IMPLANT FAILURES AND

MANAGEMENT

CRITERIA FOR SUCCESS

Clinical immobility
No impairment in the function of adjacent tissues
No continuing, progressive radiolucency surrounding the
implant, no crestal bone loss

AILING IMPLANTS
It is least seriously affected of the three pathologic states

Exhibits soft tissue problems (Peri-implant mucositis.)

Has a favourable prognosis.

FAILING IMPLANTS
Shows evidence of
Pocket formation
Bleeding upon probing
Purulence
Progressive bone loss

Poor prognosis when compared with Ailing Implants

If properly treated, a failing implant may be saved.

FAILED IMPLANTS
Rapid progressive bone loss
Horizontal mobility beyond 0.5mm
Pain during percussion or function
Continued uncontrolled exudate
Generalized radiolucency around an implant
More than one half of the surrounding bone lost around an
implant
Implant inserted in poor position making them useless for
prosthetic support.

CLASSIFICATION OF
COMPLICATION
Swedish team ( Branemark et al)
1) Loss of bone anchorage.

Mucoperiosteal perforation.

Surgical trauma.
2) Gingival problems

Proliferative gingivitis.

Fistula formation.
3) Mechanical complications.

Fixture fracture.

Fracture of prosthesis.

 U.C.L.A team.
1) Complication in stage I surgery.
a) Mental nerve damage.
b) Perforation of sinus, nasal cavity.
c) Excess counter sink.
d) Thread exposure.
e) Jaw fracture.
f) Wound dehiscence.
g) Facial abscess.
h) Suture abscess.
i) Loose cover screw.

Complication during stage II surgery.

a) Poor selection of fixture height.
b) Damaged hex.
c) Loose abutment.
d) Fractured abutment screw.
e) Early loading by prosthesis.
f) Aspiration of instruments.
g) Thread exposure.
h) Fixture fractures.
i) Plaque and calculus formation.
j) Periodontal problems.

Prosthetic complications.
a) Insufficient space b/w the fully bone anchored prostheses.
b) Screw fractures.
c) Acrylic or porcelain fractures.
d) Posterior fixture failures in posterior maxilla.

METHODS OF DIAGNOSIS
Clinical observation
Radiographic findings
Culturing

CLINICAL OBSERVATION
Tissue tone - indicator of health or pathology in the underlying
tissues.
Localized inflammation - perigingival site or 5mm of the
abutments - often indicates loss of biological seal or alveolar
bone loss or both.
Exudates - perigingival site or fistula indicate an underlying
pathologic condition.

 Probing pocket depth - helpful in diagnosis, not be possible shape of the implant or the position of a fixed prostheses.
Deep probable area that bleeds profusely when probed further investigation.

RADIOGRAPHIC FINDINGS
Useful - extent of integration around the dental implant.
Also indicated - clinical pathology and radiographic
interpretation of the surrounding osseous structures - extent of
degenerative process.
Periapical --- most commonly used.
Panoramic --- extend the areas covered.
Occlusal radiographs --- possible buccolingual changes.

 CT scan are currently used to determine the extent of osseous

breakdown in areas beyond those directly involved with the
implant.

The presence of fistula --- gutta-percha or silver points.

CULTURING
Type or source of the infection present.

Organism -- drug sensitivity tests -- appropriate medical

regimen.

LOCAL RISK FACTORS

Quantity and the type of bone.
Oral hygiene levels.
Previous periodontal disease and current disease status.
Occlusal patterns and habits.
Peri-implant soft tissue.
Implant surface technology.
Implant location.

SYSTEMIC RISK FACTORS

Rheumatoid disease.
Long term steroids.
Reduced salivary flow.
Diabetes mellitus.

OTHER RISK FACTORS

Smoking.
Alcoholism.
Stress.
Psychological disorders.

CHRONOLOGICAL DISTRIBUTION
OF FAILURES
Biological failures - the loss or the failure to achieve
osseointegration
Two different time frames
- Early failure
- Late failure

EARLY FAILURE
Weeks to a few months after implantation
Interaction of an etiological agent with a wound healing
process whose desired outcome is osseointegration

Overheating of the bone.

Too much force used while placing.
Contaminated implant.
Contaminated osteotomy.
Epithelial cells in osteotomy site.
Poor quality of bone.

LATE FAILURE
Occur much later
Pathological processes involving a previously osseointegrated
implant
Pathological processes classified into
disturbances in biomechanical equilibrium or overload
alterations of the host-parasite equilibrium

BIOMECHANICAL IMBALANCE.
Clinically, loss of osseointegration is evidenced by -- periimplant radiolucency and mobility.
Replacement of the highly specialized bone C.T with a fibrous
capsule.

