Complications in dental implant therapy

COMPLICATIONS IN IMPLANT
THERAPY
PRESENTER:
EESHA MODY
II MDS
SRM DENTAL COLLEGE, CHENNAI

Accidents
Unfortunate incident that
happens unexpectedly
and unintentionally,
during a surgery
Complications
Difficulty- appear lately,
once surgery is already
performed
Annibali S, Ripari M, La Monaca G, Tonoli F, Cristalli MP. Local accidents in dental implant surgery: prevention and treatment. International Journal of Periodontics & Restorative Dentistry. 2009 Jun 1;29(3).

Early
complications
Late
complications
Appear in the immediate postoperative
period and interfere with healing
Arise during the process of
osseointegration.

WHEN TO SAY AN IMPLANT HAS FAILED?
Schnitman
and Schulman
Mobility <1mm
Radiologically
observed
radiolucency
Bone loss < 1/3rd
height of bone
Gingival
inflammation
Functional service
for 5 years in 75%
of patients
In place > 60
months
Lack of cervical
saucerization on
radiographs
Lack of mobility
No pain and
tenderness
No gingival
hyperplasia
No evidence of
a widening peri-
implant space
on radiograph
Chainin, Silver Branch, Sher, and Salter:
Prashanti E, Sajjan S, Reddy JM. Failures in implants. Indian Journal of Dental Research. 2011 May 1;22(3):446.

Mckinney, Koth, and Steflik:
Subjective criteria
•Adequate function.
•Absence of discomfort.
•Patient belief that esthetics,
emotional, and psychological
attitude are improved.
Objective criteria
•Good occlusal balance and VD
• Bone loss <1/3rd the vertical
height of the implant
•Gingival inflammation
vulnerable to treatment.
• Mobility < 1 mm
•No infection associated with
the dental implant.
•No damage to adjacent tooth.
•No parasthesia
•Healthy collagenous tissue
without PMN infiltration
Success criteria
•Provides functional service for
5 years in 75% of implant
patients.

Individual unattached implant that is immobile
when tested clinically.
Absence of periimplant radiolucency.
Bone loss <0.2 mm annually after the implant’s
first year of service
No signs and symptoms of pain, infections,
necropathies, paraesthesia, or violation of the
mandibular canal.
Success rate: 85% at the end of a 5-year
observation period and 80% at the end of 10-
year observation.
REVISED CRITERIA Alberktson, Zarb, Washington, and Erickson:

CLASSIFICATION
Annibali et al:

Surgical
complications
Biologic
complications
Technical or
mechanical
complications
Materials,
Esthetic and
phonetic
complications
Carranza FA, Newan MG, Takei HH.Clinical Periodontology,9th edition, Saunders, Philadelphia, 2002
• Hemorrhage and
hematoma
• Neurosensory
disturbances
• Damage to
adjacent teeth
• Inflammation
• Dehiscence and
recession
• Periimplantitis and
bone loss
• Implant loss or
failure
• Screw loosening
and fracture
• Implant fracture
• Fracture of
restoration
• Esthetic
complications
• Phonetic
complications
Carranza:

Positional failures
Soft tissue failures
Biomechanical failures
Failure due to loss of
integration
Chee, W., Jivraj, S. Failures in implant dentistry. Br Dent J 202, 123–129 (2007).
According to British dental journal:

According to Cranin:
Yeshwante B, Patil S, Baig N, Gaikwad S, Swami A, Doiphode M. Dental Implants-Classification, Success and Failure–an Overview. IOSR J. Dental Med. Sci. 2015 May 14;14(5):01-8.

LOCAL COMPLICATIONS
Localcomplications
Infection
Edema
Ecchymoses and
haematomas
Emphysema
Flap dehiscence
Sensory disorders

1. Infection
Peri-implant
mucositis
Peri-
implantitis
Hyperplastic
fistulations,
mucositis
Mucosal
Abscess

• Peri-implant mucositis:
Peri-implant mucositis was defined as reversible inflammatory changes of the periimplant soft
tissues without any bone loss (Albrektsson & Isidor 1994)
Renvert, S., Roos-Jansåker, A.-M., & Claffey, N. (2008). Non-surgical treatment of peri-implant mucositis and peri-implantitis: a literature review. Journal of Clinical Periodontology, 35, 305–315.

