implant related complications

1. IMPLANT RELATED COMPLICATIONS

2. INTRODUCTION
Dental implant surgery has become routine treatment in
dentistry and is generally considered to be a safe surgical
procedure with a high success rate. However, complications
should be taken into consideration Many of the
complications can be resolved without severe problems,
however, in some cases, they can cause dental implant
failure or even life threatening circumstances.
Failures occur when the professional and/or the patient
do not obtain the desirable results. Iatrogenic acts are
regarded as accidents, complications or failures caused by a
deficient praxis of the professional. (Annibali et al, 2009)

3. Evaluation Of Parameters For
Success Or Failure Of Implants
 Absence of mobility
 Average radiographic marginal bone loss of less
than 1.5mm during the first year of function and
0.2mm annually thereafter.
 Absence of pain and or paresthesia.
 Measurement of probing depths related to a
fixed reference point and assessment of bleeding
on probing.
Eur J Oral Sci 1998; 106: 527–551.

4. El Askary et al in 1999 gave eight warning signs of
implant failure:
1. Connecting screw loosening
2. Connecting screw fracture
3. Gingival bleeding and enlargement
4. Purulent exudates
5. Pain (not very common)
6. Fracture of prosthetic component
7. Angular bone loss
8. Long standing infection and soft tissue sloughing

5. Classification Of Implant
failures
…E.S Rosenberg, J.P.Torosian and J. Slots
…Abdel Salam El Askary, Roland Mefert andTerrence Griffin
…Kees Heydenrijik, Henny JA Meijer, Wil AVan der et al
… Marco Esposito, Jan Michael Hirsh, Ulf Lekholm et al
…Sumiya Hobo, Eiji Ichida, LilyT Garcia
5

6. 1. Infectious Failure:
…Clinical signs of infection
with classic symptoms of
inflammation
…High plaque and gingival
indices
…Pocketing
…Bleeding, Suppuration
…Attachment loss
…Radiographic peri-implant
radiolucency
…Presence of
granulomatous tissue upon
removal
2. Traumatic Failure:
…Radiographic periimplant
radiolucency
…Mobility
…Lack of granulomatous
tissue upon removal
…Lack of increased
probing depths
…Low plaque and gingival
indices
A) E.S Rosenberg, J.P. Torosian and J. Slots
classified as :
6

7. B) Marco Esposito, Jan Michael Hirsh, Ulf Lekholm et al have
classified oral implant failures according to the osseoi ntegration
concept.
1)Biological Failures:
•Early or primary (Before loading)
•Late or secondary (After loading)
2)Mechanical failures:
•Fracture of implants, connecting screws,
bridge framework, coatings etc
3)Iatrogenic Failures
• Improper implant angulation and alignment, nerve
damage
4)Inadequate Patient adaptation
• Phonetics, esthetics, psychological problems.
7

8. C) Kees Heydenrijik, Henny JA Meijer, Wil A Van der et al
classified to occurrence in time as:
1) Early Failures:
• Surgical trauma
• Insufficient quantity or quality of bone
• Premature loading of implant
• Bacterial infection
2) Late Failures:
Soon late failures: Implants failing during first year of
loading. Overloading in relation to poor bone quality and
insufficient bone volume.
Delayed late failures: Implant failing in subsequent years.
Progressive changes of the loading conditions in relation
to bone quality, volume and peri -implantitis.
8

9. Swedish Team
( Branemark et al)
U.C.L.A team
(Beumer, Moy)
1. Loss of bone anchorage:
a.Mucoperiosteal
perforation
b.Surgical trauma
2. Gingival problems:
a.Proliferative gingivitis
b.Fistula formation
3. Mechanical complications:
a.Fracture of
prosthesis, gold screws,
abutment screws
1. Complications in Stage I
surgery;
2. Complications in Stage II
surgery:
3. Prosthetic complications:
D) Sumiya Hobo, Eiji Ichida, Lily T Garcia enlisted
various complications occurring in implants as:
9

10. E) Abdel Salam el Askary, Roland Meffert and
terrence griffin …
According to etiology
Restorative
factor
Host
factor
Surgical
factor
Implant
selection factor
According to timing of failure
Before stage II After stage II After restoration
According to origin of infection
Peri- implantitis
(Infective process,
bacterial origin)
Retrograde peri-implantitis
(Traumatic occlusion origin,
non infective, forces off the long
axis, premature or excessive
loading)
10

11. F)According to Carranza
1.Surgical complications
 Hemorrhage and hematoma
 Neurosensory disturbances
 Damage to adjacent teeth
2.Biologic complications
 Inflammation
 Dehiscence and recession
 Periimplantitis and bone loss
 Implant loss or failure

12. 3.Technical or mechanical complications
 Screw loosening and fracture
 Implant fracture
 Fracture of restorative materials
4.Esthetic and phonetic complications

13. G)According to Louie Al-Faraje
Preoperative complications
 Insufficient bone
 Insufficient vertical space
 Inadequate horizontal space
 Inadequate interarch space
 Limited jaw opening
 Maxiilary & mandibular tori
 Close proximity to vital structures

