Oral Maxillofacial Surg Clin N Am 15 (2003) 243 – 249

Complications associated with the placement of

dental implants
Leon Ardekian, DDSa,b,*, Thomas B. Dodson, DMD, MPHc
a
Department of Oral and Maxillofacial Surgery, Rambam Medical Center, 35245 Haifa, Israel
b
Department of Medicine, The Technion, Haifa, Israel
c
Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine,
Boston, MA, USA

Replacing missing teeth with osseointegrated den-
tal implants is a predictable technique, as evidenced
by an overall 5-year implant survival rate that ranges
between 93% and 97% [1 – 3]. Few studies, however,
systematically have addressed the frequency or nat-
ural history of complications related to the use of
dental implants [4 – 7]. Reported complication rates
range so widely (ie, 1% – 40%) as to be rendered
clinically meaningless [4,6,8]. Differences in reported
rates may be attributable to differing definitions of
complications. Even less has been written about risk
factors for developing surgical complications related
to the use of dental implants [5,9].
Knowledge regarding the type and frequency of
complications that can occur with implants is an
important aspect of treatment planning, surgeon-
patient communication, informed consent, and post-
treatment care. The purposes of this article are to
(1) summarize the reported types and frequencies of
implant-associated complications, (2) identify risk
factors for developing complications associated with
This article was prepared with support in part from the
Midcareer Investigator Award in Patient-oriented Research
NIH/NIDCR K24 DE000448 (T.B. Dodson).
* Corresponding author. Department of Oral and
Maxillofacial Surgery, Rambam Medical Center, 35245
Haifa, Israel.
E-mail address: ardekian@hotmail.com (L. Ardekian).
the use of dental implants, and (3) suggest strategies
to avoid complications.
Materials and methods
The authors have conducted a structured review of
the literature. It is beyond the scope of this article to
perform a complete review of the literature; rather the
authors have identified high-quality articles that deal
with implant-related complications. They applied
expert natural history and prognosis search filters
available through Ovid. The authors identified addi-
tional articles by hand searching retrieved articles,
reviews, monographs, and textbooks. All available
clinical studies from 1981 to 2002 that presented
success data regarding dental implants were eval-
uated, and type and prevalence of reported complica-
tions data were abstracted. Articles excluded from this
review were reports on implants placed in association
with other local reconstructive procedures (eg, sinus
grafting). A total of 325 study abstracts were iden-
tified and reviewed. 112 articles were retrieved and
evaluated in detail, and of these articles, 85 were
included in this article.
Complications were classified as operative or
inflammatory. Operative complications occurred dur-
ing or as a result of an operation and included
bleeding, nerve injury, displacement of the implant,
fracture, or injury to adjacent teeth. Inflammatory
complications occurred at any stage of the implant
treatment and included infection, periimplantitis,

1042-3699/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1042-3699(03)00014-1
244 L. Ardekian, T.B. Dodson / Oral Maxillofacial Surg Clin N Am 15 (2003) 243–249
periimplant mucositis, mucosal hyperplasia, and
fistula formation.
Results
The overall reported complication rate averaged
25% and ranged from 1% to 45%. Operative com-
plications averaged 15% and ranged from 1% to 30%
[1,4,5,8]. Inferior alveolar nerve (IAN) injury ranged
from 1% to 30%. Serious bleeding, implant displace-
ment, mandibular fractures, and injury to adjacent
teeth occurred in less than 1% of cases. Inflammatory
complications comprised approximately 10% of all
complications and ranged from 1% to 32%. The
average complication rates reported for periimplant
mucositis, hyperplastic mucositis, periimplantitis, and
fistula formation were 10%, 7%, 9%, and 6%, respec-
tively [4,5,7,10,11].
Operative complications
Bleeding and hematoma
Hematoma formation and bleeding after implant
placement reportedly occurs in 0% to 29% of cases
[12 – 14]. Bleeding is commonly controlled with local
measures and is considered a minor complication.
