EKLAVYA DENTAL COLLEGE AND HOSPITAL

DEPARTMENT OF PERIODONTICS

TOPIC : IMPLANT RELATED COMPLICATIONS

GUIDED BY

SUBMITTED BYDR. VIVEK CHATURVEDY (M.D.S) – HOD AND SENIOR LECTURERDR. SHIVENDRA PAL SINGH (M.D.S.) – SENIOR LECTURER A. AFSANA

FINAL YEARBATCH 2016-17

IMPLANT RELATED COMPLICATIONS

•Introduction

•Definitions - implant success,survival,failure

•Implant complications and types• Surgical complications• Biologic complications • Prosthetic complications • Esthetic and phonetic

complications

•Conclusion

CONTENTS:

3

INTRODUCTION• Implantology is an ever growing field.

• The ultimate goal of dental implant therapy is to satisfy the patient’s desire to replace one or more missing teeth in an esthetic, secure, functional, and long-standing manner.

•Yet, despite of long term success of implant therapy, complications do occur in a percentage of cases.

•Some complications are relatively minor and easy to correct, but others are more significant, resulting in loss of implants, failure of prostheses, severe loss of tissues etc..

•It is mandatory to classify all those clinical complications that can arise.

Definitions• Implant survival is simply defined as any

implant that remains in place at the time of evaluation, regardless of any untoward signs, symptoms, or history of problems.

• Sleepers are the implants that are present but not connected to any restoration and not providing support or function.

• Implant success is defined as an implant with no pain, no mobility, no radiolucent peri-implant areas, and no more than 0.2mm of bone loss annually following the first year of loading.

– Albrektsson et al

• It is also defined as any implant retained restoration in which

(1) the original treatment plan is performed as intended without complications,

2. all implants that were placed are remain stable and functioning without problems,

3. peri-implant hard and soft tissues are healthy and

4. both the patient and the clinician are pleased with the results..

IMPLANT COMPLICATIONS

CLASSIFICATION:

• Biologic complications• Surgical complications• Prosthetic or Technical or mechanical

complications• Esthetic complications

Surgical complications

• Hemorrhage and hematoma• Neurosensory disturbances• Implant malposition

Surgical complications are those problems or adverse outcomes that result from surgery, including procedures used for implant placement, implant exposure, and augmentation procedures.

SURGICAL COMPLICATIONS

1.Hemorrhage and hematoma

• Bleeding during surgery is suspected and usually easily controlled.

• Smaller vessels will naturally constrict or retract to slow the hemorrhage.

• Serious bleeding when it is inaccessible and internal (within the connective tissue and soft tissue spaces) – is the most problematic.

• Large hematomas are susceptible to infection and they can even expands to displace tongue and soft tissues, leading to airway obstruction.

• Treatment: 1. Suturing the bleeding vessel,2. Compression or by finger pressure, 3.the use of hemostatics - microfibrillar

collagen gauzes, oxidized cellulose, reabsorbable fibrin.

4. Antibiotics for large hematomas.

• EMERGENCY CASES – airway management and surgical intervention to isolate hematomas and stop the bleeding.

• One of the most problematic surgical complications is - Injury to nerve - can cause damage that may be permanent or temporary.

• More than 50% of neurosensory changes after surgery are permanent.

• Causes – cut, tear or puncture of nerve

- implant compression - damage to nerve

2.Neurosensory disturbances

• Neuropathy thus results which follows 2 clinical patterns :

1. Hypoesthesia – is a neuropathy defined by impaired sensory function that is sometimes associated with phantom pain.

2. Hyperesthesia – is a neuropathy defined by the presence of pain phenomena with minimal or no sensory impairment.

• Some neuropathies will resolve, whereas other will persist.

Several implants in contact to the Inferior Alveolar nerve in patients with postoperative paresthesia.

• Malpositioning of dental implants is usually the result of poor treatment planning before the implant surgery, lack of surgical skill etc…

• Ideal implant position – accurate preparation, insertion, and placement of the implant into the alveolus in a proper 3-D geometry according to apicoronal, mesiodistal, and buccolingual parameters, as well as implant angulation relative to the final prosthetic restoration and gingival margins.

