COMPLICATIONS,

FAILURES AND
MAINTAINENCE OF
DENTAL IMPLANT

Presented by:
Dr Rasleen Sabharwal
Final year- Post graduate
Dept of Prosthodontics

Contents

Introduction
Parameters for success or failure evaluation
Parameters for evaluating failing implants
Parameters for evaluating failed implants
Reasons of implant failures
The different failures and their management
Maintenance of implant prosthesis
Conclusion
References

Introduction
The role of a dental professional is not just limited to the
treatment of the oral condition presented by the patient, his
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.
The dental implant is a foreign structure that the physiologic
system of the body has to accept. Though made of a material
with properties close to the body tissues, the implant is still
different and is definitely susceptible to the various biological and
mechanical problems.

Evaluation Of Parameters For Success Or Failure Of Implants

At the first European workshop on Periodontology in 1994, certain

success criteria were considered for osseointegration and agreed
as:

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.

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

Parameters used for evaluating failing implants

Clinical signs of late infection

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

Bleeding on probing
Sulcus Bleeding Index (SBI)

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

Pocket probing depth (PPD)

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

Mucosal recession (REC)

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

Probing attachment levels (PAL)

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

Parameters used for evaluating failed implants

Clinical signs of early infection

Pain or sensitivity

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

Clinically discernable mobility

Radiographic signs failure

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

Dull sound on percussion

Microbiota in relation to failing and failed implants

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral
Sci 1998; 106: 527551.

El Askary et al in 1999 gave eight warning signs of implant

failure:
1.
2.
3.
4.
5.
6.
7.
8.

Connecting screw loosening

Connecting screw fracture
Gingival bleeding and enlargement
Purulent exudates
Pain (not very common)
Fracture of prosthetic component
Angular bone loss
Long standing infection and soft tissue sloughing

Biological factors contributing to failures of osseointegrated oral implants: etiopathogenesis EJOS

1998

Classification of implant complications and

failures
Acc to El Askary et al:
1. According to etiology

Host factors
Surgical placement
Implant selection
Restorative problems

2. According to timing of failure

- Before stage II (after surgery)

- At stage II
- After restoration

Complications and maintainence of implants. British dental journal 1999

3. According to the origin of infection

- Peri - implantitis
- Retrograde peri-implantitis
4. Soft tissue complications
5. Bone complication
6. Mechanical complications

II. According to UCLA team (Beumer and Moy)

1. Complications in first stage surgery
2. Complication in second stage surgery
3. Prosthetic complications

ETIOLOGY

Osteoporosis
Diabetes
Smoking
Parafunctional habits
Poor home care
Juvenile and rapidly progressive periodontitis
Bone quality and quantity
Irradiation therapy

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Surgical placement

Off axis placement

Lack of initial stabilization
Overheating bone
Minimal space b/w implants
Placing implants in immature bone
Contamination of implant body

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Implant selection

Improper implant type in improper bone

Too short implant , crown root implant unfavorable
Width of the implant
Number of implant
Improper implant design

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Restorative problems

Excessive cantilever
Pier abutment
Fit of the abutment
Prosthetic design
Improper occlusal scheme

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Connecting implants to natural teeth

Premature loading
Excessive torquing

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Acc to timing of failure

Before stage II
At stage II
After restoration

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Acc to origin of infection

Peri impantitis
Retrograde peri-implantitis

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Soft tissue complications

Exposure of cover screws

Proliferative gingivitis
Exposure of threads

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Bone complications

Vertical defects
Horizontal defects
Progressive marginal bone loss
Fixture mobility

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

Mechanical complications

Component #
Abutment screw #
Prosthesis #
Malpositioned fixture

Prosthetic complications with dental implants. Int.J.Oral and maxillofacial surgery 2006; 21;6;234.

Complications during First stage surgery:

Problem
Possible causes
Hemorrhage
Lesions or injury of
during drilling
an artery

Implant mobility after Soft bone, imprecise

placement
preparation
Exposed
implant
threads
Swelling
lingually
directly after implant
placement
at the
mandibular symphysis
Substantial
postoperative
pain
remaining after some
days
Indian dental academy

Solutions
The implant placement will stop the
bleeding
Remove the implant and
replace with
one of larger diameter. If the mobility is
small, prolong the healing time.

