GOOD MORNING

DENTAL
IMPLANT
FAILURES
- By Dr.Jyothi S.G.

CONTENTS

Introduction
Systemic factors contributing to implant failure
Osseointegration
Systemic influences on alveolar bone
Osteoporosis
Psychosocial factors influencing implant success
Errors in maintaining sterility
Errors due to implant contamination
Errors in surgical technique
Errors in implant positioning
Errors in implant exposure
Pitfalls in implant dentistry from a laboratory
perspective

 Prosthetic salvage of surgical misadventures

in implant placement
Prosthodontic considerations in first stage
implant failures
The influence of tobacco use on endosseous
implant failures
Implant design and manufacturing as
predictors of implant failure
Soft tissue conditions influencing implant
failure
Microbiologic contribution to soft-tissue
health
Microbiologic mechanism for implant failure
Peri - implantitis
Diagnosing the failing implant
Predictors of failure
Treating the failing implant
Conclusion

Biology of Osseointegration (Branemark)

 Albrektson describes the physiologic

conditions that are required for
osseointegration, including
adequate bone cells to achieve bone
healing,
adequate nutrition to these cells
(blood supply), and
adequate stimulus for bone repair.
When these conditions are present,
osseointegration can be achieved with
a high degree of success.

INTRODUCTION
The goal of implant therapy is to
provide long-term replacement for
missing dentition on ideally positioned
osseointegrated implants.
Advances in radiographic imaging,
splint construction, bone regeneration
capabilities,
and
soft-tissue
reconstruction permit placing implants
predictably in acceptable positions.

 Surgery for dental implants is

a procedure with a high rate of
patient success defined as
providing a viable implantsupported
prosthesis
that
satisfies the patient.
However, as with any medical
procedure, failures occur.

 In a few cases, acceptable surgical and

prosthetic outcomes do not meet with
satisfaction from the patient.
Such failures probably often have little to
do with the implant team's technical
competence.
As with most complex reconstruction
procedures that involve a degree of
collaboration between an imlantologist
and a patient, patient factors that
influence the imlantologist - patient
relationship and the patient's compliance
with imlantologist requests may play a
key role in this procedure's ultimate
success.

 An implant or a tooth diagnosed as a clinical

failure is easier to describe than is a success.
Signs and symptoms of failure for an implant
are
1) horizontal mobility beyond 0.5mm or any clinically
observed vertical movement under less than 500 g
force,
2) rapid progressive bone loss regardless of the stress
reduction and periimplant therapy,
3) pain during percussion or function,
4) continued uncontrolled exudate in spite of surgical
attempts at correction,
5) generalized radiolucency around an implant,
6) more than one half of the surrounding bone is lost
around an implant, and
7) implants inserted in poor position , making them
useless for prosthetic support.

CLASSIFICATION
Based on the cause of implant
failure
Preoperative
Intra operative
Post operative

PREOPERATIVE
Patient Selection
Comprehensive
treatment
with
osseointegrated implants begins
with
patient
evaluation
and
selection.
Considerations should be given to
chronic illnesses because they
contribute
to
reduced
organ
reserve and the patient's ability to
have the surgical placement of
implants.

 Matukas
reviewed
potential
medical risks associated with
surgery for dental implants. He
reviewed several diseases that
potentially can reduce organ
Cardiovascular
reserve
Heart failure
Coronary artery disease
Hypertension
Unexplained arrhythmia
Respiratory
Chronic obstructive pulmonary disease
Asthma

Gastrointestinal
Nutritional status
Hepatitis
Malabsorption syndrome
Inflammatory bowel disease

Genitourinary
Chronic renal failure

Endocrine
Diabetes
Thyroid disease
Pituitary/adrenal disease

 Musculoskeletal
Arthritis
Osteoporosis
Neurologic
Stroke
Palsy
Mentation

 Fonseca and Davis have recommended that absolute

medical contraindications to endosseous implant
surgery include

Pregnancy,
Granulocytopenia,
Steriod use,
Continous antibiotic coverage,
Brittle diabetes,
Hemophilia,
Ehlers-danlos syndrome,
Marfan's syndrome,
Osteoradionecrosis,
Radiation, renal failure,
Organ transplants,
Anticoagulant therapy,
Fibrous dysplasia, and
Crohn's disease.

