Transcript HandOutforVDDS

Prevention and Management Of Complications
In Implant Dentistry
Evidence Based
Medicine / Dentistry
EBM is the conscientious, explicit
and judicious use of best evidence
in making decisions about care of
individual patients.
Cochrane Center
Oxford, England
3 Components of Evidence
Based Dentistry
1)
Scientific Literature
2)
Professional Experience and advise
3)
Patient’s treatment desire and goal
“Train The Brain”
Dr. Mark H.E. Lin
Complications In
Implant Dentistry
Host / Patient
Related
Dentist / Surgeon
Related
Clinical Protocol
Related
Systemic
Conditions
Treatment
Planning
Local Factors
Psychological
Status
Surgical
Grafting
Smoking
Periodontitis
Prosthetic
Restorative
Maintenance
Host / Patient Related:
Medical Status
Absolute Contraindications to Surgery
Relative Contraindications / Risk Factors to Surgery
Susceptibility to Infections and healing
response in question
Host / Patient Related:
Medical Status:
Absolute Contraindications
For Surgery (Dental alveolar, implant, hard or soft tissue
grafting)
– Debilitating diseases:
• Active cancer
• chemotherapy
• radiation therapy
• transmittable infections- hepatitis, HIV
– Impaired healing capacity diseases:
• Uncontrolled diabetes
• Uncontrolled hypertension
• immune compromised disease
• history of osteomylitis in operative site
Host / Patient Related:
Medical Status:
Absolute Contraindications
– Recent myocardial infarction (M.I.), cerebrovascular
accident, uncontrolled clotting / bleeding disorders
– Pregnancy
– Chronic or severe alcoholism
– Drug abuse
– Psychiatric disorders
– I.V. bisphosphonate use or long term oral
bisphosphonate
– Uncontrolled periodontal disease
– ASA IV or V patients
Host / Patient Related:
Medical Status:
Relative Contraindications / Risk Factors
For Surgery (Dental alveolar, implant, grafting)
– Debilitating diseases: Inactive cancer
– Impaired diseases: Controlled diabetes, controlled
hypertension
– Myocardial infarction (M.I.) history of >1 year
– Oral bisphosphonate
– Smoking habits
– Periodontal disease
American Society of Anesthesiologists
(ASA) Classifications
ASA I: a normal, healthy patient, without systemic
disease.
ASA II: a patient with mild to moderate systemic
disease.
ASA III: a patient with severe systemic disease, which limits or
alters activity but is not incapacitating.
ASA IV: a patient with severe systemic disease, which is
incapacitating and is a constant threat to life.
ASA V: a moribund patient not expected to live more than 24
hours without an operation.
Elective Implant surgeries are
NOT indicated for ASA IV or V
patients
For a patient at risk, strict
adherence to the standard
protocol does not always yield
the expected results.
Infection
Invasion and multiplication of
microorganisms in body tissues, which may
be clinically inapparent or result in local
cellular injury due to competitive
metabolism, toxins, intracellular replication,
or antigen-antibody response.
Dorland’s Illustrated Medical Dictionary 27th, Edition
Factors Associated with Increased risk of
infection for dental implant procedures
Systemic Factors
1.
2.
3.
4.
5.
6.
7.
Diabetes
Long term corticosteroid use
Immunocompromised systemic disorders
Smoking
Malnutrition, obesity
Elderly population
ASA III or IV classifications
Factors Associated with Increased risk of
infection for dental implant procedures
Local Factors
1.
2.
3.
4.
5.
6.
7.
Use of type or procedures of graft material
Generalized periodontal disease
Tissue inflammation
Odontogenic infections
ill-fitting provisional prosthesis
Incision line opening
Inadequate oral hygiene
Factors Associated with Increased risk of
infection for dental implant procedures
Surgical Factors
1. Poor aseptic technique
2. Compromised skill and experience of the
surgeon
3. Increased duration of surgical time
4. Wound contamination during surgery
5. Foreign body introduction (graft material,
implants, debris, etc….)
Infection Prophylaxis
1) Aseptic Surgical techniques applied
during all clinical grafting
procedures.
2) Pre-operative Rx: Amoxicillin 500mg
x 4 tablets (2 g), 1 hour prior to
surgery (Scientific Evidence)
Post-operative 1 tablet t.i.d. for 1
week following surgery (Optional)
Infection Prophylaxis
3) Chemical Plaque control:
Preoperative rinsing with .12%
Chlorhexidine digluconate for 1
minute.
Postoperative rinsing for 2-3 weeks
with good oral hygiene.
4) Monitor and close follow up:
Patient to return to clinic at 1-2
weeks to evaluate healing
status.
Infection Prophylaxis
5) Confirm lack of localized infection
from adjacent tooth (endodontic
origin) or soft tissues (periodontitis)
spreading into grafting site.
Diabetes
1. Higher prevalence in Adult African Americans,
native and Hispanic Americans
2. Risk factors: Genetics, obesity, advancing
age and inactive lifestyles.
3. Characterized by:
1. Peripheral resistance to insulin
2. Increased production of glucose by the liver
3. Altered pancreatic insulin secretion.
Oral Manifestations for a Diabetic Patient
1.
2.
3.
4.
5.
6.
7.
8.
9.
Poor wound healing (soft tissues, osseointegration)
Higher susceptibility to oral infections
Xerostomia
Higher incidence of dental caries
Pronounced hyperplasia of attached gingival
Increased accumulation of plaque and food debris
Neuropathy (burning mouth, tingling, numbness)
Greater incidence and severity of periodontal disease
Candidiasis and lichenoid reactions
Signs of Hypoglycemia:
1.
2.
3.
4.
5.
6.
7.
Sweating
Palpitations
Tachycardia
Nausea
Hunger
Tremulousness
The symptoms may progress to coma and
convulsions without intervention.
Management of type I diabetic patients:
(To prevent Insulin shock)
1. Patient instructed to take their usual dosage of
insulin medications
2. To eat a normal meal prior to appointment
3. Schedule the appointment early in the morning
4. Patient to communicate with dentist if they feel
symptoms of an insulin reaction
5. A source of sugar available in office (orange juice,
candy, sugar packs)
6. May consider Antibiotic prophylaxis coverage to
prevent infections which is related to the fasting
blood glucose levels.
Dental Managements
1. Minimize stress
2. Decrease risks of infection (Post operative
antibiotics: Amoxicillin 500 mg, t.i.d. or
Clindamycin 300 mg, t.i.d. for 7-10 days)
3. Avoid untoward metabolic imbalances during dental
therapy
4. Instructions for diet and medications to avoid
hypoglycemia.
Management of Hypoglycemia
1. Sugar source readily available (sugar
packets, candy, orange juice)
2. Dextrosol 3mg tablets of glucose
3. Glucagon 1 mg IM
4. 50% Glucose solution 50 ml IV
Bisphosphonates Induced
Osteonecrosis of the Jaws (ONJ)
Defined as a non healing bone in the
mandible or maxilla present for 8
weeks in a person that is on
Bisphosphonates and hasn’t
received radiation to the jaws.
Risk of osteonecrosis of the jaws
• Exposed bone is dead with usually no
pain.
• Pain may occur due to secondary infection
• The jaw bones are susceptible because
the jaw bone remodels 10 times that of
long bones in the body.
Bisphosphonates
• Used for treatment of osteoporosis, metastatic
bone cancer and Paget’s disease.
• Oral form:
• IV form:
Fosamax, Boniva, Actinol
Aredia, Zonita
Mechanism of Bisphosphonates
• Mechanism of action by suppressing and
reducing bone resorption by osteoclasts.
• Bisphosphonates inhibit osteoclasts by killing
them when they take up the drug during
resorption.
• Bisphosphonates binds to the hydoxyapatite in
the bone
Bisphosphonates
• IV medications are worse then oral types.
• Risk increase after being on oral medications
for > 3 years.
• IV takes 6 months to build to toxic level
• Oral takes 3 years to build to toxic level
• 140 IV reported cases versus 40 Oral cases
• Incidence: IV:
• Incidence: Oral:
.8%-12%
.01%-1%
Signs of ONJ
• Sclerosis and thickening of the lamina dura
• Widening of the periodontal ligament (PDL)
• Mobile teeth with pain
• Exposed bone with necrosis of bone and soft
tissues
• Non healing bone post surgical wound
Treatment of ONJ
• We don’t know what is the best treatment protocol.
Dr. Robert Marx seems to be the expert on this topic.
• Peridex rinse over surgical wound
• Antibiotics:
a) Pen VK
b) Levoquin (limit to 21 days due
to liver toxicity)
• Reduce risk of secondary infections and osteomylitis
of the jaws.
• 50 % of cases will spontaneously heal.
• 50 % of cases will require additional surgeries.
Prevention of ONJ
• Non invasive dental procedures are safe.
• Invasive dental procedures safe before 3 years.
• After 3 years- a drug holiday with consent of
prescribing physician to a CTX of >= 150 pg/ml.
Serum C terminal telopeptide test
(CTX)
• After 3 years of Bisphosphonate use, need a CTX to
determine safety level.
