Académique Documents
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Culture Documents
Contents
Introduction
Definitions
Predictors of implant success or failure
Warning signs of implant failure
Criteria for implant success:
Implant quality scale:
Classifications of implant failures
.Enhancing outcome in esthetic implant dentistry
.implant maintenance
Conclusion
Bibliography
Introduction
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.
But Success cannot be guaranteed, what one
can guarantee is to care, to do ones best and to be
there to help in the rare instance that something goes
wrong
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Succes
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And failure
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Failure is
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Definitions
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.
(Askary et al ID 1999 vol8 no2 173-183)
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.
Failed Implants:
Those with progressive bone loss, with clinical
mobility and that which are not functioning in
the intended sense.
Surviving implants:
Described by Alberktson, that applies to
implants that are still in function but have
been tested against the success criteria.
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Negative factors
Bone type (type 3 and 4)
Low bone volume
Patient more than 60yrs old
Limited clinician experience
Systemic diseases
Auto-immune disease
Chronic periodontitis
Smoking and tobacco useUnresolved caries,
endodontic lesions,frank pathology
Maxillary, particularly posterior region
Short implants (<7mm)
Eccentric loading
Inappropriate early clinical loading
Bruxism and other parafunctional habits
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1. Infectious 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
2. Traumatic Failure:
Radiographic periimplant
radiolucency
Mobility
Lack of granulomatous
tissue upon removal
Lack of increased
probing depths
Low plaque and gingival
indices
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U.C.L.A team
(Beumer, Moy)
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Surgical
factor
Restorative
factor
Implant
selection factor
After stage II
After restoration
Retrograde peri-implantitis
(Traumatic occlusion origin,
non infective, forces off the long
axis, premature or excessive
loading)
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Functional
problems
Psychological
problems
Failing Implant
Bone loss
Combination
Dentist (Oral
surgeon,
Prosthodontist,
Periodontist)
Dental
hygienist
Laboratory
Technician
Patient
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According to etiology
Host
factor
Surgical
factor
Implant
selection factor
Restorative
factor
Host factor
Medical status
Habits :
Oral status
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A. Host factors
MEDICAL STATUS medical history is essential to rule out any of
the following conditions or disorders. If yes medical consultation
Bone dieases
Autoimmune
osteoporosis
osteomalacia
? hyperparathyriodism
fibrous dysplasia
paget dz
multiple myeloma
? osteomylitis
sjogren syndrome
? SLE
? scleroderma
? HIV
Endocrine
DM
Thyroid
disorders
Pregnancy
Avoid to place
implant in pregnancy
Hypertension
MI
Congestive heart
failure
SABE
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HABITS
1) Smoking:
Significance
Causes alveolar vasoconstriction and decreased blood flow
Impaired wound healing due to compromised polymorphonuclear
leucocytes function, increased platelet adhesiveness as well as
vasoconstriction caused by nicotine.
Poor bone quality
In case of poor oral hygiene, smokers have 3 times more marginal bone
loss then non-smokers
Recommendations:
1. Obtain a smoking history
2.Advice on risks of periodontal breakdown
3.Advice on the prognosis .Smoking cessation
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Parafunctional habits:
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Prevention
Increased number of implants to be placed
Avoid cantilevers and occlusal contacts in lateral excursions
Use of occlusal splint which is relieved over the implant.
Use of wide diameter implant to provide greater surface area.
Progressive bone loading and prosthetic design that improves the
distribution of stresses throughout the implant system.( By Misch
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ORAL STATUS:
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Prevention
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IRRADIATION THERAPY
Significance
Xerostomia
Susceptibility to infection
Osteoradionecrosis
Endarteritis of vessels causes decrease in oxygen supply
Prevention
Waiting period of 9-12 month between radiation therapy and implant
treatment.
Hyperbaric oxygen therapy 20 treatments of 90 min. each at 2 to
2.4atm before surgery.
Antibiotic regimen 3 days before (augmentin 500mg every 12 hrs).
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According to etiology
Host
factor
Surgical
placement
Implant
selection factor
Restorative
factor
SURGICAL PLACEMENT
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
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Problem
Occlusal load lie at an angle
Solutions
1) Prerestoring the implant position by
grafting
2) To place the implant with an angulation.