Relative contraindications.
Infectious hepatitis,
Recent myocardial infarction,
Blood dyscrasias,
Uncontrolled diabetes,
Severe alcoholism,
Chronic steroid use,
Renal diseases, and
Uncontrolled metabolic
disorders

 Zeitler and Fridrich reported that tissue

perfusion and microvascular diseases
have an important role in wound
healing.
In their report, they described the
importance of tissue oxygenation and
oxygen tension as they relate to tissue
perfusion as factors in tissue healing.
Systemic diseases such as diabetes
mellitus and collagen diseases such as
scleroderma,
systemic
lupus
erythematosus, rheumatoid arthritis,
and
Sjogren's
syndrome
have
microvascular changes that can cause
decreased oxygenation due to poor
vascularity and have poor wound healing
potential.

 Evidence suggests that bone disorders

such as osteoporosis may compromise
the
success
of
dental
implant
placements that require preliminary
bone building.
Albrektsson has outlined the response
of bone tissue to endosseous implants.
He describes the physiologic conditions
that are required for osseointegration,
including adequate bone cells to
achieve
bone
healing,
adequate
nutrition to these cells (blood supply),
and adequate stimulus for bone repair.

 Albrektsson also states that there is a

"primary interference to integration."
These include traumatic surgery, in
which the frictional heat generated
during placement of the implant causes
necrosis of the surrounding cells and
causes a lack of healing and integration.
The
second
interference
to
bone
integration is an implant bed of low
healing potential.

What
can
cause
recipient site of
potential?

an
low

implant
healing

Albrektsson states that there are some

indications
that
various
systemic
diseases such as rheumatoid arthritis
negatively influence osseointegration.

THE INFLUENCE OF TOBACCO USE ON

ENDOSSEOUS IMPLANT FAILURES
It has been shown that dentate
smokers have a higher incidence
and greater severity of periodontal
disease and that smokers treated
with dental implants have a greater
risk of developing peri-implantitis.
a case was reported on the relation
of smoking to impaired intraoral
wound healing and the loss of
endosseous implants.

PSYCHOSOCIAL FACTORS INFLUENCING

IMPLANT SUCCESS
1. Patients
who
lack
external
support
(financial, social).
2. Patients who lack the cognitive capacity (or
skill capacity).
3. Patients who have emotional problems.
4. Patients
who
have
a
pattern
of
interpersonal problems
5. Patients who consistently engage in
behaviour
6. Patients who maintain general health and
illness attitudes and beliefs.

ERRORS DUE TO ANATOMIC

VARIATIONS AND ABNORMALITIES

Ideal fixture placement depends

on
a
detailed
preoperative
clinical
assessment
of
bone
configuration,
quality,
and
quantity.
Periapical
and
panoramic
radiographs of the maxilla and
mandible
usually
provide
additional methods to assess
bone conditions.

 Periapical views are necessary when the

implant is to be placed in approximation
to the natural dentition.
Intraoral dental radiographs accurately
locate the position of the adjacent roots
and help to avoid iatrogenic injury to
these structures.
When necessary, lateral cephalometric
radiographs as well as CT provide
additional cross-sectional information
on
bone
height
and
anatomic
configuration.

 Relation to the inferior alveolar

nerve
Relation to the mental nerve
The bone immediately surrounding
the region of the nasal cavity and
maxillary sinus is often thin, and
these areas may be penetrated
accidentally when placing implants.
The lingual aspect of the mandible
in the molar region is another area
in
which
errors
in
implant
placement can occur.

