Dental Traumatology 2003; 19: 160164 Printed in Denmark.

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Copyright # Blackwell Munksgaard 2003 DENTAL TRAUMATOLOGY ISSN 16004469

Case Report

External and occlusal trauma to dental implants and a case report

Flanagan, D. External and occlusal trauma to dental implants and a case report. Dent Traumatol 2003;19:160^164. # Blackwell Munksgaard, 2003. Abstract ^ Dental implants subjected to traumatic forces can survive. Cortical bone seems to provide a protective energy-absorbing mechanism in the collagen polymer that helps to prevent microcracking and fracture of bone. The collagen polymer has cross-linking bonds that break and absorb the energy of a traumatic impact so as not to cause damage to the main polymer chain. A case reported demonstrates that a traumatic force damaged the implant prosthetic crown, but not the bone encasing the implant or the integration of the implant. Dental implants have been used to replace teeth that havebeen extractedor otherwise removed.When dental implants are placed, initial stability is an important treatment success factor. One review of the experimental literature showed that a newly placed dental implant will tolerate micromotion of less than 150 mm and still osseointegrate but excessive micromotion causes brous encapsulation (1). However, there is little data as to what happens to an osseointegrated implant after sustaining trauma from an external force. How much sudden force will an integrated implant sustain and remain integrated? The amount of force needed to avulse or cause `dis-osseointegration'of an osseointegrated implant probably depends onthe density of the bone housing the implant, surface texture, diameter and length of the implant and angle of incident, duration, magnitude and frequency of the force (2^6). The force of trauma would probably need to irreparably damage the osteocytes and cellular structures that are in close proximity to the implant surface and/or create a space between the implant and bone for epithelial down-growth to cause a failure of the implant. Forces in the molar bicuspid region, the prime chewing area in humans, range between 120 and 150 N. Occlusal pre-maturities of less than 200 mm show no signicant increase of implant load level (7). It may be that these occlusal forces may not cause failure of integrated implants if they do not Dennis Flanagan
1671 West Main St., Willimantic, CT 06226, USA Key words: dental implant; trauma; component failure; osseointegration Dennis Flanagan, 1671West Main St., Willimantic, CT 06226, USA Tel: 1860 456 3153 Fax: 1860 456 8759 e-mail: dffdds@mindspring.com Accepted 22 August, 2002

induce a micromovement of more than 150 mm. The 150-mm dimension may be important for integrated implants as well. It is known that an osseointegrated implant may be at risk if it is subjected to chronic, severe, direct nonaxial (eccentric) forces of occlusion (8,9).These damaging occlusal forces are chronic and variable in magnitude, direction and frequency. Interestingly, short implants canbe used for anchorage for the small, uni-directional and constant forces for orthodontic tooth movement (10). If a force does not cause failure of an implant immediately, it may rst fracture the implant or a component screw on the rst occasion. The tensile strength of the implant abutment screws varies according to the alloy, manufacturer design, size and manufactured lot (11,12). An impacting force couldpossibly fracture the overlying bone housing an implant. The interaction of the bone and implant interface under an external sudden force is unknown. A study in rabbit femurs showed that the torque removal force of implants at 3-month post-insertion ranged from 27 to 59 N (13). Titanium oxide layer thickness, micropore congurations and crystal structures of titanium oxide apparently aect bone tissue response with respect to removal torque. Oxide layers 600^1000 nm demonstrated signicantly stronger bone responses in evaluation of removal torque than implants with an oxide layer less

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Trauma to dental implants than 200 nm; however, whether these properties have their eect individually or synergistically is unknown (14). It has been suggested that a placement torque force of greater that 42 N cm allows a newly installed implant tobe immediately subjectedto non-functional loading. That is, a newly placed single implant can be tted immediately with a provisional crown but so as to be out of the path of movement of the opposing teeth. Most of these cases were reported to be in anterior sites, and therefore likely in an area of increased bone density which enhances initial implant stability. These areas are also subjected to lesser forces than in posterior areas (15^17). In these cases, the occlusal forces of the opposing dentition are not in direct contact with the new crown/implant complex.The forces to bear are usually those of the soft tissues (tongue and mucosa) and compressed food boluses from mastication. The bone around the newly placed implant is probably able to resist these lesser forces and would not move the newly placed implant more than 150 mm in the required rigid bone that encases it. Schnitman et al. (18) reported that immediate placement and true functional loading was possible with cross-arch stabilization but the survival rate was 85%. Implant immobilization brought about by the arc of the prosthesis and distribution of the force of occlusal load are probably the key factors. This arch form distribution and multiplicity of implants probably prevents any implant movement beyond 150 mm. Ithasalsobeenreportedthatdentalimplantsplacedin the anterior mandibular interforaminal area can be placedinimmediatetruefunctionandprovideimmediate retention foranoverdenture (19). In maxillary overdentures with four to six implants, the forces of occlusion can loosen component screwsbut apparently do not readily cause implant loss in the short term of 3.2 years (20). Interestingly, implants fracture at the samerateinthemaxillaandmandible,andimplantfractures occur more frequently in partially edentulous restorationsthan in completelyedentulous arches (21). It is not known if the 150-mm limit of movement in bone for newly placed implants holds for osseointegrated implants as well. Dental implants are subjected to a multiplicity of force parameters that need to be studied. Case report A 30-year-old woman required extraction of tooth #9. The root had sustained a lingual root fracture; endodontic and full crowntreatmentswereperformed but this treatment failed and the tooth was deemed unrestorable. The tooth was extracted and a 4.5 15 Frialit-2 implant (Frident, Mannheim, Germany) was immediately placed. A 1-mm gap at the lingual