3) To place angulated abutments.
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Solution
Remove & reinsert the larger size implant.
if not possible 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
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Failure increases
Bone loss
Connective tissue
interface formed
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non-titanium instrument
by glove powder
by the operatory error
42
According to etiology
Host
factor
Surgical
placement
Implant
selection factor
Restorative
factor
43
Number of implants
Misch stated that the use of more implants decreases the
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According to etiology
Host
factor
Surgical
placement
Implant
selection factor
Restorative
factor
RESTORATIVE PROBLEMS
Excessive Cantilever
Pier abutments
No passive fit
Improper fit of the abutment
Bending moments
Connecting implants to natural teeth
Improper occlusal scheme
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Excessive cantilevers
Used implant-supported
prosthesis.
Mesial C. > Distal C.
Opposing arch
ideally a denture
no lateral forces on cantilever
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Solution
increase no. of implants
improve stress distribution by splinting additional
abutment until 0 clinical mobility is observed.
non-rigid connection but chances of
intrusion of the tooth.
Criteria
1) no observable clinical mobility of natural abutment.
2) no lateral force should be designed on prosthesis.
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Pier Abutments
Tooth as pier
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No passive fit
Bone loss
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Important guidelines to
follow
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Possible cause
Lesion or injury of
an artery
Implant mobility
after placement
Soft bone
Imprecise
preparation
Exposed implant
threads
Swelling lingually
Incision of an
directly after implant artery branch
placement at the
sublingually
Solutions
-The implant placement will
stop the bleeding.
-Simple tamponade , bone
wax, gelfoam , surgicel ,
avitene can also be used
Remove the implant and
replace with one of larger
diameter. If the mobility is
small prolong the healing
time
Cover the threads with
coagulum or place a
membrane
EMERGENCY: send the
patient to a specialist
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center for coagulation of
Granulation tissue
around the implant
head
Possible causes
Solutions
Imperfect
osseointegration
Lack of integration
Damaged inner
thread of abutment
screw
Insufficient bone
milling
Prosthetic problems
Problem
Possible
causes
Pain or sensation Misfit
when tightening between
gold screws
prosthesis
(during try in of and
prosthesis)
abutments
Loosening of one Occlusal
or more
problem
prosthetic screws
at the first
inspection after
two week
Solutions
Cut the prosthesis; interlock the
pieces, and solder the prosthesis
at the laboratory. Retry the
prosthesis
Retighten, verify the occlusion, and
recheck after two weeks.
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Prosthetic problems
Loosening of
prosthetic screws
at the second
check or later
Fracture of a
prosthetic screw
or an abutment
screw
Occlusal problem or
misfit between
prosthesis and
abutments
Too large extension
Unfavourable
prosthetic concept
Occlusal problem, lack
of fit between the
prosthesis and the
abutment or
unfavourable
prosthetic design
Prosthetic problems
Fracture of the
framework
Weak metal
frame end or
too large
extension
Bruxism or
parafunction
Implant fracture
Occlusal
overload
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Prosthetic problems
1. Continuing
bone loss around
one or more
implants
Infection
(periimplantitis)
2. Continuing
bone loss around
one or more
implants
Occlusal
overload
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Lack of Osseointegration
Adell et al proposed that lack of osseointegration can be due to
Surgical trauma
Perforation through covering mucoperiosteum during healing
Repeated overloading with microfractures of the bone at early
stages
Functional problems
Proper function of the implants is dependent on two main types of
anchorage related and prosthesis related.
Anchorage related factor
Osseo integration
Marginal bone height
Prosthesis related factor
Prosthesis design
Occlusal scheme
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Aesthetic problem
Aesthetic outcome is affected by four factors:
Implant placement
Soft tissue management
Bone grafting consideration
Prosthetic consideration
Psychological problems
high expectations of the patient
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Bone loss
Bone functions as a support for the implant and that any
disturbance in its function may lead to eventual loss of the implant.