 Bone quality ranges from dense,

compact, and relatively avascular
bone to cancellous bone with a
spongy texture.
The type of implant design
selected should match the quality
of bone into which it is placed.
Press-fit implant design -high
percentage of cancellous bone.
Pretapped implant -bone is dense,
compact, and poorly vascularized.

 Screw-shaped
implant
design
provides greater surface area for
interaction with the host bone
tissue,
enhanced
initial
stabilization, greater resistance to
sheer forces.
Primary stability is important for
the bony integration and long-term
success of the implant.

ERRORS IN MAINTAINING
STERILITY
A
proper
sterile
operating
environment is one of several
factors critical to the achievement
of successful osseous integration.

ERRORS DUE TO IMPLANT

CONTAMINATION
Contamination of the implant surface
interferes with osseointegration and
must be scrupulously avoided.
Surgical gloves should be free of
powder residue

 Surface contamination could eliminate

the implant's unique ability to integrate
with the adjacent bone.
Contaminants can become the bad
apple in the barrel and lead to tiny or
even widespread areas of interference
with the osteoblast-titanium oxide
connection interaction.
Implant site should be irrigated.
Titanium implants must be carried by
titanium instruments.

ERRORS IN SURGICAL TECHNIQUE

Successful
implant
placement
depends highly on proper surgical
technique
Maintaining an adequate blood
supply
Reducing
hard-and
soft-tissue
surgical trauma
Incisions
Osteotomy technique

 Healthy, viable bone is critical for the

successful integration between the bone
and the implant surface.
Therefore, heat injury to bone must be
avoided during the drilling process.
A study by Eriksson and Albrektsson
showed that there should temperature for
heat-induced injury to bone tissue is 47 0C
applied for 1 minute.
Temperatures above this level result in
bone resorption and fat cell degeneration.

 Three factors causing overheating of

bone:
1) inadequate irrigation at the time
of the implant site preparation,
2) generating excess heat by force
torquing the drills into dense bone,
and
3) using dull drill bits, especially in
the case of dense bone

 Heat-injured bone is replaced by less

differentiated
tissue,
which
is
incapable of the normal adaptive
remodeling ability of bone.
Additionally, a study showed that the
heating of bone above the critical
470C level significantly affects the
bone's ability to regenerate.
The capacity of the host site to
regenerate bone is critical for the
process of osseointegration to take
place.

How to minimize heat generation

during drilling?

Using sharp drills

A gradual increase in drill diameter.
Drill speed
Eriksson and Albrektsson have shown that
2000 rpm is the optimal rotational speed for
the creation of endosseous implant sites.
According to Misch cancellous bone should
be drilled at 800 rpm, whereas dense bone
should be drilled at a speed of 1500 rpm.

 Copious irrigation with chilled

normal saline solution
Such irrigation not only cools the
bone and drill but also lessens the
accumulation of cutting debris that
can become interposed between
the bone and implant surfaces.
Eccentric movements of the drill
should be avoided.

 Bone drills that bind and lock

during site preparation should be
freed by reversing direction and
should not be rocked back and
forth to disengage the drill.
Such
movements
not
only
increase
the
size
of
the
preparation but also possible
cause for injury and lead to
necrosis of bone cells.

 Countersinking of the implant site is

often necessary to accommodate the
flared neck of the implant, care must
be taken when thin cortical plates are
present.
In this situation, the countersinking
drill may reduce the thickness of the
cortex to such an extent that it
devitalized the bone and leads to early
exposure of the implant surface.
It also decreases the cortical support
against vertical forces and predisposes
the implant to functional overload.

ERRORS IN IMPLANT
POSITIONING

An implant may integrate successfully with

the surrounding bone but ultimately be a
clinical failure because it is too poorly
positioned
to
support
a
functional
prosthetic restoration.
Attention
to
proper
intraoperative
angulation as well as maintenance of a
parallelism between implant and between
implants and the natural dentition,
contribute to optimal and successful
prosthetic design and function.