• Peri-implantitis
Peri-implantitis is defined as an inflammatory process which affects the tissues around an
osseointegrated implant in function, resulting in the loss of the supporting bone, which is often
associated with:
Bleeding & Suppuration
Increased probing depth
Mobility
Radiographical bone loss

• History of periodontitis
• Smoking
• Poor oral hygiene
• Exposed threads and surface coatings
• Deep pockets (placed too deep, placed into deficiencies)
• No plaque removal access (ridge lap crown, connected prostheses)
Predisposing factors
Klinge, B., Hultin, M., & Berglundh, T. (2005). Peri-implantitis. Dental Clinics of North America, 49(3), 661–676

• Increased clinical probing pocket depth
• Bleeding
• Suppuration
• Swelling of the peri-implant tissues
• Hyperplasia
Clinical appearance of peri-implantitis
Indicator of pathology in peri-implant tissues
Radiographic evidence: Vertical destruction of the
crestal bone in the shape of a saucer or rounded
beaker extending the full circumference of the
implant.

• Peri-implant radiography
• Peri-implant probing
• Mobility
• Suppuration
• Clinical indices
• Microbiology tests
Diagnosis
Appearance of a saucer shaped lesion around the implant.
Probing the peri-implant sulcus with a blunt, straight
periodontal probe allows the assessment of the following
parameters:
i. Peri-implant probing depth
ii. Distance between the soft tissue margin and a reference
point on the implant
iii. Bleeding after probing
iv. Exudation and suppuration from the peri-implant space.i. Implant mobility is an indication for lack of osseointegration.
ii. Serves to diagnose the final stage of osseodisintegration and
may help to decide that an implant has to be removed.
Histological examinations show an infiltration with neutrophils
and high numbers of leukocytes with implants that have
increased gingival inflammation
i. Gingival index
ii. Sulcus bleeding index
iii. Plaque index
Bacterial culture, DNA probes, polymerase chain reaction,
monoclonal antibody and enzyme assays to monitor the
subgingival microflora
Mombelli, A., & Lang, N. P. (1998). The diagnosis and treatment of peri-implantitis. Periodontology 2000, 17(1), 63–76.

Periotest
RFA
Periotest provides objective measurement of
tooth or implant mobility by assessing
damping characteristics of periodontium.
Utilizing RFA involves sending magnetic pulses to a
small metal rod temporarily attached to the
implant.
As the rod vibrates, the probe reads its resonance
frequency and translates it into an ISQ value.

Implant Stability Quotient (ISQ)
Huwiler MA, Pjetursson BE, Bosshardt DD, Salvi GE, Lang NP. Resonance frequency analysis in relation to jawbone characteristics and during early healing of implant installation. Clinical oral implants research.
2007 Jun;18(3):275-80.

• Higher values are generally observed in the mandible than in the maxilla.
Initial ISQ value
High
Small drop in stability
normally levels out with
time
A big drop in stability or
decrease should be
taken as a warning sign.
Low
Expected to be higher
after the healing period
The opposite could be a
sign of an unsuccessful
implant and actions
should be considered

Diagnostic differences between periimplantitis & periimplant mucositis
Clinical parameter Peri-implant
mucositis
Peri-implantitis
Increased probing depth May or may not be present Present
BOP Present Present
Suppuration May or may not be present Present
Mobility Absent May or may not be present
Radiographic bone loss Absent Present

Peri-implant
pockets <3mm
No visible plaque
No bleeding
No therapy
Consider reduction
of recall frequency
Plaque index >1,
and/or bleeding on
probing
Clean implants
Improve oral
hygiene
Treatment
Mombelli, A., & Lang, N. P. (1998). The diagnosis and treatment of peri-implantitis. Periodontology 2000, 17(1), 63–76.

