A Survey Regarding the Nature and Type of Dental Implant

Complications in Private Practices in the Province of Ontario

by

David Chvartszaid

A thesis submitted in conformity with the requirements

for the degree of Masters of Science
Faculty of Dentistry
University of Toronto

Copyright by David Chvartszaid 2011

A survey regarding the nature and type of dental implant complications

in the province of Ontario
David Chvartszaid
Masters of Science
Faculty of Dentistry
University of Toronto
2011

Abstract
Aims and Objectives: To investigate the experience of implant complications and opinions on
complications among dentists in private practices in Ontario.
Methods: In 2010, a web-based anonymous survey was distributed to 2034 Ontario dentists with
valid e-mail addresses.
Results: 527 dentists replied to the survey, of which 469 utilized implants. Most complications
were preventable. The most important cause of complications was poor planning. The most
severe complication was permanent paraesthesia. Fewer than 5% of patients experienced a
complication in 2009. There was little agreement among general dentists, oral surgeons,
periodontists, and prosthodontists on the causes of complications, some agreement on preventive
strategies to avoid complications, and significant agreement on severity of complications and
their preventability.
Conclusions: A significant proportion of dentists in Ontario had encountered an implant
treatment complication in 2009. Since most complications are preventable, efforts at decreasing
their prevalence and severity should be pursued.
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Acknowledgments
I would like to gratefully acknowledge the numerous individuals who contributed to the success
of this project: my thesis supervisors Drs. Howard Tenenbaum and David Locker, my committee
members Drs. Jim Lai and Leslie Laing-Gibbard, and my fantastic friend Dr. Amir Azarpazhooh.
Without you this project would not have been possible.
This thesis is dedicated to the memory of Dr. David Locker whose untimely passing earlier this
year was a tremendous loss to everyone who knew him.

iii

Table of Contents
Abstract
Acknowledgements
Table of Contents
List of Tables
List of Appendices
Chapter 1: Introduction
Chapter 2: Definitions and Classifications
2.A: Terminology in the medical literature
2.B: Terminology in the dental implant literature
2.C: Classification of complications: introduction
2.D: Classification of complications in the medical literature
2.E: Classification of dental implant complications
Chapter 3: Literature Review on Implant Complications
3.A: Studies on implant complications study results
3.B: General study characteristics of reviews reporting implant treatment
outcome and complication data
3.B.I: Thoroughness in reporting of complications
3.B.II: Study setting
3.B.III: Implant companies investigated in the literature
3.C: Geographic location survey of dentists
3.D: Treatment evolution and caution in interpretation of results from past
reviews
3.E: Malpractice studies
3.F: Clinicians opinions on complications
3.G: Conclusion and rationale for further study
Chapter 4: Materials and Methods
4.A: Aims and objectives
4.B: Methods
4.C: Sample size calculations
4.D: Survey implementation
4.E: Data analysis
Chapter 5: Demographics
5.A: Results and tables
5.B: Discussion
Chapter 6: Complications and Corrective Actions
6.A: Surgical complications results
6.B: Prosthodontic complications results
6.C: Biological complications results
6.D: Patient-related complications results
6.E: Complications reported by each professional group results
6.F: Corrective actions taken in response to complications results
6.G: Complications and corrective actions discussion
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6.G.I: Surgical complications discussion

6.G.II: Prosthodontic complications discussion
6.G.III: Biological complications discussion
6.G.IV: Patient-related complications discussion
6.G.V: All complication types overall discussion
6.G.VI: Corrective actions discussion
Chapter 7: Opinions on Complications
7.A: Causes of complications results
7.B: Causes of complications discussion
7.C: Preventive strategies to decrease occurrence of complications results
7.D: Preventive strategies to decrease occurrence of complications
discussion
7.E: Severity of complications results
7.F: Severity of complications discussion
7.G: Source of knowledge about complications results
7.H: Source of knowledge about complications discussion
7.I: Responsibility to keep dentists informed about potential implant
complications results
7.J: Responsibility to keep dentists informed about potential implant
complications discussion
7.K: Percentage of patients experiencing complications results
7.L: Percentage of patients experiencing complications discussion
Chapter 8: Preventability of Complications
8.A: Results
8.B: Discussion
Chapter 9: Overall Discussion and Conclusions
9.A: Study limitations
9.B: Study strengths
9.C: Implications and conclusions
Bibliography
Appendix 1 Survey

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List of Tables
Table
Table 2.1: Examples of terms and definitions used in the medical literature related to
complications
Table 2.2: Examples of the definitions of the term complications used in the dental
implant literature
Table 2.3: Classifications focusing on all complications
Table 2.4: Classifications of prosthodontic complications
Table 2.5: Classifications of surgical complications
Table 2.6: Other classifications of implant complications
Table 3.1: The most common complications according to Goodacre et al. (1)
Table 3.2: Complication data reported for implant-supported single crowns after an
observation period of 5 years by Jung et al. (2)
Table 3.3: The most common technical complications for implant-supported FPDs
after an observation period of 5 years according to Pjetursson et al. (3)
Table 3.4: Complications data from Berglundh et al. (4)
Table 3.5: Number of studies reporting on specific categories of complications in
comparison to the overall number of studies included in the reviews
Table 3.6: Percentage of studies that reported specific complications in a review by
Berglundh et al. (4)
Table 3.7: Number of studies conducted in a university, specialist, or general practice
setting in comparison to the overall number of studies included in the reviews
Table 3.8: Number of multi-centre studies relative to the total number of studies
included in the reviews
Table 3.9: Certain implant companies are over-represented in the implant literature
number of studies utilizing implants of specific companies in comparison to the total
number of studies included in the reviews
Table 3.10: The 5 most common implant brands utilized in different countries or
geographic regions
Table 3.11: Classification of complications according to Givol et al. (5)
Table 3.12: Clinical performance scale for implants according to Van Waas et al. (6)
Table 3.13: Clinical performance scale score for a range of complications according
to Van Waas et al. (6)
Table 5.1: Survey flow
Table 5.2: Comparison between Ontario dentist population, survey e-mail list, active
e-mail list, and survey responders
Table 5.3: Demographic characteristics surgical/prosthodontic expertise, practice
focus
Table 5.4: Demographic characteristics year of graduation, number of
patients/implants treated
Table 6.1: Surgical complications reported by survey responders (N=419) in 2009
Table 6.2: Surgical complications reported by each professional group in 2009
Table 6.3: Prosthodontic complications reported by survey responders (N=435) in
2009
Table 6.4: Prosthodontic complications reported by each professional group in 2009
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Table 6.5: Biologic complications reported by survey responders (N=433) in 2009

Table 6.6: Biologic complications experienced by each professional group in 2009
Table 6.7: Patient-related complications reported by survey responders (N=397) in
2009
Table 6.8: Patient-related complications reported by each professional group in 2009
Table 6.9: Top 20 complications reported by the largest percentage of general dentists
in 2009
Table 6.10: Top 20 complications reported by the largest percentage of oral surgeons
in 2009
Table 6.11: Top 20 complications reported by the largest percentage of periodontists
in 2009
Table 6.12: Top 20 complications reported by the largest percentage of
prosthodontists in 2009
Table 6.13: Corrective actions taken by survey responders (N=424) in 2009 in
response to complications
Table 6.14: Corrective actions taken by each professional group in 2009
Table 7.1: Causes of complications chosen by survey responders (N=397)
Table 7.2: Causes of complications chosen by each professional group
Table 7.3: Strategies to prevent occurrence of complications chosen by survey
responders (N=405)
Table 7.4: Strategies to prevent occurrence of complications chosen by each
professional group
Table 7.5: Most severe complications chosen by survey responders (N=403)
Table 7.6: Most severe complications chosen by each professional group
Table 7.7: Sources of knowledge about complications identified by survey responders
(N=418)
Table 7.7b: Sources of knowledge about complications identified by survey
responders who graduated in the last 10 years (N=50)
Table 7.8: Sources of knowledge about complications identified by each professional
group
Table 7.9: Responsibility for informing dentists about potential implant complications
as chosen by all responders (n=418)
Table 7.10: Responsibility for informing dentists about potential implant
complications as chosen by each professional group
Table 7.11: Cross-tabulation of opinions about the responsibility to keep dentists
informed about implant complications as chosen by each professional group against
every other professional group (0.008 level of statistical significance)
Table 7.12: Percentage of patients experiencing complications reported by each
professional group and by all survey responders (n=428)
Table 7.13: Cross-tabulation of percentage of patients experiencing complications
reported by each professional group against every other professional group (0.008
level of statistical significance)
Table 8.1: Preventability of complications

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List of Appendices
Appendix 1 Survey

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Chapter 1
Introduction
Patients come into contact with healthcare providers, including dentists, to address a range of
physical and emotional ailments and conditions. Many of these interactions are positive, freeing
patients from the burden of disease that limited their well-being and leading to improvements in
their health status or quality of life. However, complications can occur in the process or outcome
of care that do not allow patients to reach the full benefit of the therapeutic interventions
intended for them. Although Socrates first, do no harm has always been at the center of
medical practice, the issue of treatment complications is being increasingly recognized and
addressed as a serious health care problem by government agencies (7, 8), non-governmental
organizations (9), in popular culture (10-13), and in scientific literature (14, 15). Many medical
errors and complications are suspected to be preventable (16, 17), and, hence, substantial
research efforts, educational initiatives, and government policies are being directed at prevention
of complications (8).

Implant therapy is a commonly utilized and highly successful treatment modality for the
management of missing teeth (18, 19). However, numerous complications may be encountered
during the various phases of therapy (3, 4, 20, 21). While the types of complications that can be
encountered are well known, the degree to which they are actually encountered in contemporary
private practices is uncertain. In particular, the experience of implant complications in the
province of Ontario and the opinions of dentists regarding implant complications are unknown.

In light of these observations, the primary objective of this study was to determine the nature and
the types of complications arising from dental implant therapy carried out in private practices in
the province of Ontario and as reported by the treatment providers. Other specific objectives
were:
1) to determine the causes of complications as perceived by the treatment providers;
2) to determine if the types of complications experienced in private practices differ based on
educational background of the treating dentist;
3) to determine the relative severity ranking of complications as perceived by the treatment
providers.

This thesis will proceed in the following manner. The thesis is divided into 9 chapters. Sections
within chapters are identified by capital letters, and, where necessary, subsections are identified
by roman numerals. Chapters 2 and 3 will review the pertinent literature on complications.
Chapter 2 will focus on the nomenclature related to complications, while chapter 3 will focus on
the specific reports regarding complications in the dental implant literature. Chapter 4 will
outline the materials and methods used in the thesis. Chapters 5 through 8 will report the data
gathered in the survey and discuss the results. Chapter 5 will report and discuss the basic
demographic attributes of the survey responders. Chapter 6 will report and discuss the dentists
experience of complications in 2009. Chapters 7 and 8 will report and discuss dentists opinions
on various topics related to complications including the causes of complications, possible
strategies for preventing complications, severity of complications, and preventability of
complications. Chapter 9 will discuss the overall findings focusing on the strengths and
limitations of the project as well as the conclusions.

Chapter 2
Definitions and Classifications
2.A: Terminology in the medical literature
Terms, definitions, and classifications vary widely in the medical and dental literature related to
complications. Several terms have been used in the medical literature to refer to the negative
occurrences arising in the process of patient care or to events elevating the risk of these negative
occurrences (Table 2.1). Definitions of these terms tend to overlap (22), and the use of these
terms is not consistent across studies (Table 2.1). Some authors define the terms by actually
providing their definitions, while others implicitly define the terms by providing examples and
letting the reader infer their meaning. A 2002 review of over 100 studies (including 42
randomized controlled trials (RCTs)) in the surgical literature (23) revealed that only 34% of the
studies provided definitions of complications. Similarly, the term preventability is often used
but is rarely defined.

Table 2.1: Examples of terms and definitions used in the medical literature related to
complications

adverse medical event

an injury to the patient that may have been the result of medical or surgical
intervention that may prolong hospitalization, produce disability, death or both
(24)
adverse event
Serious adverse event is defined as an event that results in death, is lifethreatening, requires inpatient hospitalization or prolongation of existing
hospitalizations, results in persistent or significant disability/incapacity, or
necessitates surgical re-intervention. [Food and Drug Administration (FDA)
as quoted in Dekutoski et al. (25)]
an unintended harm, injury, or loss that is more likely associated with the
patients interaction with the health care delivery system than from an attendant
disease process [Medicare as quoted in Dekutoski et al. (25)]
unanticipated problem involving risks to study participants or others [National
Institute of Health (NIH) as quoted in Dekutoski et al. (25)]
an injury that was caused by medical management (rather than the underlying
disease) and that prolonged the hospitalization, produced a disability at the time
of discharge, or both (26)
any unexpected or undesirable event occurring as a result of surgery (27)
an injury that was caused by medical management and that results in
measurable disability (8)

unpreventable adverse event

an adverse event resulting from a complication that cannot be prevented given

the current state of knowledge (8)
adverse occurrence
Adverse occurrence is any medical event in the course of patients treatment
that had the potential for causing harm to patient. This term (adverse
occurrence) was selected to avoid connotations of blame often associated with
the term complication. (28)
complication
undesirable development arising during or out of the delivery of patient care
Institute of Medicine (29)
Complications are unintended and undesirable diagnostic or therapeutic events
that may impact the patients care. Complications should be recoded and
analysed relative to disease severity, patient co-morbidities, and ultimately their
effect on patient outcomes. (25)
disease or disorder, which, as a consequence of a surgical procedure, will
negatively affect the outcome of a patient (27)
errors or adverse events
Errors are events in your practice that made you conclude, That was a threat to
patient well-being and should not happen. I dont want it to happen again.
Such an event affects or could affect the quality of care you give to patients.
Errors can be large or small, administrative or clinical, or actions taken or not
taken. Errors might or might not have discernable effects. Errors are anything
you identify as something wrong, to be avoided in the future. (30)
harm
impairment of the physical, emotional, or psychological function or structure of
the body and/or pain resulting therefrom (31)
medical error
failure of the planned action to be completed as intended or the use of a wrong
plan to achieve an aim [including] problems in practice, products, procedures,
and systems (7)
an adverse event or near miss that is preventable with the current state of
medical knowledge (8)
medical mistake
Some examples of medical mistakes are when a wrong dose of medicine is
given; an operation is performed other than what was intended for the patient; or
results of a medical test are lost of overlooked. (32)
near miss

an event or situation that could have resulted in an accident, injury or illness,

but did not, either by chance or through timely intervention (8)
negligence
care that fell below the standard expected of physicians in their community
(26)
patient safety
freedom from accidental injury due to medical care, or medical error (7)
sentinel event
A sentinel event is an unexpected occurrence involving death or serious

physical or psychological injury, or the risk thereof. Serious injury specifically

includes loss of limb or function. The phrase risk thereof includes any process
variation which would carry a significant chance of a serious adverse outcome.
(33)

2.B: Terminology in the dental implant literature

Although the medical literature appears to use a range of terms to refer to untoward events or
risks thereof (Table 2.1), the term complication is used most frequently in the dental implant
literature. Interestingly, almost none of the studies and reviews actually defined the term
complication. Where definitions of the term were provided, they were usually inconsistent
(Table 2.2). This thesis maintained the use of the term complication in the interests of
consistency and used it in a broad context. In this thesis, an implant complication was defined as
an event that requires (or may require) corrective action that, if not taken, may compromise the
outcome of treatment with osseointegrated dental implants. The use of the term complication
does not automatically imply that an error was made during the treatment planning, execution, or
follow up, or that there was necessarily a direct negative impact on the patient (although both of
these conditions are frequently true). Occasionally, a negative impact on the patient is avoided
due to the subsequent skilful efforts of the members of the dental team (including the laboratory
technician), as well as the patients frequent ability to adapt to or to accept slight departures from
ideal appearance, form, or function (34-36).
Table 2.2: Examples of the definitions of the term complications used in the dental
implant literature

unexpected deviations from the normal treatment outcome (37)

may represent an increased risk of failure but are either of temporary significance or are
amendable to correction (38)
chair time is required after incorporation of the prosthesis (39)
a reversible or irreversible unfavourable condition (40)
causes annoyance or inconvenience to the patient and the practitioner, can be financially
burdensome if it occurs frequently, and may be a sign of impeding failure (modified after
Taylor 1998 (41))

Two other terms failure and maintenance are occasionally used by some authors in
specific circumstances in the context of implant complications. Failure is most commonly
used to refer to implant failure (i.e., complete loss of osseointegration). However, some authors
use this term more broadly to indicate not only loss of osseointegration but also substantial
departures from health or severe positional or structural problems that prevent a successful
prosthesis fabrication (20, 42). To avoid confusion and lack of clarity, this study used the term
failure to refer strictly to implant failure (i.e., complete loss of osseointegration) keeping in
line with the most frequent use of this term. Making the distinction between discussions of
failure and complication has also been advocated by others (38).

Some authors refer to the time-dependent process of upkeep of implant-supported prostheses

(especially, implant-supported overdentures) as maintenance (43-45). The utilization of
implant-supported overdentures presents unique challenges related to the use of mucosal surface
for support and the use of resin acrylic materials in the fabrication of the prostheses. The shape
and form of denture-bearing mucosal surfaces can change with time, acrylic can wear at the
occlusal interface, and the attachments holding the overdenture to the implants may lose their
retentive qualities. As a result, regular re-evaluation of the patient, minor denture base and
occlusal surface adjustments, as well as modification and replacement of retentive elements may
be required. This study did not use the term maintenance in keeping with the desire to avoid
(wherever possible) procedure- or prosthesis-specific terminology. Hence, these adverse events
(e.g., overdenture clip loosening or acrylic fracture) were referred to as complications.

2.C: Classification of complications: introduction

No universal system for classifying complications exists. Classifications of complications may
focus on the errors (e.g., a patient receiving a medication that the patient is known to be allergic
to), the complications or outcomes of complications (e.g., the patient experiencing an
anaphylactic shock), or the steps taken to address the complication (e.g., medical treatment given
to treat the anaphylactic shock). A simple example of endosseous implant placement in a poor
position can also be used to illustrate the distinction among these ideas. A treatment provider

might neglect to consider the final restorative outcome during treatment planning and execution
(an error). This error may initiate a sequence of untoward events starting with poor implant
position (a complication) and leading to a poor restorative outcome and an unhappy patient
(an outcome of the complication). To remedy this situation, the poorly positioned implant may
be removed and replaced with a new implant in a more optimal position permitting a satisfactory
restoration to be fabricated for the patient (steps taken to address the complication).

Clearly, not all errors lead to complications because some errors are recognized and remedied
before they produce a frank negative outcome. These are occasionally referred to as silent
errors, near misses or close calls (8). Similarly, not all complications actually produce a
patient-perceived negative outcome, since some negative outcomes may be managed to
seamlessly produce an adequate result at the end of treatment. For example, a poorly positioned
implant may occasionally be restored with extra effort to produce an acceptable result despite the
poor implant position. In this manner, the patient is not the only potential injured party resulting
from a complication. In a multi-disciplinary treatment scenario, other members of the treatment
team may also be victims of a complication insofar as they may need to take actions to address
the complication and prevent it from having an adverse impact on the patient.

Some classification systems of complications focus on errors made in the process of care. For
example, six categories of errors have been identified (30) in a family practice setting and
included administrative, communication, diagnostic, documentation, medication, and surgical (or
procedural) errors. Classifications focusing on errors permit attention to be zeroed in on specific
aspects or processes of care where errors are being made. They may facilitate identification of
adverse issues and allow for those issues to be addressed and corrected before frank
complications arise. However, although complication classifications focusing on errors have an
intuitive appeal, they may have a strong subjective component and may not account for the fact
that an error may be silent (i.e., may not lead to an actual complication). Some authors have
argued strongly against examining errors solely in terms of failed processes and without any link
to subsequent patient harm (22). To address this issue, some classifications attempt to take both
the errors and their outcomes into account by drawing a distinction between errors that do and do
not negatively impact on the patient. For example, the National Coordinating Council for
Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Medication

Errors (31) is a classification that focuses on presence of three factors error, harm, and death.
These three factors combine to create a 5-category classification that includes the subheadings of
no error, error but no harm, error and temporary harm, error and permanent harm, and
error and death (31).

Classifications focusing on the actual complications are more objective since no attempt is made
to second-guess why the complication arose (i.e., what the error was). However, each
complication may have a multitude of causes and may have a multitude of severity outcomes
depending on other details of the situation. Hence, classifications focusing exclusively on
complications themselves do not necessarily provide the best estimate of the ultimate treatment
burden that the patient will need to endure to remedy the complication.

Classifications focusing on steps needed to address the complication tend to be most objective
and permit a quick appraisal of treatment burden on the patient. They also intrinsically permit an
evaluation of severity of underlying complication not by attempting to ascertain the burden of
complication on the patient, but by assessing invasiveness or financial burden of steps taken to
address the complication. For example, the T92 complication classification system for in-patient
surgical outcomes (46) grades severity of complications by relying heavily on the type of
intervention used to manage the complication and whether there was permanent disability or
death. Variables were selected as indicators of severity based on their objectivity and ready
retrospective availability from chart entries (47). In this regard, some studies consider reoperation as an important marker of poor surgical outcome because of its objectivity (25).
However, these classification systems do not address the causes of complications and are of
limited value in formulating and executing approaches to complication prevention.

2.D: Classification of complications in the medical literature

Several classifications of errors, adverse events, and complications have been proposed for a
number of health care settings (e.g., intensive care units (48) and hospital administration (49)),
medical procedures, service providers, and service recipients (i.e., patients (50)). These

classifications have been developed for use in a number of medical disciplines including family
medicine (30), pharmacology (31), oncology (51), general surgery (14, 52-54), and several
surgical subspecialties such as spine surgery (25). Moreover, many individual adverse events
themselves have numerous definitions and measurement scales. For example, a 2001 systematic
review (55) identified 41 different definitions and 13 grading scales of surgical wound infections
from an evaluation of 82 studies. Although a number of attempts have been made to classify
errors and complications, none of the classification systems have gained wide-spread acceptance
even within the individual sub-disciplines or for specific procedures (56).

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2.E: Classification of dental implant complications

Similarly to the observations from the medical literature (55, 56), no single universally accepted
classification system for implant-related complications exists. Several approaches to classifying
all or some implant complications have been suggested (1-4, 20, 57, 58). Two general
approaches appear to have been used by authors in classifying implant complications. Some
authors attempted to classify all types of implant complications (1, 57). Other authors attempted
to classify only some implant complications united either by the particular phase of therapy
during which they tend to occur (such as surgical (58, 59) or prosthodontic complications (2, 4))
or by some other feature in the process (e.g., reversible complications (60)) or outcome of care
(e.g., aesthetic complications (61)). All the above-mentioned classifications are summarized in
Tables 2.3 through 2.6.

Table 2.3: Classifications focusing on all complications

Esposito et al. (20)

Goodacre et al. (57)

and Goodacre et al.
(1)

Zarb & Schmit (62)

biological complications implant failure (failure to achieve or

maintain osseointegration)
mechanical complications fracture of implants, connecting screws,
bridge frameworks etc.
iatrogenic complications nerve damage, wrong alignment of the
implants etc.
inadequate patient adaptation phonetic, aesthetic, psychological
problems etc.
surgical
implant loss
bone loss
peri-implant soft tissue
mechanical
aesthetic/phonetic
surgical complications

at stage I surgery

following stage I surgery

at stage II surgery

following prosthodontic treatment (e.g., soft tissue

complications)
prosthodontic complications

structural

cosmetic

functional

delayed complications
maintenance requirements

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Table 2.4: Classifications of prosthodontic complications

Jung et al. (2)

Berglundh et
al. (4)

Aglietta et al.
(63)

biological complications disturbances in the function of the implant

characterized by a biological process affecting the supporting tissues
e.g., peri-implantitis and soft tissue complications
aesthetic complications appearance classified as unacceptable or semioptimal by dental professionals or patients
technical complications mechanical damage of implants, implant
components and /or supra-structures
e.g., fractures of implants, screws, or abutments; fractures of
luting cement (loss of retention); fractures or deformation of the
framework or veneers; loss of the screw access hole restoration;
screw or abutment loosening
biological complications disturbances in the function of the implant
characterized by biological processes that affect the tissues supporting the
implant
e.g., implant loss and reactions in the peri-implant hard and soft
tissues
technical complications collective term for mechanical damage of the
implant, implant components and suprastructures
biological complications not defined

e.g., peri-implantitis and soft tissue complications

technical complications damage to the integrity of the implants or of the
meso- and supra-structures

e.g., implant fractures, veneer fractures, framework fractures,

abutment or screw fractures, loss of retention and screw loosening

Table 2.5: Classifications of surgical complications

Misch & Wang
(59)

Greenstein et
al. (58)

treatment plan-related
e.g., wrong angulation, improper implant location, lack of
communication
anatomy-related
e.g., nerve injury, bleeding, cortical plate perforation, sinus
membrane complication, devitalization of adjacent teeth
procedure-related
e.g., mechanical complications (overheating the bone, not tapping
dense bone, over-preparation of the osteotomy), lack of primary
stability, mandibular fracture, ingestion and aspiration
other
e.g., iatrogenic damage and human error
oral soft tissue complications
e.g., hemorrhage, nerve injury, tissue emphysema, infections,
wound dehiscence, aspiration or ingestion, pain control
hard tissue complications
e.g., periapical implant pathosis, mandibular jaw fracture, lack of
implant primary stability, inadvertent penetration into maxillary
sinus or nasal fossa, complications associated with sinus elevation

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Table 2.6: Other classifications of implant complications

aesthetic complications
(61)

reversible complications
(60)

aesthetic complications not defined

loss of interdental papilla

gingival recession

exposure of implant margin

restoration too buccal or too palatal

poor emergence profile

chronic inflammation
reversible complications complications whose negative impact
is either temporary or is easily corrected

intraoperative complications

immediate/early postoperative complications

late postoperative complications

prosthetic-related (mechanical/biologic) complications

aesthetic/soft tissue-related complications

Several challenges occur in attempting to classify dental implant complications, to ascertain their
frequency of occurrence, or to interpret the findings of the reviews on this subject. First, the
same adverse occurrence for example, a loose prosthetic screw may have several outcomes
ranging in severity from trivial to severe (64). A loose screw that occurred under a screwretained fixed restoration may be accessed and managed simply and uneventfully; a loose screw
under a cemented fixed restoration may be much more difficult to access and manage. The most
significant negative impact might occur if the restoration is destroyed in the process of gaining
access to the screw, requiring fabrication of a new prosthesis. In other words, looking at a
complication in isolation and without regard for the steps that are needed to remedy the
complication does not tell the whole story (as alluded to earlier in Section 2.C).

