Implant Complications and Failures

IMPLANT COMPLICATIONS
AND
FAILURES

Contents
 Introduction
 Definition – Implant
 Parts of an Implant
 Basic terminologies
 Factors that influences implant outcomes
 Implant success criteria
 Complications
1) Surgical complications
2) Biologic complications
3) Complications related to Augumentation procedures
4) Complications related to Placement and loading protocols
5) Prosthetic and mechanical complications
6) Esthetic and phonetic complications
 Implant removal
 Conclusion
 References
Contents

Introduction
 Dental implant therapy is a well‐established dental
treatment modality that provides benefits for edentulous
and partially edentulous patients.
 Implant dentistry is currently being practiced in an
atmosphere of enthusiasm and optimism, because our
knowledge and ability to provide service to our patients
has expanded so greatly in such a short period.

 Since the introduction of the concept of osseointegration, the success of dental
implants has increased dramatically because of better understanding of bone response
and the improvement in bone loading concepts
 The role of dentist is not just limited to the treatment of the
oral condition presented by the patient, their responsibility
further extends to identify the kind of complication or failure
that may occur or has occurred either during the course of
treatment or post treatment.

 An Implant is an alloplastic material or device that is surgically placed into the oral
tissue beneath the mucosal or periosteal layer or within the bone for functional,
therapeutic, or esthetic purposes.
- Glossary of Periodontal Terms
Definition - Implant

OSSEOINTEGRATION
A direct contact, on the light microscopic level, between living bone
tissue and an implant.
IMPLANT OUTCOMES
Implant outcomes are reported as the presence or absence of the implant
at the time of the last examination, regardless of whether the implant was
functional, suffered from bone loss, or had other problems.
. Carranza, 11th edition
- Glossary of Periodontal Terms,2001

IMPLANT SUCCESS
Implant success is defined by specific criteria used to evaluate the
condition and function of the implant. In the classic definition, Albrektsson and
colleagues defined success as an implant with no pain, no mobility, no
radiolucent peri-implant areas, and less than 0.2 mm of bone loss annually after
the first year of loading
IMPLANT SURVIVAL
Implant survival is defined as an implant that remains in place at the
time of evaluation, regardless of untoward signs and symptoms or a history of
problems
Carranza, 11th edition

EXTANT IMPLANTS
Extant implants that are healthy and functioning under an implant-
retained restoration.
SLEEPERS
. Implants that are osseointegrated but not functional are referred to as
sleepers and should not be considered successful merely because they are
present and osseointegrated.

Ailing
implants
• Ailing implants are those showing radiographic bone loss without
inflammatory signs or mobility.
Failing
implants
• Failing implants are characterized by progressive bone loss, signs of
inflammation and no mobility.
Failed
implants
• Failed implants are those with progressive bone loss, with clinical
mobility and that which are not functioning in the intended sense.
Surviving
implants
• Surviving is a term described by Alberktson that applies to implants
that are still in function but have not been tested against success
criteria.
El Askary et al., 1999

Factors that infuences
Implant Outcomes
 Anatomic Location
 Implant Design
 Placement and Loading Protocols
 Immediate Implant Placement
 Immediate Occlusal Loading
 Bone Augmentation
 Risk Factors
 Smoking
 Diabetes
 Periodontitis

“Implant Success”
Review of past and
present concepts

Earlier concepts,
Schnitman and Schulman in 1982
 Mobility less than 1 mm in any direction.
 Bone loss not greater than one third of the vertical height of the
bone.
 Gingival inflammation amenable to treatment.
 Functional service for 5 years.

Chainin, Silver Branch, Sher, and Salter in 1982
 In place for 60 months or more.
 Lack of significant evidence of cervical saucerization on radiographs.
 Freedom from hemorrhage
 Lack of mobility.
 Absence of pain and tenderness.
 No pericervical granulomatosis or gingival hyperplasia.
 No evidence of a widening peri-implant space on radiograph.