Peri-implant
pockets
>3mm
No loss of
bone
Loss of bone
Periapical radiographs taken

No bone loss
No visible plaque
No bleeding
Consider correction of
unfavourable soft tissue
morphology
Plaque index >1, and/or
bleeding on probing
Clean implants
Improve oral hygiene
Consider correction of
unfavourable soft tissue
morphology

Bone loss
Pockets 4-5mm
No visible plaque
No bleeding
No suppuration
Plaque index >1,
and/or bleeding on
probing and/or
suppuration
Pockets >5mm
Local problem
Moderate bone loss
Extensive bone loss
Generalized or
associated with
periodontal disease
• Consider correction
of soft tissue
morphology
• Clean implants
• Improve oral hygiene
• Consider use of antiseptic agent
• Correction of soft tissue
morphology
• Treatment with local
delivery device
• Treatment with local
delivery device
• Surgical intervention
• Comprehensive treatment
including mechanical
debridement, systemic
antibiotics, surgical
intervention

• Hyperplastic fistulations and mucosal abscess
1. Bacteria can be found at the connection between the implant and the cover screw/abutment.
2. Fistulations and hyperplastic mucositis are often found in conjunction with loose prosthetic
components.
3. Fistula formations and abscesses can occasionally be seen in relation to dense food particles
trapped in the peri-implant crevice.
Esposito, M., Hirsch, J., Lekholm, U., & Thomsen, P. (1999). Differential diagnosis and treatment strategies for biologic complications and failing oral implants: a review of the literature. The International journal of
oral & maxillofacial implants, 14 4, 473-90 .

2. Edema
Swelling - more noticeable 24 hours after performing surgery
Wide flaps
Bone
regenerating
techniques
Surgery timeCauses:
Hsu YT, Mason SA, Wang HL. Biological implant complications and their management. Journal of the International Academy of Periodontology. 2014 Jan;16(1):9-18.

Cold pack
NSAIDs
MANAGEMENT
Corticosteroids

3. Ecchymosis and haematomas
Arterial trauma Severe bleeding Hematomas
(<2 mm)
(2 to 10 mm) (>10 mm)

Signs and Symptoms
Swelling and elevation of floor of the mouth
Increase in tongue size Profuse bleeding from the osteotomy site
Hsu YT, Mason SA, Wang HL. Biological implant complications and their management. Journal of the International Academy of Periodontology. 2014 Jan;16(1):9-18.

Treatment
Posterior mandible
Bleeding site during implant osteotomy
Middle lingual of mandible
Anterior lingual of mandible
Invading the mandibular canal

4. Emphysema
The condition is characterized by air being forced underneath the tissue, leading to swelling,
crepitus on palpation, and with potential to spread along the fascial planes.
1. Inadvertent insufflation propulsion of air into tissues under skin or mucous membranes
2. Air from a high-speed handpiece, air/water syringe, an air polishing unit or an air abrasive
device can be projected into a sulcus, surgical wound, or a laceration in the mouth
McKenzie, W. S., & Rosenberg, M. (2009). Iatrogenic Subcutaneous Emphysema of Dental and Surgical Origin: A Literature Review. Journal of Oral and Maxillofacial Surgery, 67(6), 1265–1268.
Marek E, Kot K, Kozłowski A, Lipski M. Air emphysema after drying the cavity with an air syringe. Journal of Stomatology.;71(5):444-8.
Subcutaneous emphysema is a rare but serious side effect of dental and
oral surgery procedures.
Causes

1. Facial or cervico-facial swelling coincident with dental
treatment.
2. Swelling can close the eye, and it can appear several hours
after therapy.
Signs and Symptoms
Crepitus
Greenstein, G., Cavallaro, J., Romanos, G., & Tarnow, D. (2008). Clinical Recommendations for Avoiding and Managing Surgical Complications Associated With Implant Dentistry: A Review. Journal of
Periodontology, 79(8), 1317–1329.

• Antibiotic and mild analgesic therapy
• Close observation
• Reassurance
• Symptoms usually subside in 3 to 10 days.
Treatment

5. Aspiration and Swallowing of instruments
Pingarrón Martín, L., Morán Soto, M. J., Sánchez Burgos, R., & Burgueño García, M. (2009). Bronchial impaction of an implant screwdriver after accidental aspiration: report of a case and revision of the literature.
Oral and Maxillofacial Surgery, 14(1), 43–47.
Thin, pointed instruments increase the risk of perforation and
pneumothorax.