Second, many specific complications occur on a continuum with healthy states or

inconsequential departures from the ideal. Hence, it is not always easy to determine that a
complication has actually occurred. Two examples will be used to illustrate this point. All new
prostheses (especially those involving treatment of large edentulous spans) are likely to produce
some temporary degree of speech deficit and discomfort, and, hence, require a period of
adaptation or learning by the patient (34-36). At what time point after prosthesis insertion,
should continued presence of a speech deficit or inability to become accustomed to the feel of the

13

prosthesis be classified as a complication? At the same time, many biological tissues undergo
changes over time, while the prostheses undergo wear and tear. Soft tissue form is likely to
change causing instability to the removable tissue-borne prosthesis; acrylic is likely to wear
causing changes to the appearance and function of the prosthesis; the color of a metal-ceramic
prosthesis may begin to depart from that of adjacent teeth as the enamel and porcelain do not
undergo color changes in the mouth to the same degree. All these time-dependent changes may
require prosthesis modification or even replacement. Do these changes constitute a
complication? At what point (if ever) after successful prosthesis wear, can an adverse
experience (for example, a need to replace a prosthesis) be regarded simply as a consequence of
natural phenomena, or should such events always be regarded as a complication? The issues of
establishing time horizons and thresholds for identification of complications have also been
widely acknowledged in the medical literature (47).

Third, since no uniform definitions for implant complications exist, inter-study comparisons of
different complications must be interpreted with caution (57). This is particularly true for
biological complications, where different criteria for soft tissue complications were used in
various studies (3). Fourth, no universal agreement exists on how best to calculate and report
complication rates of occurrence. Occurrence of complications may be reported per number of
units (implants, restorations, or patients) treated or per unit of time (1, 57). Without access to the
underlying data, it is often impossible to compare results obtained in various studies (57). The
issues of inconsistency of reporting and the lack of accepted principles of accrual, display, and
analysis of complication data have also been raised in the medical context (23).

Fifth, most implant complications are procedure-dependent in terms of type, frequency, or both.
For example, sinus membrane perforation as a clinically significant complication occurs most
prominently in cases of sinus elevation (65). Implant loss, on the other hand, occurs with all
types of implant therapies. However, the frequency of implant failure reported in some studies is
higher with some prosthetic procedures (e.g., unplanned maxillary overdentures (66)) and with
some surgical procedures (e.g., simultaneous implant placement combined with grafting (4)).
For example, a 2002 systematic review (4) found that the early failure of implants used for
replacement of single missing teeth was 0.76%. However, this increased to 3.35% (an increase
of almost 400%) when implants were inserted immediately following tooth extraction or in early

14

loading situations. Hence, the range of procedures undertaken by a dentist or group of dentists
would have a significant impact on the types of complications that might be encountered.
Similarly, the range of complications reported in any given trial is determined partly by the
interventions undertaken within the trial.

Lastly, caution must be exercised in interpreting average results. Each implant treatment
involves the interplay of numerous patient, provider and procedural factors. Focusing on only
one of these factors for example, survival of implant-supported single crowns betrays the fact
that each factor operates within a large sea of semi-dependent and independent variables many of
which might have a direct or indirect impact on the main factor in question. Thus, while it is
possible to calculate the numerical average survival of implant-supported crowns, this value may
not be applicable to all clinical situations or to all operators. In particular, novice clinicians are
known to be more likely to make errors and to have complications both in the medical (67-69)
and the dental implant (70) fields.

15

Chapter 3
Literature Review on Implant Complications
3.A: Studies on implant complications study results
As discussed previously, several reviews and systematic reviews have attempted to identify and
quantify the occurrence of complications related to treatment with endosseous dental implants
(Section 2.E). The most comprehensive reviews (1, 57) have examined the entire scope of
complications beginning with the surgical appointment until the latest follow up. Other reviews
have limited themselves to specific phases of therapy such as the surgical or immediate postoperative complications (58, 59) or complications that might occur over the maintenance period
(43, 71). Implant complications associated with specific types of prostheses have also been
evaluated (2, 3, 43, 63, 71). Several reviews have focused on the evaluation of specific
complications, such as abutment screw loosening in single-implant restorations (72), severe
intra-operative hemorrhage (73), or implant failure (20, 38). The issues of complication
prevention and management have also been addressed (58, 59).

By far the most well-researched implant treatment complication is implant failure (i.e., loss of
osseointegration) (20, 38, 74). Overall, the failure rate of implants was 7.7% (20). Implant
failures are usually categorized according to chronological criteria into early and late failures.
Early failure signifies failure to establish osseointegration and occurs within the first few months
after surgical implant surgical placement and prior to insertion of the implant-supported
prosthesis. Hence, surgically-mediated factors (e.g., surgical trauma and local anatomic
conditions) and host-healing factors are usually thought to be important (20). Approximately
half of all failures (3.6%) fall into the early failure category (20). Late failure signifies
breakdown of established osseointegration phenomena and occurs after prosthesis insertion and
typically within the first two years of loading (18, 75). Bone quality, bone quantity and
overloading are felt to be the leading causes of late implant failures (20). The importance of
peri-implant inflammation and infection as a significant cause of implant failures is controversial
and may not be applicable to all implant systems (74).

16

One research group (57) examined 216 studies covering the years 1981 to 2001 and catalogued
complications occurring during both the surgical and the prosthodontic phases (Table 3.1).
Complications were divided into six categories: surgical, implant loss, bone loss, peri-implant
soft tissue, mechanical and aesthetic/phonetic. The estimates of complication rates ranged
widely across the studies from which the average estimates were derived. The total sample sizes
of the studies on the basis of which the average complication rates were calculated also varied
widely, reflecting the paucity with which some complications have been reported in the
literature. Some complications were mentioned in most studies, and their prevalence data was
based on a large total sample size. For example, the prevalence of gingival inflammation and
proliferation was reported in 13 studies having the combined sample size of 17,565 implants.
Other complications were not mentioned frequently (e.g., opposing prosthesis fracture), and the
total sample size of the studies reporting them was much smaller. None of the studies examined
in these reviews evaluated all of the complications simultaneously. The authors concluded that
implant complications were frequently encountered and suggested that implant-supported
prostheses tend to have a greater incidence of complications compared to other types of dental
prostheses (e.g., single crowns, FPDs etc.) (1).
Table 3.1: The most common complications according to Goodacre et al. (1)

>10% of patients,
prostheses, or
implants

<10% of patients,
prostheses, or
implants

overdenture clip/attachment loosening 30% of prostheses

hemorrhage-related complications 24% of patients
resin veneer fracture (FPD) 22% of prostheses
overdenture reline needed 19% of prostheses
overdenture clip/attachment fracture 17% of prostheses
porcelain veneer fracture (FPD) 14% of prostheses
overdenture fracture 12% of prostheses
opposing prosthesis fracture 12% of prostheses
aesthetic complications with prostheses 10% of prostheses
acrylic resin base fracture 7% of prostheses
neuro-sensory disturbance 7% of patients
prosthesis screw loosening 7% of screws
fenestration/dehiscence prior to stage 2 surgery 7% of implants
phonetic complications 7% of prostheses
abutment screw loosening 6% of screws
gingival inflammation/proliferation 6% of implants
prosthesis screw fracture 4% of screws
metal framework fractures 3% of prostheses
abutment screw fractures 2% of screws
fistulas 1% of implants
implant fractures 1% of implants
mandibular fractures 0.3% of patients

17

Several systematic reviews focused on complications associated with specific types of implantsupported prostheses such as single crowns (2), fixed dental prostheses (3), fixed dental
prostheses with cantilever extensions (63), and overdentures (43, 45, 71). A systematic review
and meta-analysis of the 5-year survival and complication rates of implant-supported single
crowns (2) concluded that after an observation period of 5 years, high survival rates for implants
and implant-supported single crowns can be expected. However, biological and particularly
technical complications were reported to occur frequently (Table 3.2) (2).

Table 3.2: Complication data reported for implant-supported single crowns after an
observation period of 5 years by Jung et al. (2)

survival rate of implants (supporting single crowns) 96.8% after 5 years

survival rate of single crowns (supported by implants) 94.5% after 5 years of function
survival rate of metal-ceramic crowns (95.4%) was better than the survival rate of all-ceramic
crowns (91.5%)
peri-implantitis and soft tissue complications occurred adjacent to 9.7% of single crowns
6.3% of implants had bone loss exceeding 2 mm over the 5-year observation period
cumulative incidence of crowns having unacceptable or semi-optimal aesthetic appearance
8.7%
cumulative incidence of implant fractures 0.14% after 5 years
cumulative incidence of screw or abutment loosening 12.7% after 5 years
cumulative incidence of screw or abutment fracture 0.35% after 5 years
cumulative incidence of ceramic or veneer fractures 4.5%
complications based on crown composition:
metal-ceramic 75%
all-ceramic 18%
metal-acrylic 7%
complications based on method of crown retention:
screw-retained 12%
cemented 88%

A systematic review examining the incidence of complications of implant-supported fixed partial

dentures (FPDs) after an observation period of 5 years (3) reported high survival of FPDs. The
overall survival of implant-supported fixed partial dentures (with or without modification) was
95% after 5 years and 86.7% after 10 years of function. However, only 61.3% of patients were
free of any complications after 5 years. Soft tissue complications occurred in 8.6% of FPDs after
5 years. Technical complications (e.g., implant fractures, connection-related and suprastructurerelated complications) were also frequent (Table 3.3) (3). The authors concluded that significant

18

amount of chair time may be required during the maintenance period following conclusion of
treatment (3).

Table 3.3: The most common technical complications for implant-supported FPDs after an
observation period of 5 years according to Pjetursson et al. (3)

veneer fracture (acrylic, ceramic or composite) 13.2% after 5 years

loss of screw access hole restoration 8.2% after 5 years
screw loosening 5.8% after 5 years
loss of retention of cemented restoration 2.9% after 5 years and 16% after 10 years
screw fracture 1.5% after 5 years and 2.5% after 10 years
implant fracture 0.4% after 5 years and 1.8% after 10 years

A 2002 systematic review (4) examined the incidence of biological and technical implant
complications reported in prospective studies at least 5 years in duration. The complication data
were categorized according to the type of implant therapy the patients were undergoing,
underscoring the fact that the type and frequency of implant complications may be treatmentspecific (Table 3.4) (4). It was observed that the number of studies examining treatments with
overdentures (15 studies), fixed complete dentures (14 studies) and fixed partial dentures (14
studies) was significantly higher than the number of studies reporting on single-tooth
replacements (8 studies). The number of studies reporting complications with immediate
placement/early loading (3 studies) and augmentation procedures (2 studies) was particularly
small (4). This highlights the fact that novel treatment concepts are likely to have few long-term
studies to give guidance as to the types of complications (and their frequency) that may be
experienced with these novel treatment concepts.

19

Table 3.4: Complications data from Berglundh et al. (4)

implant loss
prior to loading 2.5% of implants
after loading 2-3% of implants (failure is higher in implant-supported
overdentures)
sensory disturbance absence or low incidence (1-2%) after 1 year post-surgery
soft tissue complications 0.1-0.3% per patient during the 5 year period (higher
incidence in implant-supported overdentures)
peri-implantitis limited information
crestal bone loss limited information
implant fracture <1% of implants during 5 year period
technical complications related to implant components 0.19-1.59% per patient during
the 5 year period depending on the type of restoration (highest incidence in implantsupported overdentures)
technical complications related to suprastructures 0.17-1.90% per patient during the 5
year period depending on the type of restoration (the highest incidence observed with
implant-supported overdentures)

Several reviews and systematic reviews addressed the occurrence of complications with implantsupported overdentures (43, 45, 71). Several complications specific to implant-supported
overdentures (rather than being specific to removable prostheses, in general) have been identified
including anchorage system maintenance and replacement (i.e., matrix and patrix replacements
and adjustments), soft tissue reactions, and prosthesis fractures. Some research indicates that the
occurrence of technical and soft tissue complications is higher with implant-supported
overdentures compared to fixed implant-supported prostheses (4). There is a long history of
debate as to the best anchorage system for implant-supported overdentures, including the impact
of the anchorage system on the occurrence of complications (43, 71). Although conflicting
reports have been presented, recent analyses of the available research appear to indicate that
complications involving anchorage system (e.g., matrix replacement, bar fracture, clip loosening
etc.) were the most common complications involving implants-supported overdentures, and that
the method of anchorage appears to have a limited influence of the prosthetic outcome (43, 71).

Conflicting conclusions have been drawn with respect to the difference in the occurrence of
complications between maxillary and mandibular implant-supported overdentures, with some
researchers finding higher rates of complications with maxillary implant-supported overdentures
(71) and others finding no such difference (43). The possible higher occurrence of complications
with maxillary implant-supported overdentures has been attributed to limitations in vertical space

20

for the prosthetic components, which may lead to a higher risk of fractures (71). Higher failure
rates of implants supporting maxillary implant-supported overdentures have also been reported
occasionally, although this finding has not been observed in the majority of investigations (66,
71, 76). All reviews pointed out that the lack of uniform, standardized categorizations for
complications and significant variations in study design on implant-supported overdentures
preclude thorough analysis of certain complications and drawing firm conclusions.

Claims of superiority of one dental implant brand over another are made frequently by
manufacturers. A 2003 systematic review (77) evaluated evidence from controlled clinical trials
looking for a relationship between characteristics of dental implants and their clinical
performance. The study examined seven clinical outcomes, six of which represented various
aspects of complications: failure of osseointegration, unaesthetic outcomes, peri-implant
mucositis, marginal bone loss, mechanical problems at the interface, and mechanical failure of
the implant. It was concluded that, contrary to manufacturers claims, the existing scientific
literature does not generally support superiority in performance of some design characteristics
over others. Short-term marginal bone behavior was one of the only variables observed to differ
slightly among different implant brands based on non-randomized controlled clinical trials, but
the authors urged caution in result interpretation owing to the possibility of bias inherent in these
less rigorous study designs (77).

A 2008 systematic review (72) examined abutment screw loosening in single-implant

restorations. The results indicated that abutment screw loosening is a relatively rare event in
single implant restorations regardless of the geometry of the implant-abutment connection
(external or internal), provided that proper anti-rotational features and torque are employed.

Overall, the reviews concluded that while the survival of implants and prostheses was high,
complications were frequent (3), possibly underreported (1, 4), and may be treatment- or
prosthesis-specific (4). In particular, complications with implant-supported overdentures were
more frequent than those with fixed implant-supported prostheses (4) (albeit with notable
exceptions such as speech problems (78), where patients report fewer problems with phonetics
with implant-supported overdentures as compared to implant-supported fixed prostheses (79)).
Variability in definitions, classifications, reporting standards, and study methodologies are likely

21

responsible for the observed variability in complication reports and frequencies reported in
various studies.

3.B: General characteristics of reviews reporting implant treatment

outcome and complication data
3.B.I: Thoroughness in reporting of complications
The degree to which implant intervention studies judiciously report all specific complications
varies (4), and a 2003 review of over 200 clinical trials (1) found that not a single study
evaluated all of the known implant treatment complications simultaneously. Unfortunately,
many studies report implant or prosthesis success or survival as the only outcome variables
(Table 3.5) (2, 3). A 2002 systematic review (4) examined the incidence of biological and
technical implant complications reported in prospective studies at least 5 years in duration.
Several categories of complications were investigated within the included studies and the
percentage of studies that actually reported any given complication was reported (Table 3.6).
The percentage of studies that actually reported any given complication varied widely depending
on the specific complication and ranged from 100% of the studies reporting the complication of
implant failure to 20% of the studies reporting crestal bone loss of more than 2.5 mm (4). Of
course, many studies might not report specific complications, because they did not occur.
However, readers and reviewers cannot ascertain if the failure to mention a specific complication
was due to its non-occurrence or due to incomplete reporting (i.e., omission).

Table 3.5: Number of studies reporting on specific categories of complications in

comparison to the overall number of studies included in the reviews
review
Jung et al. (2)
Pjetursson et al. (3)

total
number
of studies
26
21

success/
survival
26
21

number of studies reporting

biological
aesthetic
complications complications
10
7
9
*

* Aesthetic complications were not examined in this review.

technical
complications
13
11

22

Table 3.6: Percentage of studies that reported specific complications in a review by

Berglundh et al. (4)
type of complication

implant loss
persistent sensory disturbance
soft tissue complications requiring therapy
peri-implantitis
crestal bone loss >2.5 mm
implant fracture
complications related to implant components
complications related to supra-structures

percent of studies reporting

this type of complication
(%)
100
41
50
40
20
84
65
65

3.B.II: Study setting

The vast majority of data regarding complications comes from university centers and specialist
clinics (Table 3.7) (2). For example, a 2008 systematic review examining 5-year survival and
complication rates of implant-supported single crowns (2) included twenty-six studies, the
majority of which were based in the university centers. Only one study was based exclusively in
private practice, and three were based on a combined patient population seeking treatment at a
private (general) practice and a university or specialist clinic. A significant difference may exist
between university centers and specialist clinics on the one hand and private general practice on
the other. University centers and specialist clinics deal with more complex and difficult
treatments but also have the benefit of advanced education, training, experience, and equipment.
This may be particularly apparent in the area of implant complication prevention, identification,
and management. Treatment outcomes achieved in institutional environments might not be
generalizable to treatment outcomes achieved in private general practice.

23

Table 3.7: Number of studies conducted in a university, specialist, or general practice

setting in comparison to the overall number of studies included in the reviews
total
university/ specialist general combined unknown
number
hospital
practice
practice
setting
setting
of studies
studies
studies
studies
studies
studies
Theoharidou et al. (72)
27
17
8*
2
Pjetursson et al. (3)
21
13
4
4
Jung et al. (2)
26
16
6
1
3
Aglietta et al. (63)
5
4
1
Note: Theoharidou et al. (72) did not distinguish between specialist and private general practice.
review

Large university-based research centers (e.g., Gothenburg, Leuven, Malmo, Mayo, and Toronto)
represent the overwhelming majority of published implant treatment results, while a much
smaller number of studies document implant experience in private practice (80). Multi-center
studies reporting complication data are also relatively infrequent (2, 3) (Table 3.8). Populationor region-wide implant complication data are available only from Finland (81), where the status
of all implanted medical and dental devices must be reported to the regulatory authorities. The
type of data collected in the Finish dental implant register, however, is very limited.

Table 3.8: Number of multi-centre studies relative to the total number of studies included
in the reviews
reviews
Jung et al. (2)
Pjetursson et al. (3)

total number
of studies
26
21

multi-center
studies
2
5

24

3.B.III: Implant companies investigated in the literature

A large and ever-increasing number of companies are involved in the manufacture and
distribution of dental implants. A 2003 assessment revealed that approximately 80
manufacturers marketed more than 220 different implant brands around the world (77). Only a
small minority of these could provide extensive clinical documentation, and some manufacturers
appeared to market dental implants without any clinical research documentation (77). An
evaluation of several systematic reviews on implant complications (2-4, 72, 82) clearly
demonstrates that implants made by four implant manufacturers NobelBiocare/Branemark,
ITI/Straumann, Astra, and 3i are the focus of the vast majority of implant outcome data (Table
3.9). Moreover, in some parts of the world implants are manufactured and sold with no
demonstration of adherence to international standards (such as ISO 9001, EN46001, and FDA
510K) (77).
Table 3.9: Certain implant companies are over-represented in the implant literature
number of studies utilizing implants of specific companies in comparison to the total
number of studies included in the reviews
implant companies
Total
reviews
number
Nobel
ITI
Astra
3i
Other
of studies Biocare
Aglietta et al. (63)
5
1
2
1
1
Berglundh et al. (4)
51
28
8
6
1
8
Jung et al. (2)
26
10*
9
3
3*
1
Payne et al. (45)
35^
25
4
4
1
8
Pjetursson et al. (3)
21
15
3
1
2
Theoharidiou et al. (72)
27
9
6
5
2
5
Zurdo et al. (82)
3
1
1
1
* One trial involved both NobelBiocare and 3i implant brands.

Not
reported
1
-

^ Eight trials involved more than one implant brand.

The use of different brands of osseointegrated implants varies dramatically around the world and
over time (Table 3.10). Several reviews (84) suggested that the incidence of some technical
complications may be specific to certain implant systems and designs. Overall complication
types and frequencies experienced by different geographic regions may differ based on the most
common implant products utilized in that geographic region. Dramatic inter-country differences

25

in the relative utilization of specific implant-supported prostheses have been reported (85). In
particular, a 2004 survey on the use of mandibular implant-supported overdentures relative to the
use of fixed implant-supported prostheses in the treatment of completely edentulous arches noted
that some countries (e.g., Sweden) utilized fixed implant-supported prostheses almost
exclusively, while others (e.g., Netherlands) utilized implant-supported overdentures almost
exclusively (85).

Table 3.10: The 5 most common implant manufacturers utilized in different countries or
geographic regions
country/geographic region, year
UK, 1999 (86)

top 5 implant manufacturers

(percentage of the market belonging to the
specific manufacturers, if available)
Branemark (68.5%), Straumann (16.7%), Flialit
(5.5%), Astra (3.7%), others (5.5%)

Japan, 2002 (87)

Nobel, Straumann, Kyocera, Centerpulse, Astra

US, 2002 (88)

Nobel, 3i, Centerpulse, Straumann, BioHorizons

Europe, 2004 (89)

Straumann, Nobel, 3i, Zimmer, Dentsply/Friadent

New Zealand, 2004 (90)

Finland, 2006 (81)
Switzerland, 2006 (91)

Branemark (73.0%), Renew Biocare (13.9%),

Straumann (12.1%), Southern (6.2%), 3i (0.8%)
Straumann (46.7%), Astra (20.4%), Xive (9.8%),
Replace Select (5.4%), Branemark (4.6%)
Straumann (53.2%), Nobel Biocare (15.2%), 3i
(7.7%), SPI (7.4%), Frialit (3.7%)

Note: The names of implant manufacturers in this table are exactly as they appeared in the original
publications. Hence, they may not be exactly comparable owing to differences in years of original study
publication and differences in specific brands marketed by the same manufacturers in different
geographic locations.

3.C: Geographic location survey of dentists

Very limited implant-related data are available from surveys of dentists bound by a geographic
or professional association. National year-specific implant-related information is available from
Finland (for 2006) (81), Israel (for 1988) (92), New Zealand (for 2004) (90), Switzerland (for
2006) (91), and the U.S. (for 2006) (93). Hospital-based provision of implant services has been
documented in year-specific surveys of Beijing, China (for 1992) (94), Nigeria (for 2004) (95),

26

and United Kingdom (for 1999) (86, 96). Most of the available information deals with implant
service utilization and barriers to implant service utilization.

Implant utilization rates and patterns of implant practice with respect to degree of involvement in
the surgical or prosthodontic phases vary widely among countries and professional groups. In
the U.S., only 12.3% of general dentists, but 98.8% of oral surgeons and 80.4% of periodontists
surgically placed an implant in 2006 (93). In Switzerland in 2006 (91), four groups of dentists
were identified with respect to the types of implant-related services they provided to patients
52.0% were involved in both surgical and prosthodontic phases, 1.8% were involved only in the
surgical phase, 28.3% were involved only in the prosthodontic phase, and 17.8% were not
involved in implant treatment at all. A 2004 survey of New Zealand dentists (90) revealed that
only 49.5% of the dentists were providing implant services to their patients. Among those who
provided implant therapy, less than 15% carried out both surgical and prosthodontic phases. A
1999 survey of implant treatment provided by consultants in restorative dentistry within National
Health Service Hospital service in the U.K. (86) revealed that 11% were involved in both the
surgical and prosthodontic phases, 35% were primarily involved in the prosthodontic phase with
limited surgical involvement, and 56% were involved exclusively in the prosthodontic phase. By
contrast, only 3% of general dental practitioners in the U.K. had experience with dental implants
as of 2006 (96). Similarly, year-specific surveys of certain geographic regions (namely, China in
1992 and Nigeria in 2004 (94, 95)) indicated very low implant service utilization.

Several professional groups bound by national boundaries (namely, U.S. prosthodontists in 2001
(97) and members of the U.K. Association of Dental Implantology in 1998 (98)) have published
year-specific implant-related surveys of their members, focusing on the utilization of implant
services and barriers that prevent their utilization. A 2001 survey of U.S. prosthodontists
revealed that 82.2% were involved in the prosthodontic phase of implant therapy, while only
12.2% were also involved in the surgical phase of therapy (97).

27

3.D: Treatment evolution and caution in interpretation of results from

past reviews
The experience of complications arising from implant treatment is an evolving problem.
Complications experienced and reported by some clinicians or in one time period become a part
of general implant knowledge and come to guide the treatment planning and execution by other
clinicians at a later time. These negative experiences lead to the development of guidelines for
avoiding complications and strategies for their management (58-61, 99, 100). Similarly, many of
the changes and attempted improvements in implant materials, designs and treatment techniques
are made in direct response to the prior experience of complications (101, 102). Ironically,
although technological improvement are often designed to specifically diminish or eliminate the
occurrence of certain complications or to simplify their management, these new technologies and
techniques might also inadvertently introduce new unforeseen complications. For example, the
negative experiences with certain aspects of screw-retained restorations (such as the loss of
access hole restorations and the difficulty in achieving passivity of fit) led to the introduction of
cemented restorations. While cemented restorations eliminated or reduced some of these
challenges, they introduced new types of complications such as cement extrusion into periimplant tissues and difficulty in seating of the final restoration (103). Thus, the constant
advancement of implant technologies and techniques changes both the types of complications
and their frequencies.

The duration of the study follow-up and its date of publication are important parameters in the
interpretation of the study results. The length of follow-up in a trial has an impact on the
apparent cumulative incidence of complications. Many complications take time to manifest and
will not be noted in studies of short duration. For example, implant failures typically occur
within the first 2 years following implant placement (20). Therefore, studies less than 2 years in
duration will effectively under-report the occurrence of implant failure and provide a falsely high
success rate. Similarly, some prosthetic complications (e.g., implant or framework fracture,
screw loosening, and material wear) are the result of a lengthy period of repeated loading (104)
and, hence, can take years or decades to manifest themselves. These prosthetic complications
might not be detected in studies with relatively short follow-up periods. Therefore, studies with

28

short follow-up periods will effectively under-report the occurrence of many prosthodontic
complications and will provide an overly optimistic success rate.

The above notwithstanding, and despite clear advantages of long-term follow-up studies,
contemporary short-term follow-up studies have a number of positive attributes. First, several
complications (including post-operative paraesthesia (105) and phonetic difficulties subsequent
to insertion of a new prosthesis (34-36)) can be temporary in nature and are likely to diminish or
disappear over time. Hence, these complications may not be detected in studies reporting only
long-term end-point data (rather than cumulative data). Second, the constant innovation and
evolution of implant treatment protocols, materials, and techniques (101, 106, 107) has an impact
on the interpretation and contemporary relevance of studies with a long-term follow-up. The
treatment protocols of a prospective trial are rigidly set, and, in effect, it becomes a glimpse
back in time at what complications would be experienced, if the protocols utilized at the
inception of the trial were still utilized. For example, a prospective study reporting 10-year data
and published ten years ago was initiated twenty years ago a time period during which many
innovations would have occurred limiting the clinical relevance of the protocols under
investigation to the contemporary clinical practice. Furthermore, long-term outcome studies that
were initiated 10-15 years ago will not be able to report on new types of complications arising
from more recent technologies and techniques. Similarly, complications related to recently
introduced changes in materials or techniques will not be detected in reviews that exclude
recently published short-term follow-up studies. Hence, several complications related to recent
developments in treatment modalities are known to occur (e.g., fracture of the narrow diameter
internal connection implant during the surgical placement) but are not described in the literature
in great detail or at all. This leaves the interpretation of the long-term study results challenging
from the stand point of accurately reflecting the contemporary clinical reality. Similarly, the
publication date of the studies must always be taken into account when deciding if the data
contained therein is applicable to guiding current decision making.

