2 hour surgical complications: how to treat and avoid

Complications:How to Treat and Avoid

PART 4 –BIOMATERIAL RELATED FACTORS

ADDITIONAL DATA PROVIDED BY DR.PAUL BINON

PROSTHODONTIST ROSEVILLE,CA

Surgical Complications

Host Factors

Systemic Factors

Local Factors

Contributing Etiology

Non Host Factors

OperatorRelated

BiomaterialRelated

(Based on Etiology)

Surgical Complications:Non Host Factors

• Operator related• Experience• Surgical technique• Surgical protocol

• Biomaterial related• Biocompatibility• Implant surface• Implant shape

Biocompatibility

• Ti, Ti6Al4V, Al2O3 and HA are highly biocompatible and corrosion resistant

• Steinemann 1980, Williams 1981• Breme & Scmid 1990, Johansson, Larsson 1997

• Ti and Ti6Al4V show same bone response• Johansson et al., J Mat Sci: Mater Med 1993



• Biomaterial related• Biocompatibility

• Implant surface• Implant shape

Rough (vs Machined) Surface Implants(covered previously)

• Increased late failure with HA / TPS• Decreased failure in smokers• Decreased failure with short implants • Decreased failure in sinus grafts• Decreased failure if initially not stable• Decreased failure with replacement implants• Decreased failure with early / immediate load

Implant Surface : Rough vs Smooth:Hypothesis

• Rough surfaced implants are more likely to display “late” failure due to recurrent marginalinfection

• Rough surfaced implants are less likely to fail in reduced bone quality and quantity

Rough Implant Surface (vs Smooth):• Accelerated cell attachment and calcification

• Bowers et al, JOMI 1992• Johansson & Albrektsson, JOMI 1987

• Increased bone-to-implant apposition• Numerous animal and human studies

• Increased interfacial strength• Numerous animal and human studies

• Increased bone graft-to-implant apposition• Trisi et al, Int J Perio & Rest Dent, 2003

Rough vs Smooth:Clinical Predictability?

• Comparative clinical studies are few

• Short history of “new” surfaces• MTX, Osseotite, SLA, SLActive,• Osseospeed, TiUnite, Nanotite

• Recent trend: treated surface “to the top”

WARNING!Those who don’t know their history are

destined to repeat it!

“Smooth” Machined Titanium Implants Achieved a Steady State

• Titanium machined implants: (up to 18 years)• Total # implants 1,376

• Failure rate 6.11%

• Early failure rate 5.1%

• *Late failure rate 1.01%

• Titanium machined implants : (up to 28 years)

• > 2500 implants failure rate 5%

*after I yearArlin, M. Private Practice

Binon, P. Private Practice

21 years of function

Paul Binon DDS MSD prosthodontist

1985 TO PRESENT 22 YRS


16 Years Post Restoration

Time Period Patients Implants Lost Sr-% Csr-%0 Years 161 435 9 97.9 97.9

0-1 Years 157 419 15 96.4 94.41-2 Years 155 403 1 99.8 94.22-3 Years 152 395 0 100 94.23-4 Years 151 393 0 100 94.24-5 Years 143 371 0 100 94.25-6 Years 136 352 0 100 94.26-7 Years 128 336 0 100 94.27-8 Years 111 298 0 100 94.28-9 Years 102 274 0 100 94.29-10 Years 90 249 0 100 94.210-11 Years 79 225 0 100 94.211-12 Years 55 166 0 100 94.212-13 Years 40 126 0 100 94.213-14 Years 32 104 0 100 94.214-15 Years 24 80 0 100 94.215-16 Years 18 60 0 100 94.216-17 Years 13 36 0 100 94.2

2 Stage Titanium Screw Vents

Time Period Patients Implants Lost Sr-% Csr-%

0 Years 115 214 4 98.1 98.10-1 Years 112 208 4 98.1 96.21-2 Years 108 202 1 99.5 95.82-3 Years 106 198 0 100 95.83-4 Years 102 191 0 100 95.84-5 Years 95 181 0 100 95.85-6 Years 76 146 0 100 95.86-7 Years 62 117 0 100 95.87-8 Years 54 101 0 100 95.88-9 Years 42 82 0 100 95.89-10 Years 24 51 0 100 95.810-11 Years 12 33 0 100 95.8

