Complications with osseointegrated implants

Amerian D. Sones, D.M.D., MS.

Santa Monica, Calif.

Complications with a predictable implant system are possible in spite of 20 years

of longitudinal clinical study and a success rate of 90% to 96%. A potpourri of
surgical and prosthodontie complications using the Branemark implant are
presented and evaluated. Methods of avoiding prosthodontic complications due to
implant placement are discussed. Component fractures are reviewed with special
emphasis on reasons for failure. Esthetic and phonetic complications involving
restoration of the maxillary arch are discussed with possible solutions. (J PROSTHET
DENT 1989;62:581-5.)

0 sseointegration has flourished in the United
States since its introduction in North America at the Tor-
onto Conference in 1982. Studies at rapidly proliferating
centers throughout North America have confirmed the
high implant success rates originally claimed by Brane-
mark and his Swedish colleagues.1-3
Although implant success rates may be in the 90 percen-
tiles, designs for esthetic, hygienic, and functional implant
prostheses often pose challenges. With high patient expec-
tations, successful implant integration does not necessar-
ily result in a satisfied patient. This article reviews poten-
tial prosthodontic complications and discusses treatment
and planning approaches to successful reconstruction.
IMPROPER IMPLANT PLACEMENT
Longitudinal studies of alveolar bone resorption pat-
terns have documented the palatal and superior resorptive
Presented before the Pacific Coast Society of Prosthodontists
meeting, Sunriver, Ore.
10/1/13370
patterns of the maxillae and the inferior and lateral
resorptive patterns of the mandible.4p 5 Pound6 advocated
placement of the anterior teeth labial to the residual ridge
for esthetic and phonetic harmony. Fixtures placed in a
moderate to severely resorbed ridge will not be located in
a satisfactory tooth position because of the location of the
alveolar bone. As a result, the dentist is often faced with
fabricating tissue-integrated prostheses with fixtures lo-
cated lingually or buccally to the desired tooth position.
The final prosthesis may be thick buccolingually and im-
pinge on the tongue space.
Improper implant placement can result in framework
design that compromises esthetics and distribution of force
on implants. Ensuring proper implant placement requires
careful assessment of the anatomy of the residual ridge and
predetermination of final tooth position. Presurgical diag-
nosis should include a diagnostic mounting of casts and a
diagnostic wax-up with esthetic try-in. Correlation of this
information with radiographic findings facilitates surgical
stent fabrication (Fig. 1).
When fixtures deviate greatly from natural tooth posi-
tion, framework design, oral hygiene, esthetics, and me-
chanical force distribution may be compromised. In the

Fig. 1. Maxillary surgical stent. Diagnostic cast with ten-

tative placement of brass analogs to indicate implant
placement. There is minimum interocclusal space for gold Fig. 2. Labial angulation of fixtures necessitated by con-
cylinders. cavity of lateral cortical plate.

