implant failure management protocals

1. IMPLANT FAILURE & ITS
MANAGEMENT
Dr . Shiva sai vemula
3rd year MDS

2. Contents
• Definition
• Success criteria
• Diagnosis
• Esthetics success
• Classification
• Common failures and management
• Management of ailing and failing implant
• Management of hope less implant
• Conclusion
• references

3. CONTRAINDICATION
Absolute contraindications Relative contraindications
1. Recent mi 1. Connective tissue disease
2. Cerebrovascular accident 2. Autoimmune diseases
3. Valvular prosthesis surgery 3.Hiv
4.Haemophilia 4.Smoking
5.Immunosuppression- organ transplant 5. Pregnancy
6.Fibrous dysplasia 6. Osteoporosis
7.Paget’s disease 7.Vitamin d- disorders
8. Osteoradionecrosis 8. Psychological disorders

4. Definition:
Ailing implant:
• implant expresses radiographical bone loss with out inflammation and deep pocket around the
implant is evident, with absence of bleeding is defined as ailing implant.
Failing implant:
• inflammation is present and is evident by sign of edema, redness, bleeding and suppuration.
implant are immobile but radiographic bone loss is seen.
Failed implant:
• implants with progressive bone loss with clinical mobility and encapsulated by fibrous capsule is
defined as failed implant.
Surviving implant:
• implant that are still in function and not tested under success criteria is defined as surviving implant

5. SUCCESS CRITERIA FOR DENTAL IMPLANTS
Success criteria
Subjective Objective Revised

6. SUBJECTIVE CRITERIA
Adiquate function
Absence of discomfort
Patient belief that esthetics, emotional and psychological
attitude is improved

7. OBJECTIVE CRITERIA
Good occlusion balance and vertical dimension
Bone loss not > 1/3 of the vertical height of implant, absence of symptoms
and functionally stable after 5 years
No gingival inflammation
Moblity< 1mm
Absence of paraesthesia/ violation of mandibular canal and maxillary sinus

8. REVISED CRITERIA
Immobile when tested clinically.
No radiographic evidence of radiographic peri-implant radiolucency.
Bone loss < 0.2 mm after 1st years of service
Absence of pain, infection, paraesthesia and violation maxillary
sinus.
According to this criteria, success rate of 85% - in 5 years of
observation, 80%- in 10 years of observation

9. Diagnosis
Implant stability assessment
• Reverse torque test
• Implant that rotate under the applied torque are considered
as failure
• Periotest
• It is a device which is an electrically driven and
electronically monitored tapping head that percuss the
implant a total 16 times
• The entire measuring procedure takes about 4sec
• RFA (Resonance frequency analysis)

10. Esthetics success
• Pink and white esthetics score
• PES &WES

11. Pink
esthetic
score
(PES):
Mesial
papilla
Distal
papilla
Soft
tissue
level
Alveolar
contour
Soft
tissue
colour
Soft
tissue
texture
Soft
tissue
contour
0-7 : poor
8-11 : acceptable
12-14 : almost perfect

12. White
esthetic
score (WES):
Tooth form
Tooth
contour
Colour
Soft tissue
texture
Translucency
0-5 : poor
6-8 : acceptable
9-10 : almost perfect

13. HEALTH SCALE OF IMPLANTS
1.Success
No pain
0 moblity
2mm radiographic bone
loss
No exudates history
2.Satisfactory
No pain
0 moblity
2-4mm radiographic
bone loss
No exudates history
3.Compromised
Sensitivity on function
No moblity
4mm bone loss & 7mm
pocket
May have exudates
4.Failed
pain
moblity
R/F bone loss >1/2
length of implant
Uncontrolled excudate

14. CLASSIFICATION

15. Implant failure
Biological
failure
Early/primary
Late/secondary
Mechanical
failure
fracture
Connecting
screw
Bridge
framework
Iatrogenic
failure
Improper
angulation
Nerve damage
Inadequate
patient
adaptation
phonotics
esthetics
psycological

16. According to roland Implant failures
Etiology
Host factor
Restorative
problem
Surgical
placement
Implant
selection
Orgin
Peri-implantitis
Retrograde peri-
implantitis
Time of failure
Before stage II
After stage II
After restoration
Condition of
implant
Ailing
Failing
Failed
Surviving
Mode of failure
Lack of
osseointegration
Unacceptable
esthetics
Functional
problem
Psychological
problem

17. Types of complication

18. complication
Surgical
Biological
Mechanical
/technical
Esthetic
Argumentation
procedure
Loading protocols

19. Iatrogenic / Surgical
complication
Haemorrhage
& hematoma
Neurosensory
distrbances
Implant
malposition
Problems due to surgical complication:
• Damage to adjacent teeth
• Impingement on anatomic structure
• Compramised esthetics/prosthetic outcome
• Soft tissue and bony dehiscence

