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IMPLANT

FAILURES
Dept. of Periodontology & Implantology

Success is the ability to go from failure


to failure without losing your
enthusiasm

and Failure is not the end; Failure is the


opportunity to begin again, more intelligently.

GUIDED BY
PROF. DR. VARSHA RATHOD
DEAN & HOD

BY DR. IBRAHIM SHAIKH


SEMINAR NO. - 13

Contents
1. Introduction
2. Definitions
3. Predictors of implant success or failure
4. Warning signs of implant failure
5. Criteria for implant success
6. Implant quality scale
7. Classifications of implant failures
8. Conclusion
9. References

Introductio
n

The Beauty Behind The Failure

Definition
IMPLANT FAILURE :
It is defined as total failure of the implant to fulfill
its purpose (functional, esthetic or phonetic) because
of mechanical or biological reasons.

1. Askary et al. Why do dental implants fail : part I ID 1999 vol8 no2 173-183

Definition
Ailing implants:
Those that show radiographic bone loss without
inflammatory signs or mobility.

Failing Implant:
Characterized by progressive bone loss, signs of
inflammation and no mobility.

Definition
Failed Implants:
Those with progressive bone loss, with clinical
mobility and that which are not functioning in the
intended sense.

Surviving Implants:
Described by Albrektsson, that applies to implants
that are still in function but have been tested against
the success criteria.

Predictors of implant
success or failures
Bone type (type 1and 2)
Patient less than 60yrs old
Experienced Clinician
Mandibular placement
Implant length > 8mm
FPD with more than two implants
Axial loading of implant
Regular postoperative recalls
Good oral hygiene

Predictors of implant
success or failures
Bone type (type 3 and 4)
Low bone volume
Patient more than 60yrs old
Limited clinician experience
Systemic diseases
Auto-immune disease
Chronic periodontitis

Predictors of implant
success or failures
Smoking and tobacco use
Unresolved caries, endodontic lesions, frank
pathology
Maxillary, particularly posterior region
Short implants (<7mm)
Eccentric loading
Inappropriate early clinical loading
Bruxism and other parafunctional habits

Warning signs of implant


1
failures
Connecting screw loosening
Connecting screw fracture
Gingival bleeding and enlargement
Purulent exudates from large pockets
Pain
Fracture of prosthetic components
Angular bone loss noted radiographically
Long-standing infection and soft tissue
sloughing during the healing period of first
stage surgery

1. Askary et al. Why do dental implants fail : part I ID 1999 vol8 no2 173-183

Implant Success Criteria

The individual implant is immobile when tested


clinically.
No radiographic evidence of peri-implant
radiolucency
Bone loss no greater than 0.2 mm annually
Gingival inflammation amenable to treatment
Absence of symptoms of infection and pain

2. Albrektsson T. Int J. Oral Maxillofac Implants 1986; 1:11-25

Implant Success Criteria

Absence of damage to adjacent teeth


Absence of paresthesia, anesthesia or violation
of the mandibular canal or maxillary sinus
Should provide functional survival for 5 years in
90% of the cases and for 10 years in 85%.

2. Albrektsson T. Int J. Oral Maxillofac Implants 1986; 1:11-25

Implant Quality Scale

Reduction of stresses, Shorter intervals between hygiene


appointments, gingivoplasty & yearly radiographs.
Reduction
of
stresses,
drug
therapy,
antibiotics,
chlorhexidine mouthwash, surgical re-entry, revision surgery,
change of prosthesis or implants.
Reduction of stresses, removal of implants followed by bone
grafting.

3. International Congress of Oral Implantologists, Pisa, Italy, Consensus Conference, 2007

Classification
1. E.S Rosenberg, J.P. Torosian and J. Slots.
2. Kees Heydenrijik, Henny JA Meijer, Wil A Van der et
al.
3. Marco Esposito, Jan Michael Hirsh, Ulf Lekholm et al.
4. Sumiya Hobo, Eiji Ichida, Lily T Garcia.
5. Abdel Salam El Askary, Roland Mefert and Terrence
Griffin.

