Dental implant failure /certified fixed orthodontic courses by Indian dental academy

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Dental implant failure /certified fixed orthodontic courses by Indian dental academy

  1. 1. DENTAL IMPLANTFAILURES INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. CONTENTS• Introduction• Systemic factors contributing to implant failure• Osseointegration• Systemic influences on alveolar bone• Osteoporosis• Psychosocial factors influencing implant success• Errors in maintaining sterility• Errors due to implant contamination• Errors in surgical technique• Errors in implant positioning• Errors in implant exposure• Pitfalls in implant dentistry from a laboratory www.indiandentalacademy.com perspective
  3. 3. • Prosthetic salvage of surgical misadventures in implant placement• Prosthodontic considerations in first stage implant failures• The influence of tobacco use on endosseous implant failures• Implant design and manufacturing as predictors of implant failure• Soft tissue conditions influencing implant failure• Microbiologic contribution to soft-tissue health• Microbiologic mechanism for implant failure• Peri - implantitis• Diagnosing the failing implant• Predictors of failure• Treating the failing implant• Conclusion www.indiandentalacademy.com
  4. 4. Biology of Osseointegration (Branemark) www.indiandentalacademy.com
  5. 5. • Albrektson describes the physiologic conditions that are required for osseointegration, including• adequate bone cells to achieve bone healing,• adequate nutrition to these cells (blood supply), and• adequate stimulus for bone repair.• When these conditions are present, osseointegration can be achieved with a high degree of success. www.indiandentalacademy.com
  6. 6. INTRODUCTION • The goal of implant therapy is to provide long-term replacement for missing dentition on ideally positioned osseointegrated implants. • Advances in radiographic imaging, splint construction, bone regeneration capabilities, and soft-tissue reconstruction permit placing implants predictably in acceptable positions. www.indiandentalacademy.com
  7. 7. • Surgery for dental implants is a procedure with a high rate of patient success defined as providing a viable implant- supported prosthesis that satisfies the patient.• However, as with any medical procedure, failures occur. www.indiandentalacademy.com
  8. 8. • In a few cases, acceptable surgical and prosthetic outcomes do not meet with satisfaction from the patient.• Such failures probably often have little to do with the implant teams technical competence.• As with most complex reconstruction procedures that involve a degree of collaboration between an imlantologist and a patient, patient factors that influence the imlantologist - patient relationship and the patients compliance with imlantologist requests may play a key role in this procedures ultimate success. www.indiandentalacademy.com
  9. 9. • An implant or a tooth diagnosed as a clinical failure is easier to describe than is a success.• Signs and symptoms of failure for an implant are• 1) horizontal mobility beyond 0.5mm or any clinically observed vertical movement under less than 500 g force,• 2) rapid progressive bone loss regardless of the stress reduction and periimplant therapy,• 3) pain during percussion or function,• 4) continued uncontrolled exudate in spite of surgical attempts at correction,• 5) generalized radiolucency around an implant,• 6) more than one half of the surrounding bone is lost around an implant, and• 7) implants inserted in poor position , making them useless for prosthetic support. www.indiandentalacademy.com
  10. 10. CLASSIFICATION • Based on the cause of implant failure • Preoperative • Intra operative • Post operative www.indiandentalacademy.com
  11. 11. PREOPERATIVE • Patient Selection • Comprehensive treatment with osseointegrated implants begins with patient evaluation and selection. • Considerations should be given to chronic illnesses because they contribute to reduced organ reserve and the patients ability to have the surgical placement of implants. www.indiandentalacademy.com
  12. 12. • Matukas reviewed potential medical risks associated with surgery for dental implants. He reviewed several diseases that potentially can reduce organ reserve Cardiovascular Heart failure Coronary artery disease Hypertension Unexplained arrhythmia Respiratory Chronic obstructive pulmonary disease Asthma www.indiandentalacademy.com
  13. 13. • Gastrointestinal• Nutritional status• Hepatitis• Malabsorption syndrome• Inflammatory bowel disease• Genitourinary• Chronic renal failure• Endocrine• Diabetes• Thyroid disease• Pituitary/adrenal disease www.indiandentalacademy.com
  14. 14. • Musculoskeletal• Arthritis• Osteoporosis• Neurologic• Stroke• Palsy• Mentation www.indiandentalacademy.com
  15. 15. • Fonseca and Davis have recommended that absolute medical contraindications to endosseous implant surgery include• Pregnancy,• Granulocytopenia,• Steriod use,• Continous antibiotic coverage,• Brittle diabetes,• Hemophilia,• Ehlers-danlos syndrome,• Marfans syndrome,• Osteoradionecrosis,• Radiation, renal failure,• Organ transplants,• Anticoagulant therapy,• Fibrous dysplasia, and www.indiandentalacademy.com• Crohns disease.