20. Biological
Complication
Inflammation &
proliferation
Dehiscence Peri-implantitis Implant loss

21. Mechanical / technical
complication
Screw
fracture
Implant
fracture

22. Common failures and its management

23. Malpositioning of implants
Classification
proximity of
implant to other
implant
proximity of implant
to adjacent tooth
abnormal
angulation of the
implant
malposition of
implant in relation to
position of missing
tooth it replaces
Diagnosis
IOPAR /
RVG
CBCT
C/F
fracture of
prosthesis
fracture of
abutment and
screw
bone loss
peri-implantatis
Implant mobility

24. RX
• Mechanical debridement of the affected implant should be done followed by
antiseptic treatment.
• Bone grafting is necessary to provide the added bone support.
• Implant abutment can be replaced by angled abutment and custom made
abutment.
• If implant is not functionally esthetically restored – can be left unexposed
beneath the soft tissue.

25. Improper occlusal scheme
• Implant prosthesis should barely make contact and the
surrounding teeth in the arch should exhibit greater
initial contact.
• Any mobile teeth opposite to the implant prosthesis
should be extracted.
• Fixed full arch implant prosthesis – group function
occlusion / mutually protected occlusion with shallow
anterior guidance when opposing natural dentition & no
working and balancing contact on cantilever.
• In case of implant supported over denture – balanced
occlusion & monoplane in case of resorbed ridges.
C/F
Bone loss
Screw loosening,
screw fracture.
Fracture of
prosthesis
Rx

26. • To reduce the axial load on cantilever – reduce cuspal
inclination, shallow occlusal anatomy and wide grooves
and fossae is recommended
• Typically, A 30-40% of occlusal table is reduction is
suggested in the molar region because any dimension
larger than the implant diameter can cause cantilever
effect.
• Cuspal inclination increased (1) = 3x increase in
torque,so minimal cupal inclination is adviced.

27. Improper cantilever
• According to Glantz :-
DEFORMATION = FORCE OF OCCLUSION X LENGTH
WIDTH X HEIGHT X MODULUS OF ELASTICITY
• Cantilever are class 1 levers, which increases the amount of
stress on implant.
• Length of cantilever should be minimized in case of increased
occlusion height and width.
• Cantilever is influenced by type of arch, no.of implants, A-P
spreed, type of prosthesis to be used.

28. Mandibular arch cantilever
Square <12mm
Ovoid 12-20mm
tapering >20mm
Maxillary arch cantilever
Square <8mm
Ovoid 8-12mm
tapering >12mm
C/F
Progressive bone
loss
Fracture of the
framework
Prosthesis fracture
Screw loosening
Fracture of implant
abutment junction
After regenerative treatment in ailing/failing implants additional
implants can be placed to reduce to cantilever length.

29. • At each increment of 5mm in cantilever = increased
stress in 30% - 37% on cortical bone around implant
• Ratio between A-P spreed and cantilever should be
between 1.5-2 times.

30. Implant abutment misfit
• use proper abutment with platform
switch
• CAD/CAM abutment can be used.
C/F
Progressive bone loss
due to inflammation
Torque loss
Peri-implantatis
Screw loosening
Rx

31. Surgical error: Excessive
pressure
Bone cell
damage
Heat
generation
47oc for one
minute leads to
bone
necreosis.
Oversize
osteotomy
lack of initial
stability
mobility of
implant
No regeneration of the peri-implant bone
Presence of an inflammatory infiltrate in the gap between bone and implant
No organization of the peri-implant bone clot

32. Injury to the vital structures:
Injury of inferior
alveolar nerve
Paresthesis of lip
Maxillary sinus
perforation
Nasal bleeding
Maxillary sinusitis
Soft tissue
injury
Flap dehiscence
Hematomas
Exposure of implant site
Speed should not be > 1200RPM
Proper coolant should be used while osteotomy
In case of over sized osteotomy larger size implant can be
used & loading can be delayed
Rx

33. Proper flap design to prevent soft tissue injury.
Larger dehiscence can be treated by removal of granulation tissue and resuturing
If sinus perforation occurs loading should be delayed by 6 monthes.
Transantral endoscopic surgery can be done in case of maxillary sinusitis/losing implant in
maxillary sinus.
Detailed initial treatment planning and careful surgical unroof the canal and move the
neurovascular bundles inferiorly prior to implant installation – this can be done to prevent the
IAN injury.

34. Management of Ailing and Failing implant
• Identification of the cause.
• Peri-implantaitis
• Prophylactic procedure
Therapeutic strategies:
• Cumulative interceptive supportive therapy(CIST)
• In 2004 it was modified and called AKUT - concept

36. A – Mechanical debridement
• Carbon-fiber curettes, plastic hand instruments or
ultrasonic instruments with a plastic tip is used to
remove calculus.
• The use of high pressure air abrasive (sodium
bicarbonate and water )has been advocated, as this
removes the microbial deposits does not alter the
surface topography and has no adverse effect on
cell adhesion.

