Sie sind auf Seite 1von 104

Failures in Implants

Contents
Introduction
Definitions
Predictors of implant success or failure
Warning signs of implant failure
Criteria for implant success:
Implant quality scale:
Classifications of implant failures
.Enhancing outcome in esthetic implant dentistry
.implant maintenance
Conclusion
Bibliography

Introduction
Implant dentistry is currently
being practiced in an atmosphere
of enthusiasm and optimism,
because our knowledge and ability
to provide service to our patients
has expanded so greatly in such
a short period.
But Success cannot be guaranteed, what one
can guarantee is to care, to do ones best and to be
there to help in the rare instance that something goes
wrong
3

o
t
y
it
il
b
a
e
h
t
is
s
Succes
ure
il
a
f
o
t
e
r
u
il
a
f
m
o
r
go f
r
u
o
y
g
in
s
lo
t
u
o
h
wit
enthusiasm

And failure

is not the end

ity
n
u
t
r
o
p
p
o
e
h
t
Failure is
ly
t
n
e
ig
ll
e
t
n
i
e
r
o
m
,
in
a
g
a
in
g
e
b
To

When implant failsthen.


The surgeons tale
The implants were successfully integrated , but
failed because of excess loads.
or
The Restorative Dentists tale
The implants were poorly integrated and so failed
under normal masticatory loads.
either way
The Patients tale
My implants have failed!

Actually ,Success & Failure of the


implants depends upon team work i.e.the
co-operation b/w Surgeon, Prosthodontist,
Periodontist, lab technician & the Patient.

Definitions
IMPLANT FAILURE
It is defined as total failure of the implant to
fulfill its purpose (functional, esthetic or
phonetic) because of mechanical or biological
reasons.
(Askary et al ID 1999 vol8 no2 173-183)

Ailing implants:
Those that show radiographic bone loss without
inflammatory signs or mobility.
Failing Implant:
Characterized by progressive bone loss, signs of
inflammation and no mobility.

Failed Implants:
Those with progressive bone loss, with clinical
mobility and that which are not functioning in
the intended sense.
Surviving implants:
Described by Alberktson, that applies to
implants that are still in function but have
been tested against the success criteria.

10

Predictors of implant success or failure


( General dentistry 2005, 423-432)
Positive factors

Bone type (type 1and 2)


Patient less than 60yrs old
Experienced Clinician
Mandibular placement
Implant length > 8mm
FPD with more than two implants
Axial loading of implant
Regular postoperative recalls
Good oral hygiene

11

Negative factors
Bone type (type 3 and 4)
Low bone volume
Patient more than 60yrs old
Limited clinician experience
Systemic diseases
Auto-immune disease
Chronic periodontitis
Smoking and tobacco useUnresolved caries,
endodontic lesions,frank pathology
Maxillary, particularly posterior region
Short implants (<7mm)
Eccentric loading
Inappropriate early clinical loading
Bruxism and other parafunctional habits

12

Warning signs of implant failure


(Askary et al ID 1999; vol 8;
no2, 173-183)
Connecting screw loosening
Connecting screw fracture
Gingival bleeding and enlargement
Purulent exudates from large pockets
Pain
Fracture of prosthetic components
Angular bone loss noted radiographically
Long-standing infection and soft tissue
sloughing during the healing period of first
stage surgery
13

Criteria for implant success:


The individual implant is immobile when tested clinically.
No radiographic evidence of peri-implant radiolucency
Bone loss no greater than 0.2 mm annually
Gingival inflammation amenable to treatment
Absence of symptoms of infection and pain
Absence of damage to adjacent teeth
Absence of parasthesia, anesthesia or violation of the
mandibular canal or maxillary sinus
Should provide functional survival for 5 years in 90% of
the cases and for 10 years in 85%.
1:11-25)

(Albrekfsson T. :int J. Oral Maxillofac Implants 1986;

14

ant quality scale:


cale presented for implant quality of health based on clinical
uation was first suggested by James and was modified by Misc
quality of health scale criteria, has to be place in the appropr
ory, and then treat the implant accordingly.
prognosis also is related to the quality scale.

