complications in implants - jpmcpjpmcp.com/vlo3-issue1/1-10.pdf · complications were classified as...

Kaur N, Raghav Y, Kaur A, Duhan D, Katoch S, Sharma A. Complications in Implants

J Periodontal Med Clin Pract 2016;03:1-10

1 2 3 4 5 6Dr Navjot Kaur , Dr Yashbir Raghav , Dr Amarpreet Kaur , Dinesh Duhan , Dr. Sumit Katoch , Dr. Apurva Sharma

Complications in Implants

Review Article

Affiliation

1. Post Graduate Student, Department of Prosthodontics, Bhojia Dental College and Hospital, Baddi, H.P.

2. Senior lecturer, Department of Periodontology, Swami Devi Dyal Hospital & Dental College, Haryana,

India.

3. Post Graduate Student, Department of Prosthodontics, Dr.Harvansh Singh Judge Institute of Dental

Sciences & Hospital, Panjab University, Chandigarh, India.

4. Post Graduate Student, Department of Periodontology, Swami Devi Dyal Hospital & Dental College,

Haryana, India.

5. Post Graduate Student, Department of Prosthodontics, Bhojia Dental College and Hospital, Baddi, H.P

6. Post Graduate Student, Department of Prosthodontics, Bhojia Dental College and Hospital, Baddi, H.P

Corresponding Author:

Dr Navjot Kaur

Post Graduate Student, Department of Prosthodontics,

Bhojia Dental College and Hospital, Baddi, H.P.

Conflict of Interest – Nil

01

Abstarct

Despite the long term predictability of

osseointegrated implants, biologic, biomechanical

and esthetic complications can occur in small

number of cases. Inflammatory complications,

operative complications and biomechanical failures

can take place after placement of implants.

The purposes of this article are to

(1) summarize the reported types and frequencies of

implant-associated complications,

(2) identify risk factors for developing

complications associated with the use of dental

implants.

(3) critically evaluate the etiology of implant

biomechanical complications Keywords: Implant,

complications, inflammatory conditions,

biomechanical, operative

Introduction

Replacing missing teeth with osseointegrated dental

implants is a predictable technique, as evidenced by

an overall 5-year implant survival rate that ranges [1–3] between 93% and 97%. Few studies, however,

systematically have addressed the frequency or

natural history of complications related to the use of [4–7]

dental implants. Reported complication rates

range so widely (i.e, 1%–40%) as to be rendered

Vol-III, Issue - 1, Jan-Apr 2016

Complications in Implants

[4,6,8]clinically meaningless. Differences in reported

rates may be attributable to differing definitions of

complications. Even less has been written about risk

factors for developing surgical complications

related to the use of dental implants.

A complication is defined in the Glossary of Oral

and Maxillofacial Implants as an “Unexpected

deviation from the normal treatment outcome. It is

generally classified as either technical or biological,

eg, surgical complication, hemorrhage, damage to

the inferior alveolar nerve, infection, delayed [9]

wound healing, or lack of osseointegration.

Pathologic changes of the peri-implant tissues can

be placed in the general category of periimplant

disease. Inflammatory changes, which are confined

to the soft tissues surrounding an implant, are .[10}diagnosed as peri-implant mucositis Progressive

peri-implant bone loss in conjunction with a soft

tissue inflammatory lesion is termed peri-[11]

implantitis. Technical failures can occur in small

percentage of cases in the form of implant,

abutment, screw fractures and loosening of fixation

screws. Esthetic complications may occur in

patients with high esthetic expectations and less

than optimal implant placement and restorative

treatment results.

Materials And Methods

The authors have carried out a analytical review of

the literature. The authors have identified high-

quality articles that deal with implant-related

complications. They applied expert natural history

and prognosis search filters available through

PUBMED SEARCH. The authors identified

additional articles by hand searching retrieved

articles, reviews, and textbooks. All available

clinical studies from 1981 to 2015 that presented

success data regarding dental implants were

evaluated, and type and prevalence of reported

complications data were abstracted. A total of 305

study abstracts were identified and reviewed, 90

articles were retrieved and evaluated in detail, and

of these articles, 45 were included in this article.

