone.
Control of bleeding
Studies shows bimanual compressions with gauze over
the wound can achieve hemostasis to some extent.

24. Mechanical method
Sutures, ligating clips, gauzes, sponges, etc are successful in
achieving hemostasis but can only be use if the bleeders are
identified.
A study by Pigadas et al., states the need for drainage of
hematoma is necessary in achieving hemostasis, extraoral
approach is more preferred due to better visualization, retraction
and ease in ligation of arteries compare to intra oral approach.

25. A study by Pigadas et al., states the need for drainage of
hematoma is necessary in achieving hemostasis, extraoral
approach is more preferred due to better visualization, retraction
and ease in ligation of arteries compare to intra oral approach.
The submental artery is first ligated but if the bleeding does not
stop, then ligate the lingual artery (in Pirogoff’s triangle)

26. Thermal Method
Electrocautery, laser coagulation, etc are also effective in
controlling bleeding.
If the source of bleeding is from the inflamed vessels or
diffuse bleeding capillaries or from parenchymal tissues,
then chemical agents might prove to be more effective than
the above methods.

27. Topical hemostat like collagen, cellulose, gelatin, etc are
chosen for rapid arterial bleeding but for capillary
bleeding topical hemostats are the treatment of choice in
controlling bleeding.

28. According to a study by Lee et al. Floseal (contain
thrombin) controls acute bleeding from anterior MIC
(mandibular incisive canal) during implant surgery.
Moreover, ease of application of topical hemostat also
makes it a preferable option.

29. If all the above methods fail to control bleeding then ligation
of external carotid artery may be necessary.
Recent advances like use of endovascular angiography for
exact location and isolation of bleeding sources and super
selective catheterization of bleeders can be used.

30. They are used as an alternative measures in the management
of severe iatrogenic bleeding during or after surgical
procedures.

31. CONCLUSION
Implant placement in lower anterior region is often preferred
due to the favorable location and easy visualization.
However, due to various reported cases of disastrous
hemorrhagic accidents, all applicable preventive measures
are to be followed while placing implant especially in this
region to avoid life threatening complications.

32. If all adequate measures for diagnosis and treatment planning
are followed lower anterior region is no doubt a preferable area
for implant placement.