Journal of Oral Implantology

Conservative implant removal for the analysis of the cause, removal torque and
surface treatments of failed nonmobile dental implants
--Manuscript Draft--

Manuscript Number: aaid-joi-D-14-00207

Full Title: Conservative implant removal for the analysis of the cause, removal torque and
surface treatments of failed nonmobile dental implants

Short Title: Conservative implant explantation

Article Type: Clinical Research

Keywords: Periimplantitis; explantation; implant removal; counter-torque; surface treatment

Corresponding Author: Eduardo Anitua, Ph.D, M.D., D.D.S

Eduardo Anitua Foundation
Vitoria, Álava SPAIN

Corresponding Author Secondary

Information:

Corresponding Author's Institution: Eduardo Anitua Foundation

Corresponding Author's Secondary

Institution:

First Author: Eduardo Anitua, Ph.D, M.D., D.D.S

First Author Secondary Information:

Order of Authors: Eduardo Anitua, Ph.D, M.D., D.D.S

Alia Murias-Freijo, DDS, MPhil

Mohammad Hamdan Alkhraisat, DDS, PhD

Order of Authors Secondary Information:

Abstract: This study was performed to study the effect of implant surface treatment on the cause
and removal torque of failed nonmobile implants. Implant explantation was achieved
by the application of counter-torque at the implant-bone interface. The explantation
socket was carefully examined and curetted to remove any granulation tissue.
Immediate implant placement was accomplished when primary stability could be
achieved. Eighty one patients were treated according to the described treatment
protocol for the explantation of 158 nonmobile implants in the maxilla and the
mandible. The patient's mean age was 62 ± 11 years. The main cause of implant
explantation was peri-implantitis (131 implants; 82.9%) followed by mal-positioning of
the implants (22 implants; 13.9%). The explantation of 139 implants at 146 ± 5 Ncm
was performed without the need for trephine bur. However, the use of trephine burs to
cut into the first 3-4 mm were necessary in 19 explantations and the removal torque
was 161 ± 13 Ncm. All titanium plasma sprayed implants were removed due to
periimplantitis at a significantly lower torque when compared to acid etched, particle
blasted and oxidized implants. The postoperative recovery of the patients was
uneventful and the conservation of the available hard and soft tissues was successfully
achieved. The protocol followed in this study could constitute a real alternative to other
traumatic technique for the removal of failed implants and advanced stages of peri-
implantitis. The type of implant surface treatment could influence the value of removal
torque and the occurrence of periimplantitis.

