IMPLANT

FAILURES

CONTENTS

Introduction
Definition of implant failure
Signs and Symptoms
Criteria for successful Implants
Failing and Failed Implants
Classification of implant failures
Systematic factor contributing to implant failure
Perioperative errors contributing to implant
failure
Errors due to anatomic variation
Errors due to implant contamination
Error in implant position
Error in implant exposure

Peri implantitis
Prosthodontic consideration in first stage implant
failure
Factors affecting Implant Failures
Implant related factors
Host factors
Prosthodontic consideration in implant failure
Esthetic failure
Force delivery and failure mechanism
Tooth implant connection
Single implant restoration
Factor effecting choice of occlusal scheme
Important guideline to follow
Summary and conclusion
References

INTRODUCTION

Definition:An implant failure may be defined as

the first instance at which the performance of the
implant, measured in some quantitative way falls
below a specified acceptable level.
Or
Can be defined as an implant that has a hopeless
prognosis.

Signs and symptoms of implant

failure

Horizontal mobility beyond 0.5mm or any clinically

observed vertical movement under <500g force

Rapid progressive bone loss regardless of the stress

reduction and peri implant therapy

Pain during function or on percussion

Dull sound on percussion

Continued exudation in spite of surgical attempts at

correction

Generalized radiolucency around an implant

>1/2 of the surrounding bone is lost

Pocket depth of 5mm .

Bleeding on probing (BOP) Index of 2 or above

CRITERIA FOR SUCCESSFUL

IMPLANTS
The criteria used to evaluate the success of oral implant
treatment have changed considerably during the last 35
years

The criteria proposed during the first national institutes of

health consensus meeting on this subject in 1979 are now
considered inadequate according to current standard
1986 Alberktsson and colleague proposed a more
stringent set of criteria
Individual unattached implant that is immobile when
tested clinically
Radiograph that does not demonstrate evidence of per
implant radiolucency
Bone lose that is less then 0.2mm annually after the
implant first year service

Individual implant performance that is Characterized by an

absence of persistent and irreversible sign and symptoms of
pain ,infection, neuropathies, paresthesia or violation of the
mandibular canal
A success rate of 85% at the end of a 5 year observation
period and 80% at the end of a 10 year observation as a
minimum criteria for success
Smith And Zarb (1989) added to the criteria for implant
success by suggesting that the implant design should not
preclude placement of a crown or prosthesis with an
appearance that is satisfactory to the patient and dentist

Failing and failed implants

Failing Implant
DefinitionFailure process is in
early stages and is
reversible
Clinical features Progressive Marginal Bone
loss (Saucerization)
Absence of mobility
Peri implant infection (peri
implantitis)

Failed Implant
Failure process has
reached the irreversible
state
# Marginal bone loss
reaching the apical 1/3 of
implant mobility
Thin peri fixtural
radiolucency

Classification of Implant
Failures
According to Branemark et al

Loss of bone anchorage

- Mucoperiosteal perforation
- Surgical trauma

Gingival problems
- Proliferatative gingivitis
- Fistula formation

Mechanical complications
- Fixture fractures
- Fracture of prostheses, gold screws, abutment

According to Misch
Surgical failure

inability to place the abutment at the

time of surgery

Osseous healing failure

period from implant placement to

abutment connection,is related to
healing ability of bone

Early loading failure

the first year the implant serves as a

prosthetic abutment

Intermediate implant
failure

time period after the 1st yr of loading

upto following 5yrs of function

Late implant failure

after the implant and prosthesis have

been loaded for >5yrs but <10yrs.

Long term failure

failures after 10 yrs.

