complications failures and maintainence of dental implant

COMPLICATIONS, FAILURES AND

MAINTAINENCE OF DENTAL IMPLANT

Presented by:

Dr Rasleen Sabharwal Final year- Post graduate

Dept of Prosthodontics

Contents

Introduction Parameters for success or failure evaluation Parameters for evaluating failing implants Parameters for evaluating failed implants Reasons of implant failures The different failures and their management Maintenance of implant prosthesis Conclusion References

IntroductionThe role of a dental professional is not just limited to the treatment of the oral condition presented by the patient, his responsibility further extends to identify the kind of complication or failure that may occur or has occurred either during the course of treatment or post treatment.The dental implant is a foreign structure that the physiologic system of the body has to accept. Though made of a material with properties close to the body tissues, the implant is still different and is definitely susceptible to the various biological and mechanical problems.

Evaluation Of Parameters For Success Or Failure Of Implants

At the first European workshop on Periodontology in 1994, certain success criteria were considered for osseointegration and agreed as:

Absence of mobility Average radiographic marginal bone loss of less than 1.5mm

during the first year of function and 0.2mm annually thereafter. Absence of pain and or paresthesia. Measurement of probing depths related to a fixed reference

point and assessment of bleeding on probing.Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral Sci 1998; 106: 527–551.

Parameters used for evaluating failing implants

Clinical signs of late infection

Biological factors contributing to failures of osseointegrated oral implants: success criteria. Eur J Oral Sci 1998; 106: 527–551.

Bleeding on probing Sulcus Bleeding Index (SBI)


Pocket probing depth (PPD)


Mucosal recession (REC)


Probing “attachment” levels (PAL)


Parameters used for evaluating failed implants

Clinical signs of early infection

Pain or sensitivity


Clinically discernable mobility Radiographic signs failure



Dull sound on percussion

Microbiota in relation to failing and failed implants

El Askary et al in 1999 gave eight warning signs of implant failure:

1. Connecting screw loosening2. Connecting screw fracture3. Gingival bleeding and enlargement4. Purulent exudates5. Pain (not very common)6. Fracture of prosthetic component7. Angular bone loss8. Long standing infection and soft tissue sloughingBiological factors contributing to failures of osseointegrated oral implants: etiopathogenesis EJOS 1998

Classification of implant complications and failures

Acc to El Askary et al:1. According to etiology - Host factors - Surgical placement - Implant selection - Restorative problems 2. According to timing of failure - Before stage II (after surgery) - At stage II - After restoration

Complications and maintainence of implants. British dental journal 1999

3. According to the origin of infection - Peri - implantitis - Retrograde peri-implantitis

4. Soft tissue complications 5. Bone complication6. Mechanical complications

II. According to UCLA team (Beumer and Moy)1. Complications in first stage surgery2. Complication in second stage surgery3. Prosthetic complications

Complications of dental implants, J of Prosthet Dent 2004;9;1;78

ETIOLOGY Osteoporosis Diabetes Smoking Parafunctional habits Poor home care Juvenile and rapidly progressive periodontitis Bone quality and quantity Irradiation therapy


Surgical placement Off axis placement Lack of initial stabilization Overheating bone Minimal space b/w implants Placing implants in immature bone Contamination of implant body


Implant selection Improper implant type in improper bone Too short implant , crown root implant unfavorable Width of the implant Number of implant Improper implant design


Restorative problems

Excessive cantilever Pier abutment Fit of the abutment Prosthetic design Improper occlusal scheme

Connecting implants to natural teeth Premature loading Excessive torquing


Acc to timing of failure Before stage II At stage II After restoration



Acc to origin of infection Peri impantitis Retrograde peri-implantitis

Soft tissue complications Exposure of cover screws Proliferative gingivitis Exposure of threads



Bone complications Vertical defects Horizontal defects Progressive marginal bone loss Fixture mobility

Prosthetic complications with dental implants. Int.J.Oral and maxillofacial surgery 2006; 21;6;234.