  16. 16. Relative contraindications.• Infectious hepatitis,• Recent myocardial infarction,• Blood dyscrasias,• Uncontrolled diabetes,• Severe alcoholism,• Chronic steroid use,• Renal diseases, and• Uncontrolled metabolic disorders www.indiandentalacademy.com
  17. 17. • Zeitler and Fridrich reported that tissue perfusion and microvascular diseases have an important role in wound healing.• In their report, they described the importance of tissue oxygenation and oxygen tension as they relate to tissue perfusion as factors in tissue healing.• Systemic diseases such as diabetes mellitus and collagen diseases such as scleroderma, systemic lupus erythematosus, rheumatoid arthritis, and Sjogrens syndrome have microvascular changes that can cause decreased oxygenation due to poor vascularity and have poor wound healing potential. www.indiandentalacademy.com
  18. 18. • Evidence suggests that bone disorders such as osteoporosis may compromise the success of dental implant placements that require preliminary bone building.• Albrektsson has outlined the response of bone tissue to endosseous implants.• He describes the physiologic conditions that are required for osseointegration, including adequate bone cells to achieve bone healing, adequate nutrition to these cells (blood supply), and adequate stimulus for bone repair. www.indiandentalacademy.com
  19. 19. • Albrektsson also states that there is a "primary interference to integration."• These include traumatic surgery, in which the frictional heat generated during placement of the implant causes necrosis of the surrounding cells and causes a lack of healing and integration.• The second interference to bone integration is an implant bed of low healing potential.• What can cause an implant recipient site of low healing potential?• Albrektsson states that there are some indications that various systemic diseases such as rheumatoid arthritis www.indiandentalacademy.com negatively influence osseointegration.
  20. 20. THE INFLUENCE OF TOBACCO USE ONENDOSSEOUS IMPLANT FAILURES • It has been shown that dentate smokers have a higher incidence and greater severity of periodontal disease and that smokers treated with dental implants have a greater risk of developing peri-implantitis. • a case was reported on the relation of smoking to impaired intraoral wound healing and the loss of endosseous implants. www.indiandentalacademy.com
  21. 21. PSYCHOSOCIAL FACTORSINFLUENCING IMPLANT SUCCESS1. Patients who lack external support (financial, social).2. Patients who lack the cognitive capacity (or skill capacity).3. Patients who have emotional problems.4. Patients who have a pattern of interpersonal problems5. Patients who consistently engage in behaviour6. Patients who maintain general health and illness attitudes and beliefs. www.indiandentalacademy.com
  22. 22. ERRORS DUE TO ANATOMICVARIATIONS AND ABNORMALITIES • Ideal fixture placement depends on a detailed preoperative clinical assessment of bone configuration, quality, and quantity. • Periapical and panoramic radiographs of the maxilla and mandible usually provide additional methods to assess bone conditions. www.indiandentalacademy.com
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  26. 26. • Periapical views are necessary when the implant is to be placed in approximation to the natural dentition.• Intraoral dental radiographs accurately locate the position of the adjacent roots and help to avoid iatrogenic injury to these structures.• When necessary, lateral cephalometric radiographs as well as CT provide additional cross-sectional information on bone height and anatomic configuration. www.indiandentalacademy.com
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  28. 28. • Relation to the inferior alveolar nerve• Relation to the mental nerve• The bone immediately surrounding the region of the nasal cavity and maxillary sinus is often thin, and these areas may be penetrated accidentally when placing implants.• The lingual aspect of the mandible in the molar region is another area in which errors in implant placement can occur. www.indiandentalacademy.com
  29. 29. • Bone quality ranges from dense, compact, and relatively avascular bone to cancellous bone with a spongy texture.• The type of implant design selected should match the quality of bone into which it is placed.• Press-fit implant design -high percentage of cancellous bone.• Pretapped implant -bone is dense, compact, and poorly vascularized. www.indiandentalacademy.com