Complications were classified as operative or

inflammatory. Operative complications occurred

during or as a result of an operation and included

displacement of the implant, bleeding, nerve injury,

fracture, or injury to adjacent teeth. Inflammatory

complications occurred at any stage of the implant

treatment and included infection, periimplantitis.

INCIDENCE

The overall reported complication rate averaged

28% and ranged from 1% to 40%. Operative

complications averaged 18% and ranged from 1% .[1,4,5,8]

to 28% Inferior alveolar nerve (IAN) injury

ranged from 1% to 28%. Serious bleeding, implant

displacement, mandibular fractures, and injury to

adjacent teeth occurred in less than 1% of cases.

Inf lammatory compl ica t ions compr ised

approximately 10% of all complications and ranged

from 1% to 32%. The average complication rates

reported for periimplant mucositis, periimplantitis,

hyperplastic mucositis, and fistula formation were [4,5,7,12, 13]12%, 8%, 6%, and 4%, respectively. .

TPS International Team for Oral Implantology

(ITI)- implants demonstrated a mean radiographic

change in periimplant bone levels of less than 1.1 [14]

mm in the first year of function . However, the

percentages of implant sites with bone level changes

of more than 0.5 mm between years 1 and 2 was 7%

and bone level changes of more than 1 mm were 4%.

Vol-III, Issue - 1, Jan-Apr 2016

02

Patients with a history of periodontitis may

represent a group of individuals with an elevated

risk of developing periimplantitis. This view is

based on the evident susceptibility to periodontitis,

and the potential for transmission of periodontal [15]pathogens from teeth to implants.

Inflammatory Complications

Inflammatory complications can occur at any time

during implant treatment. Inflammatory

complications are divided into acute and chronic

categories. Acute inflammatory conditions include

cellulitis, perioperative infection and abscess [16-18]

formation. Chronic inflammatory conditions

include soft tissue periimplantitis (mucosal

erythema and edema) and hard tissue periimplantitis

(periimplant radiolucent lesions or progressive bone [1,3]loss ).

Acute Inflammatory Conditions

Perioperative infection after implant placement

ranges from 1% to 3% and increases the risk for [19,20]implant failure. Among the risk factors for

developing this complication is overheating of the

bone during site preparation. The use of aseptic

technique and avoidance of implant placement into

previously infected sites may reduce the risk for

infection. Prophylactic antibiotics administered

before implant placement reportedly decreased [21]

early failure rates twofold to threefold.

Chronic Inflammatory Conditions

Chronic inflammatory complications occur with a

reported frequency of 1% to [1,3,12,22,23]34%. Chronic inflammatory complications

are classified as soft tissue periimplantitis and hard

tissue periimplantitis. Soft tissue periimplantitis is

an inflammatory process that involves soft tissue

surrounding an implant without signs of bone loss.

Soft tissue periimplantitis occurs most commonly in

association with implant-supported overdentures,

with a reported frequency ranging from 10% to [24,25,26]

30. Rates of soft tissue periimplantitis

associated with implant-supported fixed prostheses [1,2,27,23]

range from 8% to 22%. Risk factors include

unstable overdentures that result in mucosal

ulceration and hyperplasia, misaligned implants

that traverse non attached gingival tissue, improper

use of the abutment or healing caps, poor oral

hygiene, , and presence of dead space under the

superstructures.

The frequency of hard tissue periimplantitis and

progressive bone loss is low. Several studies have

reported on the average marginal bone loss that

occurs during the first year after implant [1,29]placement. Mean bone loss was 0.93 mm (range

0.4 mm– 1.6 mm). The mean loss during subsequent [27]years was 0.1 mm per year (range 0 mm–0.2 mm.

Risk factors for hard tissue periimplantitis include

early implant exposure and poor oral hygiene,

infection located at the apical area of the implant.