3.Implant malposition

Ideal parameters: • Apicocoronally : 2-3mm apical to

gingival margin.• Mesiodistal implants : 1.5-2mm from

natural tooth and 2-3mm from an adjacent implant.

• Buccolingually placed, such that atleast 2mm of bone is there circumferentially around the implant.

Malpositioning results in – injury to nerves & vessels,

- paresthesia, anesthesia

- hypoesthesia, hyperesthesia

- dysesthesia, even bleeding

• To achieve better placement and minimize complications – follow proper diagnosis, radiographic imaging (CT, or cone beam CT imaging) , careful surgical exposure, establish a zone of safety away from nerve (eg 2mm)……

BIOLOGICAL COMPLICATIONS

Biologic complications

• Inflammation and proliferation• Dehiscence and recession• Periimplantitis and bone loss• Implant loss or failure

• Biological complications are those that involve the pathology of the surrounding peri-implant supporting hard and soft tissues.

1.INFLAMMATION AND PROLIFERATION

• Inflammation in the periimplant soft tissues has been found to be similar to the inflammatory

process in gingival and other periodontal tissues.• Inflamed periimplant tissues demonstrate the

same erythema, edema, swelling seen around the teeth.

• The inflammatory proliferation is an indicative of either a loose fitting implant to abutment connection or trapped excess cement that

remains buried within the soft tissue space or pockets.

Tissues surrounding implant becomes infected with bacterial pathogens.

Leading to muscular hypertrophy or proliferation.

Results with absecss formation.. Sometimes even fistula.

Correction by treating factors – loose connection, retained cement

PICTURE SHOWING FISTULA CAUSED BY LOOSE IMPLANT – ABUTMENT CONNECTION

PICTURE SHOWING INFLAMMATORY PROLIFERTION CAUSED BY LOOSE IMPLANT – ABUTMENT CONNECTION

• Dehiscence or recession of the periimplant soft tissues occurs when the support for those tissues is lacking or has been lost.

Wound dehiscence at one week post surgery in a diabetic patient with oral candidiasis

2. DEHISCENCE AND RECESSION

• Improper implant positioning predisposes periimplant tissues to recession which is a common finding.

• Periimplant soft tissues are entirely depended on surrounding bone for support.

• Soft tissue thickness and height around implant typically donot exceed about 3-4mm, and bone loss around implants often leads to recession

• Recession is a problem in case of anterior aesthetic areas.

PICTURES OF RECESSION

POOR ESTHETICS RESULTING FROM GINGIVAL RECESSION AND EXPOSURE OF CROWN MARGINS, IMPLANT COLLARS..

• 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.

3. PERIIMPLANTITIS AND BONE LOSS

• Poor oral hygiene• History of periodontitis• Diabetes • Smoking• Alcohol consumption• Exposed threads and Exposed

surface coatings (roughened surfaces)

Etiology and risk factors for peri-implantitis

PERIIMPLANTITIS

Clinical features 1. bleeding,2. suppuration,3. increased probing

depth, 4. calculus build up, 5. swelling, 6. color changes,7. mobility and 8. radiographical bone loss.

Clinical features of peri-implantitis

Treatment of periimplantitis

1.Occlusal Therapy :When excessive forces are considered the main

etiologic factor for periimplant bone loss, treatment involves an analysis of the fit of the prosthesis, the number and position of the implants, and an occlusal evaluation.

Prostheses design changes, improvement of implant number and position, and occlusal equilibration can contribute to arrest the progression of periimplant tissue breakdown.

2. The nonsurgical treatment:• Mechanical debridement–Ultrasonic scaler –Hand instruments : Plastic curette–Rubber cup & pumice

• Plaque control• Subgingival irrigation of peri- implant pockets - with

0.12% chlorhexidine; systemic antimicrobial therapy for 10 consecutive days;

• Irradiation with a soft laser for elimination of bacteria.

•

3.Surgical approach1. Access surgery : apically positioned

flap, surface modification 2. Resective surgery - Apical

repositioning of the flap following osteoplasty around the defect.