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Prosthodontic consideration
1) Interim provisional restoration:
Modified Essex retainer
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Surgical consideration
Cosmetic laser soft tissue resurfacing & sculpting
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Use of platelet-rich-plasma
Provide blood component & source of growth factor
which enhance the wound healing
3-4ml of non-activated P-R-P is sufficient
for multiple implant site
Hard tissue
consideration
enhancing osseointegration
alveolar ridge preservation
in autogenous bone graft
Soft tissue
consideration
Both
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Peri- implantitis
Progressive peri-implant bone loss in conjunction
with a soft tissue inflammatory lesion is termed periimplantitis.
Pathological changes of the peri-implant tissues
can be placed in the general category of peri-implant
disease. (Lang et al 1994)
Two primary etiological factors
1. Bacterial infection
2. Biomechanical overload
(Newman et al 1988, 1992, Rosenberg et al 1991)
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Classification of peri-implantitis
Class I
Slight Horizontal bone loss with
minimal Peri-implant defects.
TREATMENTInitial therapy for removal of
etiological factors.
Surgical therapy includes cleaning the implant
surface, Pocket elimination via Apicalpositioning
of flap.
II
Class
Class III
Class IV
Mechanical complications
These are primarily related to failure of
prosthodontic materials to resist forces and
stresses of oral function.
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Loose bar
Radiograph confirms poor
seating abutment.
Clinical evaluation after removal
of bar indicates loose abutment
screw.
Area of
concern
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Treatment:
continued
2 - Abutment screw is
tightened with
abutment driver.
3 - Bar is then
replaced and prosthetic
screws are torqued with
appropriate screw
driver.
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Loose restoration
Diagnosis:Loose abutment
screw
Treatment:
1 - Loosen screw and
remove restoration
Small
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opening
Implant hex
Abutment hex
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ture loss
(Must differentiate b/w failing and failed)
Failing Implant
Clinical signs:progressive bone loss
:soft tissue pockets and crestal bone loss
:bleeding on probing with possible purulence
:tenderness to percussion or torque forces
Causes:overheating of bone at the time of surgery
or lack of initial stability.
:inadequate screw joint closure
:functional overload
:periodontal infection (peri-implantitis)
Treatment:Interim: remove prosthesis and abutments
:irrigate with Peridex
:ultrasonic and disinfect all components
:reinsert assuring proper screw torque
:recheck passive fit of framework and88occlusion
Failed Implant
Clinical signs:
Mobilityverify fixture mobility by removing any
abutments and superstructures first.
A Dull percussion sound has been associated
with a failed implant.
Peri-implant radiolucency can be a radiographic
finding often this is not evident on an X-ray
Causes:
:surgical compromise (overheating bone and
initial lack of stability).
:Inadequate screw joint closure
:Too rapid initial loading
:Functional overload
:Periodontal infection (peri-implantitis)
Treatment
:removal of the implant
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Implant maintenance
IMPLANT
MAINTENANCE
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Hygiene aids
Super - floss
End tufted brushes
Proxy brushes
Tartar control dentrifices
Mechanical instruments
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Super - Floss
Excellent for all types of
implant restorations
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Proxy brushes
Plastic scalers
Implant supported
fixed partial
denture
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Conclusion
Failure of implant has a multi-factorial dimension.
Often many factors come together to cause the ultimate
failure of the implant. One needs to identify the cause
not just to treat the present condition but also as a
learning experience for future treatments. Proper data
collection, patient feedback, and accurate diagnostic tool
will help point out the reason for failure. An early
intervention is always possible if regular check-up are
undertaken.
As someone well said, it is not how much success we
obtain, but how best we tackle complex situations and
failures, that determine the skill of a clinician. No,
doubt, failures are stepping stones to success but not
until their etiologies are established and their
occurrence is prevented.
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REFERENCES
Misch : Contemporary implant dentistry
Atlas of implant dentistry, Cranin
Why do dental implants fail: part I : Askary et al
ID 1999 vol8 no2 173-183
Why do dental implants fail: part II : Askary et al
Id 1999 vol 3 : 265-275
A.S.Sclar; Soft tissue & esthetic considerations in
implant dentistry.
Myron Nevins; Implant therapy.
Torosian J, Rosenberg ES. The failing and failed
implant: a clinical, microbiologic, and treatment
review. J Esthet Dent. 1993.
Failures in implant dentistry.W. Chee and S. Jivraj.
British Dental Journal 202, 123 - 129 (2007)
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