• CTX <= 100 pg/ml:
• CTX = 101-150 pg/ml:
• CTX >= 150 pg/ml:
HIGH risk
Moderate risk
Low risk
• CTX improves significantly with discontinued oral
Bisphosphonates use.
• CTX is a marker for bone turnover and healing.
• Measures osteoclast function as a C terminal fragment
is cleaved during bone resorption.
Suggested Treatment Regimen
• 1) Obtain references for CTX level
• 2) Drug holiday of 4-6 months with approval
from prescribing physician.
• 3) Treat with Peridex (.12%) and antibiotics.
• 4) Monitor CTX until value is >150 pg/ml
• 5) Decide to refer or monitor for treatment
options:
A) Spontaneous resolution
B) Treat surgically
Host / Patient Related:
Psychological Status
1. Psychological and mental stability for patient
to accept and tolerate required procedures
2. Normal healing response and sequelae of
bone and soft tissue grafting procedures
3. The 3 “C’s” prior to treatment:
a) Communication
b) Compliance
c) Consent
Host / Patient Related:
Normal healing response and sequelae of bone
and soft tissue grafting procedures are:
• Hemorrhage / bleeding
• Ecchymosis / bruising
• Pain / discomfort
• Swelling
Hemorrhage / bleeding Management
1) Management of intra operative bleeding source (soft tissue /
bone) prior to suturing.
2) Proper soft tissue suturing techniques to ensure primary
closure without tension of soft tissues.
3) Proper use of sterile gauze pads with moistened sterile
saline solution with FIRM pressure over wound for 20
minutes.
4) Oral and written instructions for care to prevent vasoactive
substance (caffeine or alcohol), minimize exercise, post
operative care to minimize disturbance to wound clotting,
oral hygiene instruction care.
Ecchymosis (Bruising)
• Due to extravasation and subsequent
breakdown of blood in the subcutaneous
tissues.
• Deposition of blood from the surgery in the
interstitial tissues spaces and will be resorbed
over a time period of 1-3 weeks.
• Occurs more in fair skinned patients and elderly
patients with fragile capillaries.
Ecchymosis Management
1) Inform patient that it will be a normal
sequelae of any surgical procedure.
2) Inform patient that degree of bruising is NOT
an indicator of success / failure, traumatic /
atraumatic nature of procedure or operator.
3) Application of ice bag or cold packs
immediately after surgery for 2 days.
Pain / discomfort Management
1) Long term Local anesthetics:
a) Bupivacaine (Marcaine / Vivacaine): 0.5% w
1:200,000 epinephrine used for block anesthesia.
Duration time of 6-8 hours.
b) Articaine (Ultracaine Forte / Astracaine): 4% w 1:
200,000 epinephrine. Duration time of 4 hours.
2) Analgesics:
a) NSAIDS: Ibuprofen 400mg (600-800mg if anticipate
swelling), 1 hour prior to surgery, then 1 tablet every 6-8
hours continuous for 2-3 days.
b) Narcotics: Tylenol #3, 1-2 tablets every 4-6 hours as
required for pain relief.
Swelling Management
1) Application of ice bag or cold packs immediately after surgery
for 2 days.
2) I.V. administration of glucocorticoid steroids (prednisolone
250mg or dexamethasone 8 mg) prior to start of surgery.
3) I.M. administration of Dexamethasone / Decadron (Celestone
Soluspan Injectable)6mg/per site adjacent to surgical
wound.
4) P.O. prescription of Dexamethasone (Decadron) 4 mg with
regimen as follows:
–
–
–
–
Preoperative 4mg x 2 tablets = 8 mg, 1hour prior to surgery
Postoperative 4mg x 1 tablet = 4 mg, 1st day after surgery
Postoperative 4mg x .5 tablet = 2 mg, 2nd day after surgery
Postoperative 4mg x .5 tablet = 2 mg, 3rd day after surgery
Complication
A secondary disease or condition
aggravating an already existing one.
Dorland’s Illustrated Medical Dictionary 27th, Edition
Complication
Defined as a secondary condition that
developed during or after implant surgery
or prosthesis placement. The occurrence
of a complication does not necessarily
indicate that substandard dental care was
provided and also does not necessarily
mean that clinical failure has occurred.
Sequelae
Any lesion, condition, consequence or affection
following a clinical procedure injury or caused
by an attack of previous disease.
Dorland’s Illustrated Medical Dictionary 27th, Edition
a) Communication
Share or exchange information, news, or ideas
Oxford Dictionary 10th Edition
Allocate appropriate amount of TIME to
educate and communicate prior to consent to
treatment. Utilize patient education video,
documents and software to aid in
communication process.
b) Compliance
Disposed to agree with others or obey rules,
especially to an excessive degree. Meeting or in
accordance with rules or standards.
Oxford Dictionary 10th Edition
A quality of yielding to pressure or force without
disruption, or an expression of the measure of the
ability to do so.
Dorland’s Illustrated Medical Dictionary 27th, Edition
COMPONENTS OF CASE MANAGEMENT FOR IMPROVED
CASE ACCEPTANCE RATE
New Patient Telephone Interview
New Patient First Appointment Interview/ Consultation Interview
Diagnostic Records Appointment
- Consult with Specialists and Labs
Case Presentation(Within 1 Week), (Bring Spouse)
Acceptance
Pre-Appointment Work Up
-Pre Medications
-Inform Consents
-Financial Arrangements Confirmed
-Diagnostic Work Up
-Q/A Period
Treatment
Pending
Case Discussion Letter
Follow Up Report(1wk, 2 wks, 1 months)
Post Treatment Interview
-Follow Up photos for Patients B/A
-Request for Testimonial Letter
-Referral Request
c) Consent Process
1. Communication and patient education
2. Process of informed consents and financial
arrangements confirmed
3. Relationship and rapport development with
patients
4. Continuous monitoring support, empathy and
sincere compassionate care
Consequences of Smoking on wound healing
1. Arteriolar vasoconstriction reduces
vascularization and microcirculations of
tissues.
2. May lead to increase incidence of flap
necrosis and dehiscence to early graft
exposures.
3. Tobacco's toxic byproducts have been
implicated as risk factors for impaired
healing.
Studies on Smoking and Implants
Study # 1: 5% lost on non-smokers versus 11%
on smokers. Smokers with higher implant
failure rates in all regions except for the
posterior mandible.
Study # 2: 3% lost on non-smokers versus 7%
on smokers by number of implants. 9% lost on
non-smokers versus 22% on smokers by
number of patients. Regardless of method of
analysis, a SIGNIGICANT difference was noted
between smokers and non-smokers.
Studies on Smoking and Implants
Study # 3: Smoking cessation protocol of 1
week before surgery and 8 weeks after surgery.
-6% implant lost on non-smokers.
-38% implant lost on smokers WITHOUT smoking
cessation program.
-12% implant lost on smokers WITH smoking
cessation program.
Cessation protocol demonstrated improving
implant success on treatment of smokers.
Effect of smoking (evaluated in 9 studies)
-Significantly increases implant loss
-Consumption increases failures (2 studies)
-Consumption does note increase failure (1
study)
-Comparison (smokers/nonsmokers)
178 / 1668 implants lost in smokers (11%)
239 / 4862 implants lost in non-smokers ( 5%)
Management protocol for smokers
1) Don’t treat!
2) Smoking cessation programs
3) Treat with consent form
Tobacco and Nicotine Warning
Consent forms
Nicotine and Tobacco Warning
The nicotine in tobacco constricts the blood vessels of your body. This effect is
immediate and lasts up to one month. Furthermore, nicotine will reduce the amount of
oxygen delivered to the body. This constriction of blood vessels and reduced oxygen
delivered will affect the circulation of the tissues handled. Implant surgery and bone
grafting may require extensive manipulation of soft tissues. The use of nicotine can
compromise the healing and cosmetic outcome of these surgeries.
YOU MUST STOP SMOKING one month prior to surgery. You must not smoke for at
least three weeks following surgery. A nicotine patch may be used to help stop smoking.
However, no nicotine patch or nicotine gum may be used one month prior to surgery and
for three weeks after surgery.
________________________
Parent Signature
_______________________
Date
________________________
Witness Signature
_______________________
Date
Periodontal disease and Dental Implants
1. Implant survival in patients with a history of
treated Periodontitis ranged from 59-100%
2. 17/18 studies reported high implant survival
rates of >= 90% with turned or moderately
rough implant surfaces
3. Need for continue regular supportive
periodontal therapy
4. Statistically significantly greater risk of periimplantitis, odds ratio of 3.1 to 4.7
Iatrogenic
Any adverse condition in a patient occurring
as the result of treatment by a physician /
dentist or surgeon, especially to infections
acquired by the patient during the course of
treatment.
Dorland’s Illustrated Medical Dictionary 27th, Edition
Implant Treatment Planning
Implantology is a “Prosthetically
/ Restorative” driven discipline
with a “Surgical” component.
