Trephine burs are barrel-shaped burs that have various diameters.

The bur selected should be

slightly larger than the implant crest module because too large of a trephine bur will result in
excessive bone removal. Too small of a trephine may result in implant body particles being
removed and becoming embedded in the implant site. Copious amounts of saline should be
used to minimize thermal damage and the possibility of osteomyelitis. If the apex of the
implant is in approximation to a vital structure, the trephine bur should not be used at the
apex to avoid vital structure damage. After the implant is removed, the implant site should be
irrigated to remove any retained particles (Fig. 10.23).
Combination of Techniques: In some cases, it is prudent to remove bone one-half to three-
fourths the length of the implant (using a trephine, piezo, or high-speed bur) along with the
use of conventional extraction techniques or countertorque ratchet.
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Intraoperative Complications
Randolph R. Resnik, in Misch's Avoiding Complications in Oral Implantology, 2018
Mandibular Anterior: Intraosseous Vessels
Median Vascular Canal
On occasion, in the mandibular midline, copious bleeding may be present (e.g., “C” position,
even though no bone perforation has occurred). Bilateral sublingual arteries enter through the
lingual foramen within the lingual plate below the genial tubercles within the mandible. As
this anastomosis transverses within the anterior mandible, the canal is termed the median
vascular canal. Bleeding in this area may be significant; however, it is not associated with
any type of neurosensory impairment.
Prevention.
The presence and size of the sublingual anastomosis and the median vascular canal is easily
seen on a cross-sectional or axial image of a CBCT scan. The position of the
planned osteotomy may need to be modified if a significant anastomosis is present.
Management.
If significant bleeding occurs after implant osteotomy, a direction indicator or surgical
bur can be placed in the osteotomy site to apply pressure. If the osteotomy is completed, an
implant may also be introduced into the site, which will compress the walls of bone, thus
slowing the bleeding process (Fig. 7.20). In most cases, intraosseous bleeding is more easily
controlled in comparison to soft tissue hemorrhage.
Inferior Alveolar Artery
The inferior alveolar artery is a branch of the maxillary artery, one of the two terminal
branches of the external carotid. Prior to entering the mandibular foramen, it gives off the
mylohyoid artery. In approximately the first molar region, it divides into the mental and
incisal branches. The mental branch exits the mental foramen and supplies the chin and lower
lip, where it eventually will anastomose with the submental and inferior labial arteries.
Prevention.
The exact location of the inferior alveolar artery is easily determined via a CBCT evaluation
in the panoramic or sagittal views.
Management.
Normally, the inferior alveolar artery is located superiorly to the inferior alveolar
nerve within the bony mandibular canal. Drilling or placing an implant into the inferior
alveolar canal may predispose to significant bleeding. Hemorrhage may be controlled by
placement of an implant or direction indicator short of the canal. A 2.0-mm safety zone
should be adhered to. If bleeding does occur, follow-up postoperative care is essential
because hematoma formation within the canal may lead to a neurosensory impairment. This
condition should be monitored because it may progress to respiratory depression via a
dissecting hematoma in the floor of the mouth (Fig. 7.21).
Incisive Artery
The incisive artery is the second terminal branch of the inferior alveolar artery, which is a
branch of the maxillary artery. The incisal branch continues anteriorly after supplying in
the mandibular first molar area, where it innervates the incisor teeth and anastomoses with
the contralateral incisal artery. In rare cases, the incisive canal is large, lending to greater
bleeding during osteotomy preparation or bone grafting procedures.1
Prevention.
The exact location of the incisive canal is easily determined via a CBCT evaluation in the
panoramic or sagittal views.
Management.
Bleeding complications can occur when implants are placed into the mandibular incisive
canal, which contains the incisive artery. If bleeding does occur during placement of the
implant, a direction indicator or surgical bur can be placed into osteotomy to apply pressure
(Fig. 7.22).
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Dental Implant Intraoperative Complications

Randolph R. Resnik, in Misch's Avoiding Complications in Oral Implantology, 2018
Prevention
Intermediate Drills.
Some manufacturers do not utilize an intermediate drill in their drilling protocol. However, a
decrease in the heat and trauma generated is found with the intermediate drill. Gradual
increases in drill diameter reduce the amount of pressure and heat transmitted to the bone,
especially in the presence of dense and thick cortical bone.
Copious Amounts of Saline.
Along with external irrigation from the surgical drills, increased irrigation may be obtained
by using internal irrigation (through the surgical bur) or with supplemental irrigation via a
syringe.
Bone Dance.