As alluded to above, the composition and design of implants and components have changed
dramatically over time (101, 106, 107). For example, machined surface implants have declined
substantially in popularity and are no longer manufactured by many of the industry leaders. The
degree to which prior reports of complications experienced with a particular implant brand are

29

representative of the current complications likely to be experienced with that brand is uncertain.
Several implant designs or techniques were found to have a particularly high incidence of
implant complications and failures and their use has been abandoned or modified significantly.
Examples of such abandoned designs include IMZ implants employing mobile elements (108),
implants with very rough surfaces (e.g., titanium-plasma-sprayed [TPS]) (74), implants coated
with very thick hydroxyapatite surface coatings (74), and hollow implant designs (74). These
implant designs are no longer used, but reviews continue to incorporate data from the studies
utilizing these abandoned designs in the assessment of aggregate complication rates (63). No
review or systematic review had explicitly attempted to limit its analysis only to the designs that
are currently in use.

There are several examples of specific complications arising from implant treatment whose
frequency of occurrence appears to have diminished over time (including implant fracture,
cantilever fracture, resin fracture, and screw loosening) owing to technological improvements in
materials, techniques, and designs and owing to changes in the relative frequency of utilization
of specific prosthesis types. Improvements in material composition (specifically, the change in
the grade of titanium used) have caused implant fracture after loading (109-111) to diminish
substantially in the frequency of occurrence (102). Guidelines for dimensions of cantilevers
were introduced successfully to decrease the occurrence of cantilever fractures in fixed full-arch
prostheses (112). At one time, acrylic resin fracture was a very common prosthodontic
complication encountered with the use of single piece full-arch prostheses (44), representing
60% of all complications observed in one multi-centre study of prosthodontic specialist clinics in
Sweden in 1991 (113). While acrylic resin is still widely used in the treatment of edentulous
full-arch prostheses, it is almost never used the treatment of partially edentulous patients, who
now constitute the overwhelming majority of patients receiving implant treatment (93). Hence,
acrylic resin fractures now constitute a much smaller percentage of the total number of
complications partly due to the relatively low utilization of metal-acrylic prostheses in favour of
metal-ceramic and all-ceramic prostheses.

Screw loosening is another example of how changes in technology and design have significantly
altered the experience of this complication. Prosthetic and abutment screw loosening is a wellknown complication of implant treatment (72), and at one time the frequent occurrence of screw

30

loosening was a major impediment to the utilization of cemented restorations (103) and single
implant-supported crowns (57). Significant technological efforts were directed at improvement
of screw design and joint stability (102), and recent reviews (2) appear to indicate lower
frequencies of occurrence of screw loosening than were reported in the past. The most recent
systematic review on this topic concluded that abutment screw loosening in single-implant
restoration is a rare event regardless of the geometry of the implant-abutment connection
(external or internal), provided that proper anti-rotational features and torque are employed (72).

Taken together, the discussion above highlights the need for ongoing re-evaluation of
complications both in long- and short-term studies. Although it is common practice for reviews
on implant-related complications to exclude trials that report clinical outcomes up to five years
of prosthesis function (2-4), this may have inadvertently biased results and conclusions of these
reviews in favour of possibly outdated materials, techniques and designs, while ignoring the
contemporary clinical reality.

3.E: Malpractice studies

A unique perspective on severe implant complications is offered by studies examining legal
malpractice cases involving implant dentistry (5, 114). While the legal systems differ
dramatically across countries, useful information can nonetheless be gleaned by examining the
complications reported and their analysis. One research group (114) evaluated court decisions
and expert reports related to on-going court cases in Germany from 1984 to 2004. This group
examined inadequacies in the delivery of care in terms of the four stages of therapy (namely,
diagnosis, planning, treatment, and aftercare) during which these inadequacies occurred.
Diagnosis and planning accounted for the majority of inadequacies in delivery of care (36% and
53% respectively), while treatment (23%) and aftercare (8%) accounted for the minority of
inadequacies. Hence, the preparatory phase (diagnosis and planning) is of crucial importance
with respect to satisfactory treatment delivery. Although it is often assumed that the direct cause
of complications is intra-operative malpractice, deficits in the preparation and planning clearly
represent a critical underlying theme in serious complications (114). The authors also observed

31

that most cases (90%) involved more than one problem area, while cases involving a single
inadequacy in delivery of care were a clear minority (10%). Hence, serious complications are
likely the cumulative result of numerous mis-judgments a view that is also supported in the
medical literature (24).

The observation that most complications resulting in legal proceedings (i.e., serious
complications) were the result of a series of mis-steps (114) echoes the Swiss Cheese model of
system failure (115). This model postulates that partially effective barriers exist to prevent
complications. These barriers are visualized as slices of cheese perforated with holes (which
represent errors that may allow the complication to pass unobtrusively through the barrier).
While any given barrier may fail to catch an error, the presence of many barriers makes it likely
that the error will be caught at some point in the process of care and remedied before it manifests
as a frank complication. This suggests that for a complication to occur, an error must occur in
each of the barriers i.e., a series of errors. This is often represented pictorially by the perfect
alignment of the holes of all the cheese slices (115).

The importance of preoperative assessment seen above (114) is also highlighted by a study that
examined cases reported to the professional liability insurance carrier in Israel between the years
1992 and 1999 (5). Patients paying their own bills without third-party involvement filed all the
legal claims. Complications resulting in legal action were divided into immediate and late
groups (Table 3.11). Immediate complications were those occurring between the first- and
second-stage surgeries. Late complications were defined as those occurring following stage 2
surgery. According to the authors, all but 2 cases (59/61) were ultimately the result of
preoperative error (5). Consultants for the insurance carrier acknowledged liability in the
majority of cases (67%). In particular, liability was acknowledged in 100% of cases of loss of
sensation and implant malposition, and, in general, liability was acknowledged in a higher
percentage of immediate complications (77%) (5).

32

Table 3.11: Classification of complications according to Givol et al. (5)

category of complications

immediate complications

late complications

specific complications
(number of specific complications out of the total of 61
cases)

permanent altered sensation (16/61)

implant failure (10/61)

unfavourable implant location compromising the

prosthetic rehabilitation (7/61)

postoperative infection (3/61)

invasion of maxillary sinus (2/61)

life-threatening hemorrhage (1/61)

loss of prosthetic rehabilitation (16/61)

implant loss not resulting in the loss of the prosthetic

rehabilitation (4/61)

massive bone loss related to implant failure (2/61)

The facts that most serious complications can be traced to errors in judgment during the
preoperative phase (5, 114) and that liability was acknowledged in most cases (5, 116) lead to
two conclusions. First, they reinforce the contention that implant complications may be largely
preventable (62, 117) (similarly to the manner in which many treatment complications in the
medical field are suspected to be preventable (16, 17)). Second, they highlight the need to focus
on improvements in operator education, skill and judgment rather than improvements in implant
technology (5). The focus on these human elements is likely to lead to further reductions in
implant complications. Further technological improvements should be sought only in so far as
they facilitate acquisition of operator knowledge and skill or improve operator judgment.

3.F: Clinicians opinions on complications

Extremely limited information exists with respect to clinicians opinions on complications. Two
surveys on implant treatment outcomes in the U.K. (118) and Israel (92) asked dentists opinions
on primary determinants of treatment outcomes. In a 1999 survey in the U.K. (118), clinicians
stated that the most important reasons for implant failure were (in a decreasing order of
importance) poor bone quality, unsuitable loading, poor oral hygiene, smoking, poor surgical
technique, poor patient selection, implant type, and use of bone grafts. The importance given by
responders to poor bone quality is in agreement with comprehensive reviews on this topic (20,

33

74). In a 1988 survey of Israeli dentists (92), the most commonly cited reasons for success of
dental implants were (in a decreasing order of frequency) surgical phase, case selection,
prosthodontic phase, following manufacturers instruction, skills and knowledge, oral hygiene,
occlusal adjustments, and osseous factors. The first three reasons (surgical phase, case selection,
and prosthodontic phase) were far more commonly cited than the rest. While the information
from these two surveys is interesting, differences in study methodologies make these results hard
to reconcile with each other. Furthermore, the results of the survey from Israel (92) must be
considered in light of the year when the information was collected (i.e., 1988), since substantial
progress has been made in the field of implant dentistry since that time (101, 106, 107). This is
well-illustrated by the fact that the third most commonly used implant product on the market in
Israel at the time was blade implants a non-osseointegrated implant type that is no longer used
and bears little resemblance in method of anchorage or in surgical or prosthetic protocols to
osseointegrated screw-shaped implants.

Very little is known about severity ranking of complications by the dentists or about interpersonal agreement with respect to such rankings. A 5-point ordinal scale relating to the severity
of implant-related complications clinical performance scale for implants (Table 3.12) has
been proposed (6), with implant failure intrinsically defined in this scale as the most severe
complication. In this study (6), a panel of six specialists (two oral surgeons and four
prosthodontists) was used to rank complications that had occurred in a group of patients treated
with implant-supported mandibular overdentures (Table 3.13). Most complications received a
score of 1 or 2 (out of 4). Not surprisingly, implant failure and implant fracture received a score
of 4 (out of 4). Bone loss could not be assigned a single score due to a wide range of clinical and
radiographic circumstances. Full consensus in the ranking was sought by the authors from the
six person panel but was obtained only for 65% of the specific complications. For 87% of the
complications at least five of the six experts gave the same score (6).

A significant disadvantage of the Clinical performance scale (6) (Table 3.12) is that it
intrinsically regards implant loss as the ultimate (most severe) complication and ranks other
complications based largely on their likelihood of leading to implant loss. No support exists to
justify the ordering of options in this scale. Although loss of a unit of anchorage can be a serious
event, a number of other complications (including permanent paraesthesia, very poor aesthetic or

34

functional prosthetic outcome, very poor implant placement, jaw fracture, significant damage to
an adjacent tooth, and severe life-threatening post-operative infection) may also produce very
debilitating effects on the patient. Moreover, in some situations such as loss of an implant
under a screw-retained full-arch prosthesis loss of an implant may not have much of a
significant impact at all, because some prostheses are over-engineered/designed precisely to
allow for such a possibility. In this situation, the loss of a single implant might not affect the
stability and retention of the prosthesis, permitting its function to continue uninterrupted.
Ultimately, the impact that the complication has on the patient is an important determinant of the
severity of a complication (64). This patient-relevant aspect is absent from the Clinical
performance scale and the results of the study utilizing this scale (6) must be interpreted with
caution.

Table 3.12: Clinical performance scale for implants according to Van Waas et al. (6)
0 no complication or need for replacement
1 minor complication that does not need intervention or is easily treated
2 complication with a reasonable chance of recovery or stabilization of the situation
3 serious complication or treatment procedure that may lead to failure of the implant
4 complete failure of the implant

Table 3.13: Clinical performance scale score for a range of complications according to Van
Waas et al. (6)
Complication
- broken abutment
- hyperplastic mucosa
- incorrect occlusion or articulation
- loosening of suprastructure screws
- denture relining necessary
- minor disturbance of mental nerve
- suprastructure not fitting
- broken suprastructure
- severe disturbance of mental nerve
- bone loss
- implant loss
- implant fracture

Clinical performance scale score (6)

2
3
could be assigned a score from 0 to 3
depending on the extend of radiographic bone
loss and clinical presentation
4

35

3.G: Conclusion and rationale for further study

All reviews referred to previously (2-4) found that while survival of implants and implantsupported restorations was high, a notable percentage of patients experienced complications.
Although much knowledge has been accumulated with respect to osseointegrated implants and
complications associated with their use, much information remains unknown or is out of date.
The constant evolution of treatment strategies, technologies, and patient expectations (101, 106,
107) creates a constant need to update the existing information. In particular, current
information regarding dentists experience of implant treatment-related complications in specific
geographic locations is largely unknown. Furthermore, the nature and the types of implant
complications experienced in private practice may be different from those commonly reported in
the literature based on experience in academic centres. Opinions of dentists regarding the
causes, preventability, preventive strategies, and severity of complications are also unknown.
Hence, there is a growing and ever-present need to investigate location-specific experience with
complications in contemporary private practices.

36

Chapter 4
Materials and Methods
4.A: Aims and objectives
The aims and objectives of this research were already stated at the very beginning of this thesis
(Chapter 1). However, they are restated here again so that subsequent sections of this study can
be interpreted more easily.

The primary objective of the study was to determine the nature and the types of complications
arising from dental implant therapy in private practices in the province of Ontario as reported by
treatment providers.

Other specific objectives were:

1) to determine the causes of complications as perceived by the treatment providers;
2) to determine if the types of complications experienced in private practices differ based on
educational background of the treating dentist; and
3) to determine the relative severity ranking of complications as perceived by the treatment
providers.

It should be understood that although research is generally hypothesis driven, this is not always
possible with a survey. However, insights generated from survey analysis and interpretation may
give rise to post-hoc hypotheses that could be tested in future investigations.

4.B: Methods
This research was carried out as a survey (see Appendix 1). The survey tool was developed
based on complications arising from implant therapy that have been reported in the literature (14, 20, 38, 42, 43, 45, 57-59, 61, 63, 71, 72, 82, 84, 99, 119). This information was supplemented
by several additional sources including: 1) implant-related complications reported to the
malpractice carrier for the dentists of Ontario (Professional Liability Program PLP), 2)
personal interviews with a convenience sample of 10 dentists, and 3) a preliminary survey of a

37

convenience sample of 30 general dentists and specialists participating in clinical teaching at the
Faculty of Dentistry, University of Toronto. Legal cases involving implants that have resulted in
Canadian court judgments or in decisions by Ontario disciplinary bodies (i.e., The Royal College
of Dental Surgeons of Ontario) were also examined. The survey tool was pre-tested for length
and comprehensibility by 20 specialty graduate students at the University of Toronto. The
survey tool was revised on the basis of this test. To reiterate, although the survey tool was
developed partly on the basis of information obtained from the PLP, data from the PLP were not
included in any of the data sets nor used in any of the subsequent analyses of the survey results.

The survey tool contained two sections: basic demographic questions and questions about
implant complications. Basic demographic questions focused on the dentists level of expertise
and education with respect to surgical and prosthodontic aspects of implant therapy. No personal
identifying information was collected, and all questionnaires were anonymous and confidential.

Questions about implant complications pertained to the actual complications that the dentists had
experienced in 2009, the factors associated with those complications, and the dentists general
opinions regarding complications. Four different categories of complications related to implant
therapy were investigated surgical, prosthodontic, biological, and patient-related. The dentists
were also asked about the corrective actions they took in response to complications in 2009.
Opinions were sought with respect to preventability of complications, causes of complications,
ways to prevent complications, and severity of complications.

As just mentioned above, this study (and survey) divided implant treatment complications into
four categories surgery-related, prosthodontic, biological, and patient-related. This
classification system builds upon a classification described previously by Esposito et al. (20). In
the original iteration of this classification system (20), complications were divided into four
categories biological (e.g., implant failure), mechanical (e.g., fracture of implants, connecting
screws, bridge frameworks etc.), iatrogenic (e.g., nerve damage, wrong alignment of the implants
etc.), and inadequate patient adaptation (e.g., phonetic, aesthetic, psychological problems etc.)
(Table 2.3). In this study, the following superficial modifications were made:
1) the category of mechanical complications was renamed to prosthodontic
complications,

38

2) the category of iatrogenic complications was renamed to surgical complications, and

3) the category of inadequate patient adaptation was renamed to patient-related
complications.
The rationale for renaming mechanical complications into prosthodontic complications was
based on the idea that the term mechanical did not appear to embrace the full scope of
prosthodontic complications, such as complications that might arise even before prosthesis
fabrication (e.g., inability to take an impression). The category of iatrogenic complications
was changed to surgical complications, because most complications that fall under that
category arise as a direct result of a surgical procedure. At the same time, most implant
complications are probably iatrogenic in nature (114, 116, 117), and, hence, using the term
iatrogenic to refer only to one category of complications would appear to be inaccurate.
Moreover, for the purposes of this study, it was felt that the term iatrogenic might not be
understood fully by all dentists who might participate in the survey. Lastly, the category of
inadequate patient adaptation was renamed to patient-related complications to avoid the
inadvertent connotation that the patient is responsible for the complication. Most specific
complications in this category have direct causes in treatment execution. Poor patient response
(e.g., poor speech or poor comfort) is often a direct or indirect manifestation of other underlying
complications (e.g., poor implant position). The term patient-related complications was used,
because complications in this category often have an element of patient response or evaluation of
therapy (e.g., aesthetics, phonetics, comfort, and overall satisfaction).

This study investigated a large number of specific complications spanning all phases of implant
therapy. It simultaneously assessed more specific complications on a single dentist population
than almost any other study in this field, including some specific complications that appear to be
examined here for the first time. However, not all conceivable complications were included on
the list of specific complications investigated in this research. The selection of complications for
inclusion in this survey was based on complications reported in the literature (1-4, 20, 38, 42, 43,
45, 57-59, 61, 63, 71, 72, 82, 84, 99, 119), complications mentioned by dentists during informal
interviews, and complications mentioned by dentists during preliminary open-answer surveys,
while keeping the limitations of survey space in mind. The need to keep the survey length as
small as possible to maximize response rates was the primary constraining factor.

39

Furthermore, implant-related procedures (and complications associated with them) were not
included/addressed in this survey if they were understood to be done too infrequently, mostly by
specialists, or primarily in a hospital setting (e.g., block grafting, zygomatic implants, distraction
osteogenesis, inferior alveolar nerve transposition, and maxillofacial prostheses). Complications
associated exclusively with grafting procedures were not included (with the exception of sinus
membrane perforation), because grafting procedures have a very large number of procedure-,
material-, and technique-specific complications, and their inclusion would have tremendously
increased the number of surgical complications. (Sinus membrane perforation was included in
the survey because it is a very well-researched, frequently mentioned, and objective complication
(65).) However, certain basic complications (such as severe bleeding, severe infection, and
incision line opening, for example) and corrective actions (such as performing additional surgical
procedures and increasing the length of treatment) would apply to complications associated with
all surgical procedures, including grafting procedures, and these were included in this study.
Wherever possible, this study attempted to state specific complications in a procedure- or
prosthesis-independent fashion. Specific procedures or prostheses were mention only to increase
clarity.

Functional and phonetic adaptation takes place with the insertion of all dental prostheses (34-36).
This survey did not specify how long after prosthesis insertion a particular patient complaint of
speech defect or poor comfort should be regarded as a complication. Instead, the survey left it to
the discretion of the individual dentists to judge if the experiences of their patients constituted a
complication. The challenges of establishing time horizons and thresholds for complications
have been discusses earlier in section 2.E.

The survey was administered to the dentists most likely to be involved in the treatment of dental
implants general dentists, oral and maxillofacial surgeons, periodontists, and prosthodontists
(93). (Oral and maxillofacial surgeons will be shortened to oral surgeons in the rest of the
thesis.) The survey tool was administered using the QuestionPro web program
(http://www.questionpro.com/). Surveys were e-mailed to all general dentists and specialists
with available e-mails. The survey was conducted based on Dillmans Tailored Design Method
(120) as it applies to web-based surveys (121, 122). This approach focuses on optimizing survey
response by virtue of survey instrument design and survey implementation. In particular,

40

Dillmans Tailored Design Method for survey design utilizes Social Exchange concepts that
postulate that peoples actions are motivated by the return these actions are expected to bring.
Hence, survey design should built respondent trust and make it as easy as possible to complete
the survey while making the expected benefits (to society) clearly apparent (120).

4.C: Sample size calculations

To ensure that our sample was representative of the overall dentist population of Ontario, the
sample size calculations were based on the following four assumptions (120):
1) 5% margin of error.
2) 95% confidence interval.
3) The population size from which the sample was selected.
4) 50% response distribution rate: The response rate was essentially unpredictable with regard
to the survey in toto as well as specific questions therein. In order to assure a good response,
a conservative response rate of only 50% was presumed a priori.

Therefore, the calculation of the sample size (n) was based on the size of the population (N), the
proportion of the population expected to choose one of two responses (P= 0.5 to allow for the
maximum variance), the assumed sampling error (C= 0.05), and the Z-statistic of the confidence
interval (Z = 1.96 for 95% confidence level) (123):
n = ((N)(P)(1-P)) / ((N-1)(C/Z)2 + (P)(1-P))

The dentist population target sample was made up of four professional groups of subjects as
outlined previously. The sample size calculations were based on the total numbers of subjects in
those groups within the province of Ontario:

Oral Surgeons: Based on the total of 194 in Ontario, the sample size required was 128.

Periodontists: Based on the total of 186 in Ontario, the sample size required was 124.

Prosthodontists: Based on the total of 68 in Ontario, the sample size required was 58.

General Dentists: Based on the total of 7,154 in Ontario, the sample size required was 366.

41

Therefore, the preliminary sample size for professionals would have been 676
(=128+124+58+366). However, response rates from professional surveys are notorious for being
low. (A recent survey utilizing similar methodology at Faculty of Dentistry, University of
Toronto reported a response rate of 15% (personal communication, Dr. Amir Azarpazhooh).)
Moreover, it was anticipated that it would not be possible to obtain e-mail addresses of all
Ontario dentists to allow a random sample to be drawn, and furthermore, it was also expected
that some e-mail addresses would be invalid. Therefore, in order to account for these
shortcomings, a sample of 2621 dentists with available e-mail addresses was selected from the
total pool of 7602 dentists currently practicing in Ontario. This project was approved by the
Ethics Committee of the University of Toronto (#24931).

4.D: Survey implementation

The anonymous web-based survey was implemented between April and May 2010. A
personalized e-mail was sent to all dentists with available e-mail addresses (2621). The e-mail
described the research design and purpose of the investigation and contained a link to the actual
survey. Potential respondents were informed that completion of the survey signified their
consent. Clicking on the link to the survey took the potential respondents to the actual
anonymous web-based survey. On average, it took approximately 15 minutes to complete the
survey. Wherever possible, the order of options within the questions was randomized so that
each respondent saw the options in a different sequence. This was particularly important for the
questions with a long list of options to prevent certain options from being preferentially selected
by virtue of their preferred sequence order. Three reminders were sent 1-2 weeks apart. Each
reminder e-mail contained a slightly modified text of the original e-mail. In particular, a section
of answers to commonly asked questions about the survey was included with the reminder emails. Each subsequent reminder generated fewer additional responders. Data security and
privacy were addressed at all levels starting with survey delivery all the way through to
protecting the integrity of survey results and user data. Respondents were not given a financial
incentive to participate.

42

4.E: Data analysis

The data that were collected on-line were downloaded from the QuestionProTM website into a
Microsoft Excel file. The data were cleaned, recoded, and imported to the Statistical Package for
Social Sciences software 18.0 (SPSS, Chicago, Ill, USA) for data management and analysis. The
data underwent quantitative analysis. Summary statistics were compiled from completed surveys
to address each of the objectives. Associations among variables such as level of dental implant
experience (i.e., expertise in this field), specialty status, and types of complications were
assessed using the Chi-squared statistics with a threshold of significance set at a p-value of 0.05.
Descriptive analyses of data, including tables, frequency distributions and graphic displays were
performed. Descriptive analyses of the data were undertaken for the sample as a whole and
separately for the four professional groups (general dentists, oral surgeons, periodontists, and
prosthodontists). Experience with complication and opinions about complications were
subjected to the Chi-squared test using the Bonferroni correction, adjusting for multiple
comparisons and the possibility of increased Type II error. For several cross-tabulations, six
comparisons were made between the four groups of professionals. Consequently, the threshold
for significance was corrected to a p-value of 0.008 (derived by dividing 0.05 by 6 to account for
multiple comparisons). Non-parametric techniques constituted the bulk of tools for analysis of
this survey.

43

Chapter 5
Demographics
5.A: Results and tables
Table 5.1: Survey flow
2621 e-mails sent out
- 559 bounced, - 28 unsubscribed
2034 active

537 completed the

survey
- 68 who were not involved in implant dentistry
(60 general dentists + 2 oral surgeons + 4 periodontists + 2 prosthodontists)
469 performed implant
treatments

Table 5.2: Comparison between Ontario dentist population, survey e-mail list, active e-mail
list, and survey responders

Ontario

survey mailed out

general dentists

oral surgeons

periodontists

n 7154
% 94.1
n 2353
-527 bounced
-25 unsubscribed
% 89.8
n 1801
%
88.6

194
2.6
125
-18 bounced
-1 unsubscribed
4.8
106

186
2.4
93
-9 bounced
-2 unsubscribed
3.5
82

prostho
total
dontists
68
7602
0.9
100.0
50
-5 bounced 2621

1.9
100.0
45
active survey list
2034
(w/o bounced and
5.2
4.0
2.2
100.0
w/o unsubscribed)
n 443
33
41
20
537
all survey
responders
%
n 383
31
37
18
survey
469
responders who
%
performed implant
81.7
6.6
7.9
3.8
100.0
treatments*
*Note: All subsequent tables in this thesis present data referring strictly to the 469 dentists who responded
to the survey and were involved in implant dentistry. This is further clarified on page 46.