Treatment Sequence
Esthetic Implant Dentistry, Patrick Palacci, DDS
Improper Implant Treatment Planning
1) Improper surgical implant placements without
desired prosthetic goals treatment planned
2) Improper use of number and location of dental
implants for final prosthesis
3) Lack of understanding of Biomechanical
rationale requirements for functional loads
Pretend the following:
-you had all the time
-you had all the money
-you had all the bone
-you had all the compliance
What is the most ideal
treatment plan desired for
your patient?
Treatment planning philosophy- one of the
most important factor to success
• Don’t compromise your ideal treatment
plan with the following:
• -patient’s financial constraints.
• -unreasonable time demands for
completion.
• -insurance limitations or moral
compromises.
• -patient’s guidance on treatment
decisions.
“The Lost Syndrome”
1) Lost trust from the patient!
2) Lost patience from the patient who will
require more surgeries and procedures!
3) Lost time and require to start again
from a clinical condition in a MORE
compromised state!
4) Lost clinical chair time to redo the case!
5) Lost lots of money to redo the case!
6) Lost of peace of mind! (Lawsuit or
Regulatory College Complaint?)
Treatment planning philosophy- one
of the most important factor to
success
My rule on Treatment Planning
Only treatment plan and execute
implant treatment as you would
for your own family members.
Improper use of number and location of
dental implants for final prosthesis
Lack of understanding of
Biomechanical rationale
requirements for functional loads
Biomechanical
rationale
Definitions
• Bone Remodeling- turnover or
•
•
•
•
•
internal restructuring of previously existing
bone.
It is a coupled tissue level phenomenon.
Activation- of osseous precursor cells.
Active Resorption.
Reversal or Quiescence.
Formation.
• Remodeling cycle called
“Sigma”- in humans is 17
Weeks.
Definitions
• Strain- the change in length divided by
the original length and the units of strain
are given in percent.
• Too much bone strain at the implant
interface causes bone loss.
• The strain to bone may be caused by the
stress applied to the prosthesis.
Stress = _____
Mechanism of Implant Failure
Occlusal overload
Microdamage
Increased bone remodelling rate
Histological change in bone
at implant interface and adjacent bone
Increased effect of magnitude of strain
Stress Factors
• Excess stresses to an implant / bone interface will
cause overload and implant failure.
•
•
•
•
•
•
Complications from Stress:
-implant integration failure with fibrous tissue
formation around implant, mobility instead of rigid
fixation.
-Early crestal bone loss.
-Occlusal overload bone loss
-Screw loosening (prosthesis or abutment)
-Implant fracture (body or component)
-Prosthesis fracture (occlusal material or
framework)
5) Clinical Force factors
•
•
•
•
•
•
•
•
•
1)
2)
3)
4)
5)
6)
7)
8)
9)
Bite Forces (light vs. normal vs. heavy)
Parafunction
Crown implant height ratio
Masticatory Dynamics
Opposing Arch
Direction of load
Nature of Opposing Arch
Position of Abutment in the arch
Occlusal scheme
1) Bite Forces (light vs. normal
vs. heavy)
•
•
•
•
•
•
Implant supported Fixed Prosthetics >
Implant supported Removable Prosthetics >
Natural dentition with Porcelain Prosthetics >
Natural dentition >
Partial Removable Prosthetics >
Full Removable Prosthetics
2) Parafunction
Repeated or sustained non-functional wear that is
harmful to the stomatognathic system.
– A) Bruxism- vertical or horizontal nonfunctional
grinding of teeth. A maximum bite force recorded
at 990 psi (4-10 times normal)
– B) Clenching- a habit that generates a constant
force exerted form 1 occlusal surface to the other
without any lateral movement. Bruxing and
clenching can exist in combination.
– C) Tongue Thrust and Size- unnatural force of
the tongue against the teeth during swallowing.
Character Of Forces
• A) Force Magnitude (heavy, medium, light)
• B) Force Duration
• C) Force Type (Compressive, tensile, shear)
• D) Force Direction
• E) Force Magnifiers (Horizontal and vertical
cantilevers)
Surface Area for
maximal Bone /
implant interface
contacts
Options To Increase Surface Area
• 1) Increase Implant Numbers
• 2) Increase Implant Size and Length
• 3) Implant Design
• 4) Implant Surface conditioning
• 5) Bone Density
Surface Area for maximal Bone /
implant interface contacts.
1)
Maximize implant number.
Maximize implant diameter.
Maximize implant length.
2)
3)
(Without violation of the limits of bone volume or anatomical
structures.)
4) Bone Density Classification
D1D2D3D4-
Dense cortical ( > 1250 Hounsfield units)
Porous cortical and coarse Trabecular ( 850-1250 H. units)
Porous cortical (thin) and fine Trabecular (350-850 H. units)
Fine Trabecular (< 150 H. units)
Goals of Diameter Of Implant
1. Increase surface area
2. Compensate for unfavorable patient bite
force factors
3. Minimize cantilevers for angled implants
4. Compensate for poor bone density
5. Enhance surface for shorter implants
6. Improve emergence profile
7. Decrease screw loosening
8. Minimize component fracture
9. Facilitate oral hygiene
Approximate Surface Area Of Anterior
Natural Dentition (mm2)*
Position
Central
Lateral
Cuspid
Maxilla
204
179
273
Mandible
154
168
268
•
Jepsen, A root Surface
Measurement and a Method for xray determination of Root Surface,
Acta Odontol., Vol.21:35, 1963
Approximate Surface Area Of Posterior
Natural Dentition (mm2)*
Position
First
Premolar
Second
Premolar
First
Molar
Maxilla
234
220
443
Mandible
180
207
431
•
Jepsen, A root Surface
Measurement and a Method for xray determination of Root Surface,
Acta Odontol., Vol.21:35, 1963
Goals of Length Of Implant
1. Increase surface area
2. Compensate for unfavorable patient bite
force factors
3. Gain initial ridged fixation of dental implant
4. Compensate for poor bone density
5. Not violate any vital anatomical anatomy
(IAN, mental nerve, sinus, lingual concavities,
nasal foramen, adjacent roots, etc….)
Failure
Success
•Poor Bone Site Selection
Short, Narrow, Porous
•Bone Site Selection
High, Wide, Dense
•Implant Design
Oversized implant
•Implant Choice/Design
Bone around implant
•Poor Surgical Technique
•Surgical Technique
Proper implant placement
Adequate healing time
Sterile technique
•Poor Prosthetic Technique
•Prosthetic Reconstruction
Biomechanical design
Occlusal relationships
•Poor Patient Cooperation
•Patient Hygiene / Recall
Classification Of Oral
Implant Failures
• 1) Biological:
• A) Early or Primary (before loading):
Failure to establish osseointegration.
• B) Late or Secondary (after loading):
Failure to maintain the achieved
osseointegration.
Early or Primary (before loading): Failure
to establish osseointegration.
• 1) Inadequate quantity and quality of bone for
initial fixation of dental implant.
• 2) Experience of surgical operator.
• 3) Over heating of bone during osteotomy
preparations.
• 4) Pressure necrosis, especially in D1 bone.
• 5) Infection operatively after initial surgery.
• 6) Incision line opening leading to
complications or infections.
Goodacre C, JPD 2003
Classification Of Oral
Implant Failures
• 2) Mechanical:
• Fracture of implants, connecting
screws, bridge frameworks, coatings,
porcelain, etc….
Goodacre C, JPD 2003
Iatrogenic
1) Treatment planning flaws and complications.
2) Violation of vital anatomical structures.
3) Inappropriate application of procedure to site
requirement.
4) Compromised surgical skills.
5) Compromised prosthetic skills.
Types of Surgical Complications
A)
B)
C)
D)
E)
F)
G)
H)
I)
Surgical complications
Hemorrhage-related complications
Neurosensory complications
Mandibular fracture
Adjacent Tooth devitalization
Life-Threatening hemorrhage
Air Emboli
Violation of Mandibular canal
Aspiration of screwdriver, parts,
components
Surgical Parameter
by REGIONS
Posterior Mandible
Surgical Parameter by REGIONS
Posterior Mandible
D2 –D3 bone density
• 1) Problem: Mandibular nerve location.
• Solution: Surgical landmark to be at least 2.0 mm
above the mandibular canal to
establish a surgical zone of safety.
•
Pre-surgical diagnostic workup to measure allowed length
of implant. Use of periapical and panoramic x-rays,
tracings, CT scans to verify length.
• Surgical use of directional guide pins to verify proximity to
mandibular nerve after initial pilot osteotomy.
• Remember: “The enemy of good is perfection.” If in
doubt, use shorter implant lengths ( at least 10.0 mm)
Posterior Mandible
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Damage to Inferior
Alveolar Nerve
(IAN)
Surgical landmark to
be at least 2.0 mm
above the mandibular
canal to establish a
surgical zone of safety
Use of Periapical and
panoramic x-rays,
tracings, CT scans to
verify length.
Surgical use of
directional guide pins
to verify proximity to
mandibular nerve after
initial pilot Osteotomy.
Damage to Mental
nerve
Paraesthesia
Surgical Parameter by REGIONS
Posterior Mandible
• 2) Problem: Lingual concavity and
angulation flare of posterior
mandible.
Solution: Use of CT scans to perform
electronic surgery as part of
treatment planning. Minimal
reflection of lingual flap to
visualize lingual wall of bone
trajectory. Implant length to
meet biomechanical
requirement without
anatomical violations.
