CONTENTS

INTRODUCTION HISTORY DEFINITIONS BONE DENSITY A KEY DETERMINANT DIVISION OF AVAILABLE BONE PROSTHETIC OPTIONS QUALITY OF HEALTH/ SUCCESS CLASSIFICATION OF COMPLICATIONS IMPLANT FAILURE DUE TO:Systemic Factors Psychological Factors Operative Errors

PROSTHODONTIC CONSIDERATIONS IN STAGE-I IMPLANTS IMPLANT DESIGN AND MANUFACTURING, BIOMECHANICS RELATED TO IMPLANT FAILURE SOFT TISSUE CONSIDERATIONS MECHANICAL COMPLICATION MANAGEMENT SUBMERGED PROFILE OF IMPLANT SUMMARY BIBLIOGRAPHY

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SUCCESS AND FAILURE OF IMPLANTS

INTRODUCTION Implant dentistry is currently being practiced in an

atmosphere of enthusiasm and optimism, because our knowledge and ability to provide service to our patients has expanded so greatly in such a short period. Complications do arise in implant dentistry. These are more often due to aging, changing health conditions, long-term wear and tear, poor home care and inadequate professional

maintenance. Success cannot be guaranteed, what one can guarantee is to care, to do ones best and to be there to help in the rare instance that something goes wrong, patient appreciate and benefit from straight talk. "Unfortunately failure is often the best teacher".

HISTORY Egyptian time used to implant extracted teeth of poor /slaves who would sell it off. When human teeth not available they started using animal teeth e.g. goats, dogs and monkeys. Sea shells were also used. 1886 Bugnot attempted to use tooth buds and transplantation of teeth was tried. 1940 Farmaggini developed screw type of implants.
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1952 Dr. Branemark, orthopaedic surgeon, Sweden found that Titanium implant can be used for bone anchorage (he was doing research of microcirculation in box repair mechanism in rabbits). 1952 Osseointegration introduced by branemark 1962 Cr-Co implant, failed. 1967 Hodosch used acrylic resin in tooth form. 1966 Linkow introduced blade form implants (Cr-Co-Vanadium). Later ceramic, Ti-introduced. Charles weiss Fibro-osseous integration he claimed that fibrous tissue will act as periodontal ligament. 1980 Dr. J.P. Branemark brought his research to America. American technology quickly adapted these principles.

DEFINITIONS Dental Implant "A substance that is placed into the jaws to support a crown, or fixed or removable denture". Ailing Implant "An implant that may demonstrate bone loss with deeper clinical probing depths, but appears to be stable when evaluated at 3-4 months interval. A lamina dura may be present at the borders of osseous defect, possibly indicating a static of chronicity". Failing Implant "An implant that may demonstrate bone loss, increasing clinical probing depth, bleeding on probing and suppuration. This bone loss may be progressive". Failed Implant An implant that demonstrates clinical mobility, a peri-implant radiolucency and a dull sound when percussed.

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Early failures Occurs weeks to few months after placement, caused by factors that can interfere with normal healing process or an altered host response. Late failures Arise from pathological processes that involve a previously osseointegrated implant. Peri-implantitis An inflammatory process that affects the tissue around an osseointegrated implant in function and results in loss of supporting bone. Peri-implant mucositis A term used to describe reversible inflammatory reactions in the mucosa adjacent to an implant.

MISH BONE DENSITY CLASSIFICATION D1 Dense cortical bone (8% in anterior mandible) >1250 hounsfield units (Radiographic bone density) CT-Scan D2 Thick dense to porous cortical bone on crest and coarse trabacular bone within. (Anterior mandible, post-mandible 850-1250 HU) D3 Thin porous cortical bone on crest and fine trabacular bone within (Anterior maxilla 350-850 HU) D4 Fine trabacular bone (Post-maxilla 150-350 HU) D5 Immature, non-mineralised bone (<150 HU). Bone density is an important treatment plan modifier in several ways prosthetic factors, implant size, design, surface condition, number, and progressive loading.