Early complications:
1. Acute dyspnea
2. Asphyxia
3. Cardiac arrest
4. Laryngeal edema
Chronic complications such as
esophageal erosion and pneumonia
resulting from unrecognized aspiration
or ingestion are serious medical issues
that require further care and
hospitalization.

Bergermann, M., Donald, P. J., & àWengen, D. F. (1992). Screwdriver aspiration. International Journal of Oral and Maxillofacial Surgery, 21(6), 339–341.
• Recommended to tie all tiny and slippery instruments with silk ligatures or else use a rubber dam
Treatment

Pingarrón Martín, L., Morán Soto, M. J., Sánchez Burgos, R., & Burgueño García, M. (2009). Bronchial impaction of an
implant screwdriver after accidental aspiration: report of a case and revision of the literature. Oral and Maxillofacial
Surgery, 14(1), 43–47.

6. Flap dehiscence
• Flap dehiscence and exposure of graft material or barrier membrane
• The most common postoperative complication is wound dehiscence, which sometimes occurs
during the first 10 days
• The most common postoperative complication for submerged implants is wound dehiscence.

a) Flap tension
b) Continuous mechanical trauma or irritation associated with the loosening of the cover screw
c) Incorrect incisions
d) Poor-quality mucosa (thin biotype, traumatized),
e) Heavy smokers, patients treated with corticosteroids, diabetics, or irradiated patients
Lee, S., & Thiele, C. (2010). Factors Associated With Free Flap Complications After Head and Neck Reconstruction and the Molecular Basis of Fibrotic Tissue Rearrangement in Preirradiated Soft Tissue. Journal of
Oral and Maxillofacial Surgery, 68(9), 2169–2178.
Contributing factors

Treatment
Re-suturing Chemotherapy
Small (24 to 48 hrs)  Resuture
Large (2 to 3 cm) (>2 to 3 days)  Margins of the wound be
excised and resutured.
If the patient has traumatized wound margins, it is in the
anterior part of the mouth, or a membrane was used, consider
using chlorhexidine rinses twice a day and/or systemic
antibiotics.

Careful preoperative assessment of the soft tissues to measure the amount of keratinized
mucosa present and planning of augmentation procedures as appropriate
Minimally invasive flap elevation and reflection with careful removal of any bone debris
beneath
Proper suturing
Sensible temporization, rebasing and relining
Delaying the use of removable dentures until two weeks after surgery
Prevention

7. Sensory disturbances
• Nerve lesions can be an intraoperative
accident or a postoperative complication that
can affect the:
0%-44% incidence

Causes
Indirect Direct
• Compression, stretch, cut,
overheating, and accidental
puncture
• Postsurgical intra-alveolar
edema or hematomas- produce
a temporary pressure increase,
inside the mandibular canal

Neurological sequelae of nerve injury
AnesthesiaDysesthesiaHyperesthesiaHypoesthesiaParesthesia
(numb feeling, burning, and prickling)
(reduced feeling)
(increased sensitivity)
(painful sensation)
(complete loss of feeling of the
teeth, the surrounding skin, and
mucosa)

Classification
Misch CE. Contemporary implant dentistry. Implant Dentistry. Root Form Surgery in the Edentulous Anterior and Posterior Mandible: Implant Insertion, pg 709-713; 1999 Jan 1;8(1):90;
Seddon classification:
Mild injury caused by
compression or blunt
trauma to the nerve
Loss of axonal continuity
but the general structure of
the nerve remains intact.
Complete severance
of the nerve trunk
Neuritis, paresthesia
Paresthesia, episodic
dysesthesia
Anesthesia

Sharp needle
testing
Shortest distance
between
indentation
Mapping area of
altered feeling
Blunt cotton
swab test
Pulp testing teeth
Temperature test
Sensory testing (Bilaterally)

a) Evaluate periapical and panoramic films; if needed, a CT scan should be obtained.
b) Use appropriate magnification factor.
c) Use drill guards on burs to avoid unintentional over-penetration of the drill.
d) Allow a 1 to 2 mm safety zone between the entire implant body and any nerve canal.
e) Consider the bony crestal anatomy
Avoiding nerve injuries
• Is the buccolingual position of the crestal peak of bone
influencing the measurement of available bone?
• Consider the buccolingual position of the nerve canal.