44

Table 5.3: Demographic characteristics surgical/prosthodontic expertise, practice focus

all responders who perform

implant treatments
Surgical Expertise
advanced/average
basic knowledge/none
total
Prosthodontic Expertise
advanced/average
basic knowledge/none
total
Practice focus
exclusively prosthodontic
implant treatment
primarily prosthodontic
implant treatment and
limited surgical treatment
both surgical and
prosthodontic implant
treatment
exclusively surgical implant
treatment
primarily surgical implant
treatment and limited
prosthodontic treatment
Total
Practice focus
exclusively prosthodontic
implant treatment
both surgical and
prosthodontic implant
treatment
exclusively surgical implant
treatment
Total

general
dentists
n 383
% 81.7

oral
surgeons
31
6.6

periodon
tists
37
7.9

prosthod
ontists
18
3.8

469
100.0

% 39.4
% 60.6
n 383

100.0
0.0
31

100.0
0.0
37

72.2
27.8
18

49.5
50.5
469

% 89.4
% 10.6
n 379

51.7
48.3
29

57.1
42.9
35

100.0
0.0
18

85.0
15.0
461

% 61.4

0.0

0.0

33.3

51.4

% 14.1

0.0

0.0

33.3

12.8

% 24.3

0.0

8.1

33.3

21.7

% 0.0

87.1

70.3

0.0

11.3

% 0.3

12.9

21.6

0.0

2.8

383

31

37

18

469

% 61.4

0.0

0.0

33.3

51.4

% 38.6

12.9

29.7

66.7

37.3

% 0.0

87.1

70.3

0.0

11.3

31

37

18

469

383

total

2 PValue

<0.001

<0.001

<0.001

<0.001

45

Table 5.4: Demographic characteristics year of graduation, number of patients/implants

treated
general
dentists
Years in practice
(Year of graduation from
DDS program)
>40 (<1970)
31-40 (1970-1979)
21-30 (1980-1989)
11-20 (1990-1999)
0-10 (2000-2009)
total
Years in specialist practice
(Year of graduation from
specialty program)
>30 (<1980)
21-30 (1980-1989)
11-20 (1990-1999)
0-10 (2000-2009)
total
Years in implant dentistry
0-10
11-20
>20
total
Patients treated
0-10
>10
total
Implants placed
0
1-10
>10
total
Implants placed
(among those who placed
implants)
1-10
>10
total
Implants restored
0
1-10
>10
total
Implants restored
(among those who
restored implants)

oral
surgeons

periodon
tists

prosthod
ontists

total

%
%
%
%
%
n

8.3
24.9
27.5
28.1
11.2
338

9.7
22.6
29.0
32.3
6.5
31

2.9
26.5
26.5
17.6
26.5
34

18.8
12.5
43.8
12.5
12.5
16

8.4
24.3
28.2
27.0
12.2
419

%
%
%
%
n

0.0
50.0
50.0
0.0
2

9.7
35.5
22.6
32.3
31

11.5
31.4
20.0
37.1
35

25.0
25.0
18.8
31.3
16

13.1
32.1
21.4
33.3
84

%
%
%
n

53.3
37.1
9.6
334

22.6
32.3
45.2
31

39.4
39.4
21.2
33

25.0
25.0
50.0
16

48.8
36.5
14.7
414

% 96.7
% 3.3
n 332

60.0
40.0
30

52.9
47.1
34

73.3
26.7
15

89.5
10.5
411

%
%
%
n

63.5
33.3
3.2
312

0.0
35.5
64.5
31

3.0
51.5
45.5
33

46.7
40.0
13.3
15

52.7
35.3
12.0
391

% 91.2
% 8.8
n 114

35.5
64.5
31

53.1
46.9
32

75.0
25.0
8

74.6
25.4
185

%
%
%
n

84.0
12.0
4.0
25

69.0
24.1
6.9
29

0.0
64.3
35.7
14

16.4
77.7
6.0
403

7.5
87.8
4.8
335

2 PValue

0.104

0.872

<0.001

<0.001

<0.001

<0.001

<0.001

46

1-10
>10
total

% 94.8
% 5.2
n 310

75.0
25.0
4

77.8
22.2
9

64.3
35.7
14

92.9
7.1
337

<0.001

The survey was mailed out to 2621 dentists in Ontario with available e-mail addresses (Tables
5.1 and 5.2). Contact information was available for a greater percentage of specialists, and hence
specialists made up a greater percentage in the sample population than in the Ontario dentist
population in general (11.2% vs. 5.9%). There were 559 invalid e-mail addresses, and 28
dentists unsubscribed from the survey (i.e., they informed the investigators that they did not wish
to be contacted or did not wish to participate in the survey). The active list of responders
consisted of 2034 dentists. A total of 537 dentists replied to the survey after 3 reminders had
been sent. Among these were 68 dentists who were not involved in implant dentistry. These 68
dentists did not complete the survey, and they were not included in the survey analysis. Hence,
the final count of responders was 469. The rest of the survey results reported below will apply to
these 469 dentists, and they will be referred to as the responders. Not all responders answered
every question. Hence, for every question the total number of dentists who answered it will also
appear. The response rates (obtained by comparing the active survey list and the survey
responders involved in implant dentistry) were 23.1% for the dentists as a group and 21.3%,
29.3%, 45.1%, and 40.0% for general dentists, oral surgeons, periodontists, and prosthodontists
respectively. Survey response rates for specialists (especially, for periodontists and
prosthodontists) were higher than the response rate for general dentists. However, general
dentists made up the majority of survey responders (81.7%), with specialists making up the
remaining 18.3%. Specialists (oral surgeons, periodontists, and prosthodontists) made up 6.6%,
7.9%, and 3.8% of the responders respectively (Table 5.3).

Among the survey responders, roughly half the dentists possessed advanced or average surgical
expertise, and half possessed basic or no surgical expertise (Table 5.3). All oral surgeons and
periodontists, the majority of prosthodontists (72.2%), and 39.4% of general dentists had average
or advanced level of surgical expertise. These differences in surgical expertise among the four
professional groups were statistically significant (2 p-value<0.001).

47

Among the survey responders, the vast majority of dentists (85.0%) had advanced or average
level of prosthodontic expertise (Table 5.3). All prosthodontists, the vast majority of general
dentists (89.4%), and 50-60% of surgical specialists (oral surgeons and periodontists) had
advanced level of prosthodontic expertise. These differences in prosthodontic expertise among
the four professional groups were statistically significant (2 p-value<0.001).

Among the survey responders, with respect to performance of implant-related treatments most
dentists (51.4%) were involved exclusively in prosthodontic implant treatment, and another
12.8% were involved primarily in prosthodontic phase with limited surgical involvement (Table
5.3). Only 11.3% were involved exclusively in the surgical phase of implant therapy, and
another 2.8% were involved primarily in the surgical phase with limited prosthodontic
involvement. Approximately 21% were actively involved in both surgical and prosthodontic
phases of implant therapy. Another way to look at the same data is to consider that the vast
majority of dentists (88.7%) were involved, in some capacity, in the prosthodontic phase of
therapy, while only 48.6% were involved in some capacity in the surgical phase of implant
therapy. In other words, among the survey responders involvement in the prosthodontic phase of
implant therapy was far more common compared to involvement in the surgical phase of implant
therapy.

All general dentists reported that they were involved in the prosthodontic phase of implant
therapy, and 61.4% of them were involved exclusively in the prosthodontic phase of treatment
(Table 5.3). All prosthodontists were involved in the prosthodontic phase of implant therapy, but
only 33.3% of them were involved in the prosthodontic phase exclusively. Those involved only
in the prosthodontic phase of implant therapy were exclusively general dentists or
prosthodontists. All oral surgeons and periodontists were involved in the surgical phase of
implant therapy, and most oral surgeons (87.1%) and periodontists (70.3%) were involved in the
surgical phase exclusively. Those involved only in the surgical phase of implant therapy were
exclusively oral surgeons or periodontists.

Due to the relatively small number of survey participants belonging to certain subgroups in the
practice focus question, the five groups were recoded into three groups with respect to
provision of implant therapy prosthodontics only, both prosthodontics and surgery, and

48

surgery only (Table 5.3). Those who performed prosthodontic implant treatment exclusively
were recoded as the prosthodontics only group. This was the largest group with 51.4% of
responders. It was made up primarily of general dentists (97.5%). Those who performed both
prosthodontic and surgical phases of implant therapy were recoded as the both prosthodontics
and surgery group. This was the second largest group with 37.3% of responders. It was made
up predominantly of general dentists (84.6%) with small percentages of oral surgeons,
periodontists, and prosthodontists. Those who performed surgical implant treatment exclusively
were recoded as the surgery only group. This was the smallest group with 11.3% of the
responders and was made up of oral surgeons and periodontists. Hence, this was the only group
made up exclusively of specialists.

Approximately 2/3 of general dentists were involved with prosthodontic treatment only, while
1/3 were involved with both the prosthodontic and surgical phases of therapy (Table 5.3). The
reverse was true for prosthodontists where approximately 2/3 were involved in both the
prosthodontic and surgical phases of treatment, while 1/3 were involved with the prosthodontic
phase only. The majority of oral surgeons and 2/3 of periodontists were involved only with the
surgical phase of therapy. Only oral surgeons and periodontists were involved exclusively in the
surgical phase of implant therapy.

The date of graduation for the dentists or dental specialists did not affect participation in the
survey (2 p-value=0.104 and 0.872 respectively) (Table 5.4).

With respect to duration of involvement in implant dentistry, specialists (oral surgeons,

periodontists, and prosthodontists) were likely to be involved in implant dentistry for a longer
period of time compared to general dentists (Table 5.4). Specifically, 53.3% of general dentists
were involved in implant dentistry less than 10 years, and only 9.6% of general dentists were
involved in implant dentistry longer than 20 years. By contrast, 77.4% of oral surgeons, 60.6%
of periodontists, and 51.2% of prosthodontists were involved in implant dentistry more than 10
years. The differences were particularly pronounced when examining specialist involvement in
implant dentistry over a period longer than 20 years. Almost half of the oral surgeons and
prosthodontists have been involved in implant dentistry for more than 20 years. These

49

differences in the duration of involvement in implant dentistry among the four professional
groups were statistically significant (2 p-value<0.001).

Among the survey responders, most dentists treated a relatively small number of patients with
implant therapy (Table 5.4). In fact, 89.5% of dentists treated 10 or fewer patients with implant
therapy per month in 2009. Clear differences emerged when examining the number of patients
treated relative to the educational status. The overwhelming majority of general dentists (96.7%)
treated 10 or fewer implant-related patients per month. In other words, only a tiny percentage of
general dentists (3.3%) treated more than 10 implant-related patients per month, while a
significant percentage of oral surgeons (40.0%), periodontists (47.1%), and prosthodontists
(26.7%) treated more than 10 implant-related patients per month in 2009. These differences in
the number of patients treated with implant therapy among the four professional groups were
statistically significant (2 p-value<0.001).

Among the survey responders, most dentists (52.7%) did not provide surgical implant treatment,
while 35.3% placed between 1 and 10 implants per month in 2009 (Table 5.4). Hence, only a
minority of dentists (12.0%) placed more than 10 implants per month. Another way to look at
the same information is to consider that among those who performed surgical implant placement,
74.6% placed 10 or fewer implants, and 25.4% placed more than 10 implants per month in 2009.
Among dentists who placed implants, the vast majority of general dentists (91.2%) and the
majority of prosthodontists (74.6%) placed 10 implants or fewer per month in 2009. The
majority of oral surgeons (64.5%) and approximately half the periodontists (46.9%) placed more
than 10 implants per month. These differences in the provision of implant-related treatments
among the four professional groups were statistically significant (2 p-value<0.001).

Among the survey responders, the majority of dentists restored (more precisely, finished
restoring) between 1 and 10 implants per month in 2009 (Table 5.4). At the same time, 16.4%
did not restore any implants, and 6.0% restored more than 10 implants per month. Another way
to look at the same information is to consider that among those dentists who restored implants,
92.9% restored 10 or fewer implants per month in 2009, while only 7.1% restored more than 10
implants per month.

50

When examining only those dentists who restored dental implants in 2009, the majority of
general dentists (94.8%) and prosthodontists (64.3%) restored fewer than 10 implants per month
(Table 5.4). However, the proportion of prosthodontists who restored more than 10 implants per
month (35.7%) was much greater than the proportion of general dentists who restored more than
10 implants per month (5.2%). Among the small number of oral surgeons and periodontists who
restored implants, the majority (approximately 75%) restored fewer than 10 implants per month
in 2009. Hence, specialists (and especially prosthodontists) who restored implants in 2009 were
more heavily involved in the prosthodontic phase of implant therapy compared to general
dentists (2 p-value<0.001).

5.B: Discussion
E-mail addresses were available for only a non-random subset of dentists in Ontario. A slightly
greater percentage of specialists had e-mail addresses that were publicly available compared to
the percentage of specialists in the Ontario dentist population. This might be a reflection of the
referral nature of specialist practices, where the ability to be readily accessible to other
professionals is important. Response rates of specialists to this survey were also slightly higher
than those of general dentists. These two factors caused a slight imbalance in the final mix of
survey responders with a greater percentage of specialists among the survey responders
compared to the Ontario dentist population.

The population of responders consisted of 383 general dentists, 31 oral surgeons, 37

periodontists, and 18 prosthodontists. The sample size calculations called for 366 general
dentists, 128 oral surgeons, 124 periodontists, and 58 prosthodontists. The survey exceeded the
desired sample size for general dentists. Although high response rates were achieved from the
specialists (e.g., 45.1% response rate for periodontists and 40.0% response rate for
prosthodontists), the ability to reach the sample size for specialists was significantly hampered
by the limited number of valid e-mail addresses available and by the fact that not all dentists
were involved in implant therapy. In particular, 68 dentists (12.7%) were not involved in
implant dentistry and, hence, did not participate in the full survey. Difficulties in achieving a

51

sufficient number of responders among certain dental specialties with relatively small
constituencies (e.g., prosthodontists) to allow for reliable statistical analysis to be carried out
have been reported in previous surveys (93). The differential response rates between specialists
and general dentists could be important since this might have an impact on interpretation of the
data, but overall it was decided that a more than adequate sample size had been attained for
analysis. The small percentage of dentists among the survey responders who were not involved
in implant dentistry (12.7%) is comparable to the 17.8% of Swiss dentists who were not involved
in implant treatment in 2006 (91), but is much lower than the 50.5% of New Zealand dentists
who were not providing implant services to their patients in 2004 (90). Although these
comparative observations among these three populations are interesting, they are difficult to
explain precisely. Differences in patterns of disease in the treatment population, dentists
educational experiences and opportunities, economic structure of provision of dental services and
preferences of providers and patients for specific treatments (85) or treatment decisions may
account for the differences observed in the utilization of implant therapy.
Clear differences emerged regarding dentists treatment expertise with respect to the provision of
surgical and prosthodontic implant treatment phases. A clear majority of dentists (85.0%) had
advanced or average level of prosthodontic expertise with respect to the provision of implant
therapy, but only approximately half the dentists (49.5%) had advanced or average level of
surgical expertise. Hence, among dentists, the level of prosthodontic expertise is significantly
higher than the level of surgical expertise. This is reflected in the finding that 51.4% of the
responders focused exclusively on prosthodontic implant treatment, while only 11.3% focused
exclusively on surgical implant treatment. The dentists greater focus on the provision of
prosthodontic rather than surgical phases of implant therapy has been documented also in other
countries (90, 91). Among general dentists, 89.0% had advanced or average prosthodontic
expertise with respect to provision of implant therapy, but only 39.4% had advanced or average
surgical expertise. This finding parallels the data showing that with respect to provision of
implant therapy, the majority of general dentists (61.4%) focused exclusively on prosthodontic
treatment.

The finding of stronger knowledge base in prosthodontic phase of implant therapy compared to
the surgical phase of implant therapy among the survey responders correlates with the

52

preferential emphasis that dental Faculties in Europe (124) and North America (125) have been
placing on the prosthodontic implant experience compared to the surgical implant experience. A
2004 survey (125) of deans of 56 US and Canadian Dental Schools (39 of whom actually replied
to the survey) revealed that the vast majority of the Dental Schools (97%) provided didactic
instruction relating to implant therapy in the undergraduate curriculum. However, actual clinical
experience with dental implants was not as frequently available especially with respect to
surgical experience. While 86% of the Dental Schools reported that some of their students
received clinical experience in restoring implants, only 51% of the students actually received
clinical experience, and only 11.5% of the Dental Schools had a competency requirement. With
respect to clinical surgical experience, while 74% of the Dental Schools reported that some of
their students received this experience, only 28% of the students actually received this
experience, and only 2.8% of the Dental Schools had a competency requirement (125). A 2009
survey (124) of participants in the Association for Dental Education in Europe (ADEE)
workshop on implant dentistry reported similar findings. While all European Dental Schools
provided didactic implant education, only 70% of Dental Schools reported that their students
received clinical experience with implant prosthodontics by treating patients or by assisting
others. In comparison, an even smaller percentage of Dental Schools (53%) reported that their
students received clinical experience with implant surgical placement, and even then it was
largely in the capacity of a surgical assistant. The two leading barriers to the inclusion of
implant prosthodontics or implant surgery in the undergraduate curriculum included limited
time in the curriculum and limited staff (124).

An interesting and somewhat unexpected observation was that there was a high level of
prosthodontic expertise among surgical specialists and a similarly high level of surgical expertise
among prosthodontists. This observation was surprising since only two thirds of the
prosthodontists were actually involved in the provision of surgical implant services and less than
a third of the surgical specialists were actually involved in the provision of prosthodontic
services. This observation might be a reflection of the specialists advanced cross-training in the
complementary fields (126-128), which itself might have its origin in the need for insight into
both surgical and prosthodontic aspects during the management of complex cases likely treated
by the specialists.

53

Specialists (oral surgeons, periodontists, and prosthodontists) were involved in implant dentistry
for a longer period of time compared to general dentists. The differences were particularly
pronounced when examining specialists involvement in implant dentistry over a period of
greater than 20 years. In fact, almost half of oral surgeons and prosthodontists, one fifth of
periodontists, but only one tenth of general dentists had been involved in implant dentistry for
over 20 years. This is likely a reflection of the evolution of implant dentistry as it passed from
being principally within the realm of the specialist practice to the general practice. While oral
surgeons and prosthodontist were the first clinicians to become involved heavily in implant
dentistry (129), general dentists now provide an increasingly large portion of dental implant
services.

Not only did specialists tend to be involved in implant dentistry for a longer period of time, but
the individual specialists also tended to treat more implant-related patients. Only 3.3% of
general dentists treated more than 10 implant-related patients in a typical month of 2009. At the
same time, 40.0% of oral surgeons, 47.1% of periodontists, and 26.7% of prosthodontists treated
more than 10 implant-related patients per month. Among dentists who performed surgical
implant placement, the individual specialists also tended to place many more implants than the
general dentists. In fact, only 8.8% of general dentists placed more than 10 implants in a typical
month of 2009. At the same time, 64.5% of oral surgeons, 46.9% of periodontists, and 25.0% of
prosthodontists placed more than 10 implants per month. Greater involvement of specialists in
surgical implant placement in this survey is in agreement with a 2006 survey of US dentists,
which reported that annually the specialists placed an average of 99 implants and the general
dentists placed only 32 (93). Among dentists who restored implants, specialists (and especially
prosthodontists) tended to be more heavily involved in the restoration of implants. Only 5.2% of
general dentists but 35.7% of prosthodontists restored more than 10 implants in a typical month
of 2009. However, overall the size of implant-related practices was small in 2009. Most dentists
saw 10 or fewer implant-related patients per month (89.5% of dentists), surgically placed 10 or
fewer implants per month (88.0% of dentists), and restored 10 or fewer implants per month
(94.0% of dentists).

54

Chapter 6
Complications and Corrective Actions
6.A: Surgical complications results
Table 6.1: Surgical complications reported by survey responders (N=419) in 2009
Surgical complications
lack of primary implant stability
aborted surgical site
sinus membrane perforation (during a direct
sinus lift procedure)
surgical stent unusable
significant thread exposure
incision line opening
temporary paraesthesia
limited patient opening
cover screw or healing abutment not fully
seated
treatment not prosthetically driven
significant bleeding
wrong brand used (other than what was
requested by the referring dentist)
severe post-operative infection
implant fracture during placement
damage to adjacent tooth
permanent paraesthesia
implant dislodged into the sinus
no complications
other (specify)
Total*

116
77

Percentage of cases (N=419)

(%)
27.7
18.4

69

16.5

63
63
54
48
47

15.0
15.0
12.9
11.5
11.2

47

11.2

44
25

10.5
6.0

22

5.3

12
11
10
8
6
196
46
964

2.9
2.6
2.4
1.9
1.4
46.8
11.0
230.1

*Note: This is a multiple-response question. The total of all responses is more than 100%.

Among survey responders, 53.2% encountered a surgical complication in 2009 (Table 6.1). The
following surgical complications were reported by the largest number of dentists (the number in
brackets is the percentage of dentists who reported this complication) lack of primary implant
stability (27.7%), need to abort the surgical site (18.4%), and sinus perforation (16.5%). The
following surgical complications were reported by the smallest number of dentists damage to
adjacent tooth (2.4%), permanent paraesthesia (1.9%), and implant dislodgement into the sinus
(1.4%). (Note that in the actual survey the participants were asked if they experienced,

55

managed, or treated complications, alluding to the fact that in addition to experiencing

complications as a consequence of the treatment they provided, dentists may also be dealing with
complications that were referred to them for treatment or management. In the interests of
brevity, the verbs experienced, encountered, or reported will be used singly in this thesis
to describe complications that participants experienced, managed, or treated.) Dentists who
experienced surgical complications (419-196=223) checked off a total of 768 responses (964196=768) to this multiple-response question. Hence, on average, dentists who actually
experienced surgical complications experienced 3.4 different types of surgical complications in
2009.

56

Table 6.2: Surgical complications reported by each professional group in 2009

surgical complications

general
dentists
61
18.3^
43
12.9^
19
5.7
21
6.3
23
6.9
22
6.6
19
5.7
22
6.6
27
8.1
31
9.3^
12
3.6
12
3.6
6
1.8
2
0.6
5
1.5
4
1.2
2
0.6
184
55.1
37
11.1
334

oral
surgeons
22
71.0^
10
32.3
25
80.6^
19
61.3
23
74.2^
13
41.9
14
45.2
11
35.5
12
38.7
4
12.9
6
19.4
3
9.7
3
9.7
6
19.4
1
3.2
3
9.7
0
0.0
2
6.5
4
12.9
31

period
ontists
26
70.3^
21
56.8
23
62.2^
22
59.5^
13
35.1
12
32.4
12
32.4
13
35.1
6
16.2
4
10.8
7
18.9
5
13.5
2
5.4
2
5.4
3
8.1
0
0.0
1
2.7
3
8.1
2
5.4
37

prostho
dontists
7
41.2^
3
17.6
2
11.8
1
5.9
4
23.5
7
41.2^
3
17.6
1
5.9
2
11.8
5
29.4^
0
0.0
2
11.8
1
5.9
1
5.9
1
5.9
1
5.9
3
17.6
7
41.2
3
17.6
17

total

2 PValue

n
116
<0.001*
%
n
77
aborted surgical site
<0.001*
%
n
69
<0.001*
sinus membrane perforation (during a
direct sinus lift procedure)
%
n
63
<0.001*
surgical stent unusable
%
n
63
<0.001*
significant thread exposure
%
n
54
<0.001*
incision line opening
%
n
48
<0.001*
temporary paraesthesia
%
n
47
<0.001*
limited patient opening
%
47
<0.001*
cover screw/healing abutment not fully n
seated
%
n
44
treatment not prosthetically driven
0.066
%
n
25
significant bleeding
<0.001*
%
22
wrong brand used (other than what was n
0.022*
requested by the referring dentist)
%
n
12
severe post-operative infection
0.047*
%
n
11
implant fracture during placement
<0.001*
%
n
10
damage to adjacent tooth
0.062
%
n
8
permanent paraesthesia
0.005*
%
n
6
implant dislodged into the sinus
<0.001*
%
n
196
no complications
<0.001*
%
n
46
other (specify)
0.558
%
n
419
total
%
Note: 1) * indicates statistical significance among the four professional groups for a specific option.
lack of primary implant stability

2) ^ indicates the top three reported complications within each professional group.

57

A significant percentage of general dentists (55.1%) and prosthodontists (41.2%) did not
experience any surgical complications in 2009 (Table 6.2), while only a small percentage of oral
surgeons (6.5%) and periodontists (8.1%) did not experience any surgery-related complications.
The following complications were reported by the largest number of general dentists lack of
primary implant stability (18.3%), need to abort a surgical site (12.9%), and lack of prosthetic
treatment plan (9.3%) (Table 6.2). The following complications were reported by the largest
number of oral surgeons sinus membrane perforation (during a direct sinus lift procedure)
(80.6%), significant thread exposure (74.2%), and lack of primary implant stability (71.0%).
The following complications were reported by the largest number of periodontists lack of
primary implant stability (70.3%), sinus membrane perforation (during a direct sinus lift
procedure) (62.2%), and poor surgical stent design (59.5%). The following complications were
reported by the largest number of prosthodontists lack of primary implant stability (41.2%),
incision line opening (41.2%), and lack of prosthetic treatment plan (29.4%). There was a
statistically significant difference in the experience of all commonly mentioned complications
among the four professional groups.

A much more significant proportion of oral surgeons and periodontists experiences specific
surgical complications compared to general dentists and prosthodontists (Table 6.2). None of the
specific surgical complications were experienced by more than 18.3% of general dentists or by
more than 40.2% of prosthodontists, while four surgical complications (including lack of primary
implant stability, sinus membrane perforation, and poor surgical stent design) were experienced
by more than 50% of oral surgeons and periodontists.

58

6.B: Prosthodontic complications results

Table 6.3: Prosthodontic complications reported by survey responders (N=435) in 2009
Prosthodontic complications
healing abutment loosening
poor implant position
prosthesis loosening or dislodgement
limited interocclusal clearance for restoration
resin/acrylic/porcelain fracture
implant-supported overdenture clip loosening
cement extrusion
unable to fully seat impression coping or
prosthesis
incorrect impression taken (or had to repeat
impression)
prosthetic screw fracture
prosthesis failure
prosthetic or abutment screw head striping
implant is non-restorable
implant fracture during function
implant-supported overdenture clip fracture
no complications
other (specify)
Total*

172
171
161
84
79
65
62

Percentage of cases (N=435)

(%)
39.5
39.3
37.0
19.3
18.2
14.9
14.3

55

12.6

54

12.4

54
45
27
20
17
13
96
26
1201

12.4
10.3
6.2
4.6
3.9
3.0
22.1
6.0
276.1

*Note: This is a multiple-response question. The total of all responses is more than 100%.

Among the survey responders, 22.1% did not experience any prosthodontic complications in
2009 (Table 6.3). The following prosthodontic complications were reported by the largest
number of dentists (the number in brackets is the percentage of dentists who reported this
complication) healing abutment loosening (39.5%), poor implant position (39.3%), and
prosthesis loosening or dislodgement (37.0%). The following prosthodontic complications were
reported by the smallest number of dentists implant is non-restorable (4.6%), implant fracture
during function (3.9%), and implant-supported overdenture clip fracture (3.0%). Dentists who
experienced prosthodontic complications (435-96=339) checked off a total of 1105 responses
(1201-96=1105) to this multiple-response question. Hence, on average, dentists who actually
experienced prosthodontic complications experienced 3.2 different types of prosthodontic
complications in 2009.