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DIVISIONS OF AVAILABLE BONE
Division Abundant

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Dimension >5mm width >10-13 mm height >7mm length <30 degrees angulation C/I ratio <1 Barely sufficient 2.5-5 mm width bone >10-13 mm height >12 mm length <20 degrees angulation C/I ratio <1

Treatment Option Division A root factor

Compromised Bone

Deficient bone

Osteoplasty Division A root form Augumentation Demanding esthetic Great force factor Narrow implant Division B root form Plate form Unfavorable in: Osteoplasty (C-w) Width (C-w) Augmentation Height (C-h) Fixed prosthesis Length Demanding esthetics Angulation (C-a) Great force factor Endosteal 30 degrees Root form C/I ratio 1 Ramus frame Subperiosteal Arch form Angulation Cost Time Transosteal Several atrophy Augmentation Basal bone loss Treatment of choice Flat maxilla Endosteal Pencil thin Root form mandible Ramus frame Subperiosteal

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PROSTHETIC OPTIONS

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FP-I: Fixed prosthesis; Replaces only the crown; looks like a natural tooth. FP-II: Fixed; replaces crown and a portion of root; crown contour appear normal in occlusal half, but elongated/hypercontoured in gingival half. FP-III: In addition to FP-2, replaces edentulous site, uses denture teeth and acrylic gingiva or porcelain to metal. RP-IV: Removable overdenture; supported completely by implant RP-V: Removable overdenture; supported by both implant and soft tissue. QUALITY OF HEALTH/ SUCCESS Criterias by Alberktsson et al. Immobile Per-implant radiolucency Vertical bone loss <0.2mm, first year. Absence of pain, infections, neuropathies, paresthesia, or violation of mandibular canal. Success rate of 85% - at end of 5 yrs. 80% - at end of 10 yrs Other Criterias by Mish:1. Longevity. 2. Pain: Unlike the tooth the implant is never temperature sensitive, hence early warning signs and symptoms are absent. Percussion
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with forces of 500gm are clinically used to evaluate tooth/implant pain/discomfort. Presence of pain requires removal of implant pain from rigid implant is early problem, where pain from mobile implant can occur early /late in treatment. Tenderness to percussion usually implies healing proximal to nerve /bone stress beyond physiologic limits. If implant

tenderness immediately postsurgeyr occurs in proximity of inferior alveolar canal implant unthreaded for few mm and reevaluated after 3/more wks for symptoms. If tenderness is after stage-I healing and not due to surgical encroachment on an anatomic landmark, stress may be the causative element. Treatment stress management: Occlusion with parafunctional habits should be addressed in the presence of implant sensitivity Modify prosthesis Place additional implants

3. Rigid Fixation:Horizontal mobility beyond 0.5mm or any clinically observed vertical movement under less than 500 gm force. 4. Percussion: Pain on percussion / function.

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5. Bone loss:-

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Rapid progressive bone loss regardless of the stress reduction and peri-implant therapy, more than half surrounding bone is lost around on implant. 6. Radiologic Evaluation: Generalised radiolucence around an implant. 7. Peri-implant disease: Continued uncontrolled exudates in spite of surgical

attempts at correction. Sleepers:Implants inserted in poor position making them useless for prosthetic support, but maintains bone height beneath the mucosa. 8. Probing Depth:Probing pressure 20 gm, sterile periodontal probe used Indication of marginal bone/crestal bone loss As sulcus depth increases oxygen tension decreased bacteria grow in implant sulcus. Sulcus depth should be maintained at <4mm depth Checked for every 3-4 months for the first one year after prosthesis delivery Probing will also reveal tissue consistency, bleeding, and exudates.

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9. Bleeding Index (BI):Indication of sulcus health:Gingival bleeding when

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probing

is

correlated

to

inflammation and plaque index. Gingivitis, deep sulcular pocket, plaque index, Loe & Silness Gingival Index. Sulcus depth <5mm but BI increase chlorhexidine mouth rinses Sulcus depth >5mm and BI increased gingivectomy, revision surgery. 10) Rigid Fixations:Means absence of observed clinical mobility. A normal tooth moves 56 to 73 m. The healthy implant moves <75 m that means it has '0' clinical mobility. Lack of mobility does not always indicate direct boneimplant interface. It means at least a portion of an implant is in direct contact with the bone, although percentage of bone contact cannot be predicted. Mobile implant indicates presence of connective tissue between implant and bone. Mobility may be due to trauma/ bone loss.