Mckinney, Koth, and Steflik in 1984
Subjective criteria
 Adequate function.
 Absence of discomfort.
 Patient belief that esthetics, emotional, and psychological attitude are
improved.
Success criteria
 Provides functional service for 5 years in 75% of implant patients.

Objective criteria
 Bone loss no greater than one third of the vertical height of the implant,
absence of symptoms and functionally stable after 5 years.
 Gingival inflammation vulnerable to treatment.
 Mobility of less than 1 mm buccolingually, mesiodistally, and vertically.
 Absence of symptoms and infection associated with the dental implant.
 Absence of damage to adjacent tooth or teeth and their supporting structures.
 Absence of parasthesia or violation of mandibular canal, maxillary sinus, or
floor of nasal passage.
 Healthy collagenous tissue without polymorphonuclear infiltration.

Era of Revised criteria for implant success
Alberktson, Zarb, Washington, and Erickson in 1986
 Individual unattached implant that is immobile when tested clinically.
 Radiograph that does not demonstrate evidence of periimplant radiolucency.
 Bone loss that is less than 0.2 mm annually after the implant’s first year of
service.
 Absence of persistent and/or irreversible signs and symptoms of pain, infections,
necropathies, paraesthesia, or violation of the mandibular canal.
 In content of criteria mentioned, a success rate of 85% at the end of a 5-year
observation period and 80% at the end of 10-year observation as a minimum
criterion for success.

Esposito et al.,1998 (1st European Workshop on Periodontology)
 Absence of mobility and
 An average radiographic marginal bone loss of less than 1.5 mm during
the first year of function and less than 0.2 mm annually
 Absence of pain/parasthesia.
 Probing depths related to a fixed reference point and
 Bleeding on probing should be measured.
 The success criteria, which were initially targeted for evaluation as 5
years survival has changed to target of 10-year survival rate.

World Workshop on the Classification of Periodontal and Periimplant Diseases
and Conditions (2017)
 Absence of clinical signs of inflammation.
 Absence of bleeding and/or suppuration on gentle probing.
 No increase in probing depth compared to previous examinations.
 Absence of bone loss beyond crestal bone level changes resulting from
initial bone remodelling.

Complications – Gen. defn
 A secondary disease or condition aggravating an already existing
one.

Prevelance of Implant Complications
Pjetursson et al., 2004 found that the most common technical complication:
 Fracture of veneers (13.2% after 5 years),
 Loss of the screw access hole restoration (8.2% after 5 years),
 Abutment/occlusal screw loosening (5.8% after 5 years), and abutment/occlusal screw
fracture (1.5% after 5 years).
 Fracture of implants occurred infrequently (0.4% after 5 years; 1.8% after 10 years).
 Biologic complications, such as periimplantitis and soft tissue lesions, occurred in 8.6%

Prevelance of Implant Complications
 Zitzmann and Berglundh, 2008
 Periimplant mucositis- 50% of implant sites.
 Periimplantitis-12% to 43% of implant sites
 Goodacre et al., 1999 inclusion of edentulous patients having overdentures,
seemed to indicate a significantly higher percentage of complications.
 Esposito et al., 1999 biological failures were relatively low at 7.7%.

Implant Complications
1) Surgical complications
2) Biologic complications
3) Complications related to augumentation procedures
4) Complications related to placement and loading protocols
5) Prosthetic and mechanical complications
6) Esthetic and phonetic complications

Implant complications
Biologic complications
A. Inflammation and proliferation
B. Dehiscence and recession
C. Periimplantitis and bone loss
D. Implant loss and failure
Surgical complications
A. Hemorrhage and hematoma
B. Neurosensory disturbances
C. Implant malposition

Augumentation procedures - complications
A. Autogenous Bone Harvesting and Grafting
B. Guided bone regeneration
C. Sinus Bone Augmentation
i. Lateral Window Sinus Lift
ii. Crestal (Osteotome) Sinus Lift
Implant loading protocols - complications
A. Immediate Implant Placement
B. Immediate Loading after implant placement
C. Implant Placement using a Flapless approach