THEJOURNALOFPROSTHETIC DENTISTRY 581


Fig. 3. A, Fixtures placed in close proximity necessitated
use of contoured gold cylinders with Duralay wax index for
final impression copings. B, Final porcelain-fused-to-met-
al restoration suggests potential hygiene problem.
edentulous maxillae, extreme labial inclination of fixtures
may result from the labial concavity of the lateral cortical
plate (Fig. 2). Post accessholes exiting the labial surfaces
of the teeth provide difficult esthetic problems. Fixtures
placed too close together may preclude the active use of a
fixture in the final prosthesis design (Fig. 3). Fixtures
placed in buccal version prevent generation of occlusal
forces in the long axis of the fixture (Fig. 4).
ABUTMENT SCREW FRACTURE
Component fractures usually present as mobility of the
prosthesis, and the patient seeks prosthodontic instead of
surgical evaluation. Of particular concern is abutment
screw fracture, which can be a serious problem (Fig. 5).
If the abutment screw breaks at the O-ring, a common
occurrence, the remainder can easily be retrieved. How-
ever, if the fractured abutment screw is buried within the
internal threads of the fixture, it may be unretrievable. The
osseointegrated fixture may be destined for nonuse and
buried beneath the mucosa. A fixed tissue-integrated pros-
thesis may need to be changed to a tissue bar with an over-
denture as a final restoration.
Prevention of abutment screw fracture begins with
582
SONES
Fig. 4. A, Severe buccal angulation of left posterior
fixture necessitates final prosthesis with buccal placement
of post recess opening. B, Final porcelain-fused-to-metal
restoration with buccal placement of post access opening.
ensuring a passive framework fit and carefully equilibrated
occlusion. Other factors of importance in considering
abutment screw fracture are the amount of ridge resorp-
tion, the length and number of fixtures, the opposing den-
tition, the angulation of the fixtures, and parafunctional
habits.
In a severely resorbed mandible, fixtures supporting a
fixed tissue-integrated prosthesis may be subjected to ex-
cessive masticatory forces by the mesial and distal cantile-
ver and also from the occlusogingival lever arm that
extends from the occlusal surface of the teeth to the nar-
row neck of the abutment screw. These factors may
increase the risk of abutment screw fracture in bruxing pa-
tients and if complicated by a distal angulation of the fix-
tures, the occlusal forces may generate more strain than the
abutment screw can bear (Fig. 6).
Distal inclination of fixtures is commonly related to (1)
the natural lingual concavity of the mandible and (2) the
placement of the fixtures with the mandible opened. In the
latter, the surgeon may incorrectly judge the angulation of
the fixtures relative to the occlusal plane. The optimal an-
gulation of the fixtures at the correct vertical dimension of
occlusion must be anticipated and achieved.
Looseness of the tissue-integrated prosthesis is not un-
NOVEMBER 1989 VOLUME 62 NUMBER 6
COMPLICATIONS WITH OSSEOINTEGRATED IMPLANTS

Fig. 5. Abutment screw fracture located at abutment Fig. 7. Mandibular fixtures are stable. Broken abutment
screw neck. screw is seen in right terminal fixture. Horizontal alveolar
troughing with granulation tissue seen clinically (A) sur-
rounding all fixtures is likely related to original counter-
sinking during fixture placement. AU fixtures are inte-
grated.

Fig. 6. A, Lateral cephalometric radiograph indicates

severe distal angulation of mandibular fixtures. Fig. 7. B, Radiographic view of condition in Fig. 7, A.

Fig. 8. Framework fracture likely the result of inade-

Fig. 6. B, Distal inclination of abutments relative to oc- quate thickness of metal surrounding terminal gold cylin-
clusal plane. der.