• Treatment with corticosteroids and non-steroidal antiinflammatory drugs - to control
inflammatory reactions that provoke nervous compression.
• Topical application of dexamethasone (4 mg/ml) for 1 or 2 minutes enhances recovery
• Oral administration (high doses)- within one week of injury- prevention of neuroma formation
Treatment
Pharmacotherapy
Misch, Carl E. DDS, MDS*; Resnik, Randolph DMD, MDS† Mandibular Nerve Neurosensory Impairment After Dental Implant Surgery: Management and Protocol, Implant Dentistry: October 2010 - Volume 19 - Issue
5 - pg 378-386

NEUROPRAXIA:
Remove offending element
Corticosteroids
Recovery on 1 to 4 weeks
AXONOTMESIS:
Remove offending element
Corticosteroids
Recovery on 1 to 3 months
NEUROTMESIS:
Complete anesthesia for more than 3 months
May have triggering signs or increase in sensation
to sharp stimuli

• Intraoperative nerve section – microsurgery techniques to re-establish nerve continuity.
• Neurosensorial loss - checked at different moments to determine with precision the evolution of
the lesion
• Resort to microsurgery if, after four months - patient’s situation has not improved, pain persists
and there is a remarkable loss of sensitivity.
Surgical therapy

Alternative
Chrcanovic, B.R., Custódio, A.L.N. Inferior alveolar nerve lateral transposition. Oral Maxillofac Surg 13, 213–219 (2009).

Although it may be considered rare, since 1984 there have been atleast
11 case reports of life threatening hemorrhagic episodes as a
consequence of placing implants in the mandible.
Lesions in any sublingual, lingual, or submaxillary artery
Surgeries in the lower and anterior area of totally edentulous
patients who have a deficit in the quality and quantity of bone.
SURGICAL COMPLICATIONS
1. Life threatening haemorrhage:

There are primarily 2 arteries that supply the floor of the mouth and are related to life threatening
haemorrhage:
1. Lingual artery
2. Facial artery
2nd anterior branch of the ECA
Major vessel to the tongue
3rd ant branch of ECA
Supply parts of the face

More prone
patients fall in the
following category
Group I: high risk
patients
Group 2: medical-
systemic risk
• Patients with serious systemic diseases (rheumatoid
arthritis, osteomalacia, imperfect osteogenesis)
• Immunodepressed (HIV, immunosupresory treatments)
• Drug addicts (alcohol, etc.)
• Unreliable patients (mental or psycological disorders)
• Irradiated patients (radiotherapy)
• Patients with coagulation disorders (anticoagulated
patients or those with haemostatic disorders)
• Severe smokers
Buser, D., Arx, T., Bruggenkate, C., & Weingart, D. (2000). Basic surgical principles with ITI implants. Clinical Oral Implants Research, 11, 59–68.

Treatment
1. Bimanual compression.
2. Pull out the tongue and observe if the bleeding decreases.
3. Elevate the head. This may decrease the blood flow to the region by 30%.
4. Place an oropharyngeal airway behind then tongue.
5. Place hemostatic agents at the osteotomy site.
6. Push with firm pressure against the transverse process of the 4th cervical vertebra in the neck,
on the side of bleeding.
Procedures in the hospital:
1. Ligation of the afflicted vessel.
2. Endotracheal intubation.
3. Emergency tracheotomy

2. COMPLICATIONS ASSOCIATED WITH MAXILLARY SINUS LIFT:
A. Schneiderian membrane perforation
• The Schneiderian membrane- characterized by periosteum overlaid with a thin layer of
pseudociliated stratified respiratory epithelium
• Constitutes an important barrier for the protection and defence of the sinus cavity.