3. Regenerative surgery : guided tissue regeneration, bone grafting

4. Surface decontamination –•Chemical agents - hydrogen peroxide, citric acid, 35% phosphoric acid•Laser therapy

It is defined as total failure of the implant to fulfill its purpose (functional or esthetic) because of mechanical or biological reasons.

4. IMPLANT LOSS OR FAILURE

• Implant loss or failure is generally considered relative to the time of placement or restoration.

• Early implant failures occur before implant restoration.

Causes- when the implant did not achieve osseointegration, or the integration was weak or affected by infection, movement or impaired wound healing.

• Late implant failures occur after the implant has been restored.

Causes – infection , implant overload, impaired healing.• Preoperative antibiotic therapy may

decrease the failure rate of dental implants.

RADIOGRAPGH OF EARLY FAILED IMPLANT CAUSED BY LACK OF OSSEOINTEGRATION

PROSTHETIC COMPLICATIONS

Prosthetic or mechanical complications occur when the strength of the materials is no longer able to resist the forces that are being applied to resist the forces that are being applied.

Prosthetic complications

• Screw loosening and fracture• Implant fracture• Fracture of restorative

materials

1. Screw loosening and fracture• Screw-retained single crowns attached to

extremely hexed implants (i.e., those with narrow or standard-diameter restorative interface connection surfaces) are particularly prone to this type of mechanical complication.

• Screw loosening was a problem in earlier designs.

• Newer designs and abutment screws are improved with increased clamping forces which has helped to reduce the rate of screw loosening

• Abutment or prosthesis screw loosening is corrected by retightening the screws.

• Detection of loose screw is greatly diminished in a prosthesis with multiple implants.

2. Implant fracture

• Implant fracture results in loss of the implant and possibly the prosthesis.

• Furthermore, the removal of fractured implant creates a large osseous defect.

• Causes – 1. design and material 2. nonpassive fit of the prosthetic

framework. 3. physiologic or biologic overload

• Patients with bruxism seem to be at higher risk for such event.

• Therefore, they should be fitted with occlusal guards in conjunction with placement of the final prosthesis.

Management:Removal of the implant and its replacement by another one

(a) Implant fractured in maxillary posterior region. (b) Implants retrieved. (c)Substitution for a wider diameter in the same surgery

3. Fracture of restorative materials

• Failure or fracture of materials used for implant-retained restorations can be significant problem.

• Eg. in veneers (acrylic, composite, or ceramic) that are attached to superstructures.

ESTHETIC and PHONETIC COMPLICATIONS

Esthetic complicatio

ns

• Esthetic complications• Phonetic problems

• Esthetic complications arise when expectations are not met. Its risk is increased for patients with high esthetic expectations and less than optimal patient-related factors ( e.g. high smile line, thin gingival tissues , high esthetic demands of patient etc).

• Harmonious tooth shape, size, and ideal soft tissue contours are the key factors for successful esthetic outcomes.

CAUSES –• poor implant position• deficiencies in the existing anatomy of the

edentulous sites that were reconstructed with implants,

• insufficient bone supportTREATMENT –• Gingiva colored materials used to replace

lost ginvival anatomy, angulated abutments, superstructures – good esthetic results

• In unsatisfied cases, implants could be removed, case is reevaluated and possibly re-treated

Pink porcelain used on implant- supported fixed restoration to mask

the high gingival margin

Phonetic problems:• Implant prostheses that are fabricated with

unusual palatal contours (e.g. restricted or narrow palatal space) or that have spaces under and around the superstructure can create phonetic problems for the patient.

• This is particularly problematic when full arch, implant-supported, fixed restorations are fabricated for patients who have a severely atrophied maxilla.

Treatment : • Such patients are best served with an

implant-assisted maxillary over denture because the design facilitates replacement of missing alveolar structure and avoids creating spaces that allow air to escape during speech.

CONCLUSIONDental implant placement is not free of complications, as complications may occur at any stage and that may be surgical, biological, mechanical or esthetic.

Careful diagnosis and treatment planning along with the use of diagnostic imaging, precise surgical techniques can prevent many of the problems.

An thorough understanding of the anatomy, biology and wound healing of the surgical area are essential in preventing complications.