15

16

Classification Of Implant failures


E.S Rosenberg, J.P. Torosian and J. Slots

Kees Heydenrijik, Henny JA Meijer, Wil A Van der et al


Marco Esposito, Jan Michael Hirsh, Ulf Lekholm et al
Sumiya Hobo, Eiji Ichida, Lily T Garcia
Abdel Salam El Askary, Roland Mefert and Terrence Griffin

17

A) E.S Rosenberg, J.P. Torosian and J. Slots


classified as :

1. Infectious Failure:
Clinical signs of infection
with classic symptoms of
inflammation
High plaque and gingival
indices
Pocketing
Bleeding, Suppuration
Attachment loss
Radiographic peri-implant

radiolucency
Presence of
granulomatous tissue upon
removal

2. Traumatic Failure:
Radiographic periimplant
radiolucency
Mobility
Lack of granulomatous
tissue upon removal
Lack of increased
probing depths
Low plaque and gingival
indices
18

B) Marco Esposito, Jan Michael Hirsh, Ulf Lekholm et al


have classified oral implant failures according to the
osseoi ntegration concept.
1)Biological Failures:
Early or primary (Before loading)
Late or secondary (After loading)
2)Mechanical failures:
Fracture of implants, connecting screws,
bridge framework, coatings etc
3)Iatrogenic Failures
Improper implant angulation and alignment, nerve
damage
4)Inadequate Patient adaptation
Phonetics, esthetics, psychological problems.
19

C) Kees Heydenrijik, Henny JA Meijer, Wil A Van der et


al classified to occurrence in time as:
1) Early Failures: Causes attributed are:
Surgical trauma
Insufficient quantity or quality of bone
Premature loading of implant
Bacterial infection
2) Late Failures:
Soon late failures: Implants failing during first year of
loading. Overloading in relation to poor bone quality and
insufficient bone volume.
Delayed late failures: Implant failing in subsequent years.
Progressive changes of the loading conditions in relation
to bone quality, volume and peri -implantitis.
20

D) Sumiya Hobo, Eiji Ichida, Lily T Garcia enlisted


various complications occurring in implants as:
Swedish Team
( Branemark et al)

U.C.L.A team
(Beumer, Moy)

1. Loss of bone anchorage: 1. Complications in Stage I surgery;


a. Mucoperiosteal
perforation
b. Surgical trauma
2. Complications in Stage II surgery:
2. Gingival problems:
a. Proliferative gingivitis 3. Prosthetic complications:
b. Fistula formation
3. Mechanical complications:
a. Fracture of
prosthesis, gold screws,
abutment screws

21

E) Abdel Salam el Askary, Roland Meffert and


terrence griffin
According to etiology
Host
factor

Surgical
factor

Restorative
factor

Implant
selection factor

According to timing of failure


Before stage II

After stage II

After restoration

According to origin of infection


Peri- implantitis
(Infective process,
bacterial origin)

Retrograde peri-implantitis
(Traumatic occlusion origin,
non infective, forces off the long
axis, premature or excessive
loading)
22

According to failure mode


Unacceptable
Lack of
osseointegration aesthetics

Functional
problems

Psychological
problems

According to condition of failure


Ailing Implant

Failing Implant

Failed Implant Surviving Im.

According to supporting tissue type


Soft tissue loss

Bone loss

Combination

According to responsible personnel

Dentist (Oral
surgeon,
Prosthodontist,
Periodontist)

Dental
hygienist

Laboratory
Technician

Patient

23

According to etiology

Host
factor

Surgical
factor

Implant
selection factor

Restorative
factor

Host factor
Medical status

Habits :

Oral status

24

Etiology : host factor

A. Host factors
MEDICAL STATUS medical history is essential to rule out any of
the following conditions or disorders. If yes medical consultation
Bone dieases

Autoimmune

osteoporosis
osteomalacia
? hyperparathyriodism
fibrous dysplasia
paget dz
multiple myeloma
? osteomylitis

sjogren syndrome
? SLE
? scleroderma
? HIV

Endocrine

DM
Thyroid
disorders

Pregnancy

Avoid to place
implant in pregnancy

In all these conditions ,chances of


success rate are poor but implant
therapy not contraindicated except
few.
CV Dieases

Hypertension
MI
Congestive heart
failure
SABE

25

HABITS
1) Smoking:

