Failures In Dental Implants

2003

Table of content

Introduction
Definition
Classification
Failures of endosseous implants

According to etiology
According to timing of failure
According to failure mode
According to condition of failure
According to supporting tissue type

Treatment
Summary
Conclusion
Reference

Introduction
Osseointegrated dental implants
represent a widely accepted and
documented treatment modality for
the rehabilitation of the partially or
totally edentulous ridge.
Apart from the success , it also have
its failures, due to various factor .

The focus of implant research is

shifting from descriptions of clinical
success to the identification of factors
associated with failure.
Few studies, however, systematically
address the frequency or nature of the
risk factors responsible for failure and
complications in the use of dental
implants.

A better understanding of the

factors associated with implant
failure provide data for the planning
of future studies, facilitate clinical
decision-making, and may enhance
implant success.

Definition
Implant failure: The total failure of the
implant to fulfill its purpose (functional,
aesthetic or phonetic) because of
mechanical or biological reasons.
Peri-implantitis : in periodontics, a term
used to describe inflammation around a
dental implant, usually its abutment

History
SUBPERIOSTEAL IMPLANTS
This implants was first developed by
DAHL(1940) .

 It used direct bone impression

technique

 Disadvantages
Slow osseointegration
Difficult retrievability
Excessive bone loss
Exteriorization by downgrowth of
epithelium.

 TRANSOSTEAL IMPLANTS
(mandibular staple implants, staple
bone implant ,and transmandibular
implants)
Combines subperiosteal and endosteal
components
Developed by SMALL (1968)
Mostly used in mandibular anterior
region

Bone loss around the posts has

proved a frequent problem

 ENDOSTEAL IMPLANTS

Classification
By Meffert
Ailing Implant
Failing Implant
Failed Implant

 Ailing implant:
Implants exhibiting
soft tissue
problems
exclusively are
classified as ailing
and have a more
favorable
prognosis.

 Failing implant:
An implant that is
progressively
losing its bone
anchorage, but is
still clinically
stable, can be
defined as failing

 Failed implant:
Implant with
mobility excessive
bone loss (>70%)
not amenable to
treatment are
failed implant

 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 failure mode

Lack of osseointegration
Unacceptable aesthetics
Functional problems
Psychological problems

According to supporting tissue type

Soft tissue loss
Bone loss
Combination

According to etiology
Host factor
Medical status
Habits
Oral status

Systemic factors

Osteoporosis:
Significance
More common in
women
Greater loss of
trabecular bone than
cortical bone
Difficult to achieve
immediate stability
Generally have
minimal alveolar
bone height

 Prevention
Hyperbaric oxygen therapy
Treatment for osteoporosis(Hormone
Replacement Therapy , dietary calcium,
weight bearing exercise)
Use of hydroxyapatite coated implants to
provide a biomechanical bonding rather
than a mechanical one
Increase no.. of implants to distribute load

Diabetes
Significance
Liability of infection
due to fragility of
vessels so as to
alter blood supply
Impaired wound
healing

 Surgical stress can release endogenous

norepinephrine which can cause
significant increase in plasma glucose
level

 Prevention
Screen patients for
diabetes
If patient is diabetic
get medical
consultation
If uncontrolled,
treatment postponed
till condition is under
control
Preoperative
antibiotic prophylaxis,
aseptic technique,
atraumatic tissue
handling and frequent
and close follow up

Smoking
NICOTINE AND ACRYLHYDROCARBONS
Depress osteoblastic
activity ,reduces collagen
synthesis ,inhibits
osteosynthesis .
Also causes local
vasocontriction

CARBON MONOXIDE
Forms
carboxyhemoglobin

HYDROGEN
CYANIDE
Inhibits cellular
respiratory
enzymes

Tissue
hypoxia &
altered tissue
healing

Smoking
Significance
Causes alveolar vasoconstriction and
decreased blood flow
Impaired healing
Poor bone quality
In case of poor oral hygiene , smokers
have 3 times more marginal bone loss
then non-smokers

 Smoking cessation
2weeks before and
3 weeks after
surgery

Parafunctional habits
Significance
Most common cause
of implant bone loss
or lack of rigid
fixation during the
first year after
implant insertion
Commonly manifests
as connecting screw
loosening because of
overload

 Failures are higher in maxilla because of

decrease in bone density
Forces are in excess of normal
physiologic masticatory load limit.