Hematoma formation after placement of dental
implants usually resolves completely with minimal
sequelae [13,14]. Life-threatening bleeding is rare,
and only seven cases are reported in the literature
[15 – 19]. Sublingual, submental, or submandibular
swelling in conjunction with tongue elevation was
observed in all seven of these cases. Suggested risk
factors for bleeding include location, perforation of
the lingual cortex, and implant length. All of the
implants in the case reports were placed in the canine
or premolar region, perforation of the lingual cortex
intraoperatively was noted, and all implants were
18 mm or larger.
Careful preoperative preparation and intraopera-
tive attention may reduce the risk of significant
bleeding. Preoperative CT imaging with coronal
reconstruction promotes a better understanding of
the local anatomy and may reveal unanticipated
concavities in the lingual cortex of the mandible. A
CT-guided prefabricated surgical splints guides the
osteotomy bur to its proper position while avoiding
perforation of the lingual cortex, especially in the
presence of extensive sublingual fossae. During site
preparation, the surgeon may note the presence of
small fragments of soft tissue on the bur, which
suggests lingual perforation. Intraoperative probing
can be helpful for detection of bony perforations.
Using implants smaller than 16 mm also may reduce
the risk of lingual perforation and reduce the like-
lihood of this problem.
Nerve injury
The incidence of neurosensory disturbance after
placement of dental implants ranges from 0.6% to
36% [3,12 – 14,20 – 36]. In general, research in the
area of posttraumatic trigeminal nerve deficits is
compromised by the lack of uniform comparable data
documenting nerve injury, absence of a ‘‘gold stan-
dard’’ for neurosensory testing, and selection bias
associated with censored data caused by lack of
follow-up. In implant research, these problems are
compounded by the poor or absent documentation of
the injury, inconsistency in description and manage-
ment of sensory disturbances, and variable denomi-
nators (ie, patients or implants).
Inferior alveolar nerve injury during implant place-
ment may result from direct mechanical damage to
the nerve, compression of the nerve and vessels,
damage to vessels with bleeding into the canal that
results in a compartment-like syndrome, or the forma-
tion of a traumatic neuroma [37]. The risk factors for
IAN injury during implant placement include the use
of nerve repositioning or lateralization procedures
and implant placement in the severely atrophic man-
dible [25,31,32,38].
Preoperative CT imaging of the atrophic posterior
mandible may facilitate the prevention of IAN injury
associated with implant placement. Intraoperative peri-
apical radiographs can be helpful during site prepara-
tion to estimate apical position of the implant site in
relation the IAN before implant insertion. The diag-
nosis and documentation of nerve injury after implant
placement is crucial for management. It is useful to
separate injuries according to whether they have been
complete or partial, as determined by detailed sequen-
tial neurosensory testing. Effective treatment of nerve
injuries depends on the clinician’s capacity to assess
the nature and severity of the injury and estimate the
probability of spontaneous recovery. Standardized,
serial neurosensory examinations are critical to the
decision-making process. Early postoperative anesthe-
sia suggests that direct, significant injury to the IAN
and removing the implant promotes early decompres-
sion of the nerve and may improve outcome.
Mandible fractures
Mandible fractures after implants placement are
rare (reported frequency of V 0.2%) [2,39]. Etiolo-
 L. Ardekian, T.B. Dodson / Oral Maxillofacial Surg Clin N Am 15 (2003) 243–249
gically, fractures may occur because implant site
preparation creates an area of stress concentration
and weakness in the bone. Routine oral activities
could result in pathologic fracture. The major risk
factor for fracture is a severely atrophic mandible
[7,33,40 – 43]. Other risk factors include lateralization
of the IAN in association with implant placement,
osteoporosis, and trauma to the mandible after
implant placement [44]. To prevent fractures, the
authors advocate imaging the severely atrophic
mandible to evaluate better the three-dimensional
anatomy of the proposed site. Avoidance of wide
implants in cases of nerve lateralization also may
decrease this risk. In cases of severe resorption, bone
grafting to increase mandibular volume and bulk may
be indicated.