Etiology : host factor

Significance
Causes alveolar vasoconstriction and decreased blood flow
Impaired wound healing due to compromised polymorphonuclear
leucocytes function, increased platelet adhesiveness as well as
vasoconstriction caused by nicotine.
Poor bone quality
In case of poor oral hygiene, smokers have 3 times more marginal bone
loss then non-smokers
Recommendations:
1. Obtain a smoking history
2.Advice on risks of periodontal breakdown
3.Advice on the prognosis .Smoking cessation

26

Parafunctional habits:

Etiology : host factor

Bruxism is the multidirectional nonfunctional grinding of


teeth. Clenching occurs in one direction (vertically).
Bruxism is more aggressive. Attrition usually appears on
the incisal edges of anterior teeth.
Significance
Most common cause of implant bone loss or lack of rigid fixation
during the first year after implant insertion.
Commonly manifests as connecting screw loosening because of overload.
Failures are higher in maxilla because of decrease in bone density.
Forces are in excess of normal physiologic masticatory load limit.( upto
1000 psi).

27

Etiology : host factor

Prevention
Increased number of implants to be placed
Avoid cantilevers and occlusal contacts in lateral excursions
Use of occlusal splint which is relieved over the implant.
Use of wide diameter implant to provide greater surface area.
Progressive bone loading and prosthetic design that improves the
distribution of stresses throughout the implant system.( By Misch

28

ORAL STATUS:

Etiology : host factor

Poor home care:


Suprabony connective tissue fibers are
oriented parallel to the implant surface
Susceptible to plaque accumulation and
bacterial ingress

Spontaneous loss of the perimucosal seal

Chances of implant failure increases

29

Prevention

Etiology : host factor

It is recommended that the patient be recalled


frequently, preferably at a minimum of 3 months
intervals. Periodontal indices, bleeding on probing and
radiographic evaluation should be performed, using
plastic tipped probes for checking pocket depths.
Soft tissue debridement should be performed by means
of plastic curettes and plastic tips for ultrasonic
scalers, and topical and systematic antimicrobial drugs
should be used
Provide space beneath the superstructure to allow
cleansing aids

30

Etiology : host factor

IRRADIATION THERAPY
Significance
Xerostomia
Susceptibility to infection
Osteoradionecrosis
Endarteritis of vessels causes decrease in oxygen supply
Prevention
Waiting period of 9-12 month between radiation therapy and implant
treatment.
Hyperbaric oxygen therapy 20 treatments of 90 min. each at 2 to
2.4atm before surgery.
Antibiotic regimen 3 days before (augmentin 500mg every 12 hrs).

31

According to etiology

Host
factor

Surgical
placement

Implant
selection factor

Restorative
factor

SURGICAL PLACEMENT
Impaired healing and infection due to improper flap design
Overheating the bone and exerting too much pressure
Contamination of implant body before insertion
Placement of implant in immature bone grafted site
Severe angulation
Minimum space between implants
Lack of initial stabilization

32

Etiology : surgical factor

a) Off-axis placement (severe angulation)


Due to

A) Alveolar process resorption


B) Unexperienced surgeon
C) Improper surgical stent

Problem
Occlusal load lie at an angle

Shear & tensile forces increases


Chances of failure increases
33

Etiology : surgical factor

Solutions
1) Prerestoring the implant position by
grafting
2) To place the implant with an angulation.
3) To place angulated abutments.

34

b) Lack of initial stability

Etiology : surgical factor

Due to oversized osteotomy


Gap develop between implant & bone
Lack of osseointegration

In an experimental investigation, gaps in the range of


0.25 mm around CPTi implants healed, but with less bone
contact than the controls.
When the gap size increased to 0.7mm-1.7mm,
a thin soft tissue layer was found to develop
around the implant.
35

Etiology : surgical factor

Solution
Remove & reinsert the larger size implant.
if not possible remove insert HA graft material
roll the implant moistened in blood & saline & in the
particulate slurry until thin layer of slurry clings to it
reinsert the implant

36

Etiology : surgical factor

c) Improper healing & infection


because of improper flap design
No single flap design is optimal for implant surgery.
But improper flap design infection & bacterial ingress
chances of failure increases

Note: basic surgical procedure, flap design ,


blood supply, visibility,access, primary
closure should be considered.