Titanium 3.25mm STERI OSS


0 Years 104 213 2 99.1 99.10-1 Years 102 210 7 96.7 95.81-2 Years 93 195 1 99.5 95.32-3 Years 91 191 1 99.5 94.83-4 Years 86 178 1 99.4 94.24-5 Years 80 166 0 100 94.25-6 Years 69 136 0 100 94.26-7 Years 56 110 0 100 94.27-8 Years 44 88 0 100 94.28-9 Years 39 80 0 100 94.29-10 Years 21 48 0 100 94.210-11 Years 13 31 0 100 94.2

Titanium 3.8mm Steri Oss


0 Years 65 99 0 100 100

0-1 Years 60 88 3 96.6 96.6

1-2 Years 55 80 0 97.5 96.6

2-3 Years 51 69 0 100 96.6

3-4 Years 47 65 0 100 96.6

4-5 Years 43 61 0 100 96.6

5-6 Years 35 50 0 100 96.6

6-7 Years 29 42 0 100 96.6

Tapered Titanium 4.3mm Replace & Replace Select

History of Previous Periodontitis:(Correlation with Implant Complications)

• Private practice, 13 year study period• 1,511 implants in 334 patients• 151 compromised (PCP), 923 implants• 183 healthy (PHP), 588 implants• Higher Failures with PCP vs PHP• “Early” Failures similar in both groups• “Late” Failures primarily the HA group

PCP PHP

Overall Survival 90.6% 93.7%

HA Implant Survival 81% 92.6%

• Rosenberg et al, JOMI, V 19, #6, 2004“A Comparison of Characteristics of Implant Failure and Survival in Periodontally Compromised and Periodontally Healthy Patients: A Clinical Report”

PCP = PERIO COMPROMISED

PHP = PERIO HEALTHY

Core Vent System (Zimmer):Titanium vs HA Coated Implants

• Titanium Screw Vents• 435 Screw Vents• Alloy and pure• 3.7mm diameter• Straight wall design• 18 year follow-up

• HA Coated Micro Vents• 268 Micro Vents• Hydroxyapatitie coating• 3.25mm & 4.25mm• Straight wall design• 17 year follow-up

Murray Arlin, full time private practice


0-1 Years 157 419 15 96.4 94.41-2 Years 155 403 1 99.8 94.22-3 Years 152 395 0 100 94.23-4 Years 151 393 0 100 94.24-5 Years 143 371 0 100 94.25-6 Years 136 352 0 100 94.26-7 Years 128 336 0 100 94.27-8 Years 111 298 0 100 94.28-9 Years 102 274 0 100 94.29-10 Years 90 249 0 100 94.210-11 Years 79 225 0 100 94.211-12 Years 55 166 0 100 94.212-13 Years 40 126 0 100 94.213-14 Years 32 104 0 100 94.214-15 Years 24 80 0 100 94.215-16 Years 18 60 0 100 94.216-17 Years 13 36 0 100 94.2

2 Stage Titanium Screw Vents


0-1 Years 97 193 1 99.5 98.51-2 Years 97 192 7 96.4 94.92-3 Years 96 185 1 99.5 94.43-4 Years 94 183 5 97.3 91.84-5 Years 92 178 0 100 91.85-6 Years 90 174 10 94.3 86.56-7 Years 85 159 2 98.7 85.47-8 Years 76 138 0 100 85.48-9 Years 63 114 0 100 85.49-10 Years 45 85 1 98.8 84.410-11 Years 38 73 6 91.8 77.511-12 Years 30 52 1 98.1 76.012-13 Years 27 43 1 97.7 74.213-14 Years 18 25 0 100 74.214-15 Years 8 9 0 100 74.215-16 Years 5 5 0 100 74.2