Posterior Mandible
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Perforation of
Lingual concavity
Profuse
uncontrollable
bleeding
Use of CT scans or
tomography films
identify anatomical
concavity
Damage to Lingual
nerve
Surgical use of
directional guide pins
to verify angulation
Reflection of flap to
palpate and measure
concavity undercut
Contraindications to posterior
single –tooth implant
• 3) Inadequate bone volume –
• Width-consider grafting or alveloplasty or implant
placement with guided bone regeneration.
• Length- Mesialdistal, intratooth space, need >7 for
a 4.0mm implant with 1.5mm between implant and
adjacent tooth.
• Height- no treatment, shorter implants, or
particulate grafting of exposed threads.
Posterior Mandible
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Inadequate Width
of Buccal bone
volume
GBR technique to graft
buccal aspect after
implant stability
achieved
Buccal threads of
implant exposed
Soft tissue
irritation
Continuous lost of
buccal plate after
functional loading
Alveoloplasty of
platform to gain width
and interocclusal
space
Use of smaller diameter
implant to accept
compromise (>4.0 mm)
Posterior Mandible
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Inadequate Height
of vertical bone
volume
Use of shorter implants
Violation of IAN
Increased crown /
implant ratio with
increased vertical
cantilever
No treatment for
implants with “shorten
dental arch concept”
GBR of vertical
exposed threads
(unpredictable)
Angulated implants
Nerve Repositioning
Surgical Parameter
by REGIONS
Anterior Maxilla
Position of Implant placement in 3 DIMENSION
Buccal / Palatal Position:
Implant platform to be at INCISAL EDGE with 1/3
buccal to edge and 2/3 palatal to edge of adjacent
teeth.
Mesial / Distal Position:
1.5-2.0mm between implant and adjacent tooth,
3.0mm between 2 adjacent implants.
Apical / Coronal Position:
Implant platform to be 3.0 mm apical to free gingival
margin of adjacent teeth or ideal position.
Implant Position Related To
Retention Mechanism
Cement retained
Buccal / Palatal Position:
Implant platform to be at INCISAL EDGE with 1/3
buccal to edge and 2/3 palatal to edge of adjacent
natural dentition.
Screw retained
Buccal / Palatal Position:
Implant platform to be at CINGULUM aspect relative
to adjacent natural dentition.
Maxillary Anterior
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Exact implant
position placement
requirement for
HIGHLY esthetic
demanding
prosthetic results
Too Shallow
placement leads to
interface showing
Placement of implant
platform to level of 3.0
mm apical to adjacent
free gingival margin
Soft tissue thin
biotype recession
risks
Use of screw retain due
to lack of interocclusal
space
Compromised
emergence profile
Maxillary Anterior
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Exact implant
position placement
requirement for
HIGHLY esthetic
demanding
prosthetic results
Use of screw retain to
avoid need for cement
Too Deep
placement leads
difficulty in cement
clean up
Creation of deep
soft tissue pocket
inaccessible by
oral hygiene aids
Use of custom
abutment to raise level
of desired margin of
crown for cement
option
Use of pre-mucosal
extensions (PME)
abutments to raise
crown margin
Maxillary Anterior
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Exact implant
position placement
requirement for
HIGHLY esthetic
demanding
prosthetic results
Avoid by use of
Lindenman drill to
counteract dense
palatal bone
Too Buccal
placement will lead
to inappropriate
emergence profile
of prosthetic crown
Buccal bone with
potential
dehiscence and
soft tissue
recessions
Use of customized
UCLA abutment to
offset poor angulation
Use of screw retained
crown with access hole
through facial aspect
Remove implant
Maxillary Anterior
Factors to
Potential
Consider in Zone Complications
Exact implant
position placement
requirement for
HIGHLY esthetic
demanding
prosthetic results
Too Palatal placement
will compromise
lingual bulk of final
prosthesis
Potential phonetic
interferences
Creation of ridge-lap
over buccal aspect
Potential violation of
incisive foramen/canal
Treatment
Options
Screw retain prosthetic
implant crown
Use of customized
UCLA abutment to
correct emergence
profile
Removal of implant
Palatal placement requires ridge lap
and compromised phonetics
Surgical Parameter
by REGIONS
Anterior Mandible
Surgical Parameter by REGIONS
Anterior Mandible
• D1-D2 bone density
• 1) Problem: Overheating during
osteotomy
preparations.
– Solution: Prepare osteotomy with
constant pumping motion
and use higher torque
speed. Use new drills with
copious COOLED
irrigations and incremental
drill sequence.
Surgical Parameter by REGIONS
Anterior Mandible
• 2) Problem: Pressure necrosis of devital
zone of bone around
implants. (Early signs of RL
around implants during healing
with symptoms of pain to
patient.)
• Solution: Must bone tap with hand
ratchet each osteotomy site
prior to surgical implant
placement.
Reverse torque final
implant position by 1/4 - 1/2
turn to relieve internal stresses and
pressure.
Maxillary Anterior
Factors to
Potential
Consider in Zone Complications
Dense D1 bone
density
Overheating of bone
causing bone necrosis
Over pressure of bone
causing pressure
necrosis of devitalized
bone around implant
Treatment
Options
Prepare with high
torque speeds
Use new sharp drills
Copious cooled saline
irrigation with pumping
motion
Use specialized dense
bone drills
Bone tap prior to
implant placement
¼ back turn of final
implant position to
release stress
Surgical Technique Specific For D1-D2 Bone Types
• 1) Use new and sharp drills for osteotomies.
• 2) Use chilled saline with internal and external
copious irrigation.
• 3) Use “Pumping” motion to allow osteotomies
to cool down between advancement in
depth.
• 4) Use marginal enlargement of osteotomies with
sequential drill sizes.
• 5) Must bone tap prior to implant placement.
• 6) After initial implant placement, reverse
torque implant by ¼ - ½ turn.
• 7) Can consider immediate or early loading.
Surgical Parameter by REGIONS
Anterior Mandible
• 3) Problem: Resorption pattern of anterior
mandible resulting with
lingualized implant
angulations and position.
• Solution: Fabrication of Surgical guides
from approved wax up of
final prosthesis. May need to
compromise with thicker
amount of lingual acrylic.
Surgical Parameter by REGIONS
Anterior Mandible
• 4) Problem: Resorption pattern or
anatomical pattern
resulting in steep lingual
concavity.
• Solution: Pre-surgically diagnose
situation with use of lateral
ceph radiographs or CT
scans. Surgical reflection
of lingual flap with direct
vision inspection and
instrument protection.
Resorption
pattern
Anterior Mandible
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Perforation of
Lingual concavity
Profuse
uncontrollable
bleeding
Use of CT scans or
tomography films
identify anatomical
concavity
Damage to Lingual
nerve and artery
Surgical use of
directional guide pins
to verify angulation
Reflection of flap to
palpate and measure
concavity undercut
Surgical Parameter by REGIONS
Anterior Mandible
• 5) Problem: Location of Mental foramen with
or without anterior loop.
Solution: Locate the mental nerve by
anatomical location relative to
the face. Vertical line through
pupils of the patient’s eyes
passes through infraorbital
and mental foramen. Finger
width lateral to ala of the nose
also is on this vertical
landmark.
Surgical dissection to identify
and locate the mental nerve
with safety zones marked.
Anterior Mandible
Factors to
Potential
Consider in Zone Complications
Treatment
Options
Location of mental
foramen and nerve
Identify the mental
foramen and provide
zone of surgical safety
of >3.0 mm
Paraesthesia to
innervations
supply of mental
nerve
Surgical reflection to
identify and protect
mental foramen and
contents
Surgical Parameter
by REGIONS
Posterior Maxilla
Surgical Parameter by REGIONS
Posterior Maxilla
D3-D4 bone density:
1) Problem: Violation of Maxillary Sinus
Solution: Determine need for sinus
augmentations prior to implant placement.
Need minimal of 5.0 mm of autogenous
recipient bone for simultaneous implant
placement with sinus graft.
Posterior Maxilla
Factors to
Potential
Consider in Zone Complications
Compromised
height due to
violation of
maxillary sinus
Treatment
Options
Sinus augmentations
Radiographs, CT
scans to determine
Angulated implants
treatment plan to
manage lack of
Short implants
height
No Treatment and
utilize “shorten dental
arch concept”
Surgical Parameter by REGIONS
Posterior Maxilla
• 2) Problem: Bone density with least implant
contact (50%).
Solution: Use a bone condensing (osteotomes)
rather than bone removing
(osteotomies) technique for
implant site preparations.
Posterior Maxilla
Factors to
Potential
Consider in Zone Complications
Treatment
Options
D3, D4 bone type,
least density of all
Don’t use final drill size
for desired implant
diameter to use
compressive forces of
implant insertion into
smaller Osteotomy
Biomechanical
complications due
to high bite force
Posterior zone with
high bite forces
Least amount of
bone implant
contact (BIC)
Use of tapered implant
design or aggressive
thread design (Nobel
Active Implant)
Extend healing periods
Implant Prosthetic
concepts
Implant Prosthetic Concepts
1)
2)
3)
4)
5)
6)
7)
Minimize ( < 3 units ) number of pontics.