 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

Poor home care

Significance
Main factor of implant failure
Plaque accumulation leads to loss of
permucosal seal and ingress of bacteria
Pathogens are similar to those causing
periodontitis
Spread of infection from neighboring
teeth can occur

 Prevention
Patients with implants be evaluated at
regular visits for periodontal
maintenance procedures and any
clinical signs and symptoms of periimplant disease be recorded and
treated.

 Maintenance
programs should be
designed on an
individual basis,
precise recall
intervals, methods of
plaque and calculus
removal, and
appropriate
antimicrobial agents
for maintenance
around implants

 Provide space beneath the

superstructure to allow cleansing aids

Irradiation therapy
Significance
Xerostomia
Susceptibility to infection
Osteoradionecrosis
Endarteritis of vessels causes decrease
in oxygen supply
Of significance in patients requiring
implant supported maxillofacial
prosthesis following cancer treatment.

 Prevention
Hyperbaric oxygen
therapy
Waiting period of 612 months between
radiation therapy and
implant treatment.
Wait for a longer
healing period
following implant
placement.

Pregnancy
Implant surgery procedures are
contraindicated
Almost 15% pregnancies are
terminated by spontaneous abortion
or miscarriage during first trimester
Dental prophylactic appointments
are suggested in 2nd and 3rd
trimester.

 Hygienist and dentist should realize

that in middle and late 3rd
trimester ,hypotension can occur in
supine mother as a result of pressure
of the fetus on the inferior vena cava
.

According to etiology
Surgical placement
Severe angulation
Lack of initial stabilization
Impaired healing
Overheating the bone
Minimal space between the implants
Placing implant in immature bone
Placement in infected socket

Severe angulation
Significance
Improper implant
placement
compromises
aesthetics and
function

 Offset loading deleterious to implant, the

angled load increases the amount of
crestal bone stresses around the implant
body, transforms a greater percentage of
the force to tensile and shear force and
reduces bone strength in compression
and tension.
These could lead to interface breakdown,
bone resorption, prosthetic screw
loosening, and restoration fracture.

 Prevention
To graft the area to allow proper implant
placement
Use of angulated abutments

 Lack of initial stabilization

Use of excessive force to disengage a
locked drill
Faulty hand positioning during drilling
Poor bone quality
Use of finger rest during osteotomy
preparation

 Prevention
Mastering the surgical skills
Proper drill grip
Use of sharp drills

Impaired healing
Impaired healing and infection due to
improper flap design
There is no single flap design that is
optimal for implant surgery. The basic
surgical procedure, flap design, blood
supply, visibility, access and the
primary closure are the factors that
should be regarded in implant
placement.

Overheating
Overheating the bone and exerting too
much pressure can cause
Bone cell death occurs if temp are >45
Strong correlation between overheating
of the bone and implant failure
Excessive pressure leads to bone cell
necrosis
Connective tissue interface forms
leading to lack of integration

 Specific critical temperature is 56 O

C.
If the temperature rises of 47 O C for
1-2 minute will cause damage to the
bone tissue.
A combination of copious irrigation
system and sharp drill should be
used

 Prevention
External irrigation
No pressure to be
applied while
drilling
Graded series of
drills to be used
Use of sharp drills
at high speed

Minimal space between

implants
A space of 3-5mm
between implants to
allow biologic space to
avoid necrosis due to
blood supply
impairment
To maintain proper oral
hygiene protocol
Denser the bone more
the space required
Space of 1.5 mm
between implant and
adjacent teeth to avoid
impairment of blood
supply to PDL

Placement in infected site

Implant may fail due to
immediate placement into an infected
socket or a existing pathologic lesion
(cyst)
Migration of infection from a
neighboring tooth

 Prevention
Careful examination
Avoid placement in infected socket
Waiting period of 2-6 mon is indicated
Mucous membrane disinfection, skin
preparation and isolation of the surgical
field with barrier draping can be
accomplished to the level appropriate
for the procedure intended.