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Conservative implant removal for the analysis of the cause, removal torque and surface
1 treatment of failed nonmobile dental implants
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7 Anitua E1,2 MD, DDS, PhD, Murias-Freijo A1,2 DDS, MPhil, Alkhraist MH2 DDS, PhD.
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Private practice in oral implantology, c/ Jose Maria Cagigal 19, 01007 Vitoria, Spain
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12 Eduardo Anitua Foundation, c/ Jose Maria Cagigal 19, 01007 Vitoria, Spain.
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22 Short title: Conservative implant explantation
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33 Correspondence address: Dr. Eduardo Anitua, Eduardo Anitua Foundation; C/ Jose Maria
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35 Cagigal 19, 01007 Vitoria, Spain; Phone: +34 945160653, e-mail:
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38 eduardoanitua@eduardoanitua.com
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 Abstract
1
2
3 This study was performed to study the effect of implant surface treatment on the cause and
4
5 removal torque of failed nonmobile implants. Implant explantation was achieved by the
6
7
application of counter-torque at the implant-bone interface. The explantation socket was
8
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10 carefully examined and curetted to remove any granulation tissue. Immediate implant
11
12 placement was accomplished when primary stability could be achieved. Eighty one patients
13
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15 were treated according to the described treatment protocol for the explantation of 158
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17 nonmobile implants in the maxilla and the mandible. The patient's mean age was 62 ± 11 years.
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20 The main cause of implant explantation was peri-implantitis (131 implants; 82.9%) followed by
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22 mal-positioning of the implants (22 implants; 13.9%). The explantation of 139 implants at 146
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± 5 Ncm was performed without the need for trephine bur. However, the use of trephine burs to
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27 cut into the first 3-4 mm were necessary in 19 explantations and the removal torque was 161 ±
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29 13 Ncm. All titanium plasma sprayed implants were removed due to periimplantitis at a
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32 significantly lower torque when compared to acid etched, particle blasted and oxidized
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34 implants. The postoperative recovery of the patients was uneventful and the conservation of the
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37 available hard and soft tissues was successfully achieved. The protocol followed in this study
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39 could constitute a real alternative to other traumatic technique for the removal of failed
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42 implants and advanced stages of peri-implantitis. The type of implant surface treatment could
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44 influence the value of removal torque and the occurrence of periimplantitis.
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51 Key words: Periimplantitis; explantation; implant removal; counter-torque; surface treatment.
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 Introduction
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3 The wide acceptance of dental implants as the choice to replace lost dentition have significantly
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5 increased the number of patients being treated with implant-supported prosthesis. It is
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estimated that more than half a million implants in United states, about 120 000 implants in
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9 1, 2
10 France, 185 000 in Spain, 410 000 in Italy and 420 000 in Germany are placed every year .
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12 This is partly motivated by the reliability and high success rate of implant-based oral
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15 rehabilitation, making this option predictable and safe 3. The implant survival rate of implant-
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17 supported fixed partial denture is reported to be 92-97% 4.
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However, an implant failure rate of at least 3% is occurring and there will be a need to
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23 efficiently resolve failure cases. Implant failure could arise as a result of infection
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25 (periimplantitis), biomechanical stresses as well as improper positioning that may require the
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28 removal of the implant 5.
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31 Peri-implantitis is an inflammatory process around an implant, which includes both soft tissue
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34 inflammation and progressive loss of supporting bone beyond biological bone remodeling 6.
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36 Advanced stages of periimplantitis would result in severe bone loss around the dental implants
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and indicate the need for implant removal.
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42 Inadequate communication between the surgeon and restorative dentist would result in
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44 improper implant positioning and/or angulations 7. Solutions for improper implant positions
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47 include second surgeries or prosthetic compensation, solutions that will increase time and cost
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8, 9
49 to achieve functioning prosthesis . Implant-osseous osteotomy and distraction osteogenesis
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have been reported for the repositioning of malpositioned implants 10.
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55 A failed implant site would present reduced bone volume (horizontally and vertically) that
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57 would increase the difficulty for resolving such clinical problem. Traumatic implant removal
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60 would further complicate the accomplishment of prosthetic rehabilitation with satisfactory
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 function and esthetics. It would also increase the risk for vascular injury with important
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2 consequences if occurs in the floor of the mouth. For that, it is important to perform minimally
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5 invasive implant removal not only for conserving the available bone and gingival tissues but
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7 also to permit the identification and diagnosis of pathological lesions 11.
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Different techniques have been reported to explant a failed dental implant that include block
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13 resection, buccal bone osteotomy, and trephine osteotomy . However, these techniques
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15 require the protection of neighboring tissues and may need the application of regenerative
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18 techniques to restore the surgical area. Consequently, immediate placement of dental implants
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20 would be jeopardized and cost and time necessary to complete the treatment will increase. In a
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23 recent study a minimally invasive implant removal is achieved by a circumferential osteotomy
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25 performed with piezosurgery 13.
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32 The majority of technique available to remove failed implants does not allow to quantitatively
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34 measure the force necessary to remove the implant. For that, in this study, a conservative
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37 implant explantation is performed by the application of counter-torque to break the implant-