 Too far to the buccal or in lingual version

may integrate successfully, this can
cause a bone dehiscence, a lack a
bicortical support, and eventual implant
exposure.
Implants placed in lingual version also
can cause irritation of the mobile tissue
in the floor of the mouth.
In addition to having proper orientation
and alignment in bone, implants should
be placed a minimum of 2 mm from each
other or from natural teeth.
This amount of space is necessary for
the formation of an esthetic and
anatomically functional prosthesis.

ERRORS IN IMPLANT
EXPOSURE

Generally 4 to 6 months are allowed for

healing of an endosseous integration to
take place before the implants are
exposed and healing abutments placed.
When exposing implants in the anterior
maxilla,
the
esthetics
of
future
restorations should be considered because
an unesthetic restoration is also a failure.
Factors to consider include providing
sufficient soft-tissue bulk for a convex
ridge form, creation of interproximal
papillae and proper gingival contour, and
assuring that there is keratinized gingiva,
surrounding the labial aspect of the
crown.

PITFALLS IN IMPLANT DENTISTRY

FROM A LABORATORY
PERSPECTIVE
Restorative nightmares created by lack of adequate

communication among all implant team membersrestorative, surgical, patient and laboratory-when
treatment planning cases.
Not being able to meet patients expectations of
esthetics and function of implant supported
restorations due to improperly placed implant fixtures.
Not being able to meet patients expectations and
desires for the type of prosthesis, fixed or removable,
because treatment option limitations were not fully
explained by the restoring doctor or not fully
understood by the patient.
Increased restoration cost-not anticipated but
incurred-when additional components must be bought
or made in attempt to restore improperly placed
implants.

PROSTHETIC SALVAGE OF SURGICAL

MISADVENTURES IN IMPLANT
PLACEMENT

However, if ideal implant position is

not achieved and prosthetic salvage
may be necessary to retrieve the
case.
The ability to correct adverse fixture
angulations
for
prosthetic
reconstruction
is
therefore
a
necessary and important aspect of
implant rehabilitation.

 Slight Angulation
Moderate angulation

 When complications occur, the

precipitating factors must be
identified and eliminated, if
possible.

IMPLANT DESIGN AND

MANUFACTURING AS PREDICTORS OF
IMPLANT FAILURE
Macroscopic
Structure
Surface Composition

Microscopic Structure

Implant
Success

SOFT TISSUE CONDITIONS

INFLUENCING IMPLANT FAILURE

MICROBIOLOGIC MECHANISM FOR

IMPLANT FAILURE :
When implants fail due to compromise of the
soft tissues, there is destruction of the biologic
seal similar to the disruption of the
perimucosal seal in periodontitis.
Because the microflora is similar with diseased
implants and teeth, one could hypothesize that
the mechanism for bone destruction around
implants would be similar to that of teeth.
However, the literature has not yet definitively
proved this to be true; only through clinical
reports and limited patient series we can make
this analogy.

 The
destruction
of
the
supporting
apparatus of teeth is through a sequence of
events that involve endotoxin, cytokines,
and cells of the periodontal region.
Endotoxin is a component of the cell walls
of all gram-negative bacteria, such as those
involved
with
periodontitis:
A.
actinomycetemcomitans, B. forsythus, P.
gingivalis, P. intermedia, W. recta, and oral
spirochetes.
Macrophages are activated by endotoxin
and produce proteases that destroy
collagen and proteoglycans.

 These activated macrophages produce

cytokines such as interleukin-1 (IL-1) and
prostaglandin E2 (PGE2).
IL-1 acts in an autocatalytic fashion to
stimulate more macrophages and activate
fibroblasts to produce additional proteases
and to produce more PGE2.
The osteoblast is the target cell of PGE2,
leading to resorption of bone.
It is likely that these mechanisms are
present in inflammation mediated implant
failure. It follows that treatment of
inflamed implants with bone loss involves
detoxification of the implant surface and
removal of endotoxin.