Schneiderian membrane perforation occurs in 10% to 60% of
all procedures

• Anatomical variations such as a maxillary sinus septum, spine, or sharp edge are present
• Very thin or thick maxillary sinus walls
• Angulation between the medial and lateral walls of the maxillary sinus seemed to exert an
especially large influence on the incidence of membrane perforation.
Causes

• Folding the membrane up against itself as the
membrane is elevated
• Suturing
• Resorbable collagen membrane
<5mm perforation
• Lamellar bone + Resorbable collagen membrane
5-10mm perforation
• Lamellar bone
• Lamellar bone + buccal pad of fat
• Bone block graft>10mm perforation
Management
Hernández‐Alfaro F, Torradeflot MM, Marti C. Prevalence and management of Schneiderian membrane perforations during sinus‐lift procedures. Clinical oral implants research. 2008 Jan;19(1):91-8.

B. Loss of the implant or graft materials into the maxillary sinus
Galindo-Moreno, P., Padial-Molina, M., Avila, G., Rios, H. F., Hernández-Cortés, P., & Wang, H.-L. (2011). Complications associated with implant migration into the maxillary sinus cavity. Clinical Oral Implants
Research, 23(10), 1152–1160.
Causes
Changes in intrasinal
and nasal pressures
Autoimmune reaction
to the implant, causing
peri-implant bone
destruction and
compromising
osseointegration
Resorption produced
by an incorrect
distribution of occlusal
forces

Treatment
Immediately retrieve surgically via an intraoral approach or endoscopically via the transnasal route to
avoid inflammatory complications
Prevention
A bone reconstruction procedure of the maxilla should be performed.

3. MANDIBULAR FRACTURE
• Associated with atrophic mandibles
• Central area of the mandible has a greater risk for this complication

Causes
1. Stress fractures at weakened sites where implants were placed.
2. Nerve transposition in conjunction with implant insertion.
Predisposing factors
1. Osteoporosis
2. Stress at the implant location
3. Trauma

• Reduction and stabilization of the fracture with titanium miniplates
or resorbable miniplates.
• Splinting implants to reduce and immobilize the fracture
Treatment
Precaution
• Thin mandibular alveolar crests- increase width by performing bone grafts
• Accurate tomography imaging study

MALPOSITION OR ANGULATION OF AN
IMPLANT
• ‘Malpositioned implant’ is an implant placed in a position that creates restorative and
biomechanical challenges for an optimal result.
• Incorrect implant placement may result in screw loosening of the superstructure and stress
concentration on the bone around the implant.
Watanabe, F., Hata, Y., Mataga, I., & Yoshie, S. (2002). Retrieval and replacement of a malpositioned dental implant: A clinical report. The Journal of Prosthetic Dentistry, 88(3), 255–258.

Deficiency of
the osseous
housing around
the proposed
implant site
Causes
The surgeon is not fully
aware of the 3-
dimensional design of
the final restoration
for proper load
acceptance
No surgical guide
is used to indicate
the ideal axial
direction and
position
The occlusal
plane is not
well established

Treatment
Use of repositioning system.
Improves esthetic effects, the
biomechanical behaviour of the
implant

• Assess the characteristics of the edentulous zone subject to rehabilitation using clinical and
radiological CT, or cone beam CT imaging
• Use short or tilted implants (approximately 30°)
• Avoid anatomical structures (mental nerve, maxillary sinus).
Precautions

INJURY TO ADJACENT TEETH
This problem arises more frequently with single implants
Positioning an implant
close to the root of a
tooth may cause:
a. Compressive
resorption of the
cementum
b. Cutting of the
neurovascular
bundle of vital teeth
Signs & symptoms:
a. pain/ increased
sensitivity
b. Partial or complete
loss of vitality
c. Apical radiolucency
d. Root resorption

• Use of a surgical guide, radiographic analysis and CT scan can help locate the implant placement.
• Inspection of a radiograph with a guide pin at a depth of 5 mm will facilitate osteotomy angulation
corrections
• Prevent a latent infection of the implant from the potential endodontic lesion, endodontic
treatment should be performed
Precautions