Complications/Factors
leading to implant failures
.Surgical factors (early failures)
Stage I surgery
1) Overheating of bone - necrosis,osteomyelitis
2) Lack of primary stability - bone loss
3) Infection
4) Lack of osseointegration
5) Poor placement or angulation, slips, eccentric drills
6) Damage to vital structures
7) Implant fracture
8) Inadequate no. of implants

Stage II surgery
1) Loose abutment
2) Poor fixtures
3) Early loading by
prosthesis
4) Poor abutments

Prosthetic factors
(late failures)
1.Improper design, shape, contours
2.Poor fit of prostheses
3.Occlusal forces
4.Inaccurate framework
5.Cantilever extension
6.Framework fracture, prosthesis
fracture
7.Functional problems eg. speech

Systematic factors contributing to

implant failure

It is important for the implant team to understand

the risk factors responsible for implant failures
Systematic disease like diabetes, collagen disease
like scleroderma , systematic lupus erythematous,
rheumatoid arthritis have microvascular changes
.
Therapeutic radiation to the mandible and maxilla
and long term steroid therapy also results in poor
vascularity and may contraindicate implant use
Osteoporosis ,paget disease hormone disorders
and renal tumors may also compromise implant
ossiointegration

Perioperative errors contributing

to implant failure

Error due to anatomic variations and

abnormalites
Errors due to implant contamination
Errors in surgical technique
Errors in implant position
Errors in implant exposure

Errors due to anatomic variation

and abnormalities

Ideal fixture placement depends on a preoperative clinical

assessment of bone
configuration quality and quantity

In addition careful digital palpation of lingual surface of

mandible provide information on the configuration of the bony
surface.

Often this area is concave, perforation of the lingual plate can

occur if the bony prominence And concavity are not
anticipated

Errors due to implant contamination

Contamination of the implant surfaces interferes
with osseointegration

Errors in surgical technique

Successful implant placement depends highly on

proper surgical technique
Maintaining an adequate blood supply and reducing
hard and soft tissue surgical trauma lessen the
perioperative causes of failed implant
Incision design..
When there a minimal amount of keratinized tissue
the incision should be placed buccal or labial to the
alveolar crest.
Such placement minimizes the possibility of
compromising the blood supply to this area ,and
preserves the keratinized tissue as a part of the
lingually based flap.

Healthy ,viable bone is critical for the success for

integration between the bone and the implant
surface

A study by Eriksson and Albrektsson showed that the

threshold temperature for heat induced injury to bone
tissue is 47C applied for 1mit . (JPD 50;101,1983)

Error in implant positioning

An implant may integrate successfully with the surrounding

bone but ultimately be a clinical failure because it is too
poorly positioned to support a functional prosthetic restoration
Attention to proper intraoperative angulation as well
maintenance of a parallelism between implants and between
implant and natural dentition , contribute to optimal and
successful prosthetic design and function.
Implant placed too buccal or lingual, this can cause a bone
dehiscence, a lack of bicortical support, and eventual implant
exposure

Error in implant exposure

Generally 4-6 months are allowed for healing..

If there is an adequate amount of keratinized gingiva
but is not located over the implant, a labial or buccal
flap can be elevated and the tissue shifted to surround
the implant
When exposing implant in the anterior maxilla
providing sufficient soft tissue bulk for a convex ridge
form
Creation of interproximal papilla
Proper gingival counter
Assure that there is keratinized gingiva surrounding the
labial aspect of the crown

Prosthodontic considerations in first stage

Implant failures

Most common postoperative complication involves

soft tissue breakdown of the wound and exposure
of the implant body or cover screw
Forces on the mucosa cause the soft tissue to be
compressed over the implant ,.
Perforation of the soft tissue also may be caused
by supracrestal protrusion of the implant or
inadequate tightening of the cover screw
Insertion of the interim prosthesis too early also
may affect the healing process adversely ,
resulting in gingival perforation and implant
exposure.
Premature loading can lead to micromovement..

The totally edentulous patient should not wear

any prosthesis over the implant sites for
approximately 2 weeks
After 2 weeks the old denture must be relieved
over the implant site and relined with a resilient
soft liner material

Peri Implantitis
Definition- American Academy of
Periodontology defines Peri implantitis as
progressive Peri implant bone loss in
conjunction with a soft tissue
inflammatory
lesion.
Causes :
Bacterial Accumulation
Overloading or
Combination

ETIOLOGIC FACTORS
Two primary etiologic factors are acknowledged today
as causative in peri implant marginal bone loss:
Bacterial

infection

Biomechanical

overload

Biomechanical Overload
Bone loss at the coronal aspect of implants can
result form biomechanical overloading and the
resultant microfractures at the coronal aspect of the
implant-bone interface. The loss of osseointegration
in this region results in apical down growth of
epithelium and connective tissue.