37

Etiology : surgical factor

d) Overheating the bone and exerting


too much pressure
Excessive pressure

Bone cell damage

Failure increases

Bone loss

Connective tissue
interface formed

Inverse relationship b/w speed & heat production


Recommended speed- 2000 rpm with graded series
of drill size with external irrigation
38

Etiology : surgical factor

Note: Bone cell death occurs at a


temperature of 47 degree and
higher when drilling is performed for
1 minute.

39

Etiology : surgical factor

e) Placement of implant in immature bone


grafted site
Minimum waiting period of grafted site6-9 mth

woven bone present before this period, which is fastest


formed bone (partly mineralized &Unorganized)
Not suitable for implant-bone integration

Lamellar bone ideal for


implant prosthetic support
40

Etiology : surgical factor

f) Contamination of implant body before


insertion
D/t

non-titanium instrument
by glove powder
by the operatory error

By autoclaving the contaminated implant

Bake the bacteria on implant surface

Impossible for phagocytic cell to clean the surface

No close adaptation to the bone


41

Etiology : surgical factor

Implant should be cleaned with radiofrequency


glow discharge unit or plasma cleaner
Metal instrument should be titanium tipped

42

According to etiology

Host
factor

Surgical
placement

Implant
selection factor

Restorative
factor

Implant selection factor


Improper implant type in improper bone type
length of the implant
width of the implant
number of the implant
improper implant design

43

Length of the implant..


Misch proposed the range of 10mm-16mm length.
The success rate is proportional to the implant length and
the quantity and quality of available bone. The rate of
failure can be expected to rise proportionately as the
depth of the bone diminishes to less than 10mm.

The greater the crown implant ratio, the greater the


amount of the force with any lateral force. This means
that the implant with unfavorable crown implant ratio will
be more influenced by lateral forces. Therefore,
maximum implant length must be used for the greatest
stability of the overlying prosthesis.
44

Width of the implant


Misch recommended that not less than 1 mm of bone
surrounding the fixture labially and lingually is mandatory
for the long term predictability of dental implants because
it maintains enough bone thickness and blood supply.

it is advisable to use a large- diameter implant in


accordance with the available bone width because it
offers greater surface area, greater mechanical
engagement of the cortical bone, and initial rigidity.

Using a wide implant in a narrow ridge results in labial


or lingual dehiscence that leaves the implant affected
by the damaging shear stresses.
45

Number of implants
Misch stated that the use of more implants decreases the

number of pontics and the associated mechanics and strains


on the prosthesis, and dissipates stresses more effectively
to the bone structure. It also increases the implant bone
interface and improve the ability of the fixed restoration
to withstand forces.
Contrary to this Smith et al correlated between the
increased number of implants and the high failure rate
caused by wound contamination that might occur because of
the long operating time.

46

According to etiology

Host
factor

Surgical
placement

Implant
selection factor

Restorative
factor

RESTORATIVE PROBLEMS
Excessive Cantilever
Pier abutments
No passive fit
Improper fit of the abutment
Bending moments
Connecting implants to natural teeth
Improper occlusal scheme
47

Etiology : restorative facto

Excessive cantilevers
Used implant-supported
prosthesis.
Mesial C. > Distal C.

Cantilever extensions cause load magnification and


overloading of the implant next to the cantilever
extension, which in turn leads to bone loss
With occlusal forces acting on the cantilever, the
implant becomes a fulcrum and is subjected to
rotational forces
48

Etiology : restorative facto

Amount of force increases if


Length of cantilever
distance between implants
crown height
direction of force
position of arch

Opposing arch
ideally a denture
no lateral forces on cantilever

Not preferred ----moderate to


severe parafunctional habits
49

Etiology : restorative facto

Connecting implants to teeth


Not preferred
Difference b/w implant & tooth movement
in vertical & lateral direction

50

Etiology : restorative facto

Solution
increase no. of implants
improve stress distribution by splinting additional
abutment until 0 clinical mobility is observed.
non-rigid connection but chances of
intrusion of the tooth.

