Trigeminal (TG) nerve injury is a common cause for complaints by patients left with lifelong orofacial neuropathy after dental treatment.1–3 TG injuries are characterized by neurosensory disturbances, such as pain, numbness or altered tingling-type sensations (paresthesia), within the teeth, skin, and the mucosa.4–7 The inferior alveolar nerve (IAN), mental nerve (MN), and lingual nerve (LN) are the most commonly damaged nerves during dental implant treatment6,8–12 with some studies reporting an incidence rate of up to 40% of nerve damage after implant placement surgery in the mandible related to the depth and the width of the implant bed preparation.8,11,13–20
Local anesthetic (LA) injections also cause TG damage due to mechanical or chemical injury.8,20–24 Hemorrhage within the inferior dental canal can cause chemical nerve injury (related to the iron content in the hemoglobin directly irritating the nerve tissue) or damage due to direct mechanical pressure and indirect ischemia.22,24–26 TG injury may also be caused by bone graft harvesting,27 third molar surgery, endodontics, ablative surgery, trauma, thermal stimuli and ischemia, and orthognathic surgery, or a combination of these etiologies.3,4,8,11,24,28–34
Iatrogenic TG injuries may result in a neurological deficit ranging from total loss of sensation (anesthesia) to a mild decrease in feeling (mild hypesthesia), troublesome altered sensation (dysesthesia),4,35–39 whereby up to 70% of the affected patients can have pain.4 These symptoms may be constant, spontaneous, or evoked (allodynia is a pain response to a normal stimulus) and interfere significantly with everyday functions such as speech, eating, kissing, among many others.4 Thus, these injuries have a significant negative effect on the patient's self-image, quality of life, and significant psychological effects that may include suicidal thoughts because of their pain.20,40,41 The consequences of implant therapy can be devastating for these patients as the treatment results of IAN injuries are also often disappointing.42
Adjunctive procedures are also sometimes attempted to avoid implant nerve injury.43 However, previous studies have indicated that regardless of the surgeon's experience, these high-risk procedures that include bone graft harvesting, posterior alveolar distraction, and nerve lateralization may be more likely to result in injury themselves.11,27,44–47 The most significant issue with dental implant nerve injuries is that higher standards of planning and care would minimize the chances of nerve injuries from occurring.48,49
A recent study showed an alarming lack of written consent for relatively high-risk elective surgery of implant placement in the mandible.48 However, an informed consent process based on adequate assessment, diagnosis, and treatment planning is crucial particularly in high-risk cases.48,50–53 The Association of Dental Implantology (ADI) of the United Kingdom, Faculty of General Dental Practice (FGDP) as well as other international associations such as the Academy of Osseointegration (AO), International Congress of Oral Implantologists (ICOI), the International Team for Implantology (ITI), and the American Academy of Implant Dentistry (AAID) all regularly publish guidelines12,51,54–56 on implant surgery and minimum requirements for diagnostic elements. It is not clear, however, as to whether every clinician who practices the placement of implants follows these guidelines. Studies into whether patients are consented appropriately with respect to iatrogenic nerve injury related to implant dentistry also need to be carried out.
This study aimed to specifically explore the opinion and clinical experiences of a cohort of experienced implant dentists on the incidence and cause of TG injury related to implant surgery in the United Kingdom.
A questionnaire was designed in accordance with the aims of the study, using online software hosted by SurveyMonkey (surveymonkey.com, London).57 The questionnaire consisted of 41 questions, which were adapted from a previous study.22 The questionnaire was piloted to improve the accuracy and clarity of the questions. The dentists who took part in the pilot study did not complete the final version of the survey.
All dentists (n = 405) attending ADI's national congress on dental implantology were invited to complete the survey. Reminders were issued throughout the congress held between May 1, 2013 and May 3, 2013 to encourage maximum participation. To reduce sampling bias, nonattending members of ADI were also invited to participate through electronic postings. Finally, members of the British Association of Oral Surgeons (BAOS) were invited to complete the online questionnaire. Within the framework of this survey, a dentist was defined as experienced in implant dentistry if they had any postgraduate training in implant dentistry (eg, Postgraduate [PG] Diploma) and had placed more than 100 implants in total. Only dentists who placed implants in the posterior mandible (irrespective of their experience level) were admitted to the study. The study closed on 30th May 2013.