SURGICAL COMPLICATION
HEMORRHAGE
Bleeding may result from
Soft dissection
Managed by applying
pressure for 5-10mins

Intraosseous surgery
Managed by forcing
sterile bone wax into
bleeding site.
Placement of implant itself in the final prepared osteotomy ceases
bleeding .

 Perforation on the lingual aspect of the alveolar process in the

distal segment of the jaw causes lingual artery injury.
This may lead to life threatening airway obstruction.

INFERIOR ALVEOLAR NERVE

INJURY
When an instrument or the implant contacts the nerve, the
patient experiences a pain sensation even under anesthesia.
Implant installation - postponed - shorter implant placed at a
later date.

LINGUAL NERVE INJURY

Damage to the lingual nerve - loss of sensitivity in the anterior
two thirds of the tongue.
Prevented - avoiding any type of release incision in the lingual
direction.
Incisions must always be crestal, with vestibular release
incisions.
Flaps on the lingual side must be elevated carefully, in tight
contact with the bone.

OPENING THE NASAL OR

MAXILLARY SINUSES
After completion of implant bed preparation the bed should be
carefully probed, to identify any possible perforation.
If an oro-antral or an oro-nasal tract is detected radiographs
taken immediately.
Perforation minor - shorter implant is placed and the patient
is informed.
Antibiotic coverage prescribed.

BROKEN BUR
Occurs - bur gets bind to the bone and an effort is made to
remove it by wriggling the handpiece shank

Prevention grasp the handpiece beneath its head at the

point of bur emission with the thumb and fore finger and press
the fingers together.

The bur is pinched between its head and the bone, and force it
vertically upward and out of the bone in a non-torque
influenced movement.

If broken bur occur radiograph taken

Usually broken bur is deep in the osteotomy

Patient informed

Aggressive attempts to remove the bur should

be
avoided

If bur is not in a critical location it is best to leave it

untouched.

OVERSIZED OSTEOTOMY
Cause

Lack of experience
Prevention

Bone tapping and implant seating ultra low speed

handpiece

Using a mark on the rotary instrument to dictate the exact

moment to reverse the motor direction.

Safer approach stop the motor at a point four to five

rotations from final seating and complete the procedure
with the hand held ratchet wrench.

Treatment

Large diameter implant

Osteotomy oversized - for an implant system (no larger

diameter implants) - remove the implant - particulate
hydroxyapatite graft - place the implant.

FRACTURED CORTICAL PLATES

Cause misdirection of a drill, presence of an unexpected
anatomic irregularity

If periosteum is attached to cortical plate- good prognosis.

If the fragment becomes detached, it can be wedged back into

position - prognosis is guarded

 MANDIBLE FRACTURE

Manson et al 1990 said that fracture of mandible in

connection with the placement of dental implants is relatively
rare.
Fracture can occur
During bone
site preparation

Excessive stress
during mouth opening

Prevention

Limited stress to jaw during healing period

Avoid over tightening of screws

Do not use wide diameter implants with large threads

Management

Immediate implant retrieval from fractured bone

Rigid connection of osseointegrated implants with rigid

external fixation in order to obtain immediate stability.

Soft diet for 45 days

POST OPERATIVE COMPLICATION

HEMATOMA
Prevented by

Proper intraoperative hemorrhage control

Careful post operative compression of the mucosal flaps

covering the implants

Immediate application of cold packs

In case of extensive hematoma antibiotics are prescribed

to prevent secondary infection.

INCISION LINE OPENING

Most common post operative complication

If the design of the removable interim prosthesis
is
involved, it is corrected

Patient is instructed to rinse 2-3 times daily with

chlorhexidine - gently debride the incision line with a soft
brush

Within few days to weeks the soft tissue will

granulate into the opening.

Resuturing is contraindicated.

CHRONIC PAIN

Implant placed close to mandibular canal may cause

irritation of the inferior alveolar nerve

Such patients may experience chronic pain

Even in the advanced stages of peri-implantitis, the

inferior alveolar nerve may become affected.

Antibiotics are prescribed followed by removal of the

implant as soon as the acute symptoms subside.

RADIOLUCENCIES

If, at 4 or 8 weeks postoperative examination, the

radiographs shows periimplant lucency, osseointegration
will not occur.

The patient is informed and

the implant is removed.

INFECTION
Characterized clinically by

Pain

Swelling

Suppurative exudate from the wound

1 or 2 sutures are removed for drainage of pus
If the patient experiences fever, an antibiotic regimen is
indicated.

IMPLANT EXPOSURE
Cause
Suturing the flaps under tension
Pressure from soft tissue borne prosthesis
Management
The wound is left open

The denture is modified so as no to exert force on the area

of implant exposure.

