Risks and complications

Surgical complications are inevitable during a career in surgery. A complication rate of 2% means that 1 in every 50 patients will experience complications. For clinicians, this means a 98% success rate. But for every 50^th patient, it means a 100% complication rate. The speaker recommended that we always consider such statistics from the patient’s perspective. Most complications can be prevented by controlling local and general contributing factors.

“A complication rate of 2% means that 1 in every 50 patients will experience complications”

Haemorrhaging is an immediate complication which every surgeon should be able to manage. All surgeons should:

• be familiar with anticoagulants and drug interactions
• be able to diagnose the individualised anatomy of the surgical field
• be able to prevent haemorrhage in the submandibular-sublingual space with lingual protection when drilling, since it should be considered as a life-threatening emergency

In order to reduce the risk of potential mandibular fracture in highly atrophic cases, it is important to preserve the mandibular structure; not drill through the lower border; not place too many implants; and ensure that there is adequate distance between implants.

Regarding nerve injuries, most cases reported as a consequence of implant surgery refer to mandibular nerve damage (up to 30% – a very worrying figure). The key is to act as soon as the injury is suspected, remove the implant(s) within 12–30 hours and refer the patient for further management. Another related issue is neuropathic pain, a neurosensory disturbance which is often caused by nerve injuries but sometimes arises from an obscure.

“The key is to act as soon as the injury is suspected”

Grafting complications can be summarised as:

• wound dehiscence, caused by poor technique, tension across the suture line or contamination/necrosis of the augmented material
• perforations of the Schneiderian membrane, a very frequent complication which may lead to release and dissemination of the graft material throughout the sinus and to sinusitis
• unrealistic expectations, the most common of which is what can be achieved by GBR

Whilst penetration of the sinus floor by an implant is unlikely to cause clinical signs or symptoms, in cases of reduced residual alveolar height and compromised implant stability, displacement of the implant into the sinus is a risk. Loss of an implant or grafting material into the sinus will often require ENT intervention.

Poor implant positioning is the most common complication and it is almost always caused by the surgeon, either because of lack of planning, disorientation, or inadequate skill. This can lead to long-term problems such as functional deficit, aesthetic compromise or higher risk of biological complications. Implant removal to correct these issues is rarely a simple treatment.

“Poor implant positioning is the most common complication”

The treatment of surgical complications means that the patient must undergo more surgery; the site will become even more compromised; and there will be even more risk with subsequent procedures.

The impact of a complication is far-reaching. For the patient, they are affected not only physically but also psychologically and financially. For the surgeon, they are affected psychologically, legally and financially; their reputation will also be affected. There is therefore a lot to gain by preventing complications in the first place. This requires:

• comprehensive patient assessment
• restoration-driven preparatory planning
• competent and aseptic surgical technique

Checklists are highly recommended for preventing complications. The speaker said that surgical error is the final result of several factors that coincide, and compared the situation to the holes in Swiss cheese, which come together to be aligned by chance (Figure 1).

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