3.25mm HA Micro Vents

Time Period Patients Implants Lost Sr-% Csr-%0 Years 49 73 0 100 100

0-1 Years 49 73 0 100 1001-2 Years 49 73 1 98.6 98.62-3 Years 49 72 1 98.6 97.33-4 Years 48 69 3 95.7 93.04-5 Years 48 66 5 92.4 86.05-6 Years 45 60 2 96.7 83.16-7 Years 43 55 1 98.2 81.67-8 Years 37 48 0 100 81.68-9 Years 32 43 1 97.7 79.79-10 Years 23 31 0 100 79.710-11 Years 21 28 0 100 79.711-12 Years 15 19 1 94.7 75.512-13 Years 9 11 0 100 75.513-14 Years 6 7 0 100 75.5

4.25mm HA Micro Vents

0%

5%

10%

15%

20%

25%

0 1-2 3-4 5-6 7-8 9-10

11-12

13-14

Time Period (Years)

Failu

re (%

)

4.25mm HAM icro Vents

3.25mm HAM icro Vents

Titanium StraightScrew Vents

Titanium 3.25mmHL

Titanium 3.8mmHL

FAILURE PERCENTAGEFAILURE PERCENTAGE

N=73

N=195

N=435

N=213

N=214

BONE LOSS

HA Coated Implants:Increased Bone Loss & Late Failures

• Morris and Ochi, JOMI 1998• Lee at al, JOMI, 2000• Wheeler, SL, JOMI 1996• Guttenberg, SA, Comp Contin Educ Dent, 1993• Saadoun and Le Gall, Comp Contin Educ Dent, 1996• Watson et al, Int J Prosth, 1998• Lauc et al, Collegium Antropologicum, Supp 1, 2000• Simunek et al, Clin Oral Impl Res, 2002• Jones at al, OOO 1997Albrektsson, T, JOMI 1998• Galindo-Moreno, Clin Oral Impl Res, 2005• Schwartz-Arad et al, JOMI 2005• Artzi et al, Clin Oral Impl Res, 2006• Arlin unpublished

TPS “Late” Peri-implantitis / Failures:ITI (TPS) vs Branemark (Machined)

• 77 ITI, 73 Branemark, both 97.3% survival at 3 years

• Machined: non-integrated “early” failures i.e. pre restoration• TPS : peri-implantitis “late” failuresi.e. after restoration

• Peri-implantitis: 10.0 % TPS / 0% Machined

• “Steady-state”: 87.1% TPS / 95.5% Machined

• Astrand et al, “A 3 Year Follow-up Report of a Comparative Sudy of ITI Dental Implants and Branemark System Implants in the Treatment of the Partially Edentulous Maxilla”, in Clin Implant Dent Relat Res, 2004, 6:130-141

“Smooth” Machined Titanium Implants Achieved a Steady State

• Titanium machined implants: (up to 18 years)

• Total # implants 1,376

• Failure rate 6.11%

• Early failure rate 5.1%

• *Late failure rate 1.01%

• *after I year•Arlin, M. Private Practice,

21 Months Post (First)

1 Year Post Explant


0 Years 400 1043 26 97.5 97.5

0-1 Years 351 894 7 99.2 96.7

1-2 Years 262 641 3 99.5 96.3

2-3 Years 196 641 3 99.5 96.1

3-4 Years 145 355 0 100 96.1

4-5 Years 118 294 2 99.3 95.4

5-6 Years 82 191 1 99.5 94.9

6-7 Years 64 160 1 99.4 94.3

7-8 Years 48 125 1 99.2 93.6

8-9 Years 32 91 0 100 93.6

9-10 Years 15 47 0 100 93.6

TPS & SLA Straumann ITI Designs

A Comparison of ITI Solid Screw Implants with a TPS or SLA surface

Failures Total % Failures

TPS 13 342 *3.5%

SLA 10 504 1.98%

• Conclusion:1. The TPS or SLA may not be significantly different re. “Early Failure Rate”2. The TPS surface may predispose to a higher incidence of significant late

crestal bone loss and failure (5 fold increase failure compare to SLA)

• * one patient accounted for 6 early “infection” failures•*if this patient is removed the rate falls to 2.01%

“Early Failures” (all etiologies)