IMPLANT MOBILITY
Due to

Bone necrosis

Implant movement

Infection

Patient informed about the situation - implant removed to

prevent further damage.
Infection
(+)
(-)
Implant installation is
Larger diameter implant

postponed
placed

PROSTHETIC COMPLICATION
CRITERIA FOR IMPLANT SUCCESS
(Smith & Zarb)

Mean vertical bone loss less than 0.2mm annually after

the first year of function or service.

No persistent pain, discomfort, or infection attributable to

the implant.

85% success rate - end of 5 year postrestorative period &

80% success rate - end of 10 years postrestorative or
function.

SCREW LOOSENING AND FRACTURE

More common in maxilla 50% than mandible 20%
Causes

Inadequate torque application

Inaccurate framework abutment interface

Arch form

Cantilever extension

INADEQUATE TORQUE APPLICATION

Recommended torque - prosthetic gold screws is 10 Ncm

and for abutment screw is 20 Ncm

A manual torque converter is available to adjust torque

between 10 Ncm and 20 Ncm.
It is recommended that all screws be tightened with a
torque driver.

 Patients advised at the prosthetic delivery appointment &

during hygiene recall appointments to monitor for prosthesis
loosening.
Movement present - saliva can be seen percolating at the
interface
Prosthesis - removed and all components examined.
If any of the screws are loose, they are replaced.

CANTILEVER EXTENSION
The cantilever distance beyond the distal implant determines the lever
arm length and the amount of force that is transmitted to the implants,
framework and component.

For mandible 15mm or less

For maxilla 10mm or less

Factors
Arch form
Bone quality
Parafunctional habits

Over extension of the cantilever may lead to

Screw loosening
Prosthesis
or Fracture
loosening

Implant loss

INACCURATE FRAMEWORK ABUTMENT INTERFACE

An ideal framework abutment connection is one that has

circumferential contact and is without an opening at the
interface.
A non passive fit will create stresses in the screws and on the
implant

Screw loosening and lack of osseointegration

 When evaluating the fit, screws should be tightened one at a

time while observing the lift of the frame and the open
interfaces.
Torquing all screw before evaluating the interface -- bend the
framework giving the appearance of accuracy.

If these frames are allowed to seat -- constant stress on the

implant and the component.

IMPLANT FRACTURE

Fractures occurs due to

Fatigue
Trauma
The most frequent area of fracture is just below the abutment
level.

 Treatment includes removal of the fragments

Maeglin 1988 - Usually apical portion of the implants is
osseointegrated and should be left behind, if not to be
replaced, to prevent further osseous loss.

ESTHETIC FAILURES

It is a major problem in maxillary anteriors due

to
Labial inclination of implants
Gingival recession

Implant inclination can be corrected using angled

abutments upto 30

Gingival recession requires mucogingival surgery for

correction.

 Gingival margin, normally follows crestal bony margins.

Gingival recession often occurs if the facial plates of the bone
is lost or if it is extremely thin following implant insertion.

FRAMEWORK FRACTURE

A cross sectional dimension of at least 4mmx6mm is needed.

Common areas of framework fracture are :
Solder joints
-

Distal to the distal most implant

 Zarb et al 1990 reported an increased incidence of

framework breakage if extensions in the mandible exceed
20mm.
Fractured solder joint is reindexed intraorally - soldered.
Heat of soldering - destroy any acrylic veneering material replace after the framework fit has been verified after
soldering.

UNFAVOURABLE IMPLANT LOCATION AND AXIS

ORIENTATION

Esthetics, phonetics, hygiene and prosthetic design may

be compromised by poor implant position.

In extreme situations, implants may be so poorly

positioned that it is impossible to include them in the treatment
plan.

MAINTENANCE GUIDELINES
The long term success of the dental implant lies to a great
extent, in the ability of the patient to control daily plaque.
Twice daily - 30 sec. Chlorhexidine rinse recommended for
at least 1 week after stage 2 surgery.
A soft tooth brush or flat end-tuft brush is used in addition to
rinsing.

 Plastic scalers are used to remove calculus

Metal instruments, including ultrasonic scalers, are not

recommended because tthey can lead to rough surface

 After removal of hard deposits the prosthesis and abutments

are selectively polished with a

Rubber cup
Flossing cord
Aluminum oxide polishing paste is recommended to avoid
scratching of the titanium abutments and prosthetic
suprastructure.

MAINTENANCE INTERVALS
Appropriate recall intervals are determined on an
individual basis, taking into consideration the patients history
and present evaluation.

At prosthesis delivery
Oral hygiene instruction given

One month after prosthesis delivery

Review of home care techniques
Calculus removal and coronal polish

Three months later

Examination of tissues
Calculus removal and coronal polish
Establishment of a recall interval between 3 & 6 months