口腔种植学是口腔教育中较新的学科。虽然现在我们都有共识，种植⽛相关的理论知识，⽆论是治疗⽅案的规划，还是后期的随访和维护，对于每⼀个职业⽛医都⾮常重要。然⽽，在当下全球的口腔医学本科培养体系中，它的覆盖程度还远远落后于其重要性。 在此背景下，香港大学口腔医学院联合⾹港⼤学的线上教育专业团队，历时⼀年有余，设计并制作了这门为期五周的⽹络公开课，旨在传播以循证医学为基础的，客观、全⾯的⽛种植学相关知识。这门课程⾯向全球，双语教学，完全免费。学员将在20 多位全球领先的种植学专家的带领下，完成五个模块，系统地学习⽛种植学。
手术后并发症
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En provenance du cours de The University of Hong Kong
口腔种植学 （Implant Dentistry）
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À partir de la leçon
种植牙手术
第3模块的课程将关注种植体的植入。我们将讨论植入方案，以及常见的重要临床决定，例如种植体植入的时间等。我们还将探讨在后期手术治疗期间的预期，包括并发症和风险。除了理论知识，本模块还包含一系列临床应用视频，详细介绍手术设置，手术技术，植入步骤和缝合技术等。
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Nikos MattheosClinical Associate Professor in Implant Dentistry
The University of Hong Kong
Good day. Welcome to this session on "When Implants Go BAD!"
We're not here to scare you but,
yes, we are here to scare you!
Things can go bad if you do it for long
enough and you do it enough times.
This is a very big topic, so today,
we're really going to be only concentrating on some
of the more common surgical complications.
Now, what is a complication?
Well, it's defined as an unanticipated problem
that arises following, and is a result of,
a procedure, a treatment, or illness.
Well, if you look at surgical complications,
I guess, probably the worst thing is
the patient can actually die from it,
from what you do, and, believe me,
that has actually happened a number of times
around the world, but we won't go into that
because they are certainly fairly rare
occurrences, so we're not going to cover that today.
Then, of course, the next most distressful
situation for surgeons, as well as, patients
alike, is, generally, haemorrhage.
I mean, to a patient, bleeding is something
that is very, very distressing,
and something that we should know about.
Now, we are certainly not talking about
bleeding, like in this situation here, where
you can actually see the blood squirting out:
"This is an action shot!"
That is really an intraoperative inconvenience
and it'd probably just slow us down, maybe
10, 15 minutes, we have to stop the bleeding
before we get back to what we have to do.
We're also not talking about this sort of scenario.
These are, basically, just severe bruising, and
that can happen to a perfectly healthy patient.
It can also happen to just any normal,
totally uneventful surgical procedures.
So as long as you warn the patient
beforehand, this is really not
a complication here, in any shape or form.
Now, this is, perhaps, the kind of scenario
where we create dangerous situations.
When you pick up an OPG and you say,
"Nope, might be a bone, I can put some
implants in there and that's easy."
That's exactly the kind of situation where we
end up with these sorts of problems.
Life threatening haemorrhage, haemorrhage
of the mouth, severe haemorrhage,
emergency tracheostomy, near fatal
airway obstruction, this is serious
haemorrhage we are dealing with here.
And as you can see, the list goes on and on and on,
and fortunately not too many of these patients actually
end up dying, but certainly, they come close to it.
So, what actually happens here?
So, if you didn't expose the surgical site properly,
and you just placed the implant, you think
you're very good, and there's haemorrhage of
the floor of the mouth from perhaps just even
very small lingual perforation during implant placement.
And that's exactly what the problem is,
because there's very little bit of bleeding
and that's why you don't realize it's there.
You suture up, send the patient home,
and the problem is identifying the problem.
The patient goes home, it's slow
progressive post-operative haemorrhage,
and generally the patient won't be,
because you already told them they're
going to get some swelling, so they do not
contact you for a day or two, and
slowly, with the haemorrhage with the
haematoma building up, the floor of the
mouth is lifted up, and it causes an
elevation of the tongue, and very quickly,
it can obstruct a patient's airway.
And that very quickly becomes life threatening.
The fact that it is undiagnosed,
the further it is undiagnosed,
the more dangerous that becomes.
Obviously, a thorough understanding of
the anatomy of this area will reduce
the incidence of these sorts of problems.
This is why we conduct cadaver workshops.
Now, how to manage this is certainly way
beyond the scope of these types of sessions here.
I'll refer you to a chart provided by a
good friend of mine, Dr. Lydia Lim.
You know, if you really want to learn this,
you would have to attend a proper training course.
In fact, that's what the oral surgeons are trained to do.
So, if you're going to do these sorts of procedures,
I suggest you have a very good working
relationship with your oral surgeon,
because one day you might just need them
to help you get out of trouble.
Well, you haven't killed your patient,
your patient hasn't bled to death,
probably the next most distressing thing
would be if you injured a nerve.
The patient rings you up and says,
"I got a numb lip" or a numb cheek or whatever.
Now, if you look up these statistics on
some of these publications here,
this is a publication that covers well over
200 publications on implant complications,
if you look at the figures, 7% incidence of
neurosensory disturbance, that's actually very high.
I've certainly never seen that in my practice.
Now, when we talk about trigeminal nerve injury,
the first thing we tend to think of is injury
to the inferior alveolar dental nerve.
But, one thing we also forget is
the infraorbital nerve, that can also be
quite easily injured if you are perhaps
just doing a releasing incision, when
you're doing soft tissue grafting or
guided bone regeneration procedures.
When we look at the inferior alveolar nerve
injury, the most common, of course,
we are talking about actually direct
injury to the nerve and usually
it's with the drilling during the osteotomy preparation.
Of course, the severity of that depends on
how much you actually traumatize the nerve.
Unfortunately, that's often, it can certainly be permanent.
It can also have a haematoma formation
and that leads to, fortunately, in most cases,
a transient neurosensory disturbance.
These next two, the down fracture
and bone formation are certainly less
common causes of neurosensory disturbance.
Now, this is a pre-operative CT scan of
a patient that was treated by a very caring,
and certainly very meticulous general practitioner
who was going to operate in the right mandible area.
The purple dots were the areas identified by the
radiology center as where the inferior alveolar nerve is.
Now, post-operatively, when the problem happened,
I was asked to look at this case and I actually
plotted where I think the actual nerve is,
which is a somewhat different position.
So, unfortunately, this particular clinician
actually went ahead and used the radiologist's
measurements and actually placed the implants.
Well, unfortunately, both of those implants ended
up partially or almost completely in the nerve.
Now, surprisingly, the first question this
clinician asked me was, "Shouldn't the radiologist
be responsible in some way?"
I said, my answer was, "Excuse me,
Doc, who did the drilling?"
So, I think it's pretty obvious that the lesson here
is never trust anyone but yourself.
If you are the one drilling, you are the one
responsible for what happens.
So, next time, before you tackle your next case,
particularly if it's a complex case,
ask yourself these questions:
Are you aware of the potential complications?
And are you capable of managing
these complications if they occur?
The honest answer from yourself
to these questions will probably determine
how soon or when you get your next complication.
Good luck, and let's see.
Hopefully you have a lot of happy patients!
See you next time!
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