Prosthetic and mechanical complications
A. Screw loostening and fracture
B. Implant fracture
C. Fracture of restorative materials
Esthetic and phonetic complications
A. Esthetic complications
B. Phoenetic problems

1) Surgical
complications
A. Hemorrhage and hematoma
B. Neurosensory disturbances
C. Implant malposition

A) Hemorrhage
Bleeding during surgery – easily controlled
 Smaller vessels – naturally constrict / retract
 Sizable vessel injured – difficult to control -
inaccessible – floor of mouth / posterior
maxilla – life threatening

Post-operative bleeding
More prone patients fall in the following category:
 Irradiated patients (radiotherapy),
 Patients with coagulation disorders.
 Severe smokers
 Patients with serious systemic diseases (rheumatoid
arthritis, osteomalacia, imperfect osteogenesis),
 Immunodepressed (HIV, immunosupresory treatments),
 Drug addicts (alcohol, etc.),
 Unreliable patients (mental or psychological disorders).
(Buser et al., 2000)

 Proper postoperative instructions – to prevent and manage minor
bleeding.
 Physician approval to discontinue or reduce medications that
increase bleeding tendency – 7 to 10 days before surgery.
 Include the treating medical practitioner in the management
decisions if postoperative bleeding is excessive or persistent.

Hematoma Formation
 Submucosal or subdermal hemorrhage into the
connective tissues and soft-tissue spaces can
result in hematoma formation.
 Bruising and small hematomas typically resolve
without special treatment or consequence.
 Larger hematomas - susceptible to infection -
 Prescribe antibiotics - Large hematoma.

 Life threatening may happen with
surgical procedure related to
anterior mandible or with
perforation lingual mandibular
cortex
 In this emergency - primary
airway management and surgical
management to isolate and stop
bleeding.
 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

Bleeding site during
implant osteotomy
Arteries Treatment
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, vaso constriction,
cauterization , ligation
Invading the mandibular
canal
Inferior alveolar artery Bone graft
Treatment of hemorrhage at an implant osteotomy
site (Park and Wang, 2005)

B) Neurosensory disturbances
 Caused by drilling or implant compression of the
nerve
 Hypoesthesia or hyperesthesia
 Most common with “Lateral nerve repositioning”.
It is associated with 100% neurosensory
dysfunction and 50% remains permanent
Misch & Resnik, 2010

• INDIRECT
Postsurgical intra-alveolar
edema or hematomas-
produce a temporary pressure
increase, especially inside the
mandibular canal
• DIRECT
Compression, stretch, cut,
overheating, and accidental
puncture
(Annibali et al., 2009)
Causes
 Poor flap design,
 Traumatic flap reflection,
 Accidental intraneural injection,
 Traction on the mental nerve in an elevated flap,
 Penetration of the osteotomy preparation
 Compression of the implant body into the canal
Misch & Wang., 2008

Recommendations to avoid nerve injuries
during Implant placement
 Include nerve injury in informed consent.
 Measure radiograph with care
 Always consider bucco lingual position of the nerve canal.
 Allow 1-2 mm safety zone.
 Use drill guard
 Keep radiograph and patient’s chart as powerful evidence.
Worthington et al., 2004

Treatment
 Too much proximity between the implant and a nerve removal as soon as possible
 Treatment with corticosteroids and non-steroidal anti-inflammatory drugs - to
control inflammatory reactions that provoke nervous compression.
 Topical application of dexamethasone for 1 or 2 minutes enhances recovery.
 Oral administration (high doses)- within one week of injury- prevention of neuroma
formation
(Misch & Resnik, 2010)

C) Implant malposition
Common reasons for implant malpositioning are:
1. Poor Rx planning
2. Lack of surgical skill
3. Poor communication between surgeon and restorative dentist

 Apico-coronally – implant platform 2-3 mm apical to the
gingival margin.
 Implant platform - placed at or above the level of the
gingival margin, a metal collar or implant exposure can
occur yielding an unesthetic result.
 Implant platform - placed too apically, a long
transmucosal abutment will be necessary to restore the
implant - can lead to a deep pocket and difficult hygiene
access for the patient and clinician.