59

Table 6.4: Prosthodontic complications reported by each professional group in 2009

Prosthodontic complications
healing abutment loosening
poor implant position
prosthesis loosening or dislodgement
limited interocclusal clearance for
restoration
resin/acrylic/porcelain fracture
implant-supported overdenture clip
loosening
cement extrusion
unable to fully seat impression coping
or prosthesis
incorrect impression taken (or had to
repeat impression)
prosthetic screw fracture
prosthesis failure
prosthetic or abutment screw head
stripping
implant is non-restorable
implant fracture during function
implant-supported overdenture clip
fracture
no complications
other (specify)
Total

n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n

general
dentists
133
37.3^
152
42.6^
140
39.2^
76
21.3
66
18.5
53
14.8
52
14.6
50
14.0
47
13.2
38
10.6
37
10.4
19
5.3
15
4.2
11
3.1
8
2.2
70
19.6
24
6.7
357

oral
surgeons
14
56.0^
2
8.0
1
4.0
1
4.0
0
0.0
0
0.0
3
12.0^
0
0.0
2
8.0
5
20.0^
2
8.0
1
4.0
1
4.0
2
8.0
0
0.0
10
40.0
0
0.0
25

period
ontists
15
42.9^
5
14.3
9
25.7^
2
5.7
1
2.9
3
8.6
6
17.1^
1
2.9
2
5.7
6
17.1^
3
8.6
3
8.6
0
0.0
2
5.7
0
0.0
15
42.9
2
5.7
35

prostho
dontists
10
55.6
12
66.7^
11
61.1^
5
27.8
12
66.7^
9
50.0
1
5.6
4
22.2
3
16.7
5
27.8
3
16.7
4
22.2
4
22.2
2
11.1
5
27.8
1
5.6
0
0.0
18

2 PValue

total
172
171
161
84
79
65

0.127
<0.001*
<0.001*
0.022*
<0.001*
<0.001*

62
55

0.686
0.033*

54

0.498

54

0.073

45
27
20

0.791
0.030*
0.002*

17
13
96

0.207
<0.001*
0.001*

26

0.378

435

According to the survey, 42.9% of periodontists, 40.0% of oral surgeons, 19.6% of general
dentists, and only 5.6% of prosthodontists did not experience any prosthodontic complications in
2009 (Table 6.4). The following complications were reported by the largest number of general
dentists poor implant positioning (42.6%), prosthesis loosening or dislodgement (39.2%), and
healing abutment loosening (37.3%). The following complication were reported by the largest
number of oral surgeons healing abutment loosening (56.0%), prosthetic screw fracture

60

(20.0%), and cement extrusion (12.0%). The following complications were reported by the
largest number of periodontists healing abutment loosening (42.9%), prosthesis loosening or
dislodgement (25.7%), prosthetic screw fracture (17.1%), and cement extrusion (17.1%). The
following complications were reported by the largest number of prosthodontists poor implant
positioning (66.7%), resin/acrylic/porcelain fracture (66.7%), and prosthesis loosening or
dislodgement (61.1%).

Among the commonly mentioned prosthetic complications (Table 6.4), there were no statistically
significant differences in the experience of the following complications among the four
professional groups healing abutment loosening (2 p-value=0.127), prosthetic screw fracture
(2 p-value=0.073), and cement extrusion (2 p-value=0.686). However, among the commonly
mentioned prosthetic complications, there were statistically significant differences in the
experience of the following complications among the four professional groups poor implant
position (2 p-value<0.001), resin/acrylic/porcelain fracture (2 p-value<0.001), and prosthesis
loosening or dislodgment (2 p-value<0.001).

A more significant proportion of prosthodontists was exposed to prosthodontic complications

compared to other specialists and general dentists (Table 6.4). Five complications were reported
by 50% or more of prosthodontists, while only one complication was reported by more than 50%
of oral surgeons, and none were reported by more than 50% of general dentists and periodontists.
In fact, if the complication of healing abutment loosening or dislodgement were disregarded
from the analysis, then prosthodontic complications are revealed to be experienced by relatively
small percentages of surgical specialists. The second most commonly reported prosthodontic
complications (after healing abutment loosening or dislodgement) were prosthetic screw
fracture (reported by only 20.0% of oral surgeons) and prosthesis loosening and dislodgment
(reported by 25.7% of periodontists).

61

6.C: Biological complications results

Table 6.5: Biological complications reported by survey responders (N=433) in 2009
Biological complications
implant failure
gingival inflammation
healing abutment too short (leading to soft
tissue overgrowth)
recession (implant collar or abutment visible)
no interproximal papilla (must be clinically
significant)
severe continuous bone loss
multiple implant failures in the same patient
presence of a fistula
bisphosphonate-related osteonecrosis of the
jaws
mandibular fracture
no complications
other (specify)
Total*

167
124

Percentage of cases (N=433)

(%)
38.6
28.6

121

27.9

109

25.2

100

23.1

96
54
47

22.2
12.5
10.9

0.7

1
124
8
954

0.2
28.6
1.8
220.3

*Note: This is a multiple-response question. The total of all responses is more than 100%.

According to the survey, 28.6% of responders did not experience any biological complications in
2009 (Table 6.5). The following biological complications were reported by the largest number
of dentists (the number in brackets is the percentage of dentists who reported this complication)
implant failure (38.6%), gingival inflammation (28.6%), and healing abutment being too short
(leading to soft tissue overgrowth) (27.9%). The following biological complications were
reported by the smallest number of dentists presence of a fistula (10.9%), bisphosphonaterelated osteonecrosis of the jaw (0.7%), and mandibular fracture (0.7%). Dentists who
experienced biological complications (433-124=309) checked off a total of 830 responses (954124=830) to this multiple-response question. Hence, on average, dentists who actually
experienced biological complications experienced 2.6 different types of biological complications
in 2009.

62

Table 6.6: Biological complications experienced by each professional group in 2009

Biological complications
implant failure
gingival inflammation
healing abutment too short (leading to
soft tissue overgrowth)
recession (implant collar or abutment
visible)
no interproximal papilla (must be
clinically significant)
severe continuous bone loss
multiple implant failures in the same
patient
presence of a fistula
bisphosphonate-related osteonecrosis
of the jaws
mandibular fracture
no complications
other (specify)
Total

n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n

general
dentists
113
32.2^
89
25.4^
75
21.4
76
21.7^
65
18.5
50
14.2
30
8.5
26
7.4
1
0.3
0
0.0
119
33.9
7
2.0
351

oral
surgeons
22
73.3^
16
53.3
19
63.3^
12
40.0
14
46.7
19
63.3^
11
36.7
8
26.7
1
3.3
0
0.0
1
3.3
0
0.0
30

period
ontists
24
68.6^
13
37.1
16
45.7^
13
37.1
10
28.6
18
51.4^
9
25.7
10
28.6
1
2.9
0
0.0
2
5.7
1
2.9
35

prostho
dontists
8
47.1
6
35.3
11
64.7^
8
47.1
11
64.7^
9
52.9^
4
23.5
3
17.6
0
0.0
1
5.9
2
11.8
0
0.0
17

2 PValue

total
167
124
121
109
100
96
54
47
3
1
124
8

<0.001*
0.006*
<0.001*
0.005*
<0.001*
<0.001*
<0.001*
<0.001*
0.094
<0.001*
<0.001*
0.772

433

Almost all specialists (oral surgeons, periodontists, and prosthodontists) experienced a biological
complication, while only 66.1% of general dentists experienced a biological complication in
2009 (Table 6.6). Among general dentists, the following biological complications were reported
most commonly implant failure (32.2%), gingival inflammation (25.4%), and recession around
an implant (21.7%). Among oral surgeons, the following biological complications were reported
most commonly implant failure (73.3%), healing abutment being too short (63.3%), and severe
continuous bone loss (63.3%). Among periodontists, the following biological complications
were reported most commonly implant failure (68.6), severe continuous bone loss (51.4%), and
healing abutment being too short (45.7%). Among prosthodontists, the following biological
complications were reported most commonly no interproximal papillae (64.7%), healing
abutment being too short (64.7%), and severe continuous bone loss (52.9%). There was a

63

statistically significant difference in the experience of all commonly reported biological

complications among the four professional groups (Table 6.6).

A much larger proportion of specialists reported biological complications compared to general

dentists (Table 6.6). None of the biological complications were reported by more than 50% of
general dentists (the most commonly reported biological complications was implant failure
reported by 32.2% of general dentists). By contrast, four biological complications were reported
by more than 50% of oral surgeons, two biological complications were reported by more than
50% of periodontists, and three biological complications were reported by more than 50% of
prosthodontists.

6.D: Patient-related complications results

Table 6.7: Patient-related complications reported by survey responders (N=397) in 2009
Patient-related complications

patient complaint of food impaction

slight patient dissatisfaction with aesthetics
ability to clean prosthesis impaired
patient cannot get used to prosthesis (poor
comfort)
speech impaired with prosthesis
significant patient dissatisfaction with aesthetics
aspiration or ingestion
no complications
other (specify)
Total*

120
96
56

Percentage of cases (N=397)

(%)
30.2
24.2
14.1

24

6.0

21
16
6
190
16
545

5.3
4.0
1.5
47.9
4.0
137.3

*Note: This is a multiple-response question. The total of all responses is more than 100%.

According to the survey, 47.9% of responders did not experience a patient-related complication
in 2009 (Table 6.7). The following patient-related complications were reported by the largest
number of dentists (the number in brackets is the percentage of dentists who reported this
complication) patient complaint of food impaction (30.2%), slight patient dissatisfaction with
aesthetics (24.2%), and impaired ability to clean prosthesis (14.1%). The following patientrelated complications were reported by the smallest number of dentists speech impaired with
the final prosthesis (5.3%), significant patient dissatisfaction with aesthetics (4.0%), and

64

aspiration or ingestion (1.5%). Dentists who experienced patient-related complications (397190=207) checked off a total of 355 responses (545-190=355) to this multiple-response question.
Hence, on average, dentists who actually experienced patient-related complications experienced
1.7 different types of patient-related complications in 2009.

Table 6.8: Patient-related complications reported by each professional group in 2009

Patient-related complications
patient complaint of food impaction
slight patient dissatisfaction with
aesthetics
ability to clean prosthesis impaired
patient cannot get used to prosthesis
(poor comfort)
speech impaired with prosthesis
significant patient dissatisfaction with
aesthetics
aspiration or ingestion
no complications
other (specify)
Total

n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n

general
dentists
89
27.6^
69
21.4^
39
12.1^
16
5.0
12
3.7
7
2.2
3
0.9
165
51.2
14
4.3
322

oral
surgeons
6
23.1^
8
30.8^
4
15.4^
2
7.7
1
3.8
2
7.7
0
0.0
13
50.0
1
3.8
26

period
ontists
16
47.1^
11
32.4^
7
20.6^
4
11.8
3
8.8
3
8.8
2
5.9
9
26.5
0
0.0
34

prostho
dontists
9
60.0^
8
53.3^
6
40.0^
2
13.3
5
33.3
4
26.7
1
6.7
3
20.0
1
6.7
15

total
120
96
56
24
21
16
6
190
16

2 PValue
0.006*
0.017*
0.014*
0.247
<0.001*
<0.001*
0.043*
0.006*
0.619

397

Among the survey responders, 51.2% of general dentists, 50.0% of oral surgeons, 26.5% of
periodontists and 20.0% of prosthodontists did not experience a patient-related complication in
2009 (Table 6.8). General dentists reported the following complications most commonly
patient complaint of food impaction (27.6%), slight patient dissatisfaction with aesthetics
(21.4%), and impaired ability of clean prosthesis (12.1%). Oral surgeons reported the following
complications most commonly slight patient dissatisfaction with aesthetics (30.8%), patient
complaint of food impaction (23.1%), and impaired ability to clean prosthesis (15.4%).
Periodontists reported the following complications most commonly patient complaint of food
impaction (47.1%), slight patient dissatisfaction with aesthetics (32.4%), and impaired ability to
clean prosthesis (20.6%). Prosthodontists reported the following complications most commonly

65

patient complaint of food impaction (60.0%), slight patient dissatisfaction with aesthetics
(53.3%), and impaired ability to clean prosthesis (40.0%). There was a statistically significant
difference in the experience of almost all patient-related complications among the four
professional groups. The complication of patient cannot get used to the final prosthesis
(comfort impaired) was the only exception (2 p-value=0.247).

66

6.E: Complications reported by each professional group results

The same data on complications that has already been presented in Tables 6.1 through 6.8 with
the focus on each of the four types of complications can be reorganized to focus on each of the
four professional groups. Tables 6.9 through 6.13 will present the 20 most common
complications reported by each of the four professional groups.

Table 6.9: Top 20 complications reported by the largest percentage of general dentists in
2009
type of complication
prosthodontic
prosthodontic
prosthodontic
biological
patient-related
biological
biological
biological
patient-related
prosthodontic
biological
prosthodontic
surgical
prosthodontic
prosthodontic
biological
prosthodontic
prosthodontic
surgical
patient-related

specific complication
poor implant position
prosthesis loosening
healing abutment loosening or dislodgement
implant failure
patient complaint of food impaction
gingival inflammation
recession around implant or abutment
healing abutment too short (leading to soft tissue overgrowth)
slight patient dissatisfaction with aesthetics
limited interocclusal space for restoration
no interproximal papilla (must be clinically significant)
resin/acrylic/porcelain fracture
lack of primary implant stability
implant-supported overdenture clip loosening
cement extrusion
severe continuous bone loss
unable to fully seat restoration
incorrect impression taken
aborted surgical site
ability to clean prosthesis impaired

percentage of
general
dentists (%)
42.6
39.2
37.3
32.2
27.6
25.4
21.7
21.4
21.4
21.3
18.5
18.5
18.3
14.8
14.6
14.2
14.0
13.2
12.9
12.1

Overall, the following complications were reported by the largest percentage of general dentists
in 2009 (the number in brackets is the percentage of general dentists who reported this
complication) poor implant position (42.6%), prosthesis loosening or dislodgement (39.2%),
and healing abutment loosening (37.3%) (Table 6.9). None of the complications were reported
by more than 50% of general dentists. Only 2 of the top 20 complications reported by the largest

67

percentage of general dentists were surgical complications, and none of these were in the top 10.
In the top 20 complications reported by the largest percentage of general dentists, there were 9
prosthodontic, 6 biologic, 3 patient-related, and 2 surgical complications.

Table 6.10: Top 20 complications reported by the largest percentage of oral surgeons in
2009
type of complication
surgical
surgical
biological
surgical
biological
biological
surgical
prosthodontic
biological
biological
surgical
surgical
biological
surgical
biological
surgical
surgical
patient-related
biological
patient-related

specific complication
sinus membrane perforation (during a direct sinus lift procedure)
significant thread exposure
implant failure
lack of primary implant stability
healing abutment too short
severe continuous bone loss
surgical stent unusable
healing abutment loose
gingival inflammation
no interproximal papilla (must be clinically significant)
temporary paraesthesia
incision line opening
recession around implant or abutment
cover screw of healing abutment not fully seated
multiple implant failure in the same patient
limited patient opening
aborted surgical site
slight patient dissatisfaction with aesthetics
fistula
patient complaint of food impaction

percentage of
oral surgeons
(%)
80.6
74.2
73.3
71.0
63.3
63.3
61.3
56.0
53.3
46.7
45.2
41.9
40.0
38.7
36.7
35.5
32.3
30.8
26.7
23.1

Overall, the following complications were experienced by the largest percentage of oral surgeons
in 2009 (the number in brackets is the percentage of oral surgeons who experienced this
complication) sinus perforation (80.6%), significant thread exposure (74.2%), and implant
failure (73.3%) (Table 6.10). Nine complications were reported by more than 50% of oral
surgeons. Oral surgeons experienced mostly surgical and biological complications there were
only 3 other complications in the top 20 complications reported by the largest number of oral
surgeons, and only 1 in the top 10. In the top 20 complications reported by the largest number of

68

oral surgeons, there were 9 surgical, 1 prosthodontic, 8 biologic, and 2 patient-related

complications.

69

Table 6.11: Top 20 complications reported by the largest percentage of periodontists in

2009
type of complication
surgical
biological
surgical
surgical
surgical
biological
patient-related
biological
prosthodontic
biological
biological
surgical
surgical
patient-related
surgical
surgical
biological
biological
prosthodontic
biological

specific complication
lack of primary implant stability
implant failure
sinus membrane perforation (during a direct sinus lift procedure)
surgical stent unusable
aborted surgical site
severe continuous bone loss
patient complaint of food impaction
healing abutment too short
healing abutment loose
recession around implant or abutment
gingival inflammation
significant thread exposure
limited patient opening
slight patient dissatisfaction with aesthetics
incision line opening
temporary paraesthesia
no interproximal papilla
fistula
prosthesis loosening or dislodgement
multiple implant failure in the same patient

percentage of
periodontists
(%)
70.3
68.6
62.2
59.5
56.8
51.4
47.1
45.7
42.9
37.1
37.1
35.1
35.1
32.4
32.4
32.4
28.6
28.6
25.7
25.7

The following complications were experienced by the largest percentage of periodontists in 2009
(the number in brackets indicates the percentage of periodontists who experienced this
complication) lack of primary implant stability (70.3%), implant failure (68.6%), and sinus
perforation (62.2%) (Table 6.11). Six complications were reported by more than 50% of
periodontists. In the top 20 complications reported by the largest number of periodontists, there
were 8 surgical, 2 prosthodontic, 8 biological, and 2 patient-related complications. Periodontists
experienced mostly surgical and biological complications (accounting for 16 out of the top 20
complications) there were only 4 other complications in the top 20 complications reported by
the largest percentage of periodontists, and 2 in the top 10.

70

Table 6.12: Top 20 complications reported by the largest percentage of prosthodontists in

2009
type of complication
prosthodontic
prosthodontic
biological
biological
prosthodontic
patient-related
prosthodontic
patient-related
biological
prosthodontic
biological
biological
surgical
surgical
patient-related
biological
patient-related
surgical
prosthodontic
prosthodontic

specific complication
poor implant position
resin/acrylic/porcelain fracture
healing abutment too short
no interproximal papilla (must be clinically significant)
prosthesis loosening
patient complaint of food impaction
healing abutment loose
slight patient dissatisfaction with aesthetics
severe continuous bone loss
implant-supported overdenture clip loosening
implant failure
recession around implant or abutment
lack of primary implant stability
incision line opening
ability to clean prosthesis impaired
gingival inflammation
speech impaired with prosthesis
treatment not prosthetically driven
prosthetic screw fracture
limited interocclusal space for restoration

percentage of
prosthodontists
(%)
66.7
66.7
64.7
64.7
61.1
60.0
55.6
53.3
52.9
50.0
47.1
47.1
41.2
41.2
40.0
35.3
33.3
29.4
27.8
27.8

The following complications were reported by the largest percentage of prosthodontists in 2009
(the number in brackets is the percentage of prosthodontists who experienced this complication)
poor implant position (66.7%), veneering material fracture (66.7%), and healing abutment
being too short (64.7%) (Table 6.12). Ten complications were reported by 50% or more of
prosthodontists. Only 3 of the top 20 complications reported by the largest number of
prosthodontists were surgical complications, and none of these were in the top 10. In the top 20
complications reported by the largest number of prosthodontists, there were 3 surgical, 7
prosthodontic, 6 biological, and 4 patient-related complications.

71

6.F: Corrective actions taken in response to complications results

Table 6.13: Corrective actions taken by survey responders (N=424) in 2009 in response to
complications
Corrective actions
communicated (consulted) with another
professional about an issue with the case
increased length of treatment
retook impression
remade prosthesis
performed additional surgical procedure(s)
dealt with patient's dissatisfaction
referred patient to a specialist
trephined (removed) the implant
submerged the implant (put it to sleep)
increased fee for treatment
contacted PLP (Professional Liability Program)
none
total*

Percent of cases (N=424)

(%)

260

61.3

202
124
112
107
103
50
40
24
20
13
63
1118

47.6
29.2
26.4
25.2
24.3
11.8
9.4
5.7
4.7
3.1
14.9
263.7

*Note: This is a multiple-response question. The total of all responses is more than 100%.

Only 14.9% of survey responders indicated that they did not undertake any corrective actions in
response to a complication in 2009 (Table 6.13). The following corrective actions were reported
by the largest number of dentists (the number in brackets is the percentage of dentists who
reported taking this corrective action) communicated with another professional about an issue
with the case (61.3%), increased treatment length (47.6%), and retook impression (29.2%). The
following corrective actions were reported by the smallest number of dentists submerged the
implant (put it to sleep) (5.7%), increased fee (4.7%), and contacted PLP (3.1%).

72

Table 6.14: Corrective actions taken by each professional group in 2009

Corrective actions
communicated (consulted) with
another professional about an issue
with the case
retook impression
remade prosthesis
trephined (removed) the implant
submerged the implant (put it to
sleep)
performed additional surgical
procedure(s)
increased length of treatment
increased fee for treatment
dealt with patient's dissatisfaction
contacted PLP (Professional Liability
Program)
referred patient to a specialist
none
Total

general
dentists
n 223
% 65.4^

oral
surgeons
8
26.7

period prostho
total
ontists dontists
17
12
260
47.2^
70.6^

n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n

0
0.0
0
0.0
13
43.3^
6
20.0
23
76.7^
20
66.7^
2
6.7
11
36.7
2
6.7
0
0.0
3
10.0
30

2
5.6
4
11.1
9
25.0
2
5.6
28
77.8^
27
75.0^
2
5.6
12
33.3
6
16.7
0
0.0
2
5.6
36

113
33.1
100
29.3^
16
4.7
14
4.1
52
15.2
141
41.3^
9
2.6
74
21.7
5
1.5
48
14.1
55
16.1
341

9
52.9^
8
47.1
2
11.8
2
11.8
4
23.5
14
82.4^
7
41.2
6
35.3
0
0.0
2
11.8
3
17.6
17

124
112
40
24
107
202
20
103
13
50
63

2 PValue
<0.001*
<0.001*
<0.001*
<0.001*
0.003*
<0.001*
<0.001*
<0.001*
0.091
<0.001*
0.015*
0.313

424

According to the survey, 16.1% of general dentists, 10.0% of oral surgeons, 5.6% of
periodontists, 17.6% of prosthodontists did not undertake any corrective actions in response to a
complication in 2009 (Table 6.14). Most general dentists reported taking the following
corrective actions communicated with another professional about an issue with treatment
(65.4%), increased treatment length (41.3%), and remade prosthesis (29.3%). Most oral
surgeons reported taking the following corrective actions performed additional surgery
(76.7%), increased treatment length (66.7%), and trephined (removed) an implant (43.3%). Most
periodontists reported taking the following corrective actions performed additional surgery
(77.8%), increased treatment length (75.0%), and communicated with another professional about
an issue with treatment (47.2%). Most prosthodontists reported taking the following corrective

73

actions increased treatment length (82.4%), communicated with another professional about an
issue with treatment (70.6%), and retook impression (52.9%).

There was a statistically significant difference in the utilization of almost all corrective actions
among the four professional groups (Table 6.14). The only exception related to dealing with
patients dissatisfaction (2 p-value=0.091), where a relatively similar percentage of all four
professional groups reported undertaking this corrective action in 2009.

74

6.G: Complications and corrective actions discussion

6.G.I: Surgical complications discussion
The lack of primary implant stability was the most widely reported surgical complication.
Primary stability is an important determinant of future implant success (38, 74) and is a key
determinant in advanced implant treatment approaches such as immediate placement and
immediate loading (130). Lack of primary stability makes the implant unsuitable for immediate
placement or immediate loading applications, and necessitates a submerged (two-stage) approach
to avoid micromotion trauma. In type IV bone (131) and with short implants, primary stability
can be especially hard to achieve, and high failure rates have been reported previously with
classic protocols in these scenarios (132). However, more contemporary approaches with
modified surgical protocols advocating under-preparing the osteotomy and involving the use of
osteotomes to compress the bone have been shown to yield comparable results even in type IV
bone (133). The same surgical principles have been utilized successfully to ensure primary
stability and successful integration of short implants (134, 135).
Having to abort surgical site (after attempting unsuccessfully to place an implant) was the
second most widely reported surgical complication. This complication can be related to the
inability to achieve primary stability (which was the most commonly mentioned surgical
complication, as discussed above), but can also be related to errors in osteotomy preparation,
significant loss of adjacent osseous plates, and bone of poor quality.

Miscommunication (or lack of communication between various treatment providers) has been
recognized as a significant component of some complications related to implant therapy (119).
The concept of prosthetically-driven treatment emphasizes that the purpose of osseointegrated
implants is to provide support or retention to the prostheses, and hence the implants position
must permit these functions to be carried out successfully. Problems can arise when implant
placement proceeds without prosthodontic reconstruction in mind, either because prosthodontic
input is not obtained (i.e., treatment is not prosthetically driven) or because prosthodontic input

75

is not communicated in a manner that is usable during the surgical phase (i.e., surgical stent is
unusable). The experiences relating to the miscommunication differed among the four
professional groups responding to this survey. A significant proportion of general dentists and
prosthodontists reported treatment not being prosthetically driven as a complication (the third
most common complication for both professional groups). By contrast, only a minority of
surgical specialists (oral surgeons and periodontists) reported this complication in the survey. At
the same time, surgical stent is unusable was reported by 60% of surgical specialists (who are
the end-users of the surgical guides), but by less than 10% of general dentists and prosthodontists
(who tend to fabricate the surgical guides). These observations may echo the occasional lack of
communication between those involved in the surgical and prosthodontic phases of therapy, as
well as the lack of understanding about the limitations and challenges of each of the treatment
phases (surgical and prosthodontic).

6.G.II: Prosthodontic complications discussion

The top three prosthodontic complications reported by the largest number of dentists included
healing abutment loosening, poor implant position, and prosthesis loosening or dislodgement.
Dentists reported these three complications almost twice as often as they did any other
prosthodontic complication. Healing abutment loosening or dislodgement is a frequently
occurring complication that is usually easily remedied but may require a very minor surgical
intervention. The frequency of this complication has not been reported commonly in the
literature. Inadequate tightening of the healing abutment, incomplete seating of the healing
abutment (usually, due to hard or soft tissue interference or impingement), and interference from
a removable prosthesis or opposing teeth are the most likely factors to account for the loosening
of healing abutments.

Poor implant position is an umbrella term for departures from the ideal prosthetically-determined
implant position in the mesio-distal, bucco-lingual, or apico-coronal orientation. Severe cases of
implant malposition usually involve significant departures from the ideal position or departures
in more than one of the orientations noted above. The most difficult implant malpositions to
resolve successfully prosthetically are those with implants angled too buccally and positioned too
buccally and too shallowly simultaneously. In very severe situations, an implant might be

76

judged to be non-restorable and might have to be removed, repositioned surgically (136), or not
included in the final prosthesis. A much smaller percentage of dentists reported experiencing a
non-restorable implant (4.6%) compared to the percentage of dentists who reported experiencing
a poorly positioned implant (39.3%). This indicates that while poor implant position is a
significant issue, it can usually be resolved by virtue of prosthetic ingenuity and patient
adaptability.

