Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
2003
Table of content
Introduction
Definition
Classification
Failures of endosseous implants
According to etiology
According to timing of failure
According to failure mode
According to condition of failure
According to supporting tissue type
Treatment
Summary
Conclusion
Reference
Introduction
Osseointegrated dental implants
represent a widely accepted and
documented treatment modality for
the rehabilitation of the partially or
totally edentulous ridge.
Apart from the success , it also have
its failures, due to various factor .
Definition
Implant failure: The total failure of the
implant to fulfill its purpose (functional,
aesthetic or phonetic) because of
mechanical or biological reasons.
Peri-implantitis : in periodontics, a term
used to describe inflammation around a
dental implant, usually its abutment
History
SUBPERIOSTEAL IMPLANTS
This implants was first developed by
DAHL(1940) .
Disadvantages
Slow osseointegration
Difficult retrievability
Excessive bone loss
Exteriorization by downgrowth of
epithelium.
TRANSOSTEAL IMPLANTS
(mandibular staple implants, staple
bone implant ,and transmandibular
implants)
Combines subperiosteal and endosteal
components
Developed by SMALL (1968)
Mostly used in mandibular anterior
region
ENDOSTEAL IMPLANTS
Classification
By Meffert
Ailing Implant
Failing Implant
Failed Implant
Ailing implant:
Implants exhibiting
soft tissue
problems
exclusively are
classified as ailing
and have a more
favorable
prognosis.
Failing implant:
An implant that is
progressively
losing its bone
anchorage, but is
still clinically
stable, can be
defined as failing
Failed implant:
Implant with
mobility excessive
bone loss (>70%)
not amenable to
treatment are
failed implant
According to etiology
Host factor
Surgical factor
Implant selection factor
Restorative factor
According to etiology
Host factor
Medical status
Habits
Oral status
Systemic factors
Osteoporosis:
Significance
More common in
women
Greater loss of
trabecular bone than
cortical bone
Difficult to achieve
immediate stability
Generally have
minimal alveolar
bone height
Prevention
Hyperbaric oxygen therapy
Treatment for osteoporosis(Hormone
Replacement Therapy , dietary calcium,
weight bearing exercise)
Use of hydroxyapatite coated implants to
provide a biomechanical bonding rather
than a mechanical one
Increase no.. of implants to distribute load
Diabetes
Significance
Liability of infection
due to fragility of
vessels so as to
alter blood supply
Impaired wound
healing
Prevention
Screen patients for
diabetes
If patient is diabetic
get medical
consultation
If uncontrolled,
treatment postponed
till condition is under
control
Preoperative
antibiotic prophylaxis,
aseptic technique,
atraumatic tissue
handling and frequent
and close follow up
Smoking
NICOTINE AND ACRYLHYDROCARBONS
Depress osteoblastic
activity ,reduces collagen
synthesis ,inhibits
osteosynthesis .
Also causes local
vasocontriction
CARBON MONOXIDE
Forms
carboxyhemoglobin
HYDROGEN
CYANIDE
Inhibits cellular
respiratory
enzymes
Tissue
hypoxia &
altered tissue
healing
Smoking
Significance
Causes alveolar vasoconstriction and
decreased blood flow
Impaired healing
Poor bone quality
In case of poor oral hygiene , smokers
have 3 times more marginal bone loss
then non-smokers
Smoking cessation
2weeks before and
3 weeks after
surgery
Parafunctional habits
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
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
Prevention
Patients with implants be evaluated at
regular visits for periodontal
maintenance procedures and any
clinical signs and symptoms of periimplant disease be recorded and
treated.
Maintenance
programs should be
designed on an
individual basis,
precise recall
intervals, methods of
plaque and calculus
removal, and
appropriate
antimicrobial agents
for maintenance
around implants
Irradiation therapy
Significance
Xerostomia
Susceptibility to infection
Osteoradionecrosis
Endarteritis of vessels causes decrease
in oxygen supply
Of significance in patients requiring
implant supported maxillofacial
prosthesis following cancer treatment.
Prevention
Hyperbaric oxygen
therapy
Waiting period of 612 months between
radiation therapy and
implant treatment.
Wait for a longer
healing period
following implant
placement.
Pregnancy
Implant surgery procedures are
contraindicated
Almost 15% pregnancies are
terminated by spontaneous abortion
or miscarriage during first trimester
Dental prophylactic appointments
are suggested in 2nd and 3rd
trimester.