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39 bone union. The failed nonmobile implants are analyzed to retrieve data about implant type,
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surface treatment, cause for implant removal, and the removal torque. The effect of surface
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44 treatments on the cause for implant removal and removal torque is analyzed.
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47 Materials and methods
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54 Patients were treated between March, 2010 to March, 2014 for dental implant removal. The
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56 inclusion criteria were:
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60  Patients aged over 18 years.
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  Explantation of at least one nonmobile implant.
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 Identification of the indication for explantation.
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5  Recording of the removal torque.
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10 Patients/implants that did not meet any of these criteria were excluded from the study.
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13 Prior to surgery and in order to make a proper treatment plan, all patients underwent standard
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16 diagnostic protocol consisting of reviewing the medical and dental history, diagnostic casts, and
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18 radiographic evaluation.
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21 Surgical procedure
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25 Patients received 2 g of amoxicillin (600 mg of clindamycin for allergic patients) and 1 g of
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27 acetaminophen 60 minutes before surgery. Local anesthesia was achieved by inferior alveolar
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nerve block anesthesia and buccal and/or lingual infiltration anesthesia using articaine
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32 hydrochloride with epinephrine (1:100,000). A crestal incision was practiced to elevate a full
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34 thickness flap and expose the surgical site and peri-implantitis was classified according to the
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37 status of surrounding bone 14, 15 into:
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40 Class I: Slight horizontal bone loss with minimal peri-implant bone defect.
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Class II: Moderate horizontal bone loss with isolated vertical defect.
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47 Class III: Moderate to advanced horizontal bone loss with broad circular bony defect.
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50 Class IV: Advanced horizontal bone loss with broad circumferential vertical defect as well as
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53 loss of oral and/or vestibular bony wall.
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56 However, the extraction of malpositioned implants could be performed without the reflection of
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58 a mucoperiosteal flap if no implants would be inserted. Implant explantation was carried out
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 using an extraction kit (BTI Biotechnology Institute, Vitoria, Spain). For that, a ratchet was
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2 first engaged into the implant connection (Figure 1). The choice of the insert was based on the
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5 recommendations of the manufacturer although in some cases the insert was shortened using a
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7 cutting disk for better retention. The removal torque was exerted by a wrench in counter-
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10 clockwise direction maintaining a perpendicular position of the assembly in relation to the
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12 implant platform (Figure 1). Only in cases where the torque wrench opened (the maximum of
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wrench torque was set at 200 Ncm), the extraction assembly was removed and specialized
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17 trephine burs were employed to cut into the first 3-4 mm of implant-bone contact (Figure 2).
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19 The implant explantation was then continued with the torque wrench. For all cases, the
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22 removal torque was registered in the patient's record.
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25 The explantation socket was carefully examined to identify abnormalities and the status of the
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28 bony walls. The socket was carefully curetted to remove any granulation tissue. The decision
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30 for immediate implant placement was based on the design of the prosthesis and the possibility
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32 to achieve primary stability of the implant. The insertion of the dental implant was done with a
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35 surgical motor at an insertion torque of 25 Ncm and then continued manually to finish the
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37 implant placement.
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41 The low-speed drilling and the design of the bone drills permitted the collection of bone
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43 particles during the preparation of implant site. The harvested autologous bone was stored in
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the fraction 2 of the PRGF-Endoret (BTI; Vitoria, Spain) until use. This resulted in the
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48 formation of a fibrin clot that glued together the autologous graft particles. Fibrin-glued bone
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50 graft was applied to fill the gap between implant and bone. Fibrin membrane, prepared from F1
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53 of PRGF, was compressed to provide thin and consistent membrane that was then applied to
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55 cover the surgical site before flap reposition and suturing (interrupted suture) with
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58 monofilament 5/0 nylon suture. Postoperatively, patients were instructed to perform light and
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 gentle brushing of the tooth/structures close to the surgical area after 24 h and to avoid chewing
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2 on the operated site.
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6 To obtain plasma rich in growth factors (PRGF), peripheral blood was extracted by
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8 venipuncture into four 9 mL extraction tubes containing 3.8% sodium citrate (BTI
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Biotechnology Institute S.L, Vitoria, Spain) and processed according to the manufacturer
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13 instructions. Fifty µl of calcium chloride solution (PRGF activator; BTI Biotechnology Institute
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15 S.L, Vitoria, Spain) per each milliliter of plasma were employed to activate platelets and fibrin
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18 formation.
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21 Postoperative phase:
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Follow-up visits were scheduled to remove sutures and to detect any surgical complications.
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27 Clinical evaluation and implants status were also monitored. After at least 4 months, a second
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29 surgery was then performed to connect transepithelial abutments (Multi-Im, BTI, Vitoria,
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32 Spain). Success or failure of osseointegration was annotated in the patients records.
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35 Data collection and statistical analysis
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38 The patient was the statistical unit for the description of demographic data. Mean and standard
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41 deviations were calculated for the age variable while relative frequency was calculated for the
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43 gender. The implant was the statistical unit for the statistical description of indication for