 Mesiodistal implants - 1.5–2 mm from a natural tooth and 2–3 mm from an adjacent
implant to maintain an adequate biologic dimension.
 Violation of biologic width around an implant can lead to bone loss.

 Implants that are placed too close to each other or natural teeth can be difficult to
restore.
 Improperly spaced implants - chronic inflammation and periimplantitis.
 Conversely, implants placed with excessive distance from an adjacent tooth or
implant which may predispose the implant to bone loss, screw loosening, screw
fracture, or implant fracture, as well as difficulties with hygiene.

 Buccolingually - at least 2 mm of bone circumferentially around the implant.
 Implant exposure - abscess and/or suppuration.
 Implants - palatally/lingually - prosthetic compensation

 Instrumentation (e.g., drills) directed at or near the adjacent tooth - injury to the
periodontal ligament, tooth structure, and nerve of the tooth.
 On insertion, dental implants will follow the trajectory of the osteotomy prepared by
the surgical drills.
 Care must be taken - osteotomy - planned path of insertion, not to encroachment on
the mandibular canal or mental foramen, perforation into the maxillary sinus or nasal
cavity.

Improper implant location and placement – pre cautions
 Assess the characteristics of the edentulous zone subject to rehabilitation using
clinical and radiological CT, or cone beam CT imaging
 Use short or tilted implants (aproximately 30º)
 Avoid anatomical structures (mental nerve, maxillary sinus).
Dreiseidler et al., 2009

Injury to Adjacent teeth -Precautions
 Use of a surgical guide, radiographic analysis and CT scan can help locate the
implant placement.
 Inspection of a radiograph with a guide pin at a depth of 5 mm will facilitate
osteotomy angulation corrections (Greenstein et al., 2008).
 Guidepin location radiographs - reduce the potential for damaging adjacent teeth.

2) Biologic
complications
A. Inflammation and proliferation
B. Dehiscence and recession
C. Periimplantitis and bone loss
D. Implant loss and failure

A) Inflammation and proliferation
 Similar to plaque induced gingival lesions
 Also common with loose implant- abutment or abutment
crown connection and excessive cement retained after
restoration.
 Fistula – resulting from loose abutment connection
 Correction of precipitating factors effectively resolves
the problem

B) Dehiscence and recession
 Common when the supporting hard and soft
tissues are thin, lacking or lost
 Improper implant positioning also predisposes
periimplant tissues to recession.
 Spray et al, 2000 recommended this thickness to
be 2 mm or greater to support the buccal soft
tissue

Dehiscences may be prevented by
1) Careful preoperative assessment of the soft tissues to measure the amount of
keratinized mucosa present and planning of augmentation procedures as
appropriate;
2) Minimally invasive flap elevation and reflection with careful removal of any
bone debris beneath;
3) Proper suturing;
4) Delaying the use of removable dentures until two weeks after surgery.

Treatment
Speroni et al., 2010; Stimmelmayr et al., 2010
 Small Dehiscence - No Surgical Correction
 Large Dehiscence - Resuturing Free connective tissue grafts - allows
better esthetical results , maintenance of periimplant health

C) Peri-implantitis
Periimplantitis was defined as a plaque associated
pathologic condition occurring in the tissue around dental
implants, characterized by inflammation in the
periimplant mucosa and subsequent progressive loss of
supporting bone.
- Carranza

 Bacterial infections play the most important role in the failure of dental
implants
 Gram-negative anaerobic bacteria including porphyromonas gingivalis,
prevotella intermedia and actinobacillus actinomycetemcomitans,
 Resemble the pathogens in periodontal disease
Peri-implantitis - Etiology

Biomechanical factors
 An occlusal overload may play a significant role in the failure of the
implant resulting in progressive bone loss around the implant
Patient related factors
 Systemic Diseases
Social factors
 Inadequate oral hygiene
 Smoking
 Drug abuse
Para functional habits
 Bruxism

Signs
 Swelling
 Redness of the peri-implant marginal tissues
 Calculus build up
 Bleeding on probing
 Suppuration
Peri-implantitis - Diagnosis

Probing :
Blunt, straight plastic periodontal probe
 Automated probe
 TPS probe
Assess:
a) Peri-implant probing depth
b) Bleeding on probing
c) Exudation and suppuration from the peri-implant space.