Contamination of implant body

before insertion
Primary considerations are protection
of the patient and staff from crosscontamination, as well as protection
of the implant surface from
contamination during the installation
process

Principal Cleaning and

Sterilization Procedure
1. Clean and disinfect
instruments and drills.
Alternative: Disinfect,
clean by hand and put in
an ultrasonic cleaner.
2. Dry the instruments.
Place in sterilization
packets.
3. Sterilize the instrument
using a steam autoclave
(according to the
recommendations of the
manufacturer of the
autoclave).

 Implant Selection
Improper implant length
Number of implant

 Improper implant length

Success rate is proportional to implant
length
Long term success of implant dependent on
bone-implant contact hence short implant
means higher stress concentration
Maximum implant length must be used for
greatest stability of overlying prosthesis

 Prevention
Maximum possible length must be used
for the available bone height
In posterior maxilla, sinus lift procedure
can be attempted

 Number of implants
use of more no. of implants decreases
the no. of pontics and the associated
mechanics and strains on the prosthesis
and dissipates stresses more effectively
to the bone structure. It also increases
the implant bone interface and improves
the ability of the fixed restoration to
withstand load.

 Restorative problems
Screw loosening
Excessive Cantilever
No passive fit
Improper fit of the abutment
Improper occlusal scheme
Bending moments
Connecting implants to natural teeth

Screw loosening
Most common manifestation
Reasons :
Screw design
Inadequate torque application
Cantilever extension
Inaccurate framework abutment interface
Occlusal discrepancy and jaw relationship
Fixture position and arch form

Screw design
conical screw
has a inclined
plane
Flat head screw
has straight
plane giving
more equal
distribution of
force.

Inadequate torque
application
Amount of torque
suggested the
manufacturers on
the abutment
screw range from
20 to 35 N/cm and
a torque wrench is
required to obtain
a more consistent
value

Inadequate framework
abutment interface

Occlusal discrepancy and jaw

relation
Occlusal forces
should be shared
evenly by all
implants .
Occlusal
adjustments during
lab remounts , as
well as intraorally
during insertion of
prosthesis.

Arch form
Destructive screw
loosening as well
as fracture of the
screw may take
place due to
destructive forces .

Square arch
cantilever

cantilever
A-P spread

Tapered arch
cantilever

cantilever
A-P spread

Ovoid arch
cantilever

cantilever
A-P spread

Cantilever extension
Recommended
cantilever
extension on
mandible is 15 mm
or less and in
maxilla is 10 mm
or less when five
implants are used .

2
x

Framework fracture
Occlusal gingivally
having greater
dimension to resist
fracture

Excessive Cantilever
Non-ideal cantilever:
long distal cantilever
demonstrating bone
loss and poor
support.
Cantilever extensions
cause load
magnification and
overloading of the
implant next to the
cantilever extension,
which in turn leads to
bone loss

 With occlusal forces acting on the

cantilever, the implant becomes a
fulcrum and is subjected to axial,
rotational forces

 Distal extension cantilever must be

approached with caution as the force
generated is higher in 1st and 2nd
molar region

 The weakest link in the cantilever

design is the location and size of the
pontic and the intensity of occluding
masticatory forces. These forces tend
to be greatest in distally located
pontic cantilevers. A mesial
cantilever is favoured over a distal
cantilever for this reason

 Ideal cantilever: mesial cantilever

implant prosthesis.
Non-ideal cantilever: long anterior
cantilever due to poor implant
location, incorrect prosthetic work-up,
inadequate lip support and
compromised design. Incisal loading
will lead to prosthetic failure.

Failures In Dental Implants

Table of content

Introduction
Definition
Classification
Failures of endosseous implants

According to etiology
According to timing of failure
According to failure mode
According to condition of failure
According to supporting tissue type

Surgical failure
Restorative failure
Esthetic failure
Review of literature
Summary
Conclusion
Reference

No passive fit
One of the most critical elements
affecting the long-term success of a
multiple implant restoration is the
passive fit between the framework
and the underlying fixtures.

