ITI Treatment Guide, Vol 8 - Biological and Hardware Complications in Implant Dentistry - U. Brägger (2015)

ITI Treatment Guide
Volume 8
2
ITI
Treatment
Guide
Volume 8
Biological and Hardware Complications in Implant

Dentistry
Editors:
D. Wismeijer, D. Buser, S. Chen
Authors:
U. Brägger, L. J. A. Heitz-Mayfield
3
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4
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electronic, mechanical, photocopying, or otherwise,
without prior written permission of the publisher.
Illustrations: Ute Drewes, CH-Basel,

www.drewes.ch
Copyediting: Triacom Dental, D-Barendorf,
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Graphic concept: Wirz Corporate AG, CH-Zürich
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5
ISBN:
978-3-86867-282-4 (ebook)
978-3-86867-240-4 (print)
The materials offered in the ITI Treatment Guide are for educational
purposes only and intended as a step-by-step guide to treatment of
a particular case and patient situation. These recommendations are
based on conclusions of the ITI Consensus Conferences and, as
such, in line with the ITI treatment philosophy. These
recommendations, nevertheless, represent the opinions of the
authors. Neither the ITI nor the authors, editors and publishers
make any representation or warranty for the completeness or
accuracy of the published materials and as a consequence do not
accept any liability for damages (including, without limitation, direct,
indirect, special, consequential or incidental damages or loss of
profits) caused by the use of the information contained in the ITI
Treatment Guide. The information contained in the ITI Treatment
Guide cannot replace an individual assessment by a clinician, and
its use for the treatment of patients is therefore in the sole
responsibility of the clinician.
The inclusion of or reference to a particular product, method,

technique or material relating to such products, methods, or
techniques in the ITI Treatment Guide does not represent a
recommendation or an endorsement of the values, features, or
claims made by its respective manufacturers.
All rights reserved. In particular, the materials published in the ITI

Treatment Guide are protected by copyright. Any reproduction,
either in whole or in part, without the publisher’s prior written
consent is prohibited. The information contained in the published
6
materials can itself be protected by other intellectual property rights.
Such information may not be used without the prior written consent
of the respective intellectual property right owner.
Some of the manufacturer and product names referred to in this

publication may be registered trademarks or proprietary names,
even though specific reference to this fact is not made. Therefore,
the appearance of a name without designation as proprietary is not
to be construed as a representation by the publisher that it is in the
public domain.
The tooth identification system used in this ITI Treatment Guide is

that of the FDI World Dental Federation.
7
The ITI Mission is …
“… to promote and disseminate knowledge on all

aspects of implant dentistry and related tissue
regeneration through education and research to the
benefit of the patient.”
8
Preface
While implant dentistry today is well documented

and demonstrates predictable outcomes, a
significant proportion of patients still experience
complications. It is therefore a must for all
practitioners to know the causes of implant-related
complications and how to avoid and manage them.
Volume 8 of the ITI Treatment Guide series

provides clinicians with the latest evidence-based
information on the origins and treatment of
biological as well as technical and mechanical
complications. An up-to-date analysis of the
current evidence is based in part on the
proceedings of the 4th ITI Consensus Conference
held in Stuttgart in 2008 and the 5th ITI Consensus
Conference held in Bern in 2013, as well as on a
review of the current literature. The diagnosis and
treatment of biological and technical complications
are examined closely in 16 clinical cases presented
by clinicians from all over the world.
The mission of the ITI “… to promote and

disseminate knowledge on all aspects of implant
dentistry to the benefit of the patient” as always
provides the background against which this
volume of the ITI Treatment Guide series has been
written.
9
10
Acknowledgment
We would like to thank Dr. Kati Benthaus of the ITI

Headquarters for her invaluable assistance in the
preparation of this volume of the Treatment Guide
series. We would also like to express our gratitude to
Ms. Juliane Richter (Quintessence Publishing) for
typesetting and for coordinating the production
workflow, Mr. Per N. Döhler (Triacom Dental) for his
editing support, and Ms. Ute Drewes for her excellent
illustrations. We also acknowledge continuing support
from Institut Straumann AG, ITI’s corporate partner.
11
Editors and Authors
Editors:
Daniel Wismeijer
DDS, PhD, Professor
Head, Section of Implantology and Prosthetic Dentistry
Department of Oral Function and Restorative Dentistry
Academic Centre for Dentistry Amsterdam (ACTA)
Gustav Mahlerlaan 3004
1066 EA Amsterdam, Netherlands
E-mail: d.wismeijer@acta.nl
Daniel Buser
DDS, Dr med dent
Professor and Chair
Department of Oral Surgery and Stomatology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
12
E-mail: daniel.buser@zmk.unibe.ch
Stephen Chen
MDSc, PhD
Clinical Associate Professor
School of Dental Science
University of Melbourne
720 Swanston Street
Melbourne VIC 3010, Australia
E-mail: schen@balwynperio.com.au
Authors:
Urs Brägger
Dr med dent
Professor and Chair
Department of Reconstructive Dentistry and

Gerodontology
Freiburgstrasse 7
13
E-mail: urs.braegger@zmk.unibe.ch
Lisa J. A. Heitz-Mayfield
BDS, MDSc, PhD
Professor
International Research Collaborative
University of Western Australia
Nedlands, WA 6009, Australia
E-mail: heitz.mayfield@iinet.net.au
14
Contributors
Bilal Al-Nawas
Dr med, Dr med dent, Professor
Johannes Gutenberg-University
Medical Center
Department of Oral and Maxillofacial Surgery
Augustusplatz 2
55131 Mainz, Germany
E-mail: al-nawas@mkg.klinik.uni-mainz.de
Urs C Belser
DMD, Dr med dent, Professor

Gerodontology
Freiburgstrasse 7
15
E-mail: urs.belser@unige.ch
Michael M. Bornstein
Dr med dent, Associate Professor
Head, Section of Oral Radiology and Stomatology
Freiburgstrasse 7
E-mail: michael.bornstein@zmk.unibe.ch
Urs Braegger
Dr med dent
Professor and Chair

Gerodontology
Freiburgstrasse 7
E-mail: urs.braegger@zmk.unibe.ch
16
Daniel Buser
DDS, Dr med dent
Professor and Chair
Freiburgstrasse 7
E-mail: daniel.buser@zmk.unibe.ch
Agnieszka Frydrych
BDSc(Hons), MDSc, FRACDS(Oral Med), FOMAA
Associate Professor (Oral Medicine)
17 Monash Avenue
E-mail: agnieszka.frydrych@uwa.edu.au
Alexandros Grous
Dr med, Dr med dent
17
Grous Dental Clinic
2 Vasileos Alexandrou Street
11634 Athens, Greece
E-mail: alex@grousdental.com
Lisa J. A. Heitz-Mayfield
BDS, MDSc, PhD
Professor
International Research Collaborative
E-mail: heitz.mayfield@iinet.net.au
Stefan Hicklin
Dr med dent, Senior Lecturer

Gerodontology
Freiburgstrasse 7
18
E-mail: stefan.hicklin@zmk.unibe.ch
Tim Joda
Dr med dent, MSc, Senior Lecturer

Gerodontology
Freiburgstrasse 7
E-mail: tim.joda@zmk.unibe.ch
Janice Kan
BDSc(Hons), DCD Pros
Perth Prosthodontics
Suite 3, Southbank Central
38 Meadowvale Ave
South Perth WA 6151, Australia
E-mail: dr.jkan@perthpros.com.au
Daan Kruger
DDS, MSc Oral Implantology
19
Section of Implantology and Prosthetic Dentistry
E-mail: d.y.kruger@acta.nl
Peer W. Kämmerer
Dr med, Dr med dent
University of Rostock
Schillingallee 35
18057 Rostock, Germany
E-mail: peer.kaemmerer@uni-rostock.de
Tomas Linkevičius
DDS, Dip Pros, PhD, Associate Professor
Institute of Odontology,
Faculty of Medicine, Vilnius University
20
Žalgirio 115/117
LT-08217 Vilnius, Lithuania
E-mail: linktomo@gmail.com
Maximilian Moergel
Dr med, Dr med dent
Johannes Gutenberg-University
Medical Center
Augustusplatz 2
55131 Mainz, Germany
E-mail: maximilian.moergel@unimedizin-mainz.de
Andrea Mombelli
Dr med dent, Professor
Université de Genève
Section de Médecine Dentaire
Division de Physiopathologie Buccale et Parodontie
Rue Barthélemy-Menn 19
21
1205 Genève, Switzerland
E-mail: andrea.mombelli@unige.ch
Joris Muris
DDS
Department of Material Science
University of Amsterdam and VU University

Amsterdam
E-mail: j.muris@acta.nl
Giovanni E. Salvi
Dr med dent, Professor
Department of Periodontology
Freiburgstrasse 7
E-mail: giovanni.salvi@zmk.unibe.ch
22
Bruno Schmid
Dr med dent
Private Office
Bayweg 3
3123 Belp, Switzerland
E-mail: info@brunoschmid.ch
Sandro Tettamanti
Dr med dent

Gerodontology
Freiburgstrasse 7
E-mail: tettamanti@hispeed.ch
Hans-Peter Weber
DMD, Dr med dent
Professor and Chair
Department of Prosthodontics and Operative Dentistry
23
Tufts University, School of Dental Medicine
One Kneeland Street, Rm. 220
Boston, MA 02111
United States of America
E-mail: hp.weber@tufts.edu
Philipp Wick
Dr med dent
Weststrasse 4
E-mail: philipp.wick@gmx.ch
Daniel Wismeijer
DDS, PhD, Professor
Head, Section of Implantology and Prosthetic Dentistry
24
E-mail: d.wismeijer@acta.nl
25
Table of Contents
1 Introduction
L. J. A. Heitz-Mayfield, U. Brägger
2 Literature Review
2.1 Statements and Recommendations Obtained from

the 4th and 5th ITI Consensus Conferences
2.1.1 Proceedings of the 4th ITI Consensus Conference

2008

2013
2.2 Literature Review: Biological Complications
L. J. A. Heitz-Mayfield
2.3 Literature Review: Hardware Complications and

Failures
U. Brägger
2.3.1 Mechanical and Technical Risks
26
2.3.2 Effect of Improved Components on Complications
and Failure Rates
2.3.3 Complication and Failure Rates with Cemented

versus Screw-retained Reconstructions
2.3.4 Complication and Failure Rates with Metal versus

Ceramic Abutments
2.3.5 State of the Art of CAD/CAM-assisted Production

of Implant-supported Reconstructions
2.3.6 Overdentures
2.3.7 Survival Rates of Reconstructions Obtained from

Systematic Reviews
3 Etiology and Risk Factors: Biological

Complications
3.1 Peri-implant Infections
3.1.1 Peri-implant Biofilms
3.1.2 Risk Factors for Peri-implant Infection
3.1.3 Hardware Complications Presenting as Biological

Complications
3.2 Non-plaque-related Biological Complications
27
3.2.1 Complete Loss of Osseointegration and Occlusal
Overload
3.2.2 Other Theories for the Etiology of Loss of

Osseointegration
3.2.3 Non-plaque-related Oral Mucosal Disorders
4 Etiology and Origin of Hardware Complications
U. Brägger
4.1 Materials and Interfaces
4.2 Absorption of Kinetic Energy and Biomechanical

Risks
4.3 Hardware-related Complications and Failures
4.3.1 Implant Body
4.3.2 Implant Body/Abutment Interface
4.3.3 Abutment Screw
4.3.4 Abutment Body
4.3.5 Retention of Superstructures: Screw-retained and

Cemented
4.3.6 Closure Screws, Healing Abutments, Mucosa

Formers
28
4.3.7 Attachment System for Overdentures
4.3.8 Mesostructures
4.3.9 Reconstruction
5 Management of Biological Complications
5.1 Treatment of Peri-implant Mucositis
5.2 Treatment of Peri-implantitis
5.2.1 Pre-treatment Phase
5.2.2 Non-surgical Debridement
5.2.3 Early Reassessment
5.2.4 Surgical Intervention
5.2.5 Immediate Postsurgical Care
5.2.6 Maintenance
5.2.7 Implant Removal
5.2.8 Concluding Remarks
6 Management of Hardware Complications
29
U. Brägger
6.1 Hardware Complications
6.1.1 Fracture and Loss of Implants
6.1.2 Unfavorable Three-dimensional Position of the

Platform
6.1.3 Complications Related to Abutments
6.1.4 Complications Related to Abutment Screws
6.1.5 Complications Related to Retention
6.1.6 Complications Related to Healing Abutments
6.1.7 Complications Related to Systems for

Overdentures
6.2 Superstructure-related Complications
6.2.1 Denture Teeth and Acrylic
6.2.2 Wear and Attrition
6.2.3 Ceramic Chipping
6.3 Iatrogenic Reasons
7 Prevention of Biological Complications
30
7.1 Prevention of Peri-implant Infections
7.1.1 Treatment Planning
7.1.2 Preparation of the Patient
7.1.3 Preparation of the Recipient Site
7.1.4 Implant Placement
7.1.5 Prosthesis Design
7.1.6 Supportive Care
7.1.7 Diagnostic Monitoring of the Peri-implant Tissues
7.1.8 Frequency of Recall
7.2 Prevention of Loss of Osseointegration Due to

Occlusal Overload
7.3 Prevention of Non-plaque-related Oral Mucosal

Disorders
7.4 Concluding Remarks
8 Prevention of Hardware Complications
U. Brägger
8.1 Prevention of Complications Related to

Components and Reconstructions
8.1.1 Implant Body
31
8.1.2 Implant/Abutment Connection
8.1.3 Abutment Body and Abutment Screw
8.1.4 Third-party Components
8.1.5 Retention: Screw-retained and Cemented
8.1.6 Closure Screw, Healing Abutment, Mucosa

Formers
8.1.7 Attachment Systems for Overdentures
8.1.9 Superstructures
8.2 Risk Management
9 Clinical Case Presentations
Biological Complications
9.1.1 Iatrogenic Complications Managed by Replacing

Prosthetic Components: Non-surgical Approach
B. Schmid
9.1.2 Peri-implantitis Treated with Access-Flap Surgery
9.1.3 Excess Cement Resulting in Peri-implant

Infection Presenting as a Draining Sinus Tract
32
T. Linkevičius
9.1.4 Peri-implantitis Modified by Submucosal Excess

of Cement: Regenerative Peri-implantitis Therapy and
Six-year Follow-up
G. E. Salvi
9.1.5 Peri-implantitis Treated by an Antimicrobial and

Regenerative Approach
A. Mombelli, P. Wick
9.1.6 Recurrent Peri-implantitis Leading to Implant

Removal
Biological Complications (Other than Infections)
9.2.1 Removal of a Malpositioned Implant and Direct

New Implant Placement with Simultaneous Contour
Augmentation using GBR
D. Buser, U. Belser
9.2.2 Oral Lichen Planus Associated with the Peri-

implant Mucosa
A. Frydrych
9.2.3 Peri-implant Carcinoma
33
M. Moergel, P. W. Kämmerer, B. Al-Nawas
9.2.4 Peripheral Giant-cell Granuloma Associated with

Peri-implant Tissues
M. M. Bornstein
9.2.5 Peri-implantitis Resulting in Bisphosphonate-

related Osteonecrosis of the Jaw
M. M. Bornstein
9.2.6 Metal Allergy
D. Wismeijer, D. Kruger, J. Muris
Hardware Complications
9.3.1 Management of a Fractured Implant Supporting a

Screw-retained Metal-ceramic Restoration
H. P. Weber, A. Grous
9.3.2 Retreatment of a Patient with Multiple Biological

and Technical Complications and Failures
S. Hicklin, S. Tettamanti, U. Brägger
9.3.3 Management of a Technical Complication Caused

by a Fractured Zirconia Abutment
T. Joda, U. Brägger
34
9.3.4 Repeated Acrylic Fractures on a Mandibular
Fixed Full-arch Implant-supported Metal/Acrylic
Prosthesis
J. Kan
10 Etiology, Management, and Prevention of Hardware

Complications with Implant-supported Reconstructions
U. Brägger, S. Hicklin
11 Conclusions
12 References
35
36
1 Introduction
The replacement of missing teeth with implant-

supported prostheses is a well-documented, predictable
treatment method. High five- and ten-year survival rates
of both the implants and the implant-supported
prostheses have been reported (Pjetursson and
coworkers 2014). However, both the clinician and
patient should be aware that a significant percentage of
patients treated with dental implants will experience a
complication requiring a dental visit within the first 5
years. Given the steady growth in the number of
implants placed and restored over recent years, the
number of complications may also be expected to
increase in the future. Therefore, the diagnosis,
management, and prevention of implant-related
complications are important issues to consider as a part
of everyday practice.
Complications may be categorized as biological or

hardware-related.
Biological complications are associated with the

surrounding peri-implant tissues (peri-implant mucosa
or bone).
Hardware complications may be associated with the

implant or with the prosthetic components. Following
37
the definitions by Salvi and Brägger (2009), a technical
complication is defined as a complication that affects
the laboratory-fabricated components of the prosthesis,
while a mechanical complication is one associated with
the manufacturer-fabricated components. Thus,
hardware complications include both technical and
mechanical complications, as well as other types of
complications, for example fracture of the luting cement
or loss of the occlusally screw-retained restoration.
Furthermore, complications may be classified as minor

(those that can be rectified at chairside with minimal
intervention and minimal cost) or major (those that
require numerous visits or are associated with
considerable cost). Major complications may result in
either implant loss, or failure of the prosthesis, or both.
Compromised esthetics may be a consequence of either
biological or hardware complications.
The present Volume 8 of the ITI Treatment Guide

series addresses etiology, management, and prevention
of biological and hardware complications that occur
following successful osseointegration, with the implant
in function. Biological complications described in this
volume include complete loss of osseointegration
(implant failure); peri-implant infections (peri-implant
mucositis and peri-implantitis); bisphosphonate-related
osteonecrosis of the jaw (BRONJ) in relation to
osseointegrated dental implants; peri-implant oral
mucosal disorders; material allergies; and carcinomas/
tumors.
38
Hardware complications outlined in this volume include
implant fracture; abutment or screw fracture; abutment
or screw loosening; prosthesis framework fracture;
prosthesis veneering material fracture; loss of the
occlusally screw-retained restoration; and—in the case
of cemented prostheses—fracture of the luting cement
(loss of retention). Reasons for ill-fitting restoration
margins are also discussed, as well as complications
arising from insufficient space for restorative
components due to inadequate treatment planning.
While various complications may appear similar in their

clinical presentation, the clinician must be able to make
the correct diagnosis and understand the underlying
cause of the complication in order to implement the
appropriate treatment strategy. Furthermore, some
hardware complications, such as an abutment-screw
fracture or prosthesis-screw loosening, may present
clinically as a biological complication (e.g. a draining
sinus). For the successful management of both hardware
and biological complications, an accurate diagnosis and
evaluation of the cause of the complication is therefore
the first important step.
In this treatment guide, step-by-step procedures for the

management of various complications are outlined and
illustrated by individual case descriptions. The
important topic of how to prevent complications is also
discussed in detail.
Volume 8 of the ITI Treatment Guide series aims to

provide the clinical and laboratory team with valuable
information concerning the etiology and risk factors,
39
management and prevention of biological and hardware
complications occurring after the implant has been
restored.
40
2.1 Statements and Recommendations Obtained from
the 4th and 5th ITI Consensus Conferences

2008
International Journal of Oral and Maxillofacial

Implants 2009, Vol. 24 (Supplement): Consensus
statements and recommended clinical procedures
regarding risk factors in implant therapy (Cochran and
coworkers 2009)
Introductory remarks
The group was asked to address the available evidence

for potential risk factors in implant therapy. The authors
were requested to prepare narrative reviews using a
systematic approach, and were provided with general
topics rather than specific research questions. The four
reviews presented for discussion within the group
addressed: (1) systemic conditions and treatments as
risks for implant therapy, (2) history of treated
periodontitis and smoking as risks for implant therapy,
(3) mechanical and technical risks in implant therapy,
and (4) local risk factors for implant therapy. The
group’s participants critically reviewed each of the
review papers produced by its members, and
amendments were made following thorough discussion.
Systemic conditions and treatments
41
Clinical recommendations
With respect to systemic conditions and treatments as

risk factors for implant therapy, the following
recommendations can be made:
• A thorough medical history is essential to identify

potential systemic risks.
• Risks for implant failure and risks for medical

complications should be differentiated and evaluated. In
some instances, conditions and their treatments may
pose increased risks for implant failure, whereas the
risk for the patient may be minimal. As an example,
there are no data to support withholding implant
treatment for patients with diabetes or osteoporosis.
However, these patients need to be informed of the
possibility of implant complications.
• Where there is a potential risk of a medical

complication—for example, osteonecrosis of the jaw in
patients taking oral bisphosphonates and patients
undergoing radiotherapy—the option of implant therapy
should be chosen restrictively, and the patient should be
informed specifically, taking into account the current
level of uncertainty with regard to the consequences.
For patients with a life-threatening systemic disease,
implant placement should be postponed until the
patient’s medical condition is stabilized and has
improved.
History of treated periodontitis and smoking
42
With respect to a history of treated periodontitis and

smoking, the following recommendations can be made:
• History of treated periodontitis. A history of treated

periodontitis is not a contraindication for implant
placement. However, patients with a history of treated
periodontitis should be informed of an increased risk of
implant failure and peri-implantitis. Patients with a
history of periodontitis should receive individualized
periodontal maintenance and regular monitoring of peri-
implant tissue conditions.
• Smoking. Smoking is not a contraindication for

implant placement. However, patients should be
informed that the survival and success rates are lower in
smokers. Heavy smokers should be informed that they
are at greater risk of implant failure and loss of
marginal bone. Patients who smoke should be informed
that there is an increased risk of implant failure when
sinus augmentation procedures are used.
• History of treated periodontitis and smoking

combined. Patients who smoke and have a history of
treated periodontitis should be informed that they have
an increased risk of implant failure and peri-implant
bone loss.
Mechanical and technical risks
43
With respect to mechanical/technical risks, the
following recommendations can be made:
• In general, implant reconstructions should be

planned to minimize mechanical/technical risks.
• Patients receiving implant therapy should receive

regular maintenance care in order to detect mechanical/
technical complications early, particularly in patients
with overdentures.
• Both cemented and screw-retained implant-

supported reconstructions can be recommended.
• Patients should be evaluated for bruxism.
Local risk factors
With respect to local risk factors, the following

recommendation can be made:
• Special care should be taken in selection of implant

diameter and design in areas with limited interdental
space.

2013
International Journal of Oral and Maxillofacial

Implants 2014, Vol. 29 (Supplement): Consensus
statements and clinical recommendations for prevention
44
and management of biologic and technical implant
complications (Heitz-Mayfield and coworkers 2014)
Introductory remarks
Implant treatment is highly successful, as documented

in a wealth of scientific literature. However, patients
and clinicians should expect to see complications within
their daily practice. The aim of the papers presented by
this group was to address the prevention and
management of technical and biologic complications in
order to make recommendations both for clinical
practice and future research. Three topics were chosen
within the field of complications of implant treatment,
and these addressed prevention and therapy of peri-
implant disease and prevention of technical
complications.
Three systematic reviews were conducted and formed

the basis for discussion of working group 5. The
discussions led to the development of statements and
recommendations determined by group consensus based
on the findings of the systematic reviews. These were
then presented and accepted following modifications as
necessary at plenary sessions.
Effects of anti-infective preventive measures on

biologic implant complications and implant loss
Consensus statements
The aim of the review by Salvi and Zitzmann (2014)

was to systematically appraise whether anti-infective
45
protocols are effective in preventing biologic implant
complications and implant loss after a mean observation
period of at least ten years following delivery of the
prosthesis. Out of fifteen included studies, only one
comparative study assessed the effects of adherence to
supportive periodontal therapy (SPT) on the occurrence
of biological complications and implant loss. In view of
the lack of randomized trails, observational studies
including adherence and lack of adherence to SPT were
considered valuable in order to estimate the effects of
SPT on implant longevity and the occurrence of
biological complications.
• Overall, the outcomes of this systematic review

indicated that high long-term survival and success rates
of dental implants can be achieved in partially and fully
edentulous patients adhering to supportive periodontal
therapy (SPT).
• Long-term implant survival and success rates are

lower in patients with a history of periodontal disease
adhering to SPT compared with those without a history
of periodontal disease.
• The findings of this systematic review indicate that

pre-existing peri-implant mucositis in conjunction with
lack of adherence to SPT was associated with a higher
incidence of peri-implantitis.
Treatment guidelines
Preventive measures before implant placement
46
• Residual periodontal pockets are a risk for peri-
implant disease and implant loss. Therefore, completion
of active periodontal therapy aiming for elimination of
residual pockets with bleeding on probing should
precede implant placement in periodontally
compromised patients.
• In cases of residual probing depths (PD) ≥ 5 mm

with concomitant bleeding on probing, full-mouth
plaque scores > 20%, and associated risk factors, re-
treatment and periodontal reevaluation are
recommended before implant placement.
• In subjects diagnosed with aggressive periodontitis,

an SPT program with shorter intervals is a prerequisite.
• During implant treatment planning, factors to be

considered that may result in biological complications
include: insufficient keratinized mucosa and bone
volume at the implant recipient site, implant proximity,
three-dimensional implant position, and design and
cleansability of the prosthesis. Alternative restorative
solutions should be considered according to a patient’s
individual circumstances.
Preventive measures after implant placement
• All oral healthcare providers, including

undergraduate students, should be trained to recognize
clinical signs of peri-implant pathology and maintain or
reestablish peri-implant health.
47
• After delivery of the definitive implant-supported
prosthesis, clinical and radiographic baseline
measurements should be established.
• During SPT, an update of medical and dental history

and a clinical inspection of the implant-supported
prosthesis including the evaluation of iatrogenic factors
(e.g. cement remnants, misfit of prosthesis, implant
proximity with insufficient access for interproximal oral
hygiene) should constitute the basis of a proper
diagnostic process.
• Regular diagnostic monitoring of the peri-implant

tissues includes assessment of presence of plaque,
probing depth (PD), bleeding on gentle probing
(approx. 0.25 N), and/or suppuration.
• Changes in PD from a fixed landmark should be

assessed regularly and compared to previous
examinations.
• In the presence of clinical signs of disease, an

appropriate radiograph is indicated in order to detect
radiographic bone-level changes compared to previous
examinations.
• A diagnosis of peri-implant health is given in the

absence of clinical signs of inflammation. A recall
frequency of at least once per year is recommended
unless systemic and/or local conditions require more
frequent intervals. In cases of peri-implant health,
professional cleaning including reinforcement of self-
48
performed oral hygiene is recommended as a preventive
measure.
• A diagnosis of peri-implant mucositis is given in the

presence of individual clinical signs of soft tissue
inflammation (e.g. redness, edema, suppuration) and
bleeding on gentle probing. If mucositis is diagnosed, in
addition to reinforcement of self-performed oral
hygiene, mechanical debridement with or without
antiseptics (e.g. chlorhexidine) is delivered. The use of
systemic antibiotics for the treatment of peri-implant
mucositis is not justified. Therapy of peri-implant
mucositis should be considered as a preventive measure
for the onset of peri-implantitis.
• A diagnosis of peri-implantitis is given in the

presence of mucositis in conjunction with progressive
crestal bone loss. When peri-implantitis is diagnosed,
early implementation of appropriate therapy is
recommended to prevent further progression of the
disease.
Therapy of peri-implantitis
The focused question for the review by Heitz-Mayfield

and Mombelli (2014) was: In patients with
osseointegrated implants diagnosed with peri-
implantitis, how successful is treatment aimed at
resolution of the disease?
49
Currently, there is no standard of care for treating peri-
implantitis. Various clinical protocols for treating peri-
implantitis have been proposed, including mechanical
debridement, the use of antiseptics and local and
systemic antibiotics, as well as surgical and
regenerative procedures. In view of the lack of
comparable randomized controlled trials (RCTs), this
review has taken a broader approach to capture as many
relevant studies as possible, including randomized and
observational studies, but with consideration to the
strengths and limitations of the included research.
The ideal goal of the treatment of peri-implantitis would

be the resolution of disease, i.e. no suppuration or
bleeding on probing, no further bone loss, and the re-
establishment and maintenance of healthy peri-implant
tissues. A composite outcome to reflect this would
include absence of peri-implant PD ≥ 5 mm with
concomitant bleeding on probing and no suppuration, in
addition to no further bone loss. If these criteria are met,
it can be assumed that no further intervention other than
nonsurgical maintenance care would be required, and
the treatment outcome would therefore be regarded as
successful. Unfortunately these data were rarely
reported in the literature and therefore a compromise
composite criterion for successful treatment outcome
was employed, i.e. implant survival with mean PD < 5
mm and no further bone loss. Although there is no
consensus in the literature on whether a 5-mm peri-
implant PD alone represents health or disease, this
threshold was adopted for the purposes of the review.
This review was based on 33 studies reported in 43
papers including case-series of at least 5 patients treated
50
with the same protocol and comparative studies. No
studies were found comparing surgical and nonsurgical
protocols. Based on this literature, the following
conclusions were drawn:
1. The case definition of peri-implantitis remains

unclear and varies substantially between studies.
2. There is a great variety of treatment protocols for

both nonsurgical and surgical treatment.
a. Nonsurgical therapy included: debridement with

hand and powered instruments, air-powder abrasive
devices, laser treatment, and local and systemic
antimicrobial agents.
b. Surgical therapy included: elevation of a

mucoperiosteal flap and removal of granulation tissue
to gain access to the implant and defect surfaces,
decontamination of the implant surface (various
techniques) with or without implant surface
modification. Some studies also evaluated resective
therapy or a variety of regenerative procedures. The
majority of the studies employed systemic antimicrobial
administration.
3. The following elements are common to most

protocols for peri-implantitis therapy:
a. Pretreatment phase including establishment of good

oral hygiene.
51
b. Anti-infective treatment including implant surface
cleaning achieved by nonsurgical/surgical access.
c. Supportive maintenance care.
4. The available evidence does not allow

recommendation of specific treatment options for peri-
implantitis. However, improvement of clinical
parameters was reported for the majority of patients,
although complete resolution according to a composite
success criterion was not usually achieved for all
patients. Favorable short-term outcomes were reported
in many studies; however, lack of disease resolution as
well as progression or recurrence of disease and implant
loss, despite treatment, were also reported.
5. Interpretation of the results of studies is complicated

by unclear or high risk of bias, heterogeneity of study
design, and difficulty of generalizing outcomes to
practice settings due to frequent exclusion of patients
who smoke, those with poorly controlled diabetes, and
other conditions that may affect clinical outcomes.
6. There are no data investigating patient-reported

outcomes and economic analysis of therapy.
7. Peri-implantitis therapy was associated with soft-

tissue recession, which was most evident following
surgical treatment. Postsurgery complications including
membrane exposure and infection were also reported.
Treatment guidelines
52
1. As peri-implantitis is an infection associated with the
presence of a submucosal bacterial biofilm around
implants, the primary goal of therapy must be the
resolution of the infection, which is achieved by the
disruption of the biofilm, the removal of calculus and/or
overhanging restoration margins, and the prevention of
recurrence of the disease.
2. It is important to try to establish if iatrogenic or other

factors have contributed to the infection, for example
ill-fitting or noncleansable overcontoured prostheses,
malpositioned implants, or foreign bodies such as
impression material or excess luting cement.
Noniatrogenic factors may include impacted dental
floss.
3. The following sequence of treatment of peri-

implantitis is normally recommended.
a. Pretreatment phase including:
i. Thorough assessment and diagnosis.
ii. Reduction of risk factors for peri-implantitis; in

particular poor oral hygiene, prostheses that prevent
adequate access for plaque control, tobacco use,
presence of periodontal diseases, and systemic diseases
that may predispose to peri-implant disease.
iii. If required, prosthesis removal and adjustment/

replacement.
53
b. Nonsurgical debridement focused on maximal
removal of biofilm, with or without antimicrobials.
c. Early reassessment of peri-implant heath; normally

within one to two months
d. Surgical access if resolution of peri-implantitis has

not been achieved. This should include:
i. Full-thickness mucoperiosteal flaps and removal of

granulation tissue to allow thorough cleaning of the
implant surface.
ii. Thorough surface decontamination of the implant

and restorative components. The following techniques
have been proposed: locally applied chemicals, gauze
soaked with saline or antiseptics, hand-powered
instruments, air-powder abrasives, Er-YAG lasers,
photodynamic therapy, and implant surface
modification. There is no evidence for the superiority of
any one approach.
iii. Surgical therapy might also include regenerative or

resective approaches:
1. Regenerative approaches include filling of the

intraosseous peri-implant defect with a bone substitute/
graft/bioactive substance with or without a resorbable
barrier membrane. Defect morphology for regeneration
would normally require a contained defect. Submerged
healing might reduce the risk of membrane exposure.
Re-establishment of osseointegration following
treatment has not been demonstrated in humans.
54
2. Resective approaches include osseous recontouring
with apical positioning of the flap.
iv. Immediate postoperative anti-infective protocol

should include daily chlorhexidine rinsing during the
healing period until mechanical oral hygiene can be
resumed. In the absence of evidence comparing surgical
treatment with or without antibiotics, peri- or
postoperative systemic antibiotics are recommended in
view of the aggressive nature of disease. Professional
support of healing and plaque control will be needed
during this phase.
e. Clinical monitoring should be performed on a

regular basis and supplemented by appropriate
radiographic evaluation as required. Supportive
maintenance therapy including reinforcement of
effective oral hygiene and professional biofilm removal
should be provided on a frequency determined by oral
health and the risk profile, likely to be between every
three to six months.
4. Surgical access is likely to be needed for the majority

of deep lesions due to the difficulty of accessing the
threads and surfaces of the implant.
5. The patient should be advised that:
a. Recession of the peri-implant mucosa should be

expected following peri-implantitis treatment, in
particular after surgical therapy.
55
b. Progression or recurrence of disease might require
additional therapy or implant removal.
6. The clinician should consider implant removal as a

treatment option. Factors influencing this decision may
include the severity of the peri-implantitis lesion, the
position of the implant, the surrounding tissues, or when
the treatment outcomes are likely to be unsatisfactory.
7. Referral to specialist care for non-responding peri-

implantitis should be considered.
8. Regular assessment of peri-implant health is

recommended during SPT to identify disease at an early
stage.
9. Training of dental team professionals should include

diagnosis and management of peri-implant disease.
Survival rates of implant-supported fixed prostheses

over the last decades
The systematic review by Pjetursson and coworkers

(2014) was conducted to compare the survival and
complication rates of implant-supported prostheses
published up to the year 2000 with those reported in
studies published after the year 2000. An association
between period of publication and fixed implant-
supported prosthesis outcomes was found with higher
survival rates and overall lower rates of mechanical and
technical complication reported in more recent clinical
56
studies. However, the incidence of reported technical
complications is still high. The difference in survival
rates are most evident for screw-retained prostheses,
where the reported survival rate of 77.6% in the older
publications was increased to 96.8% in the more recent
ones.
Treatment Guidelines
Risk of fracture—implants
1. Implant fracture is a rare complication. To avoid

implant fracture it is recommended that clinicians
consider the use of appropriately designed and
manufactured implants with properly investigated and
documented low fracture rates. Similarly, the clinician
should use implants manufactured from materials that
have been thoroughly investigated.
2. The risk of implant fracture can be considered

extremely low when:
a. The appropriate distribution, number, and diameter

of implants are used.
b. Implants are placed using a restoratively driven

protocol.
c. Implants are combined with an adequately fitting

prosthesis
Risk of fracture and/or loosening—prosthetic screws
57
Fracture of manufacturer screws made to specified
tolerances can be influenced by three factors:
mishandling, misfit, and occlusal forces.
1. Mishandling: To reduce the risk of fracture of

prosthetic screws, it is recommended that a clinician
follow the manufacturer’s instructions for use.
2. Misfit: An inadequately fitting framework may be a

predisposing factor to prosthetic screw fracture or
loosening. It is recommended to prioritize evaluation of
the accuracy of the interface between the machined
head of the screw and its seating surface over the entire
area of contact to reduce the risk of loosening and
fracture.
3. Occlusal forces, usually in the presence of other

predisposing factors, misfit, and mishandling, may lead
to prosthetic screw fracture or loosening.
Risk of fracture and/or loosening—abutments
1. It is recommended that the clinician carefully

evaluate the differential etiology of screw loosening, as
the literature does not differentiate sufficiently between
abutment or prosthetic screw loosening to conclude
which type of screw is more likely to loosen.
2. Metal abutment fracture is a rare complication.

