15. implant failures and maintenance.pptx

PG III YR SSK

1. Implant failures

2. Contents Introduction Definitions Criteria for implant success Estheic success Warning signs of implant failure Failing and failed implants Classification of implant failures Factors contributing to implant failures Implant maintenance Conclusion References

3. In current trends replacement of missing teeth with implants is an effective and predictable treatment modality . Nevertheless , failures still happen despite high implant survival and success rates. The process of osseointegration – key to the success of dental implants INTRODUCTION

4. Definition Implant failure : implant failure is defined as the total failure of the implant to fulfil its purpose because of mechanical or biologic reasons. - Aksary , Meffert

5. Osseointegration : O sseointegration is the direct attachment of osseous tissue to an implant without any intervening connective tissue. It's a structural and functional connection between living bone and the surface of an implant. GPT 9

6. Ailing implants: An implant that may demonstrate bone loss with deeper clinical probing depths but appears to be stable when evaluated at 3-4 months interval. Ailing implants are those showing radiographic bone loss without inflammatory signs or mobility.

7. Failing implants: An implant that may demonstrate bone loss, increasing clinical probing depths, bleeding on probing, and suppuration. Bone loss may be progressive. Failing implants are characterized by progressive bone loss, signs of inflammation and no mobility.

8. Failed implants : An implant that demonstrates clinical mobility, a peri-implant radiolucency, and a dull sound when percussed. A failed implant is non-functional and must be removed. Failed implants are those with progressive bone loss, with clinical mobility and that which are not functioning in the intended sense

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10. Criteria for implant success Individual, unattached implant is immobile when tested clinically No evidence of peri-implant radiolucency Vertical bone loss of less than 0.2 mm annually following the implants first year of service Absence of persistent &/ irreversible signs & symptoms such as pain, infections, neuropathies, paresthesia, violation of mandibular canal Success rate of 85% at the end of 5 year & 80% at 10 year period 10 Albrektsson , Zarb , Worthington, Eriksson. The long – term efficacy of currently used dental implants : a review & proposed criteria of success. The international Journal of Oral & Maxillofacial Implants. 1986;1 (1): 11-25

11. Absence of persistent signs/symptoms such as pain, infection, paraesthesia and violation of vital structures Implant immobility No continuous peri implant radiolucency Negligible progressive bone loss (<0.2 mm annually) during 1 st year of function Patient dentist satisfaction with the implant supported restoration American academy of Periodontology, 2003 .

12. Esthetic Success

13. White Esthetic Score

14. Implant quality assessment scale

15. Warning signs of implant failure :

16. Failing implant Failure process is in early stages and is reversible Clinical features- Progressive Marginal Bone loss (Saucerization) Absence of mobility Peri implant infection (peri implantitis ) Failed implant Failure process has reached the irreversible state Marginal bone loss reaching the apical 1/3 of implant mobility Thin peri fixtural radiolucency Failing & failed implants

17. Parameters used for evaluating failed implants Clinical signs of early infection Swelling, Fistulas, Suppuration, Mucosal dehiscences , Osteomyelitis 509 implants – 36 soft tissue perforations recorded ; 4 (11%) – did not integrate - other signs of infection around 20 implants ; 6 (30%) were early failures 17 Quirynen M. Periodontal aspects of osseointegrated fixtures supporting a partial bridge. an up to 6-year retrospective study. J Clin Periodontol 1992; 19: 118–126.

18. 18 Mobility – cardinal sign Esposito et al. Biological factors contributing to failures of osseointegrated oral implants (I). Success criteria & epidemiology. European Journal of Oral Sciences; 106: 527-551 Pain or sensitivity Radiographic signs of failure

19. Parameters to evaluate failing implants Progressive bone loss Clinical signs of late infection Bleeding on probing Absence of keratinized mucosa 19

20. CLASSIFICATIONS Rosenberg et al., classification of implant failures :

21. Infectious failures : Clinical signs of infection with classic symptoms of inflammation. High plaque and gingival indices. Pocketing. Bleeding. Suppuration. Attachment loss. Radiographic peri-implant radiolucency. Presence of glaucomatous tissue upon removal.

22. Traumatic failures : Radiographic peri-implant radiolucency. Mobility. Lack of glaucomatous tissue upon removal. Lack of increased probing depths. Low plaque and gingival indices.