14. Intraoperative complications
 Improper angulation
 Improper location
 Bleeding
 Neurosensory disturbances
 Injury to adjacent teeth
 Cortical plate perforations
 Lack of primary stability
 Mechanical complications
 Ingestion/aspiration
 Mandible fracture

15. Postoperative complications
 Edema
 Hematoma
 Emphysema
 Wound dehiscence
 Infection
 Implant mobility
 Implant fracture
 Screw loosening
 Esthetic complications
 Phonetic complications

16. PREOPERATIVE COMPLICATIONS

17. Improper patient selection

18. Insufficient bone

19. Inadequate vertical space

20. Inadequate horizontal space

21. Interarch space

22. Limited jaw opening

23. Tori

24. Close proximity to vital
structures

25. INTRAOPERATIVE COMPLICATIONS

26. Improper implant angulation
(Trakol 2000)
 Anatomy of bone
 Future prosthesis
 Acceptable angulation < 15

27. Improper implant location
Tarnow et al

28. Prevention
 Surgical guides
 Parallelling pin
 Avoid finger rest
Management
 Angled/custom made abutments
 Large diameter drills

29. Bleeding
Causes of bleeding:
 Lesions in any sublingual, lingual,
perimandibular or submaxillary artery
 Surgeries in the lower and anterior area of
totally edentulous patients who have a deficit
in the quality and quantity of bone.

30. Invasive treatments
( Bacci et al., 2010)
International Normalized Ratio (INR) < 4
Adequate hemostatic measures are
followed
Use atraumatic surgery techniques

31. Bleeding site during
implant osteotomy
Arteries Treatments
Posterior mandible Mylohyoid Finger pressure at the site
Middle lingual of
mandible
Submental Surgical ligation of facial
and lingual
arteries
Anterior lingual of
mandible
Terminal branch of
sublingual or submental
Compression,
vasoconstriction,
cauterization, or ligation
Invading the mandibular
canal
Inferior alveolar artery Bone graft
Treatment of a hemorrhage at an implant osteotomy site
(Park & Wang, 2005)

32. Neurosensory disturbances
Causes
 poor flap design
 traumatic flap reflection
 accidental intraneural injection
 traction on the mental nerve in an elevated flap
 penetration of the osteotomy preparation and
compression of the implant body into the canal
(Misch & Wang, 2008).

33. Management
 Drill guards
 Unscrewing
 Drugs ( clonazepam,carbamazepine,vitamin B)
 Refer to neurosurgeon

34. Contamination of implant body
Cause
…non-titanium instrument
…by glove powder
…by the operatory error
By autoclaving the contaminated implant
Bake the bacteria on implant surface
Impossible for phagocytic cell to clean the surface
No close adaptation to the bone
34
Jung Hwa Park

35. Management
 Implant should be cleaned with
radiofrequency glow discharge unit
 gamma irradiation (GI)
 oxygen plasma (OP)
 ultraviolet (UV)

36. Injury to adjacent teeth
Management
•Endodontic treatment (Sussman 1998)
•Orthodontic correction (Annibali 2009)

37. Cortical plate perforation
Misch 2008
Management
 Bone grafts/membranes
 Implant exposure >2/3rd of implant length-remove

38. Lack of primary stability (Javed)
Due to oversized osteotomy
Gap develop between implant & bone
Lack of osseointegration
Management
 Remove & reinsert the larger size implant.
 if not possible  remove insert HA graft material
roll the implant moistened in blood & saline & in the
particulate slurry until thin layer of slurry clings to it 
reinsert the implant
38

39. Mechanical complications
Excessive pressure Bone cell damage Bone loss
Connective tissue
interface formed
Failure increases
…Recommended speed- 2000 rpm with graded series
of drill size with external irrigation
39

40. Management
 external and/or internal irrigation
 cool saline irrigation
 intermittent pressure on the drills
 pausing every 3 to 5 seconds
 using new drills, and an incremental drill
sequence
Misch et al

41. Aspiration and swallowing of
instruments

42. Management
 Vital emergency if the instrument has entered the
airways.
 Recommended to tie all tiny and slippery instruments
with silk ligatures or else use a rubber dam (Bergermann
et al., 1992).
 Gastroscopy or colonoscopy with a proper medical
follow-up required to locate.