Greater caution is advised with ceramic abutments. It is
recommended that the specific material-based
requirements of ceramics should be respected when
choosing, designing, and handling these abutments.
58
Risk of fracture of framework and/or veneering
materials
1. Currently framework fracture is a rare complication.

The choice of material, appropriate design, and method
of fabrication are all factors in reducing the risk of
framework fracture.
2. To reduce the risk of fracturing the veneering

materials, the framework must provide adequate
support for the veneering ceramic or resin in order to
avoid excessive thickness of the veneering material.
3. When choosing the material and determining

framework design, it is recommended that the final
contour of the definitive prosthesis be visualized prior
to framework fabrication.
4. Scheduled regular maintenance appointments should

include a careful occlusal review. It is recommended
that clinicians undertake any required adjustments to
the prosthesis, inclusive of meticulous polishing of
worn ceramic surfaces, to reduce the risk of fracturing
of the veneer material.
Quality assurance
It is recommended that clinicians, technicians, and

manufacturers employ a tracking system for implants
and restorative components. Clinicians should be aware
that not all implant systems have the same level of
documentation. The clinician should be aware of the
origin of the components used.
59
2.2 Literature Review:
Biological Complications
In earlier longitudinal studies reporting on outcomes of

implant-supported prostheses, the focus was
predominately on implant survival. In many
publications, information regarding the occurrence and
nature of both technical and biological complications
associated with the implant or the prosthesis was not
reported (Berglundh and coworkers 2002).
In 2002, Berglundh and coworkers published the first

systematic review addressing the incidence of
biological and technical complications in implant
dentistry, reporting on prospective longitudinal studies
of at least a five-year duration. They included 51 studies
in a meta-analysis, and reported a higher incidence of
soft tissue complications for patients treated with
implants supporting overdentures than for fixed
prostheses. They found that most studies reported only
on implant loss, while biological complications were
considered in only 40% to 60% of the studies and
technical (hardware) complications in only 60% to 80%
of the studies. The authors concluded that the incidence
of biological and technical complications was likely
underestimated.
Furthermore, where reported, biological complications

associated with osseointegrated dental implants were
described using a wide range of terms including;
implant loss, peri-implantitis, bone loss, soft-tissue
60
hyperplasia, mucosal overgrowth, and soft-tissue
complications. The inconsistencies in the terminology
used have made it difficult to interpret data from these
studies relating to the incidence or prevalence of these
complications.
Pjetursson and coworkers as well as other authors have

published a series of systematic reviews focusing on the
survival and complication rates of implant-supported
prostheses after an observation period of at least five
years (Pjetursson and coworkers 2004; Jung and
coworkers 2008; Aglietta and coworkers 2009;
Pjetursson and coworkers 2012; Pjetursson and
coworkers 2014). These systematic reviews indicate
that hardware complications occur approximately three
to four times more frequently than biological
complications. When evaluating implant-supported
fixed partial dentures, 8.6% (95% CI: 5.1%–14.1%) of
them had had a biological complication after five years
(Pjetursson and coworkers 2004). Jung and coworkers
(2008) evaluated the biological complication rate of
implant-supported single crowns in longitudinal studies
with a mean follow-up of five years and found a five-
year cumulative soft-tissue complication rate of 7.1%
(95% CI: 4.4%–11.3%), and a five-year cumulative
complication rate for implants with bone loss > 2 mm of
5.2% (95% CI: 3.1%–8.6%). A systematic review
analyzing the survival and complication rates of
implant-supported fixed dental prostheses with
cantilever extensions found the five year estimates for
peri-implantitis were 5.4% (95% CI: 2%–14.2%)
(Aglietta and coworkers 2009).
61
At the First European Workshop on Periodontology in
1993, the terms peri-implant mucositis and peri-
implantitis were clearly defined. Peri-implant mucositis
was defined as inflammation of the peri-implant
mucosa, and peri-implantitis as inflammation of the
peri-implant mucosa in addition to loss of supporting
bone (Albrektsson and Isidor 1994). Recent
publications have used these definitions, resulting in a
clearer insight into the prevalence and incidence of
these biological complications.
Cross-sectional studies are valuable for determining the

prevalence of biological complications in individuals
with implant-supported prostheses. In recent years, a
number of these studies have been published with the
aim of determining the proportion of subjects within a
population with peri-implant mucositis and peri-
implantitis.
Mombelli and coworkers (2012) published a review

focused on the epidemiology of peri-implantitis. Based
on the data from 23 studies reporting information on the
presence of signs of peri-implantitis in populations of at
least 20 implant cases, they suggested that the
prevalence of peri-implantitis is in the order of 10% of
implants and 20% of patients during a five- to ten-year
period after implant placement.
A subsequent systematic review and meta-analysis

including 9 studies with 1,497 participants and 6,283
implants reported summary estimates of 63.4% of
participants for the frequency of peri-implant mucositis
62
and 18.8% of participants for the frequency of peri-
implantitis (Atieh and coworkers 2013).
There has, however, been great variation in reported

prevalence data for peri-implantitis with some authors
reporting a lower prevalence in the order of 1.8% - 10%
of subjects over a ten-year period (Buser and coworkers
2012; Cecchinato and coworkers 2013).
One of the difficulties in determining the prevalence of

peri-implantitis is that authors use different bone-loss
thresholds to define a case of peri-implantitis. One
example illustrating this is described in a study from
The University of Oslo, Norway, where a group of 109
subjects who had received dental implants between
1990 and 2005 were clinically and radiographically
examined a mean of eight years after restoration of the
implants. The prevalence of peri-implantitis depended
on the bone loss thresholds and probing-depth
thresholds used. The prevalence of peri-implantitis was:
47.1% of subjects when defined as inflammation and
detectable bone loss; 20.1% of subjects when defined as
bleeding on probing at peri-implant pockets ≥ 4 mm
with bone loss ≥ 2 mm; and 11.7% of subjects when
defined as bleeding on probing at peri-implant pockets
≥ 4 mm with bone loss ≥ 3 mm (Koldsland and
coworkers 2010). Obviously, the prevalence of peri-
implantitis will depend on the thresholds and definition
used. In addition the prevalence of peri-implantitis is
also likely related to the subjects within the
convenience sample examined. Factors including the
skill of the treating clinician, the proportion of smokers
or periodontal patients within the population, and the
63
frequency and nature of the supportive care program
will have an impact on the prevalence of peri-implant
mucositis and peri-implantitis.
As the use of dental implants increases worldwide, it is

likely that the prevalence of biological complications
will also increase. Clinicians need to be aware of the
procedures for management and prevention of these
complications outlined in this Treatment Guide volume.
2.3 Literature Review:

Hardware Complications and Failures
U. Brägger
2.3.1 Mechanical and Technical Risks
A literature review was prepared for the ITI Consensus

Conference in Stuttgart to identify mechanical and
technical risks for implant-supported reconstructions
(Salvi and Brägger 2009). Ten conditions with a
potential impact on the integrity of implant-supported
reconstructions and their prosthetic components were
identified after searching the literature:
• Type of retentive elements supporting overdentures
• Presence of cantilever extension(s)
• Cemented versus screw-retained reconstruction
• Angled/angulated abutments
64
• Bruxism
• Crown/implant ratio
• Length of the superstructure
• Prosthetic materials
• Number of implants supporting a fixed dental

prosthesis (FDP)
• History of mechanical/technical complications
A total of 35 clinical reports compared the events

observed over at least four years with or without these
potential risk conditions.
Regarding overdentures, it was found that, independent

of the retention elements, patients required multiple
prosthetic maintenance. Technical/mechanical
complications occurred more frequently with ball
retainers than with bars. Retention was perceived to be
better with bars compared to ball retainers; the lowest
retention was found for magnets. Metal frameworks
were recommended to reduce the observed rate of resin
body fractures where no framework was present.
When short FDP with or without cantilevers were

followed within the same study population, no
difference in the rate of technical/mechanical
complications was documented. In one study,
cantilevers exceeding 15 mm in length were associated
65
with a high risk of framework fracture and, therefore,
remakes of full-arch reconstructions.
The few studies that compared cemented and screw-

retained crowns and short FDP did not indicate an
increased risk. Similarly, the available data did not
indicate an increased risk for reconstructions on
angulated versus straight abutments.
An unfavorable crown-to-root ratio has traditionally

been perceived as a risk factor for implant loss. There
was, however, no evidence to be found in the literature
that the ratio of crown height versus osseointegrated
implant length would determine the incidence of
complications or failures. However, smaller
reconstructions were more prone to complications than
extended ones. Reconstructions with previous
complications or multiple complications did
demonstrate a higher risk for the definitive mechanical/
technical failure, especially—and significantly more
frequently—in bruxers (patients with attrition). One
study also reported more chipping on veneered titanium
versus gold frameworks.
One of the main findings of this review was that the 10

factors examined did not affect the integration of the
implant or the crestal bone height.
The small number of papers included and the quality of

the data presentation available at the time did not allow
a pooled statistical analysis in terms of a meta-analysis.
66
2.3.2 Effect of Improved Components on Complications
and Failure Rates
In 2013, at the most recent ITI Consensus Conference

held in Bern, Switzerland, a major focus was on
consensus statements and recommendations for clinical
procedures regarding prosthetic materials and
production processes.
It was assumed that the continuous improvement of

prosthetic components would result in better survival
and success rates for implant-supported reconstructions.
One way to assess any such improvement would be to
compare event rates reported in older and newer
publications (Pjetursson and coworkers 2014)
The year 2000 was chosen as a cut-off, and results from

31 older studies were compared to data from 108 more
recent studies. Estimated five-year survival rates for
cemented reconstructions increased from 95.2% to
97.9%, for screw-retained reconstructions from 77.6%
to 96.8%.
The survival rates for implant-supported single crowns

increased from 92.6% to 97.2%, for FDP from 93.5% to
96.4%.
In the older studies, annual rates for screw loosening

ranged from 0.79% to 6.08%. This means that after five
years, 3.9% to 26.2% of the reconstructions were
affected. The more recent studies reported event rates
between 0.62% and 2.29%, affecting between 3.6% and
10.8% of the reconstructions at five years.
67
Annual rates for abutment screw fractures ranged from
0.16% to 0.44% (0.8%–2.2% at five years) in the older
publications. This was reduced to 0% to 1.2% (0%
–5.8% at five years) in the more recent studies.
Fractures of the veneering material ranged from 0.25%

to 4.28% per year in the older studies but remained high
at 0.64% to 5.82% per year in the more recent studies.
The rates for implant and framework fractures and for

loss of retention did not change significantly.
The total incidence of technical complications reported

ranged from 2.32% to 10.46% per year in the older
studies and even higher, with 3.55% to 15.19%, in the
more recent studies.
While the survival rates of the reconstructions were

increased and the abutment-related failures/
complications were reduced considerably, veneer
chipping and total events seemed to have increased,
according to newer publications.
This could be explained by an increased awareness on

the part of clinical researchers for the need to report in
detail all events related to the quality of the
superstructure and the components rather than
concentrating on implant survival and changes in bone
level.
2.3.3 Complication and Failure Rates with Cemented

versus Screw-retained Reconstructions
68
One of the systematic reviews prepared for the 2013 ITI
Consensus Conference focused on the clinical
performance of screw-retained versus cemented fixed
implant-supported reconstructions (Wittneben and
Millen 2014). A thorough search identified 4,324 titles
of publications. Ultimately, 73 publications were
included for analysis. The number of publications and
the quality of the data presentation allowed a pooled
analysis and a random-effect Poisson regression
analysis when several studies were summarized.
Estimated failure rates and the weights of all included

studies related to cemented and screw-retained
reconstructions were presented based on 5,858
reconstructions observed over a mean observation
period of 5.4 years.
Of these, 59% were screw-retained, while 41% were

cemented. Grouping into single crowns, shorter FDP,
and full-arch FDP did not reveal any significant
difference in failure rates between cemented and screw-
retained reconstructions.
When the material was considered, the cemented all-

ceramic crowns revealed higher failure rates than metal-
ceramic crowns. A similar difference was not found for
the screw-retained implant crowns.
Technical complications as a whole occurred more

frequently with cemented reconstructions than with
screw-retained reconstructions. “Loss of retention” and
“screw loosening” as separate events were also
significantly more frequent with cemented
69
reconstructions, while “ceramic chipping” was more
frequent in the screw-retained ones.
As far as biological complications are concerned, the

presence of fistulas/suppuration
* was more frequently observed with cemented
restorations. Overall, biological events were
significantly more frequent with cemented prostheses.
2.3.4 Complication and Failure Rates with Metal versus

Ceramic Abutments
A third systematic review focused specifically on the

survival and success rates of abutments (Zembic and
coworkers 2014). The search returned 24 publications
(1996–2012) for data extraction.
Three randomized clinical trials presented data

comparing zirconia versus titanium, alumina versus
titanium, and titanium versus gold abutments.
Components from eight commercially available implant

systems were involved, with external and internal
connections.
However, of the total 2,186 abutments analyzed, only

134 were ceramic abutments. The mean observation
period was 5.5 years.
The quality of the data presentation and the number of

publications allowed the pooled calculation of event
rates per 100 objects per year. Ceramic abutments
survived at 97.5% at five years; metal abutments, at
70
97.6%. The estimated rate of mechanical complications
was 8.9% for ceramic abutments and 12.0% for metal
abutments.
The percentage of technical complications was 1.3

times higher for implants with external connections.
Eight studies also reported on incorrect fit affecting 1

ceramic and 19 metal abutments (20 out of 2,186
implant-abutment connections).
2.3.5 State of the Art of CAD/CAM-assisted Production

of Implant-supported Reconstructions
The fourth systematic review covered the available

evidence to support the use of computer-aided design/
computer-aided manufacturing (CAD/CAM)
technology for the production of custom prosthetic
components and frameworks (bars) (Kapos and Evans
2014). Of the seventeen publications included, two
reported on CAD/CAM crowns, six on implant CAD/
CAM abutments, and nine on implant-supported CAD/
CAM frameworks.
The short-term survival rates were high for CAD/CAM

single crowns, with no failure reported in one study
with 24 crowns and only 1 out of 75 crowns that had to
be remade in another study.
The short-term survival of CAD/CAM individualized

abutments was also high, with no failed abutments in
four studies and 1 out of 58 and 3 out of 40 abutment
failures in two other studies.
71
The data on CAD/CAM frameworks included
observation times between 24 and 120 months. One
study reported 5 out of 26 framework failures; another
study reported 2 out of 67 framework failures. A third
study reported 5 out of 66 framework failures. No
failures were reported in four studies; one study did not
comment on prosthetic survival.
In addition to the failures, a rather high incidence of

chipping was reported for at least four studies
considering complications, whereas four studies
reported no technical complications and one study
focused on bars only.
In summary, this implies that the availability of CAD/

CAM technology has not eliminated the risks for
hardware-related complications.
2.3.6 Overdentures
Several systematic reviews have explored the prosthetic

maintenance needs for implant-supported overdentures.
The most frequent hardware-related problems reported

are associated with the activation or replacement of
patrix-matrix components, as well as maintenance
required for the overdenture or restorations in the
opposing jaw.
A time-dependent analysis of reported maintenance

with implant-supported overdentures resulted in
continuous rates for the maxilla and the mandible
72
during year 1, between years 1 and 5, and after year 5
(Cehreli and coworkers 2010).
It was also found that the type of the attachment system

did not have an effect on the prosthetic outcome with
the overdenture (Cehreli and coworkers 2010).
This review was based on 49 clinical studies and listed

hardware-related events including: patrix loosening;
patrix activation; patrix replacement; patrix fracture;
dislodged, worn or loose matrix or housing; matrix
activation; matrix replacement; matrix fracture; fracture
of the implant-supported overdenture; fracture of the
acrylic above a patrix; fractured denture teeth; relining
of implant overdentures; fabrication of a new
overdenture.
The evaluation of pooled data from several clinical

studies yields weak conclusions. When analyzing the
data, it becomes obvious that there is always a range of
observed complication rates. Therefore, fewer
complications did occur in some patient groups, and the
procedures and components yielding the best outcomes
should be identified and applied.
A significant piece of information is that the inclination

of the implants had an adverse influence on
prosthodontic maintenance. Not least for the prevention
of overdenture-related complications, prosthetically
driven implant placement is needed (Walton and
coworkers 2001).
73
Whereas the reported survival rates of implant-
supported overdentures are very high, a substantial
number of maintenance visits are required and time
needs to be invested during the years following the
insertion of overdentures.
A regular maintenance schedule is recommended for

early detection of component wear, so that the affected
components can be replaced before extensive repairs
are needed.
2.3.7 Survival Rates of Reconstructions Obtained from

Systematic Reviews
Numerous systematic reviews have focused on the

estimated survival and success rates expected with
different types of reconstructions.
The event rates per 100 reconstructions per year were

retrieved from observed events and extrapolated to five
or ten years’ exposure.
These estimated event rates were the basis for statistical

comparisons of the outcomes with various types of
reconstructions.
In Figure 1, the expected prostheses survival rates of

various tooth or implant-supported reconstructions were
marked graphically, based on the systematic reviews by
Aglietta and coworkers 2009, Harder and coworkers
2009, Heydecke and coworkers 2012, Jung and
coworkers 2008, Jung and coworkers 2012, Koller and
coworkers 2011, Lulic and coworkers 2007,
74
Sunnegardh and coworkers 2012, Pjetursson and
coworkers 2004, Pjetursson and coworkers 2007,
Pjetursson and coworkers 2008, Pjetursson and
coworkers 2012, Rohlin and coworkers 2012, Romanos
and coworkers 2012, Romeo and coworkers 2012,
Sailer and coworkers 2007, Sailer and coworkers 2012,
Salinas and coworkers 2010, Schley and coworkers
2010, Stavropolou and coworkers 2007, Tan and
coworkers 2004, van Heuman and coworkers 2009,
Wasseman and coworkers 2006, Wittneben and
coworkers 2009, and Zurdo and coworkers 2009.
Fig 1 Survival rates of prostheses, obtained from

systematic reviews reporting on expected failure rates
with various types of tooth- and/or implant-supported
reconstructions.
The overview demonstrates that failure rates increase

with time. Differences between the reconstructions can
be observed after only a brief exposure; and the range
75
of the estimated failure rates increases drastically after
longer exposure periods.
One would like most patients to be found in the upper

right corner of the graph; reality, however, tells a
different story.
Patients, treatment providers, and insurance companies

will have to accept the fact that the incidence of
prosthetic failures and complications is increasing. The
steepness of the progress depends on the type of
reconstruction and is associated with patient-related and
other risk factors.
It is therefore important to avoid and control as many

risk factors as possible during the treatment planning
phase as well as during the production and insertion of
implant-supported reconstructions and their regular
prophylactic maintenance.
Evidence-based analyses of the literature as presented

in this volume of the ITI Treatment Guide therefore
have a direct impact on clinical practice and feed
knowledge into the clinical process.
* In this book, to acknowledge the geographic usage of

the terms “fistula” and “draining sinus,” the authors and
contributors use both nomenclature based on the
Americal Association of Endodontists’ (AAE)
definitions and on the ITI’s Glossary of Oral and
Maxillofacial Implants (ISBN-13: 978-3-938947-00-5).
76
Nomenclature based on the American Association of
Endodontists (AAE) definitions: Fistula: An abnormal
communication pathway between two internal organs or
from one epithelial-lined surface to another epithelial-
lined surface; not a sinus tract. Sinus tract: A pathway
from an enclosed area of infection to an epithelial
surface; the opening or stoma may be intraoral or
extraoral and represents an orifice through which
pressure is discharged; usually disappears
spontaneously with elimination of the causative factor
by endodontic treatment.
Nomenclature based on the Glossary of Oral and

Maxillofacial Implants: Fistula: Abnormal connection
between two anatomic cavities or an anatomic cavity
and the external body surface. They can form as a result
of trauma, infection, or inflammation.
77
2 Literature Review
78
3.1 Peri-implant Infections
In health, the peri-implant soft tissue forms a collar

around the implant/abutment (or implant/prosthesis)
junction. The peri-implant soft tissue consists of an
epithelial component (keratinized oral epithelium and
non-keratinized junctional epithelium) and a
connective-tissue component (Fig 1). The epithelium is
separated from the peri-implant marginal bone by
approximately 1–1.5 mm of connective tissue. The
coronoapical dimension of the junctional epithelium is
approximately 2 mm; however, this may vary
depending on factors including the depth of implant
placement, the soft-tissue phenotype, and the type of
implant-abutment connection. When the peri-implant
mucosa is healthy there are no clinical signs of
inflammation (i.e. no bleeding on gentle probing).
Fig 1 Schematic diagram illustrating a bone level

implant and the surrounding peri-implant tissues. (a)
79
Epithelium (keratinized and non-keratinized barrier
epithelium). (b) Connective tissue, (c) Marginal bone
crest. (d) Implant/prosthesis junction: (Left) Peri-
implant health. (Right) Peri-implant mucositis.
Fig 2 Schematic diagram of peri-implantitis (marginal

bone loss and clinical signs of inflammation).
Once exposed to the oral cavity, microorganisms

rapidly colonize the transmucosal part of the implant/
abutment. In health, there is equilibrium between the
bacterial challenge and the host response. The peri-
implant soft tissue may be considered as a barrier that
protects the zone of osseointegration from factors
released from bacterial plaque and the oral cavity.
Peri-implant infections (also referred to as peri-implant

diseases) are caused when an imbalance between the
bacterial biofilm challenge and the host defense occurs,
resulting in an inflammatory process.
80
When there are clinical signs of inflammation of the
peri-implant mucosa (bleeding on gentle probing, 0.25
N) without the loss of supporting bone, the definition is
peri-implant mucositis (Zitzmann and Berglundh 2008)
(Fig 1).
When there are clinical signs of inflammation (bleeding

on gentle probing, 0.25 N) in addition to loss of
supporting bone the definition is peri-implantitis
(Zitzmann and Berglundh 2008) (Fig 2).
In the case of peri-implantitis, probing depths greater

than 5 mm with suppuration and/or bleeding on probing
are frequently present (Figs 3a-b).
Recession of the peri-implant mucosa may also be

associated with peri-implant infections (Fig 4).
Fig 3a An implant diagnosed with peri-implantitis.

Deep probing depth of 8 mm and suppuration on
probing.
81
Fig 3b Periapical radiograph showing peri-implant bone
loss associated with the same implant as in Fig 3a with
the prosthesis in place. The marginal bone is
approximately at the level of the eighth thread.
82
Fig 4 Two implants diagnosed with peri-implantitis.
Recession of the peri-implant mucosa and biofilm
formation on the exposed implant threads.
83
Fig 5 Plaque and calculus on the lingual surface of an
implant-supported prosthesis in the mandible, resulting
in clinical signs of inflammation and peri-implant
mucositis.
Fig 6 Calculus and biofilm at the implants at sites 41

and 31, both of which are affected by peri-implantitis.
3.1.1 Peri-implant Biofilms
84
The cause-and-effect relationship between biofilm
formation at implants and peri-implant mucositis has
been clearly demonstrated in humans (Pontoriero and
coworkers 1994; Zitzmann and coworkers 2001; Salvi
and coworkers 2012). In these studies, when oral
hygiene was discontinued in order to allow undisturbed
plaque accumulation, clinical signs of peri-implant
inflammation (bleeding on probing) appeared after a
few days and resolved when oral hygiene was reinstated
(Salvi and coworkers 2012).
The composition of peri-implant biofilms associated

with this inflammation, which may lead to further peri-
implant infection in a susceptible host, is influenced by
the local environment and is very similar to the
microbiota on the remaining teeth in partially dentate
subjects. Therefore, subjects with untreated periodontal
disease, residual deep periodontal pockets, and/or poor
oral hygiene are at greater risk for the development of
peri-implantitis (Costa and coworkers 2012; Heitz-
Mayfield and Huynh-Ba 2009; Ferreira and coworkers
2006) (Figs 5 and 6).
Biofilms associated with peri-implant infection (peri-

implant mucositis and peri-implantitis) have been
studied extensively using various microbiological
techniques. The majority of studies has found the
composition of the submucosal microbiota to be similar
to that found in chronic periodontitis, with a mixed
anaerobic infection dominated by Gram-negative
bacteria. Some studies, however, have found high
numbers of other microorganisms not commonly
associated with periodontal disease, including enteric
85
rods and yeasts, or microorganisms associated with
extraoral infections such as staphylococci
(Staphylococcus aureus and Staphylococcus
epidermidis) or peptostreptococci (Leonhardt and
coworkers 2003; Fürst and coworkers 2007; Persson
and coworkers 2010). The microbiota associated with
peri-implant mucositis appear to be similar to those
associated with peri-implantitis (Máximo and
coworkers 2009; Casado and coworkers 2011),
suggesting that supramucosal plaque formation and the
development of peri-implant mucositis are the
precursors to peri-implantitis.
Fig 7 Peri-implant infection (peri-implant mucositis)

associated with non-keratinized peri-implant mucosa,
caused by impaction of a food particle.
86
Fig 8 Peri-implantitis associated with the middle
implant, where the peri-implant mucosa is non-
keratinized and movable.
3.1.2 Risk Factors for Peri-implant Infection
Inadequate plaque control
Poor oral hygiene or any factor that prevents adequate

plaque control around implants can be considered a risk
for peri-implant infection (Ferreira and coworkers
2006).
Inadequate width of keratinized peri-implant mucosa
An inadequate width of attached keratinized peri-

implant mucosa has been found to be associated with an
increased risk of peri-implant infection in some studies
(Schrott and coworkers 2009; Lin and coworkers 2013;
Brito and coworkers 2014). It is suggested that the lack
of keratinized mucosa may compromise the ability to
87
maintain an adequate plaque control. Furthermore,
impaction of food particles or foreign bodies may
occur, causing an infection (Figs 7 and 8).
Fig 9 An implant placed too close to the adjacent tooth

resulting in peri-implant infection.
Iatrogenic risk factors
Surgical phase. Surgical-phase iatrogenic risk factors

associated with peri-implant infection include
malpositioned implants and inadequate grafting
techniques. Implants placed too close together, or too
close to neighboring teeth, do not allow adequate space
for oral hygiene procedures and plaque control (Fig 9)
(Abi Nader and coworkers 2014).
Implants should be placed in a correct three-

dimensional position with sufficient bone volume
(minimum of 1 mm) surrounding the endosseous
portion of the implant. If the implant is malpositioned
88
and the endosseous portion of the implant is not
completely surrounded by an adequate volume of bone,
the implant surface may become contaminated with a
biofilm, leading to infection and progressive peri-
implant bone loss.
Similarly, if bone augmentation procedures at the time

of implant placement are unsuccessful and result in
incomplete osseointegration of the implant, the implant
surface will be more easily contaminated with a biofilm
if the peri-implant soft-tissue barrier is compromised
(Fig 10).
Fig 10 Cone-beam CT scan. Absence of a facial bony

wall at the implant, resulting from an unsuccessful bone
augmentation procedure. Management of this case is
described in Chapter 9, case 9.2.1.
89
90
Figs 11a-c An implant-supported prosthesis with poor
access for cleansability. Plaque and calculus formation
are seen in this case diagnosed with peri-implantitis. (a)
Lingual view. (b) Buccal view. (c) Periapical
radiograph illustrating peri-implant bone loss at both
implants.
91
Fig 12a Peri-implant mucositis caused by an inadequate
fit of the screw-retained crown at site 22.
Fig 12b Periapical radiograph of the case illustrated in