Technique:- To assess mobility is almost same to natural teeth. Two rigid instruments apply labiolingual force of approximately 500gm. This can be graded as;
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0 Absence

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1 Detectable horizontal movement 2 Visible mobility up to 0.5mm horizontally 3 Severe horizontal movement >0.5mm 4 Visible moderate to severe horizontal and any visible vertical movement. Tooth with mobility of 0.5mm, which was due to occlusal trauma may revert back to normal rigid fixation by removing the cause, but this rarely occurs in implants. An implant with >0.5 mm mobility should be removed. Periotest: Periotest (Siemens Corporation) is a computer mechanical device developed by Schulte, that measures the dampening effect of objects. It develops a force of 12 to 18 gm/n. The soft surface or mobile object will give higher recordings that a hard or rigid object. Recordings range from 8 to +50 numbers. Teeth with absence of mobility 8 to +9. The bone density around the implant may be correlated with these numbers. Percussion:It is neither an indication of clinical health nor of rigid fixation. Therefore the ranging sound that occurs on percussion will be same for both 2 mm of bone and 16mmof bone-implant interface.

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It can be used to diagnose pain, tenderness with an implant, but it is misleading if used to determine the status of rigid fixation. Bone Loss:Crestal bone loss in initial therapy is an indicator of the need for initial preventive therapy. Whenever possible implant should be placed at /above the level of bone crest to avoid an increase in sulcus depth subsequent to abutment placement. Initial bone loss is due to occlusal traumatic stress, parafunction. Secondary bone loss due to bacteria and increased stress. In threaded implant the distance between each thread (thread pitch) is usually 0.6mm and can be used as radiographic marker. In general if bone loss is more than the one-half of implant height is said to be failure regardless of original amount of implant-bone contact. Radiographic Evaluation: One of the easiest clinical tool to assess the implant crestal bone loss. It only illustrates mesial and distal crestal levels clearly, however, early bone loss is more on facial aspects. Parallel IOPA is very difficult to take with implant therefore apex of implant will be apical to tooth and muscle attachment. Bitewing and periapical radiograph without apex are best to assess the crestal bone loss.
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Both the region the thread area must be very clear, if these borders are fuzzy then radiograph is not said to be diagnostic for crestal bone loss assessment.

Peri-implant radiolucency-indication of failure may be due to bacteria infection, non-rigid fixation, local bone healing disorders, dehiscence, contamination of drill, overheating of bone.

Periapical Radiolucency:If accompanied by fistula surgical re-entry and sectioning of apical portion of implant suggested. An absence of radiolucency around an implant does not mean bone is present at the interface, especially in anterior mandible. 40% of decrease in density is necessary to produce traditional radiograph difference because of dense cortical bone. Radiograph Schedule:Baseline radiograph at initial DD of prosthesis 6 months -> is compared with baseline 1 year bitewing radiograph If no changes then for every 3 yrs If changes reduction of stress, oral hygiene modified accordingly. If bone loss is found after stage-II most commonly due to parafunction habits. Night guards, stress reduction

Peri-implant Disease:
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Always plaque associated:-

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Gingivitis may be ANUG, ulcerative hormonal, drug induced, spontaneous occurring in tooth and implant.

Unlike tooth there is no connective tissue attachment barrier (1mm) to protect crestal bone around an implant.

Periodontitis may be Bacterial Adult onset Rapidly progressive Localized juvenile Prepubertal periodontitis Term peri-implantitis is used for implants to describe bone

loss around an implant stress induced, bacterial induced/ combination of both. An exudates/ disease abscess and indicates exacerbation bone of loss.

periimplant

possible

accelerated

Antibiotics + chlorhexidine after 1 to 2 wks if it remains surgical reversion of periimplant area.