Criteria
1) no observable clinical mobility of natural abutment.
2) no lateral force should be designed on prosthesis.
51

Etiology : restorative facto

Pier Abutments

Main complication d/t difference of mobility of tooth & implant


2 situations arise
Implant as pier

Act as class 1 lever


Non rigid attachment

Tooth as pier

Tooth act as living pontic or


pontic with a root
stress breaker not indicated

52

No passive fit

Etiology : restorative facto

One of the most critical elements affecting the


long-term success of a multiple implant restoration is
the passive fit between the framework and the
underlying fixtures.
A passive fit reduces long term stresses in the
superstructure, implant components, and bone
adjacent to the implants.
A poorly fitting implant framework can cause
mechanical complications such as loose screws or
fractured components.
53

Etiology : restorative facto

Improper fit of abutment


Improper locking b/w abutment-fixture interface

Increased microbial population &


increased strain on implant component

Bone loss

Rapid screw-joint failure

54

Improper occlusal scheme

Etiology : restorative facto

Important guidelines to
follow

Infraocclusion upto 30 microns of implant supported


restoration
No balancing contacts on cantilevers.
No guidance on single implants.
Freedom in centric.
Occlusal table directly proportional to implant diameter.
Narrow occlusal width.
Implant length: crown-root ratio ideal 1:2 ,
Acceptable 1:1 for removable denture.
Avoidance of cantilever length.
Maximum 10 to 15 mm is advised. 7 mm is optimum .
Shallow central fossae with tripodal cuspal contacts.
No contact in lateral excursion.
Slight contact in centric occlusion.

55

According to timing of failure


Before stage II
After stage II
After restoration

56

First stage surgery


Problem
Hemorrhage during
drilling

Possible cause
Lesion or injury of
an artery

Implant mobility
after placement

Soft bone
Imprecise
preparation

Exposed implant
threads

Too narrow crest

Swelling lingually
Incision of an
directly after implant artery branch
placement at the
sublingually

Solutions
-The implant placement will
stop the bleeding.
-Simple tamponade , bone
wax, gelfoam , surgicel ,
avitene can also be used
Remove the implant and
replace with one of larger
diameter. If the mobility is
small prolong the healing
time
Cover the threads with
coagulum or place a
membrane
EMERGENCY: send the
patient to a specialist
57
center for coagulation of

Injury to neurovascular bundle


The posterior mandible in particular presents
significant challenge when severe atrophy
leaves little, if any bone superior to inferior
alveolar canal.

The solution to limited space for posterior mandible fixture


placement includes detailed initial treatment planning and careful
surgery to unroof the canal and move the neurovascular bundle
58
inferiorly prior to fixture installation

Second stage surgery + abutment connection


Problem

Slightly sensitive but


perfectly immobile
implant
Slightly painful and
mobile implant
Difficulty inserting a
transfer screw, gold
screw or healing cap
Inability to perfectly
connect the abutment
to the implant

Granulation tissue
around the implant
head

Possible causes

Solutions

Imperfect
osseointegration

Cover the implant for 2-3


months and test again

Lack of integration

Remove the implant

Damaged inner
thread of abutment
screw
Insufficient bone
milling

Change the abutment


screw

Place a local anesthesia,


use a bone mill with guide,
remove the bone, clean
with saline solution, and
replace the abutment
Traumatic placement Open the area and
of the implant;
disinfect with
compression from the chlorhexidine. If the
transition prosthesis; lesion is
59 too large,
a lid above the cover consider a bone

Prosthetic problems
Problem

Possible
causes
Pain or sensation Misfit
when tightening between
gold screws
prosthesis
(during try in of and
prosthesis)
abutments
Loosening of one Occlusal
or more
problem
prosthetic screws
at the first
inspection after
two week

Solutions
Cut the prosthesis; interlock the
pieces, and solder the prosthesis
at the laboratory. Retry the
prosthesis
Retighten, verify the occlusion, and
recheck after two weeks.

