Screwdriver aspiration A complicationof dental implant placement
Michael Bergermann 1, Paul d. Donald 2, Daniel F. ~Wengen 1University of California, Davis Medical Center, and 2Department of Otolaryngology - Head and Neck Surgery, Center for Skull Base Surgery, University of California, Davis, California, USA
M. Bergermann, P. J. Donald, D. E glWengen: Screwdriver aspiration. A complication of dental implant placement. Int. J. Oral Maxillofac. Surg. 1992; 21: 339-341. © Munksgaard 1992
Abstract. Endosseous implants are part of the prosthodontic rehabilitation of patients who have undergone radical t u m o r resection in the oral and maxillofacial area. Several complications arising from the use of these implants have been reported. Intraoperafive aspiration of a screwdriver as a rare and life-threatening complication is presented. It was followed by a chain of further complications including pneumothorax, late laryngeal obstruction requiring tracheotomy, and pleural effusion requiring drainage. To prevent similar complications, we reco m m e n d general anesthesia when placing dental implants in patients who have previously undergone extended radical t u m o r surgery of the oral cavity.
For patients who have undergone radical resection of a malignant tumor in the oral cavity, an important part of functional and cosmetic rehabilitation is prosthetic reconstruction with either fixed or removable dentures s. During the last 20 yea~s, the use of osteointegrated dental implants has gained rapid and widespread acceptance in the treatment of edentulous patients. Long-term follow-up studies have demonstrated a high success rate 1,2,4. The use of osteointegrated implants was extended for percutaneous fixation of facial prostheses and hearing aids 3. The placement of osteointegrated implants in bone grafts and even in previously irradiated bone has been recommended 5,9. These implants can also provide patients with improved prosthetic rehabilitation after having been cured of a malignancy of the oral cavity. Over the last 2 years, placement of Brfinemark titanium endosseous implants (Nobelpharma Company, Gothenburg, Sweden) has become a routine procedure in the rehabilitation of US tumor patients. Several authors have discussed various complications arising from the use of endosteal implants, including mental nerve disturbances, implant loss, mandibular fracture, and life-threatening hemorrhage 6,7. An unusual life-threatening complication is presented that was followed by a chain of further complications. The management of these complications is described.
Case report M.S., a 69-year-old white woman, underwent transmucosal fixation of abutments of the Brfinemark system under local anesthesia. Two years before this, she had undergone resection of a squamous cell carcinoma of the anterior floor of the mouth (T2N2M0) with composite resection of the interforaminal part of the mandible, bilateral resection of the anterior floor of the mouth, and radical neck dissection on the right side. The tongue and the floor of the mouth were reconstructed with a pectoralis major musculocutaneous flap. Eight months later, the mandible was reconstructed by cancellous iliac bone graft in a Dacron tray. Eighteen months after tumor surgery, four BrSnemark implants were placed into the reconstructed mandible under general anesthesia. Six months later, the patient was scheduled for placement of the abutments under local anesthesia and sedation. She was otherwise healthy and did not use any medication. Preoperative EKG, chest radiograph, complete blood cell count, and serum chemistry were within normal limits. The mandibular implants were all covered with mucosa. The patient had a fully intact dentition in the maxilla. Although she had some trismus, there was enough space between maxilla and mandible to handle the instruments of the Br~nemark system. Intraoperative exploration showed all cap screws to be covered with bone. This bone had to be drilled away to expose the implants. Because of this unexpected procedure, duration of surgery was longer than anticipated. The patient's trismus precluded optimal mouth 'opening during this prolonged procedure. Because of her increasing fatigue and discomfort, it was decided to conclude the
Key words: mandible reconstruction; endosseous implants; aspiration, foreign body. Accepted for publication 3 September 1992
procedure and to complete the surgery under general anesthesia in a second stage. The previously removed cap screws were relocated. Because of the patient's decreasing ability to keep her mouth open, it became more and more difficult to handle the instruments in the oral cavity. A mouth prop was not tolerated by the patient. The Br~nemark screwdriver (Fig. 1), which is 24 mm long, slipped into the floor of the mouth and disappeared in the pharynx as, at one point in the procedure, the patient sat bolt upright. She appeared to have swallowed the instrument. She did not cough or show any other signs of aspiration or respiratory distress. An im-
Fig. 1. Screwdriver of the Brfinemark system (length in mm).
340
Bergermann et al.