37. B. Antiseptic treatment
• Type of implant surface determines the method of decontamination.
1. Critic acid
2. Chlorhexidine gluconate
3. Stannous fluoride
4. Tetracycline
• Contact with a supersaturated solution of antimicrobials /antibiotics for 30-60 sec
have been used for the preparation of implant surface ,as they have the highest
potential for the removal of endotoxins from both the hydroxyapatite and the
titanium implant surface.
• In general 3-4 weeks of regular administration are necessary to achive positive
treatment results.
• Prolonged application time of citric acid is not recommended for use on HA
surface, since it impair the ability to bond.

38. C. Antibiotic treatment
• Before starting antibiotic treatment A and B have to be applied.
• During the last 10 days of antiseptic treatment antibiotic treatment should be used.

39. D. Regenerative therapy
• Its done only if infection is controlled succefully, as evidenced by absence of
suppuration and reduced edema. Treatment to restore the bony architecture should
be done.
• Recommeded to remove prosthesis 8 weeks prior to surgery treatment in order to
ensure optimal results and to allow the soft tissue to heal and collaps around the
implant site.
• 1st step in surgical therapy is to degranulate the defect .
• 2nd exposing
• 3rd visualizing and instrumentation then grafting with allograft, alloplastic graft, HA /
bioglass

40. The treatment options for managing implant failure
• Removal of failed implant.
• There are different technique in
removal of failed implants those are:
• Use counter torque rachet is the
least invasive technique for removing
an implant.(works well in maxilla)
• In mandible, where the bone is
denser, it is advisable to use a bur
360 degrees around an implant to
remove bone at least one half its
length before counter torquing
counter-torque rachet
piezo tips
high speed burs
elevators
forceps
reverse screw
acombination of these tools.

41. Methods of
implant
removal
Fractured
Screw not
engageable
Bone removal
technique
Screw
engageable
Revers screw
technique
No fracture
with internal
connection
ratchet not
engageable
bone removal
technique
ratchet
engageable
counter torque
rachet
technique
no internal
connection
screw not
engageable
bone removal
technique
screw
engageable
revers screw
technique
Hopeless implant

42. Treatment alternatives following removal of failed implant
Re-evaluate
orginal treatment
plan
Implant not critical
for restoration
Proceed to final
restoration
Critical for
restoration
Place new implant
in adjacent site
Hybride implant tooth
FPD/Tooth supported
FPD/RPD
Perform new
implant at same
site
Unsuccessful
Consider second
re-do
successful

43. Conclusion
• Failure of implant can be multi factorial. often many factors come together to
cause the ultimate failure of the implant.an early intervention is always possible if
regular check-up are done.
presurgical diagnosis, Rx planning & mock surgery
use of surgical guide and adherence to proven principles
understanding of anatomy, biology and wound healing
no substitute for training and clinical experience for
preventing, recognizing and managing complication
Tips to avoid complications

44. References
• Koth DL, McKinney RV, Stefik DE. Davis QB. Clinical and statistical analyses of human clinical trials with the single crystal
aluminum oxide endusteal dental implant Five-year results Journal of Prosthetic Dentistry 1988 Aug 16002) 226-34
• Smith DE, Zarb-GA. Criteria for success of osseointegrated andosseous implants. Prosthet Dent 1999,62-567-72.
• Esposito M, Hirsch M, Lekholm U, Thomsen Biological factors contributing to failures of osseointegrated oral implants,(1),
Etopathogenesis. European journal of oral sciences. 1998 Jun;106(3):721-44 Misch CE, Perel ML, Wang H, et al. Implant
sucess, survival, and failure the international Congress of Orang (ICO) Pise Consensus Conference implant Dent
2008;17(1) 5-15
• Ekfeldt A, Christiansson U, Eriksson T, et al. A retrospective analysis of factors associated with multiple implant failures in
masillae. Clin Oral Implants Res 2001;12(5)-462-467.
• Apse Zarb GA, Schnitt A, Lewis DW. The longitudinal affectiveness of osseointegrated dental implants.
• The Truto study Perimplant mucosal response. Int J Periodontics Restorative Dent 1991;1195-111
• Smeets R, Henningsen A, Jung Q. Helland M, Hammacher C, Stein IM, et al. Definition, etiology, prevention and
treatment of peri-implantitis-A review Head Face Med 2014:10:34
• Lang Lindhe 1 Maintenance of the implant patient. In Lang N Lindhe, eds. Clinical periodontology and implant dentistry.
Vol. 2: Clinical concepts, 5th ed. Oxford WileyBlackwell, 2008: Chapter 60
• McAlarney ME. Stavropoules DN: Determination of cantilever length anterior posterior spread assuming failure criteria to
be the compromise of the petisthesis retaining screw prosthesis joint, int)Oral Maxillofac Implants 199611331-319

45. Thank you