60

Prosthetic problems
Loosening of
prosthetic screws
at the second
check or later

Fracture of a
prosthetic screw
or an abutment
screw

Occlusal problem or
misfit between
prosthesis and
abutments
Too large extension
Unfavourable
prosthetic concept
Occlusal problem, lack
of fit between the
prosthesis and the
abutment or
unfavourable
prosthetic design

Verify the occlusion and/ or


the prosthetic fit
Reduce the extension
Change the prosthetic design.
In all cases, change the
prosthetic screws
If the occlusion or the
adaptation of the prosthesis
seems right, modify the
prosthetic design (reduce or
eliminate extensions, reduce
the width of occlusal surfaces,
reduce cuspal inclination, add
implants, etc)
61

Prosthetic problems
Fracture of the
framework

Weak metal
frame end or
too large
extension
Bruxism or
parafunction

Implant fracture

Occlusal
overload

Remake the prosthesis; modify the


prosthetic design (reduce or
eliminate extensions, reduce width
and height of occlusal surfaces,
reduce cusp inclination, add
implants, etc).
Make a nightguard
Remove the implant with a special
trephine drill, wait 2- 6 months, if
possible, and place a wider implant.
Review the prosthetic design(place
more implants, etc) and remake the
prosthesis

62

Prosthetic problems
1. Continuing
bone loss around
one or more
implants

Infection
(periimplantitis)

2. Continuing
bone loss around
one or more
implants

Occlusal
overload

Remove the etiolgical factors (poor


plaque control, prosthesis geometry
in relation to the mucosa, etc). Look
for bacterial pockets around the
natural teeth. Possibly make a
bacteria test. Cut open the lesion.
Adjust the peri-implant tissues
(gingival graft). Consider a bone
regeneration procedure
Modify the prosthetic design (reduce
or eliminate extensions, reduce the
width of occlusal surfaces, reduce
cuspal inclination, add implants, etc)

63

According to failure mode


Lack of
Osseointegration
Unacceptable
Aesthetics
Functional
Problems
Psychological
Problems

64

Lack of Osseointegration
Adell et al proposed that lack of osseointegration can be due to
Surgical trauma
Perforation through covering mucoperiosteum during healing
Repeated overloading with microfractures of the bone at early
stages

Functional problems
Proper function of the implants is dependent on two main types of
anchorage related and prosthesis related.
Anchorage related factor
Osseo integration
Marginal bone height
Prosthesis related factor
Prosthesis design
Occlusal scheme
65

Aesthetic problem
Aesthetic outcome is affected by four factors:
Implant placement
Soft tissue management
Bone grafting consideration
Prosthetic consideration

Psychological problems
high expectations of the patient

66

According to supporting tissue type


Soft tissue problems
Bone loss
Both soft tissue and bone loss

67

Soft tissue problems


Gingival loss leads to continuous recession around the implant with
subsequent bone loss. This will lead to a soft tissue type of
failure.
Significance of attached gingiva surrounding implants
facilitates impression making.
provide tigth collar around the implant.
prevent recession of marginal gingiva.
prevent spread of inflammation to deep tissue.

68

Ono,Nevin,Cappetta classified keratinized gingiva based on


reflection of quantity & location in mucogingival
surgery during implant placement

Type 1- flap can be apically positioned to


increase the zone of keratinized gingiva on
facial side

Type 2-minimum keratinized tissue on ridge but little on facial aspect

Type 2 class I- gingival graft

69 graft on buccal side,


Type 2 class II- gingival
Apically positioned flap on lingual site

Type 3- no attached gingiva on the ridge or facial aspect.


A gingival graft which is apically postioned to increase the
Zone of attched gingiva.

70

Bone loss
Bone functions as a support for the implant and that any
disturbance in its function may lead to eventual loss of the implant.

Loss of marginal bone occurs both during


the healing period and after abutment connection
Bone loss in mandible is higher during the healing period.
In maxilla, bone loss is higher after abutment connection

71

Factors that contribute to marginal bone loss:

Surgical trauma such as detachment of the periosteum and


damage cased during drilling
Improper stress distribution caused by defective prosthetic
design and occlusal trauma
Physiological ridge resorption
Gingivitis, which if allowed to progress will lead to ingression
of bacteria and their toxins to the underlying osseous structures.