23. According to osseointegration concept 24 Biological failures Mechanical failures Iatrogenic failures Inadequate patient adaptation Esposito et al. Biological factors contributing to failures of osseointegrated oral implants (I). Success criteria & epidemiology. European Journal of Oral Sciences; 106: 527-551

24. Biological failures Early / primary Surgical trauma Bacterial contamination Delayed wound healing Early loading of dental implants 25 Late / secondary Traumatic Infective factors Al- Sabbagh & Bhavsar . Key local & surgical factors related to implant failure. Dent Clin N Am 2015; 59: 1-23

25. El Askary classification

26. According to etiology Host factor 27 Surgical factor Restorative factor Implant selection factor

27. Restorative factor Excessive cantilever Pier abutments No passive fit Improper fit of the abutment Improper prosthetic design 28 Improper occlusal scheme Bending moments Connecting implants to natural teeth Premature loading Excessive torquing

28. According to timing of failure 29 Before stage II After restoration At stage II

29. According to origin of infection Periimplantitis (Infective process,bacterial origin) 30 Retrograde Periimplantitis (traumatic occlusion, non infective, forces off the long axis)

30. According to failure mode 31 Functional problems Psychological problems

31. According to soft tissue type 32 Soft tissue problems Bone loss Both Soft tissue & bone loss

32. Systemic factors contributing to implant failure Systematic disease Therapeutic radiation Osteoporosis , paget disease, hormone disorders and renal tumors Bisphosphonates Gender and age Smoking

33. Perioperative errors contributing to implant failure Error due to anatomic variations and abnormalites Errors due to implant contamination Errors in surgical technique Errors in implant position Errors in implant exposure

34. Errors due to anatomic variation and abnormalities

35. Errors due to implant contamination Contamination of the implant surfaces interferes with osseointegration

36. Errors in surgical technique Successful implant placement depends highly on proper surgical technique Maintaining an adequate blood supply reducing hard and soft tissue surgical trauma Incision design osteotomy

37. Error in implant positioning Implant malposition

38. Error in implant exposure

39. Peri Implantitis Definition- American Academy of Periodontology defines Peri implantitis as “progressive Peri implant bone loss in conjunction with a soft tissue inflammatory lesion.”

40. Pathogenesis

41. BACTERIAL INFECTIONS Most authors have assumed that peri-implant diseases (mucositis, peri-implantitis) are comparable to periodontal diseases in that they are primarily plaque-induced. If plaque accumulates on the implant surface, the sub epithelial connective tissue becomes infiltrated by large number inflammatory cells and the epithelium appears ulcerated and loosely adherent.

42. CLASSIFICATION Peri-implantitis - Class 1 Peri-implantitis - Class 2 Peri-implantitis - Class 3 Peri-implantitis - Class 4

43. Class 1 Slight horizontal bone loss with minimal peri-implant defects

44. Class 2 Moderate horizontal bone loss with isolated vertical defects .

45. Class 3 Moderate to advanced horizontal bone loss with broad, circular bony defects .

46. Class 4 Advanced horizontal bone loss with broad, circumferential vertical defects, as well as loss of the oral and/or vestibular bony wall.

47. Lindhe and Meyle from the Consensus Report of the 6 th Europea Workshop on Periodontology concluded that risk indicators for periimplantitis included (1) poor oral hygiene, (2) a history of periodontitis, (3) diabetes, (4) cigarette smoking, (5) alcohol consumption, and (6) implant surface

48. Factors related to implants Implant length & diameter 49 Naert & colleagues – shorter implants , large number of implants per patient, low number of implants per prosthesis- high risk for failure Decrease in 1mm length – increase hazard rate 0.16 Smaller diameter of implants – failure rate is high Implant surface characteristics Cochran – increasing surface roughness – increases risk of failure

49. Host factors Patient dissatisfaction with the result. Inadequate patient follow-up Failure to maintain hygiene Para functional habits Systemic health( medical complications) Medications- alter tissue metabolism and repair Social habits like smoking, stress, alcohol abuse affect wound healing Poor bone quality and quantity

50. Complications/Factors leading to implant failures Surgical factors (early failures) Stage I surgery 1) Overheating of bone - necrosis,osteomyelitis 2) Lack of primary stability - bone loss 3) Infection 4) Lack of osseointegration 5) Poor placement or angulation, slips, eccentric drills 6) Damage to vital structures 7) Implant fracture 8) Inadequate no. of implants

51. Stage II surgery 1) Loose abutment 2) Poor fixtures 3) Early loading by prosthesis 4) Poor abutments

52. Prosthetic factors (late failures) 1.Improper design, shape, contours 2.Poor fit of prostheses 3.Occlusal forces 4.Inaccurate framework 5.Cantilever extension 6.Framework fracture, prosthesis fracture 7.Functional problems eg . speech