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Implant Quality Scale
Group I (Optimum health)

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Clinical Conditions No pain or tenderness on palpation, percussion, or function. Rigid fixation; no horizontal or vertical mobility under 500g load (IM 0). <1.5mm crestal bone loss from Stage II. <1.0mm bone loss in preceding 3 years. After 1st year, stable probing (sulcus) depth <4mm. No exudates history No radiolucency 0 to 1 bleeding index No pain or tenderness on palpation, percussion, or function. Rigid fixation; no horizontal or vertical mobility under 500g load (IM 0). 1.5 to 3mm crestal bone loss. <1.0mm bone loss in preceding 3 year periods. May be >4mm probing depth from the original tissue thickness or 1st year bone loss, but stable in last 3-year periods. Past transient exudates history (+) or (-) No radiolucency 0 to 1 bleeding index (may have a transient BOP 2 condition). No pain on palpation, percussion, or function. +/- Slight tenderness initial rigid fixation; 0 to 0.5 mm horizontal (IM 0 to 2) mobility after prosthesis delivery; no vertical mobility. >3mm bone loss the 1st year >1mm crestal bone loss in preceding 3 years, but less than total bone loss (implantitis). >5mm probing depth and

Management Normal maintenance

II (Satisfactory health)

Reduce stresses Shorter intervals between hygiene appointments Gingivoplasty. Yearly radiographs.

III (Compromised health)

Reduce stresses. Drug therapy, antibiotics, chlorhexidine. Surgical reentry, revision surgery. Change in prosthesis and/or implants.

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increasing in preceding 3 years. +/- History of exudates 1 to 2 weeks in last 3 years. +/- Slight radiolucency around crestal portion of implant 1 to 3 bleeding index

IV (Clinical failure any of the following conditions)

Pain on palpation, percussion, or function. >0.5mm mobility horizontally; any vertical mobility (IM 3 to 4). Uncontrolled progressive bone loss. More than loss of bone supporting the implant. Uncontrolled exudates. Generalized radiolucency. "Sleepers". Implants surgically removed Implants exfoliated

Removal of implant

V (Absolute failure)

Bone graft

This scale was first presented by James later modified by Mish.

CLASSIFICATION OF COMPLICATIONS Swedish team (Branemark et al) I. Loss of bone anchorage 1. Mucoperiosteal perforation 2. Surgical trauma II. Gingival problems 1. Proliferative gingivitis. 2. Fistula formation III. Mechanical complications 1. Fixture fractures 2. Fracture of prostheses, gold screws, abutment screws

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UCLA team (Beumer. Moy)

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1. Complications in stage I surgery 1. 2. 3. 4. 5. 6. 7. 8. 9. Mental nerve damage Penetration into a sinus, nasal cavity or through inferior border of the mandible. Excess counter sink Thread exposure Eccentric drills, taps Stripping of threads Jaw fracture Ecchymosis, more common in older patients Wound dehiscence space abscess, submental, submandibular abscess, Ludwigs angina 11. Suture abscess 12. Loss cover screw. 2. Complication in Stage II surgery 1. 2. 3. 4. 5. 6. 7. 8. 9. Poor selection of fixture height Incorrect fixture placement, more than 35 0 cannot be used prosthtically Damaged hex nut on top of fixture Loss abutment Fracture abutment screw Early loading by prostheses Poor air-flow pattern with high water design Aspiration of instruments Thread exposure

10. Facial

10. Fixture fractures 11. Excess bone resorption 12. Plaque / calculus formation

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13. Periodontal problems

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14. Poor selection of abutment height 3. Prosthetic complications : 1) Insufficient space beneath the fully bone anchored prosthesis 2) Abutments penetrate through alveolar mucosa (unattached tissue) 3) Screw fractures: gold or abutment screws 4) Acrylic or porcelain fracture 5) Posterior fixture failures in the maxilla This library dissertation presents a view of the complication that arise in the stages of diagnosis, patient selection, counseling, per-operative procedures, surgical procedures, post insertion and maintenance stages and their prevention and remedies.

IMPLANT FAILURE DUE TO i) Systemic Factors:Potential medical risks (Matukas 1988): 1. Cardiovascular Heart failure, CHD, hypertension,

unexplained arythmea. 2. Respiratory COPD, chronic obstructive pulmonary disease, Asthma. 3. GIT Nutritional disorders, Hepatitis malabsorption,

inflammatory bowel disease. 4. Genitourinary Chronic renal failure. 5. Endocrine Diabetes, thyroid disease, pituitary/adrenal disease.
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6. Musculoskeletal, arthritis, osteoporosis. 7. Neurologic Stroke, Palsy. Absolute Medical Contraindications: Pregnancy Granulocytopenia Steroid use Continuous antibiotic coverage Brittle diabetes Hemophelia Ehler-Dahnlos syndrome Marfan's syndrome Osteo-radionecrosis Renal failure Organ transplants Anticoagulant therapy Fibrous dysplasia Crohn's Disease

ii) Psychological Factors: Lack of support Cognitive difficulty Mental retardation Dementia Psychosis

Emotional problems Interpersonal problems

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Behavioral problems

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Problematic attitudes and beliefs.