 A poorly fitting implant framework

can cause mechanical complications
such as loose screws or fractured
components. It can also cause
biological problems such as pain,
tissue reaction, bone loss, or loss of
integration. There can be many
causes of the misfit.

 Factors that impair achievement of

passive fit
Dimensional changes in ceramo-metal
restorations during firing cycle
Improper impression technique
Improper metal type for casting

Dimensional changes in ceramometal restorations during firing

cycle

Due to repeated firing there can be

distortion in the ceramo-metal
restorations .

Improper impression technique

Jomi ,1998, 12 , 234

 Analog variance
the abutment for screw retention usually
is fabricated in titanium or titanium
alloy.
the laboratory analog often is made of
stainless steel , brass, or aluminum .
Manufacturers often do not machine
analogs with the same accuracy as the
actual abutment for screw retention .

 Threads in
aluminum or brass
may get distorted
so , dentist should
take care that the
analog is flush and
properly seated
with the transfer
coping before the
stone is poured .

 Stone expansion
because the addition silicone or
polyether shrinkage is 0.1 % to 0.06% ,
the expansion of the die stone should
be in similar range .
polyether or addition silicone is
suggested for the impression , which is
poured in ADA classification III or IV die
stone , which expands a similar
amount as the impression shrinks .

 Acrylic shrinkage
sprinkle on method is used for
fabrication of base plate .
light cure acrylic can be used instead
of cold cure acrylic resin.

 Wax distortion .
when wax pattern is removed from the
abutment for screw and sprued before
casting , the strain may release and
distort the pattern.
screw retained casting may be more
accurate and passive when fabricated
in smaller sections to reduce distortion
.

 A thick pattern ( like large implant

metal frameworks) need larger
casting rings or wax with high
strength , high softening temp and
low flow percentage.

 Soldering
When the casting is not passive the
superstructure is separated around
the offending abutment .
The distance of the casting
separation is 0.005 to 0.008 inch , or
thickness of two sheets of paper.

 Too small separation dimensional

change when casting is is heated and
expands
Too large separation shrinkage of
solder during solidification

 Prevention
Sectioning and
soldering have
been commonly
used to improve fit
in case of long span
fixed prosthesis

 Laboratory technique should minimize

casting shrinkage and inaccuracies, and a
non-passive framework try-in technique
should achieve a stable and passive fit .

Improper fit of abutment

Improper locking between two parts
leads to an increased microbial
population and increased strain on
the implant component
There is a direct correlation between
implant- abutment rotational misfit
and screw joint failure

 Prevention
Fit of the components must be checked
before taking the impression

Bending moments
It can be defined as a situation in which
occlusal forces on an implant supported
prosthesis exert a bending moment on
the implant cross section at the crestal
bone, leading to marginal bone loss
and/or eventual implant fatigue

 Significance
High bending moments acting on
osseointegrated implants due to
transverse forces are believed to be
potential contributors to mechanical
implant failure.
higher number of mandibular implants
may decrease the bending moments
affecting mandibular fixed-detachable
prostheses during unilateral biting tasks.

 Prevention
Careful treatment plan to select
appropriate site
Avoiding or reducing cantilevers
Narrowing dimension of final prosthesis
Centering the occlusal contacts

Connecting implants to natural

teeth
Because of the
difference between
natural tooth and
implant
movements in
vertical and lateral
directions,

 because of the potential difference in

the way they react to static and
dynamic load and because of the
difference in proprioception rigid
connection between implant and
tooth is questionable.

 Combined
tooth/implant
restorations could be a
potential complication
and could cause an
intrusion of a natural
abutment regardless of
the type of connection
(rigid or nonrigid).
Avoid connecting the
implant and natural
tooth

 According to origin of infection

Peri-implantitis
Retrograde peri-implantitis

Peri-implantitis
One of the main cause of implant
failure
It begins as periimplant mucositis
Partially edentulous mouth are at
higher risk of failure then completely
edentulous mouth.
Higher chance of cross infection from
periodontitis sites to implant site

 bacterial plaque is
considered as the
primary etiologic
factors in the loss of
teeth and the implants.
Clinical findings
include marked
gingival inflammation,
deep pocket formation,
and progressive bone
loss.