According to etiology
Surgical placement
Severe angulation
Lack of initial stabilization
Impaired healing
Overheating the bone
Minimal space between the implants
Placing implant in immature bone
Placement in infected socket
Severe angulation
Significance
Improper implant
placement
compromises
aesthetics and
function
Prevention
To graft the area to allow proper implant
placement
Use of angulated abutments
Prevention
Mastering the surgical skills
Proper drill grip
Use of sharp drills
Impaired healing
Impaired healing and infection due to
improper flap design
There is no single flap design that is
optimal for implant surgery. The basic
surgical procedure, flap design, blood
supply, visibility, access and the
primary closure are the factors that
should be regarded in implant
placement.
Overheating
Overheating the bone and exerting too
much pressure can cause
Bone cell death occurs if temp are >45
Strong correlation between overheating
of the bone and implant failure
Excessive pressure leads to bone cell
necrosis
Connective tissue interface forms
leading to lack of integration
Prevention
External irrigation
No pressure to be
applied while
drilling
Graded series of
drills to be used
Use of sharp drills
at high speed
Prevention
Careful examination
Avoid placement in infected socket
Waiting period of 2-6 mon is indicated
Mucous membrane disinfection, skin
preparation and isolation of the surgical
field with barrier draping can be
accomplished to the level appropriate
for the procedure intended.
Implant Selection
Improper implant length
Number of implant
Prevention
Maximum possible length must be used
for the available bone height
In posterior maxilla, sinus lift procedure
can be attempted
Number of implants
use of more no. of implants decreases
the no. 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 improves
the ability of the fixed restoration to
withstand load.
Restorative problems
Screw loosening
Excessive Cantilever
No passive fit
Improper fit of the abutment
Improper occlusal scheme
Bending moments
Connecting implants to natural teeth
Screw loosening
Most common manifestation
Reasons :
Screw design
Inadequate torque application
Cantilever extension
Inaccurate framework abutment interface
Occlusal discrepancy and jaw relationship
Fixture position and arch form
Screw design
conical screw
has a inclined
plane
Flat head screw
has straight
plane giving
more equal
distribution of
force.
Inadequate torque
application
Amount of torque
suggested the
manufacturers on
the abutment
screw range from
20 to 35 N/cm and
a torque wrench is
required to obtain
a more consistent
value
Inadequate framework
abutment interface
Arch form
Destructive screw
loosening as well
as fracture of the
screw may take
place due to
destructive forces .
Square arch
cantilever
cantilever
A-P spread
Tapered arch
cantilever
cantilever
A-P spread
Ovoid arch
cantilever
cantilever
A-P spread
Cantilever extension
Recommended
cantilever
extension on
mandible is 15 mm
or less and in
maxilla is 10 mm
or less when five
implants are used .
2
x
Framework fracture
Occlusal gingivally
having greater
dimension to resist
fracture
Excessive Cantilever
Non-ideal cantilever:
long distal cantilever
demonstrating bone
loss and poor
support.
Cantilever extensions
cause load
magnification and
overloading of the
implant next to the
cantilever extension,
which in turn leads to
bone loss
Table of content
Introduction
Definition
Classification
Failures of endosseous implants
According to etiology
According to timing of failure
According to failure mode
According to condition of failure
According to supporting tissue type
Surgical failure
Restorative failure
Esthetic failure
Review of literature
Summary
Conclusion
Reference
No passive fit
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.
Analog variance
the abutment for screw retention usually
is fabricated in titanium or titanium
alloy.
the laboratory analog often is made of
stainless steel , brass, or aluminum .
Manufacturers often do not machine
analogs with the same accuracy as the
actual abutment for screw retention .
Threads in
aluminum or brass
may get distorted
so , dentist should
take care that the
analog is flush and
properly seated
with the transfer
coping before the
stone is poured .
Stone expansion
because the addition silicone or
polyether shrinkage is 0.1 % to 0.06% ,
the expansion of the die stone should
be in similar range .
polyether or addition silicone is
suggested for the impression , which is
poured in ADA classification III or IV die
stone , which expands a similar
amount as the impression shrinks .
Acrylic shrinkage
sprinkle on method is used for
fabrication of base plate .
light cure acrylic can be used instead
of cold cure acrylic resin.
Wax distortion .
when wax pattern is removed from the
abutment for screw and sprued before
casting , the strain may release and
distort the pattern.
screw retained casting may be more
accurate and passive when fabricated
in smaller sections to reduce distortion
.