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46 implant removal, location, removal torque, and manufacturer (surface treatment). Mean and
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48 standard deviation were calculated for torque values. Relative frequency was calculated for
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51 indication for implant removal, implant location, and surface treatment.
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54 Shapiro-Wilk test was performed to evaluate if the data of insertion torque. Kurskal-Wallis test
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56 was perofmed to detect the staitistical significant of the effect of surface treatments on the
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59 removal torque. Mann-Whitney test was applied for pairwise comparison between the surface
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 treatments. The statistical significance was set at p < 0.05. All the statistical analyses were
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2 performed using the SPSS v15.0 for Windows statistical software package (SPSS Inc.,
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5 Chicago, IL, USA).
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11 Results
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15 This study reports the data of 81 patients with 158 nonmobile implant explantations which
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17 fulfilled the inclusion criteria. All patients received periodontal cleaning sessions and oral
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20 hygiene instructions before surgery (Figure 3).
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23 Fifty six patients were females and the patient's mean age was 62 ± 11 years (range: 34-81
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25 years). Seventy nine (50%) implant explantations were performed in the maxilla and 35.3%
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28 were in the anterior sectors. The main cause for implant explantation was peri-implantitis
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30 (Figure 4; 131 implants; 82.9%) followed by mal-positioning of the implants (22 implants;
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33 13.9%). One implant was extracted due to fracture of prosthetic components and 2 were
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35 transitional implants. Another 2 implants were affected by bisphosphonate-related
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osteonecrosis of the jaws (BRONJ).
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41 The peri-implantitis was classified according to the classification proposed by Jovanovic and
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43 14, 15
Spiekermann . Periimplantitis Class III affected 28 implants and class IV affected 103
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46 implants.
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49 Implant type: The removed implants were classified according to the surface treatments into
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acid etched, particle blasted, particle blasted + acid etched, oxidized, titanium plasma sprayed,
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54 and turned implants. One implant was hydroxyapatite coated. Most of the implants removed
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56 were acid etched (47.5%) and oxidized (19.6%) as shown in table 1.
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 Removal torque: The implant removal technique followed in this study allowed the registration
1
2 of the torque necessary to remove the implant. The explantation of 139 implants were
3
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5 performed without the need for trephine burs. The removal torque of these explantations was
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7 146 ± 5 Ncm. However, The use of trephine burs was necessary in 19 explantations and the
8
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10 removal torque was 161 ± 13 Ncm. The indications of using trephine bur were an initial
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12 removal toque higher than 200 Ncm (15 implants), fractured implants (3 implants) and
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fractured prosthetic component (one implant).
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18 The torque necessary to break the implant-bone union showed variations between the different
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20 surface treatments. The torque value distribution according to the type of surface treatments did
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23 not follow the normal distribution (Shapiro-wilk test, P < 0.05). The Kruskal-Wallis test
24
25 showed the presence of statistically significant effect of surface treatments on the removal
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28 torque (P = 0.000). The pairwise comparison was then performed through the application of
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30 Mann-Whitney test (Table 2). The removal torque was lower (statistically significant) for
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32 titanium plasma sprayed implants on comparison with the other surface treatments. The
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34
35 removal torque was the highest (statistically significant) for acid etched and particle blasted
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37 implants.
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41 Periimplantitis was the cause of removal of all implants that were titanium plasma sprayed.
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43 This was also the case of more than 80% of the acid etched, particle blasted and oxidized
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implants. About 44% of particle blasted + acid etched implants and 67% of turned implants
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48 were extracted due to periimplantitis.
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54 Complications: Fracture of 3 implants were reported and the extraction of the implants was
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56 continued with a trephine burs (Figure 5). The implants were from Noble Biocare, Astratech
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 and Biomet 3I. Post-operative recovery was eventful and pain due to surgical intervention was
1
2 successfully managed with oral analgesics.
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6 Post-explantation alveolous: After the removal of the implants, the granulation tissue was
7
8 carefully removed and the bony walls were examined with a dental probe. Indentation of
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10
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implant's threads was observed to be printed on the alveolar walls indicating the minimally
12
13 invasiveness of the technique. Immediate implant placement was achieved with adequate
14
15 primary stability in 13 cases (Figure 6). Extensive bone resorption and/or the absence of buccal
16
17
18 plate of the alveolous were managed by socket grafting with PRGF clot prepared from F2 that
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20 was covered with fibrin plug prepared from F1. The new implant placement was performed in a
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23 second surgery after 4 months of bone healing (Figure 7). Worth to mention, the soft tissue
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25 closure of the defects in patients affected by BRONJ was successfully achieved.
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32 Discussion
33
34
35 Different methods have been described to remove osseointegrated dental implants. Some of
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37
38
them include trephining a bone block in which the dental implant is present, the use of thin bur
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40 at low speed with irrigation to separate the implant from the surrounding bone and In 2004,
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42 Massei et al. reported the induction of a localized thermonecrosis at the bone-implant interface
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44
45 through the application of an ultrahigh frequency electrosurgical device 16. These methods have
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47 the limitation of being traumatic and of jeopardizing the explantation socket for future implant
48
49
50 placement. Less invasive techniques like counter-ratchet technique and reverse screw technique