PERI-IMPLANTITIS
Peri-implantitis : inflammatory changes
confined to the soft tissue surrounding an
implant.
Peri-implantitis
:
radiographcially
detectable
peri-implant
bone
loss
combined with a soft-tissue inflammatory
lesion that demonstrates suppuration and
probing depths 6mm. The process
begins at the coronal aspect of the
implant, whereas the more apical portion
remains
clinically
stable
(osseointegrated).

Microbiology :
Multiple studies have demonstrated that
maintenance of optimal soft-tissue health
around functioning implants results in a
peri-implant microflora predominated by
streptococci and nonmotile rods.
This is essentially identical to the
microflora around healthy teeth.
Putative
periodontal
pathogens,
for
example,
Porphyromonas
gingivalis,
prevotella intermedia, or spirochetes,
were either not recovered at all or were
minor components of the subgingival flora
in healthy sites.

Treatment
Efforts at decontaminating the pathologically exposed
implant surface fall primarily into one of two broad
categories : mechanical and chemotherapeutic.
Provide diligent treatment of periodontal conditions in
the natural dentition.
Observe and correct mechanical cofactors
Prescribe chlorhexidine mouth rinses
Prescribe anaerobic and aerobic antibiotic therapy for
several weeks.
Remove
component
hardware
to
manage
inflammatory disease surgically.
Consider chemical and physical treatment of the
fixture.
Consider guided bone regeneration to restore
lost bone.

What steps can be taken

prudently to salvage a failing
Three phases related to the
fixture?
intervention process are offered:
(1) observing for predictors of
failure, (2) diagnosing the source
of the failure, and
(3) treating the condition(s)
responsible for the decline in
implant restoration health.

GOOD MORNING

DENTAL IMPLANT FAILURES

Continued

Precautions to be taken
Avoid positioning implant heads above the
alveolar ridge crest.
Develop flaps that are well vascularized and
mobile.
Observe well-established soft-tissue repair
principles.
Tightly secure all cover screws.
Reaffirm dietary laws with the patient.
Intercept trauma from opposing dentition with
bite splints.
Apply principles of infection management
early.

 Observe for noncompliance and diet

transgressions.
Reline or remove poorly fitting
interim prostheses.
Test for osseintegration (Periotest,
controlled reverse torque).
Consider
dentoalveolar
causes
(adjacent teeth, jaw fractures, periimplantitis).

 Precisely position healing and permanent

abutments.
Respond quickly to signs of abutment
related inflammations.
Frequently
observe
transitional
appliances for adequacy and implant.
Review oral hygiene responsibilities and
techniques.
Provide oral prophylaxis as often as
indicated.

 Poorly compliant patients require

more frequent professional services.
Be aware of the average life
expectancy of fixture parts and
attachments.
Periodically plan re-treatments of the
case
to
accommodate
new
developments.
Recall
periodicity
must
be
individualized.

CONCLUSION
Prevention, interception, and recovery are
the watchwords of restoring the failing
implant.
Any adverse findings related to implant
components,
peri-implant
disease,
radiographic
changes,
or
persistent
patient complaints should be interpreted
as threatening to the life of the implant.
Problematic patient factors must be
anticipated, compromised surgical or
prosthetic conditions must be recognized,
and acquired implant disease states must
be treated early and vigorously.

 First stage implant failure can be

prevented but not treated. Early second
stage failure may represent a biologic
failure or injudicious technique.
Late second stage failure is usually a
product of lack of care, mechanical
loading, or poorly understood inflammatory
conditions.
Optimal implant health is the only sure
predictor of future implant well-being.
An ailing implant is a failing implant. Signs
of adverse developments should prompt an
immediate
diagnostic
initiative
and
corrective action.