Prosthesis loosening is a well-known complication and one whose management may range from
trivial to severe. Prosthesis loosening due to screw loosening is usually a function of excessive
forces on the prosthesis, improper use of torque driver for screw tightening, and poor joint and
screw function (72). Prosthesis loosening of cement-retained prostheses is usually due to
excessive forces on the prosthesis, poor abutment-prosthesis interface design, and use of
temporary cements. Estimates of the frequency of these occurrences vary, but prosthesis
loosening has consistently been reported as being one of the most frequent prosthodontic
complications of fixed prostheses (1-3, 57). A 2008 systematic review of single implantsupported restorations concluded that screw loosening occurred with the cumulative incidence of
12.7% after 5 years, while loss of retention due to fracture of luting cement occurred with the
cumulative incidence of 5.5% after 5 years (2). A 2004 systematic review of fixed partial
dentures supported by implants concluded that screw loosening occurred with the cumulative
incidence of 5.8% after 5 years, while loss of retention due to fracture of luting cement occurred
with the cumulative incidence of 2.9% after 5 years (3). As suggested in Section 3.D, the
occurrence of this complication may be less frequent nowadays than in the past. The most recent
systematic review on this topic concluded that abutment screw loosening in single-implant
restoration is a rare event regardless of the geometry of the implant-abutment connection
(external or internal), provided that proper anti-rotational features and torque are employed (72).

6.G.III: Biological complications discussion

Implant failure is one of the most consistently reported complications in the dental implant
literature (Tables 3.5 and 3.6 and Section 3.B.I) (2, 3). Implant failure along with prosthesis
failure are two of the basic benchmarks used in the vast majority of studies as primary outcome
variables. A large number of endogenous and exogenous factors have been identified as

77

causative or contributory factors to implant failure (20, 38, 74), and several theories have been
advanced to explain the mechanisms of implant failure (137, 138). Most theories focus on
infectious agents, healing deficits and loading factors to account for the clustering of implant
failures soon after implant placement (early failure) or within 1 year of loading (late failure).
Longitudinal studies have suggested repeatedly that the occurrence implant failure after two
years of placement occurs rarely (18, 20, 75). The literature seems to suggest that implant
success rates have improved in the last 30 years possibly owing to better understanding of the
biological and mechanical determinants of osseointegration as well as technological
improvements.

Implant failure is not synonymous with prosthesis failure. In this regard, large fixed
prosthodontic reconstructions are often over-engineered and allow for limited implant loss
without significant harm to the functionality of the actual reconstruction. Along these lines,
implant-supported overdentures may continue to function on a reduced number of implants. In
fact, recent research indicates that a smaller number of implants (compared to the number that is
commonly utilized) may be sufficient to support an overdenture in at least some applications
(139-141). Two other concepts related to implant treatment outcomes deserve to be mentioned
success and survival. A successful implant (142) is one that conforms to a series of
predetermined parameters. A failed implant is one that is no longer osseointegrated and, hence,
is mobile and is unable to serve its primary functions of prosthesis support and retention. A
failed implant must be removed. A surviving implant is one that does not satisfy all of the
parameters of success (e.g., by experiencing significant bone loss), but is still present in the
mouth and is still performing its prosthesis-holding role. The designation of surviving implant
does not imply a diseased state or a higher risk of future failure. It simply reflects a departure
from the set of predetermined idealized parameters (142).

6.G.IV: Patient-related complications discussion

Most problems grouped under the category of patient-related complications involve the interface
between the patient and the prosthesis fabricated for the patient. These complications may arise
due to errors in prosthesis fabrication or design, due to constraints on prosthesis design imposed
by local anatomic limitations (including malpositioned implants), or due to insufficient

78

adaptation by the patient (either due to insufficient time allotted for adaptation or due to a toodrastic a change in the transition from a provisional to a final prosthesis). It is important to
recognize that the time-dependent process of patient adaptation to the prosthesis takes place with
the insertion of all dental prostheses, including implant-supported and -retained prostheses (3436). Hence, the contributions of unrealistic patient expectations, poor dentist consent and poor
communication between the patient and treating clinician(s) can also play a role, if this period of
adaptation or its extent is not anticipated by the patient.

The most commonly reported patient-related complication among the survey responders was the
patient complaint of food impaction. This issue has received only limited attention in the
literature, and its frequency of occurrence is uncertain. In addition to the several general factors
mentioned in the preceding paragraph that can lead to patient-related complications in general,
several other scenarios can lead specifically to the complication of food impaction, including the
frequent tilting of natural teeth next to edentulous spaces where implant-supported restorations
are subsequently placed, and the fact that implant diameter tends to be narrower than the
diameter of the teeth that they replace. Both of these scenarios lead to existence of spaces
between the restoration and the adjacent natural teeth (or other restorations) where food debris
can accumulate.

6.G.V: All complication types overall discussion

Several observations suggest that while numerous complications are encountered in clinical
practice (as attested to by the results from this survey and data reported in several other studies
(1, 3, 4, 57)), severe complications are relatively rare (143). Most of the specific complications
reported in the survey by a large proportion of the survey respondents are relatively easily
managed and largely without permanent detrimental effects. On the other hand, a number of
surgical complications that are difficult to manage or are likely to result in significant patient
disability (such as severe post-operative infection, implant fracture during placement, damage to
adjacent tooth, permanent paraesthesia, and implant dislodgement into the sinus) were reported
by fewer than 3% of respondents. Similarly, among patient-related complications significant
patient dissatisfaction with aesthetics was one of the least commonly chosen complications
(4.0% of the dentists). Removal of the implant (i.e., trephining it out) and submerging of the

79

implant (i.e., putting it to sleep) were reported by a very small number of dentists, suggesting
that most implant issues are resolved in clinical practice without resorting to these last resort
measures. Similarly, PLP had been contacted by a very small percentage of dentists, suggesting
that severe complications are either encountered relatively infrequently or do not usually lead to
significant dissatisfaction by the patient.

The relative infrequency of severe complications reported in this thesis survey parallels
observations made by others (143). For example, a 7-year report on 353 patients treated at Mayo
Clinic with 1778 implants (143) revealed that although some sort of difficulty, challenge or
complication was encountered in the management of many patients, almost all were successfully
and conservatively managed. Implant-supported prosthesis use had to be permanently
discontinued in only 4 patients (who returned to the use of a conventional removable appliance).

Only a small percentage of dentists reported experiencing complications other than those listed
as options for each of the four complication categories. Only 11.0% of responders reporting
surgical complications, 6.0% of responders reporting prosthodontic complications, 1.8% of
responders reporting biologic complications, and 4.0% of responders reporting patient-related
complications selected other as an option. Furthermore, the overwhelming majority of other
responses were actually incorrect entries in the survey. Scrutiny of participants other entries
revealed that most other responses were already provided among the options but were missed
by the responders. The somewhat high 11.0% of other responses under the surgical
complications was due to dentists entering implant failure, which did not appear as an option
until the survey takers reached the question about biologic complications (four questions later).
The very small percentage of dentists selecting other signifies that most key complications
were accounted for in the survey.

As alluded to above, the proportion of dentists reporting specific complications must be viewed
in light of several factors. First, the proportion of dentists performing particular procedures
would likely have an impact on the frequency of complications reporting. For example, sinus
membrane perforation as a clinically important complication would only occur to those who
perform direct sinus lift procedures. Similarly, the large number of dentists who did not report a
surgical complication in 2009 must be considered in the context of a limited number of dentists

80

involved in the surgical phase of implant treatment (Table 5.3). Second, it must also be viewed
in light of referral patterns and the likelihood of the patient reporting a specific type of concern
to a specific professional. For example, the patient would likely bring implant-supported
overdenture looseness due to clip fracture to the attention of a general dentist or a prosthodontist
rather than to the attention of an oral surgeon or a periodontist.

There was a significant difference between the four professional groups with respect to
experience of complications. First, the four professional groups reported a different mix of
complications. General dentists and prosthodontists experienced a wide array of complications
as evidenced by a fairly even mix among the four complication categories present in the top 20
complications reported by the largest percentage of general dentists and prosthodontists. By
contrast, oral surgeons and periodontists experienced principally surgical and biological
complication categories in the top 20 complications reported by the largest percentage of oral
surgeons and periodontists. The number of biologic complications experienced was relatively
constant among the four professional groups. The more narrow range of complications
experienced by surgical specialists is possibly related to their more restrictive scope of practice.
This survey revealed that only a minority of surgical specialists were involved in the
prosthodontic phase of therapy (Table 5.3).

Second, complications were reported by different percentages of the four professional groups.
None of the specific complications were reported by more than 50% of the general dentists. The
most commonly reported complication poor implant position was reported by 42.6% of
general dentists. By contrast, 9 complications were reported by more than 50% of the oral
surgeons, 6 complications were reported by more than 50% of periodontists, and 10
complications were reported by more than 50% of prosthodontists. This difference could
indicate that specialists are exposed to and manage a wider mix of complications compared to
general dentists. This is likely due to the greater number of patients seen for implant therapy by
the individual specialists than general dentists (Table 5.4), due to the referral patterns of patients
with complications to specialists, and due to the specialists longer duration of involvement in
implant dentistry (Table 5.4) (and, hence, greater length of follow-up for treated patients). It is
also likely that patients presenting to specialists for implant treatment might have treatment
needs and problems that are more complex than those seen in patients who are selected for

81

treatment by general dentists. Readers are specifically cautioned against misinterpreting the
data as if implying that certain groups experience complications more frequently than
others. The data presented in this thesis does not allow any statements to be made with
respect to the frequency of occurrence of events.

6.G.VI: Corrective actions discussion

Corrective actions were investigated in this survey as an entity that is distinct from complications
themselves. It was thought to be important to differentiate the issues that may give rise to
corrective actions from the corrective actions themselves. Some items among the corrective
actions such as removing an implant or putting an implant to sleep were likely to be
undertaken only in response to a complication. Others such as discussing the treatment with
another clinician or referring a patient to a specialist may have been undertaken for a variety of
reasons. This potential uncertainty in interpretation was obviated by specifying within the
survey that the question on corrective actions referred specifically to actions taken in response to
a complication.

Very few dentists chose to increase fees in response to a complication in 2009. This is an
interesting finding in light of the fact that many corrective actions such as remaking the
prosthesis or conducting an additional surgical procedure are likely to require additional time
and financial commitments by the dentists. Maintaining the fees at the original pre-complication
level is possibly a deliberate strategy by the dentists to diffuse a tense situation and to keep the
patients trust and confidence. In fact, reduction or waiving of fees as a goodwill gesture is one
of the simple strategies that may help prevent or minimize patient dissatisfaction and risk of a
complaint or a lawsuit (144). By contrast, raising fees or attempting to enforce fees collection in
the context of a complication or a patients dissatisfaction with treatment are some of the reasons
suspected to contribute to the patients decision to file a lawsuit or a complaint to a regulatory
body (145-147). A review of legal cases in Israel (5) revealed that patients paying their own bills
without third-party involvement filed all the legal claims, suggesting that finances may play an
important role in the patients attitudes towards complications.

82

Chapter 7
Opinions on Complications
7.A: Causes of complications results
Table 7.1: Causes of complications chosen by survey responders (N=397)
Causes of complications
poor treatment planning
unrealistic patient expectations
lack of experience
poor patient compliance
poor inter-professional communication
compromised medical status
poor knowledge of complications
failure to refer to a professional with greater experience (not
referring to a specialist)
poor knowledge of implant concepts
poor clinical skills
treatment not prosthetically driven
company advertising portraying implant treatment as very simple
and risk-free
poor exam
ignoring dental disease elsewhere in the mouth
lack of follow up
conducting surgical procedure in an infected site
excessive implant system complexity
poor consent
failure to follow manufacturer's recommendations
Total*

286
226
191
182
167
160
150

Percent of cases
(N=397)
(%)
72.0
56.9
48.1
45.8
42.1
40.3
37.8

149

37.5

148
139
137

37.3
35.0
34.5

112

28.2

96
86
78
73
65
52
45
2542

24.2
21.7
19.6
18.4
16.4
13.1
11.3
640.3

*Note: This is a multiple-response question. The total of all responses is more than 100%.

Survey responders stated that the following were the most important underlying causes of
complications (the number in brackets is the percentage of dentists who selected the option)
poor planning (72.0%), unrealistic patient expectations (56.9%), and clinicians lack of
experience (48.1%) (Table 7.1). The following underlying causes of complications were judged
to be least important excessive complexity of the implant system (16.4%), poor consent
(13.1%), and failure to follow manufacturers recommendations (11.3%).

83

Table 7.2: Causes of complications chosen by each professional group

n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%

general
dentist
225
70.8^
170
53.5^
142
44.7
144
45.3^
132
41.5
121
38.1
105
33.0
108
34.0

oral
surgeon
27
93.1^
21
72.4^
21
72.4^
18
62.1
15
51.7
14
48.3
19
65.5
16
55.2

n
%
n
%
n
%
n
%

102
32.1
97
30.5
108
34.0
89
28.0

18
62.1
20
69.0
12
41.4
7
24.1

causes of complications
poor treatment planning
unrealistic patient expectations
lack of experience
poor patient compliance
poor inter-professional communication
compromised medical status
poor knowledge of complications
failure to refer to a professional with
greater experience (not referring to a
specialist)
poor knowledge of implant concepts
poor clinical skills
treatment not prosthetically driven
company advertising portraying
implant treatment as very simple and
risk-free

perio

prostho

total

20
57.1^
26
74.3^
17
48.6
16
45.7
9
25.7
21
60.0^
16
45.7
16
45.7

14
93.3^
9
60.0
11
73.3^
4
26.7
11
73.3^
4
26.7
10
66.7
9
60.0

286

17
48.6
13
37.1
6
17.1
14
40.0

11
73.3^
9
60.0
11
73.3^
2
13.3

148

226
191
182
167
160
150

2 PValue
0.003*
0.033*
0.007*
0.149
0.012*
0.041*
<0.001*

149
0.020*

139
137

<0.001*
<0.001*
0.002*

112
0.232

n 66
13
8
9
96
<0.001
% 20.8
44.8
22.9
60.0
n 56
13
11
6
86
ignoring dental disease elsewhere in
0.001
the mouth
% 17.6
44.8
31.4
40.0
n 58
9
3
8
78
lack of follow up
0.001
% 18.2
31.0
8.6
53.3
n 53
10
6
4
73
conducting surgical procedure in an
0.096
infected site
% 16.7
34.5
17.1
26.7
n 56
8
1
0
65
excessive implant system complexity
0.014
% 17.6
27.6
2.9
0.0
n 35
8
6
3
52
poor consent
0.053
% 11.0
27.6
17.1
20.0
failure to follow manufacturer's
n 32
4
4
5
45
0.048
recommendations
% 10.1
13.8
11.4
33.3
n 318
29
35
15
397
Total
%
Note: 1) * indicates statistical significance among the four professional groups for a specific option.
poor exam

2) ^ indicates the top three reported complications within each professional group.
3) indicates the bottom three options for each professional group.

84

General dentists (Table 7.2) stated that the most important causes of complications were poor
planning (70.8%), unrealistic patient expectations (53.5%), and poor patient compliance (45.3%).
Oral surgeons stated that the most important causes of complications were poor planning
(93.1%), clinicians lack of experience (72.4%), and unrealistic patient expectations (72.4%).
Periodontists stated that the most important causes of complications were unrealistic patient
expectations (72.4%), compromised medical status (60.0%), and poor planning (57.1%).
Prosthodontists stated that the most important causes of complications were poor planning
(93.3%), poor inter-professional communication (73.3%), poor knowledge of implant-related
concepts (73.3%), clinicians lack of experience (73.3%), and treatment not being prosthetically
driven (73.3%).

Although there was some agreement with respect to the causative importance of some options
(such as poor planning and unrealistic patient expectations both of which featured prominently
as the most important causes for the survey responders as a whole and for the individual
professional groups), there was significant disagreement among the professional groups with
respect to the causes of complications in terms of absolute percentages and the relative
importance of specific causes (Table 7.2). The differences of opinion among the four
professional groups were statistically significant (2 p-value<0.05) for 15 out of 19 potential
causes of complications. Only the following four potential causes of complications
demonstrated agreement among the four professional groups with respect to the frequency with
which they were selected conducting surgical procedure in an infected site (2 p-value=0.096),
poor consent (2 p-value=0.053), poor patient compliance (2 p-value=0.149), and company
advertising portraying implant treatment as very simple (2 p-value=0.232).

7.B: Causes of complications discussion

Very little is known about the broad underlying causes of complications related to the use of
osseointegrated implants. Although each specific complication type may have its own unique set
of causative factors, the rationale for this question was to gain an understanding of the broad

85

issues that dentists thought were important as (direct or indirect) causative or contributing agents
to the occurrence of complications, in general. In particular, it was important to include
educational, organizational, and design factors that can lead to complications rather than focus
exclusively on individual practitioners clinical judgement or manual proficiency (7). Future
investigations could build on the main themes identified in this survey and tailor them to the
particular needs of more specific research questions. However, it was essential to begin with
more general issues so that the overarching problems could be identified.

Some agreement in the relative importance of the causes of complications was observed among
the four professional groups. For example, two causes (poor planning and unrealistic patient
expectations) were observed to be consistently among the most important causes of
complications, while three causes (poor consent, failure to follow manufacturers
recommendations and excessive implant system complexity) were consistently observed to be
among the least important causes of complications. However, significant differences of opinion
(2 p-value<0.05) were observed among the four professional groups with respect to the majority
of causes of complications. This is likely due to the differences in the scope of practice related
to implant therapy (Tables 5.3 and 5.4) and the resultant differences in the types and frequency
of complications and potential causes of complications seen by the different professional groups.

Poor planning was selected as the most important cause of implant complications (Table 7.1).
This reflects the concept that poor decisions made at the planning stage can have a significant
and far-reaching negative impact at multiple stages of implant treatment and follow up. This
notion that poor planning plays a pivotal role in the occurrence of complications is supported by
the studies examining malpractice cases in Germany (114) and Israel (5).
Unrealistic patient expectations was selected as the second most important cause of
complications (Table 7.1). The prominent role of unrealistic patient expectations among the
causes of complications was somewhat unexpected, since only a fraction of complication types
involve direct patient perceptions and evaluations. However, many complications ultimately
have an impact on patient-relevant outcomes such as therapeutic experience (length of treatment,
cost, number and invasiveness of interventions etc.) and aesthetic and functional outcomes. The
elective nature of dental implant treatment, the patients frequent lack of awareness of the

86

challenges of their care, the dentists frequent difficulty in visualizing the prosthodontic endresult, and the difficulties in restoring the hard and soft tissues lost subsequent to natural tooth
loss can make it a challenge to meet patients expectations. Patients present to dentists with
anatomic realities and limitations as well as a set of expectations (148, 149). The ability to meet
patients expectations is one of the dominant determinants of patients satisfaction with
treatment, and presence of unmet expectations can lead to decreased satisfaction with treatment
(150-153). Although the patients anatomic realities and limitations may be ascertained readily
during pre-operative or intra-operative assessment, patient expectations with respect to treatment
experience and outcome of care are far more difficult to judge accurately pre-operatively and to
modify.

As dental implants have moved from being a novel therapeutic saviour used to address the
debilitating consequences of edentulism to a readily available consumer commodity advertised
as a seamless cure for all things dental, patients exposure to and awareness of dental implants
have increased significantly (154, 155) and have resulted in patients having high expectations of
implant treatment (148, 156). In particular, while the first patients seeking treatment with
osseointegrated implants focused on improvements in function (19, 157), patients in the
contemporary society increasingly seek aesthetic as well as functional improvements (158). All
interventions involve the time-dependent elements of healing and adaptability (34-36), neither of
which is completely under the dentists control. All artificial devices depart somewhat from the
biological structures they aim to replace and emulate. This departure from ideal may provide
the focus point for disagreement between providers and consumers of care. Despite the
shortcomings of all artificial devices, studies have repeatedly and convincingly demonstrated
high levels of patient satisfaction with implant prostheses (159, 160). Although managing
patient expectations is never easy, the data in this thesis suggest that meeting the patients
expectations may be especially difficult due to constraints that can be imposed by complications.
The data from this thesis that place unrealistic patient expectations so prominently as a
possible causative factor of complications associated with dental implants corroborate
observations from the medical field (50, 161). The suggestion that patients themselves
(including their conduct, communication skills, and expectations) may play a role in causing or
contributing to the occurrence of some complications is an intriguing possibility that is being

87

increasingly explored in the medical field (50). As shown in a survey of physicians conducted in
2002 (161), 58% of respondents thought that patients were often or somewhat often at least
partially responsible for errors made in their own care.
Clinicians lack of experience was selected as the thirds most important cause of complications
(Table 7.1). This assertion finds some support in the clinical dental literature. For example,
some studies have reported implant failure to be greater among novice surgeons (162). In
particular, one research group (70) observed that inexperienced surgeons (defined as those who
placed fewer than 50 implants) had an implant failure rate that was twice that of more
experienced colleagues, and the highest failure rate was observed for the first nine cases. At the
same time, other studies have suggested that level of training does not impact on the success rate
for dental implant treatment (163). In this regard, an investigation of implant failure rates as a
function of oral surgery resident level of training concluded that these two variables were
independent of each other (163). However, this finding must be interpreted with caution. A high
level of supervision is likely present in a surgical residency program and this would be expected
to mitigate against errors, complications, and failures that might otherwise occur. By contrast,
practitioners in private practice, who may have limited knowledge and experience, do not have
the luxury of continual expert advice and oversight and inadvertently may make erroneous
judgments that clinicians with greater experience would not be expected to make.

Based on the foregoing, it would seem that clinicians with limited prior implant treatment
experience should expect a learning curve (70) and should choose treatment cases accordingly
(131, 164, 165). Indirect support for the concept that learning and experience have an impact on
treatment outcome is found in the literature documenting the early experiences and experiments
with osseointegrated implants carried out by the Branemark group (19, 166, 167). This group
identified four chronological phases based on the gradual changes and improvements in
treatment protocols developmental phase (the earliest) and three routine phases 1, 2, and 3
(with the 3rd phase being the most recent) (167). During the developmental phase, treatment was
developed by trial and error based on fundamental surgical and prosthodontic principles.
Moving from developmental phase to routine phases 1 through 3, the treatment techniques,
materials and approaches continued to be modified, refined, and perfected based on prior
experience during the preceding phases and creating, in the end, a standard treatment

88

methodology. Comparisons of outcome data among these four phases clearly show that the
earliest developmental groups had the highest failure rates, while the lowest failure rates were
seen in the latter groups (especially, routine groups 2 and 3) (167).
In the medical literature, clinicians lack of experience has also been cited as an important
causative factor in complications. Several studies (67, 68) correlated the level of residency
training with the number or severity of errors. For example, in separate investigations it was
found that prescription errors were more common among first year residents than among other
clinicians (67), and that mistakes were more common with inexperienced clinicians, or when
new techniques were introduced (69). Physicians are known to acknowledge the role that
experience plays in achieving successful treatment outcomes. A 2002 survey of physicians (161)
demonstrated that respondents thought that a preventable error is more likely to occur at a lowvolume hospital (as opposed to a high-volume hospital), and, similarly, limiting high-risk
procedures to those who perform many of these procedures was one of the most effective
possible solutions to the problem of medical errors.

Although, the putative causative factors that were investigated in this question on the causes of
complications may seem intuitive, only a minority of them have been rigorously investigated.
Concerns have been raised about drawing quick conclusions between the hypothesized causative
processes and the adverse outcomes (complications) they are eventually presumed to cause (22).
The objective of this thesis was to ascertain dentists opinions regarding the causes of
complications. Until strong clinical research is able to support the importance of these factors,
caution is advised in interpretation of the dentists opinions on the causative factors leading to
complications.

89

7.C: Preventive strategies to decrease occurrence of complications

results
Table 7.3: Strategies to prevent occurrence of complications chosen by survey responders
(N=405)
Preventive strategies
better treatment planning
be self-critical and learn from complications
treatment to be prosthetically driven
refer difficult cases to a specialist
better dentist education
better inter-professional communication
better patient education
implant companies to publish more information about
complications
better dissemination of research about complications
greater research into complications
greater pre-testing of technologies before introduction to the
market
follow manufacturer recommendations
establish mandatory implant complication reporting system
greater professional body role
establish a specialty of implantology
Total*

275
230
229
218
209
195
172

Percent of cases
(N=405)
(%)
67.9
56.8
56.5
53.8
51.6
48.1
42.5

149

36.8

148
140

36.5
34.6

92

22.7

84
46
43
25
2255

20.7
11.4
10.6
6.2
556.8

*Note: This is a multiple-response question. The total of all responses is more than 100%.

Most survey responders (Table 7.3) stated that the following actions should be undertaken to
decrease the occurrence of complications (the number in brackets represents the percentage of
dentists who selected the option) better treatment planning (67.9%), being self-critical and
learn from complications (56.8%), and treatment to be prosthetically driven (56.5%). The
following options were selected least often when answering what should be done to decrease the
occurrence of complications mandatory implant complication reporting (11.4%), greater
professional body role (10.6%), and establishment of the specialty of implantology (6.2%).

90

Table 7.4: Strategies to prevent occurrence of complications chosen by each professional

group
Preventive strategies
better treatment planning
be self-critical and learn from
complications
refer difficult cases to a specialist
treatment to be prosthetically driven
better dentist education
better inter-professional
communication
better patient education
implant companies to publish more
information about complications
better dissemination of research about
complications
greater research into complications
greater pre-testing of technologies
before their introduction to the market
follow manufacturer recommendations
establish mandatory implant
complication reporting system
greater professional body role
establish a specialty of implantology
Total

n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%

general
dentists
217
66.8^
175
53.8^
157
48.3
179
55.1^
162
49.8
153
47.1
136
41.8
119
36.6
114
35.1
111
34.2
72
22.2
65
20.0
28
8.6
20
6.2
19
5.8
325

oral
surgeons
23
74.2^
26
83.9^
23
74.2^
22
71.0
17
54.8
15
48.4
10
32.3
13
41.9
13
41.9
12
38.7
5
16.1
10
32.3
6
19.4
8
25.8
0
0.0
31

period
ontists
23
67.6^
21
61.8^
27
79.4^
15
44.1
20
58.8
17
50.0
17
50.0
11
32.4
13
38.2
10
29.4
10
29.4
5
14.7
8
23.5
8
23.5
5
14.7
34

prostho
dontists
12
80.0^
8
53.3
11
73.3^
13
86.7^
10
66.7
10
66.7
9
60.0
6
40.0
8
53.3
7
46.7
5
33.3
4
26.7
4
26.7
7
46.7
1
6.7
15

2 PValue

total
275
230
218
229
209
195
172
149
148
140
92
84
46
43
25

0.623
0.013*
<0.001*
0.014*
0.457
0.521
0.256
0.870
0.465
0.653
0.448
0.298
0.005*
<0.001*
0.095

405

Most general dentists (Table 7.4) stated that the following actions should be undertaken to
decrease the occurrence of complications better treatment planning (66.8%), treatment to be
prosthetically driven (55.1%), and dentists to be self-critical and learn from complications
(53.8%). Most oral surgeons stated that that the following should be done to decrease the
occurrence of complications be self-critical and learn from complications (83.9%), better
treatment planning (74.2%), and refer difficult cases to specialists (74.2%). Most periodontists
stated that the following should be done to decrease the occurrence of complications refer

91

difficult cases to specialists (79.4%), better treatment planning (67.6%), and be self-critical and
learn from complications (61.8%). Most prosthodontists stated that the following should be done
to decrease the occurrence of complications treatment to be prosthetically driven (86.7%),
better treatment planning (80.0%), and refer difficult cases to specialists (73.3%).