53. Mechanical or prosthetic complications Screw Loosening and Fracture: frequent in screw-retained FPDs screw loosening in 6% to 49% of cases at the first annual check-up.- Jemt et al. 1994. in the patient with a prosthesis retained by multiple implants, the ability to detect a loose screw is greatly diminished

54. Implant fracture fatigue of implant materials and weakness in prosthetic design or dimension are the usual causes of implant fractures • Balshi listed three categories of causes (1) design and material, (2) nonpassive fit of the prosthetic framework, and (3) physiologic or biomechanical overload.

55. Biologic complications Inflammation and proliferation of peri-implant soft tissue Dehiscence and recession Peri-implantitis and progressive bone loss Implant loss or failure

56. Inflammation and proliferation: common with loose implant abutment or abutment crown connection and excessive cement retained after restoration. Correction of precipitating factors effectively resolves the problem

57. Dehiscence and recession: Common when the supporting hard and soft tissues are thin, lacking or lost.

58. Implant loss or failure: Two types: 1. Early implant failure Occurs before osseointegration. Osseointegration is jeopardized by infection, movement or impaired wound healing 2. Late implant failure Occurs after prosthesis installation probably due to peri-implantitis, progressive bone loss or overload

59. Factors associated with increased failure rate

60. Considerations for Implant Maintenance Maintenance of Peri -Implant Tissues: Similar to the natural dentition Oral self care of utmost importance

61. Objectives of Implant Maintenance Control inflammation (reduce bacterial load) Maintain bone (radiographic monitoring) Maintain function (e.g. check for mobility) Monitor for early signs of problems

62. Determining the frequency of maintenance using Bleeding on Probing Bleeding on probing frequency >16% Sites Increase frequency of maintenance by one month ( i.e , every 4 months increased to every 3 months) <10% Sites Decrease frequency of maintenance by one month ( i.e , every 2 months decreased to every 3 months)

63. Peri -Implant Probing

64. Peri -Implant Radiography a. assesses interproximal bone b. exposes component mis -fit c. may detect residual cement

65. Implant Maintenance Protocol

66. Hygiene aids

67. Implant Home Care Toothbrush Modified Bass technique

68. Rotadent ®

69. Oral B Sonicare

70. Proxabrush ® Interdental System

71. Flossing

72. Interdental aids

73. Oral irrigation Lowest setting pressure Directed away from to tissue Damage can cause bacteraemia

74. Chemotheraupeutic agents

75. Straumann ® TiBrush Titanium bristles for less damage to metal implant surface structure More effective and efficient at debriding implant surface Significant reduction in treatment time Excellent access to implant threads with fine titanium bristles

76. Straumann ® TiBrush Initial situation Straumann brush

77. The Implant Maintenance Appointment 1) Review of the patient’s medical history and general health 2) Assessment of the implant(s) 3) Proper instrumentation and polishing of the implant(s) 4) Reinforcement of home-care routine and specific recommendations.

78. Instrument selection Scratchless to the surface of an implant Based on location and tenacity of deposits. Rigid to withstand pressure from stroke Adaptable to sulcus

79. Contraindicated: • Metallic instruments • Ultrasonics and Air Polishing Indicated: • Material softer than implant • plastic, graphite, titanium

80. Implacare instruments Implant Prophy system

81. Graphite reinforced nylon Universal, Gracey1/2, Gracey11/12, Gracey 13/14, Sickle H5/33 Sharpened 5 times and wear resistant 10 times SteriOss Scaler system

82. Calculus engaged from apical side and opened in coronal direction. Depending on location, horizontal, vertical and oblique stroke. Exploratory type to avoid tissue damage.

83. Polishing Rubbercups with tooth paste or prophy paste or commercially available polishing paste with tin oxide. Subgingival irrigation Non-metallic rounded tip with side portals

84. Buchter et al. Irrigation with 0.2% chlorhexidine + debridement using plastic curettes + (a) Bioresorbable polymer releasing 8.5% doxycycline ( Atridox ) (b) No adjunctive treatment Patients in group (a) showed a significantly greater gain of CAL than those in group (b) Reduction of BOP and PD was statistically significant only in group (a) Br J Oral Maxillofac Surg 2004; 42: 439–44.