Fig 12a.. Inadequate fit of the screw-retained crown at
site 22.
Prosthetic phase. Iatrogenic risk factors for peri-

implant infection include inadequate prosthesis design,
poor fit, inadequate seating, or excess luting cement.
Overcontoured or poorly designed implant-supported
prostheses that prevent adequate access for oral hygiene
procedures may lead to peri-implant infection in
susceptible individuals (Figs 11a-c). The association
between implant-supported prostheses with inadequate
access for oral hygiene and peri-implantitis has been
clearly demonstrated (Serino and Ström 2009).
92
Fig 13a Peri-implant infection caused by inadequate
seating of the cemented crown at site 12.
Fig 13b Radiograph. Inadequate seating of the implant

crown at site 12.
93
Fig 14a Periapical radiograph. Excess luting cement
following crown cementation and associated peri-
implant marginal bone loss at site 21.
94
Fig 14b A draining sinus (arrow) on the facial peri-
implant mucosa and a deep peri-implant pocket with
bleeding on probing at site 21.
Other iatrogenic factors including inadequate fit of the

abutment or prosthesis (Figs 12a-b), incorrect seating of
a cemented prosthesis (Figs 13a-b), or the presence of
submucosal excess luting cement (Figs 14a-b) may also
cause bacterial accumulation and result in clinical
inflammation and peri-implant infection.
Implant surface as a risk factor for peri-implant

infection
While there is no evidence that the surface

characteristics of a properly placed and integrated
implant influence the initiation of peri-implantitis, it has
been documented that rough surface implants (e.g.
titanium plasma-sprayed, TPS) are more likely to
develop peri-implantitis than micro-rough implant
surfaces if the implant surface becomes exposed to the
oral environment (Lang and Berglundh 2011).
However, once initiated, the progression of peri-implant
infection and progression of bone loss may be related to
host susceptibility as well as to the implant surface
characteristics.
Case reports indicate that hydroxyapatite-coated

implants with a thick coating, are likely to develop peri-
implantitis leading to implant loss if the hydroxyapatite
coating detaches (Piatelli and coworkers 1995).
95
Systemic conditions as potential risk factors for peri-
implant infection
Cigarette smoking may increase the risk for peri-

implant infection (Lindquist and coworkers 1997;
Heitz-Mayfield and Huynh-Ba 2009). Smoking is a risk
factor for general health and oral health and has a
chronic effect on many aspects of the inflammatory and
immune systems. The deleterious effects of smoking
include impaired wound healing, reduced collagen
production, impaired fibroblast function, reduced
peripheral circulation, and compromised function of
neutrophils and macrophages (Palmer and coworkers
2005). The biological processes involved in
osseointegration and the maintenance of peri-implant
bone levels are likely affected by tobacco smoking,
providing an explanation for the lower implant survival
and success rates reported in smokers (Clementini and
coworkers 2014; Chen and coworkers 2013; Vervaeke
and coworkers 2013).
Diabetes mellitus is associated with various systemic

complications, including retinopathy, nephropathy,
neuropathy, micro- and macrovascular disturbances,
and impaired wound healing. In the oral cavity,
xerostomia, caries, and periodontitis have been linked
to diabetes mellitus. The increased susceptibility to
periodontitis is thought to be due to a negative influence
of diabetes on the inflammatory mechanisms resulting
in a deregulated host defense, impaired wound healing,
and microvascular problems (Graves and coworkers
2006).
96
Studies evaluating implant-related biological
complications in patients with diabetes are scarce, and
the influence of glycemic control has not been
evaluated. Nevertheless, one survey of 212 non-
smoking subjects with 578 implants found that the 29
individuals with diabetes mellitus had a higher
prevalence of peri-implantitis compared to those
without diabetes (Ferreira and coworkers 2006).
3.1.3 Hardware Complications Presenting as Biological

Complications
The presence of a draining sinus may be observed

clinically when there is a peri-implant infection that
drains through the peri-implant mucosa. A draining
sinus may be associated with peri-implant mucositis or
peri-implantitis, and its primary cause may either be
biological (plaque-related) (Figs 15a-b) or hardware-
related (Figs 16a-d). Hardware complications may
include a loose abutment or screw, abutment or screw
fracture, incorrect prosthesis seating, or—in the case of
a cement-retained prosthesis—the presence of excess
luting cement (Fig 14a-b). Hence, a careful assessment
involving a clinical and radiographic evaluation is
required to make an accurate diagnosis.
97
Fig 15a Peri-implantitis at site 12 with a draining sinus
(arrow) associated with significant bone loss.
98
Fig 15b Periapical radiograph. Bone loss to
approximately the third thread (arrow) of the implant at
site 12.
Fig 16a A draining sinus and swelling on the facial

mucosa at the screw-retained implant crown at site 21.
99
Fig 16b Periapical radiograph of the screw-retained
implant crown at site 21. There is no marginal bone
loss.
100
Figs 16c-d The initiating factor associated with this
infection was found to be a loose abutment screw. In
addition, there had been a technical error during the
fabrication of the crown, resulting in a visible gap
between the crown and the abutment where bacteria
could accumulate.
3.2.1 Complete Loss of Osseointegration and Occlusal

Overload
There are case reports describing complete loss of

osseointegration (implant failure) where occlusal
overload is presumed to be the cause. In these cases,
there are usually no signs of peri-implant infection
reported, and a radiograph shows a narrow radiolucent
area surrounding the entire endosseous portion of the
implant (Figs 17a-d). This is in contrast to the
101
radiographic bone-loss pattern of progressive crestal
bone loss observed in peri-implantitis induced by the
biofilm-related inflammatory response.
Fig 17a A removable partial upper prosthesis with

combined rigid support (telescope crown at implant 23)
and non-rigid support (clasps at teeth 14, 15, 27). The
combination of rigid and non-rigid support over a
period of eight years may have resulted in occlusal
overload of the rigid implant retainer and a loss of
osseointegration.
102
Fig 17b Implant 23 with shallow probing depths and no
clinical signs of infection. The patient had noticed
implant mobility for two days.
Fig 17c Periapical radiograph. Implant with a

radiolucent area around the entire area of the
endosseous part of the implant.
103
Fig 17d The implant has completely lost integration.
Case courtesy of Professor Nicola Zitzmann.
Fig 18 Erosive oral lichen planus associated with the

peri-implant mucosa. Management of oral lichen planus
is presented in Chapter 9.2.2.
104
Fig 19 Squamous cell carcinoma associated with a
dental implant. The Management of this case is
described in Chapter 9.2.3.
In a case series published by Piattelli and coworkers

(2003), 51 implants were retrieved due to mobility over
a five-year period and examined histologically. Almost
all of the implants had been inserted in posterior
(premolar-molar) regions of both jaws. In all
specimens, there was the presence of a 600- to
1,100-µm thick connective tissue between implants and
surrounding bone. In every case, the surrounding bone
was compact and highly mineralized and no bacteria
were found in the most coronal portion of the implants.
A scarce inflammatory cell infiltrate was present in the
connective tissue of some specimens. In about 10% of
specimens, the epithelium tended to surround the
perimeter of the implant. These histologic findings are
consistent with the hypothesis that late failures of
osseointegrated implants can be caused by a
combination of poor bone quality, mechanical trauma to
105
bone, and overloading. It is suggested that the load has
exceeded the capacity of the host bone, and hence
osseointegration is completely lost. Patients who report
parafunctional habits such as bruxism or clenching may
be at greater risk for this type of biological
complication.
3.2.2 Other Theories for the Etiology of Loss of

Osseointegration
Other explanations proposed by some authors for the

etiology of peri-implant marginal bone loss and loss of
integration include “a foreign body reaction”
(Albrektsson and coworkers 2013). There is, however,
currently no cohesive scientific evidence to support this
theory.
3.2.3 Non-plaque-related Oral Mucosal Disorders
Oral mucosal disorders found in the oral cavity may

also affect the peri-implant mucosa. These conditions
should be distinguished from peri-implant infection,
which may have a similar clinical appearance, and a
thorough history and biopsy is usually required to make
the correct diagnosis.
Oral lichen planus
Oral lichen planus (OLP) is a common inflammatory

mucocutaneous disease that frequently manifests itself
intraorally and may present on peri-implant mucosa.
OLP can appear in many forms, the most significant
being the erosive lichen planus (Fig 18). OLP may
106
sometimes resemble other chronic mucosal
inflammatory diseases hence a biopsy is essential to
ensure accurate diagnosis (Parashar 2011). Recent
studies have concluded that OLP is not a risk factor for
peri-implantitis and that implants do not influence
manifestations of OLP (López-Jornet and coworkers
2014).
Carcinomas/tumors
While their incidence is rare, carcinomas may occur

around dental implants and usually present as an
exophytic mass (Fig 19). A recent literature search
identified 25 reported cases of peri-implant carcinoma
and one sarcoma (Moergel and coworkers 2014). Eight
of the patients reported alcohol/tobacco consumption.
In most of the reported cases, patients exhibited risk
factors for possible malignant transformation: previous
carcinoma (n = 12), lichen (n = 4), irradiation (n = 3),
and leukoplakia (n = 3).
107
Fig 20 Peripheral giant-cell granuloma associated with
an implant at site 32. The management of this case is
Peripheral giant-cell granuloma
Another infrequent biological complication that may

occur around a dental implant is the peripheral giant-
cell granuloma (PGCG). The PGCG is a benign reactive
exophytic lesion of unknown etiology. Although it is
the most common giant-cell lesion of the jaws, there
have been only 12 published case reports in association
with implants (Galindo-Moreno and coworkers 2013).
The clinical appearance is usually that of an exophytic
multi-lobed lesion surrounded by pink-reddish tissue
(Fig 20). A biopsy and histological examination are
required to confirm the diagnosis.
108
Fig 21 Periapical radiograph. Implant with BRONJ. The
management of this case is described in Chapter 9.2.5.
Implant-associated bisphosphonate-related
osteonecrosis of the jaw
Bisphosphonate-related osteonecrosis of the jaw

(BRONJ) associated with dental implants is a rare
biological complication (Fig 21). The risk of BRONJ
appears to be much lower when the drug is taken orally
than when it is administered intravenously, but appears
to increase with the duration of bisphosphonate therapy.
Successfully osseointegrated implants that later develop
osteonecrosis around the implant after bisphosphonate
administration have been reported in the literature
(Kwon and coworkers 2012; López-Cedrún and
coworkers 2013). Histological features of these lesions
show necrotic bone with empty lacunae infiltrated by
inflammatory cells and bacterial colonies. Three types
of bone destruction pattern may be observed: (1)
complete necrosis of the bone around the implant
(frozen type), (2) extensive osteolysis around the
implant with or without sequestra (osteolytic type), and
(3) sequestration of bone with an implant maintaining
direct implant-bone contact (en-bloc sequestration
type). En-bloc sequestration of bone with the implant
might be one of the characteristics of implant-related
BRONJ that differs from peri-implantitis-induced bone
destruction (Kwon and coworkers 2012).
109
Fig 22 Suspected metal allergy to the non-titanium
healing abutments. The Management of this case is
Metal allergies
Hypersensitivity reactions to metals used in implant-

supported prostheses have been reported, with
symptoms such as dermal inflammatory reactions
(facial eczema, dermatitis, and rashes) and mucosal
hyperplasia (Fig 22). Allergic responses to titanium
have also been reported in a few studies, although the
significance of titanium as the cause of allergic
reactions remains unproven (Javed and coworkers
2013). Thus, in rare circumstances and for some
patients, the use of certain metals may result in an
allergy. Cutaneous allergy tests are required to confirm
the diagnosis (Sicilia and coworkers 2008; Javed and
coworkers 2013).
110
3 Etiology and Risk Factors: Biological Complications
111
4.1 Materials and Interfaces
Several options exist when retaining a superstructure

with implants. Consequently, the number of interfaces
involved in the load transfer differs as well. Removable
prostheses function via various attachment systems such
as spherical attachments, a bar system, or LOCATOR®
abutments (Zest Anchors, LLC, Escondido, California,
USA). A screw retained crown or FDP can be fixed
with occlusal screws clamping the superstructure via
abutments onto the implants. The abutment may also be
constructed as part of the crown, and a direct fixation
into/onto the implant via an abutment screw can be
provided. Cemented crowns or FDPs are retained via
abutments that are connected to the implants. Instead of
cementing in the oral cavity, a superstructure can also
be bonded to a base that is tightened into/onto an
implant as a one-piece reconstruction.
Figures 1 a-f illustrate the various options for

suprastructure retention and clearly reveals the
potentially increasing susceptibility for hardware
complications with the rising complexity of the
construction.
The superstructures are either cemented or screw-

retained. The screw-retained reconstructions may
require separate abutments or may be manufactured in
one piece. The newer option with a bonding base is
shown as well (Fig 1c).
112
A static representation of an implant-supported
reconstruction/abutment complex already leaves the
clinician with the notion that the reliability of the
processed materials and the maintenance of a tight
interface over many years of function is challenging.
This impression becomes even more striking when
these complexes are visualized during function, i.e.
simulated in a fatigue test.
The materials’ physical/mechanical properties have to

withstand compressive, tensile, and torsional forces
along axial and lateral vectors, with changing
amplitudes and peaks (e.g. during trauma).
Every material chosen for implants, abutments,

abutment screws, copings, occlusal screws, male/female
components of attachment systems, frameworks,
veneers, and denture teeth exhibits its own physical
properties when exposed to forces; these include:
• Hardness (resistance to compression)
• Module of elasticity (resistance to tension)
• Cohesive strength (resistance to a single intense

load)
• Fatigue (microscopic cracks appearing on repeated

loading create and extend fissures until catastrophic
failure occurs)
• Yield strength or overload (the point at which a

material starts to deform permanently)
113
By ISO-standardized testing, properties of the material
such as its ultimate tensile or compressive strength can
be assessed, compared, and modified.
Manufacturers devoted to quality also test new

components by means of finite-element analyses as well
as cyclic loading.
In addition to the choice of material per se, the

dimensions of the components should not exceed
certain critical values in order to withstand forces. For
example, the occlusal screw of a reduced-diameter
implant/reconstruction complex needs to be optimized
to survive long-term exposure to function. In addition to
the linear dimensions, the shape of the object, such as
the cross-section of a component, is also crucial. The
height and width and the diameter of rectangular,
elliptic, round, or hollow cylindrical cross-sections of
reconstructions greatly affect deflection and stress
under load. When designing components and dental
laboratory work, general physical laws have to be
respected to minimize hardware complications (Wiskott
2011).
Figures 1a-f allow a view into the “innards” of the

reconstruction/abutment/implant complex that is usually
invisible to the clinician. Next to the material
properties, the most important survival factor is
interface stability. At least eight interfaces are present:
• Implant bore/abutment screw
• Implant/abutment base
114
• Abutment/abutment screw head
• Abutment/reconstruction (coping; cement interface)
• Abutment bore/occlusal screw
• Occlusal screw head/reconstruction
• Reconstruction /abutment or implant platform
• Additional interfaces with mesostructures
The design of the mating interfaces will modify the

clamping effect at these interfaces (flat vs. conical
surfaces). Peak force concentrating at specific points
should be avoided, as well as edges, ledges, and
notches. The physical characteristics of the mating
interfaces should be adapted, e.g. to obtain a predictable
failure mode for an abutment screw. Wear due to
differences in hardness and to interposed rough
particles may weaken the clamping effect.
Another issue is the precision of the components; they

must be of consistent quality and subject to stringent
quality management. The accepted tolerance—e.g. with
regard to rotation between the abutment and the internal
implant interface—is a typical measure of production
quality standards.
In addition to interfaces held together by the clamping

effect, some interfaces involve an adhesive connection
between a veneering material and a framework. As
mentioned in the literature review, the weakest link in
115
most of today’s dental reconstructions is cohesive and
adhesive failure at the framework-veneer interface.
Fig 1a Tissue-level implant with a screw-retained

crown and an abutment for screw fixation.
116
Fig 1b Bone-level implant with a ceramic abutment and
a cemented separate crown.
117
Fig 1c Bonding base on a tissue-level implant.
118
Fig 1d Mucosa former on a bone-level implant.
119
Fig 1e LOCATOR® abutment on a bone-level implant.
Fig 1f Spherical attachment on a tissue-level implant.
Figs 1a-f Examples of implant/abutment/reconstruction

complexes associated with tissue-level implants, bone-
level implants, abutments for cementation, screw
retention, healing abutments, attachment systems. (1)
Implant body; (2) Implant body/abutment interface; (3)
Abutment screw; (4) Abutment body; (5) Retention:
cemented or screw-retained; (6) Closure screw, healing
abutment, mucosa former; (7) Attachment for
overdentures; (8) Mesostructure (not shown); (9)
Reconstruction.
4.2 Absorption of Kinetic Energy and Biomechanical

Risks
120
During intraoral function, implant-supported
reconstructions are exposed to forces that can be
grouped according to intensity, frequency, direction,
material composition, contact area, shape of the acting/
reacting masses, and the presence and quality of
intermediate structures.
Intensity. Chewing forces during biting and mastication

have been found to range between 108 and 174 N
(Helkimo and coworkers 1977), 93 and 368 N
(Haraldson and coworkers 1979), and 161 and 299 N
(Lujan-Climent and coworkers 2008) in the incisor
region. Measured by surface electromyography, the
maximal biting forces in the molar region ranged
between 446 and 1,220 N (Ferrario and coworkers
2004). During active phases of bruxism, extreme
sportive activity, spasms, or trauma, still higher forces
may be expected.
Reconstructive and component materials, veneering

material combinations, and screws clamping abutments
or reconstructions onto/into implants have to withstand
these intensive stress peaks in order not to cause
complications or failures. Excessive peak forces or
continous repeated jiggling may even compromise
osseointegration; however, there is no clear evidence
for the effect of overload in the etiology of loss of
osseointegration. Critical bending moments describe the
force needed to cause permanent deformation and/or
rupture of a material or combination of materials.
121
Frequency. Daily tooth contact during physiologic
function has been estimated to last for a few minutes.
Under stress or during parafunction, these phases may
be prolonged. The risk of damage is higher the longer
the exposure exists. The total exposure is responsible
for the wear, loosening, or fracture due to fatigue.
Direction. The notion that axial forces are less prone to

inflicting damage than non-axial forces is generally
accepted in reconstructive and implant dentistry. While
the effect on bone loss of non-axial loading has not
been confirmed by scientific evidence, the resulting
shear forces may be associated with ceramic chipping
and countertorque, resulting in screw loosening.
Unidirectional and multidirectional forces may have
detrimental consequences for the affected materials.
Contact area. A mass in motion hitting an object, or a

mass pressed onto another object with force, will result
in deformation, depending on the size and shape of the
contact area distributing the forces to a point or to a flat
or irregular surface. The force (action) will trigger a
reaction of equal magnitude. If the object (the implant-
supported reconstruction) cannot move and convert the
force into kinetic energy, the force has to be absorbed.
This is described by the material’s coefficient of elastic
deformation. Elasticity and flexibility describe the
capacity of an object to absorb force. If the materials in
a combination do not have the same elastic
deformation, stress builds within the object, potentially
causing e.g. ceramic chipping.
122
If the object cannot move or deform, the force will be
propagated to the weakest element and result in
damage: deformation, breakage, cracks, opening of
interfaces. Loosened screw joints are acute events; wear
or microcracks are chronic effects.
Forces may affect the implant material, any prosthetic

components such as abutments or screws, as well as the
materials of the superstructures. In addition, any
connections (interfaces) between implants, components,
and the superstructure may be loosened. Forces may act
directly on the contact area, but distant areas may also
be affected through deformation of the materials due to
leverage.
The physical characteristics of interposed particles

while polishing, during grinding, cutting, or caused by
attrition promote the deterioration of the materials.
Biomechanics. During mastication, proprioception

coordinates chewing motions and chewing forces.
Proprioception with implants is reduced by about a
factor 10 compared to vital teeth (Hämmerle and
coworkers 1995).
To what extent this might be responsible for the higher

rate of ceramic chipping in metal-ceramic
reconstructions on implants compared to teeth is not
clear.
At least for the mixed tooth-implant-supported FDP, no

protective mechanism exists; more frequent failures and
123
complications have been reported with this type of
reconstruction (Lang and coworkers 2004).
The biomechanical conditions in the oral cavity induce

aging, which affects the deterioration of materials.
Exposure to saliva, food, and drink, with temperature
and pH changes, the exposure to bacterial biofilm, the
anaerobic environment, and tissue-secretion products
leaking into the interfaces may also induce corrosion,
attrition, and material degradation. Function against
opposing hard natural or artificial materials and
interposed particles cause wear.
Similar types of exposure may also include

interventions such as oral hygiene, professional
maintenance procedures, or manipulation by dentists/
technicians altering the integrity of surfaces and
materials. Scaling, polishing, instrumentation with
ultrasonic tips, grinding, adjustments, retightening,
changing components, the use of chemical agents—all
these may have an effect on the structures; they are
meant to prevent damage, but they also carry with them
a certain risk of triggering microcracks as initial lesions.
4.3 Hardware-related Complications and Failures
Table 1 in Chapter 10, page 190 lists the site of origin

of hardware-related complications and failures, the key
parameters involved, the management and prevention of
such events, starting with the implant and proceeding to
the reconstruction (bottom-up).
124
4.3.1 Implant Body
Most documented oral implants are made of grade IV

titanium. Implants vary in body design, threads, neck
design, platform, connection, apex, length, and
diameter. They may be placed with the platform at bone
level or near the mucosal level. Rough surfaces and
improved chemical surface characteristics provide
faster healing and more attractive loading protocols.
Small-diameter implants may increase the risk of

implant fracture (Zinsli and coworkers 2004; Allum and
coworkers 2008), while, for example, almost no
instances of implant fractures have been reported with
regular-diameter implants.
The implant body has to withstand the axial and lateral

forces with effective amplitudes during function.
Parafunction and possible peak loads, e.g. in
encountering unexpectedly hard food particles or in
trauma, may result in excessive stress. The physical
properties of the implant material should guarantee a
certain flexibility and resistance to permanent
deformation. The load is transferred to the bone around
the osseointegrated implant.
The three-dimensional position of the implant platform

is crucial for the successful construction of an esthetic
and functional reconstruction. The position ultimately
determines whether prefabricated components can be
used or if custom components need to be fabricated.
The position of the platform defines whether screw
retention is possible or if angulation is needed.
125
Space requirements for components and superstructures
in all dimensions must be respected together with
anatomical and surgical limitations. Unfavorable
platform positions will cause biologically unacceptable
connections between the superstructure and abutments/
implants in terms of oral hygiene as well as diagnostic
and maintenance procedures. Finally, the esthetic result
will largely depend on the correct platform position.
4.3.2 Implant Body/Abutment Interface
A wide variety of matching interface designs exists for

the connection between an implant and an abutment.
The connections may be grouped according to external,
internal connections, one-piece or two-piece
configurations, butt joint vs. morse taper connection.
The number of surfaces (hexagon/octagon, three

grooves, multiple parallel flat surfaces) and the shapes
of the “notches” may vary.
4.3.3 Abutment Screw
Most abutments are tightened with a torque-control

device to a recommended value between 28 and 35
Ncm.
Some abutments employ friction fit, using low

temperatures for seating, which results in an expanding
abutment volume at body temperature.
While many complication and failures were related to

non-optimal connection characteristics during the early
126
phases of implant dentistry, the newer components
exhibit a lower incidence of abutment loosening or
fractures (Theoharidou and coworkers 2008).
From a biomechanical point of view, maintaining the

friction between the threads of the abutment screw and
the bore of the implant interface remains a challenge.
Regarding the interfaces between zirconia and titanium,
the tribological effect on the connection (wear) has been
studied to a limited extent (Stimmelmayr and coworkers
2012).
4.3.4 Abutment Body
An abutment portfolio must satisfy almost any clinical

demand for cementation or screw retention of crowns
and FDP, and with a variety of attachments for
overdentures. Gold, titanium, and ceramic abutments
with their inherent mechanical and biological
characteristics are available.
The physical integrity of the abutments is crucial for the

long-term stability of the superstructure. A modular
design allows exchanging a used or fractured abutment
without the need for a remake of the superstructure.
This can be achieved by features for interchangeable
repositioning and predetermined breaking points for
uncomplicated removal of fractured components.
The superstructure can be either cemented or screw-

retained onto an abutment that is itself screw-retained
on the implant. An alternative fixation can be achieved
127
via direct screw retention of a superstructure on an
implant.
The stability of the connecting interfaces is essential for

the function of the superstructure. If loosening occurs,
retightening a screw is only possible if the abutment
screw or occlusal screw is accessible. This may be
readily achieved by removing the screw-access closure
if the head of the screw had been protected with an
easily removable material (e.g. Teflon) (Moráguez and
Belser 2010).
Screw retention may also be provided by abutments for

transversal screw retention or by short angulated
abutments with features for screw retention.
CAD/CAM abutments
Most implant systems offer a wide range of abutments

to cover a large percentage of all prosthetic indications.
Great progress has also been made in the area of custom
abutments. CAD/CAM production can be regarded as
the solution for cases not restorable with standard
prefabricated abutments—or it can be regarded as the
standard modality, e.g. for esthetic ceramic crowns
(Kapos and Evans 2014).
4.3.5 Retention of Superstructures: Screw-retained and

Cemented
The main advantage of screw-retained crowns is easier

and more predictable retrievability compared to
cemented superstructures. In case of technical or
128
biological complications, controlled removal may offer
clinical advantages.
Screw-retained reconstructions can also be fabricated

with precision copings; several in-vitro studies
demonstrated greater precision for screw-retained
compared to cemented superstructures (Keith and
coworkers 1999; Tosches and coworkers 2009).
Screw-retained superstructures may favor the growth of

potentially pathogenic bacteria. This is expressed by an
unpleasant smell while retrieving screw-retained
reconstructions. Bacterial samples obtained at and
underneath such superstructures have revealed the
presence of anaerobic bacteria and a flora resembling
the flora from periodontal pockets (Keller and
coworkers 1998). Chlorhexidine gel or similar
disinfectant substances have been administered to
minimize the growth of anaerobic bacteria provoking
bad breath. Due to the fast clearance of these
substances, a limited long-term effect can be expected.
The occlusal screw is the smallest component in the

complex. The dimension and design of the screw head,
the shank and the thread pitch and the material
influence its mechanical characteristics, e.g. the torque
that can be applied, the torque needed to remove the
superstructure, as well as resistance and elasticity.
Sakaguchi and Borgersen (1993, 1995) have described

the complex relationships associated with a
superstructure secured with an occlusal screw on an
abutment torqued into an implant. While pressing the
129
superstructure tightly with the crown margin onto the
base of the abutment or the implant, the clamping force
may reduce the pressure connecting the abutment head
and the abutment base, which is a potential reason for
abutment-screw loosening. This may be avoided by
choosing a one-piece reconstruction with engaging or
non-engaging connections screwed onto an internal
connection.
The ultimate proof of stability achieved with a

component or combination of designs/materials lies in
the long-term use in patients. Exposure to the oral
environment and safe handling of the components
during fabrication and maintenance ultimately
determine the successful function of an implant/
superstructure complex.
Abutment height, abutment axes (straight or angulated),

and conicity determine whether a superstructure can be
cemented. In multiple-unit reconstructions, a lack of
parallelism must be corrected for. A threshold limit of 4
mm for abutment height is recommended if cementation
is planned (Misch and coworkers 2006).
Antirotational features such as grooves or flat surfaces

are required for single-unit reconstructions. Neither
parallel surfaces nor undercuts are acceptable for
multiple-unit reconstructions.
The space needed for the cement may be anticipated

and considered in the analogue/coping components.
130
While adhesive technology has reduced the minimal
dentin abutment height required for cementation for
single crowns and onlays, the choice of the cement
affects the retention of implant superstructures only
minimally.
Roughening the abutment surfaces may increase the

retention minimally.
Cements have been developed for seating

reconstructions on teeth. There is no consensus as to
which cement should be used when and exactly how it
should be applied. Increasing concern is being
expressed with regard to cement residue associated with
severe infection in tissues around abutments and
implants.
A brush technique while applying cement may be

preferable to uncontrolled filling of the crown. Pushing
down the crown with excess cement may open up the
soft-tissue collar, and the cement flow may reach deep
down into the connective tissue (Wadhwani and Chung
2013). Cement residue may react chemically and could
evoke foreign-body reactions similar to impression
material injected into the tissue around teeth (O’Leary
and coworkers 1973; Ree 2001). Similar to calculus,
cement residue may facilitate plaque accumulation and
biofilm growth. In addition, cement residue is difficult
to detect and remove.
Crown margins reaching the implant shoulder or

margins ending on abutments require perfect precision.
Ill-fitting reconstructions should not be accepted. They
131
reflect transfer errors and problems with occlusal
adjustment. They function as niches for bacteria and
cause biological complications, especially when
combined with cement residue. In addition, oral
hygiene procedures such as flossing cannot be
performed properly.
4.3.6 Closure Screws, Healing Abutments, Mucosa

Formers
After the surgical procedure, the access to the implant

platform and connection can be closed in a variety of
ways.
For submerged healing, a small and short cover screw is

preferable. A slightly higher cover screw may assist in
positioning and stabilizing a membrane. Wider and
higher healing caps and mucosa formers may then be
chosen for a semi-submerged or transmucosal healing
period.
Healing caps can be exchanged to a more suitable

design during second-stage surgery or be replaced with
provisionals; the latter are mainly used for the final
tissue-management stage, following the concept of
dynamic compression (Wittneben and coworkers
2013a).
Complications originating with these components are

related to tissue overgrowth, impinging soft and hard
tissue (i.e. graft particles), damage/wear to the
screwdriver insert, or the use of corroded, non-original,
non-pristine components.
132
4.3.7 Attachment System for Overdentures
The quality of life of edentulous patients can be

radically improved with dental implants (Wismeijer and
coworkers 1995; Timmerman and coworkers 2004). An
abundance of prosthetic components exists on the
market to improve denture retention (Osman and
coworkers 2012). The components should be resistant
to large forces and, if the retentive force is diminished,
activation or replacement by new components should be
straightforward. A small retention area is responsible
for securing the function of a full-arch reconstruction,
resulting in concentrated stress and wear. It is therefore
not surprising that the maintenance requirements for
overdentures in both jaws are considerable, irrespective
of the attachment system used and irrespective of the
number of implants supporting the overdenture.
Each additional interface and material combination

represents an additional risk factor. It seems logical to
prefer a one-piece resistant reconstruction that can be
attached to the implant with one abutment screw. This
leaves the complex with the lowest risk for hardware-
related complications.
Due to limiting anatomical conditions or unfavorable

divergent axes and space requirements, the regular
range of abutments and attachment systems for fixed
and removable reconstructions may not be sufficient to
provide a reasonable reconstruction. In such instances, a
mesostructure fabricated manually or via CAD/CAM
133
connected to an abutment may provide the necessary
modifications to support a superstructure. These
sometimes very sophisticated, but bulky implant/
reconstruction complexes result in additional hardware-
related risks.
4.3.9 Reconstruction
In general, implant-supported superstructures are

fabricated and designed similarly to tooth-supported
reconstructions. Any differences are related to the
connection to the implant, the different biomechanical
characteristics of implants and abutment teeth, and the
space required for the connection to the implant.
To restore a functional dentition after the loss of teeth

and surrounding tissues, various occlusal concepts have
been advocated for practical reasons. These concepts
were originally derived from the natural dentition and
applied in conventional prosthodontics.
The desire of patients to chew comfortably can be met

by various occlusal concepts and simple bite-
registration methods. Occlusal factors and details of
occlusion seem to be of minor importance for the
outcome of implant-supported reconstructions (Carlsson
2009).
Looking for information related to parafunction and

overloading, excessive forces, etc., Hsu and coworkers
(2012) found 15 clinical reports in which associations
with marginal bone loss, damage to resin or ceramic
veneers, attachment systems, denture base fractures,
134
component fractures, loosening, or even implant failure
were reported, especially in cases with parafunction.
While the biological limit for overload and its effect on
crestal bone levels is unknown (Chang and coworkers
2013), the effect of stress and fatigue on prosthetic
materials obviously require considerable maintenance
(Papaspyridakos and coworkers 2012).
Sound comprehensive prosthetic-care concepts need to

be applied along with surgical skills as a basis for
successful prosthetic laboratory work. The choice of
components, materials, material combinations, and
production processes meeting high clinical and
laboratory standards will result in a reconstruction/
abutment/implant complex with a good chance for long-
term survival. In addition, risk mitigation involves a
plan how to proceed in the event of a complication or
failure.
135
4 Etiology and Origin of Hardware Complications
U. Brägger
136
5.1 Treatment of Peri-implant Mucositis
Therapy of peri-implant mucositis should be considered

as a preventive measure for the onset of peri-implantitis
(Salvi and Zitzmann 2014). Treatment of peri-implant
mucositis includes a thorough removal of the supra- and
submucosal peri-implant biofilm in combination with
reinforcement of self-performed oral hygiene. Non-
surgical mechanical removal of calculus and biofilm
can be performed using a range of instruments,
including hand curettes and ultrasonic devices with
plastic, carbon-fiber, or titanium tips. Peri-implant
biofilms can also be removed using air-abrasive
devices, Erbium-YAG lasers, photodynamic therapy, or
rubber polishing cups. The clinician should choose a
method that minimizes damage to the surface of the
transmucosal parts of the prosthesis or implant.
Antiseptics such as chlorhexidine solution or gel can
also be recommended as an adjunct to mechanical
cleaning.
Importantly, if contributing factors such as an ill-fitting

or overcontoured prosthesis, a loose abutment or screw,
or the presence of a foreign body are identified, these
must be corrected in order to achieve a satisfactory
treatment outcome.
Peri-implant mucositis is considered to be a reversible

condition, as was demonstrated in an experimental
human study where clinical signs of peri-implant
137
inflammation (bleeding on probing) resolved when oral
hygiene was reinstated after a period of three weeks of
undisturbed plaque accumulation (Salvi and coworkers
2012).
Studies evaluating various treatment protocols using a

variety of antiseptic agents and toothpastes have shown
significant clinical improvements with a reduction in
bleeding on probing, and probing depths following
treatment (Figs 1a-c and 2a-b).
However, in these studies complete resolution of the

peri-implant mucositis in all cases is infrequently
reported. The location of the implant-supported
restoration margin may influence the treatment
response. This was shown in a clinical study where
implants diagnosed with peri-implant mucositis with
submucosal restoration margins had less favorable
treatment outcomes compared to those with equi- or
supramucosal margins (Heitz-Mayfield and coworkers
2011).
The use of systemic antibiotics for the treatment of peri-

implant mucositis is not justified (Hallström and
coworkers 2012).
138
Fig 1a Peri-implant mucositis at implant site 11.
Bleeding on probing caused by inadequate oral hygiene
resulting in plaque accumulation and inflammation.
139
Fig 1b Periapical radiograph. No marginal bone loss at
sites 11 and 12, confirming the diagnosis of peri-
implant mucositis.
Fig 1c Resolution of the of peri-implant mucositis at

site 11 (no bleeding on probing) four weeks following
non-surgical debridement and oral hygiene instructions
(flossing and brushing).
140
Fig 2a Implant at site 35 diagnosed with peri-implant
mucositis caused by an impacted food particle. Swelling
and redness of the peri-implant mucosa. There was also
bleeding on probing.
Fig 2b Resolution of the peri-implant mucositis

following debridement, oral hygiene instructions and
application of chlorhexidine solution twice daily for one
week.
5.2 Treatment of Peri-implantitis
Once a patient is diagnosed with peri-implantitis, it is

important to implement an anti-infective treatment
protocol. If left untreated, it is likely that there will be
progression of bone loss and possible eventual loss of
the implant.
141
The primary goal of peri-implantitis treatment should
be to establish healthy peri-implant tissues. A cause-
related treatment approach is required, aimed at
resolution of the infection and the prevention of disease
progression. Secondary goals may include peri-implant
bone regeneration and fill of the intrabony defect.
There are many different peri-implantitis treatment

approaches reported in the literature; however, it is not
yet known which is the most effective (Esposito and
coworkers 2012).
A recent systematic review prepared for the 5th ITI