Both soft tissue and bone loss


If failure starts from soft tissue, then it usually is
considered to be due to a bacterial factor. However, if
failure starts at the bone level, then it is considered to
be due to a mechanical factor. Both bone and soft
tissue may be involved together.
72

Enhancing esthetic outcome


in implant dentistry
Prosthodontic
considerations
Surgical
consideration
Use of
plateletrich-plasma

73

Prosthodontic consideration
1) Interim provisional restoration:
Modified Essex retainer

Resin bonded FPD

Use of transitional implants to


Support an interim provisional restoration

74

2) Prosthetic guided soft tissue healing:


Custom abutment & tooth form restoration

Custom tooth form healing abutment

75

Surgical consideration
Cosmetic laser soft tissue resurfacing & sculpting

Creating harmony with cosmetic PD surgery

76

Use of platelet-rich-plasma
Provide blood component & source of growth factor
which enhance the wound healing
3-4ml of non-activated P-R-P is sufficient
for multiple implant site
Hard tissue
consideration

enhancing osseointegration
alveolar ridge preservation
in autogenous bone graft

Soft tissue
consideration
Both
77

Peri- implantitis
Progressive peri-implant bone loss in conjunction
with a soft tissue inflammatory lesion is termed periimplantitis.
Pathological changes of the peri-implant tissues
can be placed in the general category of peri-implant
disease. (Lang et al 1994)
Two primary etiological factors
1. Bacterial infection
2. Biomechanical overload
(Newman et al 1988, 1992, Rosenberg et al 1991)
78

Classification of peri-implantitis
Class I
Slight Horizontal bone loss with
minimal Peri-implant defects.
TREATMENTInitial therapy for removal of
etiological factors.
Surgical therapy includes cleaning the implant
surface, Pocket elimination via Apicalpositioning
of flap.

II

Class

Moderate horizontal bone loss with isolated


vertical defects.
TREATMENT
Initial therapy for removal of etiological
factors
Surgical therapy includes cleaning the implant
surface pocket
Elimination and adjunctive treatment using
79
systemic antimicrobials

Class III

Class IV

Moderate to advanced horizontal


bone loss with broad, circular
bony defects.
TREATMENT
Initial therapy for removal of etiological
factors
Surgical therapy includes cleaningthe implant
surface
pocket elimination via osseous regeneration
and adjunctive antibiotic treatment
Advanced horizontal bone loss with broad
circumferential vertical defects as well as loss
of buccal and lingual bony wall.
TREATMENT
.Initial therapy for removal of etiological factors
.Surgical therapy includes cleaningthe implant
surface,pocket elimination via bone regeneration
techniques, possibly autologous bone transplants
with adjunctive antibiotic therapy.
80

Mechanical complications
These are primarily related to failure of
prosthodontic materials to resist forces and
stresses of oral function.

81

Fractured abutment screw

Tip of the explorer is placed on the top


portion of the fractured abutment
screw.
With slight apical pressure and a

counterclockwise circular motion, the


fragment can often be unscrewed.
Care must be taken not to damage
the internal threads of the implant.

When Screw Fragment removed ,replace with


appropriate new abutment and screw. Verify seating
with a radiograph prior to final torque.
Replace prosthesis and secure with new retention
82
screws.

Loose Healing Abutment


Radiographic evaluation of a
loose healing abutment.

Removal of healing abutment


indicates a distorted screw

Treatment:Replace with new


healing abutment

83

Loose bar
Radiograph confirms poor
seating abutment.
Clinical evaluation after removal
of bar indicates loose abutment
screw.

Area of
concern

Diagnosis- possible loose or


fractured abutment screw
Treatment:Retorque abutment
screw.

84

Treatment:
continued
2 - Abutment screw is
tightened with
abutment driver.
3 - Bar is then
replaced and prosthetic
screws are torqued with
appropriate screw
driver.

85

Loose restoration

Radiographic Evaluation: Small


opening at abutment-implant
interface

Diagnosis:Loose abutment
screw

Treatment:
1 - Loosen screw and
remove restoration

Small
86
opening

Implant hex

2 - inspect the implant hex


for damage
3 - inspect the restoration
for damage

(A) No Damage to fixture or restoration


replace restoration and secure with the
same screw.Verify seating with
radiograph prior to final torque.Recheck
occlusion with shimstock.

Abutment hex

(B) Damaged fixture hex and or restoration


replace restoration and secure with
appropriate new screw.