85. Renvert et al. Debridement + subgingival application: (a) Minocycline microspheres ( Arestin ) (b) 1 mL of 1% chlorhexidine gel Repeated antimicrobial therapy after1 month and 3 months Reduction of BOP (12 months) and PD (6 months) in group (a) was statistically higher than that in group b. J Periodontol 2008; 79: 836–44.

86. Surgical Open debridement Apically positioned flaps Regenerative osseous procedures Mucogingival procedures

87. Laser-assisted treatment of peri-implantitis Laser systems with bactericidal effects, tissue ablation and detoxification were proposed for periimplantitis therapy. Erbium-doped yttrium, aluminium and garnet ( Er:YAG ). Donot cause alterations. promoted re- osteointegration . -good stabilization of blood clots and -good contact of substitutive materials with the implant surface

88. Schwarz et al. Er:YAG laser showed the improvement of BOP was greater than that using a mechanical treatment (plastic curettes) combined with an antiseptic agent (0.2% chlorhexidine digluconate ). Reduction of the peri -implant pocket and attachment gain after 6 months Clin Oral Investig 2006; 10: 279–88.

89. Removable Implant Prosthesis Typically easier to clean than fixed prostheses Unsplinted implants easily brushed and flossed Bar connections require interproximal access

90. Fixed Implant Prosthesis Typically ridge lap at abutments Adjacent abutments may have tight embrasures Pontics on splints may have wide embrasures

91. Introduction:  The purpose of this monocentric retrospective observational investigation is to evaluate the implant failure rate observed in an oral surgery department and analyze the risk factors associated with them. Preventative measures will be suggested to reduce the incidence of implant failure.  Material and method:  All implants removed between 2014 and 2020 were analyzed. The main criterion assessed was the overall failure rate over 6 years of activity;the secondary criteria were the risk factors associated with implant failure.

92. Results:  12 out of 376 implants placed between 2014 and 2019 in 11 patients (mean age: 55.5 ±11.5 years);sex ratio M/F=5/6) were removed, for an overall failure rate of 3.11%. The majority, 83% (10/12) of the lost implants, were in the maxilla, while only 17% (2/12) were placed in the mandible. The main risk factors identified were: a III−IV bone type density (75%, 9/12), pre-implant sinus lift surgery (42%, 5/12) smoking (8.3%, 1/12), surgical site infection (8.3%, 1/12) and rheumatoid arthritis (8.3%, 1/12).  Conclusion :  The failure rate observed in this oral surgery unit is consistent with the other international studies, confirming the compliance with good clinical practices of the healthcare team. Pre-implant bone surgery is the major risk factor to consider before implant surgery.

93. Management of Local Causes of Implant Failure . If there is obvious mobility following implant failure, the implant needs to be removed right away . To prevent further alveolar bone loss that would make the alternative of replacing the failed implant with a new one more challenging, it is crucial to recognize a failing implant as soon as possible. The patient should be motivated to perform an adequate level of plaque control on a regular basis. If an implant does fail or is unable to form bone around it, the most important thing is its rapid removal to avoid more bone loss because if the implant is left, more and more bone will be lost in order to place another implant . The possible treatment options for implant failure include the replacement of a faulty implant right away with one with a larger diameter, simultaneous replacement of failed implant with a guided bone regeneration (GBR) procedure, and a staged approach where the lost tissue is first rebuilt and the implant is then placed following site healing (delayed approach )

94. Management of Implant Fractures There are some points that are important to remember while dealing with cases of fractured implants. The length and diameter of the intended implants need to be taken into account when arranging therapy for a patient with incomplete dentition. To construct the prosthesis appropriately and prevent fracture, risk reduction may necessitate more implants.

95. Esthetic Complications and Management Due to Implant Malpositions There are some points that are important to remember while treating esthetic complications due to implant malpositions . Ensure that the patient is aware of the dangers and esthetic implications of the procedure. Ideal esthetic results are frequently impossible to achieve because of pre existing hard and soft tissue defects . The site’s hard and soft tissues should be carefully measured with respect to the intended implant position. The facial bone’s thickness should remain at 2 mm. Ensure that the implant is positioned in the proper 3D location as defined by the restoration. The implant should be positioned in the apico -coronal plane (between 2 and 3 mm apical to the predicted mucosal boundary of the implant restoration), mesiodistal plane (at least 1.5 mm away from the roots of adjacent teeth), and orofacial plane (at the level of the gingival edge and 1.5 mm orally to the facial curve of the arch).

96. Complications and Management in Guided Bone Regeneration Give the soft tissue enough time to heal before doing a GBR operation. Prior to surgery, all sources of infection (e.g., periodontally , endodontically , or hopelessly involved teeth) must be eliminated.