Consensus Conference identified a number of study
protocols where successful treatment outcomes were
achieved in the majority of patients at twelve months
(Heitz-Mayfield and Mombelli 2014). This systematic
review also found that, while favorable short-term
outcomes were documented in many studies, a lack of
disease resolution as well as progression and recurrence
of the disease and implant loss despite treatment were
also reported (Heitz-Mayfield and Mombelli 2014).
The following sequence of treatment is recommended,

based on similarities in the treatment approaches
between studies included in this systematic review
(Heitz-Mayfield and coworkers 2014):
5.2.1 Pre-treatment Phase
142
• Assessment of the peri-implant soft tissues, bone
levels and the prosthesis in order to make a diagnosis
and to establish the cause of the infection.
A correctly aligned radiograph showing the marginal
bone levels should be made and clinical probing
measurements recorded. This will give an indication of
the severity of the bone loss, and allow identification of
any hardware or technical complication that may
manifest itself as a biological complication, for example
an inadequate fit of prosthetic components. In addition,
obtaining previous radiographic records from the time
of the prosthesis insertion will allow a comparison with
the current marginal bone levels.
• Reduction of risk factors for peri-implant

infection—in particular poor oral hygiene, inadequate
prosthesis design, tobacco use, presence of periodontal
diseases and systemic diseases that may predispose to
peri-implant infection.
Treatment may include:
– Smoking cessation counseling
– Periodontal therapy in partially dentate patients

with the presence of pockets greater than 5 mm, with
concomitant bleeding on probing
– Individual oral hygiene instructions
143
• If the prosthesis is screw-retained, it may have to be
removed to assess the prosthetic components or modify
the prosthesis’ contours. Removal may also improve
access to the implant surface for subsequent
debridement.
5.2.2 Non-surgical Debridement
Non-surgical debridement should be aimed at the

removal of calculus and biofilm supramucosally, and on
the contaminated implant surface if accessible (Figs 3
and 6a-b). This can be achieved using a range of
instruments including curettes or ultrasonic instruments
with carbon-fiber or plastic tips (Fig 3), air-abrasive
devices using sodium bicarbonate or glycine powder
(Fig 4), Er:YAG lasers, or photodynamic therapy.
Due to the topography of the implant and the limited

access to the implant surface, care should be taken
using instruments submucosally in deep pockets to
avoid breakage of the instrument, or damage to the
surrounding tissues.
Antiseptics (e.g. chlorhexidine), local antimicrobials

(e.g. minocycline-HCL microspheres) (Figs 5a-b), or
systemic antimicrobials may be used in conjunction
with the non-surgical debridement. The severity of the
peri-implantitis lesion appears to play a role in the
success of non-surgical therapy, with a more favorable
treatment outcome at implants without advanced bone
loss and without deep peri-implant probing depths.
144
Fig 3 Removing calculus and biofilm using a titanium
curette from an implant with peri-implantitis.
145
Fig 4 Non-surgical debridement using an air-abrasive
device (glycine powder). The flexible tip of the air-
abrasive device is placed approximately 3 mm
submucosally.
146
Figs 5a-b Applying a local antimicrobial agent
(minocycline microspheres) following non-surgical
debridement using a titanium curette for the treatment
of peri-implantitis at site 15.
Fig 6a Calculus and biofilm formation on the implants

at sites 41 and 31, which had been diagnosed with peri-
implantitis. Inflamed peri-implant mucosa. Labial view.
147
Fig 6b Clinical photograph illustrating calculus and
biofilm formation on the implants at sites 41 and 31.
The implant-supported crowns are splinted and screw-
retained. Lingual view.
148
Figs 7a-b Resolution of the peri-implant infection at the
implants shown in Figs 6a-b following non-surgical
debridement using a titanium curette, administration of
systemic antimicrobials for seven days, and improved
oral hygiene. Peri-implant mucosal recession following
treatment. (a) Labial view. (b) Lingual view.
5.2.3 Early Reassessment
If a successful treatment outcome is achieved within

approximately one to two months following non-
surgical management, the patient should be provided
with regular supportive care and monitoring (Figs 7a-b).
If resolution of the infection is not achieved, i.e. there is
persistent suppuration or deep probing depths with
bleeding on probing, further active therapy—usually
involving surgical access—should follow.
5.2.4 Surgical Intervention
149
Surgical protocols may involve an open flap
debridement approach, a regenerative approach, or a
resective approach.
All surgical protocols include the elevation of a full-

thickness mucoperiosteal flap, followed by the removal
of the peri-implant inflammatory granulation tissue
enabling access to the implant surface for
decontamination (Fig 8).
Fig 8 Clinical photograph illustrating intra-surgical

implant surface decontamination using a titanium brush
(TiBrush; Institut Straumann AG, Basel, Switzerland),
in a surgical handpiece, which oscillates in a clockwise/
counterclockwise direction (900 oscillations per
minute). Sterile saline solution (NaCl) is used for
irrigation and cooling.
150
Implant surface decontamination protocols are many
and varied and may include the use of:
• Hand instruments with plastic, carbon-fiber, or

titanium tips
• Ultrasonic devices
• Titanium brushes
• Air-abrasive devices using sodium bicarbonate or

glycine powder
• Er:YAG, CO2 or Nd:YAG laser
• Photodynamic therapy
• irrigation and/or rubbing of the implant surface using

chemical agents such as hydrogen peroxide, phosphoric
acid, sterile saline, chlorhexidine, or
ethylenediamenetetraacetic acid (EDTA)
• Carbide or diamond bur to modify the implant

surface (also described as implantoplasty)
Open-flap debridement. Elevation of a full-thickness

mucoperiosteal flap, which frequently includes vertical
releasing incisions, enables access to the implant
surface for decontamination (Figs 9a-b and 10). When
the peri-implant bone defect has no intraosseous
component, this technique is the most suitable (Figs
13a,d). A reduction in probing depths, bleeding on
151
probing, and recession of the peri-implant mucosa are
expected outcomes following this treatment modality.
Regenerative surgical protocol. A regenerative surgical

approach aims to regenerate the peri-implant defect and
may be applied when an intraosseous defect component
is present. Following implant-surface decontamination,
the intraosseous component of the peri-implant defect is
filled with a graft material that may also be covered
with a barrier membrane (Figs 11 and 12a-f).
Various graft materials including autogenous bone,

allogeneic decalcified freeze-dried bone, xenogeneic
bone mineral, phytogenic calcium carbonate,
hydroxyapatite, or beta-tricalcium phosphate have been
documented in an attempt to regenerate peri-implant
defects. In some protocols, non-resorbable membranes
of expanded polytetrafluoroethylene (ePTFE) or
resorbable collagen or else synthetic membranes have
been used to cover the graft material (Fig 11). The use
of biologically active agents such as growth factors or
enamel matrix derivatives may also be considered when
regeneration of the peri-implant defect is the goal of
treatment. Healing following a regenerative approach
may be either submerged—if the prosthesis can be
removed—or transmucosal.
152
Fig 9a Schematic diagram. Elevation of a full
mucoperiosteal flap to enable access to the implant
surface for biofilm removal using a titanium curette.
Fig 9b Schematic diagram. Positioning of the flap

margins following implant surface decontamination.
153
Fig 10 Full mucoperiosteal flap raised with vertical
releasing incisions to enable adequate access to implant
22 for surface decontamination.
154
Fig 11 Schematic diagram. Intrabony peri-implant
defect filled with bone-graft material and covered with
a barrier membrane. The flap margins are approximated
to allow transmucosal healing.
Fig 12a Circumferential three-wall intrabony peri-

implant defect at site 11 following flap elevation and
removal of the inflammatory granulation tissue.
155
Fig 12b The same intrabony defect filled with
deproteinized particulate bovine bone mineral (Bio-
Oss®, Geistlich, Wolhusen, Switzerland).
Fig 12c A resorbable collagen barrier membrane (Bio-

Gide®) covering the graft material.
156
Fig 12d After positioning of the flap margins and
suturing.
Fig 12e Five years after regenerative surgical

management of the peri-implantitis at site 11. The
patient was seen for regular maintenance care. The peri-
implant tissue is healthy.
157
Fig 12f Peri-implant radiograph five years after
regenerative surgical treatment of peri-implantitis at site
11. Stable marginal bone levels.
Defect morphology may influence the treatment

outcome for regenerative procedures. A three-wall
contained circumferential defect will have more
regenerative potential than a two-wall intraosseous
defect where one bone wall is missing (Figs 12a-f and
13a-d).
The addition of a connective-tissue graft, with the aim

of minimizing soft-tissue recession, has also been
documented in a case series including 10 patients
(Schwarz and coworkers 2014).
158
159
Figs 13a-d Schematic diagrams illustrating various peri-
implant defect configurations. (a) Peri-implant defect
with loss of the buccal bone wall and no intraosseous
defect component. (b) Peri-implant defect with loss of
the buccal bone wall and a two-wall intraosseous
defect. (c) Peri-implant defect with a circumferential
intraosseous defect. This defect configuration is most
suitable for regeneration. (d) Vertical bone loss
160
resulting in a peri-implant defect with no intraosseous
component.
Fig 14a Schematic diagram. Resective surgical

approach to peri-implantitis treatment. Removal of
alveolar bone peaks to allow implant surface
decontamination.
161
Fig 14b Schematic diagram. The flap margins are
repositioned apically once the bone has been removed
and the implant surface has been decontaminated. This
usually results in part of the implant surface becoming
supramucosal.
Resective surgical protocol. A resective surgical

approach is aimed at pocket reduction and involves the
removal of the alveolar bone peaks surrounding the
peri-implant defect. Once the implant surface has been
decontaminated, the flap is positioned apically resulting
in significant soft-tissue recession and exposure of the
implant surface (Figs 14 a-b and 15).
Fig 15 Clinical situation after a resective surgical

approach.
Intra-surgical modification of the implant surface, using

carbide or diamond polishing burs, in an attempt to
smooth the implant surface, or remove implant threads,
may also be made when a resective surgical protocol is
162
chosen. This implant surface modification is commonly
referred to as implantoplasty. While the effect of this
surface modification on the implant diameter has not
been thoroughly investigated, it has been shown that it
may compromise the strength of the implant, resulting
in an increased risk of implant fracture (Chan and
coworkers 2013).
163
Figs 16a-b Application of chlorhexidine solution with a
postsurgical soft brush.
5.2.5 Immediate Postsurgical Care
Postsurgical care should enable adequate biofilm

control by daily rinsing with chlorhexidine solution
during the early healing period, when oral hygiene
procedures are not possible. The use of a postsurgical
soft toothbrush, specifically designed to apply the
chlorhexidine to the site, may also be beneficial in the
first weeks following surgery (Heitz and coworkers
2004) (Figs 16a-b). Systemic antimicrobials in the
postoperative care phase are frequently used and are
recommended.
Given the aggressive nature of the peri-implantitis

lesion and the accumulation of periodontal pathogens in
deep peri-implant pockets, the rationale for the use of
systemic antimicrobials is to suppress the microbial
load and specific periodontal/peri-implant pathogens.
However, there are currently no randomized controlled
trials evaluating the effect of systemic antimicrobials
for peri-implantitis treatment. Possible side effects of
systemic antimicrobials should be discussed with the
patient prior to administration.
5.2.6 Maintenance
An important phase of the peri-implantitis treatment

protocol involves the provision of individualized
maintenance care. Regular monitoring, oral hygiene
reinforcement, and professional supra-mucosal biofilm
164
removal are required to avoid reinfection or the
recurrence of peri-implantitis (Fig 17).
The frequency of maintenance care will depend upon

the risk assessment for each patient related to patient-
related risk factors, such as smoking habits, periodontal
status, diabetes, and oral hygiene, and local risk factors,
such as access for biofilm removal.
Fig 17 Maintenance care using an air-abrasive device

with glycine powder at site 41 six months following
surgical treatment for peri-implantitis.
5.2.7 Implant Removal
In some patients, despite treatment, persistent or

recurrent infection occurs requiring removal of the
implant. Furthermore, when advanced bone loss has
occurred, or when treatment will result in a
compromised esthetic outcome, the patient may choose
165
to have the implant removed rather than undergo peri-
implantitis treatment.
The implant should be removed, where possible, in a

conservative manner avoiding additional damage to
neighboring structures and preserving as much bone as
possible. Today, the preferred method for implant
removal, where possible, is to use an implant-retrieval
device. Many implant manufacturers have a specific
tool that can be used to remove the implant by reversing
it at high torque. The prosthesis and abutment should
first be removed and the implant retrieval device
inserted counterclockwise into the internal aspect of the
implant (Fig 18a). A ratchet is then attached to the
retrieval device and torque is applied to the implant,
typically counterclockwise, until the osseointegration is
broken and the implant can be removed (Fig 18b).
166
Fig 18a Schematic diagram. Implant retrieval device
inserted counterclockwise into the internal aspect of the
implant to be removed.
Fig 18b Counterclockwise torque to remove the

implant.
167
Figs 19a-b Five implants in the mandible. The implant
supported-fixed prosthesis has been removed to allow a
thorough examination. (a) Buccal view. (b) Lingual
view.
168
Fig 19c Cone beam CT scan showing severe bone loss
at the middle implant, extending to within 1 mm of the
apex.
Fig 19d The middle implant, which was removed using

an implant-retrieval device.
169
Fig 19e Following treatment (surgical access flap and
implant surface decontamination) of the remaining 4
implants, which also showed peri-implantitis, the
implant-supported prosthesis was modified and
reconnected. Supportive peri-implant maintenance care
was provided every four months.
In the few cases where an implant-removal device

cannot be used, for example due to a fracture or
splitting of the implant, careful removal of the
surrounding bone using a piezoelectric device or bur,
followed by removal of the implant using forceps is
possible.
Where bone removal is necessary, care should be taken

to preserve the palatal bone wall in the maxilla and the
lingual bone wall in the mandible so that further
implant placement or bone augmentation procedures
can be facilitated.
170
While the use of a trephine bur to remove implants has
been described in the literature and is shown in Chapter
9.3.1, this method should be avoided if possible, as it
may result in excessive bone removal.
Adequate radiographs to assess proximity of the

implant to neighboring structures should be obtained
prior to implant removal in order to avoid
complications.
Consideration must also be given to the replacement of

the lost implant. In some instances, modification and re-
connection of the existing prosthesis may be possible
(Figs 19a-e), while in other instances placement of a
new implant and fabrication of a new prosthesis will be
required. Bone augmentation procedures may be
necessary to enable an adequate bone volume for
further implant placement. In some cases, an alternative
solution such as a removable partial prosthesis may be
the preferred option.
5.2.8 Concluding Remarks
Until further evidence is available to distinguish the

relative effectiveness of the various protocols, the
clinician should choose the most appropriate treatment
method according to the needs of the individual case.
The relative costs as well as the effectiveness of
procedures/materials should be considered and
discussed with the patient. Some studies have described
elaborate protocols combining numerous materials and
techniques, which means the costs of treatment increase
with no clear advantage in treatment outcome.
171
Healing following treatment of peri-implantitis (and
peri-implant mucositis) usually results in peri-implant
mucosal recession, which may result in a compromised
esthetic outcome. The possibility of adverse events such
as soft-tissue recession or recurrent infection should
therefore be discussed with the patient prior to
treatment.
Management of non-plaque-related biological

complications such as oral lichen planus (Chapter
9.2.2), peripheral giant-cell granuloma (Chapter 9.2.4),
or carcinoma (Chapter 9.2.3) involves taking a thorough
medical history and an appropriate biopsy for
histopathologic evaluation in order to make a definitive
diagnosis. Referral to an oral-medicine specialist or an
oral and maxillofacial surgeon is recommended for
assessment and appropriate treatment. Examples of the
treatment of various non-plaque-related biological
complications are outlined in the case reports in Chapter
9. While such complications are rare, the consequences
may be severe and the clinician must be familiar with
their clinical presentation in order to avoid
misdiagnoses and inappropriate treatment.
172
5 Management of Biological Complications
173
6.1.1 Fracture and Loss of Implants
When implants fracture and the decision is made to

replace the implant in the same position, steps need to
be taken to retrieve the part of the implant that remains
embedded in the bone. The following cases illustrate
some of the management issues associated with loss of
implants due to implant fracture.
A reduced-diameter regular-neck tissue-level implant at

site 13 had been placed in a thin ridge to avoid a GBR
procedure and to offer a less costly solution. After five
years, the patient complained about a mobile implant
crown (Figs 1a-f). A fracture line was visible on the
periapical radiograph at the level of a vertical bony
defect. The crown could be removed completely,
together with the neck portion of the implant. Three
weeks later, the mucosa had completely overgrown the
now submerged implant fragment.
A mucoperiosteal flap was raised so the fractured

implant could be removed. Since the implant platform
was lost, the explantation set and corresponding
trephine could not be used (ten Bruggenkate and
coworkers 1994).
174
Fig 1a Radiograph obtained after the patient had
complained about a mobile implant crown. A vertical
bone defect reached the level of the abutment screw. A
fracture line was visible.
175
Fig 1b Ruptured coronal part of a reduced-diameter
regular-neck tissue-level implant together with the
cemented crown.
176
Fig 1c After removal of the fractured coronal part, soft
tissue had grown over the implant fragment within a
few weeks.
Fig 1d The remaining implant fragment had to be

removed by separating it from the surrounding bone
with small drills. This resulted in a large bone defect on
the buccal aspect.
177
Fig 1e A new tissue level implant with a regular-neck
design but with a standard diameter (4.1 mm) was
placed. This intervention required considerable bone
augmentation.
178
Fig 1f After cementation of the new crown, a tissue
defect remains, despite augmentation procedures.
The still osseointegrated implant fragment was

therefore separated from the surrounding bone with
drills and removed towards the buccal side.
Later, a GBR procedure was performed and a new

implant (Regular Neck, diameter 4.1 mm; Institut
Straumann AG, Basel, Switzerland) was placed. The
new metal-ceramic crown and associated surgical
procedures were offered to the patient free of charge.
The implant fragment had to be removed before a new

implant could be placed. This was associated with
additional surgical and prosthetic interventions,
morbidity, discomfort and considerable costs; legal
consequences may also ensue.
In the mid-seventies, Schroeder and coworkers (1988)

treated patients with free-end situations at the
University of Bern, Switzerland using an earlier
generation of Straumann dental implants, the so-called
basket-type implants.
For the case presented in Figures 2a-e and 3a-i, this had
been the only alternative to a removable partial denture.
The implants were placed in the molar area and often
splinted to natural teeth. The patient had originally
received metal-ceramic FDP (i35-x-i37 and i47-x-x-44).
The FDP were cemented on the abutment teeth with

zinc-phosphate cement but screw-retained on the
179
implants. This concept keeps available options open in
case the retention is lost on the more mobile abutment
of the FDP. After the loss of the hollow-cylinder
implant 35, a new FDP was fabricated (34-x-x-i37).
After the loss of tooth 34, the one-piece implant 37
fractured. It was decided to leave the well-integrated
basket-cylinder implant in place. The morbidity
associated with the removal of the large fragment in this
mandibular molar region was considered too high.
Two implants (Regular Neck, diameter 4.1 mm;

Straumann) were then placed at sites 34 and 35; a
cantilever FDP (i34-i35-x) now ensured function in this
quadrant.
Fig 2a Three-unit metal-ceramic FDP (i35-x-i37) on

hollow-cylinder and basket implants as delivered (July
1985).
180
Fig 2b The radiograph of June 1994 shows the mesial
implant missing; a new FDP (34-x-x-i37) is present.
Fig 2c In the periapical radiograph with a gutta-percha

point in January 2002, the endodontically treated tooth
34 with its post-and-core seems to be hopeless. The
tooth was extracted and the FDP was separated mesially
of implant 37.
181
Fig 2d The distal abutment had failed because of an
implant fracture. The radiograph of January 2007 shows
a new FDP (i34-i35-x). The fragment of implant 37
remains integrated in the bone.
182
Fig 2e The coronal part of the implant ruptured at the
base to the basket construction.
For the same patient as in Figures 2a-e, the failure of a

mixed tooth/implant-supported FDP (i47-x-x-44) is
documented.
The original FDP was delivered in July 1985. After

eight years, loss of retention was noticed at the natural
abutment. The tooth was endodontically treated and a
post-and-core adapted underneath the retrievable FDP.
The original reconstruction could be maintained until
the abutment tooth was extracted.
Later, a new implant was placed at site 44. The old

basket-type implant was then splinted with a synOcta®
Regular Neck (RN) implant (Straumann). (The original
aluminum impression posts were still available from the
manufacturer.)
This patient is a typical example of a case with multiple

complications and failures. In the maxilla, the
reconstructions exhibited loss of retention, caries, and
other problems. At present, the maxilla is restored with
an overdenture supported by implants 15 and 13 and
natural teeth 23 and 25.
183
Fig 3a Periapical radiograph of a FDP (i47-x-x-44;
same patient as in Fig 1) delivered in July 1985.
184
Fig 3b In November 1993, a loss of retention was
observed at the tooth abutment. Tooth 44 was
endodontically treated and received a post-and-core.
Fig 3c The repaired FDP a week later.
Fig 3d In November 1997, it was decided to remove the

periapically infected tooth 44.
185
Fig 3e A regular-neck standard-diameter implant was
placed at site 44 in April 1998.
Fig 3f Occlusal view of the one-piece basket-type

implant 47 with the prosthetic post for screw retention
and the synOcta® abutment 44.
186
Fig 3g Impression taking with the old but still available
impression post for the basket-type implant as well as
with the synOcta® open-tray impression post (at that
time not yet color-coded).
Fig 3h Control radiograph of the FDP (i47-x-x-i44)

combining an old- and a new-generation implant.
187
Fig 3i Panoramic radiograph obtained after
reconstruction of the maxilla with an overdenture with
four spherical attachments on implants 14 and 12 and
natural teeth 23 and 24 (December 2012).
6.1.2 Unfavorable Three-dimensional Position of the

Platform
When implants are placed without a properly designed

prosthodontically driven treatment plan, this can result
in an unfavorable three-dimensional position of the
implant platforms relative to each other (with multiple
implants) and adjacent teeth. The following cases
illustrate the problem of implant malposition and the
management issues that arise.
Interference with standard prosthetic procedures. In

the following clinical situation, the three-dimensional
positions of the implants interfere with standard
prosthetic procedures. The extruded mandibular
anteriors almost touch the palatal papilla. Regular-neck
188
tissue-level implants were placed at sites 13, 11, 21, and
23. There is not enough space for a regular connection
to implants 11 and 21 (Figs 4a-f).
The patient received a long-term provisional (i13-x-

i11-i21-x-i23) and was scheduled for orthodontic
treatment in the mandible after extraction of tooth 31 to
provide space for the prosthetic components. A
reduction of the lower anteriors by preparation, crown
lengthening, composite, or veneers was discussed as an
alternative.
Distances not respected. In this clinical case, two

implants had been placed at sites 46 and 47. The choice
of implant platform (two regular-neck tissue-level
implants) and the distances from the adjacent teeth, as
well as the position of the implant platform in relation
to the cementoenamel junction of tooth 48, resulted in a
situation that created reconstructive problems (Figs
5a-b).
The distances do not favor a three-unit FDP, while the

reconstruction on implant 47 cannot be given an
optimized emergence profile.
The patient had already worn several reconstructions of

different designs but rejected all of them due to food
impaction. The final version uses two long-term
temporary crowns, which leave an intentional gap.
189
Fig 4a Frontal view illustrating the limited space
between the tissue level implants at sites 13, 11, 21, 23.
The patient has a deep bite and the mandibular anteriors
seem to be extruded towards the opposing jaw.
Fig 4b The laboratory-made long-term provisional

(i13-x-i11-i21-x-i23) is directly screw-retained on the
implants. The lower incisors come close to the occlusal
screws at sites 11 and 21.
190
Fig 4c The inserted long-term provisional will be used
to manipulate the soft tissues for improved emergence
profiles, papilla formation, and phonetics. The patient
will also undergo orthodontic therapy with intrusion of
the lower incisors, of which one will be extracted. This
will create more space for the components required for
the occlusally screw-retained FDP on tissue-level
implants in the maxilla.
191
Figs 4d-f Radiographs of the implants at sites 13, 11,
21, and 23 with the long-term provisional in place. The
improvised connections of the temporary abutments are
visible.
Fig 5a Unfavorable distances between implants and

between implants and adjacent teeth. As a compromise,
two long-term provisional crowns were fabricated with
a gap to test if food impaction could be reduced
compared to the different crown and FDP designs the
patient had previously tried.
192
Fig 5b The emergence profile of the molar crown was
unfavorable due to the small implant platform; it was
positioned too far coronally, and the distance between
the implant and the molar was too great.
Axes not respected. The two implants 11 and 21 had be

en placed in combination with a GBR procedure (Figs
6a-i). However, they were positioned too far facially
and with unfavorable implant axes. Since facially bone
was still present, a soft-tissue grafting procedure was
performed to provide an adequate tissue seal. Long-
term provisionals achieved an acceptable esthetic result.
The long-term stability of the facially bone plate is at
risk.
193
Fig 6a Implants 11 and 21, ready to be restored.
Fig 6b The implants were placed too far labially.
194
Fig 6c The axes of the two implants were tilted too far
labially.
Fig 6d Poor result with the first set of provisionals.
195
Fig 6e Soft-tissue graft to improve the condition of the
mucosa.
Fig 6f First wax-up.
196
Fig 6g CARES® abutments (Straumann) with labial
access channels.
Fig 6h Second wax-up with the CARES® abutments.
197
Fig 6i Definitive crowns.
6.1.3 Complications Related to Abutments
Hardware complications can occur at the level of the

abutments, as illustrated in the following case.
Abutment fracture. A 65-year-old patient received two

implant-supported fixed reconstructions (x-i16-i15-x-
i13-x-i11 and x-i22-x-x-i25-i26) (Figs 7a-e).
The screws of the FDP in the first quadrant loosened

repeatedly. Merely retightening the occlusal screw did
not stabilize the situation. The FDP was removed
completely and the abutments were controlled and
retorqued. It was then noted that the base of one of the
abutments had fractured from the rest of the component.
The synOcta® abutments (Straumann) are fabricated

from three components: a base, the abutment, and the
abutment screw. In this instance the “laser suture” had
198
broken. A new corresponding abutment was inserted
and torqued to 35 Ncm, and the FDP was now stable for
ten years. The occlusion and articulation were checked
and the patient was advised to wear the existing
protective splint regularly.
Fig 7a After removal of the FDP (x-i22-x-x-i25-i26),

whose occlusal screw of the FDP loosened repeatedly.
The coronal part of the synOcta® abutment on implant
25 had fractured from its base and could be removed.
199
Fig 7b The abutment screw was removed with the base
of the abutment.
Fig 7c The synOcta® connection was free of fragments.

A pristine abutment could be inserted.
200
Fig 7d The FDP were reseated after controlled
torqueing of all the abutments (35 Ncm) and occlusal
screws (15 Ncm).
Fig 7e The patient was motivated to wear a protective

nightguard.
201
Fig 8a The implant crown with the solid abutment had
fractured in a bicycle accident. The broken abutment
component could be removed by the emergency dentist
with a probe. A healing screw had been inserted.
Fig 8b A matching new solid abutment was chosen and

screwed in place at 35 Ncm.
202
Fig 8c The—still intact—metal-ceramic crown could be
reused but had to be adapted in the area of the groove
and the flat surface of the abutment.
203
Fig 8d The abutment was shaped to match the old
crown.
Fig 8e Fit Checker (GC, Tokyo, Japan) was used to

evaluate the amount of reduction required.
Fractured abutment due to trauma. A 60-year-old

patient had received a metal-ceramic crown cemented
on a solid abutment. She had lost the crown in a bicycle
accident and injured her lip. After emergency treatment
and healing of the lip wound, she was examined to
investigate the options of a remake or repair of the
crown (Figs 8a-e).
The remaining fragment of the solid abutment could be

removed manually. A corresponding new solid
abutment was inserted at 35 Ncm of torque. The shape
of the abutment was adapted to the inside of the crown.
Fit Checker (GC Corporation, Tokyo, Japan) was used
to indicate and guide the amount of material
removalrequired.
204
The interior aspect of the crown (the “groove part”) had
to be adjusted because the old Bonefit® implants
(Straumann) provided no stop position. The internal
round conical connection did not allow the exact
replacement of a torqued abutment (as there was no
index). The abutment and crown could be adjusted to a
satisfactory level of marginal fit and good retention for
cementation. The crown was cemented with a glass-
ionomer cement.
6.1.4 Complications Related to Abutment Screws
Several problems arising from the screws connecting

the abutment to the implant may be encountered in
clinical practice.
Damage to abutment-screw insert. A 70-year-old

patient was referred for removal of an abutment with a
non-engaging abutment screw. The dentist had decided
to remake a metal-ceramic crown after severe ceramic
chipping, but the abutment screw could not be removed;
obviously, the insert had been damaged. A stainless-
steel drill from the service set was used to drill directly
into the head of the abutment screw. These drills are
applied at low speed with ample irrigation (Fig s 9a-f).
The extraction bolt could then be inserted into the

cavity. The threads engaged the lateral walls of the
drilled access canal so that the ratchet could pry the
abutment loose. A healing abutment was inserted after
careful rinsing of the connection area, and the patient
was referred back for the fabrication of the planned new
crown.
205
Fig 9a SynOcta® abutment (Straumann) surrounded by
excessive soft tissue that had overgrown the implant
shoulder. The abutment screw was filled with debris.
Fig 9b The head of the abutment screw was damaged,

so that the screwdriver did not engage. Steel drills from
the service set were used to drill through the head of the
abutment screw.
206
Fig 9c Ample irrigation was necessary to avoid
overheating the surrounding tissue.
Fig 9d An access opening about 3 mm in depth was

prepared.
207
Fig 9e The extraction bolt (6°) was first turned into the
component manually until it caught. The torque was
applied with the ratchet set at the “unscrew” level.
Fig 9f The removed synOcta® abutment.
208
Fig 10a Components of the service set applied for the
guided removal of fractured abutment screws in a bone-
level implant: thread-removal tools, drilling guides,
milling cutters, drills, and taps.
209
Fig 10b The metal-ceramic crown 23 had loosened
repeatedly. A torque of more than 35 Ncm was applied,
which resulted in fracture of the abutment screw.
210
Fig 10c Application of a thread-removal tool as a first
attempt for easy retrieval of the fractured component.
211
Fig 10d The fragment could not be removed in this
manner.
212
Fig 10e Positioning of the drilling guide.
213
Fig 10f With the milling cutters (left-hand cutting),
fragments were removed down to the base of the
abutment.
Fractured screw of a gold abutment. To restore a

missing canine at site 23, a metal-ceramic crown was
constructed on a bone-level implant. A control
radiograph was taken with the impression post in place.
The patient appeared repeatedly as an emergency
patient due to screw loosening. The one-piece crown
was finally torqued to more than 35 Ncm; as a
consequence, the abutment screw fractured with a
fragment remaining in the CrossFit® connection. The
radiograph with the impression post showed that no
close fit was present; obviously, the impression post for
a narrow CrossFit connection had been used. The
technician had therefore used the wrong implant analog
and the wrong gold coping.
As could be expected, the CrossFit® (Straumann)

connection of the final crown was not good either, as
the walls did not match—which explained the repeated
loosening. After applying the service set for bone-level
implants and components, the fractured segment could
be removed under controlled conditions (Figs 10a-m).
Following rinsing, the correct RC impression post was
used and a well-fitting crown was fabricated. No more
screw loosening occurred with the new crown.
214
Fig 10g The stop on the drilling guide prevented
overinstrumentation.
215
Fig 10h Changeover to the steel drills (left-hand
cutting)
Fig 10i Final drill guided by the precision instrument to

remove the fragment.
216
Fig 10j The necessary depth was reached with the final
tap. The remaining particles were removed completely
from the bore in the implant.
Figs 10k-m The radiographs finally revealed the cause

of the failure: an incorrect impression post—narrow
CrossFit® instead of regular CrossFit®—had been
used. As a consequence, the lab used the wrong implant
217
analog and a gold abutment that was too small, so the
CrossFit® connection was not functional. The
corresponding gaps can be seen in the first two
radiographs (arrow), whereas no gap is present with the
new regular CrossFit® impression post.
Removal of an abutment screw. In a 35-year-old

patient, tooth 11 had to be replaced with an implant
crown due to trauma. A Regular CrossFit® RC
(Straumann) bone-level implant was placed in
combination with a GBR procedure.The patient wore a
long-term provisional crown for four months to adapt
the soft-tissue profile and to optimize the papilla
configuration using the dynamic compression technique
(Wittnebenand coworkers 2013b). During delivery of
the definitive one-piece CARES®zirconia crown
(Straumann), the abutment screw fractured at about 30
Ncm. The base of the abutment screw remained in the
RC connection (Figs 11a-v).
The position of the crown had changedafter the fracture.