Responses were collected using the SurveyMonkey (surveymonkey.com) software. The system was set to disallow multiple responses per e-mail address but to allow the participants to re-enter the survey and update their responses at a later date. Data were exported into Excel (Microsoft Version 2011) and/or the “Statistical Package for Social Sciences” (Version 22; SPSS Inc., Chicago, IL) format and analyzed using descriptive and frequency analysis statistics.
General Demographics of the Responders
One hundred eighty-seven of 405 dentists (46.2%) responded to the survey. The most frequent age group of the respondents was 40 to 49 years (n = 61), followed by 50 to 59 years (n = 53), and 30 to 39 years (n = 46). Seventeen were between 60 and 69 years and 3 were between 70 and 80 years of age. Most respondents were in full-time general practice followed by those in specialist practice and practice limited to implantology. Oral and Maxillofacial Surgery (the specialty of Oral Surgery [OS] in the United Kingdom requires a single dental degree, whereas the separate medical specialty of Oral and Maxillofacial surgery [OMFS], requires both dental and medical degrees) represented the largest group of specialists (n = 33, OS, and n = 4, OMFS). Other specialties included prosthodontics (n = 10), periodontology (n = 11), restorative dentistry (n = 4), and endodontics (n = 3).
Postgraduate training of the participants in implant dentistry
Although the training was dominated by industry-organized courses (42%), 40 of the 164 respondents (24%) had specialty training in an allied discipline (eg, prosthodontics, periodontology, or oral surgery), 43 (26%) had completed an accredited certificate course, and 77 (47%) had a Postgraduate (PG) Diploma or MSc in implant dentistry.
The surgical implant experience of the participants
Total implant experience estimated by the respondents ranged between 164,350 and 288,000 implants, with 62 responders placing up to 50 implants in total annually (Fig. 1). Experience of implant placement within the mandible indicated that 19 placed less than 10 implants per annum on average, followed by 46 who placed up to 25 implants per annum. Between 25 and 200 mandibular implants were placed by 99 (58%) responders. Seven practitioners reportedly placed between 201 and 300 mandibular implants. Only one practitioner reported placing more than 500 mandibular implants.
Consent Process for Implant Placement in the Posterior Mandible
Determination of treatment needs index and/or complexity of treatment
Fifty-nine of the 144 responders (41%) used SAC classification (ADI Guidelines on Implantology, 2012),54 whereas 60 (42%) said that they followed FGDP Guidelines on Training Standards in implant dentistry58 to determine whether the complexity of a given case fell within their level of clinical competence or experience. Cologne ABC risk assessment scores59 was used only by three responders. Forty-three (30%) responders did not carry out any risk or complexity assessment before obtaining consent for surgery.
One hundred responders used an individualized, case-specific, consent letter, whereas 55 relied on a proforma consent form that included a general warning about common complications. Seventy-five percent of the 187 participants thought it to be essential to disclose the relative risk and benefits of alternative implant treatment strategies as part of the informed consent process.
Disclosure of possible risks and complications
A minority included warnings of specific complications only if the safety zone was <4 mm (Table 1). The possible adverse effects of TG nerve damage on quality of life, interference with applying make-up, or speaking and kissing were not routinely disclosed to the participants.
Use of articaine in inferior dental blocks
Ninety-three reported that they do not use articaine in inferior dental blocks (IDBs), whereas 31 did use articaine in IDBs.
Ninety-two of 128 responders (72%) indicated that they do home checks 6 to 12 hours after surgery for the early identification of inferior alveolar nerve injury (IANI). Other measures included closely monitoring and controlling postoperative infection after operating in the posterior mandible (58%), removing the implant (38%), and referral for immediate management by an expert/specialist (37%), as soon as IANI is diagnosed. Some dentists indicated that they would decompress the nerve (19.5%) and 20 others (15.6%) indicated that they would observe and monitor the nerve injury for a few weeks before deciding on any definitive surgical intervention to see whether the injury would heal spontaneously.
TG Nerve Injuries Related to Implant Surgery in the United Kingdom
Respondents' experience of nerve damage
Most respondents (94% of 128 responses) stated that they did not experience any IANI (63%) or lingual nerve injuries (LNIs) after implant surgery. Forty-three (23%) participants did, however, encounter between 1 and 5 IANIs compared to seven participants (4%) who saw 1 to 5 LNIs associated with implant treatment. No dentists saw more than 6 LNIs related to implant placement, but very small numbers of dentists did encounter between 6 and 10 or 11 and 20 implant-related IANIs (n = 3 and n = 2, respectively). Many of these injuries were of immediate onset (54%). Twenty-eight percent of IANIs and 79% of LNIs were permanent.