 Prevention
Selection of implant candidate
Maintenance of good oral hygiene
Regular recall appointments with the
periodontist
Early intervention , treatment at the
stage of mucositis

 The destruction of the marginal bone in a

bacterially induced peri-implantitis is
difficult to differentiate from bone loss due
to other factors.
Occlusal factors are more likely to be
implicated where there has been
History of Parafuction
History if breakages of super structure or
retaining screws.
Angular or narrow pattern of bone loss.
Excessive cantilever extensions.

 Bacterial factors are

implicated where
there is Poor oral hygiene
Retention of cement in
the subgingival area
Inflammation,
exudation and
proliferation of soft
tissues.
Wide sauscerized areas
of marginal bone loss
visible on radiographs.

 Management of peri-implantitisocclusal factors should be identified

and corrected.
Contaminated surfaces are
disinfected with a topical antiseptic
or antibiotic solution.

Retrograde peri-implantitis
Retrograde implant failure can be due to
bone microfractures caused by
premature implant loading or
overloading, trauma or occlusal factors.
These are characterized by periapical
radiographic bone loss without gingival
inflammation.The microflora is
consistent with periodontal health.

 Prevention
Careful analysis of occlusal forces
Increased no.. Of implants
Precise placement and distribution of
implants
Proper follow up

According to failure mode

Lack of osseointegration
Unacceptable aesthetics
Functional problems

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

 Signs of a failed implant

Mobile
Easy to remove with a countertorque
Thin radiolucent zone around fixture
radiographically
Thin layer of soft tissue seen upon
fixture removal

Functional problems
Anchorage related factor
Osseointegration
Marginal bone height

Prosthesis related factor

Prosthesis design
Occlusal scheme

Aesthetic problem

Gingival risk factors

Dental risk factors
Bone risk factors
Patient risk factors

Gingival factors
Smile line
Gingival quality
Papillae of the adjacent teeth

Smile line

Gingival quality

Papillae of the adjacent teeth

Papilla thick and

short

Papilla long and thin

Dental factors
Form of natural teeth
Position of interdental point of
contact
Shape of the interdental contact

Form of natural teeth

Square tooth
form

Triangular tooth form

need for papilla
regeneration is more

Position of interdental point of

contact
If interdental papilla is found less
than 5 mm from the bone margin =
papilla regeneration is practically
possible
If interdental papilla is more than
5mm from the bone margin =
chances of papilla regeneration
decreases .

Shape of the interdental

contact
Larger the interdental contact
surface , the smaller the papillary
space and the simpler the papillary
regeneration .

Bone factors

Vestibular concavity
Adjacent implants
Vertical bone resorption
Proximal bony peak

Vestibular concavity

 Bone regeneration
or grafting is
needed before the
implant placement ,
or the implant will
have to be placed
following the bone
crest , but with
unfavorable
orientation of the
prosthesis .

Adjacent implants

Vertical bone resorption

Proximal bony peak

Patient factors
Esthetic requirement
Hygiene level
Provisionalization

Esthetic requirement
It is important to identify patients
with unrealistic esthetic demands .
Higher the esthetic demands more
cooperative the patient should be .
They should be aware of the difficulty
, limitation and duration of the
treatment .

Hygiene level
Extremely
rigourous dental
hygiene and good
plaque control
must be exercised .

Provisionalization
Provisional restoration should be
stable and not compromise the
patients ability to perform plaque
control .
If denture is used , it should be
designed to avoid all movements
that interfere with the implant zone .

 Instability may
cause severe
mucosal problem .
For esthetics , a
denture with a
metal framework
can be considered .

 Resin bonded
restoration without
tooth preparation .
Cost and problem
with bond strength
make this solution
difficult.