E.S Rosenberg, J.P. Torosian and


J. Slots.
1. Infectious
Failures

Clinical signs of infection with


classic symptoms of
inflammation

2. Traumatic
Failures

Radiographic periimplant
radiolucency.

Mobility

No granulomatous tissue upon


removal

High plaque and gingival


indices.

Pockets.

Bleeding, Suppuration &


Attachment loss.

Lack of increased probing


depths

Low plaque & gingival indices

Peri implant radiographic


radiolucency.

Presence of granulomatous
tissue upon removal

Kees Heydenrijik, Henny JA


Meijer, Wil A Van der et al
Early Failures:
Surgical trauma
Insufficient quantity or quality of bone
Premature loading of implant
Bacterial infection

Late Failures:
Soon late failures:
Overloading in relation to poor bone quality and
insufficient bone volume.
Delayed late failures:
Progressive changes of the loading conditions in relation
to bone quality, volume and peri -implantitis.

Marco Esposito, Jan Michael


Hirsh, Ulf Lekholm et al
Biological Failures:
Early or primary (Before loading)
Late or secondary (After loading)

Mechanical Failures:
Fracture of implants, connecting screws, bridge framework,
coatings etc

Iatrogenic Failures:
Improper implant angulation and alignment, nerve damage

Inadequate Patient adaptation


Phonetics, esthetics, psychological problems

Sumiya Hobo, Eiji Ichida, Lily T


Garcia
Swedish Team

U.C.L.A team

( Branemark et al)

(Beumer, Moy)

1.

Loss of bone anchorage:


a. Mucoperiosteal
perforation
b. Surgical trauma

1.

Complications in Stage I
surgery.

2.

Gingival problems:
a. Proliferative gingivitis
b. Fistula formation

2.

Complications in Stage II
surgery.

3.

Mechanical complications:
a. Fracture of prosthesis,
gold screws, abutment
screws.

3.

Prosthetic complications

Abdel Salam el Askary, Roland


Meffert and terrence griffin
According to etiology
Host
factor

Surgical
factor

Implant
selection factor

Restorative
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)

Abdel Salam el Askary, Roland


Meffert and terrence griffin
According to failure mode
Lack of
osseointegration

Unacceptable
aesthetics

Functional
problems

Psychological
Problems

According to condition of failure


Ailing Implant

Failing Implant

Failed Implant Surviving Implant

According to supporting tissue type


Soft tissue loss

Bone loss

Combined

According to etiology
Host
factor

Surgical
factor

Implant
selection factor

Restorative
factor

Host Factor

Medical status

Habits

Oral status

Host Factor
Medical Status
1. Bone diseases
Osteoporosis
Osteomalacia
? Hyperparathyroidism
? Osteomyelitis
Fibrous dysplasia
Paget disease
Multiple myeloma

Host Factor
Medical Status
2. Autoimmune Conditions
Sjogrens syndrome
? HIV
? SLE
3. Pregnancy
Should be Avoided

Host Factor
Medical Status
4. Endocrine Conditions
Diabetes Mellitus
Thyroid Disorders

Host Factor
Habits
1. Smoking
Causes alveolar vasoconstriction and decreased
blood flow.
Impaired wound healing due to compromised
polymorphonuclear leucocytes function.
Poor bone quality in case of poor oral hygiene,
smokers have 3 times more marginal bone loss
then non-smokers.

Host Factor
Habits
1. Bruxism
Increased physiologic load upto 1000 psi
Most common cause of implant failure
Manifests as screw loosening
More in maxilla

Host Factor
Habits
1. Bruxism
Prevention:
1. Increased number of implants
2. Avoid cantilevers
3. Use of occlusal splints
4. Wide diameter implants
5. Progressive bone loading and prosthetic design that
improves the distribution of stresses throughout the
implant system (By Misch)

Host Factor
Oral Status
Suprabony connective tissue fibers are
oriented parallel to the implant surface
Susceptible to plaque accumulation and
bacterial ingress

Spontaneous loss of the perimucosal seal

Chances of implant failure increases

Host Factor
Oral Status
Prevention
1. It is recommended that the patient be recalled frequently,
preferably at a minimum of 3 months intervals. Periodontal
indices, bleeding on probing and radiographic evaluation
should be performed, using plastic tipped probes for checking
pocket depths.
2. Soft tissue debridement should be performed by means of
plastic curettes and plastic tips for ultrasonic scalers, and
topical and systematic antimicrobial drugs should be used
3. Provide space beneath the superstructure to allow cleansing
aids
2

According to etiology
Host
factor

Surgical
factor

Implant
selection factor

Restorative
factor

Surgical Factor
1.
2.
3.
4.
5.
6.
7.