There was significant agreement with respect to the possible preventive strategies to decrease the
occurrence of complications. The differences of opinion among the four professional groups
were not statistically significant for 10 out of the 15 potential preventive strategies (Table 7.4).
Only the following 5 potential preventive strategies registered a statistically significant
difference in the opinions among the four professional groups treatment to be prosthetically
driven (2 p-value=0.014), greater professional body responsibility (2 p-value<0.001), be selfcritical and learn from complications (2 p-value=0.013), refer difficult cases to specialists (2 pvalue<0.001), and mandatory implant complication reporting (2 p-value=0.005).

7.D: Preventive strategies to decrease occurrence of complications

discussion
The objective of the question on preventive strategies was to elucidate what broad strategies
could be undertaken to prevent occurrence of complications. Ultimately, preventive strategies
are meant to address the causes of complications. In this regard, each complication and each
cause of complications may have its own extensive list of potential preventive strategies.
However, it was not intention of this investigation to produce an exhaustive list of overly
specific strategies but, instead, to investigate a limited set of preventive strategies that might
cover the broadest possible range while focusing on the most pertinent and widely applicable
educational, organizational, and other approaches to prevention of complications (7).

Some broad agreement on what should be done to prevent complications was observed among
the four professional groups. Three potential preventive strategies better treatment planning,
being self-critical and learning from complications, and referring difficult cases to specialists
were recommended most frequently as preventive strategies, while two other preventive
strategies establishing a specialty of implantology and establishing a mandatory implant

92

complication system were least frequently recommended. There was significant agreement
among the four professional groups with respect to most possible preventive strategies to
decrease the occurrence of complications.
Better treatment planning and treatment to be prosthetically driven were the most frequently
selected strategies for prevention of complications arising during or subsequent to treatment with
osseointegrated implants. The importance given to prosthetic treatment planning prior to
surgical intervention as a preventive strategy is an indication of a well-acknowledged
communication issue in implant dentistry (168). Surgical and anatomic restrictions may lead to
implant placement in a position that is obtrusive to an optimal restorative outcome (119). Since
surgical implant placement and restorative implant treatment are often done by two different
clinicians, the actions of one clinician can have a direct negative effect on the ability of the other
clinician to provide a satisfactory treatment outcome for the patient. The need for implant
treatment to be prosthetically driven means that optimal implant position should be dictated
largely by restorative, rather than exclusively surgical, considerations (168).
Interestingly, specialists were significantly more likely than general dentists to regard referral of
difficult cases to a specialist as a significant strategy for preventing complications. Only half of
the general dentists (48.3%) (the fifth most important prevention strategy) but 70-80% of
specialists (consistently in the top three of the most important prevention strategies) selected
referral of difficult cases to a specialist as a significant strategy for preventing complications.
This finding was echoed in the question about the underlying causes of complications. There,
failure to refer to a specialist was regarded as one of the most important causative factors by
34.0% of general dentists and by 45.7% to 60.0% of specialists. Specialists, by virtue of their
advanced education and experience (126-128, 169), are not only better able to prevent
complications but also to manage them. The contrast between the views of general dentists and
specialists may also be accounted for by their differences in the number and the difficulty of
implant patients treated by each group (Table 5.4).
The fact that the following three options mandatory implant complication system (11.4%),
greater professional body role (10.6%), and establishment of the specialty of implantology
(6.2%) were selected least often when answering what should be done to decrease the

93

occurrence of complications may suggest that dentists do not desire greater regulatory oversight
or involvement in this field. The support for a new specialty of implantology appears to be
particularly low. Regulatory statutes on the status of implantology as a dental specialty vary
widely around the world as do dentists opinions on this matter (96). Dentists in some
geographic regions support the existence or emergence of the specialty of implantology or the
necessity of additional advertisable qualifications before a practitioner is permitted to engage in
the practice of implant dentistry. For example, in a 2004 survey of a convenience sample of 104
general dental practitioners in the U.K. (among whom only 2.8% had dental implant experience)
(96), 68.9% thought that a dentist should have an implantology qualification before being able to
advertise provision of dental implant services to the public. Roughly the same percentage
(69.8%) felt that there should be a specialty of implantology. Although the specialty of
implantology exists in a number of jurisdictions (e.g., Columbia (170)), this is not so in North
America (171) or in most member states of the European Union (172). In North America, the
field of implantology is recognized to be an integral part of general dentistry and of a number of
dental specialties including oral surgery, periodontics, and prosthodontics (173). However,
informal proposals for granting specialty status to implantology have been advanced and debated
in North America (174, 175).

The development of a system that requires mandatory reporting of complications is an integral

part of a number of initiatives aimed at identification of global trends in medical adverse events.
Establishing error reporting systems (both mandatory and voluntary) has been a consistent
recommendation of a large number of organizations focusing on reduction of medical errors (e.g.
Institute of Medicine [IOM] and Quality Interagency Coordination Task Force [QuIC] (8)).
Such systems are able to identify potential problems before they could become noted by the
individual medical professionals. Only one country Finland (81) is known to keep a record
of all implanted devices (including osseointegrated dental implants) and to make this information
available publicly.
Very little is known about publics perception of what should be done to prevent medical errors.
In a 1997 telephone survey of US adults (32) the most effective strategies for prevention of
medical errors were felt to be (percentage in brackets indicates the percentage of responders who
chose that option) preventing doctors with bad track record from providing care (75%), better

94

training of doctors (69%), careful selection of doctors by patients (61%), better patient
information (54%), and formation of an independent organization to investigate causes of
medical mistakes (52%). At the same time, lawsuits against those who make medical
mistakes (29%) and stricter government regulation of health care system (27%) were felt to
be less effective in preventing complications or errors.

95

7.E: Severity of complications results

Table 7.5: Most severe complications chosen by survey responders (N=403)
Complications
permanent paraesthesia
increased number of surgical procedures
poor appearance of the final prosthesis
unable to achieve satisfactory outcome as it was originally
envisioned
damage to adjacent tooth
increased possibility of treatment failure
frequent breakage of the final prosthesis
poor comfort of the final prosthesis
increased cost of treatment
increased complexity of treatment
interference with proper speech with the final prosthesis
increased length of treatment
increased length of recovery from surgery
increased number of non-surgical procedures
temporary paraesthesia
cleaning difficulty of the final prosthesis
increased effort on the part of the dentist
increased number of radiographs
Total*

259
203
199

Percent of cases
(N=403)
(%)
64.3
50.4
49.4

181

44.9

178
178
176
165
149
136
125
117
112
106
99
87
61
29
2560

44.2
44.2
43.7
40.9
37.0
33.7
31.0
29.0
27.8
26.3
24.6
21.6
15.1
7.2
635.2

*Note: This is a multiple-response question. The total of all responses is more than 100%.

Most survey responders (Table 7.5) reported that the following were the most severe
complications (the number in the brackets indicates percentage of dentists who selected this
option) permanent paraesthesia (64.3%), increased number of surgical procedures (50.4%), and
poor appearance of the final restoration (49.4%).

96

Table 7.6: Most severe complications chosen by each professional group

Complications
permanent paraesthesia
increased number of surgical
procedures
poor appearance of the final prosthesis
unable to achieve satisfactory outcome
as it was originally envisioned
damage to adjacent tooth
increased possibility of treatment
failure
frequent breakage of the final
prosthesis
poor comfort of the final prosthesis
increased cost of treatment
increased complexity of treatment
interference with proper speech with
the final prosthesis
increased length of treatment
increased length of recovery from
surgery
increased number of non-surgical
procedures
temporary paraesthesia
cleaning difficulty of the final
prosthesis
increased effort on the part of the
dentist
increased number of radiographs
Total

n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%

general
dentists
204
63.4^
154
47.8^
155
48.1^
137
42.5
138
42.9
138
42.9
143
44.4
132
41.0
124
38.5
101
31.4
104
32.3
87
27.0
91
28.3
81
25.2
79
24.5
73
22.7
48
14.9
26
8.1
322

oral
surgeons
25
80.6^
23
74.2^
17
54.8
20
64.5^
19
61.3
16
51.6
11
35.5
14
45.2
9
29.0
15
48.4
10
32.3
11
35.5
12
38.7
8
25.8
7
22.6
4
12.9
5
16.1
2
6.5
31

period
ontists
23
65.7^
19
54.3^
19
54.3^
17
48.6
15
42.9
18
51.4
14
40.0
16
45.7
9
25.7
14
40.0
8
22.9
13
37.1
6
17.1
11
31.4
9
25.7
9
25.7
5
14.3
1
2.9
35

prostho
dontists
7
46.7^
7
46.7^
8
53.3^
7
46.7^
6
40.0
6
40.0
8
53.3^
3
20.0
7
46.7
6
40.0
3
20.0
6
40.0
3
20.0
6
40.0
4
26.7
1
6.7
3
20.0
0
0.0
15

total
259
203
199
181
178
178
176
165
149
136
125
117
112
106
99
87
61
29

2 PValue
0.122
0.043*
0.801
0.124
0.257
0.620
0.642
0.351
0.299
0.198
0.530
0.354
0.230
0.542
0.988
0.269
0.954
0.467

403

Most general dentists (Table 7.6) stated that the following complications were most severe
permanent paraesthesia (63.4%), poor appearance of the final restoration (48.1%), and increased
number of surgical procedures (47.8%). Most oral surgeons stated that the following
complications were most severe permanent paraesthesia (80.6%), increased number of surgical

97

procedures (74.2%), and unable to achieve satisfactory outcome as it was originally envisioned
(64.5%). Most periodontists stated that the following complications were most severe
permanent paraesthesia (65.7%), increased number of surgical procedures (54.3%), and poor
appearance of the final restoration (54.3%). Most prosthodontists stated that the following
complications were most severe poor appearance of the final restoration (53.3%), frequent
breakage of the final restoration (53.3%), increased number of surgical procedures (46.7%),
permanent paraesthesia (46.7%), and unable to achieve satisfactory outcome as it was originally
envisioned (46.7%).

Substantial agreement emerged in the opinions of dentists regarding the severity of

complications (Table 7.6). Almost all severity options demonstrated no statistically significant
difference in the opinions on severity among the four professional groups. Three complications
(increased number of surgical procedures, permanent paraesthesia, and poor appearance of the
final restoration) were consistently selected by the four professional groups as being most severe,
and three complications (increased number of radiographs, increased effort on the part of the
dentist, and cleaning difficulty of the final restoration) were consistently selected as being least
severe.

7.F: Severity of complications discussion

Dentists were asked to select the most severe complication(s) from a list of mostly patientfocused negative outcomes. We used patient-friendly terminology avoiding complex dental
terms where possible. Complications ranged from those affecting the process of care (e.g.,
duration of treatment, cost, recovery from surgery, number of procedures or appointments) to
those affecting the outcome of care (e.g., perception of prosthesis appearance, speech, comfort,
cleaning, and breakage). In future investigations, the opinions held by members of the public on
implant-related complications will be examined. In particular, it would be interesting to examine
if the opinions on severity of complication differ between dentists and the general public. No
such information is available in the dental implant literature, and inconsistent results have been
reported comparing opinions of medical professionals to those of patients or members of the

98

public when considering complications (56). Divergence of opinions may occur because patients
may not be aware of the importance of a symptom that they perceive as minor, while the health
care professionals may not regard an issue as a complication, if they perceive it to be a part of a
normal post-operative course (176). Whereas the patient is the only one who can give a full
account of the post-operative course, the treating clinician has a better knowledge of what to
expect and what to characterize as a deviation from normality (177). The views of both parties
may need to be taken into account to gain a better overall view.

Several severity grading scales for complications have been proposed in the medical literature
(46, 47, 52). However, the majority of studies in the medical field do not use grading scales in
reporting complications, and those studies that do use grading scales simply tend to group them
under the subjective and ill-defined categories of minor complications and major
complications (56). Although the terms major and minor are used commonly in the
medical literature, they have been applied inconsistently among authors, treatment centers, and
over time periods, and many authors have argued against their continued use (56). Along these
lines, the terms major and minor were not used in this thesis, and, instead, the respondents to
the survey were asked to select the complications or outcomes of complications that they felt
were most severe in their impact on the dentist, the patient, or both.

The survey responders selected permanent paraesthesia as the most severe complication (Table
7.5). Permanent paraesthesia (usually described as loss of sensation that persists longer than 612 months after injury) is an irreversible outcome of nerve damage. It may interfere with social
functioning and is known to be a major factor leading to litigation (both in implant dentistry
(116) and in other surgical procedures, such as surgical removal of mandibular third molars
(178)). Several studies (179, 180) have investigated alteration in inferior alveolar nerve
sensation subsequent to the surgical placement of implants in the mandible. Bartling et al. (105)
found that none of the patients in their study who had implants placed in the mandible (with the
use of computer tomography imaging when necessary) had permanent altered sensation by 6
months. In contrast, Van Steenberghe et al. (181) reported that 6.5% of patients had altered
sensation at 1 year after implant placement in the mandible. Higher rates of temporary and
permanent paraesthesia have also been reported (182) possibly owing to different study
methodologies, variations in surgical technique, or availability of advanced imaging techniques

99

(such as computer tomography and cone-beam computer tomography). Cases of permanent

paraesthesia that led to legal action have been associated with the use of unnecessarily long
implants, inadequate imaging (i.e., the use of a single rather than multiple imaging modalities),
and violation of mandibular canal during instrumentation (rather than being the result of
mucoperiosteal flap elevation) (116). Liability was acknowledged in all cases of permanent
paraesthesia (5, 116), but only in 67% of legal cases involving dental implants in general (5),
highlighting the significant role that prevention could play in combating the occurrence of this
complication.

Several items in the survey used here allow for the differentiation in the perception of severity of
various complications in the minds of the respondents. While permanent paraesthesia was
considered to be the most severe complication, temporary paraesthesia scored close to bottom of
the list (Table 7.5). This may be a reflection of the fact that a complication with temporary
effects is far more likely to be accepted by the patient than one which is permanent or longlasting. Thus, a review of legal cases in Israel involving inferior alveolar nerve paraesthesia
following implant surgery concluded that only cases of permanent paraesthesia resulted in legal
action (116). The increase in the number of surgical procedures was the second most severe
complication. It scored higher in severity compared to other items describing process of care
such as increased number of non-surgical procedures, increased length of treatment, and
increased complexity of treatment. This suggests that dentists consider surgical intervention to
be a more significant step compared to non-surgical dental interventions. In the medical
literature, re-operation is also considered a significant adverse event (25) and is one of several
parameters tracked by quality assurance programs (8).

Poor appearance (49.4%) was the third most chosen complication in severity. In the minds of the
responders, it proved to be more severe than other items that refer to the patients perception of
the restoration such as cleaning difficulty (21.6%), interference with proper speech (31.0%), and
poor comfort (40.9%). This may be a reflection of the role that aesthetics plays in our society or
of the value that patients place on appearance as either an outcome measure or as the reason for
therapy (149). Although osseointegrated implants were applied at first with the primary goal of
improving patients oral function (19, 157), more recent research initiatives as well as
improvements in technology and techniques sought to optimize aesthetic outcomes and to be

100

able to deliver optimum aesthetic as well as functional results (183-185). Numerous studies
evaluating determinants of successful outcome of prosthodontic interventions suggested that
satisfaction with aesthetics is the dominant predictor of patient satisfaction (186-188).

It would appear that there is only one other study that investigated the ranking of the severity of
complications with respect to implant dentistry (6). In the investigation by Van Waas et al. (6), a
small group of specialists ranked complications with implant-supported overdentures (Table 2.7)
using a 5-point ordinal scale the clinical performance scale for implants (Table 2.6). As
discussed earlier (Section 3.F), the clinical performance scale used by Van Waas et al. (6)
intrinsically regards implant failure as the most severe complication and judges other
complications by the likelihood with which they may lead to implant failure. Hence, it is not
surprising that implant failure and implant fracture were judged to be the most severe
complications (score of 4 out of 4), while permanent paraesthesia (referred to in this study (6)
study as severe disturbance of the mental nerve) had a score of 2 out of 4. The drawbacks of
this study (6) were discussed earlier (Section 3.F). This thesis differed in a number of significant
aspects from Van Waas et al. study (6), and this might account for the differences in results.
Van Waas et al. (6) examined complications as they would be perceived by the dentists without
regard for the subsequent steps that might be needed to remedy or treat the complication in
question. Their ranking was achieved using a consensus building method using a small number
of specialists. By contrast, this survey instrument in this thesis focused mostly on patientrelevant outcomes. The dentists in this survey were asked to choose the most severe
complications from a limited list of 18 items, and the severity ranking was inferred from the
relative frequency with which each of the complications was chosen. Implant failure and
implant fracture were not on this list, and neither were most of the other 49 specific
complications that made up the specific complications of the four questions on surgical,
prosthodontic, biologic, and patient-related complications. Notably, each complication might
create a range of difficulties ranging in severity from trivial to very severe; hence, attempting to
rank complications without the knowledge of the ultimate impact on the patient or the dentist is
of limited value (64). For example, a failed implant under a full-arch screw-retained prosthesis
can be retrieved easily (frequently without local anesthesia) and might require no additional
treatment. By contrast, an implant that has failed under a full-arch cemented prosthesis could
present an entirely different problem and one that is much more difficult to solve. An implant

101

that fails prior to prosthesis fabrication is an unfortunate event. But it has much less of an impact
than an implant that fails after it was already restored with a single crown. Lastly, for most
patients, implant failure represents just the beginning of efforts to ameliorate the effects of the
failure. It can lead to additional steps such as additional surgical procedures, increased length of
treatment, or increased fees, and it is the relative severity of these steps or outcomes that was
examined in the survey instrument used in this thesis.

Overall, there appears to be little agreement among the four professional groups as to the causes
of complications (Table 7.2), some agreement on what should be done to decrease occurrence of
complications (Table 7.3), and a great deal of agreement on the severity of complications (Table
7.6) as well as the preventability of complications (Table 8.1). This suggests that beliefs
regarding the causes of complications are specialty- or educational background-specific, and, as
such, they may be influenced by the types of procedures performed or by the types of
complications encountered in clinical practice. However, beliefs regarding the severity of
complications and their preventability appear to be independent of specialty affiliation or
educational background as evidenced by the similar choices being made by members of all four
professional groups in this survey. Perception of severity of any particular complication may
depend of such attributes as reversibility, impact on patient functioning, impact on the treatment
outcome, and even likelihood of legal or professional liability arising as a result of the
complication. Ultimately, however, the factors that govern formation of these beliefs are
unknown.

102

7.G: Source of knowledge about complications results

Table 7.7: Sources of knowledge about complications identified by survey responders
(N=418)
Sources of knowledge about implant complications
continuing education courses
my own experience
speaking with colleagues
conferences
dental implant journals
implant company representatives
textbooks
specialty program
dental school curriculum
Total*

n
346
287
227
175
164
100
94
61
25
1479

Percent of cases
(N=418)
(%)
82.8
68.7
54.3
41.9
39.2
23.9
22.5
14.6
6.0
353.8

*Note: This is a multiple-response question. The total of all responses is more than 100%.

Table 7.7b: Sources of knowledge about complications identified by survey responders who
graduated in the last 10 years (N=50)
Sources of knowledge about implant complications
continuing education courses
speaking with colleagues
my own experience
dental implant journals
textbooks
specialty program
conferences
dental school curriculum
implant company representatives
Total*

n
39
32
27
17
14
12
11
9
4
165

Percent of cases
(N=50)
(%)
78.0
64.0
54.0
34.0
28.0
24.0
22.0
18.0
8.0
330.0*

Note: This is a multiple-response question. The total of all responses is more than 100%.

Survey responders (Table 7.7) obtained the most information on implant complications from the
following sources continuing education courses (82.8%), dentists own experience (68.7%),
and speaking with colleagues (54.3%). Interestingly, the dental school curriculum (6.0%) was

103

the least important source of information regarding implant complications. The minimal
importance of dental school curriculum as a source of information regarding implant
complications was found even among those who graduated from dental school within the last 10
years (i.e., among those who likely had significant exposure to dental implant therapy as part of
their undergraduate curriculum (189, 190)) (Table 7.7b).

Table 7.8: Sources of knowledge about complications identified by each professional group
Sources of knowledge about implant
complications
continuing education courses
my own experience
speaking with colleagues
conferences
dental implant journals
implant company representatives
textbooks
specialty program
dental school curriculum
Total

n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%

general
dentist
292
86.6^
227
67.4^
183
54.3^
126
37.4
122
36.2
91
27.0
71
21.1
18
5.3
19
5.6
337

oral
surgeon
23
76.7^
25
83.3^
16
53.3
22
73.3^
13
43.3
1
3.3
11
36.7
9
30.0
2
6.7
30

period
ontists
25
69.4^
24
66.7^
19
52.8
20
55.6
21
58.3
5
13.9
7
19.4
22
61.1^
3
8.3
36

prostho
dontists
6
40.0
11
73.3^
9
60.0^
7
46.7
8
53.3
3
20.0
5
33.3
12
80.0^
1
6.7
15

2 PValue

total
346
287
227
175
164
100
94
61
25

<0.001*
0.323
0.971
<0.001*
0.041*
0.012*
0.168
<0.001*
0.927

418

General dentists (Table 7.8) obtained most of their information concerning complications with
implant treatment from continuing education courses (86.6%), their own experience (67.4%),
and by speaking with colleagues (54.3%). Oral surgeons obtained most of their information on
implant complications from their own experience (83.3%), continuing education courses
(76.7%), and conferences (73.3%). Periodontists obtained most of their information on implant
complications from continuing education courses (69.7%), their own experience (66.7%), and
their specialty program training (61.1%). Prosthodontists obtained most of their information on
implant complications from specialty program (80.0%), their own experience (73.3%), and by
speaking with colleagues (60.0%). For each of the four professional groups, dental school

104

curriculum was one of the least likely sources of information about implant complications (range
from 5.6% to 8.3%)

7.H: Source of knowledge about complications discussion

The survey responders indicated that the most common source of information about implant
complications was continuing education courses. The importance of continuing education
courses in implant education observed in this survey parallels the observations made in several
national surveys (90, 91). For instance, almost all dentists involved in the provision of implant
care in Switzerland in 2006 undertook further training in implantology (91), and 65.8% of all
New Zealand dentists attended at least one continuing education implant course (90).

Personal experience appears to play a significant role in providing dentists with knowledge and
information about complications arising from therapy with osseointegrated implants. This
observation is encouraging because it suggests that dentists are able to learn from the
complication that they had observed or experienced. This observation of the importance of
personal experience is substantiated by the findings obtained from the answers to the question in
the thesis survey relating to what should be done to prevent complications. There, being selfcritical and learning from complications was the second most commonly chosen option (second
only to better treatment planning) as a key to what should be done to decrease occurrence of
complications (Table 7.3).

Dental school curriculum was ranked consistently as one of the least important sources of
information regarding the management and aetiology of complications. However, this must be
viewed in the context of the relatively recent widespread introduction of implant dentistry into
the undergraduate curriculum (189, 190). Nonetheless, even among recent graduates (Table
7.7b) dental school was still ranked as one of the least important sources of information. This
may reflect an actual void in the undergraduate implant curriculum or a poor recall of learned
information. Although education in implant dentistry is now a consistent part of virtually all

105

dental school curricula (189, 190), the topic of complications is perhaps being inadequately
addressed.

In relation to the foregoing, osseointegrated dental implants have been successfully utilized in
academic centers since the late 1960s (19). However, dental implants were introduced to the
undergraduate curriculum only relatively recently. Two 2002 surveys of dental schools in
Europe (189) and the United States (190) demonstrated that prior to 1990 only a small
percentage of schools offered undergraduate implant courses. The percentage of schools
teaching undergraduate implant courses rose rapidly during the 1990s, and by 2000 the vast
majority of schools offered these courses. Surveys of dentists in the U.K. (96) and New Zealand
(90) corroborated these findings. Only 24.5% of responders to a 2004 survey of general dental
practitioners in the U.K. stated that they were taught implant dentistry at an undergraduate level
(96). A 2004 survey of New Zealand dentists (90) showed that only 20.5% had implant
curriculum in their primary degree program. This percentage corresponded roughly to the 20.5%
of the New Zealand dentists who graduated within the last 10 years.

106

7.I: Responsibility to keep dentists informed about potential implant

complications results
Table 7.9: Responsibility for informing dentists about potential implant complications as
chosen by all responders (n=418)
Responsibility for informing dentists about potential
implant complications
my own it is my responsibility to educate myself
implant company
regulatory body
dental school
Total

Percent
(%)
77.8
8.4
7.4
6.5
100.0

Frequency
325
35
31
27
418

Table 7.10: Responsibility for informing dentists about potential implant complications as
chosen by each professional group
Responsibility for informing
dentists about potential implant
complications
my own it is my responsibility
to educate myself
implant company
regulatory body
dental school
Total

general
dentists
n
%
n
%
n
%
n
%
n
%

271
80.4^
28
8.3
20
5.9
18
5.3
337
100.0

oral
surgeons

period
ontists

prostho
dontists

25
80.6^
2
6.5
2
6.5
2
6.5
31
100.0

20
57.1^
4
11.4
5
14.3
6
17.1
35
100.0

9
60.0^
1
6.7
4
26.7
1
6.7
15
100.0

total
325
77.8
35
8.4
31
7.4
27
6.5
418
100.0

2 PValue

0.012*

Table 7.11: Cross-tabulation of opinions about the responsibility to keep dentists informed
about implant complications as chosen by each professional group against every other
professional group (0.008 level of statistical significance)
general
dentists
general dentists
oral surgeons
periodontists
prosthodontists

oral
surgeons

period
ontists

prostho
dontists

0.978

0.005*

0.019

0.233

0.290
0.579

107

Among survey responders (Tables 7.9 and 7.10), the majority of dentist (77.8%) and the majority
of each of the four professional groups stated that it was the dentists own responsibility to
educate themselves on the subject of implant complications. However, a notable percentage of
periodontists and prosthodontists (approximately 40%) felt that the responsibility for educating
dentists about complications resided elsewhere with an implant company, a dental school, or a
regulatory body. In particular, 26.7% of prosthodontists (vs. 7.4% for the overall sample of
dentists) felt that regulatory bodies (e.g., American Dental Association [ADA], Canadian dental
association [CDA], Royal College of Dental Surgeons of Ontario [RCDSO]) have a
responsibility to educate dentists about implant complications. However, only the difference of
opinion between general dentists and periodontists (2 p-value=0.005) was statistically
significant (p-value<0.008) once the Bonferroni correction for multiple comparisons was done
(0.05/6=0.008) (Table 7.11).

7.J: Responsibility to keep dentists informed about potential implant

complications discussion
Most dentists felt that it was their own responsibility to educate themselves about implant
complications. The high value the dentists place on keeping themselves informed confirmed the
answers given to previous questions in this survey regarding the sources of information about
implant complications and regarding prevention of implant complications. The responders to
this survey had already indicated earlier (Table 7.7) that they received most of their information
on implant complications from continuing education courses, personal experience, and
consultation with colleagues.