Fig. 1. Post-operative radiograph.

was lled with Bio-Gran, a bioactive glass ceramic (Fig.1). A provisional removable denture replacing #9 was adjusted, relieved over the implant site and delivered. Six months later, an abutment was placed, torqued into place and restored with a cemented porcelain-fused-to-metal crown. The patient did well and was satised with the results of the treatment. Thirteen months later, she presented for emergency treatment with a chief complaint of a fractured #9 crown and`loose implant' She stated that she had sus. tained trauma to the implant crown at #9 by a strike from a bottle 2 days before the emergency visit. The crown appeared mobile and had an incisal porcelain fracture (Fig.2). She had no pain. There was a slight facial gingival margin swelling and redness (Fig.3). The crown appeared to be in its original position. A discussionwas heldasto possible removal andreplacement of the implant xture if it was no longer integrated. Amoxicillin 500 mg tid for 10 days was prescribed. At the next appointment, the crown was cut and removed from the abutment. The implant was found to be immobile, apparently still integrated and undamaged from the trauma of the bottle strike. The abutment retaining screw had apparently loosened from the trauma. The abutment and retaining screw were removed, inspected, found to be undamaged and replaced to their original positions. The abutment screw was again seated with a torque wrench. A new porcelain-fused-to-metal crown was constructed and cemented. The implant has not exhibited any adverse eects from the trauma 5 months laterandthere hasbeen no unusualbone loss or loosening (Fig.4).

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Fig. 2. Radiograph 2 days after trauma.

Fig. 4. Radiograph 5 months after trauma.

Fig. 3. Porcelain fracture and slight facial gingival margin inflammation 2 days after trauma.

Discussion When a natural tooth is avulsed, the bone is suddenly compressed against the conical root and the tooth is propelled occlusally breaking the supporting periodontal ligament. A dental implant has no periodontal ligament but can have threads and/or a rough surface that may preclude avulsion or at least make it an unlikely event. A tooth that is luxated may fully recover by temporarily splinting the injured tooth to its neighbors for support for healing. The treatment for a luxated, mobile implant xture is probably removal. A disosseointegrated implant xture may develop infec-

tion, brous encapsulation or epithelial down-growth and be exfoliated. Natural teeth that are fractured can be restored unless a root fracture necessitates extraction. Apparently from the case now presented, an integrated implant xture can sustain some magnitude of external trauma and survive. It is possible that the bone housing an implant can bend or fracture. A component part can bend or fracture or loosen under trauma. It seems that component parts loosen or fracture before the implant or the integrated bone housing fractures (21). Component screw loosening and fracture can occur before bone loss around implant xtures restored in occlusal disharmony. Occlusal forces are variable, frequent, multidirectional and increase the risk of failure if non-axial (22). These occlusal forces always produce stress at the neck of an implant. Axial forces produce the lowest stress (23). Occlusal prosthetic design should, at best, prevent or minimize exposure to non-axial forces. T oughness is that property of a material that measures the energy necessary to fracture the material (24). The molecular basis of the toughness and strength of bone is largely unknown. Bone is a nanocomposite of hydroxyapatite crystals and a collagen matrix. The crystals of hydroxyapatite cannot dissipate much energy from an impact, so the collagen matrix remains as the probable energy-absorbing entity. Reducing collagen cross-linking causes reduced bone strength. Apparently during an impact event, the collagenpolymer containsbonds thatbreak

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Trauma to dental implants so as to absorb the energy of the impact that protects the main polymer chain. These bonds are thought to be responsible for the toughness of bone (25^27). Microfractures of bone around implants are associated with oblique loads, high occlusal stress magnitudes and an absence of cortical bone (28). Bone microcracks are precursors to fracture.The way bone is structured helps prevent crack initiation in transverse fracture under tension, shear and tear (29). It would appear that an osseointegrated implant encased in adequate cortical bone could successfully survive a severe sudden traumatic impact of substantial force (30). Conclusions Dental implants seem to be well protected in cortical bone from traumatic impact. There is a molecular polymeric mechanism of collagen, the matrix ofbone, that helps to protect bone from fracture. The vulnerable areas of implant-restored dentition with respect to trauma seem to be in the implant xture, implant components and prostheses. It appears that the force that was incurred in this case was strong enough to fracture the porcelain of the fused-to-metal crown and loosen the abutment retaining screw. The impact force caused no apparent damage to the bone, the implant or its components except abutment screw loosening.The force delivered at the incisal edge of the crown probably induced a reverse torque to the implant and did not result in its failure or subsequent bone loss. References
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