Causes of implant-related TG nerve injuries
Inaccurate radiological identification of the IAN/MN and their anatomical variations (48%; Fig. 2) were seen to be the most frequent cause of IANI according to 54 responders.
Local Anesthetic (LA)-related IANI
One hundred thirty-two responders did not encounter any LA-related IANI. Respondents' experience of the main predictors of nerve damage related to LA during dental implant surgery is summarized in (Fig. 3). The LA infiltration-only technique was used by 70 responders for implant placement surgery in the posterior mandible, and 49 used it only in selected cases. Articaine was the most frequently cited LA used for infiltration in the posterior mandible, at 69 responders, followed by lignocaine (46 responders). Although the infiltration-only technique was stated to be always effective by 84 responders, 22 stated that the technique sometimes failed to achieve adequate anesthesia and 9 reported that it was not always very effective.
Symptoms experienced by the patients with IANI reported by the respondents are shown in (Fig. 4).
The response rate in this survey was at an average of 46.2%. This may be due to relatively low number of implants being placed by a relatively small number of dentists in the United Kingdom. Most responders were general dental practitioners who were rated to be “experienced” and had received structured implant training.
Incidence of TG Injuries
The incidence of dental implant-related nerve sensory damage (NSD) has been shown to be as high as 40% in past studies8,11,13–20 although at least one prospective large cohort study has shown that risk of TG injuries can be eliminated with meticulous attention to planning and observing good surgical protocols.60 Nevertheless, the large variation in the reported incidence of NSD suggests that this serious complication of dental implant surgery has not yet been adequately evaluated and reported.61
The results of this study suggest a lower incidence of NSD related to dental implants than that has been reported in the literature.8,11,13–20 This may be due to majority of the responders being relatively experienced surgeons in implant dentistry. Furthermore, a high percentage of the responders appeared to have some risk management strategies in place to reduce the risk of TG injuries. These include allowing a “safety zone” of 2 to 4 mm between the apex of the implant and the nerve and using shorter implant lengths of 10 mm or less when bone height is restricted. It is also possible that the LA techniques and drugs reportedly used by the participants may have had an influence on the lower incidence of NSD. A shortcoming of this study was that the participants were not specifically questioned whether the location and/or number of implants might have been associated with NSD in their experience.
Symptoms Experienced by the Patients
The NSD reported by the participants in this study are consistent with the literature, which shows that TG injury after implant placement is a serious complication that can have a profound negative effect on the well-being, psychological health, and quality of life of the patients.4,20,40–42
Cause of Injury
Inaccurate radiological identification of the IAN/MN (and their anatomical variations) was cited as the most frequent cause of IANI in this study. This is supported by the literature and highlights that cone beam computer tomography (CBCT) could play an important role in reducing the risk of TG damage, thus significant morbidity.62 In this respect, it is important to note that the American Academy of Oral and Maxillofacial Radiology (AAOMR), in their revised evidence-based position statement on the selection criteria for radiology in implant dentistry, recommended that cross-sectional imaging (CBCT) should be used for the assessment of all dental implant sites.63 Another weakness of the current study was that a possible correlation between the use of CBCT and the reported incidence of nerve damage was not investigated. The role of CBCT in this respect should be made a priority of future studies.