Mechanical complications Component # Abutment screw # Prosthesis # Malpositioned fixture

Complications during First — stage surgery:Problem Possible causes SolutionsHemorrhageduring drilling

Lesions or injury of an artery

The implant placement will stop the bleeding

Implant mobility after placement

Soft bone, imprecise preparation

Remove the implant and replace with one of larger diameter. If the mobility is small, prolong the healing time.

Exposed implant threads

Too-narrow crest Cover the threads with coagulum or place a membrane.

Swelling lingually directly after implant placement at the mandibular symphysis

Incision of an artery branch sublingually

Emergency: Send the patient to a specialist center for coagulation

Substantial postoperative pain remaining after some days

Osteitis due to a too-aggressive preparation or a bacterial contamination

Remove the affected implant.

Indian dental academy

Insensitivity of the lower lip

Incision or compression of the mandibular inferior nerve

If the insensitivity persists after a week, use a CT scan to determine which implant is causing the problem and remove it.

Exposed cover screw after a few weeks

Cover screw not placed deep enough; thin mucosa

Never try to retighten the cover screw. Prescribe vigorous oral hygiene

Abscess around a cover screw after a few weeks

Implant is not integrating (low probability) infection around the cover screw (which often is a little loose)

Remove the implant. Raise a flap, remove the granulation tissue, disinfect with chlorhexidine, change the cover screw, and re suture.

During second stage surgery + Abutment connection: Problem Possible causes Solutions

Slightly sensitive butperfectly immobile implant

Imperfect osseointegration

Cover the implant for 2 to 3 months and test again

Slightly painful and mobile implant

Lack of integration

Remove the implant.

Difficulty inserting a transfer screw, gold screw, or healing cap

Damaged inner thread of abutment screw

Change the abutment screw

Inability to perfectly connect the abutment to the implant

Insufficient milling

Place local anesthesia, use a bone mill with guide, remove the bone, clean with saline solution, and replace the abutment.

During prosthetic procedure: control after prosthesis placement:

Problem

Possible causes

Solutions

Pain or sensation when tightening old screws (during try in of prosthesis)

Misfit between prosthesis andabutment

Cut the prosthesis, interlock the pieces, and solder the prosthesis at the laboratory. Retry prosthesis.

Loosening of one or more prosthetic screw at the first inspection after 2 weeks

Occlusal problem Retighten, verify the occlusion, and recheck after 2 weeks.

Loosening of prosthetic screw at second check or later

Occlusal problem or misfit between prosthesis and abutment

Verify the occlusion and / or the prosthetic fit. Reduce the extension. Change the prosthetic design (add an implant, etc). In all cases, change the prosthetic screws.

Abscess close to an implant Poor fit of the abutment to the implant

Verify the abutment fit with a radiograph. Remove the abutment, sterilize it, remove the granulation tissue disinfect with chlorhexidine, and replace the abutment.

Development of pain after placement of the prosthesis

Disintegration of an implant, peri-implant infection

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, etc).

Fracture of veneering material

Occlusal problem, bruxism or para function.

Verify the Occlusion and make a night guard.

Fracture of the framework Weak metal frame and or too-large extension

Remake the prosthesis; modify the prosthetic design (reduce or eliminate extensions, reduce width and height of occlusal surfaces, reduce cups inclination) make a night guard

Fixture fracture Occlusal overload Remove the implant with a special trephine drill, wait 2 to 6 months, if possible, and place a wider implant.

Continuing bone loss around one or more implants

Infection (peri-implantitis)

Remove that etiologic factors . Look for bacterial pockets around the natural teeth.

Visibility of titanium abutment through the mucosa

Place a connective tissue graft

Substantial phonetic problems that do not disappear after 2 to 3 months.

Close the interim plant space (pay attention of maintenance possibilities). Make a removable gingival prosthesis.