  30. 30. • Screw-shaped implant design provides greater surface area for interaction with the host bone tissue, enhanced initial stabilization, greater resistance to sheer forces.• Primary stability is important for the bony integration and long-term success of the implant. www.indiandentalacademy.com
  31. 31. ERRORS IN MAINTAININGSTERILITY • A proper sterile operating environment is one of several factors critical to the achievement of successful osseous integration. www.indiandentalacademy.com
  32. 32. ERRORS DUE TO IMPLANT CONTAMINATION• Contamination of the implant surface interferes with osseointegration and must be scrupulously avoided.• Surgical gloves should be free of powder residue www.indiandentalacademy.com
  33. 33. • Surface contamination could eliminate the implants unique ability to integrate with the adjacent bone.• Contaminants can become “the bad apple in the barrel” and lead to tiny or even widespread areas of interference with the osteoblast-titanium oxide connection interaction.• Implant site should be irrigated.• Titanium implants must be carried by titanium instruments. www.indiandentalacademy.com
  34. 34. ERRORS IN SURGICALTECHNIQUE • Successful implant placement depends highly on proper surgical technique • Maintaining an adequate blood supply • Reducing hard-and soft-tissue surgical trauma • Incisions • Osteotomy technique www.indiandentalacademy.com
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  36. 36. • Healthy, viable bone is critical for the successful integration between the bone and the implant surface.• Therefore, heat injury to bone must be avoided during the drilling process.• A study by Eriksson and Albrektsson showed that there should temperature for heat- induced injury to bone tissue is 470C applied for 1 minute.• Temperatures above this level result in bone resorption and fat cell degeneration. www.indiandentalacademy.com
  37. 37. • Three factors causing overheating of bone:• 1) inadequate irrigation at the time of the implant site preparation,• 2) generating excess heat by force torquing the drills into dense bone, and• 3) using dull drill bits, especially in the case of dense bone www.indiandentalacademy.com
  38. 38. • Heat-injured bone is replaced by less differentiated tissue, which is incapable of the normal adaptive remodeling ability of bone.• Additionally, a study showed that the heating of bone above the critical 47 0C level significantly affects the bones ability to regenerate.• The capacity of the host site to regenerate bone is critical for the process of osseointegration to take place. www.indiandentalacademy.com
  39. 39. How to minimize heat generationduring drilling? • Using sharp drills • A gradual increase in drill diameter. • Drill speed • Eriksson and Albrektsson have shown that 2000 rpm is the optimal rotational speed for the creation of endosseous implant sites. • According to Misch cancellous bone should be drilled at 800 rpm, whereas dense bone should be drilled at a speed of 1500 rpm. www.indiandentalacademy.com
  40. 40. • Copious irrigation with chilled normal saline solution• Such irrigation not only cools the bone and drill but also lessens the accumulation of cutting debris that can become interposed between the bone and implant surfaces.• Eccentric movements of the drill should be avoided. www.indiandentalacademy.com
  41. 41. • Bone drills that bind and lock during site preparation should be freed by reversing direction and should not be rocked back and forth to disengage the drill.• Such movements not only increase the size of the preparation but also possible cause for injury and lead to necrosis of bone cells. www.indiandentalacademy.com
  42. 42. • Countersinking of the implant site is often necessary to accommodate the flared neck of the implant, care must be taken when thin cortical plates are present.• In this situation, the countersinking drill may reduce the thickness of the cortex to such an extent that it devitalized the bone and leads to early exposure of the implant surface.• It also decreases the cortical support against vertical forces and predisposes the implant to functional overload. www.indiandentalacademy.com
  43. 43. ERRORS IN IMPLANTPOSITIONING • An implant may integrate successfully with the surrounding bone but ultimately be a clinical failure because it is too poorly positioned to support a functional prosthetic restoration. • Attention to proper intraoperative angulation as well as maintenance of a parallelism between implant and between implants and the natural dentition, contribute to optimal and successful prosthetic design and function. www.indiandentalacademy.com