No Cantilevers (especially distal)
No Connection to natural teeth.
Splinting of implant crowns.
Minimize facial / lingual occlusal table.
Implant protected occlusal scheme.
Progressive bone loading concept on
softer bone.
Splinting of implant crowns
Splinting of implant crowns
Don’t Do This!
4) Occlusal load axial to implant body angle
5) Low cusp angle of crowns
7) Cantilever or offset distance ( Horizontal offset)
Indications For Open Tray
Impression Technique
1) Require adequate access for prosthetic open tray
impression copings. (Anterior regions of mouth.)
2) Multiple units to register accurate relationship by
indexing of impression copings.
3) Allow impressions with Divergent angulated
dental implants.
4) Usually require custom impression trays or
altered disposable trays.
5) Must verify seating with radiograph
6) Consider indexing with resin pattern
Indications for Closed Tray
Impression Technique
1) Require minimal access for prosthetic closed tray
impression copings. (Posterior regions mouth.)
2) Single or quadrant units.
3) Allow impressions with Parallel alignment of
dental implants.
4) Usually require stock impression trays or
disposable trays.
5) Must verify seating with radiograph.
6) Plug screw hole to avoid positive impression
registration
Implant Protected Occlusion
• 1) No premature occlusal contacts or interferences.
Timing of occlusal contacts protected by natural
dentition.
• 2) Influence of surface area
• 3) Mutually protected articulation (No lateral excursion)
• 4) Occlusal load axial to implant body angle
• 5) Low cusp angle of crowns
• 6) Crown Height (vertical offset)
• 7) Cantilever or offset distance ( Horizontal offset)
• 8) Implant crown contour (narrow B /L dimensions)
• 9) Selection of occlusal materials
• 10) Verify implant supported prosthesis have lightened
occlusion where shim stock (12 um) pulls through in
C.O. or M.I.P.
Implant
Protected
Occlusion
The Maintenance Requirement
1) Post insertion 1 week later- verification of soft
tissue health and implant protected occlusion
2) Post insertion follow up every 4 months for the
first year after loading of prosthesisverification of crestal bone changes with
radiograph, soft tissue health and implant
protected occlusion
3) Post insertion follow up every 6 months for the
second year and beyond.
3) Prosthetic Parameters:
Biomechanical rationale
Implant Prosthetic concepts
Implant provisionalization options
Open versus Closed tray impression
Screw versus cement retention
Implant protected occlusion
Management protocol for parafunctional
habits
Management Options For Compromised
Interocclusal distance
Management protocols
specific for patients with
parafunctional habits
Force Factors
1)
2)
3)
4)
5)
6)
Magnitude (light, normal, heavy)
Duration (day time, night time)
Frequency (number / unit time)
Direction (vector of forces)
Type (compression, tensile, shear)
Magnifiers (height, cantilevers,
parafunctional habits)
6) Combination
Strategies To Manage Parafunction Forces
1)
2)
3)
4)
5)
6)
7)
8)
9)
Educate patient of parafunctional habits.
Placing increased number of implants.
Placing larger diameter implants.
Placing implants in positions to reduce bending
overload or positions to promote axial loading.
Avoid use of cantilevers or pontics.
Use bruxism night guard appliances.
Increasing time intervals during prosthetic restoration
stages for progressive loading protocol.
Paying diligent attention to occlusal contact design for
“Implant Protected Occlusion” and axial loading.
Alter occlusal material of prosthetic teeth to be acrylic
resin for removable prosthesis and metal occlusal for
fixed prosthesis.
Incidence Rate Of Mechanical
Complications
1)
2)
3)
4)
5)
6)
OD loss of retention or adjustments
Resin acrylic veneer facture of FPD
OD relines required
OD clip / attachment fractures
Prosthesis screw loosening
Abutment screw loosening
30%
22%
19%
17%
7%
6%
Implant Prosthetic Complications
Complication
Etiology
OD loss of
retention or
adjustments (30%)
Lack of
Simultaneous
contact
engagements of
attachments with
differential wearing
of component parts
Solution
Pick up
attachments to be
parallel
Use customized
abutments to
correct for
unparallel implant
placements
Implant Prosthetic Complications
Complication
Acrylic Fractures
Etiology
Inadequate
interocclusal distance
from implant platform
level to opposing cusp
Solution
Osteoplasty prior to
implant placement to
increase interocclusal
distance
Consider different
attachment options
that require less
interocclusal distance
(Locator attachments)
Need >2.0 mm acrylic
resin thickness over
attachments for
strength
•
•
•
•
•
•
Space Requirements for Bar-Overdenture
-Thickness of soft tissue
2.0 mm
-Hygiene space under bar
1.5 mm
-Thickness of bar
4.0 mm
-Clip and housing
1.5 mm
-Acrylic denture base
2.0 mm
-Denture tooth
3.0 mm
• Total Height Requirement
=14.0 mm
• Compromised Height is 10.5-14.0 mm (bar
touching soft tissue, reduce thickness of
bar, attachment type altered, reduce
thickness of acrylic base and denture tooth
size.
Implant Prosthetic Complications
Complication
Etiology
Porcelain Chips
and Fracture
Unsupported
substructure
Resin acrylic
veneer fracture of
FPD (22%)
Heavy occlusion
for implant
restoration
Steep cusp angles
with lateral
excursion forces
Solution
Substructure
extension to
support porcelain
of less than 2.0 mm
thickness
Confirm implant
protected
occlusion
Shallow cusp
angles with narrow
occlusal table to
avoid lateral forces
Implant Prosthetic Complications
Complication
Porcelain Chips
and Fracture
Etiology
Solution
Inadequate
interocclusal
clearance for
abutment,
substructure and
porcelain
Treatment plan
options to manage
interocclusal
distance
Screw retain option
Metal occlusal
Zirconia with
higher incidence of
porcelain shear
fractures
Osteoplasty prior
to surgery to
submerge implant
platform level
Inter-Occlusal Space Recommendations
• 1) < 3.0 mm abutment height- Use screw
retention.
• 2) 3.0-4.0 mm abutment height- Use screw
retention or vary cement type to make
non-retrievable.
• 3) > 4.0 mm abutment height- Use
retrievable cement.
Implant Prosthetic Complications
Complication
Etiology
OD relines required Increased forces
(19%)
compared to
conventional CD
Increased use and
forces applied to
residual ridge
areas with
increased
resorption
Solution
Need relines in
bilateral residual
ridge resorption
areas to provide
load bearing areas
of OD
Incidence Rate Of Mechanical
Complications
1)
2)
3)
4)
5)
6)
OD loss of retention or adjustments
Resin acrylic veneer facture of FPD
OD relines required
OD clip / attachment fractures
Prosthesis screw loosening
Abutment screw loosening
30%
22%
19%
17%
7%
6%
Implant Prosthetic Complications
Complication
Attachment
breakage or
fractures
(17%)
Etiology
Improper loading,
angulated and/or
imbalance of
engagements of
attachments
Differential wear of
attachment parts
Soft tissue support
adequate for loading
bearing areas of OD
Inadequate
interocclusal distance
Solution
Pick up attachments
after correction of
imbalance and obtain
parallel alignment of
attachments and
achieve simultaneous
contacts of
components
Treatment plan
properly
Change attachment
types that require less
interocclusal distance
Broken Attachments
Plastic bar clip
– damaged or broken
• cut along long axis with sharp knife and
remove.
– Missing
• replace by inserting a new clip into denture
base receptacle
• if unavailable, contact Command Implant
Coordinator
Broken Attachments
Metal bar clip
– damaged or broken (replacement clip available)
• remove the clip and perforate the denture base
carefully for intraoral pick up replacement.
• Block out under the bar with wax, seat the denture
and position a new clip through access in denture
base.
• Use autopolymerizing acrylic resin with “bead brush”
technique to fill in access and connect clip to denture
base. Polish , disinfect and deliver.
• Always confirm seating of denture after repair and
evaluate occlusion.
Broken Attachments
• Metal bar clip
– Damaged or broken (replacement clip not available)
• remove all remnants of the clip from the denture base.
• block out under the bar with wax
• reline the clip area of the denture with a resilient chair side reline
material (viscogel).
– Intact clip with no retention
• carefully bend the leaves of the clip toward the bar with a thin
instrument.
• Reseat the denture to confirm increased retention.
• Recheck occlusion.
Broken Attachments
• Stud attachments
– treatment is similar to clips
• tease out “O” ring with an explorer and replace as needed.
• Fractured housing can be treated like a clip replacement.
Implant Prosthetic Complications
Complication
Abutment Screw
loosening (7%)
Etiology
Inadequate Preload
forces applied to
abutment screw with
inadequate torque
force
Solution
Confirm proper use of
torque driver, new
abutment screw insert
for each case, repeat
torque tightening 2X
with torque driver to
35Ncm.