Too-narrow crest

Cover the threads with coagulum or place

a membrane.
Incision of an artery Emergency: Send the patient to a
branch sublingually
specialist center for coagulation

Osteitis due to a too- Remove the affected implant.

aggressive preparation or
a bacterial contamination

Insensitivity
lower lip

of

the Incision or compression

of
the
mandibular
inferior nerve

If the insensitivity persists after a

week, use a CT scan to determine
which implant is causing the problem
and remove it.

Exposed cover screw Cover screw not placed Never try to retighten the cover screw.
after a few weeks
deep
enough;
thin Prescribe vigorous oral hygiene

mucosa

Abscess around a Implant

is
not
cover screw after a integrating
(low
few weeks
probability)
infection

around the cover screw

(which often is a little

loose)

Remove the implant. Raise a flap,

remove
the
granulation
tissue,
disinfect with chlorhexidine, change
the cover screw, and re suture.

During second stage surgery + Abutment connection:

Possible causes
Solutions

Problem
Slightly sensitive
but
perfectly immobile implant

Slightly painful and mobile

implant

Imperfect osseointegration

Lack of integration

Difficulty inserting a transfer Damaged

inner
thread
screw, gold screw, or healing abutment screw
cap

Inability to perfectly
Insufficient milling
connect the abutment to the
implant

Cover the implant for 2 to 3

months and test again

Remove the implant.

of Change the abutment screw

Place local anesthesia, use a

bone mill with guide, remove
the bone, clean with saline
solution,
and
replace
the
abutment.

During prosthetic procedure: control after prosthesis placement:

Problem

Pain
or
sensation
when
tightening old screws (during
try in of prosthesis)

Possible causes
Solutions

Misfit between prosthesis and Cut the prosthesis, interlock

abutment
the pieces, and solder the
prosthesis at the laboratory.
Retry prosthesis.

Loosening of one or more Occlusal problem

Retighten,
verify
the
prosthetic screw at the first
occlusion, and recheck after 2
inspection after 2 weeks
weeks.
Loosening of prosthetic screw Occlusal problem or misfit Verify the occlusion and / or
at second check or later
between
prosthesis
and the prosthetic fit. Reduce the

abutment
extension.
Change
the
prosthetic design (add an
implant, etc). In all cases,
change the prosthetic screws.

Abscess close to an implant

Poor fit of the abutment to Verify the abutment fit with a

the implant
radiograph.
Remove
the
abutment, sterilize it, remove
the
granulation
tissue
disinfect with chlorhexidine,
and replace the abutment.

Development of pain after Disintegration of an implant, If the occlusion or the

placement of the prosthesis
peri-implant infection
adaptation of the prosthesis
seems right, modify the
prosthetic design (reduce or
eliminate extensions, reduce
the
width
of
occlusal
surfaces,
reduce
cuspal
inclination, etc).

Fracture
material

of

veneering Occlusal problem, bruxism Verify the Occlusion

or para function.
make a night guard.

Fracture of the framework

Fixture fracture

and

Weak metal frame and or Remake

the
prosthesis;
too-large extension
modify the prosthetic design
(reduce
or
eliminate
extensions, reduce width and
height of occlusal surfaces,
reduce
cups
inclination)
make a night guard

Occlusal overload
Remove the implant with a
special trephine drill, wait 2
to 6 months, if possible, and
place a wider implant.

Continuing
bone
around
one
or
implants

loss Infection (peri-implantitis)

more

Remove that etiologic factors

. Look for bacterial pockets
around the natural teeth.

Visibility
abutment
mucosa

of
titanium
through
the

Substantial
problems
that
disappear after
months.
Bleeding on probing

phonetic
do
not
2 to 3
Mucositis
periimplantitis

Place a connective tissue graft

Close the interim plant space (pay

attention of maintenance possibilities).
Make a removable gingival prosthesis.
or Remove etiologic factors (poor plaque
control, prosthesis geometry in relation
to the mucosa, look for bacterial pockets
around the natural teeth. Possibly take a
bacteria test. Cut open the lesion. Adjust
the peri-implant tissues (gingival graft).
Consider a bone regeneration procedure

Maintenance:

Toothbrushes
Interproximal brushes
Dental floss
Water Pik
Prophy II
Gauge
Chlorhexidine
Mouthwashes