Basic Recommendations: Identify patient with significant psychiatric disturbance Refer to psychologist, if found disturbed Be sensitive to patient Maintain good communication "Meet the mind of the patient, before you meet the mouth of the patient". iii) Operative Errors

PROSTHODONTIC CONSIDERATIONS IN STAGE-I IMPLANTS: 1. Post-operative complications that result from stage-I

surgical conditions. Haemorhage, haematoma, edema. Extensive damage to mucoperiosteum. conditions that lead to post-operative

2. Anatomic

complications a) Damage to local structures and improper implant placement b) Damage to adjacent structures Maxillary sinus, Post-surgical lip paresthesia/ pain in mandible, Placed too close to adjacent tooth pain

c) Bone quality and primary stability of implant

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3. Pre-operative infections:

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Insufficient tightening of cover screw Preoperative contamination Retained suture If persists >7days removal of implant 4. Transmucosal prosthesis 5. Local wound breakdown and mucosal perforation 6. Systemic condition and behavior factors 7. Interim prosthetic procedure after stage-II surgery Prosthesis with increased vertical dimension, occlusal overloading and premature loading of

discrepancies, excessive forces on implant jeopardize osseointegration. Post-stage-I Post-stage-II Interim RPD Interim FPD

Fixed resin bonded interim prosthesis can be made by using orthodontic retainers and light cured resins. Most of failures occurs between stage-I implant placement and stage-II abutment connection. IMPLANT DESIGN AND MANUFACTURING AS PREDICTORS IMPLANT FAILURE: 1. Macroscopic structure Press Fit cylindrical Hollow vented cylindrical implants Fluted implant Smooth titanium screw type
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2. Surface Composition:i) Ti Ti alloys

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- Osteoblasts appear to grow well on Ti - better bond compared to Co-Cr ii) Calcium phosphate ceramics Bond (better than Ti, (33 times more MOE than bone) Poor mechanical properties

iii) Hydroxyapatite and bone growth Most common coating material over implant Enhances attachment

iv) Bio-active glass Polycrystalline ceramics (Silicon dioxide crystals)

v) Copolymer coating of implants Recent elastomer polyethalene oxide polybutalene

terephthalate copolymer Growth factor- (BM Protein)

3. Force:- Discussed under a) Force duration:Teeth contacts <30min /day Parafunctioinal habits Implant fatigue structure should be more Ti alloy is 4 times more rigid than CpTi Screw breakage is better compared to body Increase duration of force fatigue damage to cortical bone.

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b) Force type Compression, tensile, shear type of force. 3 standard thread designs V-shape - Square -Buttress c) Force Direction Bone undercuts 300 angulation load decreases compression strength by 11% decreases tensile strength by 25% as angulation increases stress around implant increases Force angle of thread alters stress d) Force magnitude will be increased in cantilevers, density of bone (D4 10 times weaker than D1 bone) Extreme angulation, parafunctional habits

Prosthodontic Considerations: 1. Forces on Implants: Vertical forces are tolerated better compared to lateral bending forces. 2. Tripod Effect: Greater the tripod increase resistance to bending Large tripod contacts easily achieved in edentulous implant supported prosthesis 3. Geometric load factors:Fewer than 3 implants Implant connected to teeth
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Implants in a line Cantilever extensions

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Occlusal plane beyond implant support These factors will lead to failure.

4. Crown Implant Ratio: Larger better tolerated in full arch restoration Smaller better tolerated in partially edentulous conditions 5. Occlusal design:Narrow occlusal table Centric contacts over implants Lingualised occlusion In partially edentulous state regular follow up is very much necessary Parafunctional habits patient is informed abut less success rate 6. Strategic Extractions:Periodontaly compromised abutments should be extracted. 7. Single implant restorations:Problems include loose screws Fracture of screws Loss of osseointegration Fracture of implants Molar restoration on single implant Here the wider diameter implants with stronger components should be used (5mm dia implant is 200% stronger than 3.75 mm dia).