Fig. 2. Intraoperative chest radiographs showing aspirated screwdriver in right main bronchus. A) Front view; B) lateral view.
mediate chest radiograph located the screwdriver in the right main bronchus (Fig. 2). The patient was intubated immediately. Removal of the foreign body by rigid bronchoscopy was done on the first attempt. The postoperative course was complicated by an extended contralateral pneumothorax, which was treated with thoracocentesis and placement of a water-sealed chest tube. In addition, the patient developed an acute airway obstruction during the following night because of swelling of the laryngeal mucosa. An emergency tracheotomy was performed under local anesthesia. After removal of the chest tube, the patient developed an extended pleural effusion, which needed drainage. The patient recovered from all these complications, and the abutments were placed under general anesthesia. She was sent home 14 days after the first procedure. Discussion
The implantation of dental fixtures for the rehabilitation of oral cancer patients has been an enormous stride in their functional and cosmetic rehabilitation. With the Brgmemark system, the surgical stages consist of an initial, relatively complex stage in which the fixtures are implanted in mandibular bone. A second, relatively simple stage is performed once the fixtures have been osteointegrated. A gingival flap is raised, the cover screws are removed, and the abutment cylinders, to which a dental prosthesis will eventually be fixed, are applied. The fixed gingiva around the cyl-
inders is reshaped and surgically adapted, and healing caps are placed over the abutments. In the usually edentulous patient, both stages can easily be performed under local anesthesia. In patients who have had oral cancer, especially those with mandibulectomy, both stages of the implantation procedure are much more difficult. Because of trismus, scar tissue, and the redundancy of reconstructive flaps, the ability of the patient to withstand the forces of retraction necessary for adequate exposure are often limited. Even with excellent local anesthesia and sedation, the pain in the temporomandibular joints, muscles of mastication, and upper cervical tissues cannot be totally ameliorated in these cases. The tools for the implantation procedure are necessarily small and may slip from the fingers. This is not a problem if the patient has a throat pack or a pharyngeal screen in place to prevent swallowing or aspiration. But, obviously, either the pack or the screen can be placed only in the intubated patient. The sudden sitting-up motion of this patient dislodged the screwdriver and was followed by its aspiration. As in this case, complications often release a cascade of subsequent problems; thus, vigilance is essential in the monitoring of such a patient. Performance of implant surgery in patients who have previously undergone
extensive resection in the oral and maxillofacial area and who have reduced mandibular opening is probably best done under general anesthesia. Once the patient is intubated, it is prudent to place a throat pack before initiation of the implant procedure. The accidental dislodgement of small instruments such as the screwdrivers or the fixture itself under local anesthesia in the difficult patient may result in aspiration with unfortunate sequelae. References 1. ADELL R, LEKHOLM U, ROCKLER B,
BP,~NEMARKPI. A 15-year study of osseointegrated implants in the treatment of edentulous jaws. Int J Oral Surg 1981: 10: 387~416. 2. ALBREKTSSONT. A multicenter report on osseointegrated oral implants. J Prosthet Dent 1988: 60: 75-84. 3. ALBREKTSSON T, BR.~NEMARK PI, JACOBSSONM, TJELLSTROMA. Present clinical application of osseointegrated percutaneous implants. Plast Reconstr Surg 1987: 79:721 30. 4. BRANEMARKPI, HANSSONBO, ADELLR, et al. Osseointegrated implants in the treatment of the edentulous jaw: experience from a ten-year period. Scand J Plast Reconstr Surg 1977: 111: 1-132. 5. JACOBSSONM, TJELLSTROMA, ALBREKTSSON T, THOMSEN P, TURESSON I. Integration of titanium implants in irradiated bone. Acta Otol Rhinolaryngol 1988: 97: 337-40.
Complication o f dental implant 6. MASONME, 'I~R1PLETTRG, ALFONSOWF. Life-threatening hemorrhage from placement of a dental implant. J Oral Maxillofac Surg 1990: 48: 201-4. 7. MASON ME, TRIPLETT RG, VAN NICKELS JE, PAREL SM. Mandibular fractures through endosseous cylinder implants: report of cases and review. J Oral Maxillofac Surg 1990: 48:311-17.
8. O'KEEFE GF, RIEGER WJ. Prosthodontic rehabilitation of the head and neck cancer patient. Semin Oncol 1988: 15: 86-99. 9. SCHMELZEISENR, HAUSAMENJE, NEUKAM FW, KAERCHERH, SCHELLERH. Microsurgical tissue reconstruction with osteointegrated dental implants. Presentation of a technique. Int J Oral Maxillofac Surg 1990: 19: 209-11.