Despite the fractured component, the provisional crown
could still be used to maintain the soft-tissue contour.
218
Fig 11a A veneered zirconia CARES® crown was
ready for delivery. During torqueing to 35 Ncm, the
abutment screw fractured at about 30 Ncm.
Fig 11b The crown could not be returned to its position.
219
Fig 11c The fractured abutment screw with the flat head
base for ceramic crowns. The apical portion had
remained in the implant.
The patient was scheduled for an open-end session, and

the service set was ordered and prepared together with
the components for the bone-level supplement. The
provisional crown was removed. The tools of the
service set were used according to the instruction
manual under good ergonomic and illumination
conditions.
A first attempt to unscrew the fractured part with the

thread-removal tool was unsuccessful, so the drilling
guide was inserted into the implant. The configuration
of the RC connection allowed accurate positioning. The
wings of the device were secured on the neighboring
teeth. The milling cutters and the drills were applied in
due order, with manual tapping at low speed and ample
cooling.
220
The most important prerequisite for correct
instrumentation is parallelization with the implant axis.
Misalignment can lead to immediate fracture of the
drills.
The cutting effect was evident, with the metal particles

transported coronally and remaining on the drills. The
site was rinsed repeatedly. The correct depth was
indicated on the instruments. Taps 1, 2, and 3 were
applied, centered by the drilling guides. Silicon oil
helped ease the tapping process. After another rinse, the
CrossFit® connection was tested for undisturbed access
with a new abutment screw.
The final fit and correct position was verified with the
definitive crown. The abutment screw was torqued in
place, keeping the screwdriver parallel and away from
the ceramic walls of the access hole and correctly
pressed onto the screw head. The access hole was then
closed with Teflon and light-curing silicone.
After one month, the site demonstrated a tight fit and

correct position, and a complete papilla had formed.
The access hole was closed with Teflon and a
composite filling. A control radiograph confirmed the
correct seating of the crown in the connection.
The fragment visible in the radiograph was removed

successfully.
221
Fig 11d Unscrewing attempt using the thread-removal
tool.
222
Fig 11e The fragment would not move.
223
Fig 11f Steel drills and the drilling guide.
Fig 11g Secure position of the drilling guide.
224
Fig 11h Drilling parallel to the long axis of the implant.
225
Fig 11i Ample cooling is required, less than 200 rpm,
left-hand drilling.
Fig 11j Drill cutting through the fragment. Loose

particles need to be rinsed out.
226
Fig 11k This tap broke due to deviation from the long
axis.
227
Fig 11l The first tap reaching the bottom of the
CrossFit® connection.
228
Fig 11m A positioning screw was used to check the
regular function of the screw retention.
229
Fig 11n The connection was rinsed carefully.
230
Fig 11o Final tap with the guidance instrument.
Fig 11p Drills and taps used to rescue the crown and
implant. The drills needed to be replaced (single use
only).
Fig 11q The original position of the CARES® crown

was restored.
231
Fig 11r The one-piece CARES® crown with a zirconia
framework and direct veneering.
Fig 11s Smile, lateral view.
232
Fig 11t Smile, frontal view.
Figs 11u-v Periapical radiographs with the zirconia

fragment and the final crown in situ.
6.1.5 Complications Related to Retention
Between the prosthetic components of an implant

system and the matching screw-retained prosthesis there
233
are always voids. A completely tight fit would make the
handling of the components impracticable. A certain
amount of tolerance is built into all interfaces.
Therespective areas are exposed to leakage. In an
anaerobic environment, microbial plaque can develop
and will be protected from any attempts at
mechanicalcleaning or antiseptic rinses. The following
two clinical cases are characterized by considerable
plaque deposits in the abutment region (Figs 12 and 13).
Thesame bacteria may also be responsible for bad
breath and may cause infection of the adjacent tissues.
Fig 12 Plaque deposits uncovered on removal of a

transversally screw-retained crown.
234
Fig 13 Abutment overgrown with plaque deposits. The
surrounding tissue is chronically inflamed.
Screw loosening with possible fistula formation. A

67-year-old patient received a bone-level implant. A
long-term provisional was provided to create an optimal
emergence profile. The patient then went on vacation
for two months; during the final week the patient had
realized that the temporary crown became mobile. She
did not see an emergency dentist abroad, and during
that short time, a fistula developed that originated from
the connection area of the mobile temporary abutment
(Figs 14a-e).
235
Fig 14a A long-term temporary crown was installed for
the conditioning of the emergence profile.
Fig 14b A favorable result with no signs of

inflammation was achieved.
236
Fig 14c During the vacation, the provisional crown
became mobile and a fistula developed.
Fig 14d After removal of the temporary crown. The

mucosa was inflamed and a small fistula is visible.
237
Fig 14e Definitive crown inserted at 35 Ncm with stable
conditions.
Cement excess. In a 45-year-old patient, a missing

lateral incisor was replaced with an implant-supported
crown. A tissue-level implant was placed fairly deeply,
with the implant shoulder at the bone crest. The metal-
ceramic crown was cemented with glass-ionomer
cement. The control radiograph revealed excess cement
pressed into the tissues. The patient was scheduled for a
surgical intervention the following day to remove the
cement particles (Figs 15a-d).
238
Fig 15a Control radiograph after cementation of a
metal-ceramic crown on a tissue-level implant at site
12.
239
Fig 15b The patient was scheduled for an open-flap
procedure the following day. The cement particles had
been pushed into the connective tissue and underneath
the periosteum.
240
Fig 15c One year after the surgical intervention.
Fig 15d Control radiograph. No more particles are

visible.
Upon flap elevation, the white particles pressed in

underneath the periosteum were evident. After careful
removal and rinsing, sutures were placed. A clinical
examination at one year revealed neither recession nor
signs of infection at the site. The radiograph showed no
bone damage.
Retrievability of cemented crowns. The safest way to

remove a cemented reconstruction is to break the
cement seal. The superstructure can be clamped with a
forceps with rubber-protected jaws. A pulsing device to
break the cement seal may be helpful (CORONAflex®;
241
KaVo, Biberach, Germany). The force applied with the
mobile abutment screw remaining in the bore must not
damage the implant connection. If the cement seal
cannot be broken, the crown must be cut down to the
depth of the cement seal between the crown and the
abutment.
In metal-ceramic reconstructions, the ceramic veneer

can be prepared with a rough diamond followed by a
steel drill. In zirconia frameworks, a special spiral-
shaped diamond seems to be efficient (JOTA service
set; Jota, Rüthi, Switzerland).
Cutting should remove the superstructure and provide

access to the abutment screw. If the screwdriver
engages at this point, the abutment can be completely
removed. If the regular screwdriver does not engage
because of prior damage to the head of the abutment
screw, the service set from the respective implant
manufacturer will be needed.
In the case shown here (Figs 16a-c), implants 46 and 45

had been restored with splinted metal-ceramic double
crowns on solid abutments, and cemented with a glass-
ionomer cement. After six months, the patient
complained about ceramic chipping that led to food
impaction.
Attempts to remove the double crown with the

CORONAflex were unsuccessful. The dentist was
advised to separate the crown with diamond burs for the
ceramic and with stainless steel drills for the
framework.
242
Apparently, the borderbetween the framework,
cementum, and abutment had been missed, so the
cutting had damaged the solid abutment with the insert
for the screwdriver. Thus for the removal of the
non-retrievable solid abutment the service set had to be
used for detorqueing the abutment in a controlled way.
Fig 16a A metal-ceramic double crown was inserted on

implants 45 and 46. Chipping in the ridge region
occurred after one year.
243
Fig 16b The crowns, which had been cemented with a
glass-ionomer cement, could not be removed even with
the CORONAflex system. The crowns were therefore
cut. During cutting, the insert for the screwdriver in the
solid abutment of the distal implant was damaged.
244
Fig 16c A conical extraction bolt was applied after
drilling an access hole into the solid abutment with the
steel drills. Ratchet and bolts with 6° conicity.
Repeated loosening of an occlusal screw. A 67-year-

old patient had received a LOCATOR® overdenture in
the maxilla and a metal-ceramic crown on a wide-neck
implant at site 46 and a cantilever FDP (x-i36) at site
36, also on a Wide Neck (WN) implant and a synOcta®
abutment (both Straumann) torqued to 35 Ncm. The
separate framework on implant 36 was made using a
gold coping. The final reconstruction was tightened to
15 Ncm as recommended by the manufacturer.
The patient experienced repeated screw loosening at

site 36.
It was decided to take a new impression and to

construct the new framework with a gold abutment. The
new FDP was a one-piece reconstruction tightened to
35 Ncm. It is expected that the biomechanical risk for
screw loosening has been reduced (Figs 17a-p).
245
Fig 17a Frontal view after insertion of a LOCATOR®-
retained overdenture in the maxilla as well as an
implant-supported crown at site 46 and a cantilever
FDP at site 36 (x-i36).
Fig 17b Lateral view of the two-unit FDP.
246
Fig 17c The FDP was transocclusally screw-retained.
Fig 17d Radiograph of site 46.
247
Fig 17e Control radiograph of site 36.
Fig 17f The cantilever FDP at site 36 was designed with

a separate synOcta® abutment for screw retention;
therefore, the retention is based on two screws.
248
Fig 17g Screw loosening at site 36 had occurred several
times.
Fig 17h A new impression was taken and a healing

abutment inserted.
249
Fig 17i The two-unit FDP was designed in one piece
with only one abutment screw.
Fig 17j Patient smile.
250
Fig 17k Frontal view.
Fig 17l Lateral view.
251
Fig 17m Lateral view.
Fig 17n Occlusal view of the palate-free overdenture.
252
Fig 17o Occlusal view after closing the access holes
with a composite restorative material.
Fig 17p One-piece reconstruction made with a gold

abutment to reduce the number of interfaces.
Non-retrievable occlusal screw. If the head of the

occlusal screw is damaged, it may be non-retrievable. In
this clinical case, the patient had already received
253
implants in the late 1980s. Due to unresolvable
endodontic problems with remaining anterior maxillary
teeth, a new treatment plan included the removal of
these teeth and the placement of additional implants.
This required the removal of the first generation of
fixed reconstructions. The existing implants in the
maxilla could be used to support a cross-arch cantilever
denture.
The attempt to remove the transocclusally screw-

retained FDP turned out to be complicated (Figs 18a-e).
Due to attrition, the head of the occlusal screw did not
engage the screwdriver. The drills of the service set
were therefore used to drill directly into the screw head.
After enlargement and drilling to a depth of 3 mm, the
extraction bolt was activated with the ratchet after the
FDP had been segmented with diamond disks and cut
back to allow rotation. Upon application of torque, the
entire complex consisting of occlusal screw, crown, and
abutment came loose in one piece.
The old implants could subsequently be splinted with

the new ones and a new reconstruction fabricated.
254
Fig 18a The patient had already received implants in the
late 1980s. A new treatment plan required the removal
of the first generation of fixed reconstructions. As a
result of attrition and the coronal position of the screw
heads, the crosshead had worn away completely in one
of the occlusal screws.
255
Fig 18b Using the spiral drills and the extraction bolt,
the entire superstructure was removed.
256
Fig 18c The FDP had to be segmented to allow
unscrewing.
257
Fig 18d After many years in function, the occlusal
screw, crown, and abutment were fused and came out in
one piece.
Fig 18e Following placement of additional implants, the

maxilla was restored with a full-arch screw-retained
FDP with denture teeth and an acrylic veneer.
6.1.6 Complications Related to Healing Abutments
The following examples illustrate some of the problems

that may be encountered with healing abutments.
Damage to the insert of a healing abutment. A patient

with a non-retrievable implant component was referred
with a request to remove the healing abutment from
implant 33 (Figs 19a-c).
258
Fig 19a The two implants were ready for impression-
taking. Deposits were present in the SCS part. The
screwdriver did not engage, so the healing abutment
could not be removed.
Fig 19b After preparing an access hole in the healing

abutment, an extraction bolt was tightened manually.
259
Fig 19c With the ratchet set to “unscrew,” the blocked
component was removed.
The patient had been scheduled for impressions in a

private practice. The connection between the
screwdriver and the healing abutment had been
damaged.
A first attempt consisted in the removal of the deposits

in the insert of the healing abutment. The connection
was damaged considerably, and no detorquing force
could be applied with a screwdriver. Therefore, a
1.6-mm drill from the service set was used to prepare a
central access hole in the healing abutment. At a depth
of about 3 to 4 mm, the 6° extraction bolt was screwed
into the hole counterclockwise. On activating the torque
ratchet, the healing abutment was removed. After
careful cleaning, a new healing abutment was tightened
manually on the implant, and the patient was referred
back to the private dentist.
260
Removal of a blocked healing abutment. A 53-year-old
patient had had a 4.1-mm-diameter regular CrossFit®
implant (Straumann) placed at site 15 at a private
practice. A healing abutment was connected to the
implant.
The dentist prepared to take an impression of the

implant, but the healing abutment could not be
removed. The dentist ordered the special service set
from the implant manufacturer, but attempts to reverse
torque of the healing abutment were unsuccessful
despite the fact that an access hole had been drilled and
an extraction bolt applied.
The patient was then referred. The retrieval of the

blocked healing abutment was challenging because the
original screw-access hole had been damaged during
the initial attempts. The corresponding screwdriver no
longer engaged the implant component (Figs 20a-e).
Given the damage to the original screw-access hole in

the healing abutment, the hole was enlarged with a
special drill from the manufacturer’s service set.
Continuous irrigation was required to reduce the heat in
the implant body. The drilling speed was limited to a
maximum of 200 rpm. Under these conditions, the
sharp edges of the drills were able to engage the healing
abutment. After preparing the new access hole, the
extraction bolt from the service set was connected and
the torque ratchet activated. Remarkably, the healing
abutment still would not loosen at a reverse torque of
approximately 50 Ncm.
261
Fig 20a The initial attempt by the restorative dentist to
rescue the blocked healing abutment was unsuccessful.
Fig 20b The access bore was widened for easier

application of the torque.
262
Fig 20c A longer extraction bolt was provided, but the
patient reacted to torques greater than 40 Ncm as he felt
pain in the bone.
Fig 20d CO2 was applied for two minutes with the
applicator for vitality testing.
The access hole was further enlarged and reverse torque

was again applied with the extraction bolt, whereupon
263
the patient began to feel pain at the implant site. The
reverse torque required was thought to be so intense
that damage to the implant connection or the bone-to-
implant interface was possible, so the blocked healing
abutment was cooled twice for 60 seconds with dry ice
(CO2) on the buccal and palatal aspects. The dry ice
was obtained from a pressurized CO2 cylinder and
placed in a hollow removable carrier encased in a pencil
stick. The interval between the first and second cooling
was 30 seconds. The patient was not anesthetized
during CO2 application, but did not report any
sensitivity or pain.
The cooling effect reduced the preload between the

CrossFit® connection of the implant and the conical
non-retrievable healing abutment. The approach of
creating an access hole for the application of reverse
torque via the extraction bolt, in combination with the
novel cryogenic effect, led to the successful removal of
the non-retrievable abutment. Neither the critical bone-
to-implant interface nor the internal implant-thread
geometry was damaged. Upon removal of the healing
abutment, it became obvious that the axis of the initial
bore drilled by the restorative dentist did not correspond
to the long axis of the implant. This might have
prevented the success of the purely mechanical reverse-
torque attempts. The combined cryomechanical
procedure saved the implant, which was successfully
restored as planned by the restorative dentist. (Case:
Joda and coworkers 2013.)
264
Fig 20e After applying CO2 to the healing abutment and
the connection area, the component could be retrieved
with less torque.
6.1.7 Complications Related to Systems for

Overdentures
Damage to the bar and sleeve. A 70-year-old patient

had received a bar overdenture in the undergraduate
course at the University of Bern, Switzerland.
The overdenture required repeated repairs due to

damage to the bar and sleeve.
It was decided to change the bar design to a

LOCATOR® overdenture design. The synOcta® 1.5
(Straumann) TO abutments were removed and replaced
with LOCATOR® (Zest Anchors LLC, Escondido,
California, USA) abutments. One of the abutments
could not be removed with the screwdriver. Application
of the stainless-steel drill followed by the extraction
265
bolt and the ratchet resulted in carefully controlled
removal of the blocked abutment (Figs 21a-d).
Fig 21a A bruxism patient had fractured teeth and

reconstructions several times. The bar components of an
overdenture also fractured on a later occasion. The four
synOcta® abutments were replaced with LOCATOR®
abutments. Three abutments could be removed using
the regular screwdriver and ratchet. To remove the
fourth abutment, the drills and extraction bolt from the
service set were needed.
266
Fig 21b Impressions of the LOCATOR® abutments
were obtained using the housings with the protective
inserts.
267
Fig 21c Final overdenture modified from a bar design to
a LOCATOR® overdenture design.
Fig 21d Occlusal view of the four LOCATOR®

abutments.
When the final LOCATOR® abutment had been

tightened, an impression was taken with the metal
housings, and the overdenture was rebased/modified.
Fractured LOCATOR®abutment. A LOCATOR®

abutment screw had fractured, with a fragment
remaining in the implant. On counterclockwise drilling
into the center of the fragment with the stainless-steel
drill, the fragment loosened and could be removed (Figs
22a-c). Very careful handling is recommended to avoid
aspiration in these cases. After rinsing, a new
LOCATOR® abutment was inserted and torqued to 35
Ncm. The overdenture could be returned to function
immediately.
268
Fig 22a This LOCATOR®-supported partial denture no
longer functioned well because one of the abutments
was broken.
Fig 22b The top of the LOCATOR® abutment was torn

off. The abutment screw was removed using the drills
from the service set.
269
Fig 22c With the new abutment, the overdenture was
again functional.
Wear of attachment systems for overdentures.

Attachment systems for the retention of overdentures
are exposed to wear. A patient presented with a partially
edentulous mandible and extreme wear of the few
remaining anterior teeth (Figs 23a-e). The patient did
not wear her removable partial denture, so the
functional and parafunctional forces were concentrated
in the anterior region.
270
Fig 23a The patient had received a LOCATOR®
overdenture supported by implants 14, 13, 11, 21, and
23.
Fig 23b Signs of severe attrition of the few remaining

mandibular anteriors. The patient did not wear her
partial denture.
271
Fig 23c The LOCATOR® abutments showed signs of
severe wear; the retentive areas were damaged.
Fig 23d The inserts in the overdenture were also heavily

worn.
272
Fig 23e All five LOCATOR® abutments were replaced,
and new inserts were provided. This repair took place
five years after delivery of the overdenture.
The LOCATOR® abutments showed heavy wear, and

the inserts were degraded. The retentive mechanism
was dysfunctional. All the LOCATOR® abutments
were replaced after five years in function and new red
inserts were pressed into the housings. This
immediately restored the retention of the overdenture.
6.2 Superstructure-related Complications
6.2.1 Denture Teeth and Acrylic
Fracture of denture teeth. The maxilla of this 55-year-

old edentulous patient had been reconstructed with an
overdenture on four implants. The mandible held a
retrievable cantilever prosthesis on 6 implants, which
273
replaced a large volume of missing tissue. Denture
tooth 31 fractured at the base and was replaced (Figs
24a-b).
Fig 24a Denture tooth 31 broken out from the acrylic

base.
Fig 24b The overdenture was repaired the same day.
274
6.2.2 Wear and Attrition
Repeated fracture of denture teeth and acrylic. This

65-year-old patient had received a cantilever prosthesis
on four implants, which was screw-retained and
veneered with acrylic. The patient experienced multiple
fractures of the denture teeth and veneer (more than ten
times). It was finally decided to change the prosthesis to
a LOCATOR® overdenture. After insertion of the
LOCATOR® denture there were no more events related
to acrylic or denture tooth fractures (Figs 25a-d).
Fig 25a The patient had received a bar-retained

prosthesis in the maxilla and a screw-retained acrylic
FDP in the mandible.
275
Fig 25b Repeated denture-tooth and acrylic fractures
occurred.
Fig 25c The FDP was changed to a LOCATOR®

device.
276
Fig 25d The LOCATOR® abutments were well
distributed. No more tooth fractures occurred.
Attrition, bruxism, chipping. The patient had lost and

fractured several teeth in an accident and was treated
with tooth-supported and implant-supported
reconstructions in December 2006. A Michigan splint
was provided to protect the reconstructions, since it was
evident that the patient was a heavy bruxer.
In March 2012, the FDP (x-25-26) was redone due to

massive chipping. In November 2013, the patient again
presented with massive chipping, destroying a
substantial share of the ceramic veneer. The chipping in
the maxilla was temporarily accepted, but the implant-
supported FDP (i35-x-i37) was scheduled for a remake
because of food impaction (Figs 26a-b).
277
Fig 26a Occlusal view of an implant-supported FDP
(i47-x-i45). The extensive chipping could be attributed
to insufficient framework support.
278
Fig 26b The patient was a severe bruxer. The lateral
view demonstrates the extensive chipping.
In cases with chipping, it often becomes evident that the

required framework support has not been provided.
6.2.3 Ceramic Chipping
In this particular case, three fixed FDP supported by

only four implants in each jaw were inserted to
rehabilitate this patient. He was a severe bruxer. Since
he refused to accept a removable appliance, a cost-
effective fixed reconstruction was provided. Severe
attrition affected the reconstructions. The esthetically
distracting loss of the veneer ceramic in the incisal
region of tooth 21 was repaired with a composite filling.
It is unclear how long this repair will survive. Since the
FDP is retrievable, alternative repairs in the laboratory
are envisioned if needed (Figs 27a-d).
279
Fig 27a Maxillary and mandibular FDP on only four
implants had been inserted. The chipped veneer at site
11 is distracting.
Fig 27b Heavy signs of wear in the maxilla.
Fig 27c Heavy signs of wear in the mandible.
280
Fig 27d Repaired upper anterior region. The incisal
edge was adhesively reshaped with composite.
6.3 Iatrogenic Reasons
In this case, the patient had expected to benefit from a

full-mouth rehabilitation. The treatment included the
placement of implants in the posterior regions, since she
had lost her molars to advanced periodontal disease. All
the teeth were prepared for ceramic crowns (Figs
28a-e).
Unfortunately, essential quality requirements related to

biological principles (biologic width, access for oral
hygiene, regular maintenance), esthetics (non-esthetic
reconstructions), surgical management (early loss of an
implant), and function were not met.
281
With respect to occlusion and articulation, the clinical
views demonstrate a non-functional situation. The
patient could not close and had no posterior contacts.
The patient suffered from severe pain, day and night.
All the reconstructive elements will have to be

disassembled and the acute pain controlled using new
temporaries before a new rehabilitation can be created.
This will have considerable financial and legal
consequences.
Fig 28a Smile line of a recent full-mouth rehabilitation.

Note the inflamed gingival margins.
282
Fig 28b The large anteriors are too long and touch the
lower lip.
Fig 28c The patient could not close in the posterior

region. The occlusal planes of the lower and upper
reconstructions did not match.
283
Fig 28d Imprecise and overcontoured reconstructions,
especially in the anterior region.
Fig 28e Ill-fitting crowns resulted in crown/tooth

fracture and endodontic emergencies.
284
6 Management of Hardware Complications
U. Brägger
285
7.1 Prevention of Peri-implant Infections
Prevention of biological complications involves

identification and management of modifiable risk
factors. The following patient-related factors are
associated with an increased risk for peri-implant
infection:
• Poor oral hygiene
• Tobacco smoking
• History of treated periodontitis
• Presence of periodontal pockets (≥ 5 mm with

concomitant bleeding on probing)
• Lack of supportive or maintenance care
• Diabetes mellitus (has also been suggested as a risk

factor, although poor control of the diabetes may be of
greater importance)
Site-related factors associated with peri-implant

infection include:
• Insufficient bone volume at the implant recipient site
• Incorrect three dimensional implant position
• Proximity of implants/teeth
286
• Insufficient width of keratinized peri-implant
mucosa
For patients presenting with multiple risk factors,

placement of implants should be delayed until all
factors have been addressed. For example, in a patient
with periodontitis with poor oral hygiene who smokes
20 cigarettes per day, the risks are expected to be much
greater than in a patient who has only one risk factor
such as tobacco smoking. Implant placement should
only be performed when the periodontal health is stable,
the patient’s oral hygiene has improved (full-mouth
plaque score/FMPS less than 20%), and smoking
cessation advice has been provided.
The following stages of the implant treatment process

play an important role in the prevention of future
biological complications:
7.1.1 Treatment Planning
As part of the treatment planning stage, a careful

assessment of the patient’s requirements and
expectations, a thorough medical and dental history,
and a comprehensive clinical examination are required.
The use of a diagnostic wax-up, a radiographic stent,
and appropriate radiographs are important in this
planning stage (Figs 1a-c). These steps will ensure that
potential patient- or site-related risk factors for future
biological complications are identified and discussed
with the patient prior to treatment commencing.
7.1.2 Preparation of the Patient
287
In patients diagnosed with chronic or aggressive
periodontitis, completion of active periodontal therapy,
aiming for elimination of residual pockets with bleeding
on probing, should precede implant placement.
In patients with a history of treated periodontitis with

residual probing depths (PD) at least 5 mm with
concomitant bleeding on probing, FMPS of more than
20% and associated risk factors, retreatment, and
periodontal reevaluation are recommended before
implant placement. The increased risk for peri-implant
infection should be discussed with patients who have a
history of periodontitis prior to implant treatment. A
maintenance care program with shorter intervals should
be planned for patients diagnosed with aggressive
periodontitis.
Tobacco smokers should be informed of their increased

risk of peri-implant infection and provided with
smoking cessation advice.
288
Fig 1a Diagnostic model of a maxillary anterior site.
Fig 1b Diagnostic wax-up.
289
Fig 1c CT scan of a mandibular molar site with
radiographic stent in situ.
Fig 2 Schematic diagram. Minimum orofacial width of

the bone required for implant placement in relation to
the implant diameter (d). In this diagram, the implant
has 1 mm of bone on the facial and palatal aspects.
290
Fig 3a Limited keratinized mucosa available in the
posterior mandible prior to implant placement.
Fig 3b Free gingival graft to increase the width of

keratinized mucosa.
Fig 3c After placement of the implants a band of

keratinized mucosa surrounds the implants, Images
courtesy of Dr. M. Roccuzzo.
291
7.1.3 Preparation of the Recipient Site
Preparation of the recipient site may involve hard- or

soft-tissue grafting procedures, to ensure an adequate
volume of bone and width of keratinized mucosa prior
to implant placement. If bone augmentation is required,
a staged or simultaneous approach may be chosen
depending on the available bone volume for correct
three-dimensional implant positioning. A minimum of 1
mm of bone surrounding the entire implant
circumference is required to avoid incomplete
osseointegration of the implant, which may result in
subsequent biological complications (Fig 2). The
appropriate choice of the implant diameter is therefore
important to prevent future biological complications.
The effect of the width of the keratinized mucosa on

peri-implant health outcomes may be influenced by a
number of factors, including the patient’s oral hygiene,
and on the supportive post-implant therapy provided
(Frisch and coworkers 2014). Nevertheless, a recent
systematic review addressing the necessity of
keratinized mucosa for peri-implant health concluded
that an adequate zone of keratinized mucosa (approx. 2
mm) is related to better peri-implant health (Brito and
coworkers 2014). Furthermore, in the completely
edentulous mandible an insufficient band of keratinized
mucosa (less than 6 mm) on the orofacial aspect was
associated with a higher incidence of biological
complications in the first year following provision of
full-arch implant-supported mandibular prostheses
(Maló and coworkers 2013). Therefore, establishing an
adequate band of keratinized tissue can be considered as
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a preventive measure for future biological
complications (Figs 3a-c). Where keratinized mucosa is
minimal or absent, soft-tissue grafting may be
performed either prior to implant placement, at the time
of second-stage surgery if submerged healing has
occurred, or following restoration of the implant as a
preventive measure.
Preparation of the Implant recipient site may also

involve orthodontic treatment to create the ideal space
for implant placement and subsequent restoration.
Orthodontic tooth extrusion may also be considered in
situations where the crown has fractured subgingivally,
in order to optimize the bone and soft-tissue volume at
the implant recipient site (Fig 4).
Fig 4 Extrusion of a fractured tooth to create a more

favorable recipient site.
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Fig 5a Schematic diagram. The green zone indicates the
ideal mesiodistal implant position; encroaching on the
red zone would mean that the implant is too close to the
adjacent teeth.
Fig 5b Ideal apicocoronal position.
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Fig 5c Ideal orofacial position.
7.1.4 Implant Placement
A correct surgical technique (sufficient cooling,

minimal pressure, sharp drills) during osteotomy
preparation is important (Buser et al. 2004) to prevent
overheating of the alveolar bone, which would result in
marginal bone loss and incomplete osseointegration of
the implant.
Correct three-dimensional positioning of an implant is

important to prevent risk of biological and esthetic
complications (Figs 5a-c). Placement of implants too
close together (less than 3 mm between adjacent
implants), or too close to neighboring teeth (distance
from implant platform to tooth less than 1.5 mm) may
result in insufficient access for adequate plaque control
and subsequent peri-implant infection (Serino and
Ström 2009; Abi Nader and coworkers 2014).
295
Malpositioned implants may result in marginal bone
loss, mucosal recession, and exposure of part of the
implant surface to the oral cavity, which enables a
biofilm to readily form on the endosseous portion of the
implant with the risk of peri-implant infection (Fig 6).
Fig 6 Schematic diagram. The implant body has been

placed too far facially, so that the implant shoulder also
projects too far facially. As a result, a portion of the
facial implant surface will not be surrounded by an
adequate thickness of bone.
The use of a surgical template aids in the correct three-

dimensional position for implant placement (Figs 7a-b).
296
Fig 7a Acrylic surgical template with an osteotomy drill
in position, facilitating an ideal position of the implant
for screw retention. Occlusal view.
297
Fig 7b Acrylic surgical guide illustrating the distance
from the zenith of the crown to the bone level. Buccal
view.
7.1.5 Prosthesis Design
A correct design of the implant-supported prosthesis

may also prevent future biological complications. By
ensuring adequate access for cleaning, the risk for
biofilm accumulation and subsequent infection is
minimized. The technician should provide sufficient
space for the use of oral hygiene aids between the
mucosa and the fitting surface of the prosthesis, and
between implants. Pontics and cantilevers should have
highly polished convex surfaces that can be easily
cleaned (Figs 8a-d). There should be no rough or sharp
edges that could tear or shred dental floss during oral-
hygiene procedures (possibly resulting in a retained
floss remnant and subsequent infection). Avoiding
excessive ridge-lap designs and minimizing the palatal
extension of prostheses may also facilitate cleansability
(Abi Nader and coworkers 2014).
298
Figs 8a-b Well-designed multi-unit implant-supported
prosthesis with a highly polished ovate ceramic pontic.
The embrasure spaces provide sufficient access for
dental floss or interdental brushes. These design
principles facilitate plaque control.
299
Figs 8c-d Well-designed single implant-supported
prosthesis with a highly polished ovate ceramic
cantilever. The notch can be easily located by the
patient to guide in inserting dental floss or an
interdental brush for plaque control. (Images courtesy
of Mr. John Lucas, technician).
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The design and the submucosal contour of the
prosthesis will influence the peri-implant tissues.
Prosthesis design should also aim to establish good
proximal contacts with contours that prevent food-
packing in embrasure areas (Fig 9).
Fig 9 Single implant-supported crown, designed with

broad contacts and ideal embrasure spaces to avoid food
trapping.
If a cement-retained prosthesis is required and the