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8. Tooth Implant Connection:-

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Tooth Periodontal ligament (moves) Implant Ankylosed to bone (rigid) Two problems:i. Mobile tooth acts as a cantilever and increases load on implant ii. Non-rigid connector will intrude the tooth.

3-options for tooth to implant connection:i) One implant one tooth rigid connection - to divide the load ii) Multiple implant tooth/teeth stress breaking attachment iii) Multiple tooth abutments incorporated in long span

restorations (here tooth will not support the prosthesis)

SOFT TISSUE COMPLICATIONS: 1. Exposure of cover screw:Because of Open wound Residual suture material Poorly adjusted denture - Sore spot - dehiscence Treatment Eliminate the cause Flap surgery to remove granulation tissue Gingival grafts

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2. Proliferative gingivitis and fistula -

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Peri-implant epithelium grow around abutment and exposed gold cylinder

Treatment Flap surgery, gingivectomy (internal bevel incision) Simple circumferential excision for fistula

3. Exposure of fixture threads: Because of advanced alveolar ridge resorption Minimal attached gingiva, shallow vestibule 1.5% of incidence noted by Adell et al (1981)

Treatment:Bone graft Cover with free gingival graft

MECHANICAL COMPLICATIONS AND MANAGEMENT i) Component Fracture: Fixture fracture:Remaining portion should be surgically removed with trephine bur Fractured portion is duplicated UCLA abutment is fitted to master cast This abutment is then screwed into fixture and prosthesis is connected ii) Abutment Screw Fracture: If screw fractures at the level of neck or head of fixture.

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Cut a groove in abutment screw fragment and use smallest drill to rotate abutment screw. If it cannot be removed then splitting the fragment will damage fixture threads. iii) Prosthesis Fracture:Fully bone anchored prosthesis can fracture at cantilever section, if appropriate waxing were not followed. Framework fracture is not a major complication when fixtures are in good condition. iv) Functional Speech Problem:Fully bone anchored prosthesis in maxilla can cause phonetic problems, because of opened interproximal embrasure areas. Artificial gingival cascade with silicone material will help to resolve the problem. v) Malpositioined Fixtures:Angulated abutments can be used. In fully implant supported prosthesis the mesostructural bar is used. Mesostructural bar may fracture because of long span, insufficient implant support, occlusal trauma. Treatment:If screw retained (fixed detachable) then remove, take index, and repair.

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If cemented coping bar fractures use electrodux (intra-oral Ti-welding).

THE SUBMERGED PROFILE OF IMPLANT I Vertical height of bone is 2mm apical to an imaginary line connecting CEJ. Here smile line framed by lip will be agreeable to the patient. II The vertical height of bone is 4mm apical to CEJ. Finished prosthesis will show slight cervical burning at the margins. III The vertical height of bone is 6mm apical to CEJ. Finished crown will be longer, it is only acceptable for low lip line patient.

SUMMARY The success or failure of an implant is as difficult to describe as the success criteria required for a tooth. The range from health to disease is similar in both conditions. The primary criteria for assessing implant quality are pain and mobility. The presence of either factor greatly compromises the implant, and removal is usually indicated. "Prevention is better than cure" the successful management of implant dentistry depends on the meticulous diagnostic, treatment planning and surgical skills of the operator.

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BIBLIOGRAPHY:

Success & Failures in Implants

Contemporary Implant Dentistry, 2nd Edn. Carl E. Misch. Principles and Practice of Implant Dentistry Charles M. Weiss, Adam Weiss. Dental Implants Charles A. Babbush. Implant therapy Myron Nevins. Clinical Periodontics & Implantology, 4th edition, Jan Lindhe. Atlas or Oral Implantology A. Normann Cranin. Soft tissue and Esthetic consideration in Implant Therapy Anthony G. Sclar. Oral Rehabilitation with Implant Supported Prosthesis V.Jameson Lopez. JADA Feb 2001, Page 191. J. Oral & Maxillofac Surgery, Clinics of North America, Vol.6, No.4. 1994. J. Prosthet. Dent. 1989, Vol.62, No.5. J. Prosthet. Dent. 2004, 91-4-319-25. J. Prosthet. Dent. 2004, 91-4-326 J. Prosthet. Dent. 2004, 91-93-96.

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