IOPA
 Reveal the peri-implant bone status as well as the marginal
bone level.
Progressive bone loss
 Definite indicator of peri-implantitis
 Should not be confused with physiological bone

Mobility:
 Serves to diagnose the final stage of osseodisintegration.
 Electronic device like periotest has been used.
Micro flora:
 Bacterial cultures
 DNA probes
 Polymerase chain reaction (PCR),
 Monoclonal antibody and enzyme assays
.

 Analysis of the fit of the prosthesis
 The number and position of the implants
 Occlusal evaluation.
Treatment
 Occlusal equilibration and improvement of the implant number and
position changes in the prosthetic design
Peri-implantitis - Management

Nonsurgical interventions consist of
Antimicrobial rinse and irrigation,
Local antibiotics,
Ultrasonic debridement,
Mechanical debridement with air-abrasive devices, and
Laser therapy.

Surgical technique :
Includes full-thickness flap elevation for access followed by
degranulation,
Surface debridement by laser or mechanical instruments,
Surface decontamination with laser or antimicrobials, and
Bone augmentation.

Application of the C.I.S.T includes the assessment of the following parameters
namely:
1) Presence or absence of dental plaque.
2) Presence or absence of bleeding on gentle probing.
3) Presence or absence of suppuration.
4) Periimplant probing depth.
5) Evidence of radiographic bone loss.
Cumulative Interceptive Supportive Therapy
(CIST) modalities

Cumulative Interceptive Supportive Therapy
(CIST) modalities
• Using rubber cups and polishing plaster, acrylic scalers for
chipping off calculus
• Effective oral hygiene practices
Mechanical
cleansing
Antiseptic therapy
(PPD – 4 to 5mm)
Rinses with 0.1% to 0.2% chlorhexidine digluconate for 3 to 4 weeks
• supplemented by irrigating locally with chlorhexidine gels
Lang et al, 2004

Antibiotic therapy
( more than 6mm )
Surgical approach
Systemic and Local antibiotics directed at the elimination of gram
negative anaerobic bacteria is administrated
1. REGENERATIVE SURGERY • using abundant saline rinses
at the defect, • barrier membranes, • close flap adaptation and •
careful post-surgical monitoring for several months. • Plaque
control is to be assured by applying chlorhexidine gels.
2. RESECTIVE SURGERY • Apical repositioning of the flap
following osteoplasty around the defect.

 Implant failure is defined as the total failure of the implant to fulfill its purpose
(functional, esthetic or phonetic) because of mechanical or biological reasons.
 Implant failure is the inadequacy of the host tissue to establish or to maintain osseo-
integration.
D) Implant failure

Classifications of Implant Failures
Rosenberg et al., (1991).,
1) Infectious failure
2) Traumatic 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.
 Radiographic peri-implant
radiolucency.
 Mobility.
 Lack of granulomatous tissue upon
removal.
 Lack of increased probing depths.
 Low plaque and gingival indices.
INFECTIOUS FAILURE TRAUMATIC FAILURE

Esposito et al., (1998) - osseointegration concept.
Biological
 Early or primary (before loading): failure to establish osseointegration.
 Late and secondary (after loading): failure to maintain the achieved
osseointegration.
Mechanical
 Fracture of implants, connecting screws, bridge frameworks, coating etc.
Iatrogenic
 Nerve damages, wrong alignment of implants, etc.
Inadequate patient adaptation
 Phonetical, esthetical, psychological problems, etc.