implant has been placed deeply, that the cement line
must not be deeper than 1.5 mm submucosally. This can
be achieved in a number of ways.
Some implant systems provide a selection of stock

abutments with cementation lines of varying heights.
Alternatively, a custom abutment can be fabricated to
place the cement line in an ideal position. This will
reduce the risk of a biological complication caused by
retained excess luting cement (Figs 10a-b). Using a
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careful cementation technique will also reduce the risk
for submucosal excess luting cement. It has also been
suggested that excess cement might be more easily
identified on a radiograph if the luting cement used
were radiopaque.
Fig 10a Screw-retained custom abutment. This enables

the final crown to be cemented at a position (approx. 1
mm submucosally) where the cement line can be
managed minimizing the risk for excess luting cement.
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Fig 10b Crown seated on the custom abutment. (Images
courtesy of Mr. John Lucas, technician).
Another treatment option that can be considered when

the restoration margin is located more than 1.5 mm
submucosally, and where direct screw retention is not
possible due to the implant angulation, is screw
retention using a transverse screw (Figs 11a-c).
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Fig 11a Custom gold abutment with transverse screw at
site 23.
Fig 11b Final prosthesis screw-retained with a

transverse screw at site 23. Occlusal view.
Fig 11c Final prosthesis screw-retained with a

transverse screw at site 23. Facial view.
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When fabricating provisional restorations on implants,
great care must also be taken to avoid biological
complications caused by rough submucosal surfaces or
by the fracture of provisional restorative materials. Fig
12 shows a peri-implant infection caused by a fragment
of the provisional composite crown, which was lodged
submucosally.
Fig 12a Peri-implant infection. The temporary crown at

site 11 has been removed. Redness and swelling at the
facial mucosa.
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Fig 12b Periapical radiograph. A dislodged fragment of
the provisional crown at site 11.
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Fig 12c Once the fragment (shown) was removed, the
infection resolved.
7.1.6 Supportive Care
Regular supportive care plays an important role in the

prevention of peri-implant infections (Costa and
coworkers 2012; Roccuzzo and coworkers 2012). An
individualized recall program should be discussed with
the patient as part of the treatment planning phase to
prevent both biological and hardware complications.
Approximately one month after delivery of the

definitive implant-supported prosthesis, clinical and
radiographic baseline measurements should be
established and recorded for future reference and
comparison. Probing depth measurements in relation to
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a fixed landmark should be recorded at four sites per
implant where possible.
Individualized oral-hygiene instructions should be

provided to ensure the patient is able to clean the
prosthesis and maintain healthy peri-implant tissues.
With regard to the ideal oral hygiene regimen, there are
very few studies comparing different products and
techniques in patients with implants (Grusovin and
coworkers 2010). The use of interdental brushes or
dental floss and an electric, sonic-powered, or manual
toothbrush is recommended to clean circumferentially
around each implant (Swierkot and coworkers 2013;
Chongcharoen and coworkers 2012) (Fig 13). The
clinician should be aware that manual dexterity varies
between individuals and may change for an individual
over time. A careful assessment of the patient’s ability
and motivation to maintain adequate plaque control is
recommended.
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Fig 13 Thick green floss used to clean the implant
abutments circumferentially.
While there is limited evidence to recommend the

routine use of antiseptic mouthrinses to prevent of peri-
implant infections, a triclosan-based toothpaste seems
to be more effective than a fluoride toothpaste in
preventing peri-implant mucositis (Trombelli and
Farina 2013).
During supportive care, the following steps are

important:
• Update of the medical and dental history
• Clinical inspection of the implant-supported

prosthesis
– Assessment of the occlusion
– Assessment for any component-related

complications such as material wear, chipping and
fractures
– Assessment of contact areas and embrasure areas,
• Clinical inspection of the peri-implant tissues
– Plaque or calculus
– Probing depths in relation to a fixed reference point
– Bleeding or suppuration on gentle probing
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– Mucosal abnormality e.g. redness, swelling,
draining sinus
• Clinical inspection of the remaining dentition and

soft tissue
• Prophylaxis or additional treatment as required
• Individualized instructions for oral hygiene
• Determination of the next recall interval
7.1.7 Diagnostic Monitoring of the Peri-implant Tissues
Regular diagnostic monitoring of the peri-implant

tissues includes assessment of presence of plaque,
probing depths, bleeding on gentle probing (approx.
0.25 N) or suppuration.
Changes in probing depth from a fixed landmark should

be assessed regularly and compared to previous
examinations. In the presence of clinical signs of
disease, an appropriate radiograph is indicated in order
to detect radiographic bone level changes compared to
previous examinations.
Peri-implant health is diagnosed in the absence of

clinical signs of inflammation. A recall frequency of at
least once yearly is recommended unless systemic or
local conditions require more frequent intervals. In
cases of peri-implant health, professional cleaning
including reinforcement of oral hygiene is
recommended as a preventive measure (Figs 14a-b).
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Fig 14a Implant monitoring at a supportive-care
appointment using a periodontal probe with light
pressure. Healthy peri-implant tissues with a probing
depth of 3 mm and no bleeding on probing.
311
Fig 14b Professional prophylaxis using a rubber cup
and polishing paste at the supportive-care appointment.
Peri-implant mucositis is diagnosed in the presence of

individual clinical signs of soft-tissue inflammation
(e.g. redness, edema, suppuration) and bleeding on
gentle probing. If peri-implant mucositis is diagnosed,
in addition to reinforcement of oral hygiene, mechanical
debridement with or without antiseptics (e.g.
chlorhexidine) is delivered. Re-evaluation should
follow approximately six to eight weeks after this
treatment. The use of systemic antimicrobials is not
recommended for the treatment of peri-implant
mucositis. There is some evidence that the regular use
of a toothpaste containing triclosan may reduce the
clinical signs of inflammation in subjects with peri-
implant mucositis (Ramberg and coworkers 2009). The
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treatment of peri-implant mucositis should be
considered as a preventive measure for the onset of
peri-implantitis (Costa and coworkers 2012).
Peri-implantitis is diagnosed in the presence of peri-

implant mucositis in conjunction with progressive
crestal bone loss. When peri-implantitis is diagnosed,
early implementation of an appropriate treatment is
recommended to prevent further progression of the
disease (see Chapter 5).
7.1.8 Frequency of Recall
The frequency of recall is dependent on the patient’s

risk profile and willingness to attend. A risk-assessment
tool may be used to guide the appropriate interval for
supportive care (Lang and Tonetti 2003). This tool
requires the evaluation of a number of factors and
calculates the risk for biological complications as either
high, medium, or low providing the rationale for recall
at three, six, or twelve months, respectively (Figs
15a-c). This risk-assessment tool can be downloaded in
several languages from the University of Bern
(www.perio-tools.com) (Lang and Tonetti 2003).
313
314
Figs 15a-c Examples of (a) high, (b) medium, and (c)
low risk with recommended recall frequencies.
The factors taken into consideration include:
• Patient age
• Number of teeth and implants present
• Number of missing teeth
• Number of bleeding positive sites
• Number of sites with a probing depth greater than 5

mm
• Periodontal bone loss
• Tobacco smoking
• Systemic conditions such as diabetes mellitus
315
7.2 Prevention of Loss of Osseointegration Due to
Occlusal Overload
For patients diagnosed with parafunctional habits such

as clenching or bruxism, an occlusal nightguard is
indicated to prevent biological and hardware
complications (Fig 16).
Fig 16 Maxillary acrylic occlusal nightguard to be worn

at night by a bruxer with an implant-supported
prosthesis.
While there is limited evidence to suggest that a

specific occlusal scheme for implant-supported
prostheses is superior, some general recommendations
for occlusal morphology include flat fossa and grooves
for wide freedom in centric occlusion, shallow occlusal
anatomy, a narrow occlusal table, and reduced cusp
inclination. A smaller (30% to 40%) occlusal table for
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molars as well as implant-protected occlusion has also
been recommended (Yuan and Sukotjo 2013) (Table 1).
Table 1 Occlusal scheme guidelines for implant-

supported prostheses, adapted from Yuan and Sukotjo
2013.
General occlusal scheme
• Centered contacts in maximum intercuspation

(point centric or freedom in centric with 1–1.5 mm)
• Light contact on firm occlusion with shimstock

(8–30 µm) passing through
• Anterior guidance with natural dentition
• No centric relation—maximum intercuspation

discrepancy
Implant-supported fixed dental prosthesis (single

unit)
• Avoid excursive guidance
• Increased proximal contact
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Implant-supported fixed dental prosthesis (multiple
unit)
• Anterior section
– Light contact in maximum intercuspation
– Flat vertical and horizontal overlap and

protrusive guidance to reduce lateral forces
– Selective excursive guidance for best

biomechanical abutment distribution
• Posterior section
– Excursive guidance on well-supported anterior

natural teeth with posterior teeth disclusion in
eccentric movements
– Canine protected or mutually protected

occlusion if canine present
– Group function occlusal scheme if canine

absent or prosthesis replacing bilateral distal
extension
– Optimum abutment support for working

guidance
7.3 Prevention of Non-plaque-related Oral Mucosal

Disorders
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A careful medical history taking and assessment of the
oral hard and soft tissues in the treatment-planning
phase, prior to implant placement is important. While
the prevention of some non-plaque related biological
complications might not be possible, if the patient is
seen on a regular basis for supportive care, an early
diagnosis and appropriate management can be made. At
each supportive care appointment, the medical history
and current medications should be updated. The patient
should be referred for appropriate assessment and
biopsy if the diagnosis is unclear.
7.4 Concluding Remarks
Identifying and reducing potential risk factors is an

effective preventive strategy for complications in
implant dentistry. Of the complications presented in this
ITI Treatment Guide, many seem to be iatrogenic.
Appropriate clinician education, training, and
experience will reduce the overall risk of complications.
Furthermore, a patient who has been informed of the

potential for future complications prior to treatment
may be less likely to see an adverse event as a
complication, but rather as part of supportive or
maintenance care. In other words, the worst type of
complication may be the unexpected one—the
complication that was not discussed during the
treatment planning stage. The most difficult scenario to
manage might be when a patient has been told that the
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implant treatment will “last a lifetime” or that “implants
are better than teeth.”
To reduce the risk of unexpected complications due to a

component or a technique, documentation of long-term
success rates is of paramount importance. Given the
rapid development of new materials and techniques
within the field of implant dentistry, it would be prudent
to think carefully about the risks and benefits of “early
adoption” before committing to the new and relatively
untested.
The incidence of biological and hardware complications

has been documented in numerous systematic reviews
(Jung and coworkers 2008; Romeo and Storelli 2012;
Pjetursson and coworkers 2012; Pjetursson and
coworkers 2014). From these reviews, it is apparent that
the incidence of hardware complications is much
greater than biological complications. The relevant
information concerning the likelihood of possible
complications and the importance of regular monitoring
and supportive care should be presented to the patient in
the treatment discussion phase of implant therapy.
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7 Prevention of Biological Complications
321
8.1 Prevention of Complications Related to
Components and Reconstructions
8.1.1 Implant Body
In order to avoid permanent deformation or fracture of

the implant body, standard implant diameters and
materials should be chosen that are optimized in terms
of material characteristics and design. Reduced-
diameter implants may play an important role in narrow
ridges and narrow spaces. They provide easier and less
expensive treatment options and lower morbidity
compared to GBR procedures (Sohrabi and coworkers
2012). This also applies for short implants compared to
sinus augmentation or nerve displacement procedures
(Neldam and Pinholt 2012; Srinivasan and coworkers
2012). There is no evidence yet that so-called mini-
implants can be recommended for definitive
reconstructions (Bidra and Almas 2013).
When the envelope of indications is stretched, however,

it is advisable to choose materials with improved
physical properties but with an equivalent
osseointegrative surface. The search for additional
indications for implant-supported reconstructions led to
the development of reduced-diameter implants
manufactured from a titanium/zirconium alloy
(Steinemann 1998; Gottlow and coworkers 2010;
Thoma and coworkers 2011).
322
Ongoing clinical testing of mandibular overdenture
cases with one reduced-diameter (3.3 mm) bone-level
implant made of grade IV titanium and one implant
with the same design but made of titanium/zirconium
alloy has demonstrated very similar clinical
performance (Al-Nawas and coworkers 2012).
Osseointegration and stable tissue integration can be
achieved with this new material while getting a chance
of better biomechanical performance for fixed
reconstructions (Barter and coworkers 2012; Chiapasco
and coworkers 2012). This improved material has been
integrated into a new set of implants by a leading
manufacturer.
The search for attractive materials in esthetically

demanding cases and for ways to avoid the use of
different materials in a reconstruction/abutment/implant
complex led to the development of zirconia implants.
This material seems to osseointegrate in a manner
similar to titanium implants (Gahlert and coworkers
2009; Bormann and coworkers 2012) but its physical
properties are completely different. The clinical
application of reduced-diameter zirconia implants has
so far been unsuccessful (Gahlert and coworkers 2012).
In addition, the one-piece implants in zirconia create
unfavorable prosthetic conditions.
The design characteristics of the platform and neck

region influence the load transfer from the
reconstruction/abutment complex to the surrounding
crestal bone, and the neck surface is in direct contact
with the adjacent soft-tissue cuff. Attempts to improve
the hardware were made (conical connection designs,
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platform switching, surface alterations), all aiming to
provide the capacity to sustain and transfer the load and
to interfere only minimally with the formation of a
stable biologic width and crestal bone level.
Any maintenance procedures such as oral hygiene or

professional supportive therapy should not damage the
implant neck (or the abutment). This applies especially
to the use of mechanical instruments, acids, abrasive
substances, lasers, and the tips of ultrasonic devices.
When performing aggressive interventions, such as
cutting a non-retrievable cemented crown, caution is
required not to damage the platform e.g. in tissue-level
implants.
Damage unintentionally inflicted with a drill may be

irreparable and will pose a problem for a precise fit of a
future reconstruction. An individual conventional
impression can be required after smoothening the
affected platform when a new reconstruction is
delivered.
If the three-dimensional position of the implant body

(axis and platform) is unfavorable relative to adjacent
and opposing structures, the prosthetic procedures will
be more complex. The reconstruction may require
esthetic, biological, or functional compromises—or the
implant may be even non-restorable. Prosthetically
driven implant planning and positioning is therefore
mandatory. This includes the depth of the platform in
relation to adjacent teeth, adjacent implants, and the
opposing jaw; the buccooral position of the platform(s);
the axis of the implant(s); and the relative positions of
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the platform and the planned reconstruction. This
applies not only to fixed reconstructions but also to
overdentures.
8.1.2 Implant/Abutment Connection
Improved connection designs have been developed to

prevent hardware-related complications and failure, and
the loosening/fracture rate has been reduced to
acceptable levels (Theoharidou and coworkers 2008)
compared to when oral implants were first introduced.
Clinicians can avoid problems by careful handling of

the connection area, by creating an open access with
healing screws and mucosa formers, and by using long-
term provisionals for conditioning the emergence
profile. Any foreign matter (tissue, graft particles,
blood) should be rinsed off before connecting a
component.
Finding the correct index position is very important.

Radiographic controls of impression posts can assist in
this, as can transfer keys for angled or modified
abutments. The impression post must match the
implant.
The abutment screw should not be pushed down into

the connection. Rather, the index of the abutment base
should first be found; only then is the abutment screw
turned slowly and without tilting.
325
In multi-unit reconstructions, it is advisable to activate
the screws alternatingly and in increments until the final
seating is achieved with the torque ratchet.
The torque recommended by the manufacturer was

optimized for the respective material and design
combinations and must be respected.
8.1.3 Abutment Body and Abutment Screw
The design of an abutment can determine where an

abutment screw will fracture in case of excessive force
onto the superstructure/implant complex—preferably in
an area that provides good access and visibility. In these
cases, the fragment can easily be removed with a probe
and rotational movements. However, an abutment screw
fragment may also be completely blocked in the
connection, or restricted access to a fragment may limit
its controlled removal. The connection area should not
be damaged while removing fragments. The microscope
may provide a direct view of the area to help locate the
problem so the fragment can be removed with an
endodontic explorer. Any drilling or retapping should
only be performed with a precise guide (from the
manufacturer’s service set).
It is a clinical reality that not only impression posts but

also abutment screws may be unintentionally
exchanged. This could happen at the laboratory or at
chairside. For example, the use of an abutment screw
with a conical head base may result in fracture of a
ceramic abutment. The threads of the abutment screw
326
must match the bore in the implant, so the use of
original abutments is advisable.
The axis of the screwdriver has to be positioned along

the long axis of the implant/abutment to find the correct
insertion position. When tightening down a crown, the
contacts with adjacent teeth or implant-supported
crowns should not be so tight that they block the screw
movement, as otherwise a fracture in the ceramic
veneer or damage to the bore/thread might occur. The
abutment screw should not be forced downwards. The
correct index should be first located and the
reconstruction/abutment held in the insertion direction.
The head of the abutment screw must be protected,
preferably with Teflon, underneath a screw-canal
restoration.
With respect to the correct handling of the components,

it also seems important to provide the clinician/
technician with assistance related to logistics,
information on new products, instruction, training,
logical (e.g. color-coded) step-by-step procedures,
exchangeable components, and, in case of problems,
assistance in the form of a service set and a well-
organized complaint system.
These issues relate not only to the implant and to

prosthetic components but also to the auxiliary parts,
such as impression posts, analogs, registration posts,
and the screwdrivers and torque ratchets.
8.1.4 Third-party Components
327
The abutment body must match the implant
configuration. Narrow, regular, and wide designs
should not be mixed; third-party abutments do not
match the original connection precisely.
Economic pressure to produce and deliver implant-

supported reconstructions at a reduced price may lead to
the acceptance of alternative solutions involving third-
party abutments (i.e. abutments made by a different
manufacturer than the implant) available on the market.
Limited access to equipment and halting investment in
laboratory equipment could also result in the selection
of third-party abutments. The designs of screw joints
such as those at the implant/abutment interfaces should
be matched carefully because the biomechanical
properties mainly depend on factors such as materials,
tolerance, connection designs, and preload (Dixon and
coworkers 1995; Gratton and coworkers 2001; Khraisat
and coworkers 2002; Meng and coworkers 2007; Lee
The aims of a recent in-vitro study (Gigandetand

coworkers 2014) were:
1. To test the in-vitro mechanical resistance of three

original implant/abutment interfaces and to compare
these original interfaces to two combinations of third-
party abutments and one of the original implants.
2. To test the influence of geometric discrepancies at

the interfaces between the implants and the original/
third-party abutments by assessing rotational misfit.
328
3. To assess and compare failure modes.
Small-diameter implants were chosen to test a high-risk

condition compared to implant/abutment connections of
standard dimensions. The null hypothesis was that there
would be no significant difference in the mechanical
characteristics between the original and third-party
interfaces.
Third-party abutments differed in the design of the

connecting surfaces, shape, dimensions, and material
and had a higher rotational misfit. All these differences
resulted in unexpected failures and may have had an
adverse effect on clinical handling. More clinical
studies testing the failure and complication rates of
reconstructions on original and third-party connections
should be performed; however, at this point it is
recommended to use abutments by the original implant
manufacturer when restoring implants.
A recent clinical study related to the survival of

alumina-reinforced zirconia abutments examined the
long-term risks associated with third-party interfaces
between implants and abutments (Kim and coworkers
2013). A total of 213 patients had received 611
externalhex implants and 328 fixed reconstructions.
Implants from five manufacturers were placed. The
ceramic abutments, however, were produced by a single
manufacturer. Posterior single-unit reconstructions
(n = 101) demonstrated an increased and clinically
unacceptable rate of technical failures. The third-party
abutments on the five implant systems were not stable
329
enough to provide satisfactory function in the posterior
area.
8.1.5 Retention: Screw-retained and Cemented
As in conventional prosthodontics on natural teeth, a

precise marginal fit must be achieved on implant/
abutment platforms. Therefore, the conventional and the
newer digital impression techniques, the production
process at the laboratory or production center, and
intraoral delivery must avoid the accumulation of errors
that lead to unacceptable gaps. A framework try-in
helps detect any need for corrections or remakes.
One-piece reconstructions directly screw-connected

with the implant have major advantages. In two-part
systems, the use of copings for screw-retained
reconstructions results in more precise gaps compared
to cemented reconstructions. It is also more predictable
to produce a “precision gap” with single-unit
reconstructions. The gap width increases with the length
of the reconstruction.
To prevent biological problems, cement gaps should be

avoided wherever possible; if required, they should be
located as far coronally as possible. Extraoral
cementation onto bonding bases is an alternative, since
the cementation process is controlled in the dental
laboratory and thereby submucosal cement residues are
avoided.
A very thin layer of cement should be applied with a

brushing technique. The reconstruction must be seated
330
slowly. Applying petroleum jelly on the outer aspect of
the crown may make cement removal easier. Residue
may be removed with Superfloss® dental floss (Oral-B,
Schwalbach, Germany), dental floss with knots, or an
interdental brush. Cement residue is explored with a
periodontal probe and air jet to open the sulcus. The
control radiograph will not help detect all cement
residue. Signs of inflammation should be checked for
during the days/weeks after cementation. Even a
temporary cement such as Temp Bond (Kerr, Orange,
California, USA) may be difficult to detect and remove
completely. Controllable cementation protocols should
therefore be developed.
The prophylactic considerations for occlusal screws are

similar to those for abutment screws. A correct original
screw must be applied. For screws from an unknown
system, a matching screwdriver must be found. In the
event of screw loosening, the entire reconstruction with
all the components have to be disassembled, cleaned,
and retightened carefully, followed by checking the
occlusion and articulation. Pristine screws have to be
used in case of repeated loosening.
Screwdrivers/ratchets must be applied correctly. The

dental technician should provide a sufficiently wide
access for the screwdriver. The screwdriver must not be
pressed against any ceramic surface around the access
hole in order not to cause cracks.
The access head of the screw must be protected,

preferably with Teflon tape. Screw-retained
reconstructions offer the advantage of retrievability.
331
They can be used to create emergence profiles and
pontic designs much more easily than the cemented
ones. Patients should be instructed to return
immediately in case of screw loosening. The
reconstruction should be retightened as soon as possible
to avoid additional damage such as screw fractures or
ceramic chipping.
Screw-retained superstructures may require an

inordinate amount of maintenance if screws loosen
repeatedly. Reasons for this complication may include:
• Insufficient framework fit
• Occlusal interference
• Loosening of the underlying abutments
• Defective screw joint
• Not enough torque due to incorrect handling or use

of a worn ratchet
• Use of a worn screw (e.g. the laboratory occlusal

screw)
Screw loosening may be controlled by eliminating

potential adverse factors, carefully cleaning the
components, using a new occlusal screw, and applying
the correct torque.
The screw access plug should hide the usually

unesthetic access hole and provide a continuous
332
functional surface. Removal should be easy, and
damage to the screw head should be avoided (Moráguez
and Belser 2010).
If the screw head is located at or slightly underneath the

occlusal surface, attrition may result in damaging of the
screwdriver insert.
Abutments and frameworks must fit correctly. For

cross-arch FDP, the Sheffield test should result in a
stable seat/fit while tightening an occlusal screw.
Frameworks should not get stuck as they are placed on
abutments. As when changing a car tire, the screws are
activated incrementally, moving from one screw to the
other. After a few minutes’ break, a second and final
adjustment is made.
Both cemented and screw-retained reconstructions

should be designed to allow optimal access for oral
hygiene and to provide access for diagnostic procedures
and professional maintenance.
It is not advisable to remove screw-retained

reconstructions at each recall appointment—this would
be impractical (time-consuming and expensive). Screw-
retained reconstructions may, however, be removed if a
clinical or radiographic examination indicates changes
in the condition of the peri-implant tissues. In such
instances, retrievable reconstructions allow direct
access to the implant platforms and the surrounding
tissue, not least for interventions to treat infections. It is
also easier to repair screw-retained reconstructions in
case of hardware-related complications. Access for the
333
treatment of biological complication is also much easier
with easily retrievable reconstructions.
8.1.6 Closure Screw, Healing Abutment, Mucosa

Formers
Complications can be avoided by choosing the most

suitable component in terms of height and width. It may
also be decided to replace a component by an
alternative one, e.g. after second-stage surgery.
In patients with a thin mucosal biotype, excessive

pressure may result in recession. Mucosa formers
should be torqued manually. Patients should perform
chemical plaque control for about one week after
surgery, after which time mechanical cleaning is
advised, e.g. with an end-tufted brush.
Before applying the screwdriver, deposits such as hard

food residue or calculus must be removed with a probe.
Detorqueing should be manual at first. With tight-fitting
components, care must be taken not to rotate the
implant. Increasing ISQ (Implant Stability Quotient)
values are indicative of successful integration. The
ratchet should be positioned so the screwdriver is
parallel to the long axis of the implant. Stop
detorqueing immediately if the patient feels pain.
8.1.7 Attachment Systems for Overdentures
Attachment components should be wear-resistant.

Components with easy chairside activation and
components that do not involve the laboratory for
334
replacement are preferred. Space requirements should
be minimal.
For an optimal overdenture support, the implants should

form an optimal support polygon and not be positioned
too closely and with the implants/abutments at a similar
vertical height. The axes of the implants should not
diverge too far. Overgrowing mucosa may inhibit the
function of an attachment.
Fig 1a Heavy plaque deposits on a full-arch fixed

denture after removal. The patient had obviously not
succeeded in cleaning successfully underneath the
reconstruction.
335
Fig 1b The corresponding occlusal view shows
accumulated plaque around the implants and abutments.
Fig 2a The removable LOCATOR® overdenture (same

patient) has been kept much cleaner.
336
Fig 2b The peri-implant situation in the maxilla
revealed clean and healthy conditions.
Some attachment systems may be difficult to keep

functional in elderly patients who cannot remove food
particles from retentive areas. These patients may be
better off with solitary attachments.
Basic occlusion concepts apply to reduce stress/load/

fatigue on attachment systems. Overdentures should be
reinforced with metal frameworks. Again, prosthetically
driven implant placement is mandatory.
Mesostructures as described in the Glossary of Oral and

Maxillofacial Implants are intermediate or middle
supporting framework connected to the infrastructure
and providing support and/or retention for the
superstructure. They should be avoided by placing
implants in a correct position. Reconstructions should
337
be as simple as possible. This can be achieved by
placing the implants in the correct position, thereby
avoiding bulky and uncleansable superstructures.
8.1.9 Superstructures
The design of a reconstruction should not interfere with

oral hygiene. Some designs such as the cantilever
extension prosthesis replacing large volumes of tissue
may be too bulky and prevent comfortable access for
plaque control in large areas.
The following example demonstrates the situation after

removal of a superstructure before the recall at the
dental hygienist (Figs 1a-b and 2a-b). The patient has
worn the reconstruction for eight years. At every third
recall appointment, the entire reconstruction was
removed for better access for professional cleaning and
ultrasonic treatment of the denture. The opposing
LOCATOR® overdenture was much more amenable to
oral hygiene.
On removal of the cross-arch extension prosthesis, it

became evident that the patient was not capable of
cleaning underneath the reconstruction, while at the
upper denture no obvious plaque formation was
observed.
When opting for a removable rather than a fixed

reconstruction, easy access for plaque control is often a
major decision factor.
8.2 Risk Management
338
Since the risks that affect the outcome of implant
treatment may arise from many sources, a
comprehensive risk scheme is proposed here. It
considers nine sources of risks, each of them with eight
potential risk factors (Table 1). Evidence can be found
in the literature for many of the factors associated with
increased risk. Most factors can be controlled by the
dentist and the patient.
Table 1 Risks that may negatively affect implant

treatment outcomes.
Risk sources Risk factors
1. Economic 1. Low GDP (gross domestic

risks product)
2. Access to technology, know-how
3. Social security
4. Income loss
5. Education, system
6. Third-party payer
339
7. Me-too products (similar or
identical to an established product
with no significant advantage over it)
8. Profit-oriented treatment (no

sustainability)
2. Provider- 1. Education, competence

related risks
2. Access to technology
3. Treatment concept
4. Surgeon/prosthodontists/general
dentist
5. Logistics, assistance
6. Collaboration with technician
7. Prophylaxis, maintenance
8. Ethics
3. Patient-related 1. Health
risks
2. Mindset, education, willingness to
cooperate
340
3. Parafunction, bruxisms
4. Periodontitis susceptibility
5. Smoking
6. Drugs
7. Handicaps
8. Risk for trauma
4. Implant-/ 1. Implant material

component-
related risks 2. Implant surface
3. Implant dimensions, design
4. Connection
5. Component materials
6. Tolerances, precision
7. Original component
8. Tools
341
5. Manufacturer- 1. Competence, experience
related risks
2. Portfolio of products
3. Quality control
4. Evidence
5. Service, complaint system
6. Logistics
7. Teaching, education
8. Innovation
6. Surgical risks 1. General surgical risk
2. Handling of bone, soft tissue,

guided bone regeneration (GBR)
3. Comprehensive planning with

periodontal pretreatment
4. Prosthetically driven implant

placement
5. Infection control, operatory
342
6. Complexity of case, self-
assessment, limits
7. Repeated interventions
8. Postsurgical care
7. Esthetic risks 1. Correct platform position
2. Soft-tissue management/
emergence profile
3. Defects, missing volume, scars
4. Papilla, large gaps
5. Smile
6. Thin mucosa
7. White Esthetic Score (WES)
8. Complications affecting esthetics,

chipping
8. Laboratory- 1. Education, competence

related risks
2. Quality
343
3. Logistics, support, availability
4. Infection control
5. Conventional production workflow
6. Digital production workflow
7. Art, ceramics
8. Esthetics
9. Superstructure- 1. Loading protocol

related risks
2. Type of reconstruction
3. Connection/fixation
4. Occlusion
5. Veneer
6. Contour, access for cleaning
7. Retrievability
8. Wear, attrition, fatigue
As indicated in the overview of reported survival and

success rates with implant-supported reconstructions,
hardware complications and failures do occur and are
344
on a gradual increase. The steepness of the increase
depends on the type of reconstruction inserted and on
patient, maintenance, and other risk factors.
By providing retrievability, repairs may be easier and

may postpone failure. Hardware-related failures and
complications can be reduced by controlling the quality
of the materials and the production process.
Factors shown to be associated with increased failure/

complication rates can be influenced and avoided. The
risk assessment should include multifactorial causes.
A
lthough associations between certain constellations and
failures/complications have been demonstrated, the real
cause often cannot be ascertained, which is reflected in
the literature. Causative factors may include material
specifications, dimensions of frameworks/veneers,
number of firing cycles, manipulation of components,
use of third-party components, and many more. This
information is usually not given in the studies related to
this topic.
Nevertheless, the risk levels shown in Figures 3 and 4

for a supposed low-risk and a supposed high-risk
individual receiving a reconstruction reflects that the
decision-making process can in fact influence most of
the critical parameters.
345
Fig 3 Example of a high-risk case.
Fig 4 Example of a low-risk case.
346
8 Prevention of Hardware Complications
U. Brägger
347
348
9 Clinical Case Presentations
9.1 Biological Complications
9.1.1 Iatrogenic Complications Managed by Replacing

Prosthetic Components: Non-surgical Approach
B. Schmid
A male patient had lost teeth 11 and 22 as a result of a

bicycle accident at age 14. In his adolescent years, a
removable prosthesis had replaced the missing teeth. At
age 21, the patient was referred by his dentist to the
university clinic for treatment of the missing teeth 11
and 22 with implants. He was in good health and a non-
smoker. The absence of teeth 11 and 22 over many
years had led to significant atrophy of the alveolar
ridge, particularly at site 11. As a first step, the alveolar
ridge was augmented using a block graft to replace the
lost bone. A Straumann SP implant (diameter 4.1 mm,
length 12 mm; Institut Straumann AG, Basel,
Switzerland) and a Straumann Narrow Neck implant
(length 10 mm) were inserted in the correct location and
axial position at sites 11 and 22, respectively, six
months later. After three months of healing and
subsequent reentry, the patient returned to the referring
dentist to receive the prosthetic restoration. The patient
was seen again six months after the restoration had been
placed. The frontal view showed a high smile line, an
irregular gingival profile, and a bluish-gray tinge to
implant crowns 11 and 22 compared to the natural
dentition (Fig 1).
349
Fig 1 Frontal view at baseline. High smile line with
irregular gingival profile from implant crown 11 to
natural tooth 21.
Fig 2 Inflamed soft tissue at the buccal aspect of

implant crown 11 with fistula formation.
Under magnification, a slightly shorter incisal edge of

implant crown 11 as well as pronounced reddening
350
accompanied by fistula formation at the buccal aspect
of implant 11 (Fig 2) was observed. Crowns 11 and 22
had been cemented. The radiographs showed a distinct
gap, particularly at implant 11, between the implant
shoulder and the edge of the crown (Figs 3a-b).
351
Figs 3a-b Implants 11 und 22 at baseline. (a) Distinct
gap between the implant and the crown due to a
cementing error at implant 11. (b) At implant 22, only a
small cementing error is seen.
As the crowns had been cemented, strong compression

resulted in cement residue being deposited in the soft
tissue, which was responsible for the inflammation
(mucositis) around the implant. If cement residue is
present, associated bone loss (peri-implantitis) is
frequently the long-term result.
Figures 3c-d show a case six years after cementation of

an implant-supported anterior crown with bone loss due
to peri-implantitis as well as cement residue around the
Narrow Neck implant.
352
Figs 3c-d (c) Radiograph of a Narrow Neck implant six
years after cementation of a crown. Cement residue is
visible on the mesial and distal aspects of the implant
353
neck. (d) Intraoperatively, the cement residue causing
the inflammation and the bone defect are clearly visible.
The removal of cement residue in deeply subgingival

cemented superstructures can be difficult (Korsch and
coworkers 2013). The ITI Consensus Statements
recommend screw-retained superstructures or a
customized mesostructures in cases where an implant
shoulder is in a deep subgingival position (deeper than
1.5 mm), in order to keep the cement within the sulcus
area (Wismeijer and coworkers 2013). There are
basically two treatment approaches to iatrogenic peri-
implantitis caused by cement residue:
• Surgical intervention to remove the cement residue

under (advantageous) visual control while leaving the
existing crown in place. Disadvantages include the
difficult surgical access and, as in this case, the fact that
an inadequate crown will still be in place.
• Non-surgical intervention to remove of the cement

residue after removing the existing restoration. An
advantage is the opportunity to prepare a new,
esthetically improved, better fitting crown.
Disadvantages include the difficult removal of cement
residue with no visual control and the high costs
associated with a new implant crown.
Given the esthetically unsatisfactory result, the patient

decided to opt for a new restoration and non-surgical
intervention. With permanent cement (in this case
Ketac™ Cem, 3M AG, Rüschlikon, Switzerland), it is
difficult to remove individual crowns cemented in one
354
piece. To avoid damaging the implant structure, it was
decided to dismantle the crown using a carbide drill.
Under local anesthesia, crowns 11 and 22 were slit open
on the buccal and palatal aspects and then removed.
Some slight damage to the soft tissue at the subgingival
edge of the crown was almost unavoidable (Fig 4). The
abutments were unscrewed and removed (Fig 5). A
periodontal curette and a sharp scoop were used to
remove the inflamed tissue and the cement residue
around the implant. The sulcus was then rinsed with
chlorhexidine digluconate (0.1%).
Fig 4 Removal of implant crown 11 using a carbide bur.