1. Screw loosening
Incidence- 8.7%
• Stress applied to prosthesis
• Crown height
• Cantilever Height or depth of antirotational component
• Platform dimensions on which the abutment is seated
Schwarz MS. Mechanical complications of dental implants. Clinical Oral Implants Research: Chapter 10. 2000 Sep;11:156-8.
Causes
TECHNICAL COMPLICATIONS

• Large diameter implants with large platform dimensions reduce the forces applied to the screw
• Decreased preload force
• Increase thread tightening
Treatment

Conclusions: The results showed that abutment
screw loosening is a rare event in SIR regardless
of geometry of implant-abutment connection,
provided proper anti-rotational and torque
features are employed.
Theoharidou A, Petridis HP, Tzannas K, Garefis P. Abutment screw loosening in single-implant restorations: a systematic review. International Journal Oral & Maxillofacial Implants. 2008;23(4):681-90.

2. Implant exposure
Complete exposure of the implant cover screw
Removal of the healing cover
Flushing of the implant with chlorhexidine, insertion of a permucosal
extension(PME)
Oral hygiene with soft toothbrush
Chlorhexidine application over the area twice each day
Protocol for partial exposure unassociated with exudate :
Can be associated with exudate and bone loss

Implant exposure with minimal bone loss
Implant exposure with exudate and bone loss
PME inserted,
tissue
approximated
Membrane can
be used
Antibiotics and
chlorhexidine
daily rinses
Uncovering of
implant, removal
of cover screw
Curetting of
granulation
tissue
Bone grafts and
membrane

3. Implant fracture
Infrequent complication
Rarely accompanied by pain or infection
Causes
1. Defects in the implant design or materials used in their construction
2. A non-passive union between the implant and the prosthesis or by
mechanical overload

Management
1. Removal of the implant followed by an autogenous graft, 8-10 weeks later, and allowed to
regenerate bone before next implant placement.
2. Early implant failure: replace with a larger diameter implant.
Contraindicated in presence of infection
IMPLANT RETRIEVAL KIT

A large number of mechanical complications have been reported :
1.Overdenture loss of retention/adjustment/clip/attachment fracture
Resin veneer fracture of fixed partial dentures
Porcelain veneer fracture
Opposing prosthesis fracture
Acrylic resin base fracture
Abutment screw loosening/fracture
Metal framework fractures
Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. The Journal of prosthetic dentistry. 2003 Aug 1;90(2):121-32.

Esthetic complications
1. Malpositioned implants
2. Inappropriate number and/or size of utilized implants
3. Peri-implant infection progressively leading to the destruction of
periimplant bone
4. Pre-existing bone or soft tissue deficiencies in the alveolar
process.
Causes
Chen ST, Buser D, Dent M. Esthetic complications due to implant malpositions: etiology, prevention, and treatment. Dental Implant Complications: etiology, prevention, and treatment. 2015 Nov 16:209-32.

For the placement of dental implants in the esthetic zone the concept of “comfort” and “danger”
zones was introduced.
The purpose of this concept was to highlight the risk of potential complications if implants are not
correctly positioned in relation to the adjacent natural teeth

Mesiodistal malposition:
An implant that is placed too close to an adjacent natural tooth falls within the mesiodistal danger
zone.
There is a risk of a reduced papilla height at the adjacent tooth
due to crestal bone resorption and modeling during the healing
phase and results in a “bone saucer.”
There may not be enough space for the soft tissues to develop at
all, resulting in complete absence of a papilla.

Coronoapical malposition
If the implant is not inserted deep
enough into the tissues:
1. The metal implant shoulder will be
visible
2. Unpleasant esthetic outcome
3. No recession of the mucosa is
present.
More common complication: implant
placed too deep into the tissues.
Seen with immediate implant
placement
1. This apical malposition can cause
recession of the facial mucosa.
2. Persistent inflammation of the peri-
implant mucosa
3. Difficulty plaque control
4. Poor soft tissue esthetic outcome.

Orofacial malposition
Implant is placed too far palatally:
1. Ridge-lap design of the implant
crown.
2. Difficult for the patient to
maintain optimum plaque control.
3. Increased the dimensions of
the crown on the palatal side,
which may impinge on the tongue
space.
Implant is placed too far facially:
1. Recession of the facial mucosa
2. Severe esthetic complications,
since the harmonious gingival
course is significantly disturbed
and often requires the removal of
the implant.