97. Implant Removal Methods of implant removal: A moveable implant can be easily removed using forceps, the counter-torque ratchet technique (CTRT), or by rotating the implant counterclockwise. The counter-torque ratchet technique (CTRT) and the reverse screw technique (RST) may be helpful where damage to the surrounding tissues is to be avoided. Both of these procedures engage the implant and reverse screw it out of the bone with a counterclockwise force. Little luxation can rotate the surrounding bone and soft tissue with minimal damage and trauma. The use of elevators, forceps, counter-torque ratchets, screw removal tools, piezo tips, high-speed burs, and trephine burs are a few techniques for removing immobile implants. The least intrusive method for removing an implant without harming neighboring structures is the CTRT. The application of CTRT should only be taken into consideration if the implant can be engaged and reverse torqued until mobile.

98. Management of Systemic Causes of Implant Failure Diabetes: A complete understanding of the patient’s medical history, present course of treatment, and degree of glycemic control throughout time, as well as limiting surgical therapy in poorly managed diabetic patients, are two fundamental aspects of surgical management for any patient with diabetes. In the last 10 15 years, there has been a significant change in how diabetes mellitus is treated medically. Patients with less-than-optimal glucose control may have a higher risk of developing postoperative complications such as infection or slow wound healing.

99. Myocardial infarction: Nitrate premedication, oxygen administration, achievement of profound local anesthesia, stress reduction measures, preoperative pain medication, and patient monitoring of blood pressure and heart rate are preventive measures. Additionally , preserving the patient’s comfort and relaxation may be helped by the use of conscious sedation. Additionally, the dental care provider must be aware of any anticoagulant or thrombolytic treatments being used and comprehend that getting oral implants does not always warrant stopping these treatments [

100. Osteoporosis: Prior to implant surgery, a current medical history should be collected. Patients at risk for metabolic bone disease need to be carefully checked and have their nutrition looked at, and any systemic problems need to be taken care of first. Physiologic calcium (1,500 mg/day) and vitamin D (400-800IU/day) dosages are advised throughout the postoperative period. Since smoking is a significant risk factor for osteoporosis and implant failure, patients should try to quit smoking and follow a balanced preoperative and postoperative diet.

101. Corticosteroids: Despite the lack of evidence to the contrary, patients who get corticosteroid therapy may not be a suitable risk category for implants. First and first, seek medical counsel. Although the validity of the evidence supporting the use of steroids may be questioned, medicolegal and other factors point to the need to err on the side of caution and administer steroids until one is certain that collapse is highly unlikely

102. Bisphosphonates: Before starting intravenous bisphosphonate medication, a patient should undergo a complete oral examination and achieve dental stability. Any infection that is still alive must be removed. Prior to administering intravenous bisphosphonates, healing must be complete if any issue necessitates oral surgery, including the placement of dental implants. Patients who are receiving intravenous bisphosphonates for asymptomatic conditions should practice adequate oral hygiene and dental care to avoid dental conditions that might necessitate dentoalveolar surgery.

103. Conclusion Although the over all success rate of implant dentistry is very high, dental implant occasionally fail The best steps to avoid encountering failing implant involve proper case selection, excellent surgical technique, placing an adequate restoration on the implant, educating the implant patient to maintain meticulous oral hygiene, and evaluating the implant both clinically and radio graphically at frequent recall visit

104. References Carl E. Misch . Contemporary implant dentistry. 3rd edition Albrektsson , Zarb , Worthington, Eriksson. The long – term efficacy of currently used dental implants : a review & proposed criteria of success. The international Journal of Oral & Maxillofacial Implants. 1986;1 (1): 11-25 Smith & Zarb .. Criteria for success of osseointegrated endosseous implants. J Prosthet Dent 1989; 62(5): 567-72 El Aksary . Why do dental implants fail ? Part I. Implant Dentistry. 1999; 8 (2) : 173 - 185 Why do implants fail ? Part II. Implant dentistry. 1999; 8 (3) :265 - 277

105. Esposito et al. Biological factors contributing to failures of osseointegrated oral implants (I). Success criteria & epidemiology. European Journal of Oral Sciences; 106: 527-551 Tonetti . Pathogenesis of implant failures. Periodontology 2000. 1994; 4 : 127-138 Rosenberg ES, Torosian JP, Slots J. Microbial differences in two clinically distinct. types of failures of osseointegrated implants. Clin Oral Imp Res 1991;2:135-44