108

7.K: Percentage of patients experiencing complications results

Table 7.12: Percentage of patients experiencing complications reported by each
professional group and by all survey responders (n=428)
Percentage of patients experiencing
complications (%)
0-5
>5

general
dentists
n 272
% 78.6
n 74
% 21.4
n 346
% 100.0

oral
surgeons
23
76.7
7
23.3
30
100.0

period
ontists
23
65.7
12
34.3
35
100.0

prostho
dontists
9
52.9
8
47.1
17
100.0

total
327
76.4
101
23.6
428
100.0

2 PValue
0.039*

Table 7.13: Cross-tabulation of percentage of patients experiencing complications reported

by each professional group against every other professional group (0.008 level of statistical
significance)
general
dentists
general dentists
oral surgeons

oral
surgeons

period
ontists

prostho
dontists

0.804

0.082

0.013

0.333

0.094

periodontists

0.374

prosthodontists

Overall, most survey responders (76.4%) stated that only 0-5% of their patients experienced a
complication in 2009, while 23.6% of dentists stated that more than 5% of their patients
experienced a complication (Table 7.12). However, while just over 20% of general dentists
stated that more than 5% of their patients experienced complications in 2009, a larger percentage
of specialists stated that more than 5% of their patients experienced complications. Almost half
of prosthodontists (47.2%) stated that more than 5% of their patients experienced complications.
However, the difference in opinion between general dentists and prosthodontists (2 pvalue=0.013) was no longer statistically significant (p-value<0.008) following the Bonferroni
correction for multiple comparisons (0.05/6=0.008) (Table 7.13).

109

7.L: Percentage of patients experiencing complications discussion

A relatively low percentage of patients was reported by their dentists to have experienced a
complication with dental implant treatment in 2009. The less than 5% complication rate may
seem low compared to the frequency of occurrence of the numerous specific complications as
reported in several narrative and systematic reviews (1-4, 20, 57) (Chapter 3). For example,
implant failure rate alone has been repeatedly reported to be around 5% (20, 21, 181). The cause
for this slightly lower than expected rate of complications is uncertain, but may be accounted for
by several factors. First, as alluded to earlier (Section 3.D), the time delay in publication of
research on complications may mean that contemporary experience of complications is, in fact,
less frequent than the research published previously on the basis of the historical data suggests.
Second, the clinical situations treated in private practices may be of lesser complexity than those
treated in academic centers (where most of the research on implant complications is published)
and, hence, clinical cases treated in contemporary private practices may be less likely to
experience complications.

A trend was observed for the specialists to report that a greater percentage of their patients
experienced a complication with respect to implant therapy as compared to the general dentists.
This was particularly pronounced in the case of prosthodontists. However, none of these trends
were statistically significant, possibly due to the limited number of prosthodontists who
completed the survey and the resultant lack of power to detect a difference.

110

Chapter 8
Preventability of Complications
8.A: Results
Table 8.1: Preventability of complications
type of
complication
surgical

is it
preventable?
yes
total

prosthodontic

yes
total

biological

yes
total

patient-related

yes
total

new
complication in
2009

yes
total

n
%
n

general
dentists
268
89.9
298

oral
surgeons
26
83.9
31

period prostho
ontists dontists
30
15
85.7
100.0
35
15

339
89.4
379

n
%
n

296
87.3
339

20
95.2
21

29
90.6
32

13
76.5
17

358
87.5
409

n
%
n

219
67.8
323

16
55.2
29

20
64.5
31

9
60.0
15

264
66.3
398

n
%
n

269
82.5
326

24
88.9
27

25
78.1
32

13
86.7
15

331
82.8
400

n
%
n

53
63.1
84

3
100.0
3

4
50.0
8

3
60.0
5

63
63.0
100

total

2 PValue
0.336

0.342

0.523

0.713

0.501

Overall, the survey responders stated that the majority of complications of all four categories
(surgical, prosthodontic, biological, and patient-related) were preventable (Table 8.1). This was
particularly so with respect to surgical, prosthodontic, and patient-related complications (where
89.4%, 87.5%, and 82.8% of the dentists respectively stated that they were preventable).
Biological complications were felt to be less preventable than the other three complication
categories, with only 66.3% of the dentists stating that biological complications were
preventable. There was no statistically significant difference among the four professional groups
with respect to opinions on preventability of any category of complications.

111

Similar information was obtained when dentists were asked about their experience with new
complications in 2009. A quarter of the dentists (24.7%) stated that they experienced a new
complication in 2009 (i.e., a complication that they were not aware of until one of their patients
experienced it). Among these dentists, 63.0% indicated that this new complication could have
been prevented had they had prior educational information about this particular complication.

8.B: Discussion
Issues of preventability were ascertained on two separate occasions. First, respondents were
asked about preventability of each of the four categories of complications. Second, the dentists
were asked whether they had experienced a new complication in 2009 that they were not aware
of until one of their patients experienced it for the first time. Those who answered yes were
asked if they thought this complication could have been prevented had they had prior
information about this specific complication.

Survey responders as a whole and all four professional groups stated that complications were
largely preventable. This was particularly apparent with respect to the surgical, prosthodontic,
and patient-related complication categories (where 80-90% of dentists stated that they were
preventable). Biological complications were also preventable but this opinion was held by a
lower percentage of dentists (66.3%). The fact that biological complications were less
preventable than the other categories may be explained by the presence of complications within
this category that are dependent on patients biological response and patients intrinsic factors
that are imperfectly understood and not necessarily under the dentists control. Under these
circumstances, the ability to precisely predict outcome of treatment (including the possibility of
negative outcome or failure) may be hampered. Three biological complications in particular
absence of interproximal papilla (191, 192), implant failure, and recession can be difficult to
predict, to treat, or both. For example, a substantial amount of literature on implant failure (20,
38, 74) has been published and a number of risk factors (74) have been identified (see Section
3A). However, the retrospective determination of the cause of implant failure in any given

112

situation is very difficult and uncertain, and the cause is often attributed to vague parameters
such as poor surgical technique or clinicians inexperience.

The issue of preventability of complications (15) has only rarely been examined in the medical
literature and even then largely indirectly. In particular, preventability has been evaluating by
estimating the proportion of adverse outcomes that are due to error or negligence (15). For
example, a severe allergic reaction that resulted from a patient receiving a medication to which
the patient was known to be allergic would be considered a preventable complication. By
contrast, preventability of complications has not been examined or defined in the dental implant
literature. In this survey, preventability was defined broadly as follows: preventability means
that with additional effort or attention the complication could have been avoided or its negative
consequences significantly diminished. To avoid the uncertainty in the definition or the
differences in interpretation of the term preventability from influencing the results, this term
was defined explicitly within the survey.

An interesting trend, that was not statistically significant, was observed between prosthodontists
and surgical specialists with respect to preventability of surgical and prosthodontic
complications. With respect to surgical complications, prosthodontists were more likely than
surgical specialists (100.0% vs. 84.8%) to think that they were preventable. With respect to
prosthodontic complications, prosthodontists were less likely than surgical specialists (76.5% vs.
92.5%) to think that they were preventable. No such trend was observed in examining biological
and patient-related complications. Each of these professional groups (prosthodontists and oral
surgeons) is challenged with treating and resolving the most difficult and tasking situations
within their respective scopes of practice. The study results might suggest that each group of
specialists may have an acute appreciation of the limitations in preventability of complications
within its own scope of practice while at the same time holding a more optimistic view of the
ability of the other specialty group to prevent complications within its scope of practice.

Preventability of complications has not been directly addressed in the dental implant literature.
However, opinions have been expressed that complications are largely avoidable given the
iatrogenic nature of many complications (5, 117). The results of three malpractice studies in
Germany and Israel (5, 114) support the contention that dental implant complications (especially,

113

severe complication) are preventable (62, 117). Reviews of these legal cases identified errors
and deficiencies in diagnosis and planning in the overwhelming majority of malpractice cases
(5). Consequently, liability was acknowledged in the majority of cases (5) and in all cases of
permanent altered sensation (5, 116). All studies highlighted the deficiencies in preoperative
assessment, diagnosis and planning as causative agents in complications. Since preoperative
assessment, diagnosis and planning occur prior to the inception of the actual treatment,
correction of errors at these stages would have far reaching positive consequences in prevention
of negative treatment occurrences and unsatisfactory outcomes.
The dentists belief in a high degree of preventability of complications is encouraging, since it
suggests that the frequency or severity of complications may be decreased. The belief in
preventability of treatment complications expressed by the respondents in this research is in an
agreement with research findings from the medical hospital management field (16, 17),
government policies (8), the views of the public (32), and the experience in reducing
complications in several inherently risky activities (such as aviation (193) and medical
anaesthesia (194)). In the Harvard Medical Malpractice study (15) errors in management were
identified in 58% of adverse events. Leape et al. (15) concluded that although prevention of
many adverse events is hampered by limitations in current medical knowledge, the high
proportion that is due to management errors suggests that many others are potentially
preventable. Several inherently risky human activities (e.g., aviation (193)) and medical
endeavours (e.g., anaesthesia (194)) have been able to decrease substantially the occurrence of
accidents or complications by rigorously seeking out and eliminating sources of errors (195).
While limitations in current knowledge preclude us from eliminating negative occurrences in
health care entirely, the successes in aviation (193) and anesthesia (194) clearly demonstrate the
potential degree to which errors, accidents, and complications can be prevented.

114

Chapter 9
Overall Discussion and Conclusions
9.A: Study limitations
The observations and conclusions reported in this thesis must be interpreted within the
limitations of the study design. In this regard, several features of the survey could have biased
the results. One problem faced by this investigation was a low response rate that probably
limited analysis of some subgroups due to low numbers (i.e. the problem of inadequate power
could have prevented some of the findings from reaching statistical significance). The survey
was relatively long and many questions had a large number of options this can lead to fatigue
on the part of the respondents and may account for lower response rates to some questions
towards the end of the survey. Due to these limitations, the outcomes of this investigation may
be regarded as preliminary. In spite of these limitations, evidence from medical and dental
literature corroborated many of the observations and conclusions, thereby enhancing the notion
that the themes explored in this survey accurately reflect the clinical experiences and opinions of
the dental professionals.
The study relied entirely on self-reporting, thereby putting faith in the dentists ability and
willingness to recall information accurately. The degree to which professionals self-report
adverse events is unknown and is understandably hard to investigate. Self-reporting of events is
a function of event recall and willingness to report it. It is hypothesized that event types that
occurred more frequently or that created a strong emotional imprint on the dentist (due to their
severity or patient impact, for example) would be more likely to be recalled and registered as a
survey response. The discrepancy between the occurrence of adverse events and their voluntary
reporting (28) as well as the discrepancy between patient-perceived occurrence of post-operative
complications and surgeon-perceived occurrence of complications (176, 177) has been reported
in several studies in the medical literature dealing with hospitalized patients. To address the
possible hesitancy of some potential survey participants in revealing information about
complications and adverse events that they experienced, the web-based survey was deliberately
conducted anonymously.

115

The response rate was 23%, which might be considered to be relatively low. However, this is
compatible with the response rates reported in a number of other recent surveys of Ontario
dentists (e.g. a 17.3% response rate in a mailing survey of Ontario dentists local anesthetic use
(196) and a 15% response rate to a web-based survey examining opinions on endodontic
treatment (Dr. Amir Azarpazhooh, Personal Communication)). Nonetheless, the desired sample
size for general dentists was actually exceeded. High response rates were achieved from the
specialists (e.g. 45.1% response rate for periodontists and 40.0% response rate for
prosthodontists), but the ability to reach the desired sample size for specialists was significantly
hampered by the limited number of valid e-mail addresses available.

E-mail addresses were available for only a non-random subset of dentists in Ontario. (This issue
was already discussed in Section 5.B.) Hence, caution should be exercised in extrapolating data
from this survey sample to the entire dentist population of Ontario.

9.B: Study strengths

The major strength of this study was the ability to investigate the experience of complications
and opinions on a range of issues related to implant complications on the same geographically
defined population of dentists. This study was one of the first of its kind to investigate the
opinions of dentists regarding complications in implant dentistry. This study was also one of the
first to evaluate a large range of complications on a large single population, and was one of the
first to report on dentists experience with a number of specific complications. Such
complications included lack of primary implant stability, having to abort a surgical site, use of a
wrong implant brand (i.e., other than what was requested by the referring dentist), surgical stent
unusable (or not made how the dentists wanted it made), and food impaction.

This study was the first to look into the distribution of specific complications reported by a
population of dentists (rather than investigating the frequency of occurrence among dentists).
The following example makes the distinction clear. If 50 occurrences of a specific complication
occurred among 50 dentists, the frequency of occurrence would be one complication per dentist.
However, it is possible that all 50 occurrences were related to one single dentist, while the other

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49 dentists had never encountered this complication. The distribution of the specific
complication in a dentist population would have taken that into account. Because only 1 dentist
out of 50 experienced the complication, only 2% (1 in 50) would have reported this complication
in this survey. Therefore, this approach allows for the determination of how widely an issue is
encountered among dentists, rather than determining how frequently it is encountered. An issue
that is reported by a small number of dentists may still be very important by virtue of its severity
or the frequency with which it occurs among those dentists. However, the educational and
preventive approaches that might be pursued would vary significantly depending on the
proportion of dentists affected by the problem.

It is important to point out that a web-based survey rather than a traditional mail-out survey was
used in this study. Web-based surveys provide a number of significant benefits over traditional
mail-based surveys, and in recent years these benefits have been increasingly acknowledged and
utilized. Web-based surveys have been demonstrated to be valid alternatives to traditional mailand telephone-based surveys (197) while potentially enhancing survey completion rates (198)
and significantly reducing turnaround time and administration costs. These advantages have led
researchers to increasingly rely on web-based surveys in preference to the traditional mail-out
surveys. The accessibility of the target population to the internet remains the most important
issue with web-based surveys (197). However, this concern was considered to be minimal for
our study due to the above average usage of the internet among Canadian dentists (199).

The medical field contains a very broad literature base on complications, but there is a dearth of
such literature in the sphere of dental implant treatment. In the course of this thesis, concepts
and examples drawn from the medical literature were frequently used. Yet, significant
differences exist in the provision and consumption of health care between the in-patient medical
setting and the out-patient dental setting. These differences must be carefully considered when
interpreting medical literature and attempting to view it with a dental setting in mind. In
particular, most patients receiving dental implants do so for elective reasons seeking
improvements in the quality of life. Therefore, dental implant treatment is almost always an
elective treatment, and the assessment of risks and benefits must be viewed in this light.

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9.C: Implications and conclusions

The goal of dental implant treatment is to address patient-centered concerns in a cost-effective
and minimally intrusive manner that provides the patient with the greatest therapeutic benefit and
exposes the patient to the least risk. Since no intervention is entirely risk-free, the range of
possible complications must always be considered. This cross-sectional survey was a
preliminary attempt to clarify the relative experience of dentists with specific dental implant
complications in contemporary private practices and to determine dentists opinions regarding
those complications. A large number of complications and corrective actions were characterized
and reported in a single dentist population serving a large and diverse community of several
million people in Ontario, Canada. The knowledge of how complications are distributed among
different professional groups of general dentists and specialists may allow future intervention
strategies to be implemented targeting these specific groups, ultimately enhancing the quality of
implant treatment delivery.
This survey is one of the first to investigate dentists opinions on complications in a systematic
manner. Overall, there was little agreement among the four professional groups regarding the
causes of complications, some agreement regarding what should be done to decrease occurrence
of complications, and a great deal of agreement regarding the severity of complications and their
preventability. This suggests that beliefs regarding the causes of complications are specialty- or
educational background-specific. Thus, they may be influenced by the types of procedures
performed or by the types of complications encountered in clinical practice. However, beliefs
regarding the severity of complications and their preventability appear to be independent of
specialty affiliation or educational background.

The majority of dentists felt that complications were preventable. This observation reinforces
research results from other healthcare settings (15-17). Preventability of complications
highlights the need to focus on improvements in operator education, skill, and judgment as well
as improvements in technology that facilitate acquisition of operator knowledge and skill or
improve operator judgment. The focus on these human elements is likely to lead to further
reductions in complications associated with implant treatment. Nonetheless, many procedures

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carry risks that are understood incompletely and cannot be prevented entirely given the current
state of knowledge. A two-pronged approach dealing with the occurrence of both preventable
and currently non-preventable complications may be actively pursued to minimize the burden of
complications. Preventable complications may be addressed through educational channels and
through improvements in inter-professional and provider-patient communication. Currently nonpreventable complications may be addressed through research into their causative elements,
through preferential selection of procedures with a favourable complication profile, and through
careful patient selection that takes into account the gravity of the underlying condition and the
probability of successful treatment outcome. The dental workplace may be designed to permit
surveillance of adverse outcomes and to permit implementation of strategies to prevent their
occurrence and recurrence. Ideally, dentists would be able to address problems in their practices
preventively before the problems actually occur. Future research efforts should investigate the
impact of various intervention strategies aimed at prevention of dental implant complications.

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Appendix 1: The Survey

Introductory page
Implant Complications Survey Consent
Dear Colleague,
I am conducting a survey to determine the nature and types of dental implant complications that
occur in private dental practices. This survey is undertaken as part of my M.Sc. research.
Your opinions are important to help us understand the nature and the causes of complications
that are encountered during implant treatment. The information gained from this study will allow
educational initiatives to focus on implant complication prevention. The ultimate aim is to
minimize the frequency of implant complications in private practices. The survey consists of
multiple-choice questions, and its completion will take approximately 15 minutes.
Your completion of this survey is completely voluntary and all responses are anonymous and
completely confidential. All necessary measures to protect your privacy have been utilized in
accordance with the University of Torontos Ethics Committee. By completing this survey you
will provide the principal investigator with permission to use its contents for research and
educational purposed only. Regulatory bodies do not have access to the surveys contents.
If you have any questions or if you experience any difficulties with the survey, you can contact
me at 647-669-3671 (david.chvartszaid@dentistry.utoronto.ca).
Your input is very important to me and to your colleagues. Thank you in advance for your
participation.
Sincerely,
David Chvartszaid, DDS, MSc
3rd year resident, Discipline of Periodontics, Faculty of Dentistry, University of Toronto

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Implant treatment expertise questions

Q1. You are a(an)

general dentist

oral surgeon

periodontist

prosthodontist
Q2. What is your level of expertise in surgical implant treatment?

advanced

average

basic knowledge

none
Q3. What is your level of expertise in prosthodontic implant treatment?

advanced

average

basic knowledge

none
Q4. With respect to implant treatment, you provide:

exclusively prosthodontic implant treatment

primarily prosthodontic implant treatment and limited surgical implant treatment

both surgical and prosthodontic implant treatment

exclusively surgical implant treatment

primarily surgical implant treatment and limited prosthodontic implant treatment

I do not place or restore dental implants

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Complication questions
Q5. Did you experience, manage or treat the following surgery-related implant
complications in 2009?
(Check all that apply.)

significant bleeding

sinus membrane perforation (during a direct sinus lift procedure)

lack of primary implant stability

had to abort a surgical site after attempting unsuccessfully to place an implant

limited patient opening or unable to fit instruments

surgical stent unusable (not made how you would have made it or does not fit)

surgical treatment not prosthetically driven (implant placed without restorative input)

implant brand used other than what was requested by the referring dentist

significant thread exposure

cover screw or healing abutment not fully seated

damage to adjacent tooth

implant fracture (during placement)

incision line opening

implant dislodged into the sinus

severe post-operative infection (e.g. osteomyelitis, sinusitis)

temporary paraesthesia (or altered sensation)

permanent paraesthesia (or altered sensation)

I did not experience and did not manage (or treat) any surgery-related implant
complications in 2009

other (briefly describe)

The question below will ask you if a particular type of complication is "preventable".
"Preventable" means that with careful attention during treatment planning, execution or
follow-up the occurrence of this complication (or complication type) could be significantly
reduced or eliminated.
Q6. In general, are surgery-related implant complications (listed above) preventable?

yes, they are usually preventable

no, they are usually not preventable

Q7. Did you experience, manage or treat prosthodontic implant complications in 2009?
(Check all that apply.)

healing abutment loosening or dislodging

poor implant position (depth/angulation/spacing)

limited interocclusal space (for prosthesis fabrication)

implant non-restorable

unable to fully seat implant component or final restoration

incorrect impression taken (e.g. wrong component used), had to repeat impression, or
unable to take impression

resin/acrylic/porcelain fracture

prosthesis loosening

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prosthetic or abutment screw head stripping

prosthetic screw fracture
implant-supported overdenture clip (attachment) loosening
implant-supported overdenture clip (attachment) fracture
implant fracture (during function)
cement extrusion subgingivally/retained cement
prosthesis failure or need to remake prosthesis
I did not experience and did not manage (or treat) any prosthodontic implant
complications in 2009
other (briefly describe)

Q8. In general, are prosthodontic implant complications (listed above) preventable?

yes, they are usually preventable

no, they are usually not preventable

Q9. Did you experience, manage or treat biological implant complications in 2009?
(Check all that apply.)

no interproximal papilla or unable to close interproximal embrasure (must be

clinically significant)

healing abutment too short (leading to soft tissue overgrowth)

gingival inflammation (peri-implant mucositis)

fistula

recession implant (or final abutment) is visible through the buccal gingiva

peri-implantitis (severe continuous bone loss)

implant failure

multiple implant failure within the same patient

mandibular fracture

bisphosphonate-related osteonecrosis of the jaw

I did not experience and did not manage (or treat) biological implant complications in
2009

other (briefly describe)

Q10. In general, are biological implant complications (listed above) preventable?

yes, they are usually preventable

no, they are usually not preventable

Q11. Did you experience, manage or treat patient-related implant complications in 2009?
(Check all that apply.)

aspiration or ingestion of implant/component/driver

speech impaired with final prosthesis

ability to clean final prosthesis impaired

patient cannot get used to final prosthesis (comfort impaired)

slight patient dissatisfaction with aesthetics

significant patient dissatisfaction with aesthetics

patient complaint of food impaction

I did not experience and did not manage (or treat) any patient-related implant
complications in 2009

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other (briefly describe)

Q12. In general, are patient-related implant complications (listed above) preventable?

yes, they are usually preventable

no, they are usually not preventable

Q13. Taking all types of implant complications into account, what percentage of your
patients treated during 2009 experienced at least one implant complication?

0-5%

6-10%

11-15%

16-20%

21-25%

26-30%

>30%
Q14. Did you take the following corrective actions as a result of an implant treatment
complication in 2009?
(Check all that apply.)

communicated with lab/dentist/specialist about an issue with the case

retook impression

remade implant-supported prosthesis

trephined out (removed) an implant

buried an implant (put implant to sleep)

performed additional surgical procedures

increased length of treatment, number of procedures or office visits

increased professional fee or lab fee

had to deal with patients dissatisfaction

contacted PLP (Professional Liability Program)

referred patient to a specialist

no, I did not take any of the above corrective actions as a result of an implant
treatment complication in 2009

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Opinions on complications
Q15. A cause of a complication is defined as an underlying issue or factor leading to a
complication.
Which of the following are the most important underlying causes of most complications?
(Check one or more.)

poor overall planning (including excessive treatment complexity or risk)

poor inter-professional communication

poor basic knowledge of implant-related concepts

poor technical/surgical skills in performing implant-related treatments

lack of knowledge on how to recognize, manage or treat complications

lack of experience

conducting surgical procedure in an infected or inflamed site

ignoring dental disease on adjacent teeth or elsewhere in the mouth

failure to follow manufacturers recommendations

poor clinical or radiographic exam

lack of follow-up

failure to refer to a professional with greater experience (poor case selection)

implant placement not prosthetically driven (e.g. not using a surgical guide)

poor consent

poor patient compliance (including very poor oral hygiene)

compromised patients medical status (including smoking)

unrealistic patient expectations (including patient demand for procedures of increased

difficulty or risk)

excessive implant system complexity

company advertising portraying implant treatment as very simple or risk-free

Q16. What do you feel should be done to decrease the frequency and severity of
complications in private practice? (Check one or more.)

follow manufacturers recommendations

greater pre-testing of technologies before their introduction to the market

better patient education and consent

better dentist education

implant placement to be prosthetically driven

better treatment planning

refer difficult cases to a specialist

greater professional body role (e.g., CDA, ODA, RCDSO) in setting and enforcing
standards

establish a specialty of Implantology

be self-critical and learn from the complications

better inter-professional (dentists, lab) communication

mandatory implant complication reporting system

implant companies to publish more information on implant complication

experience/prevention

greater research into the nature and types of implant complications

better dissemination of research information about implant complications

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Q17. The following is a list of complications or steps that may be needed to resolve a
complication.
Ultimately, all of them cause a negative treatment outcome in terms of some parameter
(such as increased cost, time, morbidity, effort etc.).
Which of the following negative outcomes are most severe? (Check one or more.)

increased cost of treatment

increased duration of recovery from surgery (increased time off work)

increased number of radiographs taken (or need for additional imaging)

increased length of treatment

increased number of non-surgical procedures

increased number of surgical procedures

increased overall complexity of treatment

increased effort on the part of the dentist(s)

temporary paraesthesia (or altered sensation)

permanent paraesthesia (or altered sensation)

damage to adjacent tooth

cleaning difficulty of the final restoration (e.g. bridge)

interference with proper speech of the final restoration

poor appearance of the final restoration

poor comfort of the final restoration

frequent breakage (need for repair) of the final restoration

increased possibility of total treatment failure in the future

inability to achieve a satisfactory outcome as it was originally envisioned

Q18. Where does most of your knowledge related to implant complications come from?
(Check one or more.)

my own experience

speaking with colleagues

dental implant journals

continuing education courses

implant company/reps

textbooks

conferences

dental school curriculum

specialty program
Q19. Whose responsibility is it to make dentists aware of the potential complications with
dental implant treatment?

my own it is my responsibility to educate myself

implant company

dental school

regulatory body

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Demographic questions
Q20. What year did you graduate from the Dental School?

1950-1959

1960-1969

1970-1979

1980-1989

1990-1999

2000-2009
Q21. If you are a specialist, what year did you graduate from the specialty program?

1950-1959

1960-1969

1970-1979

1980-1989

1990-1999

2000-2009

I am not a specialist
Q22. How many years have you been involved in implant dentistry?

0-5

6-10

11-15

16-20

>20
Q23. How many patients did you finish treating with implants in a typical month of 2009?

0-5

6-10

11-15

16-20

21-25

>25
Q24. How many implants did you surgically place in a typical month of 2009?

1-10

11-20

21-30

31-40

41-50

51-60

61-70

71-80

>80

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Q25. How many implants did you finish restoring in a typical month of 2009?

1-10

11-20

21-30

31-40

41-50

51-60

61-70

71-80

>80
Q26. Did you experience a complication in 2009 that you were not aware of until you
experienced it yourself?

yes

no
Q27. If yes, do you feel that having prior knowledge of this complication would have helped
you prevent it?

yes

no