Truhlar et al., 1998 classified failures as
Early failures
 That occur with in weeks to few months after placement.
 Caused by factors that can interfere with normal healing processes or by an
altered healing response.
Late failure
 Failure that arise from pathologic processes that involve a previously
osseointegrated implant.

El Askary et al.,1999 have divided the failures into seven categories.
1) According to etiology
Failures because of host factors
 Medical status – Osteoporosis and other bone diseases; uncontrolled diabetes.
 Habits – smoking, para-functional habits.
 Oral status – poor home care, juvenile, and rapidly progressive periodontitis,
irradiation therapy.
Restorative problems
 Excessive cantilever, pier abutments, no passive fit, improper fit of the
abutment, improper prosthetic design, improper occlusal scheme, bending
moments, connecting implants to natural dentition, premature loading, excessive
torquing.

Surgical placement
 Off axis placement (severe angulation)
 Lack of initial stabilization
 Impaired healing and infection because of improper flap design or others.
 Overheating the bone and exerting too much pressure.
 Minimal space between implants
 Placing the implant in immature bone grafted sites.
 Placement of the implant in an infected socket or a pathologic lesion.
 Contamination of the implant body before insertion.

Implant selection
 Improper implant type in improper bone type.
 Length of the implant (too short, crown–implant ratio unfavorable)
 Diameter of the implant.
2) 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).

3) According to timing of failure
 Before stage II (after surgery)
 At stage II (With healing head and or abutment insertion)
 After restoration.
4) According to condition of failure: (clinical and radiographic status)
 Ailing implants
 Failing implants
 Failed implants
 Surviving implants.

5) According to responsible personnel
 Dentist (oral surgeon, prosthodontist, periodontist)
 Dental hygienist, Laboratory technician, Patient.
6) According to failure mode
 Lack of osseointegration (usually mobility)
 Unacceptable esthetics
 Functional problems
 Psychological problems.
7) According to supporting tissue type
 Soft tissue problems (lack of keratinized tissues, inflammation, etc.)
 Bone loss (Radiographic changes, etc.)
 Both soft tissue and bone loss.

Heydenrijik et al.,2002 (referring to occurrence in time)
Early failures
 Osseointegration has never been established, thus representing an interference
with healing process.
Late failures
 Osseointegration not maintained implying processes involving loss of
osseointegration.
Soon late failures
 Implants failing during the first year of loading.
Delayed late failures
 Implants failing in subsequent years.

Factors associated with increased Failure rate
Esposcito et al., 1998

3) Complications
related to Augmentation
Procedures
A. Autogenous bone harvesting and
grafting
B. Guided bone regeneration
C. Sinus bone augmentation
i. Lateral window sinus lift
ii. Crestal (osteotome) sinus lift

A) Complication associated with
Autogenous Bone harvesting/grafting
 At donor site, Inferior alveolar nerve injury or trismus, Fracture of
mandible
 Recepient site complication, wound dehiscence, flap necrosis, graft
exposure, graft contamination, problem with graft incorporation and
resorption
 These complications can be avoided by proper surgical technique, good
planning, and an experienced operator

B) Complications of GBR
 Exposure of the barrier membrane and
necrosis of the overlying flap.
 Simian et al. 2004- 12.5% exposure rate of e-
PTFE.
 Other, infection, failure to regenerate adequate
bone volume, loss of keratinized tissue and
decrease in the depth of vestibule.

C) Complications with Sinus bone
Augumentation
Lateral window sinus lift:
 Schneiderian membrane perforation or bleeding
from nasal cavity
 20-30% of membrane perforation with conventional
instruments and 7% with piezo surgery- Kasabah
2003
 Infection - 2- 5.6%.