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52 have been developed to preserve available hard and soft tissue.
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54
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57 In this study the main cause for implant removal was advanced stages of bone loss due to
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59 periimplantitis. This was the case of all titanium plasma sprayed (TPS) implants and of more
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 than 80% of acid etched, particle blasted and oxidized implants. However, it was lower for
1
2 particle blasted + acid etched implants. This could be related to the fact that most of the
3
4
5 implants included in this study was acid etched and oxidized implants. Additionally, rough
6
7 surface implants (TPS) are more likely to develop periimplantitis than minimally rough
8
9
10 implants once exposed to the oral environment 17. Most of the peri-implant bone defects due to
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12 periimplantitis showed advanced horizontal bone loss with broad circumferential vertical bone
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14
15
defect and the loss of at least one bony wall.
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17
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19 The explantation method followed in this study allowed the registration of the torque necessary
20
21
22 to remove the implant without damaging the implant surface. This latter could serve to study
23
24 long term changes to the surface of implants after being in function in the oral cavity. The
25
26
27 removal torque was significantly higher for acid etched, particle blasted and oxidized implants.
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29 However, the removal torque is influenced by several factors like hosting bone quality, design
30
31 18-22
32
of the implant (cylindrical or screw-like), diameter of the implant and surface roughness .
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34 The counter torque needed to unscrew the implant fixture was below 200 Ncm for 139
35
36 implants. But, the use of trephine bur was only needed when the torque value was higher than
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38
39 200 Ncm (15 implants).
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41 Biomechanical studies have shown that the majority of stress transmitted to the peri-implant
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43
44 bone is concentrated at the crestal bone (the first 2 to 3 mm of implant length) regardless of the
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46 23-26
implant design , making this area essential to achieve primary implant stability. This has
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48
49 motivated us to limit the use of trephine bur to break the implant-bone contact at the first 2-3
50
51 threads of the implant. This reduced the removal torque and permitted implant explantation to
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be continued with the use of counter-torque wrench.
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 The principle mechanism of implant explantation was the application of a shear stress to break
1
2 the union between the implant and the bone and allow for implant un-screwing. The result was
3
4
5 atraumatic implant explantation and preserving at maximum the available hard and soft tissues.
6
7 Thus, immediate implant placement was possible in 13 cases which avoid the need for tissue
8
9
10 regeneration before implant placement, reducing the time and cost. Postoperative recovery of
11
12 the patients was uneventful and pain was successfully managed by oral analgesics.
13
14
15
16
17 This study suffers from the limitation of absence of control group where implants have been
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19 explanted by different technique. The time period between implant insertion and explantation
20
21
22 could not be calculated for the majority of the removed implants as these implants were placed
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24 in another clinical centers. More conservative approach than implant explantation to treat
25
26
27 periimplantitis could not be followed as significant bone loss has already progressed.
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29
30
31
32
The protocol followed in this study could constitute a real alternative to other traumatic
33
34 technique for the removal of failed implants. The conservation of available hard and soft tissues
35
36 is possible and permitted resolving implant failure at shorter time and cost by avoiding
37
38
39 advanced tissue regeneration techniques.
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41
42
43 Conclusions
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47 Periimplantitis and malpositioning of the implants were the main causes for implant
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49 explantation. Periimplantitis was the only cause for the explantation of titanium plasma sprayed
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52 implants. The application of shear stress at the implant-bone contact was effective to permit
53
54 atraumatic implant explantation. The removal torque was higher for acid etched, particle
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56
57
blasted and oxidized implants. The technique preserved at most the available bone tissue and
58
59 reduced the need for advanced tissue regeneration procedures.
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62 12
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 1
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3
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39 16. Massei G, Szmukler-moncler S. Thermo-explantation. A novel approach to remove
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7 20. Elias CN, Rocha FA, Nascimento AL, Coelho PG. Influence of implant shape, surface
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12 Mech Behav Biomed Mater. 2012; 16: 169-180.
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 Figure legends
1
2
Fig.1. Implant removal with counter-ratchet technique. a) clock-wise insertion of the ratchet into the
3
4 implant to extract. b) placement of the wrench to apply a torque in counter clockwise direction for
5
6 implant removal.
7
8 Fig. 2. Removal of the implant if the counter torque exceeds the 200 Ncm. a) deactivation of the torque
9
10 wrench. b) the use of trephine bur to break the first 3-4 mm of implant-bone contact, the insertion of the
11
12 ratchet into the implant, removal of the implant and the insertion of new implant when a good bony
13 support is available.
14
15
16 Fig. 3. a) mal-positioned implants and poor oral hygiene as indicated by the accumulation of dental
17
18 plaque on the implants surface. b) the clinical picture after receiving cleaning and polishing to improve
19 the peri-implant soft tissue. c) and d) implants with bone defects were removed and new implants were
20
21 placed. The 4 implants in the anterior sector and the old prosthesis were maintained as provisional
22
23 prosthesis.
24
25 Fig. 4. a) probing depth of 8 mm around implant supported restoration. b) radiographic evidence of
26
27 advanced peri-implant bone loss. c) the implant removal and a circumferential bone defect. d) the
28
29 removed implant presenting dental plaque accumulation at the threaded implant neck.
30
31 Fig. 5. a) Fracture of the implants at the level of the implant's neck that justifies limiting the maximum
32
33 torque to a value of 200 Ncm. b) higher magnification
34
35 Fig. 6. a) Clinical picture showing the upper removal denture and the lower overdenture. b) Panoramic
36
37 radiograph showing the evidence of bone loss around the implants supporting the lower overdenture. c)
38
39 The advanced bone loss around the implants after the reflection of mucoperiosteal flap. d) the
40 immediate placement of new implants and the placement of transepithelial abutment. e) the provisional
41
42 prosthesis for implant's immediate loading. f) Panoramic radiograph showing the newly placed
43
44 implants.
45
46 Fig. 7. a) the implants after removing the prosthesis, we can note the puss exudate around the most
47
48 mesial implant. b) status of the soft tissue after explantation and placement of new implants. c) the size
49
50 of the bone defect after implant removal indicated the need of regeneration and the deferral of implant
51 placement. d) the bone regeneration by PRGF-Endoret after 4 months were almost complete at #19 and
52
53 bridged about 80% of the defect at #22. e) Panoramic radiograph showing peri-implant bone loss around
54
55 all implants before intervention. f) The new implants supporting a new definitive prostheses.
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62 16
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Table 1
Click here to download Table: Table 1.docx