If cemented crown,
consider drilling
access screw hole and
convert to screw
retained instead of
fabrication of new
crown
Problems with Screw Loosening
1) Improper use of torque driver leading to
inadequate “preload” force application
2) Stripped screw driver or screw head
3) Use of lab screws versus definitive screws
4) Material and surface used for fabrication of
screws
5) Design of screws
6) Occlusal overload
7) Combination of any or all of the above
Implant Prosthetic Complications
Complication
Adjacent natural
tooth drifting and
opens contacts
Etiology
Solution
Viscoelastic nature of
Confirm implant
PDL with adjacent rigid protected occlusion
fixation of dental
implant
Modification of
adjacent occlusion to
natural dentitions to
prevent distal or mesial
shifting of forces when
partial edentulous
space is present
Implant Prosthetic Complications
Complication
Improper implant
placement of
implants to support
desired prosthetic
goals
Etiology
Solution
Improper treatment
planning
Customized or
angulated abutments
Surgery conducted
without prosthetic
goals
Screw retained
prosthesis with access
holes to accommodate
off angles
Improper or lack of use
of surgical guides
Removal of implants
and start again
Treatment Options when presented with
minimal Interocclusal Distance
1) Increase vertical dimension of occlusion for
restorative convenience.
2) Extract teeth involved that violated the
interocclusal distance and replace accordingly.
3) Orthodontic intrusion of opposing teeth involved.
4) Coronoplasty, crown preparations, prophylactic
endodontic therapy,
periodontal crown
lengthening options to restore teeth involved.
Treatment Options when presented with
minimal Interocclusal Distance
5) Prior to surgical placement of implants,
perform alveoloplasty of residual ridge to
increase interocclusal distance.
6) Prosthetic design: screw retain as opposed
to cement retain to implant level.
7) Restorative material: metal occlusal as
opposed to porcelain fused to metal.
Lack of Inter Occlusal Clearance:
Treatment Options
• 1) Coronal adjustment of opposing arch or
prophylactic endodontic therapy, crown
lengthening and crowns to opposing arch.
• 2) Alveloplasty prior to implant placement with
deeper surgical implant placement.
• 3) Prosthetically compensate with screw
retained and metal occlusal to decrease
required restorative clearance.
Implant Prosthetic Complications
Complication
Substructure
misfits
Etiology
Solution
Impression copings not Verify with radiograph
seated at final
of confirmed seating
impression
Inaccurate final
impression material
unable to hold
impression coping
stable
Use Medium body
around impression
coping or splinting with
pattern resin
Lab process errors
during waxing,
investing and casting
Use experienced labs
Iatrogenic / Prosthetic
Need for Provisional Restorations:
– Positional stability
– Occlusal function
– Easily cleaned and maintenance of oral
hygiene
– Nonimpinging soft tissues
– Strength and retention
– Esthetics
Iatrogenic / Prosthetic
Complication
Early soft
tissue
dehiscence
Micro
movement
pressure to
graft site
Etiology
Incorrect
design of
provisional
restoration
Solution
-Choose proper
design of provisional
restoration (fixed or
removable) with
proper relief over
surgical site
Apical pressure
- No provisional
application to
restoration
healing site
Removable Provisional
1) Acrylic RPD (flipper)
a) Need proper design for occlusal stops.
b) Adequate relief under pontic site or above grafted
site upon occlusal pressure.
c) Permanent soft tissue reline material as occlusal
force buffer.
Removable Provisional
2) Essix appliance (Acrylic removable overlay
prosthesis)
a) Need proper design for occlusal stops.
b) Adequate relief under pontic site or above
grafted site upon occlusal pressure.
c) Permanent soft tissue reline material as
occlusal force buffer.
Removable Provisional
3) Hawley orthodontic retainer appliance:
a) Need proper design of occlusal stops.
b) Adequate relief under pontic site or above grafted
site upon occlusal pressure.
c) Permanent soft tissue reline material as occlusal
force buffer.
Consequences of Peri-Implantitis
• 1) May lead to eventual implant loss.
• 2) Soft tissue exudates, abscess or infection
localized to peri-implant locations.
• 3) Guarded prognosis and continuous soft
tissue maintenance requirement for periimplant soft tissues.
• 4) Possible source of irritation and discomfort to
patient.
Possible Etiologies of PeriImplantitis
•
•
•
•
•
•
•
•
•
1)
2)
3)
4)
5)
6)
7)
8)
9)
Location of Microgap
Implant Thread Design
Surgical Trauma
Quality of bone
Occlusal Forces
Bacterial contamination
Biologic width consideration
Cement trap contamination
Combination of any / or all of above
Peri-Implantitis-Definitions
• Defined as an inflammatory process
affecting the tissues around an
osseointegrated implant in function,
resulting in loss of supporting bone.
(Albrektsson & Isidor 1994)
• Plaque-induced progressive marginal
bone loss observed on radiographs with
clinical signs of infection of the periimplant soft tissues.
(Cochrane Database of Systematic Reviews 2006)
Peri-implant Mucositis-Definitions
• Defined as reversible inflammatory
changes of the peri-implant soft tissues
without any bone loss.
(Albrektsson & Isidor 1994)
Prevalence Rates
• Peri-implant Mucositis: 8-44%
• Peri-Implantitis: 1-19%
Cement retained
1) Ideal aesthetics.
2) Questionable retrievability.
3) Retention require conventional fixed
prosthodontic principles of CHS of >7.0 mm.
4) Ideal Implant placement to support prosthesis
with use of straight or angulated abutments.
5) Ideal Occlusion or support over axially loaded
ceramics.
6) Less requirements for passivity or lab costs.
7) Removal of cement subgingival may be
compromised.
8) Depth of implant level placement should allow
ease of cement clean up.
Cement Problems
• Subgingival cement left after
cementation acting as a foreign
body reaction causing pathologic
bony and soft tissue reactions.
Dr. Mark Lin’s Cementation Technique
1) Paint and coat OUTSIDE crown margins with
Vaseline. Confirm lab provided 2 layers of die
spacers on implant abutment or scanning of
abutments.
2) Light coat of cement of choice into implant crown
restoration.
3) Pump restoration “Up and Down” motion to
release hydraulic pressure build in to allow
thinning of cement layer.
4) Removal after setting with curettes and floss.
5) Soft tissue release may be required to confirm
total removal of excess cement.
6) Verification of seating of abutment and crown to
implant platform level and cement removal.
Screw retained
• 1) Compromised aesthetics.
• 2) Reliable retrievability. (Multiple or full mouth
reconstructions.)
• 3) Retention achieved with minimal CHS of < 7.0 mm
using screw retention preload principles.
• 4) Accommodate compromised Implant placement to
support prosthesis with use of custom or angulated
abutments.
• 5) Compromised Occlusion or support over axially
loaded compromised integrity ceramics.
• 6) More requirements for passivity or lab costs.
• 7) No cement clean up considerations.
• 8) Deep implant level placements.
• 9) Transitional provisionals with multiple units.
Problems with Screw Loosening
1) Improper use of torque driver leading to
inadequate “preload” force application
2) Stripped screw driver or screw head
3) Use of lab screws versus definitive screws
4) Material and surface used for fabrication of
screws
5) Design of screws
6) Occlusal overload
7) Combination of any or all of the above
Oral Hygiene
• calculus build up can cause
areas of soft tissue
inflammation.
• may result in progressive
bone loss if left untreated.
Treatment
• remove prostheses, check
implants for mobility,
retorque abutments.
• perform maintenance
cleaning on prosthesis and
abutments.
• reinsert prosthesis with new
screws, give oral hygiene
instructions.
Maintenance and Recall
• Annually
– periapical radiographs should be taken to monitor the crestal bone
levels. (crestal bone can be at the level of the first thread in one
year with 0.1mm continued loss to approximately 1. 5 mm total
bone loss)
– remove and reinsert screw retained implant prostheses every 2
years unless indicated otherwise.
• Replace prosthesis with new retaining screws if removed.
– Cemented restorations are usually permanent (nonretrievable).
– Recall focus
• Occlusion - verify there are no excursive contacts. Should not hold
shimstock. Better to be out of occlusion
• Oral hygiene - same requirements as for natural teeth.
• Soft tissue health - periodontal probing for evidence of disease.
• Screw joint torque - check for loosened screws (most common
problem).
• Integrity of attachments - applies to overdenture / overpartials.
Maintenance and Recall
• Screw retained prosthesis
– Remove prosthetic retention screws
• Screw access holes are usually sealed with a layer of cotton pellet,
silicone plug or gutta percha the acrylic or composite resin.
• Expose the screw by drilling carefully through the resin.
• Remove the screw (slot or hex) with the appropriate screw driver.
• Throat drapes are highly recommended.
– Check for implant mobility and retorque abutments to 20 Ncm.
(hand tighten as much as possible with finger abutment driver if no
torque control device is available)
– Clean and polish abutments (Do not remove)
– Reseat restoration using new gold retaining screws.
• Tighten screws as if doing nuts on the lugs of an automobile - place all
screws back with minimal torque. Then work back and forth across
the arch until all are tightened to 10 Ncm. (hand torque with appropriate
hand screw driver if no torque controller is available)
Maintenance and Recall
• Screw retained prosthesis (cont.)