Preoperative Risk Assessment
Thirty percent of dentists admitted that they did not carry out any risk or complexity assessment before obtaining consent for an elective procedure of relatively high-risk implant placement surgery in the posterior mandible, despite clear guidelines to the contrary.51,59 This finding is consistent with a recent Italian study which concluded that, in just over 50% of the malpractice claims investigated, a large number of surgical errors were responsible for the high proportion of injuries to vital structures such as IAN 32.2% and LN 2.5%.64 The researchers have reported that in 54.5% of these cases, incomplete clinical documentation and preoperative planning were evident. It is particularly striking to note that dental implant-related NSD could be completely avoidable28 because the current evidence suggests that these injuries are commonly caused by surgical errors that are directly associated with insufficient preoperative assessment or planning.48 Inadequate radiological imaging and/or violation of established protocols and good practice guidelines published by ITI,53 AO,51 ICOI,12 ADI,54 and European65,66 seem to be responsible for these complications.10,28,52,63,66–68
The current study is consistent with the literature in suggesting that risk assessment, treatment planning, and the consent processes performed by the implant dentists may be short of the best practice guidelines in implant dentistry. This was also shown by Strietzel (2003) who documented generally insufficient patient information, during consent, on the nature of the procedure, its financial considerations, or alternatives.69 The clinician has the responsibility to recommend the best evidence-based treatment that is most appropriate to each individual patient needs and disclose all possible risks (eg, in the context of IANI; altered sensation and/or chronic neuropathic pain that may affect their daily functions and quality of life), and the alternative procedures (eg, bone grafting vs shorter implants) before proceeding with implant treatment.14,48,50,70–72 As the failure to carry out adequate examination and risk assessment and failure to conform to best practice guidelines could invalidate the consent process and lead to malpractice claims, this practice needs to be investigated in future studies and should be made a priority in training of implant dentists.
Radiological Assessment of the Implant Site
Panoramic radiographs are safe and reliable techniques for assessing bone height and space when there is sufficient bone above IAN to allow an adequate margin of safety for implant placement.60 Bartling et al (1999)17 recommended that a safety margin wider than 2 mm should be allowed when relying only on a panoramic radiograph. Kuzmanovic et al (2003)71 showed that 62% of the anatomically identified mental loops were not observed on panoramic radiographs. Similarly, a CBCT study73 found that it was not safe to use an arbitrary safety margin (of 2–4 mm) and recommended that individual assessments should be made on a case-by-case basis. Clearly, clinicians should pay attention to the likely location of vital anatomical structures and their possible variations when selecting and justifying the most appropriate method of diagnostic imaging in the mandible.74
Although the respondents believed that insufficient preoperative assessment and planning was the most common contributing factor for nerve damage, they used CBCT only infrequently. This may be because a clinically significant benefit of CBCT has not yet been shown definitively, and the risks may still be seen to outweigh the benefits.
Currently, there are many clinical situations in which CBCT would be highly desirable or strongly indicated for optimal preoperative implant planning, and such practice could help to reduce the risk of collateral damage occurring to adjacent vital structures.63,75 Moreover, CBCT data can be of further use in 3-dimensional (3D) implant navigation surgery as well as in digital workflow for the prosthetic construction. In many cases, this could change the risk/benefit analysis when selecting/justifying the diagnostic imaging method especially if the radiation is reduced further by selecting smaller field of view (FOV).76 Though, CBCT is still a highly invasive radiological technique and therefore it is recommended only as a supplementary method in implant planning by most dental organizations.12,51,53–56,66,68,77
Nevertheless, the current results and literature support the view that CBCT should be considered as the choice of diagnostic imaging when planning implant treatment in close proximity of the vital structures particularly when there is restricted bone quality or quantity.63 Additional benefits of CBCT would include the use of computer-aided design or computer-aided surgical guide manufacturing, using dynamic navigation surgical techniques,78 determination of the length and width of the implant to be placed,79–81 and identification of anatomical variations and locating nutrient canals. However, dental practitioners should prescribe CBCT imaging only when they expect that the diagnostic yield will benefit patient care, enhance patient safety, or improve clinical outcomes significantly.63,77,82
The outcome of IANI can be devastating for the effected patient. This study fortunately showed relatively low incidences of implant-related IAN and LN injury. This may have been due to many of the respondents being experienced who used some risk management strategies and had formal training in implant dentistry at Postgraduate Diploma/MSc level.
Surgeons in this survey predominately believed that nerve damage was caused as a result of inaccurate radiological identification of the IAN and MN. The study also highlighted that risk assessment, treatment planning, and the consent processes performed by implant dentists may be short of the best practice guidelines in implant dentistry.
In view of the findings of this study and the accumulating evidence for the use of 3D imaging in implant dentistry, the authors recommend the use of small FOV CBCT when operating in close proximity of vital structures in the mandible to accurately localize these structures and to select the optimum implant site and dimensions with an adequate safety margin. When doing so, established diagnostic imaging selection and justification criteria should be carefully considered with special reference to case-based risk/benefit analysis. Additional studies are indicated to show a definitive clinical significance for using CBCT in reducing the risk of TG nerve injuries in implant dentistry.
The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
The authors would like to thank the ADI for providing the funding that helped the progress of this project.
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