Table 1. Surface treatment type effect on the removal torque and frequency of
periimplantitis as cause of implant removal.

Surface Frequency Removal torque (Ncm) Periimplantitis

treatment Without With combined
Trephine bur Trephine bur
acid etched 75 155 ± 46 152 ± 32 155 ± 45 68 (90.6%)
particle blasted 18 174 ± 59 150 ± 50 170 ± 57 16 (88.9%)
particle blasted + 16 94 ± 54 200 ± 71 107 ± 65 7 (43.8%)
acid etched
oxidized 31 150 ± 44 158 ± 74 152 ± 50 25 (81%)
titanium plasma 11 89 ± 63 100 90 ± 60 11 (100%)
sprayed
turned 6 150 ± 30 - 150 ± 30 4 (66.7%)
Table 2
Click here to download Table: Table 2.docx

Table 2. Statistically significant (P < 0.05) pairwise comparisons of the effect of surface
treatment on the implant removal torque.

Group 1 Group 2
Acid etched particle blasted + acid
etched
titanium plasma sprayed
particle blasted particle blasted + acid
etched
titanium plasma sprayed
particle blasted + acid titanium plasma sprayed
etched
oxidized titanium plasma sprayed
Figure 1
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Figure 2
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Figure 3
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Figure 4
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Figure 5
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Figure 6
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Figure 7
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Cover Letter
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