  44. 44. • Too far to the buccal or in lingual version may integrate successfully, this can cause a bone dehiscence, a lack a bicortical support, and eventual implant exposure.• Implants placed in lingual version also can cause irritation of the mobile tissue in the floor of the mouth.• In addition to having proper orientation and alignment in bone, implants should be placed a minimum of 2 mm from each other or from natural teeth.• This amount of space is necessary for the formation of an esthetic and anatomically functional prosthesis. www.indiandentalacademy.com
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  46. 46. ERRORS IN IMPLANTEXPOSURE 6 months are allowed for healing • Generally 4 to of an endosseous integration to take place before the implants are exposed and healing abutments placed. • When exposing implants in the anterior maxilla, the esthetics of future restorations should be considered because an unesthetic restoration is also a failure. • Factors to consider include providing sufficient soft-tissue bulk for a convex ridge form, creation of interproximal papillae and proper gingival contour, and assuring that there is keratinized gingiva, surrounding the labial aspect of the crown. www.indiandentalacademy.com
  47. 47. PITFALLS IN IMPLANT DENTISTRYFROM A LABORATORYPERSPECTIVE • Restorative nightmares created by lack of adequate communication among all implant team members- restorative, surgical, patient and laboratory-when treatment planning cases. • Not being able to meet patients’ expectations of esthetics and function of implant supported restorations due to improperly placed implant fixtures. • Not being able to meet patients’ expectations and desires for the type of prosthesis, fixed or removable, because treatment option limitations were not fully explained by the restoring doctor or not fully understood by the patient. • Increased restoration cost-not anticipated but incurred- when additional components must be bought or made in attempt to restore improperly placed implants. www.indiandentalacademy.com
  48. 48. PROSTHETIC SALVAGE OF SURGICALMISADVENTURES IN IMPLANTPLACEMENT • However, if ideal implant position is not achieved and prosthetic salvage may be necessary to retrieve the case. • The ability to correct adverse fixture angulations for prosthetic reconstruction is therefore a necessary and important aspect of implant rehabilitation. www.indiandentalacademy.com
  49. 49. • Slight Angulation• Moderate angulation www.indiandentalacademy.com
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  53. 53. • When complications occur, the precipitating factors must be identified and eliminated, if possible. www.indiandentalacademy.com
  54. 54. IMPLANT DESIGN ANDMANUFACTURING AS PREDICTORS OFIMPLANT FAILURE Macroscopic Structure Surface Composition Implant Success Microscopic Structure www.indiandentalacademy.com
  55. 55. SOFT TISSUE CONDITIONSINFLUENCING IMPLANT FAILURE www.indiandentalacademy.com
  56. 56. MICROBIOLOGIC MECHANISM FORIMPLANT FAILURE : • When implants fail due to compromise of the soft tissues, there is destruction of the biologic seal similar to the disruption of the perimucosal seal in periodontitis. • Because the microflora is similar with diseased implants and teeth, one could hypothesize that the mechanism for bone destruction around implants would be similar to that of teeth. • However, the literature has not yet definitively proved this to be true; only through clinical reports and limited patient series we can make this analogy. www.indiandentalacademy.com
  57. 57. • The destruction of the supporting apparatus of teeth is through a sequence of events that involve endotoxin, cytokines, and cells of the periodontal region.• Endotoxin is a component of the cell walls of all gram-negative bacteria, such as those involved with periodontitis: A. actinomycetemcomitans, B. forsythus, P. gingivalis, P. intermedia, W. recta, and oral spirochetes.• Macrophages are activated by endotoxin and produce proteases that destroy collagen and proteoglycans. www.indiandentalacademy.com
  58. 58. • These activated macrophages produce cytokines such as interleukin-1 (IL-1) and prostaglandin E2 (PGE2).• IL-1 acts in an autocatalytic fashion to stimulate more macrophages and activate fibroblasts to produce additional proteases and to produce more PGE2.• The osteoblast is the target cell of PGE2, leading to resorption of bone.• It is likely that these mechanisms are present in inflammation mediated implant failure. It follows that treatment of inflamed implants with bone loss involves detoxification of the implant surface and removal of endotoxin. www.indiandentalacademy.com