Failures Total % Failures

TPS 17 342 4.97%

SLA 5 504 0.99%

“Late Failures & Ailing” (CBL > 4mm)

• Arlin, unpublished

SEQUENCE OF A TPS IMPLANT FAILURE

INSERTION

6 Months Post (First)

8 Months Post (First)2 Weeks Post Restoration

5 Months Post Restoration


DEFECT TO BE GRAFTED

10 Months Post Bone Graft

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Com

plic

atio

ns (

%)

Early Failures Late Failures Late & >4mm CBL

TPS

SLA

A Comparison of ITI Solid Screw Implants with a TPS or SLA surface

Design SR% CS% Years # Failed Early FR (%) Late FR (%)

All MTX 98.2 98.0 7 775 14 12 (1.5%) 2 (0.3%)

TSVB 98.6 98.3 8 212 3 3(1.4%) 0 (0%)

TSVWB 98.9 98.9 7 94 1 1 (1.1%) 0 (0%)

AVB 98.3 97.8 8 417 7 6 (1.4%) 1 (0.3%)

AVWB 94.2 89.2 7 52 3 2 (3.9%) 1 (1.9%)

Zimmer: MTX Surface:(FR) Failure Rates: Total / “Early”/ “Late”


Design SR CSR Years # Failed Early FR (%)

Late FR (%)

All TiUnite 96.6 96.2 6 1582 54 (3.5%) 51 (3.2%) 3 (0.3%)

3.5mm 98.6 98.6 5 73 1 (1.4%) 1 (1.4%) 0 (0%)

4.3mm 96.7 95.9 6 990 33 (3.3%) 30 (3.0%) 3 (0.3%)

5.0mm 96.3 96.1 5 510 15 (3.7%) 15 (3.7%) 0 (0%)

6.0mm 95.4 94.5 5 109 5 (4.6%) 5 (4.6%) 0 (0%)

Nobel Replace: TiUnite Surfaces(FR) Failure Rates: Total / “Early”/ “Late”

Arlin, unpublished

TiUnite vs Machined: Branemark(recent publications)

Short implants: Tiunite (97.6%) vs Machined (92.6%)Renouard and Nissan, Clin Impl Dent Rel Res, 2005

All lengths: TiUnite (98.5%) vs Machined (93.6%) Quirynen et al, Clin Oral Impl Res, 2005

Replacement: TiUnite (96.6%) vs Machined (79.3%) Alsaadi, Quirnynen and van Steenberghe, JOMI 2006

Significantly less crestal bone loss: TiUniteWatzak et al, Clin Oral Impl Res, Dec 2006

17.816.9

5.14.7

2.3 2.1 2.0 1.9

0

2

4

6

8

10

12

14

16

18

HA-MVWCoreVent

N=73 T=16 YRS

HA-MVCoreVent

N=195T=14 YRS

TitaniumSmoothN=1,359

T=17 YRS

TPSStraumann

N= 342T=10 YRS

HAReplaceN= 301

T=4 YRS

TiUniteNobelN=16

T=4 YRS

SLA Straumann

N=504T=8 YRS

MTXZimmerN=421

T= 8 YRS

Failure Rate % Comparison: Implant Surfaces

“Newer” Implant Surfaces:

• “Osseo Speed” by Astra Tech• The first fluoride modified surface• Studies prove more bone growth in less time

• “SLActive” by Straumann• Same topography but different surface chemistry vs SLA• Submerged in an isotonic sodium chloride solution• *Significantly greater mean bone-implant contact vs SLA• *Conclusion: SLActive could offer a reduction in healing time

• “Nanotite” by 3i• Solution based deposit of CaP crystals occupying 50% surface• Slow dissolution, increase in microcomplexity & 200% area• Not a plasma spray coating e.g. 2,000 vs 20,000 micrograms CaP• **Significantly > bone contact, bone thread apposition vs Osseotite