2. Crestal (osteotome) sinus augmentation
 BPPV- benign paroxysmal positional vertigo- trauma induced by
percussion with surgical hammer, along with hyperextension of
neck during operation can displace otoliths in the inner ear.
 Prevention using:
 Manual force instead of hammer percussion
 Surgical fraise/ bur in combination with osteotome
 Piezoelectric surgical instuments

4) Complications
related to Placement
and Loading protocols
A. Immediate Implant placement
B. Immediate loading after Implant
placement
C. Implant placement using a flapless
approach

A) Immediate Implant placement
 Poor implant position,
 Marginal bone loss,
 Periimplant soft tissue recession,
 Compromised esthetics,
 Failure to attain primary stability and
 Implant failure
Schulte et al., 1978

B) Immediate loading after Implant
placement
 Failure to achieve primary stability
 Toavoid complication
 Long and wide implants
 Thread design
 For full edentulous arches, mininum 4-6 implants
 Cross-arch stabilization
 Minimizing cantilever

C) Implant placement using a
Flapless approach
 Complications due to:
 Lack of operator visualization
 Improper positioning.
 It is technique sensitive that requires surgical experience,
 Proper Case selection
 An accurate surgical guide and knowledge of the anatomy
surrounding the implant site

5) Prosthetic
or Mechanical
complications
A. Screw loostening and fracture
B. Implant fracture
C. Fracture of restorative materials

A) Screw loostening and fracture
 Frequent in screw-retained FPDs
 Screw loosening in 6% to 49% of cases at the first annual
check-up.- Jemt et al., 1994.
 Corrected by retightening the screws
 Prosthesis retained by multiple implants, the ability
to detect a loose screw is greatly diminished
 Biomechanical support (and resistance) for
the restoration must be evaluated

B) Implant fracture
Fatigue of implant materials and weakness in prosthetic design
or dimension are the usual causes of implant fractures
Balshi et al, 1999 listed three categories of causes
 Design and material,
 Nonpassive fit of the prosthetic framework, and
 Physiologic or biomechanical overload.
 Bruxism – occlusal guards

C) Fracture of restorative materials
 Usually in veneers (acrylic,composite or
ceramic ) that are attached to superstructures

6) Esthetic and
Phoenetic
complications
A. Esthetic complications
B. Phoenetic problems

A) Esthetic complications
 Esthetic complications arise when
patient expectations are not met.
 Patients with high esthetic expectations
and less than- optimal patient-related
factors (High smile line, thin
periodontal soft tissues, or inadequate
bone quantity and quality)

 Esthetic complications result from poor implant position and deficiencies in
the existing anatomy of the edentulous sites that were reconstructed with
implants.
 If the implant is positioned too apical, buccal, or in the proximal space, an
unesthetic prosthetic profile will be developed.
 Use of angulated abutments, superstructures, and gingiva-colored materials
may result in an acceptable esthetic result, thus avoiding multiple surgeries.

B) Phonetic problem
 More common with full arch implant supported prosthesis
 Unusual palatal contours
 Space between implant and superstructures
 Severely atrophied maxilla

Treatment
 Such patients are best served with an
implant-assisted maxillary over denture
because the design facilitates replacement of
missing alveolar structure and avoids
creating spaces that allow air to escape
during speech.

Implant removal - Indications
 Severe peri-implant bone loss
 Bone loss involving implant vents or holes
 Unfavorable advanced bone defect
 Rapid severe bone destruction within one year of loading
 Ineffective surgical or Nonsurgical therapy
 Esthetic area proving implant surface exposure

Conclusion
 Dental implants have high predictability and long term success but its not “fail
free or complication free”. Surgical complications can be avoided by proper pre-
surgical work ups.
 Careful diagnosis and treatment planning along with the use of diagnostic
imaging, precise surgical techniques can prevent many of the problems.
 A thorough understanding of the anatomy, biology and wound healing of the
surgical area are essential in preventing complications.

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1999;8:173-85.
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1998;10:299-308.
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of osseointegrated oral implants (II) Etiopathogenesis. Eur J Oral Sci 1998;106:721-64.
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Implantologists (ICOI) Pisa Consensus Conference. Implant Dent 2008;17:5–15
 K. Karthik. Evaluation of implant success: A review of past and present concepts. J Pharm
Bioallied Sci. 2013 Jun; 5(Suppl 1): S117–S119.
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