  59. 59. PERI-IMPLANTITIS • Peri-implantitis : inflammatory changes confined to the soft tissue surrounding an implant. • Peri-implantitis : radiographcially detectable peri-implant bone loss combined with a soft-tissue inflammatory lesion that demonstrates suppuration and probing depths ≥ 6mm. The process begins at the coronal aspect of the implant, whereas the more apical portion remains clinically stable (osseointegrated). www.indiandentalacademy.com
  60. 60. Microbiology : • Multiple studies have demonstrated that maintenance of optimal soft-tissue health around functioning implants results in a peri- implant microflora predominated by streptococci and nonmotile rods. • This is essentially identical to the microflora around healthy teeth. • Putative periodontal pathogens, for example, Porphyromonas gingivalis, prevotella intermedia, or spirochetes, were either not recovered at all or were minor components of the subgingival flora in healthy sites. www.indiandentalacademy.com
  61. 61. Treatment• Efforts at decontaminating the pathologically exposed implant surface fall primarily into one of two broad categories : mechanical and chemotherapeutic.• Provide diligent treatment of periodontal conditions in the natural dentition.• Observe and correct mechanical cofactors• Prescribe chlorhexidine mouth rinses• Prescribe anaerobic and aerobic antibiotic therapy for several weeks.• Remove component hardware to manage inflammatory disease surgically.• Consider chemical and physical treatment of the fixture.• Consider guided bone regeneration to restore lost bone. www.indiandentalacademy.com
  62. 62. What steps can be taken prudentlyto salvage a failing fixture? • Three phases related to the intervention process are offered: • (1) observing for predictors of failure, (2) diagnosing the source of the failure, and • (3) treating the condition(s) responsible for the decline in implant restoration health. www.indiandentalacademy.com
  63. 63. • Avoid positioning implant heads above the alveolar ridge crest.• Develop flaps that are well vascularized and mobile.• Observe well-established soft-tissue repair principles.• Tightly secure all cover screws.• Reaffirm dietary laws with the patient.• Intercept trauma from opposing dentition with bite splints.• Apply principles of infection management early. www.indiandentalacademy.com
  64. 64. • Observe for noncompliance and diet transgressions.• Reline or remove poorly fitting interim prostheses.• Test for osseintegration (Periotest, controlled reverse torque).• Consider dentoalveolar causes (adjacent teeth, jaw fractures, peri- implantitis). www.indiandentalacademy.com
  65. 65. • Precisely position healing and permanent abutments.• Respond quickly to signs of abutment – related inflammations.• Frequently observe transitional appliances for adequacy and implant.• Review oral hygiene responsibilities and techniques.• Provide oral prophylaxis as often as indicated. www.indiandentalacademy.com
  66. 66. • Poorly compliant patients require more frequent professional services.• Be aware of the average life expectancy of fixture parts and attachments.• Periodically plan re-treatments of the case to accommodate new developments.• Recall periodicity must be individualized. www.indiandentalacademy.com
  67. 67. CONCLUSION • Prevention, interception, and recovery are the watchwords of restoring the failing implant. • Any adverse findings related to implant components, peri-implant disease, radiographic changes, or persistent patient complaints should be interpreted as threatening to the life of the implant. • Problematic patient factors must be anticipated, compromised surgical or prosthetic conditions must be recognized, and acquired implant disease states must be treated early and vigorously. www.indiandentalacademy.com
  68. 68. • First stage implant failure can be prevented but not treated. Early second stage failure may represent a biologic failure or injudicious technique.• Late second stage failure is usually a product of lack of care, mechanical loading, or poorly understood inflammatory conditions.• Optimal implant health is the only sure predictor of future implant well-being.• An ailing implant is a failing implant. Signs of adverse developments should prompt an immediate diagnostic initiative and corrective action. www.indiandentalacademy.com
  69. 69. THANK YOU www.indiandentalacademy.com

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