. The role of over loading is likely to increase

in four clinical situations:

1.

The implant is placed in poor quality bone.

2.

The implant position or the total amount of

implants

placed

does

not

favor

ideal

transmisson over the implant surface.

The patient has a pattern of heavy occlusal

3.

function associated with Para function.

4.

The prosthetic superstructure does not fit the

implants precisely.

load

Other etiologic factors such as traumatic

.
surgical
techniques, smoking, inadequate amount of

host bone resulting in an exposed implant surface at

the time of placement and a compromised host
response can act as co-factors in the development of
peri implant disease.

BACTERIAL INFECTIONS
Most authors have assumed that peri-implant diseases
(mucositis, peri-implantitis) are comparable to periodontal
diseases in that they are primarily plaque-induced.
If plaque accumulates on the implant surface, the sub epithelial
connective

tissue

becomes

infiltrated

by

large

number

inflammatory cells and the epithelium appears ulcerated and

loosely adherent.
When the plaque front continues to migrated apically, the clinical
and radiographic signs of tissue destruction are seen around both
implants and teeth.

In addition, the implant lesions

extend into the supracrestal connective
tissue and approximate/populate the bone
marrow. While the lesions associated with
teeth do not.

Additional Possible Etiologic and Modifying

Factors
In addition to bacterial infection and excessive
biomechanical loading, other etiologic and modifying
cofactors have been considered as potential initiators
of peri implant disease.
Implant
Peri

Shape and Implant Surface

implant soft tissue attachment

IMPLANT SHAPE AND IMPLANT SURFACE

Over the long term, users of the Branemark
system have generally observed peri-implant bone loss
of approximately 1.5mm during the first year implant
insertion and 0.1 mm per year in subsequent years.
Bone resorption was reported to be exclusively
horizontal in nature: vertical defects were not
observed. (Adell et al. 1986, Alberktson et al. 1988).

with other systems (eg : IMZ, care vent) higher bone

resorption rates and occasionally vertical defect have been
reported.
very little information is available regarding whether the
implant design (cylindrical ,screw type) implant surface
morphology (e.g. highly polished cervical region) the
technique of surgical placement, or other factors may be
responsible for the various peri-implant reactions.

Peri-implant soft tissue attachment

Several authors have proposed that the
maintenance of healthy peri-implant conditions
requires a collar of attached gingival around the
implant neck.
Furthermore, clinical and animal experimental
research has demonstrated that if oral hygiene is
sufficient, healthy peri-implant conditions can be
maintained even if mobile oral mucosa surrounds
the implants.

Nevertheless, if recurrent inflammation persists

around implant surrounded by mobile mucosa, it
may be prudent to surgically create a peri-implant
zone of attached gingiva, which will also simplify
implant hygiene. (Langer et all 1980).

CLASSIFICATION
Classification Peri-implantitis
Peri-implantitis

- Class 1

Peri-implantitis

- Class 2

Peri-implantitis

- Class 3

Peri-implantitis

- Class 4

Peri-implantitis - Class 1
Slight horizontal bone loss with minimal peri-implant
defects

Peri-implantitis class 2
Moderate horizontal bone loss with isolated vertical
defects.

Peri-implantitis class 3
Moderate to advanced horizontal bone loss with broad,
circular bony defects.

Peri-implantitis class 4
Advanced horizontal bone loss with broad, circumferential
vertical defects, as well as loss of the oral and/or vestibular
bony wall.