TEE JOURNAL OF PROSTHETIC DENTISTRY 583


Fig. 9. A, Modified tapered abutments replace the usual
abutment for partially edentulous maxillae. B, Final por-
celain-fused-to-metal restoration.
common (Figs. 6 and 7). Upon removal of a loose prosthe-
sis, fixtures usually remain osseointegrated. Fixture mo-
bility, radiographic evidence of a peri-implant radiolucen-
cy, or migration of fibrous connective tissue encapsulating
the fixtures is not often found (Fig. 7).
FRAMEWORK FRACTURE
Although a passive accurate fit of the framework and a
carefully equilibrated occlusion is provided, framework
fractures occur because of (1) inadequate thickness of the
metal framework or (2) poor solder joints (Fig. 8). The
fractured framework will produce slight mobility of the
prosthesis, cause excessive lateral forces on the abutments,
and may be accompanied with a fractured abutment screw.
To minimize the huccolii width of the prosthesis and
the neutral space required for the gold cylinders, it is com-
mon to thin the framework to make it as small as possible.
Adequate metal must be provided to support each cylinder
with additional thickness of metal distal to the terminal
fixture.
Metals commonly used for a tissue-integrated prosthesis
are alloys of silver palladium, which are strong, light in
weight, and cast well to gold cylinders. The high melting
point of silver palladium alloys challenges even the expe-
584
Fig. 10. A, Maxillary prosthesis has acrylic resin flange
to assist esthetic and phonetic concerns. B, Final tissue-
integrated prostheses.
rienced technician. A one-piece casting is preferred over a
soldered casting.
ESTHETICS
Esthetic concerns are more common in the consideration
of a maxillary tissue-integrated prosthesis. Assessment of
possible esthetic challenges requires careful, accurate di-
agnosis of the patient before surgical placement of fiitures.
Esthetic challenges may be prevented by evaluating (1) lip
movement and (2) quantity of residual ridge resorption.
The amount of lip movement, the length of the upper lip
in function, and lip function in relation to the residual ridge
must be noted during diagnosis.
With excessive ridge resorption, the tissue-integrated
prosthesis replaces not only missing teeth but also the
supporting residual ridge and the encompassing mucosa.
Maxillary tissue-integrated prostheses may be designed as
(1) conventional porcelain-fused-to-metal restorations
temporarily cemented to modified abutments, (2) conven-
tional tissue-integrated prostheses with labial acrylic resin
flanges, or (3) with tissue bars and overdentures. The de-
sign of the final maxillary prosthesis should be determined
in the treatment-planning stage so that the type of abut-
ments placed at the abutment connection can be antici-
pated. Planning also allows the dentist to anticipate the
N0VEMBF.B 1988 VOLUME 62 NUMBER 5
COMPLICATIONS WITH OSSEOINTRGRATRD IMPLANTS
type of impression copings and analogs to use for the final
master cast.
Patients with a short lip, a high smile line, and minimum
residual ridge resorption will likely show the metal trans-
mucosal abutment in the classic tissue-integrated prosthe-
sis. With minimum hard and soft tissue to replace, the
maxillary teeth should be positioned as pontics in a fixed
partial denture. A tissue-integrated prosthesis using mod-
ified fixture abutments may allow for conventional porce-
lain-fused-to-metal restorations (Fig. 9).
In patients with moderate to severe residual ridge
resorption, an acrylic resin flange will be needed to replace
the lost periodontium and to provide lip support regardless
of a high or low smile line. The conventional tissue-
integrated prosthesis with a ridge-lap pontic design of the
labial acrylic resin flange will restore esthetics and allow
adequate oral hygiene techniques (Fig. 10). A tissue bar and
overdenture are alternatives to this approach that may
further facilitate hygiene.
SPEECH
Numerous authors have addressed the audible speech
changes present with initial placement of a maxillary com-
plete denture. 7-gEmphasis has been placed on correct po-
sitioning of anterior teeth, proper placement of premolars
and molar teeth, and proper lingual and palatal contour of
the denture base-lo Palatograms have been used to assess
changes in lingual denture base contours. These studies
have enabled practitioners to minimize speech problems
associated with transition from natural dentition to a
removable prosthesis.
Treating a patient for implant reconstruction involves
converting a maxillary complete denture patient to a
patient with a fixed tissue-integrated prosthesis. The
elimination of the palatal denture base and the addition of
new contours representing the thickness of a gold cylinder
and surrounding the metal framework often present new
speech complications. Excessive air flow beneath the metal
framework, excessive saliva, and alteration of tongue func-
tion are reasons for these speech changes.
Minimizing speech problems involves planning the spac-
ing of fixtures more than 7 mm apart to allow for ridge
contact of the metal framework between fixtures and ridge
lap of the acrylic resin flange. With minimum ridge resorp-
tion, modified abutments with a cemented porcelain-
fused-to-metal restoration will generally satisfy esthetic
and speech expectations. Speech problems are usually re-
lated to the amount of ridge resorption; the greater the
ridge resorption, the greater the probability of speech dif-
ficulty. Some speech adaptation can be expected during
early use.
THE JOURNAL OF PROSTEETIC DENTISTRY
GINGIVAL COMPLICATIONS
Soft tissue complications most often involve hyperplas-
tic tissue or a mucosal abcess. These complications are of-
ten found in conjunction with a loose prosthesis. Solutions
to these problems include (1) soft tissue resection, (2) con-
firmation of framework fit, and (3) provision of a prosthe-
sis with hygienic contours. In addition, Peridex (chlorhex-
idine gluconate 0.12%) Proctor & Gamble, Cincinnati,
Ohio) mouthrinse and oral hygiene reinforcement are rec-
ommended. Three- to J-month recall is suggested. If debris
must be removed from the prosthesis or abutments, plas-
tic scalers are advised to limit scratching of the compo-
nents, which encourages greater debris accumulation.
CONCLUSION
The possibilities of osseointegrated implant reconstruc-
tion warrant enthusiasm. Fixtures are being successfully
integrated within the residual bone. Successful reconstruc-
tion, however, means more than successful integration.
Functional and esthetic prostheses involve careful diagno-
sis and fixture placement. Predetermination of the frame-
work design, the components to be used, and esthetic and
speech requirements will ensure a more predictable prosth-
odontic reconstruction.
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