» **Orsini et al, J. Periodontol., 2007



• Biomaterial related• Biocompatibility• Implant surface

• Implant shape

3 ½ Years Post Restoration

RADIOGRAPH FROM PREVIOUS CASE

BONE LOSS – TISSUE DEFECT

PERIO DEFECT

REASON –FRACTURED

NECK

WALLS WERE TOO THIN

REMAKE BAR & PROSTHESIS

Narrow Diameter:“Smooth” Titanium Implants

• 3I- 3.25mm:• 93.8% at 3yrs. (Anderson et al., 2001)

• Bränemark- 3.0mm:• 96.7% at 5 years (Polizzi et al. 1999)

• Steri Oss- 3.25mm• 95.8% at 11 years (Arlin, unpublished)

Narrow Diameter:Titanium Implants Survival

• Steri Oss - Titanium “Hex Lock” • 3.25mm-95.8% 13 yrs. (N=212)• 3.8 mm-94.2% 13 yrs. (N=213)

• Zimmer - Titanium “Screw Vents” • 3.3mm-92% 15 yrs. (N=31) • 3.7mm-94.25% 17 yrs. (N=435)

• ITI- “Solid Screw” (TPS + SLA)• 3.3mm-97.01% 10 yrs. (N=134)• 4.1mm-97.58% 10 yrs. (N=418)


Narrow Diameter Implants(Recent Publications)

• ITI Narrow Neck: 100% survival• Cordaro et al, Clin Oral Impl Res, 2006

• ITI Narrow Neck 97.5% survival• Romeo et al, Clin Oral Impl Res, 2006

• Small Diameter Implants: 99.6% survival• Iezzi et al, Abstract, Clin Oral Impl Res, 2006


0 Years 115 214 4 98.1 98.10-1 Years 112 208 4 98.1 96.21-2 Years 108 202 1 99.5 95.82-3 Years 106 198 0 100 95.83-4 Years 102 191 0 100 95.84-5 Years 95 181 0 100 95.85-6 Years 76 146 0 100 95.86-7 Years 62 117 0 100 95.87-8 Years 54 101 0 100 95.88-9 Years 42 82 0 100 95.89-10 Years 24 51 0 100 95.810-11 Years 12 33 0 100 95.8

Titanium 3.25mm STERI OSS


0 Years 104 213 2 99.1 99.10-1 Years 102 210 7 96.7 95.81-2 Years 93 195 1 99.5 95.32-3 Years 91 191 1 99.5 94.83-4 Years 86 178 1 99.4 94.24-5 Years 80 166 0 100 94.25-6 Years 69 136 0 100 94.26-7 Years 56 110 0 100 94.27-8 Years 44 88 0 100 94.28-9 Years 39 80 0 100 94.29-10 Years 21 48 0 100 94.210-11 Years 13 31 0 100 94.2

Titanium 3.8mm Steri Oss

Wide Diameter Implants

• Increased crestal bone loss• Ivanoff et al., JOMI 1999

• 85 Wide Platform MKII• Failure: 29% mx., 19% md.• 35% predicted failure at 402 days

• Eckert et al., JOMI 2001

• 8.2% failure one year post loading• Renouard et al., JOMI 1999

• 19.9% predicted failure at 5 years• Shin et al., Ontario Dentist, May 2004

Wide Implants

• Hypothesis:• The increased diameter encroaches upon the

critical volume of host bone needed to establish and maintain integration.

• Eckert et al., JOMI 2001

Wide Diameter Implants(Recent Publications)

• 98.4% survival-several designs• Petrone et al, Abst, Clin Oral Impl Res, 2006

• 97.89% survival-ITI Wide Neck• Bishof et al, Clin Oral Impl Res, 2006

• 100% survival-Nobel Replace• Anner et al, J Periodontol, 2005

Wide Diameter Implants-Survival

• Zimmer - “Screw Vents” • 3.7mm-95%-17 years (N=480)• 4.7mm-100%-15 yrs. (N=27)

• ITI- “Solid Screw” • 4.1mm 97.7%-7 yrs. (N=599)• 4.8mm 97.8%-7 yrs. (N=136)

• Steri Oss- “Acid Etched” • 3.8mm 94.6%-11 yrs. (N=213)• 5.0mm 93.8%-11 yrs. (N=65)