Clinical SignsProgression of pocket

depth
Radiographically
detectable bone loss
Inflammatory Reaction
of Mucosa

Implant related factors

1.Screw design:

conical screws - loosen

flat head screws - better
2.Implant body design:

smooth cylinder implant - shear force at implant-bone

interface

threaded implant - can transform and change the direction of

force through thread geometry

b) Thread

pitch:
smaller the pitch more
will be the surface

c) Thread depth:
increases surface area

Implant length :
Implant width :

increases surface area

increases surface area

Host factors
Patient dissatisfaction with the result.
Inadequate patient follow-up
Failure to maintain hygiene leading to periodontal
breakdown
Para functional habits
Systemic health( medical complications)
Medications- alter tissue metabolism and repair
Social habits like smoking, stress,alcohol abuse affect
wound healing
Poor bone quality and quantity - a vascular bone,bone
density,
type of bone,etc.

Prosthodontic consideration in
implant failure

Esthetic failure
Most common causes of esthetic
failure is loss of the interdental papilla
or Cervical positioning of the facial
gingival margin or both.
This often is caused by the surgeons
failure to take into account the patents
soft tissue needs before or during surgery

Force delivery and failure mechanisms

Moment loads (torque or torsional loads):
is defined as a vector,the magnitude of which equals
the product
of force magnitude and the perpendicular distance
from the implant
to the line of action of force.

Possible rotations
A total of six rotations may develop about three clinical co
ordinate axes.

Clinical Moment Arms

1.OCCLUSAL HEIGHT MOMENT ARM
2.CANTILEVER LENGTH MOMENT ARM
3.OCCLUSAL WIDTH MOMENT ARM

GEOMETRIC LOAD FACTORS

1.
2.
3.
4.
5.

6.

Increased bending exerted on implant has been

identified and the term bending overload has been
proposed as a major risk factor for failure
Geometric load factors that can compromise the
support and result in increased overload include
Fewer then three implant
Implants connected to teeth
Implant in line
Cantilever extensions
Occlusal plane beyond the implant support eg.
buccal and lingual cantilevering
Excessive crown implant ratio

Tooth implant connection

Problem connecting implant to teeth in that first, if a rigid

structure (implant) is connected to a non rigid structure
(tooth), the more mobile of two may act like a cantilever and
result in increased load to the rigid structure
If non rigid connector is used ,there is a tendency for teeth
to intrude ,with this intrusion there is a much greater risk of
bending overload..
The best solution is to design the implant restoration to be
fully implant supported

. ATTACHMENT TO NATURAL TEETH

Hobo

in 1986 recommended a non rigid

attachment and a Key and Key way type of
attachment between teeth and implant.
Lundgren

in 1986 recommended the use of Semi

precision attachment which detaches the teeth
from the implant prosthesis allowing a tooth to
move downward.

 The IMZ implant system uses a Intra mobile

element [IME] to act as a shock absorber during

function.
It can act as a PDL analogue.
Misch:

stated that biomechanical concern and

difference in Support should be understood and
applied before attaching natural teeth to implants.
He advocates initial occlusal contacts on the natural
teeth.
Once the equilibrium with a light bite force is
completed, a heavier CR occlusal force is applied to
have contacts on teeth as well as implant also, thus
harmonizing the occlusal forces.

Single implant restoration

The replacement of single molars with implant has

provided more problems then originally anticipated
The occlusal table of a normal sized molar is relatively
large compared with a standard sized implant (3.75-4)

The potential for bending is tremendous because a

cantilever in all 360. In order to reduce the bending a
wider and stronger support system had to be designed.

5mm diameter implants provide a stronger implant .

These feature combined with a narrower buccolingual

dimension for the restoration ,dramatically reduces the
potential for bending

Review of occlusal scheme

Lundgren , Laurell (1984) suggested the need to
minimize horizontal forces created by premature
contacts or steep cusps.
Albrektsson,et al., (1986) emphasized the need to
distribute the load mainly over the areas
supported directly by fixtures.
Jemt (1986) described that when Osseo integrated
implants are used in short span FPD and single
tooth replacements , the occlusion should be
distributed in maximum intercuspation and all cusp
interferences should be eliminated in eccentric
positions.