Soldering
When the casting is not passive the
superstructure is separated around
the offending abutment .
The distance of the casting
separation is 0.005 to 0.008 inch , or
thickness of two sheets of paper.
Prevention
Sectioning and
soldering have
been commonly
used to improve fit
in case of long span
fixed prosthesis
Prevention
Fit of the components must be checked
before taking the impression
Bending moments
It can be defined as a situation in which
occlusal forces on an implant supported
prosthesis exert a bending moment on
the implant cross section at the crestal
bone, leading to marginal bone loss
and/or eventual implant fatigue
Significance
High bending moments acting on
osseointegrated implants due to
transverse forces are believed to be
potential contributors to mechanical
implant failure.
higher number of mandibular implants
may decrease the bending moments
affecting mandibular fixed-detachable
prostheses during unilateral biting tasks.
Prevention
Careful treatment plan to select
appropriate site
Avoiding or reducing cantilevers
Narrowing dimension of final prosthesis
Centering the occlusal contacts
Combined
tooth/implant
restorations could be a
potential complication
and could cause an
intrusion of a natural
abutment regardless of
the type of connection
(rigid or nonrigid).
Avoid connecting the
implant and natural
tooth
Peri-implantitis
One of the main cause of implant
failure
It begins as periimplant mucositis
Partially edentulous mouth are at
higher risk of failure then completely
edentulous mouth.
Higher chance of cross infection from
periodontitis sites to implant site
bacterial plaque is
considered as the
primary etiologic
factors in the loss of
teeth and the implants.
Clinical findings
include marked
gingival inflammation,
deep pocket formation,
and progressive bone
loss.
Prevention
Selection of implant candidate
Maintenance of good oral hygiene
Regular recall appointments with the
periodontist
Early intervention , treatment at the
stage of mucositis
Retrograde peri-implantitis
Retrograde implant failure can be due to
bone microfractures caused by
premature implant loading or
overloading, trauma or occlusal factors.
These are characterized by periapical
radiographic bone loss without gingival
inflammation.The microflora is
consistent with periodontal health.
Prevention
Careful analysis of occlusal forces
Increased no.. Of implants
Precise placement and distribution of
implants
Proper follow up
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
Anchorage related factor
Osseointegration
Marginal bone height
Aesthetic problem
Gingival factors
Smile line
Gingival quality
Papillae of the adjacent teeth
Smile line
Gingival quality
Dental factors
Form of natural teeth
Position of interdental point of
contact
Shape of the interdental contact
Square tooth
form
Bone factors
Vestibular concavity
Adjacent implants
Vertical bone resorption
Proximal bony peak
Vestibular concavity
Bone regeneration
or grafting is
needed before the
implant placement ,
or the implant will
have to be placed
following the bone
crest , but with
unfavorable
orientation of the
prosthesis .
Adjacent implants
Patient factors
Esthetic requirement
Hygiene level
Provisionalization
Esthetic requirement
It is important to identify patients
with unrealistic esthetic demands .
Higher the esthetic demands more
cooperative the patient should be .
They should be aware of the difficulty
, limitation and duration of the
treatment .
Hygiene level
Extremely
rigourous dental
hygiene and good
plaque control
must be exercised .
Provisionalization
Provisional restoration should be
stable and not compromise the
patients ability to perform plaque
control .
If denture is used , it should be
designed to avoid all movements
that interfere with the implant zone .
Instability may
cause severe
mucosal problem .
For esthetics , a
denture with a
metal framework
can be considered .
Resin bonded
restoration without
tooth preparation .
Cost and problem
with bond strength
make this solution
difficult.
Denture base is
should be remade
or relined at a
minimum ,every
month.
Treatment
Treatment of the failure depends on
the type of failure and the cause of it.
If the causative factor can be
eliminated at the ailing implant or
failing implant stage then the condition
can be reversed.
Early detection is the key factor.
However in most cases a careful
planning is the only solution.
Implant removal
Failure of osseointegration
Off axis placement
Failed cantilevered prosthesis
Implant body fracture
Aesthetic problems
Peri-implantits
Periodontal therapy
It depends on the type and stage of
failure.
Generally apart from a good home
care protocol a regular periodontal
check up is required.
Plastic scalers are used for scaling
and root planing.
Review of literature
LOBBEZOO ET AL ,Journal of
Oral Rehabilitation 2006 33;
152159