Dental implant prosthetics Carl E Misch

IN CLINIC CLEANING
Ultrasonic cleaning
Soft prophy cups
Plastic instruments- Wiz stik

Dental implant prosthetics Carl E Misch

Recall:

The patient should be recalled two weeks after temporary sealing

procedures are done. At this time, check the prosthesis adaptation
and evaluate any problems that may be due to screw loosening.
After that recall appointment, allow approximately four weeks before
the next recall appointment. This time lapse allows the prosthesis
time to function and adapt to a new hygiene regimen. Evaluation of
level of bone is done at this time.
Next recall schedule is at 1 month, 3, 6 months & at 12 months after
prosthesis delivery. After the first year, recall schedule is at 3, 5, 7
and 12 years, to indicate prosthesis integrity, plaque control, and for
radiographic monitoring.

Dental implant prosthetics Carl E Misch

The following should be included at the recall appointments:

Oral examination : Question any abnormality, discomfort,
masticatory problem, and prosthetic functional problems.
Within the 18 month period after the first surgery, the bone is
still healing so any abnormal habits such as bruxism, should be
checked and monitored. If a problem exists, immediate
management should be done.
lntraoral examination : Check the hygiene maintenance
,abnormal pocket formation, gingival bleeding, and peri-implant
tissue condition. Carefully evaluate each individual since
conventional soft tissue indices may be not reliable in the
implant situation. Check the occlusion and reinforce plaque
control procedures.
Dental implant prosthetics Carl E Misch

Radiographic examination : check the bone density at the

fixture site and monitor marginal bone loss. With a good parallel
radiograph, the marginal bone loss is measured using the fixture
threads as a reference; the threads are machined at 0.5 mm
intervals (Branemark, et al. 1983).
As described, the marginal bone loss can range from 1.0 to 1.5
mm vertically in the first year (Adell, et al, 1981). Also check the
fit between the abutment and fixture and check for fixture
fractures. After the first year, estimated bone loss per year is less
than 0.05 - 0.1 mm and offers a predictable long-term prognosis.
Dental implant prosthetics Carl E Misch

Radiographs are made at the time of abutment connection and

prosthesis insertion; follow up radiographs are made at
1,3,5,7,10,15, and 20 year recall. After the 20 year recall
radiographs are made every five years.

Dental implant prosthetics Carl E Misch

Roles in implant maintenance

Clinical role:
Check patient every 3 to 4 months
Check for plaque control effectiveness
Expose radiographs every 12 to 18 months
If supra structure is retrievable remove and clean ultrasonically
every 12 -18 months
If implant needs repair, de-granulate, detoxify and graft with
GBR if necessary
Wait 10 12 wks before placing back in function
Dental implant prosthetics Carl E Misch

Patient role:

Plaque control
Use of Interdental brushes, hand and motorized (proxa brush,
oral-B, brush, Ratadent sonic)
Dip brush in chlorhexidine 0.12%
Use of flosses, yarns or tapes dipped is chlorhexidine

Dental implant prosthetics Carl E Misch

Hygienist role:

Check plaque control effectiveness

Check for inflammatory changes
If pathology is present probe gently with a plastic probe
Scale supra gingivally

Dental implant prosthetics Carl E Misch

Conclusion

Any material, technique or system is not devoid of any failures.

One has to be able to recognize these complications or failure,
analyze them on time and provide the necessary management.
Further once failure has occurred we have to take precaution to
prevent its occurrence in future.

REFERENCES

Contemporary implant dentistry Carl E Misch

Dental implant prosthetics Carl E Misch
Complications and maintenance of implants. British dental journal
1999,volume 187, no. 12,1-6
Complications of dental implants, J Prosthet Dent 2004;9;1;7
Prosthetic complications with dental implants. Int.J.Oral and maxillofacial
surgery 2006; 21;6;234.
Smoking and complications of Endosseous Dental Implants. Journal of
Periodontology, Feb 2002, Vol 23, No.2, Page 153 157
Biological factors contributing to failures of osseointegrated oral implants:
success criteria. Eur J Oral Sci 1998; 106: 527551.
Biological factors contributing to failures of osseointegrated oral implants:
Etiopathogenesis. Eur J Oral Sci 1998; 106: 721764