Traces of the slitting at the buccal and palatal aspects.
355
Fig 5 Occlusal view after removal of the abutment.
Clear signs of inflammation in the peri-implant soft
tissue; the implant shoulder is not visible due to the
inflamed soft tissue and the inadequate fit of the former
cemented crown. Surprisingly, the dentist had cemented
not only the crowns but also the abutments (Fig 6). This
violates the implant manufacturer’s instructions.
356
Fig 6 Removed SynOcta abutment, which had been
inappropriately cemented.
Fig 7 Open-tray impression using screw-retained

copings for a new screw-retained single-tooth
provisional.
Fig 8 Laboratory-made, screw-retained composite

provisional on implants 11 and 22. The great pressure
357
on the soft tissue caused by the emergence profile
designed by the technician is evidenced by visible
ischemia.
Fig 9 The provisionals were left in place for five

months to give the soft tissue time to mature.
At the same appointment, an impression was taken at

implant level using screw-retained impression copings
(Fig 7) to provide the patient with individual screw-
retained provisionals on implants 11 and 22 and to
proceed with soft-tissue conditioning. After the
impression, long cylindrical healing caps were installed
and the old removable prosthesis was worn for another
week, after which the custom screw-retained
provisionals were fitted on implants 11 and 22. The
pressure on the soft tissue to create the emergence
profile designed by the dental technician produced
extensive initial ischemia (Fig 8). Often this step cannot
be carried out without local anesthesia, as the pressure
exerted on the soft tissue is very painful for the patient.
358
Fixed provisionals in the esthetic zone are often
intended to shape and condition the soft tissue and
allow the dentist time to discuss and define esthetic
considerations with the patient.
After five months of wearing the provisional, the soft

tissue had matured (Fig 9). A new impression was taken
for the final restoration to transfer the emergence profile
created to the laboratory. Using gold copings, the
technician prepared two single screw-retained crowns
for implants 11 and 22.
The frontal view after treatment (Fig 10) showed that

the soft tissue was free of inflammation and presented a
harmonious gingival profile. The radiographs document
the precise fit of the new screw-retained restorations
(Figs 11a-b).
Fig 10 Definitive screw-retained metal-ceramic crowns.

Good integration of the soft tissue and harmonious
gingival profile.
359
Figs 11a-b Radiographs of implants 11 (a) and 22 (b)
after treatment.
360
The long-term follow-up ten years after insertion
showed stable soft tissue (Figs 12a-b) and new bone
formation (Figs 12c-d) despite less than diligent oral
hygiene.
361
Figs 12a-d Ten years after delivery. (a, b) The patient’s
oral hygiene is inadequate, with plaque visible between
the teeth. (c, d) The radiographs show stable bone
conditions.
362
This case documents that deep subgingival cementation
can give rise to peri-implant infection of the soft tissue
with accompanying bone loss caused by uncontrolled
cement residue. This fact has been documented by
various studies (Linkevicius and coworkers 2011,
2013). The ITI Consensus Statements recommend
screw-retained reconstructions in the anterior esthetic
zone where the crown margins are located
subgingivally, to avoid problems of this very sort.
Cementing superstructures (e.g. in the event of implant-
axis problems) should limit the cementing area to the
sulcus via mesostructures to facilitate removal of
cement residue.
363
9.1.2 Peri-implantitis Treated with Access-Flap Surgery
A 27-year-old male was referred to the periodontist for

assessment and management of implant site 41. The
implant had been placed nine years previously and
restored with a screw-retained single crown. The patient
was a cigarette smoker in good general health. He
reported he had reduced his smoking habit from 25
cigarettes per day to 15 cigarettes per day in the
previous six months.
On examination, there was calculus and plaque present

at the lower anterior teeth and at implant site 41.
Localized attachment loss was observed at teeth 32 and
42, with 2–3 mm of gingival recession. At implant site
41, there were 8–9 mm probing depths with suppuration
and bleeding on probing (Fig 1). The patient had
himself noted suppuration on finger pressure from
around the implant. A periapical radiograph showed
marginal bone loss to between thread 6 and 7 of the
implant (Fig 2). Previous radiographs were not
available for comparison. A diagnosis of peri-
implantitis was made.
364
Fig 1 Implant site 41, with bleeding and suppuration on
probing.
Fig 2 Periapical radiograph. Marginal bone loss to

between thread 6 and 7 of the implant.
365
The patient was informed that there was severe bone
loss around the implant and that one of the treatment
options to consider would be removal of the implant.
The patient was also informed that, when attempting to
treat and maintain the implant, surgical access would
likely be required considering the extent of bone loss
and depth of the peri-implant pocket. He was also
informed that recession of the mucosal margin should
be expected following treatment. The patient opted to
try to maintain the implant for as long as possible.
Fig 3 The implant following elevation of a full-

thickness mucoperiosteal flap prior to decontamination
of the implant surface. Approximately eight threads of
the implant are exposed on the facial aspect of the
implant.
366
Fig 4 Clinical photograph showing decontamination of
the implant surface using a titanium brush.
Fig 5 Implant site 41 after positioning the flap margins

and suturing.
367
Fig 6 Implant site 41 twelve months following surgical
treatment. Note the recession of the soft-tissue margin.
Fig 7 Regular supportive care. Air-powder abrasive

with glycine powder used to remove biofilm every three
to four months.
368
Fig 8 Periapical radiograph showing stable peri-implant
marginal bone levels twelve months after surgical
treatment. Marginal bone level between threads 6 and 7
of the implant.
Non-surgical treatment
The patient attended for one visit for non-surgical

debridement of his dentition and oral-hygiene
instructions. Information regarding smoking cessation
was also provided. At the implant, non-surgical
debridement was performed using titanium curettes.
Oral-hygiene instructions demonstrating a
circumferential flossing technique at implant 41 were
provided. The periodontal and peri-implant tissues were
re-evaluated at four weeks. An improvement in the
patient’s plaque control was noted with a resolution of
369
gingivitis. As expected, there was a persistent deep
probing depth at the implant, and surgical access was
planned for decontamination of the implant surface in
conjunction with systemic antimicrobial treatment.
Surgical access flap and implant-surface

decontamination
Full-thickness facial and lingual mucoperiosteal flaps

were raised with vertical releasing incisions to gain
access to the defect associated with the implant. The
inflammatory granulation tissue was removed, revealing
a circumferential bone defect with no buccal or lingual
walls (Fig 3). The defect was therefore considered
unsuitable for a regenerative approach (bone-graft
material/barrier membrane). The implant surface was
decontaminated using a titanium brush in an oscillating
handpiece with copious irrigation with sterile saline
(Fig 4).
The flaps were positioned and sutured (Fig 5) and

postoperative instructions provided. Amoxicillin 500
mg, three times a day, and metronidazole 400 mg, three
times a day, were prescribed for seven days. The patient
was instructed to rinse with a chlorhexidine mouthrinse
twice daily for one minute for a period of four weeks.
The patient was warned of possible side effects
following systemic antimicrobials. The patient was seen
for suture removal ten days after surgery and for review
at one and three months (Fig 6).
Three-month re-evaluation
370
Three months following surgical treatment, the peri-
implant infection had resolved (no suppuration or
bleeding on probing and a reduction in probing depths
to 5 mm). There was also 2 mm recession of the peri-
implant soft tissue margin. The patient was then seen on
a three-monthly basis for monitoring and supportive
care (Fig 7).
Twelve-month re-evaluation
Twelve months following surgical treatment, there were

further improvements in the health of the peri-implant
soft tissues with probing depths of 3 mm, and no
bleeding or suppuration on probing (Fig 6). No further
bone loss was observed on the radiograph (Fig 8). The
patient reported he had reduced his smoking habit but
continued to smoke approximately 10 cigarettes per
day.
Discussion
This case describes an anti-infective approach for the

management of peri-implantitis with a successful
outcome at twelve months (Heitz-Mayfield and
coworkers 2012). Importantly, a strict postoperative and
supportive care protocol was followed. Regular (three-
to four-monthly) visits will be required for future
monitoring and maintenance care for this patient.
371
9.1.3 Excess Cement Resulting in Peri-implant
Infection Presenting as a Draining Sinus Tract
T. Linkevičius
Biological complications caused by undetected cement

residue have been receiving much attention. Excess
cement might be responsible not only for rapidly
developing of peri-implantitis, but also for delayed or
chronic manifestations of the disease many years after
cementation (Wilson 2009; Linkevicius and coworkers
2013). In-vitro and clinical studies have shown that it is
very difficult or even impossible to completely clean up
excess cement at subgingival margins, so popular in
cemented restorations (Agar and coworkers 1997;
Linkevicius and coworkers 2011, 2012). Possible
outcomes of biological complications due to excess
cement range from temporary inflammation of the peri-
implant soft tissues without any serious esthetic and
functional consequences all the way to implant loss.
This report describes a case of peri-implantitis caused

by residual cement; as well as the management and
quite unusual resolution of the complication.
The patient presented in 2009 with a draining sinus

tract, tenderness on chewing, and tissue contact above
the implant-supported restoration (Fig 1). The implant
had been restored approximately three years before.
372
Fig 1 Draining sinus tract above an implant-supported
restoration.
The patient’s dental history showed that a two-piece

implant 3.5 mm in diameter and 12 mm in length
(Internal System; BioHorizons, Birmingham, Alabama,
USA) had been placed and had successfully integrated.
A standard abutment supported a metal-ceramic
restoration cemented with glass-ionomer cement
modified with a resin luting agent (Fuji Plus; GC,
Tokyo, Japan). Excess cement was removed; a
radiographic examination did not show any residue. The
treatment was considered completed; the patient was
satisfied and did not request any consultation or
intervention after the treatment until the present
occasion.
Probing showed deep pockets up to 8 mm and profuse

bleeding on probing (Fig 2). However, the general
condition of the periodontal tissue around other teeth
373
was good; bleeding on probing and the plaque index of
the other teeth did not exceed 15%.
Fig 2 Bleeding on probing.
The radiographic examination showed severe crestal

bone loss up to the third implant thread. The bone-loss
pattern was characteristic of peri-implantitis. No cement
residue was noted, and the bone level of the adjacent
teeth indicated no periodontal involvement (Figs 3a-b).
Clinical and radiological evaluation yielded a diagnosis
of chronic peri-implantitis.
374
Figs 3a-b Radiographic examination with different
positions of the holder.
375
The initial treatment plan provided for removal of the
restoration and evaluation of the peri-implant tissues.
The occlusal surface of the restoration opened to gain
access to the abutment screw, which was loosened and
the restoration was removed. A large lump of cement
residue was found on the buccal side of the implant,
invisible on the radiograph (Figs 4a-b).
376
Figs 4a-b (a) Previously undetected lump of cement
residue in the peri-implant sulcus. (b) Size of the
undercut of the restoration; removed excess cement.
An extensive undercut was present between the

cementation margin on the standard abutment (lower
arrow) and the emergence profile of the restoration on
the buccal side (upper arrow) (Fig 4b), the side of the
undercut where the cement residue was lodged in the
peri-implant mucosa. The undercut can be described as
the distance between the cementation margin (where the
cement was extruded) and the emergence profile of the
restoration. It is possible that more pronounced
undercut results in an even greater risk of cement
entrapments.
The cement residue was removed and the peri-implant

tissues rinsed with copious amounts of chlorhexidine
377
digluconate 0.12% solution (PerioAid; Dentaid,
Barcelona, Spain). There was an ulcer in the peri-
implant tissues where the cement residue had been (Fig
5a). Chlorhexidine gel (PerioAid Gel; Dentaid) was
applied on the healing abutment, which was
reconnected to the implant (Figs 5b-c). The excess gel
was washed away. The patient was instructed to rinse
the infected site with chlorhexidine digluconate solution
twice a day for one week.
378
Figs 5a-c (a) Peri-implant sulcus after removal of
excess cement. (b) Healing-abutment connection. (c)
Radiographic verification.
379
The patient returned one week after removal of the
excess cement. The draining sinus tract had
disappeared. The patient did not report any tenderness
at the site. Clinically, the soft tissues appeared healthy,
with restricted blushing of the gingiva at the former
location of the draining sinus tract. The restoration was
reconnected to the implant; the occlusal access was
isolated with polytetrafluoroethylene tape and covered
with an adhesive composite resin (Fig 6). It was decided
not to use any antibacterial drugs or perform
regenerative treatment of the peri-implantitis; the
patient was scheduled for recall visits every six months.
Fig 6 The sinus tract has healed.
The patient returned one year after removal of the

excess cement and did not have any complaints. A
radiological examination showed bony remineralization
at the previously infected implant site (Fig 7b). After
two years, full regrowth of the crestal bone around the
implant was observed (Fig 7c). During this time, the
380
patient had had his adjacent tooth replaced by an
implant.
381
Figs 7a-c (a) Reference radiograph in 2009. (b) Partial
remineralization of the bone defect in 2010. (c) Fully
established bone level in 2012. Note that in the follow-
up period, the premolar had also been replaced with an
implant supported crown.
The soft tissue was clinically healthy; the bone contours

had improved, although limited change in soft-tissue
color remained (Fig 8).
382
Fig 8 Clinical appearance of the implant-supported
restoration three years after treatment.
Discussion
The cement residue

in this clinical case had obviously caused crestal bone
resorption. After elimination of the residue, not only the
had the soft-tissue inflammation resolved, but bone
remineralization had occurred as well. This can be
compared to the remineralization of alveolar bone
around teeth. When infection has been successfully
treated and the irritants have been removed, the organic
bone matrix is remineralized. Bone regeneration occurs
in infrabony pockets in patients maintaining optimal
oral hygiene (Rosling and coworkers 1976). It can be
speculated that a similar process took place in this
implant case. The excess cement had behaved like
“artificial calculus,” which predisposed for peri-
implantitis.
383
A surgical intervention is probably not always required
as part of cement-related peri-implantitis treatment.
Once the cement residue has been removed,
remineralization of the crestal bone can occur.
384
9.1.4 Peri-implantitis Modified by Submucosal Excess
of Cement: Regenerative Peri-implantitis Therapy and
Six-year Follow-up
G. E. Salvi
A 30-year-old female patient was referred to the

Department of Periodontology of the University of
Bern, Switzerland, by a dentist in private practice.
Tooth 45 had been congenitally missing and had been
replaced with a titanium implant three years prior to the
first visit at the Department of Periodontology. The
tissue level implant had a diameter of 4.1 mm, a length
of 12 mm, and a sandblasted and acid-etched (SLA)
surface (Straumann® Dental Implant System; Institut
Straumann AG, Basel, Switzerland).
The metal-ceramic crown on implant 45 had been

cemented permanently. Implant 45 had been diagnosed
with peri-implantitis by the referring dentist in the
course of regular supportive care.
The non-smoking patient was systemically healthy and

exhibited a high standard of plaque control.
The periapical radiograph of implant 45 (Fig 1)

indicated that cement excess had not been removed
below the implant shoulder mesially and distally of
implant 45 after delivery of the implant crown. The
crown had been cemented permanently and could not be
removed without being damaged. The patient’s chief
385
complaint was to save the implant without removing the
crown for financial reasons.
Fig 1 Periapical radiograph.
Figure 2 presents a clinical buccal view of the inflamed

peri-implant mucosa at site 45 at the first examination.
The patient did not report any pain in the peri-implant
area. Pocket probing depths (PPD) up to 9 mm with
concomitant bleeding on probing (BoP) and suppuration
were detected.
386
Fig 2 Buccal view of the inflamed peri-implant mucosa.
A treatment plan including a non-surgical and a surgical

phase was presented to the patient. The non-surgical
phase included mechanical submucosal debridement
with titanium curettes under local anesthesia to remove
cement residue, followed by submucosal irrigation with
chlorhexidine digluconate solution. The patient was
instructed in the daily use of interdental brushes in
conjunction with chlorhexidine digluconate gel. A
regenerative approach to the peri-implant defect was
planned, provided a contained defect configuration was
confirmed at the time of surgery.
Figure 3 illustrates the application of a bone substitute

to the peri-implant defect to support a barrier membrane
(shown as the dark blue line).
387
Fig 3 Application of bone substitute to the peri-implant
defect.
Following elevation of a full-thickness mucoperiosteal

flap and removal of the granulation tissue, a contained
circumferential bone defect could be assessed. The
marginal bone levels of the adjacent teeth, however, had
not been affected (Fig 4).
388
Fig 4 Intraoperative view of defect. Unaffected
marginal bone levels of the adjacent teeth.
Figure 5 shows the peri-implant defect prior to the

surgical phase. The radiograph confirms that excess
cement had been removed during the non-surgical
phase.
389
Fig 5 Baseline radiograph.
After decontamination of the implant threads with

cotton pellets soaked in chlorhexidine digluconate and
saline solutions, deproteinized bovine bone mineral
(DBBM) particles (0.25–1 mm) (Bio-Oss®; Geistlich,
Wolhusen, Switzerland) were applied to the peri-
implant defect up to the transition line from the smooth
to the micro-rough implant surface (Fig 6).
Subsequently, two layers of a bioabsorbable collagen
membrane (Bio-Gide®; Geistlich) were adapted around
the neck of the implant.
390
Fig 6 Intraoperative view after implant surface
decontamination showing a DBBM application.
The mucoperiosteal flap was sutured in place around

the neck of the implant, allowing for transmucosal
healing of the soft tissues (Fig 7).
Fig 7 After wound closure (transmucosal healing

mode).
391
A periapical radiograph taken immediately after surgery
shows the fill of the peri-implant defect with DBBM
particles (Fig 8).
Fig 8 Postsurgical radiograph.
The patient was prescribed systemic antibiotics for five

days and was instructed to rinse with chlorhexidine
digluconate solution for four weeks after surgery. The
non-resorbable sutures were removed after one week;
the patient was instructed to gently brush the area with a
soft toothbrush and chlorhexidine digluconate gel in
addition to the chlorhexidine rinse. The patient resumed
interproximal cleaning with an interdental brush and
chlorhexidine gel six weeks after surgery.
392
Following the final evaluation of the treatment
outcome, the patient was referred back to the private
dental office for regular supportive care at six-month
intervals.
Figure 9 shows the clinical buccal view of implant 45

two years after regenerative therapy of the peri-
implantitis defect. PPDs of 3 mm or less without BoP
and suppuration could be assessed around implant 45.
Fig 9 Clinical situation two years after regenerative

defect therapy.
The periapical radiograph taken two years after surgery

indicates a defect fill to the smooth implant neck (Fig
10).
393
Fig 10 Periapical radiograph two years after
regenerative defect therapy.
Figure 11 shows a clinical buccal view of implant 45

six years after regenerative therapy. Redness and
swelling of the peri-implant mucosa are absent. A band
of keratinized tissue is present on both the buccal and
lingual aspects of the implant crown. The lingual view
of implant 45 six years after completion of therapy
shows an absence of bacterial deposits around the
implant crown and the neighboring teeth. This confirms
the excellent level of plaque control by the patient (Fig
12).
394
Fig 11 Six years after regenerative therapy. Buccal
view.
Fig 12 Six years after regenerative therapy. Lingual

view.
Figure 13 shows an occlusal view of the cemented

crown six years after regenerative therapy.
395
Fig 13 Six years after regenerative therapy. Occlusal
view. The periapical radiograph taken six years after
regenerative therapy reveals a defect filled to the
smooth implant neck (Fig 14).
396
Fig 14 Periapical radiograph six years after regenerative
therapy.
Discussion
The treatment of this patient started with the diagnosis

of a modifying factor for peri-implantitis (i.e. the
presence of submucosal excess cement) in the course of
supportive care in a private dental office. This
highlights the importance of regularly monitoring
implants during supportive care by clinical (i.e. peri-
implant probing, bleeding on probing, suppuration) and
radiographic means (Salvi and Lang 2004; Salvi and
Zitzmann 2014).
During the non-surgical therapy, submucosal cement

excess was removed mechanically by titanium curettes.
397
Improvement of the peri-implant soft-tissue condition
was confirmed at re-evaluation (Wilson 2009). The
presence of mucosal inflammation and residual PPDs of
6 mm or more after non-surgical therapy indicated that
the peri-implantitis had not been resolved with non-
surgical debridement in conjunction with
antimicrobials. Elevation of a full-thickness
mucoperiosteal flap, removal of granulation tissue and
thorough implant-surface decontamination constituted
the first steps of the surgical access to the peri-implant
defect (Heitz-Mayfield and Mombelli 2014). Based on
the fact that a contained circumferential defect (with
four bony walls) was detected at time of surgery, a
regenerative approach including the use of a bone
substitute and a barrier membrane seemed justified
(Heitz-Mayfield and Mombelli 2014). Although
radiographs taken two and six years after regenerative
therapy showed a filled peri-implant defect, re-
osseointegration of the previously contaminated implant
surface cannot be claimed due to a lack of histological
proof (Persson et al. 2001).
398
9.1.5 Peri-implantitis Treated by an Antimicrobial and
Regenerative Approach
A. Mombelli, P. Wick
A 73-year-old woman was referred to the Division of

Periodontology (University of Geneva School of Dental
Medicine) after repeated unsuccessful treatment of a
peri-implant infection. She was systemically healthy
and did not smoke. The patient’s history revealed that,
three years earlier, an immediate implant (Straumann
Tapered Effect RN 4.8/4.1; Institut Straumann AG,
Basel, Switzerland) had been inserted to replace the
upper right central incisor. A metal-ceramic crown had
been delivered using an adhesive resin cement. One
year later, the patient had consulted another dentist due
to discomfort in the soft tissues in the implant region.
There was a suppurating peri-implant pocket, 10 mm
deep. Peri-implant bone loss and excess luting cement
were seen on the radiograph. The situation was treated
with non-surgical debridement, amoxicillin, and
repeated submucosal irrigation with a chlorhexidine
digluconate solution. The patient was referred after the
suppuration had persisted for several months.
Figures 1 and 2 show the clinical and radiographic

situation at the time of referral. A visual inspection
showed only minimal inflammation (Fig 1). The teeth
were well maintained and periodontally healthy. Peri-
implant probing revealed a deep pocket (8 mm
mesially, 8 mm mid-buccally, 9 mm distally, 5 mm
399
palatally). There were suppuration and bleeding on
probing.
Fig 1 Minimal signs of inflammation. On the buccal

side of implant 11, there is a deep pocket with bleeding
on probing and suppuration (8 mm mesially, 8 mm mid-
buccally, 9 mm distally, 5 mm palatally).
400
Fig 2 Radiograph showing a peri-implant bone defect at
implant 11.
A radiograph (Fig 2) showed a peri-implant bone

defect. Cement residues were not visible.
A microbiological sample, taken by paper point from

the peri-implant pocket, was positive for six common
anaerobic microorganisms (Porphyromonas
gingivalis, Tannerella forsythia, Treponema
denticola, Parvimonas micra, Fusobacterium
nucleatum, Campylobacter rectus), indicating the
presence of a mixed anaerobic infection. The diagnosis
was peri-implantitis. The refractory state was assumed
to be due to persisting bacterial deposits on the implant
surface. The treatment plan called for open-flap
401
debridement and adjunctive systemic antimicrobial
therapy.
Prior to the surgical intervention, the site was cleaned

mechanically, the pocket was rinsed with chlorhexidine,
and a prescription was made for 375 mg of amoxicillin
and 500 mg of metronidazole three times per day for
seven days, beginning one hour before surgery. An
intrasulcular incision was extended from the mesial
aspect of the right canine to the mesial aspect of the left
second incisor. No vertical releasing incisions were
made. A mucoperiosteal flap was elevated and
granulation tissue was removed to expose the peri-
implant bone defect and the contaminated implant. A
large piece of excess luting cement was detected on the
buccal aspect of the implant (Fig 3). The vestibular
bony plate was missing in this area. In addition,
extensive vertical loss of periodontal attachment and
alveolar bone was seen on the neighboring lateral
incisor, due to the close proximity of the implant to the
root of that tooth.
402
Fig 3 Full-thickness flap exposing a piece of excess
luting cement. Close proximity of the implant to the
neighboring lateral incisor causing a vertical loss of
periodontal attachment and alveolar bone.
The cement residue was removed with an ultrasonic

scaler, and the implant surface was carefully cleansed
(Fig 4).
403
Fig 4 The cement residue was removed and the implant
surface carefully cleansed.
The bone defect was filled with a xenogeneic bone

substitute and covered with a collagen membrane (Fig
5).
Fig 5 The bone defect was filled with a xenogeneic

bone substitute and covered with a collagen membrane.
Passive repositioning was achieved using four

horizontal mattress sutures. The wound was secured
with interrupted sutures (Fig 6). The patient rinsed with
0.2% chlorhexidine digluconate twice a day for two
weeks. The postsurgical phase was uneventful.
404
Fig 6 Primary closure achieved with interrupted sutures.
Horizontal mattress sutures for passive repositioning.
Fig 7 shows the situation at a follow-up examination,

one year after the surgical intervention. There were no
more clinical signs of infection. Peri-implant probing
revealed no depths above 5 mm and no suppuration. At
the buccodistal aspect of the implant, the margin of the
peri-implant mucosa was positioned further apically
than before, but the implant itself was not exposed.
There was gingival recession mesial of the lateral
incisor.
405
Fig 7 One year after the surgical intervention.
Fig 8 shows the situation at the two-year follow-up. The

gingival recession mesial of the lateral incisor is less
prominent due to spontaneous partial leveling of the
gingival margin.
Fig 8 Two-year follow-up.
406
Discussion
Two aspects of this case merit closer attention: the

diagnosis and antimicrobial treatment approach and the
impact of the implant position on the outcome.
Biofilm-associated infections are notoriously resistant

to antimicrobial therapy unless the biofilm is
mechanically disrupted and the bulk of the bacterial
mass is physically removed. We therefore assumed that
the refractory nature of this local purulent infection was
due to persisting biofilm on the deeper surface areas of
the implant.
This case is a good example of a peri-implant infection

triggered and sustained by the presence of a foreign
body. In this patient, a mixed anaerobic, biofilm-
associated infection had developed due to the presence
of excess luting cement (Marsh and Devine 2011;
Mombelli and Décaillet 2011). Although suppuration
and hard-tissue damage were caused by the bacterial
infection, antimicrobial agents alone could not resolve
the condition. In fact, cement residues had appeared on
an earlier radiograph, and measures had been taken to
remove them, but the full extent of the problem had not
been recognized. Thus, this case also demonstrates the
limits of a clinical examination and conventional dental
radiography with regard to a specific diagnosis.
Overall, the outcome of the treatment aimed at

removing the cause of the infection and the
reconstructing lost structures was good. The success at
the esthetic level was partial. Due to the close proximity
407
of the implant to the lateral incisor, the infectious
process had induced a loss of periodontal attachment on
the mesial aspect of the neighboring tooth. The result
was gingival recession and the loss of the papilla
between the tooth and the implant. The implant itself
was not exposed. If the deep position of the implant
prevented exposure, on the other hand, residual probing
depths of approximately 5 mm were the consequence
(Gallucci and coworkers 2011).
The present case illustrates a specific difficulty when

positioning immediate implants in sites where the
alveolus of the extracted tooth is very close to a
neighboring tooth.
408
9.1.6 Recurrent Peri-implantitis Leading to Implant
Removal
Background

periodontist for assessment and management of implant
site 12. Implant 12 had been placed ten years previously
and restored with a cemented single crown. The patient
was a non-smoker in good general and periodontal
health.
On examination there were 7 mm probing depths at

implant 12 with suppuration and bleeding on probing.
The patient was aware of the presence of pus but had no
discomfort. A periapical radiograph showed marginal
bone loss to approximately the third thread of the
implant (Fig 1). Previous radiographs obtained from the
referring clinician indicated that there had been
progressive bone loss since the implant was restored. A
diagnosis of peri-implantitis was made.
409
Fig 1 Periapical radiograph of implant 12 showing
marginal bone loss to the level of the third implant
thread.
Following non-surgical debridement and oral-hygiene

instructions demonstrating a circumferential flossing
technique, the peri-implant tissues were reassessed at
four weeks. There was persistent infection. An
appointment was made for open-flap debridement and
implant-surface decontamination in conjunction with
systemic antimicrobials. One month following surgical
treatment, the peri-implant infection had resolved (no
suppuration or bleeding on probing and a reduction in
probing depths to 5 mm). The patient was seen on a
three-monthly basis for monitoring and supportive care.
Progressive bone loss
410
Unfortunately, recurrent peri-implantitis was diagnosed
at the eighteen-month follow-up. A radiograph taken to
monitor the marginal bone levels revealed additional
bone loss, which had progressed to the level of the ninth
thread of the implant (Fig 2). The implant was not
mobile, and there were 5-mm probing depths with some
bleeding on probing, with no suppuration (Fig 3).
Following discussion with the patient, it was decided to
remove the implant to avoid further bone loss and loss
of attachment at the adjacent teeth.
Fig 2 Periapical radiograph showing progressive

marginal bone loss to the level of the ninth thread of
implant 12 eighteen months following peri-implantitis
treatment.
411
Fig 3 Implant 12 eighteen months after surgical
treatment of peri-implantitis. Probing depths were 5 mm
with bleeding on probing.
A provisional partial denture was fabricated by the

patient’s dentist and delivered to the periodontist prior
to the implant-removal appointment. The cemented
crown and screw-retained abutment were removed (Fig
4). Following local anesthesia, the implant was
removed using an implant-retrieval tool (Nobel Biocare,
Zürich, Switzerland) (Figs 4 and 5).
412
Fig 4 The sectioned implant crown (right), the screw
retained abutment (center), and the implant (left).
Fig 5 Removal of the implant using an implant retrieval

tool and ratchet (Nobel Biocare®).
The implant-retrieval tool was inserted in a

counterclockwise direction into the internal part of the
implant. A ratchet was then attached to the retrieval tool
413
and counterclockwise torque applied until the
osseointegration was lost. There was no flap raised and
the site was debrided and allowed to heal for a period of
three months.
The treatment options for replacement of the missing

tooth were discussed with the patient. The patient
decided against additional surgical procedures and
chose to replace the missing tooth with a tooth-
supported prosthesis.
Discussion
This case illustrates that despite anti-infective treatment

of peri-implantitis, some implants in some patients may
experience recurrent infection and progressive bone
loss. This possibility should be discussed with the
patient prior to peri-implantitis therapy. This case also
describes a conservative implant-removal approach
using an implant-retrieval tool without the use of
trephine drills.
414
9.2 Biological Complications (Other than Infections)
9.2.1 Removal of a Malpositioned Implant and Direct