– Temporary reinsertion
• fill access holes with small cotton pellet and polyvinylsiloxane
impression material or putty.
– Long-term reinsertion
• fill access hole with small cotton pellet over the head of the
screw, followed by warm gutta percha and only 1-2 mm of
acrylic or composite resin.
• Cemented restorations
– Single unit
• usually nonretrievable and not removed for maintenance.
– Multiple unit (usually not indicated)
• carefully tap off with crown remover, check for mobile implants
and retorque abutment screws.
• Replace restoration with provisional luting media, and recheck
occlusion.
Hygiene Aids
•
•
•
•
•
•
Super - floss
End tufted brushes
Proxy brushes
Tarter control dentrifices
Mechanical instruments
Peridex
Incidence Rate Of Mechanical
Complications
1)
2)
3)
4)
5)
6)
OD loss of retention or adjustments
Resin acrylic veneer facture of FPD
OD relines required
OD clip / attachment fractures
Prosthesis screw loosening
Abutment screw loosening
30%
22%
19%
17%
7%
6%
Implant Prosthetic Complications
Complication
Etiology
OD loss of
retention or
adjustments (30%)
Lack of
Simultaneous
contact
engagements of
attachments with
differential wearing
of component parts
Solution
Pick up
attachments to be
parallel
Use customized
abutments to
correct for
unparallel implant
placements
Implant Prosthetic Complications
Complication
Etiology
Porcelain Chips
and Fracture
Unsupported
substructure
Resin acrylic
veneer fracture of
FPD (22%)
Heavy occlusion
for implant
restoration
Steep cusp angles
with lateral
excursion forces
Solution
Substructure
extension to
support porcelain
of less than 2.0 mm
thickness
Confirm implant
protected
occlusion
Shallow cusp
angles with narrow
occlusal table to
avoid lateral forces
Implant Prosthetic Complications
Complication
Porcelain Chips
and Fracture
Etiology
Inadequate
interocclusal
clearance for
abutment,
substructure and
porcelain
Solution
Treatment plan
options to manage
interocclusal
distance
Screw retain option
Metal occlusal
Osteoplasty prior
to surgery to
submerge implant
platform level
Implant Prosthetic Complications
Complication
Etiology
OD relines required Increased forces
(19%)
compared to
conventional CD
Increased use and
forces applied to
residual ridge
areas with
increased
resorption
Solution
Need relines in
bilateral residual
ridge resorption
areas to provide
load bearing areas
of OD
Implant Prosthetic Complications
Complication
Abutment Screw
loosening (7%)
Etiology
Inadequate Preload
forces applied to
abutment screw with
inadequate torque
force
Solution
Confirm proper use of
torque driver, new
abutment screw insert
for each case, repeat
torque tightening 2X
with torque driver to
35Ncm.
If cemented crown,
consider drilling
access screw hole and
convert to screw
retained instead of
fabrication of new
crown
Problems with Screw Loosening
1) Improper use of torque driver leading to
inadequate “preload” force application
2) Stripped screw driver or screw head
3) Use of lab screws versus definitive screws
4) Material and surface used for fabrication of
screws
5) Design of screws
6) Occlusal overload
7) Combination of any or all of the above
Implant Prosthetic Complications
Complication
Adjacent natural
tooth drifting and
opens contacts
Etiology
Solution
Viscoelastic nature of
Confirm implant
PDL with adjacent rigid protected occlusion
fixation of dental
implant
Modification of
adjacent occlusion to
natural dentitions to
prevent distal or mesial
shifting of forces when
partial edentulous
space is present
Implant Prosthetic Complications
Complication
Improper implant
placement of
implants to support
desired prosthetic
goals
Etiology
Solution
Improper treatment
planning
Customized or
angulated abutments
Surgery conducted
without prosthetic
goals
Screw retained
prosthesis with access
holes to accommodate
off angles
Improper or lack of use
of surgical guides
Removal of implants
and start again
Implant Prosthetic Complications
Complication
Substructure
misfits
Etiology
Solution
Impression copings not Verify with radiograph
seated at final
of confirmed seating
impression
Inaccurate final
impression material
unable to hold
impression coping
stable
Use Medium body
around impression
coping or splinting with
pattern resin
Lab process errors
during waxing,
investing and casting
Use experienced labs
Implant Prosthetic Complications
Complication
Acrylic Fractures
Etiology
Inadequate
interocclusal distance
from implant platform
level to opposing cusp
Solution
Osteoplasty prior to
implant placement to
increase interocclusal
distance
Consider different
attachment options
that require less
interocclusal distance
(Locator attachments)
Need >2.0 mm acrylic
resin thickness over
attachments for
strength
Problems in the field
•
•
•
•
•
•
Fractured/loosened screws
Fixture loss
Poor oral hygiene
Soft tissue reactions
Broken attachments
Fractured components
Problems in the field
•
•
•
•
•
•
Fractured/loosened screws
Fixture loss
Poor oral hygiene
Soft tissue reactions
Broken attachments
Fractured components
Fractured or loosened screws
• Usually results in localized inflammation, loose
restorations and discomfort.
– First suspicion when patient complains of discomfort or loose
implant.
• Prosthetic gold retaining screws have either a slot or hex
head.
• Abutment screws require a hex abutment driver, large slot,
hex or square driver.
– Standard and conical (estheticone) abutments have a raised hex
and require a wrench that fits over this hex.
– All other abutment screws have the slot, hex or square depression
inside the screw head.
• Loose single tooth abutments are true emergencies.
Continued rotation can risk rounding the corners of the
hex on the implant, causing a loss in anti-rotation.
Fixture loss
(Must differentiate between “failing” and
• Failing Implant
“failed”)
– Clinical signs:
•
•
•
•
progressive bone loss
soft tissue pocketing and crestal bone loss
bleeding on probing with possible purulence
tenderness to percussion or torque forces
– Causes:
• overheating of bone at the time of surgery or lack of initial
stability.
• Nonpassive superstructures
• inadequate screw joint closure
• functional overload
• periodontal infection (peri-implantitis)
Fixture loss
• Failing Implant
– Treatment:
• Interim: remove prosthesis and abutments
–
–
–
–
irrigate with Peridex
ultrasonic and disinfect all components
reinsert assuring proper screw torque
recheck passive fit of framework and occlusion
• Failed Implant
– Clinical signs:
• Mobility
– verify fixture mobility by removing any abutments and
superstructures first.
• A “Dull” percussion sound has been associated with a
failed implant
• Peri-implant radiolucency can be a radiographic finding
– often this is not evident on an X-ray
Fixture loss
• Failed Implant
– Causes
• surgical compromise (overheating bone and initial lack of
stability).
• Nonpassive superstructures.
• Inadequate screw joint closure
• Too rapid initial loading
• Functional overload
• Periodontal infection (“peri-implantitis”)
– Treatment
• removal of the implant
Iatrogenic / Surgical
Complication
Etiology
Solution
Block graft mobility
during implant
placement
Inadequate final
Osteotomy preparation
in width and/or length
for desired implant size
Prepare Osteotomy site
again to appropriate
length prior to implant
placement.
As a result the implant Consider use of bone
insertion protocol
tap drills prior to
separates the block
implant placement.
graft from recipient site
2-stage surgery with
increase healing time
Clinical Protocol
Related Block Grafts (Symphysis)
• Easier surgical access
• Larger donor graft size
• Potentially thicker volume of donor graft
• Mostly cortical with cancellous parts
• More demanding for wound closure
Clinical Protocol
Related Block Grafts (Symphysis)
Complication
Damage or
devitalization of
adjacent roots
Etiology
Solution
Not paying attention to
surgical safety zone
May require root canal
therapies to devitalized
roots of mandibular
anterior dentition
Superior aspect of
bone harvest must be
at least 5.0 mm away
from root apex of
mandibular incisors
Surgical zone of safety
to be 5.0 mm away
from roots, mental
foramen, protuberantia
mentalis / inferior
border of mandible
Clinical Protocol
Related Block Grafts (Symphysis)
Complication
Etiology
Solution
Disturbed changes
to neurosensory
perception or numb
teeth during
healing
Incidence rate of
29%
Harvest of graft
resulted in disturbance
of the neurovascular
innervations to
localized area
Reassure patients that
disturbance is
transitional and should
return within 3-6
months post
operatively
Altered sensation
of mucosa or facial
aspect of the lip or
chin area
Clinical Protocol
Related Block Grafts (Ramus)
• Difficult surgical access, especially inferior cut
• Smaller donor graft size
• Potentially thinner volume of donor graft
• Mostly cortical with few cancellous parts
• Easy wound closure
Clinical Protocol
Related Block Grafts (Ramus)
Complication
Damage to inferior
alveolar nerve
Height of
approximately 11
mm with width of
approximately 14
mm
Etiology
Solution
Inferior and medial cut
too deep and violation
of neurovascular
bundle of the IAN
Prevention and
knowing the
anatomical boundaries
Reassure patient that
disturbance is
transitional and should
gradually return within
3-6 months
Clinical Protocol
Related Block Grafts (Ramus)
Complication
Inadequate donor
size harvest, too
thin or too small
Etiology
Difficulty of surgical
access
Impaired visual access
to inferior cut
Poor patient selection
for Ramus harvest
Solution
Soft tissue incision and
reflection to access
desired size of graft
required
Use of additional site to
complete desired size
of graft
Iatrogenic / Surgical
Complication
Block graft mobility
during implant
placement
Etiology
Insufficient healing time
Lack of initial block
stability
Dead space too large or
granulation tissue
interposed between
donor and recipient site
Micro movement of graft
during healing from
prosthesis loading
Solution
If graft appears vital:
remove it, revive the
recipient site, reposition
graft and reaffix with
micro screws.