Apical implant lesions may be completely

asymptomatic or present with tenderness, persistent

pain or swelling, and fistula formation. The risk

factors for apical periimplantitis include excessive

heating of the bone during insertion, residual bone

cavities created by the placement of implants that

are shorter than the prepared surgical site, and

bacterial contamination from either extracted teeth

or a seeding mechanism from the remaining natural

teeth.

Fistula formation at the abutment–implant

Complications in ImplantsVol-III, Issue - 1, Jan-Apr 2016

03

interface may be one of manifestations of hard tissue

periimplantitis. It was reported in the literature with

an incidence of 0.02% to 25%.[1,2,28] Risk factors

for developing chronic fistulas include a gap

between the implant components that creates a nidus

for infection and poor oral hygiene.

Operative Complications:

Bleeding And Hematoma

Hematoma formation and bleeding after implant

placement reportedly occurs in 0% to 29% of cases.

[27,30] Bleeding is commonly controlled with local

measures and is considered a minor complication.

Hematoma formation after placement of dental

implants usually resolves completely with minimal [27,30]sequelae. Life-threatening bleeding is rare, and

[31,32]only seven cases are reported in the literature.

Sublingual, submental, or submandibular swelling

in conjunction with tongue elevation was observed

in all seven of these cases. Suggested risk factors for

bleeding include location, perforation of the lingual

cortex, and implant length.

A CT-guided prefabricated surgical splints guides

the osteotomy bur to its proper position while

avoiding perforation of the lingual cortex,

especially in the presence of extensive sublingual

fossae. Using implants smaller than 16 mm also may

reduce the risk of lingual perforation and reduce the

chances of this problem.

Nerve Injury

The incidence of neurosensory disturbance after

placement of dental implants ranges from 0.6% to [3,27,30]

36%. Inferior alveolar nerve injury during

implant placement may result from direct

mechanical damage to the nerve, compression of the

nerve and vessels, damage to vessels with bleeding

into the canal that results in a compartment-like

syndrome, or the formation of a traumatic

neuroma.[33] The risk factors for IAN injury during

implant placement include the use of nerve

repositioning or lateralization procedures and

implant placement in the severely atrophic

mandible.[34] Early postoperative anesthesia

suggests that direct, significant injury to the IAN

and removing the implant promotes early

decompression of the nerve and may improve

outcome.

Mandible Fractures

Mandible fractures after implants placement are [2]

rare (reported frequency of V0.2%). Etiologically,

fractures may occur because implant site

preparation creates an area of stress concentration

and weakness in the bone. The major risk factor for [7,35]fracture is a severely atrophic mandible. Other

risk factors include lateralization of the IAN in

association with implant placement, osteoporosis,

and trauma to the mandible after implant [36]placement. To prevent fractures, imaging the

severely atrophic mandible to evaluate better the

three-dimensional anatomy of the proposed site.

Avoidance of wide implants in cases of nerve

lateralization also may decrease this risk. In cases of

severe resorption, bone grafting to increase

mandibular volume and bulk may be indicated.

Implant Displacement

During implant placement or abutment connection,

there is a risk for displacing the implant from its site

to adjacent anatomic structures (eg, the maxillary [37,38]

sinus, nasal floor, or mandibular canal). Risk


04

factors for implant displacement are placement of

implants in soft (type IV) bone and in close

proximity to the maxillary sinus or mandibular

canal. To avoid this complication, a thorough

preoperative evaluation of the bone quality,

especially in posterior maxillary cases must be

done. Evaluation of the implant site with a probe

before insertion of the fixture is helpful to detect

bony perforations.

Early, Unplanned Implant Exposure

Early, unplanned implant exposure Premature

exposure of a staged dental implant because of

wound breakdown occurs with a reported frequency [1, 37]of 2% to 11%.

Early exposure of two-stage dental implants may be

associated with an increased risk for inflammatory

complications, including crestal bone loss and

periimplant soft tissue inflammation .A meticulous

closure of the wound without tension after

reconstructive procedures is valuable for avoiding

this complication.