43. Mandible fracture
Fracture can occur
 During bone site preparation
 Excessive stress during mouth opening
Manson et al 1990

45. Prevention
 Limited stress to jaw during healing period
 Avoid overtightening of screws
 Do not use wide diameter implants with large
threads
Management
 Immediate implant retrieval from fractured
bone
 Reduction & stabilisation with miniplates
 Soft diet

46. Management

47. POSTOPERATIVE COMPLICATIONS

48. Edema
Wide flaps,
Bone regenerating
techniques
surgery time

49. Management
(Misch & Resnik, 2010
Careful
management
of tissues
Non-steroid
anti-
inflammatory
drugs
cold
pack
corticosteroids

50. Hematoma/ ecchymosis

51. 
 Swelling and elevation of floor of the mouth
 Increase in tongue size
 Difficulty in swallowing or speech
 Pulsating or profuse bleeding from the floor
of the mouth or the osteotomy site

53. Emphysema
 Rare complication, though it can lead to severe
consequences (McKenzie & Rosenberg, 2009).
 Causes
Inadvertent insufflation propulsion of air into
tissues under skin or mucous membranes,
Air from a high-speed handpiece, air/water
syringe, an air polishing unit or an air abrasive
device can be projected into a sulcus, surgical
wound, or a laceration in the mouth
(Liebenberg & Crawford, 1997)

54. Management
 Antibiotics
 Analgesics
 Application of heat pack

55. Wound dehiscence

56. Contributing factors of dehiscence and exposure
of the graft material or barrier membrane
 Flap tension,
 Continuous mechanical trauma or irritation associated
with the loosening of the cover screw,
 Incorrect incisions
 Poor-quality mucosa (thin biotype, traumatized),
 Heavy smokers, patients treated with
corticosteroids, diabetics, or irradiated patients
(Lee & Thiele, 2010)

57.  Treatment
(Speroni et al., 2010; Stimmelmayr et al., 2010).
•No surgical correction
Small
dehiscence-
• Resuturing
Large
dehiscence
Free connective tissue grafts - - allows better esthetical
results , maintenance of periimplant health

58. Dehiscences may be prevented by :
 Careful preoperative assessment of the soft tissues
to measure the amount of keratinized mucosa present
and planning of augmentation procedures as
appropriate;
 Minimally invasive flap elevation and reflection with
careful removal of any bone débris beneath;
 Proper suturing;
 Sensible temporization, rebasing and relining; and
 Delaying the use of removable dentures until two
weeks after surgery.

59. Infections
 Periimplantitis
 Periimplant mucositis
Peri-implantitis is defined as an inflammatory
process which affects the tissues around an
osseointegrated implant in function, resulting in the
loss of the supporting bone, which is often associated
with bleeding, suppuration, increased probing depth,
mobility and radiographical bone loss.

60. Peri-implant mucositis was defined as
reversible inflammatory changes of the peri-
implant soft tissues without any bone loss
(Albrektsson & Isidor 1994)
Two primary etiological factors
1. Bacterial infection
2. Biomechanical overload
(Newman et al 1988, 1992, Rosenberg et al 1991)

61. Diagnostic differences between
periimplantitis and periimplant mucositis
Clinical parameter Peri-implant mucositis Peri-implantitis
Increased probing depth +/- +
BOP + +
Suppuration +/- +
Mobility - +/-
Radiographic bone loss - +

62. Classification of peri-implantitis
Class I
Class II
62
Class III
Class IV

63. Cumulative Interceptive Supportive
Therapy (CIST) modalities
(Lang et al, 2004).
 Mechanical cleansing
 Antiseptic therapy
 Antibiotic therapy
 Surgical therapy
63

64. Implant mobility
Causes
 surgical trauma
 overheating of the osteotomy
 insufficient primary stability and/or initial
overload.
 nonideal implant position resulting in
nonaxial forces during occlusion
 improper crown design
 high occlusal alignment
 improper size selection of the implant and
abutment.

65. Clinical methods to evaluate
implant mobility
 Percussion test
 Reverse torque test
 Cutting torque resistance analysis
 Periotest
Chavez 1993

66. Implant fracture
Causes
•Mechanical overloading
•Loss of supporting tissue
•Galvanic corrosion

67. Management (W.C.Gealh 2011)
 Complete removal of the fractured implant using
trephines and placement of new implant.
 Removal of the coronal portion of the fractured
implant, leaving the remaining apical part
integrated in the bone.
 Modification of prosthesis leaving the fractured
portion of implant in place.

68. Screw loosening (Jemt 1994)
Narrow implants
Stress applied to prosthesis
Preload
Abutment stability

69.  Decreased preload force
 Retightening
 Large diameter implants with large
platform dimensions reduce the
forces applied to the screw

70. Esthetic & Phonetic
complications (Bashutski 2007)
Orofacial malposition Coronoapical malposition

71. COMPLICATIONS ASSOCIATED
WITH MAXILLARY SINUS LIFT

72. Schneiderianmembraneperforation
(Tatum)
Implantdisplacement
(Beckeretal 2008)
Postoperativemaxillarysinusitis
(Uchida1998)

73. Schneiderian membrane perforation occurs in
10% to 60% of all procedures

74. Management

78. CONCLUSION
Complications happen and these complications make us
understand the subject better, as well as the deficiency in
our treatment planning. Although, surgical procedures have
been refined to aid the clinician during implant placement
but the basic principles remain the same. The bone has to
be respected and handled carefully to avoid any error from
our side.
The clinical and radiographic analysis are the
cornerstones of treatment planning of an implant case. If all
these procedures are followed, the operative and the post
operative complications related to implant therapy can be
effectively avoided and satisfactory results both for the
dentist as well as patient can be achieved.