Impaired healing and infection due to improper flap


design.
Overheating the bone and exerting too much pressure.
Contamination of implant body before insertion.
Placement of implant in immature bone grafted site.
Severe angulation.
Minimum space between implants.
Lack of initial stabilization.

Surgical Factor
1. Impaired Healing
No single flap design is optimal for implant surgery.
But improper flap design - infection & bacterial ingress chances of failure increases.
Basic principles of flap designing should be followed.

3
1

Surgical Factor
2. Bone overheating
Excessive pressure

Bone cell damage


Bone loss

Inverse relationship
between speed & heat
production

Failure increases
Connective tissue
interface formed

3
2

Surgical Factor
3. Implant contamination
By autoclaving the
contaminated implant

Impossible for phagocytic


cell to clean the surface

Non-titanium instrument
By glove powder

No close adaptation to
the bone

By the operator error

3
3

Surgical Factor
4. Off-axis placement (Severe angulation)
Occlusal load lie at an
angle

Shear & tensile forces


increases

Chances of failure
increases

3
4

Surgical Factor
5. Lack of primary stability
Due to oversized
osteotomy

Gap develop
between implant &
bone

Lack of
osseointegration

Remove & reinsert


larger size implant.

the

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

3
5

According to etiology
Host
factor

Surgical
factor

Implant
selection factor

Restorative
factor

Implant Selection Factor


1.
2.
3.

Length of the implant.


Width of the implant.
Number of implants.

Implant Selection Factor


1. Length
Misch proposed : 10 16 mm
More failures if smaller size implant is placed.
More the length greater the BIC
Crown-implant ratio increased lateral forces.

3
7

Implant Selection Factor


2. Width
Misch proposed : not less than 1 mm both buccally and
lingually.
More failures if smaller size implant is placed.
More the length greater the BIC
Crown-implant ratio increased lateral forces.

3
8

Implant Selection Factor


3. Number
Misch proposed : more the number lesser the pontics.
Smith et al contradicted this wound contamination due to
longer surgical time.

3
9

According to etiology
Host
factor

Surgical
factor

Implant
selection factor

Restorative
factor

Restorative Factor
1.
2.
3.
4.
5.
6.
7.

Excessive Cantilever
Pier abutments
No passive fit
Improper fit of the abutment
Bending moments
Connecting implants to natural teeth
Improper occlusal scheme

Implant Selection Factor


1. Excessive Cantilevers
Causes increased loads on the adjacent implant

Amount of force increases ifLength of cantilever increases

4
1

Implant Selection Factor


2. Connecting implants to teeth
Difference b/w implant & tooth movement in vertical & lateral
direction.

4
2

Implant Selection Factor


3. Improper fit of abutment
Improper locking b/w abutment-fixture interface

Increased microbial population &


increased strain on implant component

Bone loss

Rapid screw-joint failure

4
3

Contents Part
B
1. According to timing
2. According to infection - peri implantitis
3. According to tissue type
4. Mechanical Failures
5. Inhalation or swallowing of implant components
6. Conclusion

4
4

References
1.

Misch : Contemporary implant dentistry

2.

Atlas of implant dentistry, Cranin

3.

Why do dental implants fail: part I : Askary et al ID 1999 vol8 no2


173-183

4.

Why do dental implants fail: part II : Askary et al Id 1999 vol 3 :


265-275

5.

Myron Nevins; Implant therapy.

6.

Torosian J, Rosenberg ES. The failing and failed implant: a clinical,


microbiologic, and treatment review. J Esthet Dent. 1993.

7.

Failures in implant dentistry. W. Chee and S. Jivraj. British Dental


Journal 202, 123 - 129 (2007)

8.

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