• Natural emergence profile of the implant crown
• Appropriate treatment planning and implementation
• Evaluation of esthetic treatment outcome:
a) The Pink Esthetic Score (PES), which involves only the peri-implant soft tissue.
b) The modified PES to comprehensively assess the esthetic outcome of implant
reconstruction of both soft tissue and restoration.
which specifically focuses on the clinical crown supported
by implant
Management

Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue around single‐tooth implant crowns: the pink esthetic score. Clinical oral implants research. 2005 Dec;16(6):639-44.

Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of early placed maxillary anterior single‐tooth implants using objective esthetic criteria: a cross‐sectional, retrospective study in
45 patients with a 2‐to 4‐year follow‐up using pink and white esthetic scores. Journal of periodontology. 2009 Jan;80(1):140-51.

PHONETIC COMPLICATIONS
• Implant prosthesis with unusual palatal contours ( Restricted or narrow palatal space)
• Mostly observed in severe atrophied maxilla
• Excessive air flow beneath the metal framework/ excessive saliva.
Causes
Management
Implant assisted maxillary- overdenture
Sones AD. Complications with osseointegrated implants. The Journal of prosthetic dentistry. 1989 Nov 1;62(5):581-5.

FAILED OSSEOINTEGRATION
• Osseointegration was originally defined as a direct structural and functional connection
between ordered living bone and the surface of a load-carrying implant.
• Osseointegration between an endosseous titanium implant and bone can be expected greater
than 85% of the time when an implant is placed.
Schenk RK, Buser D. Osseointegration: a reality. Periodontology 2000. 1998 Jun;17(1):22-35.

Factors
1.Implant failure:
Previous failure
Surface roughness
Surface purity and sterility
Fit discrepancies
Intra-oral exposure time
2. Mechanical overloading:
Premature loading
Traumatic occlusion due to inadequate
restorations
3. Patient factors (local):
Oral hygiene
Gingivitis
Bone quantity/quality
Adjacent infection/inflammation
Periodontal status of natural teeth
Impaction of foreign bodies (including debris
from surgical procedure) in the implant pocket
4. Patient factors (systemic):
Vascular integrity
Smoking
Alcoholism
Predisposition to infection, e.g. age, obesity,
steroid therapy, malnutrition, metabolic
disease (diabetes)
Systemic illness Chemotherapy/radiotherapy
Hypersensitivity to implant components
5. Surgical technique/environment:
Surgical trauma
Overheating (use of handpiece)
Perioperative bacterial contamination,
e.g. via saliva, perioral skin,
instruments, gloves, operating room
air or air expired by patient

COMPLICATIONS ASSOCIATED WITH ZYGOMATIC
IMPLANTS
Chrcanovic BR, Albrektsson T, Wennerberg A. Survival and complications of zygomatic implants: an updated systematic review. Journal of Oral and Maxillofacial Surgery. 2016 Oct 1;74(10):1949-64.
• Most ZIs failures were occurred within the six-month postsurgical period or at the abutment
connection.
• The 12-year Cumulative Survival Rate was 95.21%.
• ZIs submitted to immediate loading presented a statistically significant higher survival rate than ZIs
submitted to delayed loading protocols.
• The main complication which seems to occur with ZIs is sinusitis, which may develop several years
after their placement.

COMPLICATIONS ASSOCIATED WITH PTERYGOID
IMPLANTS
Candel E, Peñarrocha D, Peñarrocha M. Rehabilitation of the atrophic posterior maxilla with pterygoid implants: a review. Journal of Oral Implantology. 2012 Oct 1;38(S1):461-6.
Bleeding: proximity of the
internal maxillary artery,
which runs 1 cm above the
pterigomaxillary suture.
Management: Local
hemostatic methods
Loss of implants during
placement due to drilling
beyond the pterygoid
process.
Management: Surgical
retrieval and repositioning.

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Complications in dental implant therapy

Complications in dental implant therapy

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