Wait at least 6 months of
healing with no loading.
If graft appears Non vital:
Remove it, clean
recipient site, consider
another grafting
procedure.
Bilateral Sinus Grafting
Iatrogenic / Surgical
Complication
Small Perforation
(>5 mm) of the sinus
Schneiderian
membrane
incidence rate of
10-35%
Etiology
Membrane is too thin
specific to the patient
Membrane separation
too rapid or wrong
instrumentation
Presence of mucoid
cyst
Presence of bony
septae
Solution
Continue to separate
around the small
perforation to collapse
and fold itself, then
place a resorbable
collagen membrane
patch to close the
breach integrity of
membrane.
Iatrogenic / Surgical
Complication
Large Perforation of
the sinus membrane
Etiology
Membrane is too thin
specific to the patient
Membrane separation
too rapid or wrong
instrumentation
Presence of mucoid
cyst or Presence of
bony septum
Window opening with
carbide instead of
diamond burs
Solution
-Continue to separate
around the large
perforation to collapse
itself, then place a slow
resorbable membrane
patch to close the
breach integrity of
membrane.
Attempt to suture
membrane
-Abort procedure and
reattempt entry after 612 months of healing.
During the Procedure
• Window Separation
• Haemorrhage
• Pus
• Serous Fluid
• Difficulties in Sinus Lining
Elevation
Difficulties in Window
Separation
• Cut not through Bone
• Lower Cut below Floor of Sinus
• Cut too far Anterior
• Presence of Buttress
• Laceration of Lining
Difficulties in Lining
Elevation
• Buttresses
• Undulations over Roots
• Peduncles over Roots
• Visibility and Access
• Sinus Lining Tears
Cause of Lining
Perforation
• During Periosteal Elevation
• During Window Preparation
• Inadequate Instruments
• Buttresses
Lining Perforation
Management
• Layering
• Suturing
• Abort
When Tear Occurs
continue Elevation
away from Tear
Suturing Tears
• Do NOT attempt to Suture
Thin Fragile Linings
• Larger Tears will occur
Immediately
Post-operative
•
•
•
•
•
•
Bruising
Haemorrhage
Swelling
Pain
Suture Line Opening
Infection
Delayed PostOperative
• Pain
• Infection and Swelling
• Acute Sinusitis
• Chronic Sinusitis
• Oral-Antral Fistula
During Implant
Placement
• Pus
• Sterile Serous Fluid
• Non-conversion of Graft
• Sinus Lining Perforation
Late Complications
• Infection
• Loss of Graft
• Bone Loss around Implants
• Loss of Implants
Causes of
Complications
• Pre-existing Infection
• Lining Perforation
• Surgical Field Contamination
• Graft Non-conversion
• Patient Non-compliance
Patient
Non-compliance
• Smoking
• Drugs
• Alcohol
• Poor Oral Hygiene
• Self Abuse
Surgical Field
Contamination
• Poor Surgical Technique
• Contaminated Graft Material
• Contaminated Implants
Clinical Protocol Related
Sinus Augmentations
Complication
Sinusitis
Etiology
Infection
Perforation of the
sinus membrane
Solution
Prevention of tear in
sinus membrane
Antibiotic Prophylaxis
Topical decongestants
Avoidance of any
action that creates +ve
or –ve sinus pressure.
Cessation of nose
blowing and sneezing
with open mouth
Iatrogenic / Surgical
Complication
Early soft tissue
dehiscence, flap
necrosis or premature
incision line suture
opening
Etiology
Solution
Suturing under tension -Suturing without
tension
Smoking habits
Prosthesis loading
Traumatic surgery
Infection
Insufficient
vascularization
- by oblique release
cuts or horizontal
scoring and blunt
dissection of
periosteum inferior to
mucogingival junction
prior to suturing
Iatrogenic / Surgical
Complication
Early soft tissue
dehiscence, flap
necrosis or premature
suture opening
Etiology
Sharp edges to block
bone graft or material
causing dehiscence
over thin soft tissues
Solution
-Suturing without
tension
-Contour of block
grafts to ensure
smooth, rounded sides
-Consider connective
tissue grafting prior or
in conjunction to block
graft
Iatrogenic / Surgical
Complication
Early soft tissue
dehiscence and flap
necrosis
Etiology
Suturing under tension
Smoking habits
Prosthesis loading
Traumatic surgery
Infection
Insufficient
vascularization
Suturing under tension
Sharp edges to block
bone graft or material
causing dehiscence
over thin soft tissues
Solution
-Do not try to suture
again
-Rx: antibiotics,
Chlorhexidine rinse
-Induce marginal
bleeding for healing by
granulation tissue
formation and
secondary healing
Iatrogenic / Surgical
Complication
Etiology
Early soft tissue
Suturing with tension
dehiscence, flap
necrosis with
Smoking habits
membrane exposure
Prosthesis loading
Solution
-Do not try to suture
again
-Rx: antibiotics,
Chlorhexidine rinse
-Induce marginal
bleeding for healing by
granulation tissue
formation
-If infected, remove
membrane with no
replacement and
expect partial loss of
graft
Clinical Protocol Related
Soft Tissue Grafts
Complication
Etiology
Solution
Incomplete root
coverage with Free
Gingival Grafts
Improper classification of
marginal tissue
recessions
Referral to Periodontist
Inadequate root planing
Failure to treat the planed
root with citric acid
Inadequate size of
interdental papillae
Improperly prepared
donor tissue
Take additional C.E.
courses with Drs. Pat
Allen and Michael
Pikos
Clinical Protocol Related
Soft Tissue Grafts
Complication
Incomplete root
coverage with Free
Gingival Grafts
Etiology
Inadequate graft size
Inadequate graft
thickness
Dehydration of graft
Inadequate adaptation of
graft to root and
remaining periosteal bed
Failure to stabilize the
graft
Solution
Referral to Periodontist
Clinical Protocol Related
Soft Tissue Grafts
Complication
Etiology
Solution
Incomplete root
coverage with Free
Gingival Grafts
Excess or prolonged
pressure in coaptation of
sutured graft
Referral to Periodontist
Reduction of
inflammation prior to
grafting
Trauma to graft during
initial healing
Excessive smoking
Complications In
Tissue Engineering
Host / Patient
Related
Operator / Surgeon
Related
Clinical Protocol
Related
Medical Status
Iatrogenic
Block Grafts
Psychological
Status
Surgical
Sinus
Augmentations
Smoking Effects
Prosthetic
Soft Tissue
Grafts
Advantages of Immediate Loading
• Immediate patient rehabilitation with instant
gratification by patients
• Support and contours marginal soft tissues in esthetic
zones
• Stimulation of bone regeneration with progressive
loading protocol
• Decreased clinical interventions and appointments
• Decreased treatment time / increase profit margin
Disadvantages of Immediate Loading
• Increased cost due to provisional fabrications
• Potential higher failure rate if inappropriately
applied
• Rely on patient cooperation and compliance for
success
• Need back up plan for provisional options
Indications to Immediate loading
•
•
•
•
Primary surgical implant stability of >35 Ncm
Lower anterior zones with splinting
Patient driven for esthetic zones
Aid in soft tissue contouring during healing
phase
• Compliance of soft diet by patient during
healing
Contraindications to Immediate
loading
•
•
•
•
•
Inadequate surgical initial stability of < 35 Ncm
Need for bone grafting to implant recipient site
Smokers
Periodontal disease
Poor prosthetic occlusal control of
biomechanics
• Poor patient compliance and cooperation
Indications for Flapless Surgery
1) Confirmed 3 dimensional anatomical bony
recipient site for desired implant diameter, length
and angulations.
2) Abundant keratinized attached soft tissue
adjacent the buccal aspect of implant recipient
site.
3) Adjustment to depth of drilling length with soft
tissue thickness accounted during osteotomies.
Advantages for Flapless Surgery
1) Less discomfort and morbidity for patients
2) Minimal to no swelling or bruising after
surgical procedure
3) No suturing or removal of sutures post
surgical appointment
Disadvantages for Flapless Surgery
1) Blinded procedure without flap release
2) Cannot visualize, identify and protect
important anatomical landmarks
3) Risk of bone fenestration and dehiscence
not identified
4) Risk of perforations of bone and incorrect
implant alignment
5) Experienced surgeons to attempt
Complication Management
1) Plan
2) Prepare
3) Prevent
Dr. Mark Lin’s Contact Information
• E-Mail address:
[email protected]
• Office Number:
416-221-8828
• Personal Cellular number:
416-991-8828