Implant displacement
During implant placement or abutment connec-
tion, there is a risk for displacing the implant from its
site to adjacent anatomic structures (eg, the maxillary
sinus, nasal floor, or mandibular canal) [45 – 47]. The
authors found no reports estimating the frequency of
this complication. Risk factors for implant displace-
ment are placement of implants in soft (type IV) bone
and in close proximity to the maxillary sinus or
mandibular canal. To avoid this complication, the
authors advocate a thorough preoperative evaluation
of the bone quality, especially in posterior maxillary
cases. Evaluation of the implant site with a probe
before insertion of the fixture is helpful to detect
bony perforations.
Early, unplanned implant exposure
Premature exposure of a staged dental implant
because of wound breakdown occurs with a reported
frequency of 2% to 11% [1,12,20,34,46,48 – 54].
Early exposure of two-stage dental implants may
be associated with an increased risk for inflamma-
tory complications, including crestal bone loss and
periimplant soft tissue inflammation [52,54]. Patients
with early implant exposure have an almost fourfold
increased risk for bone loss when compared with
cases in which wound integrity is maintained [52].
Dehiscence in esthetic areas may compromise the
final esthetic outcome and necessitate soft tissue
grafting. Risk factors for premature implant expo-
sure include immediate implant placement after
extraction or placement in association with recon-
structive procedures, such as bone grafts or mem-
branes. Mobile removable prostheses also may
predispose to this problem [1,51,55,56]. Denture
245
adjustment to avoid contact with the implant site is
important. To avoid premature implant exposure, any
pressure on the wound must be eliminated. A metic-
ulous closure of the wound without tension after
reconstructive procedures is valuable for avoiding
this complication.
Damage to adjacent teeth
Injury to adjacent teeth associated with implant
placement is a rare, but reported, complication
[35,57]. The authors found no reports estimating the
frequency of this complication. Injury to adjacent
teeth is caused by insufficient space between implants
and teeth or placing the implant at an improper
angulation. Adequate preoperative imaging and use
of a prefabricated splint when placing implants help
prevent inadvertent injury to adjacent teeth.
Inflammatory complications
Inflammatory complications can occur at any time
during implant treatment. For the purpose of this
article, inflammatory complications are divided into
acute and chronic categories. Acute inflammatory
conditions include perioperative infection, cellulitis,
and abscess formation [58 – 60]. Chronic inflamma-
tory conditions include soft tissue periimplantitis
(mucosal erythema and edema) and hard tissue peri-
implantitis (progressive bone loss or periimplant
radiolucent lesions) [1,3,10,33,35,37,39,41,59,61].
Acute inflammatory conditions
Perioperative infection after implant placement
ranges from 1% to 3% and increases the risk for
implant failure [20,35,38,59 – 61]. Among the risk
factors for developing this complication is overheat-
ing of the bone during site preparation. The use of
aseptic technique and avoidance of implant place-
ment into previously infected sites may reduce the
risk for infection. Prophylactic antibiotics adminis-
tered before implant placement reportedly decreased
early failure rates twofold to threefold [62]. Chlor-
hexidine rinses have been found to reduce infection
during the initial healing period [40]. When preoper-
ative antibiotics were given, there was no incremental
benefit noted with the concomitant administration of
chlorhexidine [40,62,63]. There are only sporadic
case reports on serious infections after placement of
dental implants that required hospitalization [16].