Bleeding on probing Mucositis or peri-implantitis

Remove etiologic factors (poor plaque control, prosthesis geometry in relation to the mucosa, look for bacterial pockets around the natural teeth. Possibly take a bacteria test. Cut open the lesion. Adjust the peri-implant tissues (gingival graft). Consider a bone regeneration procedure

Maintenance:

Toothbrushes Interproximal brushes Dental floss Water Pik Prophy II Gauge Chlorhexidine Mouthwashes

Dental implant prosthetics– Carl E Misch


IN CLINIC CLEANING Ultrasonic cleaning Soft prophy cups Plastic instruments- Wiz stik


Recall:

The patient should be recalled two weeks after temporary sealing procedures are done. At this time, check the prosthesis adaptation and evaluate any problems that may be due to screw loosening.

After that recall appointment, allow approximately four weeks before the next recall appointment. This time lapse allows the prosthesis time to function and adapt to a new hygiene regimen. Evaluation of level of bone is done at this time.

Next recall schedule is at 1 month, 3, 6 months & at 12 months after prosthesis delivery. After the first year, recall schedule is at 3, 5, 7 and 12 years, to indicate prosthesis integrity, plaque control, and for radiographic monitoring.


The following should be included at the recall appointments: Oral examination : Question any abnormality, discomfort,

masticatory problem, and prosthetic functional problems. Within the 18 month period after the first surgery, the bone is still healing so any abnormal habits such as bruxism, should be checked and monitored. If a problem exists, immediate management should be done.

lntraoral examination : Check the hygiene maintenance ,abnormal pocket formation, gingival bleeding, and peri-implant tissue condition. Carefully evaluate each individual since conventional soft tissue indices may be not reliable in the implant situation. Check the occlusion and reinforce plaque control procedures.


Radiographic examination : check the bone density at the fixture site and monitor marginal bone loss. With a good parallel radiograph, the marginal bone loss is measured using the fixture threads as a reference; the threads are machined at 0.5 mm intervals (Branemark, et al. 1983). As described, the marginal bone loss can range from 1.0 to 1.5 mm vertically in the first year (Adell, et al, 1981). Also check the fit between the abutment and fixture and check for fixture fractures. After the first year, estimated bone loss per year is less than 0.05 - 0.1 mm and offers a predictable long-term prognosis.


Radiographs are made at the time of abutment connection and prosthesis insertion; follow up radiographs are made at 1,3,5,7,10,15, and 20 year recall. After the 20 year recall radiographs are made every five years.


Roles in implant maintenance

Clinical role: Check patient every 3 to 4 months Check for plaque control effectiveness Expose radiographs every 12 to 18 months If supra structure is retrievable remove and clean ultrasonically

every 12 -18 months If implant needs repair, de-granulate, detoxify and graft with

GBR if necessary Wait 10 — 12 wks before placing back in function


Patient role:

Plaque control Use of Interdental brushes, hand and motorized (proxa brush,

oral-B, brush, Ratadent sonic) Dip brush in chlorhexidine 0.12% Use of flosses, yarns or tapes dipped is chlorhexidine


Hygienist role:

Check plaque control effectiveness Check for inflammatory changes If pathology is present probe gently with a plastic probe Scale supra —gingivally

Conclusion

Any material, technique or system is not devoid of any failures. One has to be able to recognize these complications or failure, analyze them on time and provide the necessary management. Further once failure has occurred we have to take precaution to prevent its occurrence in future.

REFERENCES Contemporary implant dentistry — Carl E Misch Dental implant prosthetics– Carl E Misch Complications and maintenance of implants. British dental journal

1999,volume 187, no. 12,1-6 Complications of dental implants, J Prosthet Dent 2004;9;1;7 Prosthetic complications with dental implants. Int.J.Oral and maxillofacial

surgery 2006; 21;6;234. Smoking and complications of Endosseous Dental Implants. Journal of

Periodontology, Feb 2002, Vol 23, No.2, Page 153— 157 Biological factors contributing to failures of osseointegrated oral implants:

success criteria. Eur J Oral Sci 1998; 106: 527–551. Biological factors contributing to failures of osseointegrated oral implants:

Etiopathogenesis. Eur J Oral Sci 1998; 106: 721–764

complications failures and maintainence of dental implant

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