 Denture base is
should be remade
or relined at a
minimum ,every
month.

 Aesthetic outcome is affected by four

factors
Implant placement
Soft tissue management
Bone grafting consideration
Prosthetic consideration

Treatment
Treatment of the failure depends on
the type of failure and the cause of it.
If the causative factor can be
eliminated at the ailing implant or
failing implant stage then the condition
can be reversed.
Early detection is the key factor.
However in most cases a careful
planning is the only solution.

 Implant removal
Failure of osseointegration
Off axis placement
Failed cantilevered prosthesis
Implant body fracture
Aesthetic problems
Peri-implantits

Periodontal therapy
It depends on the type and stage of
failure.
Generally apart from a good home
care protocol a regular periodontal
check up is required.
Plastic scalers are used for scaling
and root planing.

 Bone loss around implants require

surgical intervention.
Exposure of implant surface, a
thorough scaling and placement of
bone graft material are all part of the
therapy

Review of literature

Albrektsson et al. IJOMI

1986; 1:11
Suggested minimum success
criteria for dental implants
1. An individual, unattached implant is
immobile when tested clinically.
2. Radiographic examination does not
reveal any peri-implant radiolucency.
3. After the first year in function,
radiographic vertical bone loss is less
than 0.2 mm per annum.

4. The individual implant performance is

characterised by an absence of signs
and symptoms such as pain,
infections, neuropathies, paraesthesia,
or violation of the inferior dental canal.
5. As a minimum, the implant should
fulfil the above criteria with a success
rate of 85% at the end of a 5 year
observation period and 80% at the end
of a 10 year period.

Richard Palmer, BDJ, 1999,

VOLUME 187, NO. 3, AUGUST
14,127-132
There are a great many factors to
take into account to ensure
predictable successful implant
treatment.
There is no substitute for meticulous
attention to detail in all of these
areas. Failure to do so will result in
higher failure rates and unnecessary
complications.

Lisa P. Deem et al ,Implant

Dent 2002;11:243248
Osseointegrated, covered, unrestored
implants are subject to failure.
This might be caused by infection,
direct or indirect trauma, endogenous
factors, or a combination of these.
Dentists should therefore monitor the
condition of submerged integrated
implants and avoid trauma or infection
from any source while the implants are
integrating.

Micha Peled et al ,Implant Dent

2003;12:116 122
Systemic factors, such as diabetes mellitus,
can influence the success rate of dental
implants.
The authors describe their experience using
the MIS implant system (Medical Implant
System, Shlomi, Israel) for retention of
overdentures in patients with type 2 diabetes
mellitus and provide data regarding the level
of satisfaction of the patients, the
improvement of function, mucosal and
periimplant health, and bone level around
implants in this group.

 The clinical outcome of dental

implants in a selected group of
patients with well-controlled type 2
diabetes mellitus is satisfying and
encouraging.

Lobbezoo et al , Journal of Oral

Rehabilitation 2006 33; 152
159

Bruxism is generally considered a

contraindication for dental implants, although
the evidence for this is usually based on
clinical experience only. So far, studies to the
possible cause-and-effect relationship
between bruxism and implant failure do not
yield consistent and specific outcomes.
This is partly because of the large variation
in the literature in terms of both the technical
aspects and the biological aspects of the
study material.

 Nevertheless, given the seriousness

of possible biological and
biomechanical complications, careful
pre-surgical planning and (post-)
prosthetic preventive measures
should be given consideration in
bruxists.

LOBBEZOO ET AL ,Journal of
Oral Rehabilitation 2006 33;
152159

Bruxism is generally considered a

contraindication for dental implants,
although the evidence for this is
usually based on clinical experience
only. So far, studies to the possible
cause-and-effect relationship
between bruxism and implant failure
do not yield consistent and specific
outcomes.

 This is partly because of the large

variation in the literature in terms of both
the technical aspects and the biological
aspects of the study material.
Nevertheless, given the seriousness of
possible biological and biomechanical
complications, careful pre-surgical
planning and (post-) prosthetic
preventive measures should be given
consideration inbruxists.