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Implant Complications
(Case Selection
Considerations)
MICHAEL L. BILLINGSLEY, DDS, ABOMS
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Dental Implants – “Revolutionary
Era in Prosthetic Dentistry”
A Major Paradigm shift in tooth replacement.
“Game Changer”
Remarkable 20-30 years of 95-98% success rates in large multi-center studies
However, “The mouth is a hostile environment, not a friendly place for dental prostheses.
Not for everyone, and complications are to be expected. Like everything else in dentistry, “Spit Happens.”
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Complicating Factors
Local -
Soft tissue Quality and Quantity (keratinization and thickness)
Bone Quality and Quantity
Occlusion and Bruxism/ para-functional habits
Systemic –
Uncontrolled disease/ Medication side effects
Poor diet/ tobacco/ substance abuse
Age > 65 (+/-)
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Failures occur for a variety of
reasons
Any Dentist who says, “I’ve never had a failure in my practice, implants are practically foolproof.”, probably hasn’t done enough cases. Complications will appear sooner or later.
Remember, “Nothing is fool-proof to a sufficiently talented fool.”
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Reasons for failure (Loss)
Many reasons for failure, but end result is peri-
implantitis and irreversible bone loss leading to a
loss of osteointegration and loosening of the
implant.
Three levels of integration
1) bone
2) soft tissue
3) pus
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Peri-Implant Mucositis – (early sign)
Peri-implant mucositis is an inflammatory
condition resulting from bacterial colonization
which takes place in biofilms (plaques) within
the gingival sulcus around the base of the
implant and neck of the abutment.
Research shows that 2/3 of patients with
mucositis, if untreated, will progress to peri-
implantitis and likely implant failure within 5 years
of placement.
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Microbial Factors
The usual bacterial suspects are common to
Peri-implantitis and Periodontitis.
Most harmful tend to be Anaerobic bacteria
such as Actinobacter, Porphyromones, and
mycobacterium species in the deeper sulcular
areas around the necks of the implants and the
abutments. Smooth or polished surfaces are
more resistant but do not prevent colonization.
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Contributing Factors to Implant Loss
Microbial – Plaque Index/ Hygiene
Soft Tissue Quality – Keratinization / Thickness
Bone Quality and Quantity
Occlusion – sufficient numbers/ placement?
Occlusal Overload/ Bruxism/ Deep Class II bite
Predisposing Medical Conditions
Noxious Habits – Smoking, Substance Abuse
Iatrogenic issues
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Predisposing Medical Conditions
and/or Habits
THE KEY QUESTION –
“Do the patient’s medical condition and/or
noxious habits compromise the ability to provide
an Adequate Blood Supply to the oral tissues?”
Perfusion is the key to hard and soft tissue health.
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Patient Selection
Need to be very careful with any uncontrolled
systemic disease, especially:
CA, Acute CV and stroke, and end stage
Congestive Heart Failure – contraindicated
Diabetes M. Type II – If HbA1C > 7.5%
Autoimmune Disease
Certain Bone Diseases, i.e. Paget’s disease,
osteoporosis
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Age > 65
Recommend a presurgical medical evaluation
by PCP if not under current or periodic medical
protocol.
Rule out asymptomatic medical problems and
correct poor systemic disease management.
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Pre-implant Dental Evaluation
Medical assessment
Comprehensive Dental exam to include at least a Panoramic X-ray and study models.
CBCT imaging in more complicated cases (rapidly becoming a standard of care issue)
Use surgical guides (provide to Surgeon)
Very important to outline alternative treatment options, risks, and sign informed consent.
Refer for Specialty consultation where appropriate for complex cases.
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Basic Panorex to Rule Out
Pathology
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Cone Beam Computerized
Tomography. (CBCT)
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Surgical Guides eliminate
guesswork
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Pre-implant Dental Evaluation
Medical assessment
Comprehensive Dental exam to include at least a Panoramic X-ray and study models.
CBCT imaging in more complicated cases (rapidly becoming a standard of care issue)
Surgical Guides
Very important to outline alternative treatment options, risks, and sign informed consent.
Refer for Specialty consultation where appropriate for complex cases.
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The Problem with Smoking
Not only tobacco but also weed (cannabis)
Decrease in –
Capillary Blood Flow (nicotine)
Oxygen Carrying Capacity of RBC’s (CO2)
Osteoblast activity and bone deposition impairment (hydrogen cyanide)
Minimal Patient Commitment - Agree to quit at least 2 weeks prior to surgery and for at least 6 months post-placement of Implants.
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Osteoporosis Treated with
Bisphosphonates, MRONJ
Oral Bisphosphonates, i.e., Fosamax and others
have had a low incidence of osteonecrosis of
the jaws. General guidance for implant
placement is 3 years after oral meds stopped
and CTX >150.
IV Bisphosphonates, Zomedia, Aredia, others are
used for Multiple Myeloma, cause much higher
incidence of MRONJ, and are considered a
contraindication for implants.
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Osteoradionecrosis of Jaws
Depends on amount of total radiation to
Orofacial region. Should be less than 5000 Rads
(50 Gy {Grey units}) in fractionated units over
several months, and Patient 5 years post
radiotherapy.
Hyperbaric Oxygen (HBO) can be very helpful in
pre/post operative management
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Post-Resection/ Facial
Reconstruction Vascularized Free-Fibula mandibular
reconstruction cases have generally been good
candidates for implant placement.
However, soft tissue management can be
problematic/ difficult to achieve functionally
equivalent mastication (attached) gingival
coverage. May require follow-up vestibuloplasty
with skin grafting, to achieve acceptable soft
tissue interface.
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Iatrogenic (Provider) Factors
Philosophy of Implant Care
Case Selection
Appropriate Planning
Imaging (CBCT?)
Site Preparation (Grafting)
Implant surgery
Immediate vs. Delayed loading
Post-op Care and follow-up
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Philosophy of Implant TreatmentWhat is the place of implants in my
practice?
Single tooth replacement
Multi-unit to full arch
All on 4 – All on 16–or something in between
Fixed vs. Removable
“Put the implant where the bone is, or let the prosthesis dictate where the implant goes.”
Plan from the final prosthesis backward
Cemented or Screw Retained
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Hybrid of regular implants and minis
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Hybrid regulars and minis
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Case Selection
What is my comfort Level?
What will I refer to a specialist?
If I refer the case out, am I willing to do part of
the work, and how do I coordinate the
treatment plan If I am participating?
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Adequate Treatment Planning.
Medical/ Dental history
Patient’s treatment goals/ budget
Exam, X-rays/ CBCT, Models, Wax-ups
Consultant recommendations
Case presentation with alternative treatment, patient acceptance, informed consent.
Surgical guides, sequence and timing of treatment, follow-up plan, treatment alteration if implant failure or other complications
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Immediate vs. Delayed Loading
Provisional appliances during healing stages
Patient expectations and management of
transitional treatment issues.
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Post-op care and Follow-up
Recommend at least:
Immediate or ASAP follow-up for any patient
complaints.
3 month, 6 month, 1year follow-up with Panorex
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Final thoughts
PPPPPPP. (The seven P’s)
“Proper prior planning prevents P…. Poor
Performance”
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Recommended Reading
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Recommend Reading
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Recommended Membership