Misch (1991) developed IPO Implant protective occlusion for

implant supported restorations.
IPO - Medial positioned lingualized occlusion
is based on :
- Narrow occlusal table.
- occlusal table width similar to width of implant body.
- Increasing surface area.
- Design of occlusion in favour of weakest arch.
- Decreasing force of occlusal contacts.
- Eliminating or reducing all shear loads to implant to
bone interface.
- Posterior disocclusion by anterior components.
- Initial contacts on only natural teeth and later on
multiple. contacts on both teeth and implants

Factors affecting choice of occlusal

scheme
1.Arch form:
- Curve arch is favorable for less stresses
- Influences no. of implants to be placed
- Opposing arch form affects occlusion
2.Interarch distance and jaw relations :
- May prevent development of particular
occlusal scheme
- May force to adapt a particular scheme
- Affects biomechanical aspects

3. Orientation of the occlusal plane :

- Arch in which implant is placed becomes the
dominant arch and opposing edentulous arch
becomes weak arch.
- plane should favor weaker arch
4.

Abnormal mandibular movements

5. Bone support and bone mechanics :

Good bone support - occlusal contacts can be increased.
6. Occlusal material :
- affects the transmission of forces.
- affects the maintenance of occlusal contacts.

. Zarb

(1985): stated that acrylic teeth have shock

absorbing effect and can be modified for use very
easily.

They should be used to decrease overloading of implants.

However selection of occlusal material depends upon :
- Opposing occlusion.
- Remaining dentition.
- Arch to be restored.
7. Quality of Osseo integration
Its is the ability of implant to bear occlusal load .
It depends upon:
Implant length , width, design, surface coatings.
Number of implants, position of implants, orientation of
implants.

IMPORTANT GUIDELINES TO
FOLLOW

Infraocclusion upto 30 microns of implant

supported restoration
No balancing contacts on cantilevers.
No guidance on single implants.

Freedom in centric.

Occlusal table directly proportional to implant

diameter.
Narrow occlusal width.

IMPLANT

LENGTH CROWN RATIO

ideal 1:2
acceptable 1:1 for removable denture.

AVOIDANCE

OF CANTILEVER LENGTH.
maximum 10 and 20 mm is advised.
7 mm is optimum .
SHALLOW CENTRAL FOSSAE WITH TRIPODAL
CUSPAL CONTACTS.

NO

CONTACT IN LATERAL EXCURSION.

SLIGHT

CONTACT IN CENTRIC OCCLUSION.

Summary and Conclusion

Although the over all success rate of implant

dentistry is very high, dental implant
occasionally fail
The best steps to avoid encountering failing
implant involve proper case selection,
excellent surgical technique, placing an
adequate restoration on the implant, educating
the implant patient to maintain meticulous
oral hygiene, and evaluating the implant both
clinically and radio graphically at frequent
recall visit

References
.

Carl.E.Misch : Implant Dentistry, 2nd ed

Davies S.J.,Gray R.J.M.,Young M.P.J.:Good occlusal practice in the

provision of implant
borne prosthes8es.BDJ 2002;192:79-88
. Hobo, Ichida, Garcia: Osseointegration and Occlusal
Rehabilitation,1st ed.
Michael D.Wise : Failure in the Restored Dentition:Management
and Treatment,1st ed.

Palmer R,Palmer P,Howe L Dental implants: Part 10.Complications

and maintenance.
BDJ 1999 ; 187:653-658

Vincent Jimenez-Lopez : Implant-support prosthese:

Occlusion,Clinical Cases and laboratory procedures, 1st ed.pp. 2344,1995

Lindhe jan : Clinical periodontology and implant diseases

Glickman Irvin : Clinical periodontology 3rd ed. 1997
James

Robert A: Periodontal considerations in

implant dentistry JPD Aug 1973, vol 30, no. 2, 202-209
Weinberg

L A Reduction of implant loading using a

modified centric occlusal anatomy.
Int J Prosthodont 1998 ; 11:55-69
Louis.

frose , brain z.mealey periodontics

Oral

and maxillofacial surgery clinics of north America

implant failures 1998
hubertus

spiekermann Color atlas of dental medicine

implantology
Erikssonar,Albrektsson .Temperature threshold levels for
heat induced bone tissue injury JPD50;101;1983