Address:
Paul J. Donald, MD Department of Otolaryngology 2500 Stockton Boulevard Sacramento, California 95817, USA
341
Michael Bergermann 1, Paul d. Donald 2, Daniel F. ~Wengen 1University of California, Davis Medical Center, and 2Department of Otolaryngology - Head and Neck Surgery, Center for Skull Base Surgery, University of California, Davis, California, USA
M. Bergermann, P. J. Donald, D. E glWengen: Screwdriver aspiration. A complication of dental implant placement. Int. J. Oral Maxillofac. Surg. 1992; 21: 339-341. © Munksgaard 1992
Abstract. Endosseous implants are part of the prosthodontic rehabilitation of patients who have undergone radical t u m o r resection in the oral and maxillofacial area. Several complications arising from the use of these implants have been reported. Intraoperafive aspiration of a screwdriver as a rare and life-threatening complication is presented. It was followed by a chain of further complications including pneumothorax, late laryngeal obstruction requiring tracheotomy, and pleural effusion requiring drainage. To prevent similar complications, we reco m m e n d general anesthesia when placing dental implants in patients who have previously undergone extended radical t u m o r surgery of the oral cavity.
For patients who have undergone radical resection of a malignant tumor in the oral cavity, an important part of functional and cosmetic rehabilitation is prosthetic reconstruction with either fixed or removable dentures s. During the last 20 yea~s, the use of osteointegrated dental implants has gained rapid and widespread acceptance in the treatment of edentulous patients. Long-term follow-up studies have demonstrated a high success rate 1,2,4. The use of osteointegrated implants was extended for percutaneous fixation of facial prostheses and hearing aids 3. The placement of osteointegrated implants in bone grafts and even in previously irradiated bone has been recommended 5,9. These implants can also provide patients with improved prosthetic rehabilitation after having been cured of a malignancy of the oral cavity. Over the last 2 years, placement of Brfinemark titanium endosseous implants (Nobelpharma Company, Gothenburg, Sweden) has become a routine procedure in the rehabilitation of US tumor patients. Several authors have discussed various complications arising from the use of endosteal implants, including mental nerve disturbances, implant loss, mandibular fracture, and life-threatening hemorrhage 6,7. An unusual life-threatening complication is presented that was followed by a chain of further complications. The management of these complications is described.
Case report M.S., a 69-year-old white woman, underwent transmucosal fixation of abutments of the Brfinemark system under local anesthesia. Two years before this, she had undergone resection of a squamous cell carcinoma of the anterior floor of the mouth (T2N2M0) with composite resection of the interforaminal part of the mandible, bilateral resection of the anterior floor of the mouth, and radical neck dissection on the right side. The tongue and the floor of the mouth were reconstructed with a pectoralis major musculocutaneous flap. Eight months later, the mandible was reconstructed by cancellous iliac bone graft in a Dacron tray. Eighteen months after tumor surgery, four BrSnemark implants were placed into the reconstructed mandible under general anesthesia. Six months later, the patient was scheduled for placement of the abutments under local anesthesia and sedation. She was otherwise healthy and did not use any medication. Preoperative EKG, chest radiograph, complete blood cell count, and serum chemistry were within normal limits. The mandibular implants were all covered with mucosa. The patient had a fully intact dentition in the maxilla. Although she had some trismus, there was enough space between maxilla and mandible to handle the instruments of the Br~nemark system. Intraoperative exploration showed all cap screws to be covered with bone. This bone had to be drilled away to expose the implants. Because of this unexpected procedure, duration of surgery was longer than anticipated. The patient's trismus precluded optimal mouth 'opening during this prolonged procedure. Because of her increasing fatigue and discomfort, it was decided to conclude the
Key words: mandible reconstruction; endosseous implants; aspiration, foreign body. Accepted for publication 3 September 1992
procedure and to complete the surgery under general anesthesia in a second stage. The previously removed cap screws were relocated. Because of the patient's decreasing ability to keep her mouth open, it became more and more difficult to handle the instruments in the oral cavity. A mouth prop was not tolerated by the patient. The Br~nemark screwdriver (Fig. 1), which is 24 mm long, slipped into the floor of the mouth and disappeared in the pharynx as, at one point in the procedure, the patient sat bolt upright. She appeared to have swallowed the instrument. She did not cough or show any other signs of aspiration or respiratory distress. An im-
Fig. 1. Screwdriver of the Brfinemark system (length in mm).
340
Bergermann et al.