87

ture loss
(Must differentiate b/w failing and failed)

Failing Implant
Clinical signs:progressive bone loss
:soft tissue pockets and crestal bone loss
:bleeding on probing with possible purulence
:tenderness to percussion or torque forces
Causes:overheating of bone at the time of surgery
or lack of initial stability.
:inadequate screw joint closure
:functional overload
:periodontal infection (peri-implantitis)
Treatment:Interim: remove prosthesis and abutments
:irrigate with Peridex
:ultrasonic and disinfect all components
:reinsert assuring proper screw torque
:recheck passive fit of framework and88occlusion

Failed Implant
Clinical signs:
Mobilityverify fixture mobility by removing any
abutments and superstructures first.
A Dull percussion sound has been associated
with a failed implant.
Peri-implant radiolucency can be a radiographic
finding often this is not evident on an X-ray
Causes:
:surgical compromise (overheating bone and
initial lack of stability).
:Inadequate screw joint closure
:Too rapid initial loading
:Functional overload
:Periodontal infection (peri-implantitis)

Treatment
:removal of the implant

89

Fractured implant fixture head

Treatment:Eventual implant removal

90

Accidental swallowing or inhalation of components


and /or instruments

Many implant components are as small as are


the instruments used for their manipulation. When
coated with saliva a component may escape the
clinicians grip and fall into the oropharynx, reflex
swallowing may take the component out of site
almost immediately.
Prevention
Manual screwdrivers and similar instruments should
always be equipped with a safety line of dental floss.
(Minimum length of 10mm)
91

Implant maintenance

IMPLANT

MAINTENANCE

92

The following factors must be evaluated at


each maintenance appointment
oral hygiene
implant stability (evaluate mobility)
peri-implant tissue health
crevicular probing depths
bleeding
radiographic assessment (serial)
crestal bone level (expect 1.0mm marginal
bone loss during first year postinsertion;
0.1mm per year anticipated thereafter )
proper torque on screw joints
occlusion
Patient comfort and function
93

Hygiene aids
Super - floss
End tufted brushes
Proxy brushes
Tartar control dentrifices
Mechanical instruments

94

Super - Floss
Excellent for all types of
implant restorations

Butler Post Care Floss


Aid
Excellent for implant
bars and fixed hybrid
prostheses.

95

Butler Floss Aid is used


to clean the bar
including the area
contacting the tissue.

96

Proxy brushes

End tufted brushes


97

Plastic scalers

Plastic scalers are


appropriate for cleaning
around standard abutments
supporting implant bar
substructures, hybrid
prostheses and implant
supported splinted
restorations.
Plastic scaler tips are
also available for metal
handle scalers.
98

Implant supported
fixed partial
denture

Scaler tips are designed to fit the curvature of


the standard abutment.

99

Prophy paste and a


rubber cup on a prophy
head / handpiece can be
used to polish implant
bars when removal is not
indicated

100

Conclusion
Failure of implant has a multi-factorial dimension.
Often many factors come together to cause the ultimate
failure of the implant. One needs to identify the cause
not just to treat the present condition but also as a
learning experience for future treatments. Proper data
collection, patient feedback, and accurate diagnostic tool
will help point out the reason for failure. An early
intervention is always possible if regular check-up are
undertaken.
As someone well said, it is not how much success we
obtain, but how best we tackle complex situations and
failures, that determine the skill of a clinician. No,
doubt, failures are stepping stones to success but not
until their etiologies are established and their
occurrence is prevented.
101

REFERENCES
Misch : Contemporary implant dentistry
Atlas of implant dentistry, Cranin
Why do dental implants fail: part I : Askary et al
ID 1999 vol8 no2 173-183
Why do dental implants fail: part II : Askary et al
Id 1999 vol 3 : 265-275
A.S.Sclar; Soft tissue & esthetic considerations in
implant dentistry.
Myron Nevins; Implant therapy.
Torosian J, Rosenberg ES. The failing and failed
implant: a clinical, microbiologic, and treatment
review. J Esthet Dent. 1993.
Failures in implant dentistry.W. Chee and S. Jivraj.
British Dental Journal 202, 123 - 129 (2007)
102

Yoav Grossmann. Prosthetic treatment for severely


misaligned implants: A clinical report. J Prosthet
Dent 2002;88:259-6.
Goodacre C J, Bernal G, Rungcharassaeng K, Kan J
Y. Clinical complications with implants and implant
prostheses. J ProsthetDent 2003; 90: 121132.
Effect of implant size and shape on implant
success rates: A Literature review JPD
2005;94:377-81
WWW.google.com

103

104