Damage To Adjacent Teeth

Injury to adjacent teeth associated with implant

[38]placement is a rare, but reported, complication.

Adequate preoperative imaging and use of a

prefabricated splint when placing implants help

prevent inadvertent injury to adjacent teeth.

Biomechanical Complications

Biomechanical complications include acrylic resin

veneer fracture, overdenture attachment fracture,

early implant failure, porcelain fracture, acrylic

base fracture of overdentures, prosthesis/abutment

screw loosening, prosthetic framework fracture,

prosthesis/abutment screw fracture, implant body

fracture, and marginal bone loss around the [30]

implant.

Miyata and coworkers demonstrated that excessive

occlusal forces led to bone resorption around

implants, even if the peri-implant tissue was

clinically healthy. In addition, it was found that once

peri-implantitis has progressed, the efficacy of the .[31]

healing mechanism was compromised


05

Occlusal overload may cause prosthesis/abutment

screw loosening and fracture of the implant body

and abutment screw. Comparatively, screw

loosening has a higher incidence (6% versus 1% to [32]

2%). Implant fracture, in contrast, is rare, with an [33]

incidence of 1.2%.

Fractures of prosthesis components, eg,

attachments, the metal framework, or an acrylic

resin base, occur relatively often. The mean

percentages of acrylic resin base and metal

framework fractures are 7% and 3%, respectively.

Fractures of retentive devices, such as attachments,

are by far the most common complication, with an

i n c i d e n c e o f 1 7 % . T h e m o s t c o m m o n

biomechanical complications related to fixed

prostheses supported by implants are[34] resin veneer and porcelain fracture. Severe wear

or fracture of resin veneers is relatively more

common than other biomechanical complications

reported, this was clearly demonstrated in a 15-year

study that had a 90.6% survival rate of implant- [ 3 5 ]

supported prosthesis. Another common

complication is ceramic fracture. It was found that

implant-supported fixed partial dentures (FPDs)

had a significantly higher 5-year risk of

porcelain fracture or chipping compared with tooth

s u p p o r t e d F P D s ( 8 . 8 % v e r s u s 2 . 9 % , [36]

respectively). Similarly, Kreissl and colleagues

found that fracture of ceramic veneers occurred in [37] 5.7% of 112 FPDs supported by 205 implants. In

comparison, fracture of[38,39,40]the metal framework of FPDs was rare (0.5%).

Therefore, fracture of a veneer material (acrylic,

porcelain, or resin) is undeniably the most common

technical complication for implant-supported fixed

reconstructions.

[40]Management of Biomechanical Complications

Possible factors resulting in Implant overload


06

Summary

This article identifies the operative and longitudinal

and biomechanical complications associated with

the placement of dental implants and discusses

predisposing conditions and risk factors.

Surprisingly, the most common surgical

complications are neurosensory disturbances and

hematoma formation. Inflammatory complications

(both soft and hard tissue) are most commonly

associated with implant failure. A thorough clinical

and radiographic examination can be helpful in

determining morphologic abnormalities

and reducing the incidence of operative

complications, such as perforation of the lingual

cortex, associated bleeding, and damage to

contiguous structures. Careful implant site

selection, appropriate angulation, and soft tissue

handling may decrease mucosal inflammatory

complications. Longitudinal follow-up and

assessment of bone and soft tissue health

surrounding implants should promote longevity

and minimize these complications. There is no

doubt that prevention is the best way to manage

possible biomechanical complications. With a

better understanding of implant occlusion, such as

the use of more implants when shorter lengths and

smaller diameters are required, splinting of

implants in areas of heavy occlusal loading,

provision of occlusal splints for bruxers, and

selection of the proper occlusal scheme, implant

overloading can be prevented and the long-term

stability of implant-supported prostheses can be

ensured.

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09

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Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.Source of support: NIL

Copyright © 2014 JPMCP. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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