Fig. 2. Intraoperative chest radiographs showing aspirated screwdriver in right main bronchus. A) Front view; B) lateral view.
mediate chest radiograph located the screwdriver in the right main bronchus (Fig. 2). The patient was intubated immediately. Removal of the foreign body by rigid bronchoscopy was done on the first attempt. The postoperative course was complicated by an extended contralateral pneumothorax, which was treated with thoracocentesis and placement of a water-sealed chest tube. In addition, the patient developed an acute airway obstruction during the following night because of swelling of the laryngeal mucosa. An emergency tracheotomy was performed under local anesthesia. After removal of the chest tube, the patient developed an extended pleural effusion, which needed drainage. The patient recovered from all these complications, and the abutments were placed under general anesthesia. She was sent home 14 days after the first procedure. Discussion
The implantation of dental fixtures for the rehabilitation of oral cancer patients has been an enormous stride in their functional and cosmetic rehabilitation. With the Brgmemark system, the surgical stages consist of an initial, relatively complex stage in which the fixtures are implanted in mandibular bone. A second, relatively simple stage is performed once the fixtures have been osteointegrated. A gingival flap is raised, the cover screws are removed, and the abutment cylinders, to which a dental prosthesis will eventually be fixed, are applied. The fixed gingiva around the cyl-
inders is reshaped and surgically adapted, and healing caps are placed over the abutments. In the usually edentulous patient, both stages can easily be performed under local anesthesia. In patients who have had oral cancer, especially those with mandibulectomy, both stages of the implantation procedure are much more difficult. Because of trismus, scar tissue, and the redundancy of reconstructive flaps, the ability of the patient to withstand the forces of retraction necessary for adequate exposure are often limited. Even with excellent local anesthesia and sedation, the pain in the temporomandibular joints, muscles of mastication, and upper cervical tissues cannot be totally ameliorated in these cases. The tools for the implantation procedure are necessarily small and may slip from the fingers. This is not a problem if the patient has a throat pack or a pharyngeal screen in place to prevent swallowing or aspiration. But, obviously, either the pack or the screen can be placed only in the intubated patient. The sudden sitting-up motion of this patient dislodged the screwdriver and was followed by its aspiration. As in this case, complications often release a cascade of subsequent problems; thus, vigilance is essential in the monitoring of such a patient. Performance of implant surgery in patients who have previously undergone
extensive resection in the oral and maxillofacial area and who have reduced mandibular opening is probably best done under general anesthesia. Once the patient is intubated, it is prudent to place a throat pack before initiation of the implant procedure. The accidental dislodgement of small instruments such as the screwdrivers or the fixture itself under local anesthesia in the difficult patient may result in aspiration with unfortunate sequelae. References 1. ADELL R, LEKHOLM U, ROCKLER B,
BP,~NEMARKPI. A 15-year study of osseointegrated implants in the treatment of edentulous jaws. Int J Oral Surg 1981: 10: 387~416. 2. ALBREKTSSONT. A multicenter report on osseointegrated oral implants. J Prosthet Dent 1988: 60: 75-84. 3. ALBREKTSSON T, BR.~NEMARK PI, JACOBSSONM, TJELLSTROMA. Present clinical application of osseointegrated percutaneous implants. Plast Reconstr Surg 1987: 79:721 30. 4. BRANEMARKPI, HANSSONBO, ADELLR, et al. Osseointegrated implants in the treatment of the edentulous jaw: experience from a ten-year period. Scand J Plast Reconstr Surg 1977: 111: 1-132. 5. JACOBSSONM, TJELLSTROMA, ALBREKTSSON T, THOMSEN P, TURESSON I. Integration of titanium implants in irradiated bone. Acta Otol Rhinolaryngol 1988: 97: 337-40.
Complication o f dental implant 6. MASONME, 'I~R1PLETTRG, ALFONSOWF. Life-threatening hemorrhage from placement of a dental implant. J Oral Maxillofac Surg 1990: 48: 201-4. 7. MASON ME, TRIPLETT RG, VAN NICKELS JE, PAREL SM. Mandibular fractures through endosseous cylinder implants: report of cases and review. J Oral Maxillofac Surg 1990: 48:311-17.
8. O'KEEFE GF, RIEGER WJ. Prosthodontic rehabilitation of the head and neck cancer patient. Semin Oncol 1988: 15: 86-99. 9. SCHMELZEISENR, HAUSAMENJE, NEUKAM FW, KAERCHERH, SCHELLERH. Microsurgical tissue reconstruction with osteointegrated dental implants. Presentation of a technique. Int J Oral Maxillofac Surg 1990: 19: 209-11.
Address:
Paul J. Donald, MD Department of Otolaryngology 2500 Stockton Boulevard Sacramento, California 95817, USA
341