246 L. Ardekian, T.B. Dodson / Oral Maxillofacial Surg Clin N Am 15 (2003) 243–249
Chronic inflammatory conditions
Chronic inflammatory complications occur with
a reported frequency of 1% to 32% [1,3,10,33,
35,37,39,59,61,64,65]. For the purposes of this
article, chronic inflammatory complications are
classified as soft tissue periimplantitis and hard tis-
sue periimplantitis. Soft tissue periimplantitis is an
inflammatory process that involves soft tissue sur-
rounding an implant without signs of bone loss. Soft
tissue periimplantitis occurs most commonly in asso-
ciation with implant-supported overdentures, with a
reported frequency ranging from 11% to 32%
[43,57,66 – 70]. Rates of soft tissue periimplantitis
associated with implant-supported fixed prostheses
range from 7% to 20% [1,2,14,61]. Risk factors
include unstable overdentures that result in mucosal
ulceration and hyperplasia, misaligned implants,
implants that traverse nonattached gingival tissue,
poor oral hygiene, improper use of the abutment
or healing caps, and presence of dead space under
the superstructures.
Fistula formation at the abutment – implant inter-
face may be one manifestation of hard tissue peri-
implantitis. It was reported in the literature with an
incidence of 0.02% to 25% [1,2,12,13,38,48,68].
Risk factors for developing chronic fistulas include
poor oral hygiene and a gap between the implant
components that creates a nidus for infection.
The frequency of hard tissue periimplantitis and
progressive bone loss is low, but its occurrence is
well documented in the literature. If unchecked, it
may result in loss of implant support and ultimate
prosthesis loss. Several studies have reported on the
average marginal bone loss that occurs during the
first year after implant placement [1,12,13,20,71,72].
Mean bone loss was 0.93 mm (range 0.4 mm –
1.6 mm). The mean loss during subsequent years
was 0.1 mm per year (range 0 mm – 0.2 mm [14,73].
Risk factors for hard tissue periimplantitis include
early implant exposure and poor oral hygiene. Infec-
tion located at the apical area of the implant is another
manifestation of hard tissue periimplantitis and is
often associated with implant failure. The frequency
of apical periimplantitis is approximately 0.3%
[43,51,56,69,74 – 76]. These lesions are often found
at the apical part of long implants placed into dense
bone. Apical implant lesions may be completely
asymptomatic or present with tenderness, persistent
pain or swelling, and fistula formation. The risk
factors for apical periimplantitis include excessive
heating of the bone during insertion, residual bone
cavities created by the placement of implants that are
shorter than the prepared surgical site, and bacterial
contamination from either extracted teeth or a seeding
mechanism from the remaining natural teeth.
Smoking as a risk factor for developing inflam-
matory complications is controversial [9]. Enquist et
al found more loss of periimplant marginal bone loss
in smokers than in nonsmokers. This rate was corre-
lated with the amount of cigarette consumption [9].
Other researchers were unable to demonstrate a
significant correlation between smoking and inflam-
matory complications [6,9,60].
Summary
This article identifies the operative and longi-
tudinal complications associated with the placement
of dental implants and discusses predisposing con-
ditions and risk factors. Because of the variability in
the reporting of complications, only a small number
of articles present data about their incidence. Sur-
prisingly, the most common surgical complications
are neurosensory disturbances and hematoma forma-
tion. Inflammatory complications (both soft and
hard tissue) are most commonly associated with
implant failure.
Complications can be avoided or reduced by
proper patient selection and evaluation. A careful
evaluation and understanding of the bone anatomy
and architecture, including the quantity and quality of
available bone, are mandatory before implant place-
ment. In addition to the physical examination and
plain radiographs, CT imaging with the patient
wearing a radioopaque lined stent yields valuable
information and aids in the planning process. A
thorough clinical and radiographic examination can
be helpful in determining morphologic abnormalities
and reducing the incidence of operative complica-
tions, such as perforation of the lingual cortex,
associated bleeding, and damage to contiguous struc-
tures [5,6,10,61,77 – 79].
Careful implant site selection, appropriate angu-
lation, and soft tissue handling may decrease mucosal
inflammatory complications. Longitudinal follow-up
and assessment of bone and soft tissue health sur-
rounding implants should promote longevity and
minimize these complications.
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