TOO WIDE AN IMPLANT SELECTED RESULTED IN FACIAL BONE LOSS AND

TISSUE COLOR ISSUE

Tapered Implants:Advantages

• Avoid anatomic limitations • sinus, undercuts, converging roots

• Optimize stability in poor bone

• Conducive for immediate placement• Optimize initial stability

• Less risk of apical perforation

• Optimize prosthetic table

• Minimize peri-implant void

• Reduce grafting and/or membranes

Nobel Replace® Tapered

Nobel Replace Tapered Implants:

Replace design introduced in 1997Several published clinical studies:

Cumulative success rates of 97-100%Up to 1 year after prosthetic loadingSeveral: immediate implant studies

Callan et al, Implant Dent, 2000Whorle, P.S., Pract Periodontics Aesthet Dent, 1998Kan & Rungcharassaeng, Pract Perio Aesthet Dent, 2000Proussaets et al, Int J Oral Maxillofac Impl, 2002Kirketerp et al, Applied Osseointegration Research, 2002Kan and Lozada, Int J Oral Maxillofac Impl, 2003

Nobel Replace Tapered Implants:

Recent Clinical Studies:

Groismann et al, Pract Proced Esthet Dent, 2003 Chausse, Clin Oral Impl Res, 2004Kancyper et al, Abstract, AO, 2004Proussaefs and Lozada, J Prosth Dent, 2004Umezu et al, Abstract, AO, 2004Ostman et al, Clin Implant Dent Relat Res, 2005Candriello & Tomatis, Clin Impl Dent Res, 2005Arlin Murray, to be submitted for publication

Time Period Implants Lost Sr-% Csr-%

0 Years 990 13 98.7 98.7

0-1 Years 798 17 97.9 96.6

1-2 Years 410 3 99.3 95.9

2-3 Years 240 0 100 95.9

3-4 Years 99 0 100 95.9

Tapered Replace TiUnite 4.3mm

Absolute survival rate=96.6%

Design SR% CS% Years # Failed Early FR (%) Late FR (%)

All MTX 98.2 98.0 7 775 14 12 (1.5%) 2 (0.3%)

TSVB 98.6 98.3 8 212 3 3(1.4%) 0 (0%)

TSVWB 98.9 98.9 7 94 1 1 (1.1%) 0 (0%)

AVB 98.3 97.8 8 417 7 6 (1.4%) 1 (0.3%)

AVWB 94.2 89.2 7 52 3 2 (3.9%) 1 (1.9%)

Tapered Zimmer MTX Surface:(FR) Failure Rates: Total / “Early”/ “Late”


AdVent Lengths

Lengths: 8mm, 10mm, 13mm, 16mm

Tapered Implants:ITI Straumann TE4

Design Number Failures Survival

TE4 (4.1/4.8) 103 3 97.1%

• Up to 5 years follow up

Surgical Complications

Host Factors

Systemic Factors

Local Factors

Contributing Etiology

Non Host Factors

OperatorRelated

BiomaterialRelated

Summary:(Based on Etiology)

Summary: Biomaterials

• Rough Surface Implants may exhibit:• Smaller “jumping gap” re: defect fill• Higher early survival rates vs “turned” titanium• Higher early survival in poor quality/quantity bone• Higher early survival if initially mobile• Increased late failure e.g. “older” HA and TPS• Newer “rough” surfaces may not exhibit late failure rates e.g. treated

titanium (Ti Unite, SLA, MTX, Osseotite) and “newer” HA

• Smooth Surface Implants (turned titanium) exhibited:• Generally higher early failure rates vs rough surfaced implants• Failure rates more pronounced if mobile at initial placement• “Steady State” after 1 year, less than *1% late failure (*Arlin)

Summary: Biomaterials-Implant Shape

• Fracture:• Narrow internal connection may be susceptible

• Narrow diameter:• straight walled, similar survival to standard diameter

• Wide diameter:• May be associated with more bone loss,failure,recession

• Short Iength:• > Failures with “smooth” surfaces and poor bone quality• Comparable survival rates with good quality bone

• Tapered walls:• May increase stability in poor quality bone

Thank You

2 hour surgical complications: how to treat and avoid

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