New Implant Placement with Simultaneous Contour
Augmentation using GBR
D. Buser, U. Belser
A 35-year old female patient was referred to the

Department of Oral Surgery and Stomatology at the
University of Bern, Switzerland, for examination of an
implant site that had exhibited clinical signs of slightly
delayed wound healing. In addition, the referring
clinician found no evidence for a facial bone wall when
she raised a flap to gain access to the implant for
abutment connection.
Four months earlier, she had inserted a bone-level

implant in a single-tooth gap, where the lateral incisor
had been extracted due to a chronic periapical lesion on
the mesial aspect of the root (Fig 1). Implant placement
was combined with simultaneous bone augmentation
using deproteinized bovine bone mineral (DBBM, Bio-
Oss®; Geistlich, Wolhusen, Switzerland) and a
collagen membrane (Bio-Gide®; Geistlich), followed
by primary wound closure. The patient also provided
the postsurgical radiograph that displayed the implant
with a 3.5-mm healing cap (Fig 2).
415
Fig 1 Initial periapical radiograph of the upper right
lateral incisor demonstrating a periapical lesion. At that
point, the referring clinician had decided to extract the
tooth and replace it with an implant. Excellent crestal
bone levels are present at both adjacent teeth.
416
Fig 2 Radiograph following placement of a reduced-
diameter bone-level implant and a healing cap 3.5 mm
in length.
The clinical examination showed a single-tooth gap

with a missing lateral incisor in the right maxilla and a
slight gingival recession at the distal aspect of the
central incisor (Fig 3). The mucosa had healed without
signs of a fistula. We examined the implant site by
three-dimensional (3D) cone-beam computed
tomography (CBCT) to assess the 3D anatomical
situation: The implant was inserted too far facially, and
there was no radiographic evidence of a facial bone
wall (Figs 4a-b).
417
Fig 3 First re-examination at our clinic showing the
single-tooth gap with a submerged implant. The
adjacent central incisor exhibited minor gingival
recession.
418
Fig 4a Orofacial section of the CBCT demonstrating the
absence of a facial bone wall across the entire implant
surface.
Fig 4b Horizontal section of the CBCT indicating a

facial malposition of the implant and confirming the
absence of a facial bone wall.
The situation was discussed with the patient, and three

treatment options were presented. Each option included
an open-flap procedure for the most adequate
therapeutic choice to be determined intraoperatively.
• Option 1. Leaving the implant in place and

performing a second augmentation procedure using
GBR to generate a new facial bone wall.
• Option 2. Removing the implant and inserting a new

implant in a correct 3D position, combined with a
simultaneous contour augmentation using GBR.
• Option 3. Removing the implant and performing

local ridge augmentation using GBR to allow placement
of a new implant five months later.
419
The surgery was performed in local anesthesia
combined with sedative premedication. The site was
opened with a triangular flap using a distal line-angle
releasing incision at the first premolar (Fig 5).
Fig 5 The implant site was opened with a triangular flap

using a vertical releasing incision distal to the first
premolar.
Following elevation of a full-thickness flap, the

osseointegrated implant was clearly visible; no facial
bone wall was present (Fig 6). The occlusal view also
confirmed that the implant had been inserted too far
facially. The exposed implant surface was clearly
located outside the alveolar ridge (Fig 7). Chances to
generate a new facial bone wall on top of the exposed
implant surface were considered slim.
420
Fig 6 A full-thickness flap was elevated and the implant
site exposed. The osseointegrated implant had no facial
bone wall. A few remnants of DBBM particles became
visible at the bone surface lateral to the implant.
Fig 7 Occlusal view documenting the facial

malposition. The exposed implant surface was outside
the bony envelope. This required the implant to be
421
removed and a new one inserted in a more favorable
orofacial position.
It was therefore decided to remove the implant with a

special removal instrument and a hand ratchet (Fig 8).
This allowed the application of rotational torque to
fracture the bone-implant interface and loosen the
implant (Fig 9). Following implant removal, the local
anatomy was carefully checked, especially the crestal
width at the mesial and distal aspect of the single-tooth
gap (Fig 10).
Fig 8 A special removal instrument was inserted to

fracture the bone-implant interface by applying
rotational torque with a ratchet. With this technique, the
implant was easily loosened.
422
Fig 9 The removed implant still attached to the removal
instrument.
Fig 10 After implant removal. The local bone anatomy

allowed the placement of a new implant at the same
surgical appointment. The implant bed was prepared
slightly further palatally.
423
Since the crestal width was more than 6 mm, it was
decided to directly reinsert a new implant in the correct
3D position and inclination. The implant bed was
prepared and a standard-diameter bone-level implant
(regular CrossFit RC 4.1 mm; Institut Straumann AG,
Basel, Switzerland) featuring a hydrophilic surface
(SLActive®) inserted into the palatal bone.
The implant achieved good primary stability. Following

insertion of a 2-mm healing cap, it became evident that
the facial bone defect had a favorable two-wall
morphology, as previously expected (Fig 11).
Fig 11 A standard-diameter bone-level implant (BLI

4.1) was inserted in a correct 3D position, followed by
placement of a 2-mm healing cap. Two-wall defect
morphology on the facial aspect was a prerequisite for
successful contour augmentation.
The crater-like bone defect was augmented with two

bone fillers: (1) a layer of autologous bone chips (Fig
424
12) was harvested locally within the same flap
confinement using a bone scraper; and (2) a superficial
layer of DBBM particles to overcontour the local bone
anatomy on the facial aspect (Figs 13 and 14). The bone
fillers were covered by a non-crosslinked collagen
membrane (Bio-Gide®; Geistlich). The membrane was
applied in a double-layer technique (Fig 15), and the
surgery completed by tension-free primary wound
closure (Fig 16). To achieve this, the flap had to be
released at its base with an incision in the periosteum.
The postsurgical radiograph showed a well-positioned
bone level implant (Fig 17).
Fig 12 Locally harvested autologous bone chips

covered the exposed implant surface on the facial
aspect. These autograft chips were expected to
accelerate bone formation in the defect area due to their
favorable osteogenic properties.
425
Fig 13 A second layer of DBBM particles was applied
to overcontour the alveolar crest on the facial aspect of
the implant.
Fig 14 Occlusal view of the overcontoured local

anatomy. The low substitution rate of DBBM particles
was expected to contribute to the long-term stability of
the newly regenerated facial bone wall.
426
Fig 15 The bone fillers were covered with a non-
crosslinked collagen membrane, which was applied
using a double-layer technique to prolong its barrier
function and to enhance the stability of the membrane
and the bone fillers underneath.
427
Fig 16 The implant surgery was completed with a
tension-free primary wound closure. An incision of the
periosteum was needed to release the flap sufficiently.
Fig 17 Post-surgical radiograph demonstrating the

bone-level implant with its 2-mm healing cap.
428
Fig 18 At eight weeks, the implant was well integrated.
The reentry procedure was performed using a punch
technique without flap elevation.
429
Fig 19 After the reopening procedure. The small 2-mm
healing cap was replaced by a 3.5-mm healing cap. The
occlusal view confirmed the slightly palatal position of
the implant. The facial contour was now favorable for
an esthetic outcome.
Two weeks later, an open-tray impression was taken

with an addition-curing silicon material using a custom
tray in conjunction with a screw-retained impression
post. At the dental laboratory, a directly screw-retained
metal-acrylic provisional crown based on a
prefabricated temporary titanium/PEEK coping was
produced and inserted at the next appointment (Fig 20).
Fig 20 At the time of insertion of a directly screw-

retained provisional acrylic implant-supported crown
based on a prefabricated titanium abutment, the
increased cervical volume caused marked blanching of
the peri-implant mucosa before the restoration was
finally seated.
430
The appropriate cervical emergence profile was
finalized at chairside to assure a harmonious contour of
the peri-implant mucosa, prevent persisting soft-tissue
blanching, and provide adequate access for the patient’s
oral hygiene (Fig 21).
Fig 21 After the emergence profile of the restoration

was reduced at its apical aspect, the blanching
disappeared and adequate interproximal space for oral
hygiene was obtained.
Three months after placement of the provisional crown,

the peri-implant soft tissues had matured, gaining
significant volume in the embrasure areas (Fig 22). The
corresponding periapical radiograph confirmed stable
osseointegration and minor crestal bone remodeling at
the distal aspect (Fig 23). At this stage, an alginate
impression of the upper jaw before removing the
temporary crown and a final elastomeric impression
were taken (Fig 24).
431
Fig 22 Three months after insertion of the provisional
metal-acrylic crown. Conditioning and maturation of
the peri-implant soft tissue has yielded an esthetically
pleasing outcome. The soft-tissue volume in the
embrasure areas is greatly increased.
432
Fig 23 The corresponding periapical radiograph shows
the well-integrated bone-level implant and the
provisional metal-acrylic crown. Some minimal crestal-
bone resorption is present at the distal aspect.
Fig 24 At this stage, an open-tray impression was taken

using a polyvinyl siloxane elastomeric material.
After mounting the master cast in a semi-adjustable

articulator, sites 13, 12, and 11 were scanned to permit
the on-screen virtual designing of the zirconia
infrastructure for the final implant crown replacing the
missing tooth 12. The data set was sent to the
fabrication center by e-mail, where the zirconia
component was milled (ETCON-CARES®; Institut
Straumann AG, Basel, Switzerland). The zirconia
framework, which provided uniform support for the
veneering ceramic, was then built up to full anatomic
contour using e.max ZirPress (Ivoclar Vivadent,
Schaan, Liechtenstein), to which a thin layer of
manually stratified feldspathic ceramic was added on
433
the facial aspect to provide maximum esthetics (Figs 25
to 27).
Fig 25 A CAD/CAM zirconia abutment was produced

and veneered using the e.max ZirPress technique
(Ivoclar Vivadent). The incisal third was completed
with a thin layer of traditionally built-up feldspathic
ceramic to reproduce the translucency and
characteristics of the natural reference tooth.
434
Fig 26 After insertion of the final directly screw-
retained all -ceramic crown. The esthetic outcome was
satisfactory, including the well-positioned cervical
mucosa with a distinctly convex profile on the facial
aspect and the return of a harmoniously scalloped
mucosa.
435
Fig 27 Frontal view of the patient’s unforced smile
confirming an acceptable integration of the new
restoration, despite some minor differences in relative
tooth dimensions, volume, and cervical emergence
contour between implant crown 12 and reference site
22.
Final insertion of the directly screw-retained zirconia-

based all-ceramic implant crown 12 comprised
tightening of the occlusal screw to 35 Ncm, coverage
with condensed Teflon® tape, and closure of the access
channel with composite resin using an adhesive
protocol.
The post-insertion periapical radiograph documented

precise seating, an adequate flat cervical emergence
profile, and stable osseointegration (Fig 28). In fact, the
most coronal bone-to-implant contact was located at the
implant shoulder mesially and distally, confirming the
efficacy of the platform-switching concept implemented
by the bone-level implant design. The favorable clinical
and radiographic findings were confirmed at the five-
year follow-up (Figs 29a-c and 30). This was
particularly true in terms of crestal bone stability and
esthetic integration of the implant-crown complex at
site 12.
436
Fig 28 The periapical radiograph taken at insertion of
the final all-ceramic crown shows a well-integrated
bone-level implant.
437
Fig 29a The five-year examination demonstrated
symmetric and healthy peri-implant soft tissues, in
harmony with the adjacent dentition.
Fig 29b Lateral view showing complete tissue closure

of the mesial and distal embrasure areas.
Fig 29c Minor recession was still present at the distal

aspect of tooth 11.
438
Fig 30 Periapical radiograph at the five-year follow-up
showing excellent stability of the crestal bone levels.
The 4 × 4 cm CBCT image showed a thick facial bone

wall established by contour augmentation using GBR
(Figs 31a-b).
439
Fig 31a Horizontal CBCT confirming a thick and intact
facial bone wall at the five-year follow-up. The lateral
incisor implant is positioned about 2 mm palatally of
the facial emergence contour of the clinical crown.
440
Fig 31b Orofacial CBCT showing a thick and intact
facial bone wall. The bone wall extends coronally to the
implant shoulder.
Discussion
In the present case, an implant had been inserted too far

facially alio loco to replace an extracted upper lateral
incisor. Despite simultaneous bone augmentation with
GBR, no facial bone wall was present at reentry,
although this bone wall is an important prerequisite for
a long-lasting functional and esthetic result (Buser and
coworkers 2004). Following referral to the clinic, the
3D CBCT examination confirmed that a facial bone
wall was indeed missing.
In this situation, the clinician has three options to

consider as outlined at the beginning of this case report.
Regrafting an implant without a facial bone wall is only
an option if (a) the implant is located in a correct
orofacial position, with the exposed implant surface
inside the alveolar crest; and (b) the exposed implant
surface has not been contaminated by an acute peri-
implant infection. In the present case, the intraoperative
view confirmed a facial malposition, which is often the
cause of esthetic complications (Chen and Buser 2010).
The implant was therefore carefully removed with a
special removal instrument and a ratchet using a
counterclockwise rotational torque. This technique was
introduced about six years ago by several manufacturers
to loosen an osseointegrated implant by fracturing the
bone-implant interface (Froum and coworkers 2011). It
represents significant progress, as it allows implant
441
removal without damage to surrounding bone. The use
of a trephine for implant removal must now be
considered outdated—it destroys too much peri-implant
bone. In the present case, the original removal
instrument by Straumann was used, called the
“explantation tool.” Generic removal instruments are
also available, for example the BTI Implant Extraction
Kit (Anitua and Orive 2012; Biotechnology Institute
BTI, Vitoria-Gasteiz, Spain).
Following implant removal, the local anatomy allowed

the immediate insertion of a new implant. The implant
was prepared slightly further palatally, keeping a palatal
bone wall of 1 mm intact. This allowed implant
placement in a correct 3D position, positioning the
implant platform in the comfort zones (Buser and
coworkers 2004). The resulting facial bone defect had a
favorable two-wall morphology, an important
prerequisite for predictable bone regeneration.
An experimental study by Schenk and coworkers

(1994) demonstrated that new bone formation originates
from bony walls, since the essential cells for creating
new bone—angioblasts and osteoblasts—are located in
the bone marrow. In consequence, the morphology of
the defect is an important factor in predicting a
successful regenerative outcome. A bone defect with a
narrow but deep two-wall morphology is much easier to
regenerate than a wide and shallow one-wall defect
(Buser 2009). Another factor is the bone filler applied
to the defect. The bone filler should have osteogenic
characteristics, meaning that should be able to promote
442
new bone formation during initial postoperative
healing.
Since 1998, our group has preferred bioabsorbable,

non-crosslinked collagen membranes for GBR
procedures, since they are easy to handle during surgery
and do not require a reentry procedure. In addition, the
risk of complications—soft-tissue dehiscence following
GBR procedures—is low (von Arx and Buser 2006).
However, these collagen membranes only offer a barrier
function for four to eight weeks (von Arx and
coworkers 2005). These resorbable membranes must
therefore be combined with appropriate bone fillers to
compensate for the short-term barrier function.
So in 1998, based on preclinical data, we started using a

combination of two bone fillers, autologous bone chips
and xenogeneic DBBM particles (Buser and coworkers
2004; Buser and coworkers 2008b). This combination
offers synergistic optimized regenerative outcomes with
the GBR technique. Autologous bone grafts accelerate
the formation of new bone—not only at the implant
surface to establish rapid osseointegration, but also
within the superficial layer of bone substitute to
produce DBBM particles embedded in bone. The
superiority of autograft bone chips has been confirmed
in several histomorphometric experimental studies
(Buser and coworkers 1998; Jensen and coworkers
2006; Jensen and coworkers 2007; Jensen and
coworkers 2009).
It is believed that these osteogenic properties of

autograft bone chips are due to non-collagenous
443
proteins and growth factors entrapped in the bone
matrix (Bosshardt and Schenk 2009). It is also possible
that entrapped osteocytes have a positive impact on
osteogenic cells (Bonewald 2011). Recent in-vitro
studies using osteoblast cultures have demonstrated that
the harvesting technique also influences the osteogenic
potential of autograft chips (Miron and coworkers 2011;
Miron and coworkers 2013). Of four tested harvesting
techniques, bone grafts harvested with a bone mill or a
bone scraper showed the highest osteogenic potential.
DBBM particles are routinely used to cover the applied

layer of autograft chips and improve the contour of the
alveolar crest around dental implants. This
technique—called contour augmentation—is intended
to optimize the esthetic outcomes around dental
implants (Buser and coworkers 2008b). DBBM
particles are characterized by a low-substitution rate as
demonstrated by several preclinical studies (Jensen and
coworkers 2006; Jensen and coworkers 2007; Jensen
and coworkers 2009). However, there is increasing
evidence that only DBBM particles embedded in bone
have a low substitution rate. These fillers show
evidence of severe resorption in fibrous tissues, as
recently demonstrated in a preclinical study
(Busenlechner and coworkers 2012). The cellular
mechanism of this resorption is not understood yet and
needs further investigation. This underlines the
importance of the first layer of autologous bone grafts
to stimulate the ingrowth of bone into the superficial
layer of DBBM particles.
444
This has been confirmed by stable and favorable
esthetic outcomes in two case series examining single-
tooth rehabilitation with early implant placement and
simultaneous contour augmentation using GBR (Buser
and coworkers 2008a; Buser and coworkers 2009). Both
group of patients were prospectively examined by
CBCT for the status of their facial bone wall (Buser and
coworkers 2013a; Buser and coworkers 2013b). Both
studies demonstrated intact facial bone wall in 95% of
the patients. In addition, a very recent
histomorphometric study with 12 human biopsies in 10
patients confirmed the low substitution rate of DBBM
particles with a mean percentage of 32% at 14 to 80
months post-augmentation (Jensen and coworkers
2014).
The favorable results of these case series studies were

confirmed in the present case report, since the five-year
follow-up demonstrated not only a very pleasing
esthetic outcome, but also the presence of thick facial
bone wall, as documented by CBCT (Figs 29a-c to 31a-
b).
445
9.2.2 Oral Lichen Planus Associated with the Peri-
implant Mucosa
A. Frydrych
This case describes the ongoing management of a

64-year-old healthy, non-smoking female patient with
erosive oral lichen planus (OLP) affecting the gingivae
and the buccal and lingual mucosa. The peri-implant
mucosa was also affected subsequent to implant
placement.
The patient had osseointegrated implants (four in the

maxilla, four in the mandible) placed following
extraction of hopeless teeth and a healing period. The
patient had a history of OLP prior to implant placement
and had been referred to an oral-medicine specialist for
definitive diagnosis and treatment. She exhibited
generalized oral mucosal involvement. Following a
clinical assessment, biopsy, and blood tests, she was
treated with topical corticosteroids. Systemic
prednisolone was reserved for severe flare-ups.
Amphotericin lozenges were used in combination with
corticosteroid treatment to prevent the development of
oral candidiasis.
Following restoration of the implants (full-arch

maxillary fixed prosthesis supported by four implants
and two fixed prostheses each supported by two
implants in the right and left posterior mandible), the
patient received regular maintenance care, including
446
professional prophylaxis (removal of biofilm) and oral-
hygiene instruction on a six-monthly basis.
During the three years following implant placement and

restoration, the patient experienced periodic
exacerbations of her OLP, with gingival, peri-implant,
and buccal and lingual mucosal involvement. This was
not unexpected given the chronic nature of the
condition. Exacerbations were associated with
increasing mucosal erythema and with the presence of
erosive and ulcerated lesions and increasing mucosal
discomfort. Management of these exacerbations varied
depending on disease severity. Figures 1 to 4 illustrate
the presence of OLP at the peri-implant mucosa.
Fig 1 OLP, gingivae, and peri-implant mucosa.
447
Fig 2 OLP, buccal mucosa, and peri-implant mucosa.
Fig 3 OLP, buccal peri-implant mucosa.
448
Fig 4 OLP, palatal peri-implant mucosa.
Fig 5 OPG.
The first line of treatment involved the use of two

sprays of beclomethasone dipropionate spray (50 µg/
dose) on the oral mucosal lesions four times daily in
combination with 10 mg of amphotericin lozenges
twice daily. Localized non-responsive ulcerated lesions
449
were treated with intra-lesion injections of 1 mg
betamethasone solution (5.7 mg/ml). Severe generalized
flare-ups were managed with short-term systemic
prednisolone in combination with amphotericin
lozenges.
At all follow-up visits the patient had good oral hygiene

with stable peri-implant probing depths within a normal
range (2 – 4 mm). Radiographic evaluation showed
stable marginal peri-implant bone levels.
Discussion
This case demonstrates the placement of implants in a

patient with erosive OLP with generalized oral mucosal
involvement, including persistent involvement of the
peri-implant mucosa. A team of specialists was
involved in treating the patient. A correct diagnosis of
OLP is important and requires an adequate patient
history, clinical examination, and biopsy. Optimal oral
hygiene is considered important for peri-implant tissue
health and for the management of OLP. Patients should
be instructed in correct tooth-brushing and flossing
techniques and advised to use a toothpaste that does not
irritate the mucosa. The focus should be on
management of the OLP and optimal plaque control.
Despite the chronic nature of the condition and periodic

disease exacerbations, the OLP in this patient could be
managed without significant adverse outcomes over the
three-year follow-up period.
450
Oral lichen planus is a chronic, systemic,
immunologically mediated disease of unknown etiology
that commonly affects the oral mucosa (Au and
coworkers 2013). It is one of the most common non-
infectious oral mucosal diseases, affecting about 2% of
the world’s adult population (Roopashree and
coworkers 2010). Various forms of clinical presentation
are encountered, including reticular, erosive, and
atrophic forms. Oral lichen planus may sometimes
resemble other chronic mucosal inflammatory diseases,
hence a biopsy is essential to ensure an accurate
diagnosis (Parashar 2011). The treatment of OLP is
supportive and palliative only, with corticosteroids
(with or without concomitant antimycotics) forming the
first line of treatment (Al-Hashimi and coworkers
2007). Oral lichen planus is currently considered a
potentially malignant disorder; long-term—at least
annual—follow-up is recommended (van der Waal
2009),
Acknowledgments
Surgical procedures
Dr. Brent Allan, oral and maxillofacial surgeon – West

Leederville, Australia
Prosthetic procedures
Dr. Rick Lazar, prosthodontist – West Perth, Australia
Periodontal procedures
451
Dr. Albert Tan, periodontist – Perth, Australia
Oral-medicine procedures
Dr. Agnieszka Frydrych, oral-medicine specialist –

West Perth, Australia
452
9.2.3 Peri-implant Carcinoma
M. Moergel, P. W. Kämmerer, B. Al-Nawas
Oral implants are highly successful and offer long-term

benefits, especially in the rehabilitation of edentulous
patients or patients with oral defects following ablative
tumor surgery (Albrektsson and coworkers 1986), and
also after radiation therapy (Schiegnitz and coworkers
2014). With the number of implants placed globally
going into the millions, implant dentists have observed
some rare adverse events. Although carcinogenesis
around implants is an exceedingly rare phenomenon, we
recently reported about 15 patients treated for
carcinomas adjacent to implants at our clinical
department over a period of fifteen years (Moergel and
coworkers 2014). The following case represents a
patient of this cohort; it discusses possible risk factors
and makes suggestions for a recall schedule.
A 70-year-old woman was referred to our outpatient

department for evaluation of a rapidly growing
macroscopic alteration of the mucosa in the left
mandible. Her general health status was good, except
for mild hypertension treated by a beta-blocker
(atenolol 25 mg/d) and age-related arthritis suppressed
by a non-steroidal antiphlogistic (ibuprofen 300 mg) as
needed. A history of smoking or ingestion of alcohol
was denied. Intriguingly, a small carcinoma of the right
lower lip following an actinic keratosis had been
completely resected in local anesthesia by an ENT
specialist seven weeks previously.
453
The patient presented a partly ulcerous and partly
exophytic lesion of the crestal and vestibular mucosa
next to the implant at site 34. It was highly sensitive to
mechanical alteration and was surrounded by an
erythroleukoplakia (Fig 1). In addition, signs of oral
lichen planus (OLP) were found on the left buccal
surface. The dental orthopantomograph revealed slight
signs of crestal osteolysis and loss of marginal bone. No
further indications of any invasion of the mandibular
bone were initially apparent (Fig 2). The right
mandibular implants exhibited additional osteolysis,
suggesting an active peri-implantitis, but without
further affecting the surrounding mucosa. Histologic
evaluation confirmed the presence of an oral carcinoma
at site 34. The patient was prepared for radical
resection.
Fig 1 Macroscopic presence of the peri-implant mucosa.

An ulcerous lesion, highly sensitive to mechanic
alteration, next to the implant.
454
Fig 2 Preoperative orthopantomograph. Crestal osseous
lesions are present at nearly every implant. Osteolysis
may mimic peri-implantitis, so a tumor cannot be
distinguished from a benign lesion by radiological
means.
An anterolateral neck dissection was performed on the

left side, including the lymph tissue in Robbins levels
I–IV. Intraoperative frozen sections were negative for
cervical metastases, so levels V and VI were left intact
(Robbins and coworkers 2002). In the oral cavity, the
tumor was marked for resection with a safety margin
and the bridgework was divided to preserve the distal
implant. The mesial implant was resected in two steps:
a small part of the surrounding soft and hard tissues
were removed for histological and radiological
evaluation, followed by a more extended resection of
the surrounding mucosa and crestal mandible to provide
a safety margin (Fig 3). The remaining bone was
smoothed (Fig 4) and the defect covered with an
455
extraoral transpositional flap from the left nasolabial
fold.
Fig 3 Resection specimen containing the peri-implant

mucosa and bone.
456
Fig 4 Postoperative orthopantomograph.
Perioperative anti-infective prophylaxis was performed

with cephalosporin for three days and the patient
recovered well from the operation. Histological
examination revealed an invasive peri-implant
carcinoma that had invaded the bone but not spread
further into locoregional lymph nodes or produced
distant metastases. The carcinoma was resected with
ample safety margins: pT4a, pN0, pM0, pR0. Due to
the invasion of the cancellous bone, the patient was
offered radiotherapy as an adjuvant treatment option
(Figs 5a-c and 6a-c).
Fig 5a-c Micro-CT scans rendered graphically and as

originals showing the peri-implant loss of bone. The
comb-like structure may be of importance in case the
cancellous boneis invaded (Schache and coworkers
2008).
457
458
Figs 6a-c At the histological examination the tumor was
found to be in direct contact with the implant, and first
signs of an invasion of the cortical bone are apparent.
Toluidineblue, original magnifications ×100 (a, c) and
×200 (b).
Discussion
Oral squamous-cell carcinomas (OSCC) next to

implants are rare. There have been only a few case
reports and two observational studies (Abu El-Naaj and
coworkers 2007; Bhatavadekar 2012; Block and
Scheufler 2001; Chimenos-Küstner and coworkers
2008; Clapp and coworkers 1996; Cuesta-Gil and
coworkers 2009; Czerninski and coworkers 2006; De
Ceulaer and coworkers 2010; Eguia del Valle and
coworkers 2008; Gallego and coworkers 2008; Gallego
and coworkers 2009; Gulati and coworkers 2009; Kwok
and coworkers 2008; McGuff and coworkers 2008;
Meijer and coworkers 2010; Moergel and coworkers
459
2014; Moxley and coworkers 1997; Schache and
coworkers 2008).
Yet as implants are used ever more widely, even those

implant-related complications whose incidence is
extremely low may be seen more frequently in clinical
practice, simply because of the large numbers involved.
To identify patients at risk, we investigated all implant-

related carcinomas in a retrospective study for risk
factors. We had treated 15 implant-related carcinomas
at our clinical department in fifteen years. As 9 patients
had a prev
ious history of an oral carcinoma, no cause-and-effect
model could be postulated. Intriguingly, an extended
latency from the time of implant insertion to the time
the carcinoma became manifest was seen both in our
patients (53.4 months) and in the patients in the
available literature (51.6 months). Since the gender
ratio was nearly balanced, these findings underline the
clinical relevance of implants for the orofacial
rehabilitation of patients with oral carcinomas (Korfage
and coworkers 2010; Nelson and coworkers 2007; Tang
and coworkers 2008; Schiegnitz and coworkers 2014).
The most likely manifestations were an exophytic mass
adjacent to the implant and a radiotranslucency. Both of
these are findings that may mimic a harmless peri-
implantitis.
The woman whose case is presented here had not had a

previous oral carcinoma and denied important habits
generally viewed as carcinogenic triggers, such as
alcohol and cigarette use. Furthermore, she had
460
presented with signs of peri-implantitis with marginal
bone loss around the implants in the contralateral
quadrant that may have been additionally misleading.
The macroscopic presence of ulcerous

erythroleukoplakia was an important clinical sign and
characterized the lesion as high-risk, since ulcerous
erythroleukoplakia has a high potential for malignant
transformation (Reichart and Philipsen 2005). As our
patient collective revealed, patients with a history of
oral carcinoma are at risk for developing a secondary
carcinoma and should therefore be carefully examined
for macroscopic mucosal changes. Since chronic
periodontitis as a chronic inflammatory process has
been described as independent risk factor for the
development of an oral carcinoma, patients may
additionally benefit from histological examination by
scalpel biopsy if the peri-implantitis does not respond to
local treatment (Moergel and coworkers 2013; Tezal
As a clinical consequence, patients with a history of

head-and-neck cancer are at risk for developing
secondary carcinomas. In these patients, persistent peri-
implant infections that are atypically restricted to a
single implant site, a biopsy should be performed to rule
out a secondary carcinoma.
461
9.2.4 Peripheral Giant-cell Granuloma Associated with
Peri-implant Tissues
M. M. Bornstein
Giant-cell granulomas (GCG) of the jaws are benign

reactive lesions of unknown etiology, unrelated to
giant-cell tumors (osteoclastomas), which are defined as
benign but locally destructive and aggressive neoplasms
(Jundt and coworkers 2005). Depending on their
localization at the initial diagnosis, GCG are dived into
central (CGCG) and peripheral (PGCG) types. CGCGs
occur within the jawbones and appear as unilocular or
multilocular radiolucent lesions. The incidence in the
general population is very low. They are more
commonly found in the mandible, mainly in children
and young adults—patients are generally younger than
30 years—and have a greater incidence in females
(Heithersay and coworkers 2002). The clinical behavior
of CGCGs varies from slowly growing asymptomatic
swellings to aggressive lesions that may result in pain,
cortical perforation of the affected jaw site, and root
resorption (de Lange and coworkers 2007). Surgical
curettage or, in aggressive lesions, resection, are the
most common therapy modalities reported in the
literature. When using surgical curettage, damage to the
jawbone, neighboring teeth or tooth germs is often
unavoidable; recurrences are frequent. In recent years,
less invasive treatment approaches such as the
intralesional injection of corticosteroids have been
reported (Ferretti and Muthray 2011).
462
The PGCG is a rare exophytic lesion that develops on
the gingiva and alveolar ridge, and is more frequently
encountered than the CGCG type (Motamedi and
coworkers 2007). The PGCG is also more frequently
diagnosed in younger patients, located in the mandible,
but exhibits an equal gender distribution, and has a
lower tendency to recur. Although the precise etiology
of PGCGs is unknown, it has been speculated that these
lesions originate from the mucoperiosteum or the
periodontal ligament and represent a local reaction to
trauma or irritation such as tooth extraction, poor dental
restorations, ill-fitting dentures, plaque or calculus
formation, and food impaction (Mannem and Chava
2012). Management requires a surgical excision of the
lesion and regular recall examinations due to possible
recurrence (Banthia and coworkers 2013).
The present case report describes the clinical,

radiological, and histopathological features of a PGCG
associated with an implant and discusses possible
etiological factors and sequelae.
Case report

University of Bern for therapy of a recurring
hyperplasia at the peri-implant mucosa of an implant
inserted in the region of the mandibular left lateral
incisor. The patient was a former smoker (approx.
15–20 pack-years) and was under oral medication for
hypertonia and hypothyroidism. The patient had
received a fixed restoration on natural teeth in the left
463
maxilla and fixed partial dentures on implants in the
mandible several years previously. These restorations
were maintained without complications until the
implant at site 32 had exhibited signs of peri-implantitis
six months previously. Shortly afterwards, the peri-
implant mucosa had enlarged, and the hyperplasia
mentioned had developed.
The hyperplastic lesion had already been removed three

times alio loco over the course of the six months prior
to the referral, but had always recurred immediately.
The initial specimen excised had not been sent in for
histopathological examination, but the second and third
were evaluated by the pathologist. In the initial report,
the mucosal mass was not found to be conclusive and
was tentatively diagnosed as a fibrous hyperplasia with
signs of osseous metaplasia. The second
specimen—sent in and evaluated less than three months
after the first—exhibited the presence of numerous
multinucleated giant cells. Thus, the diagnosis of a
PGCG in the peri-implant mucosa of 32 had already
been established upon referral.
At the initial presentation, the lesion was located on the

buccal, but also lingual aspect of implant 32, measured
1 × 1.5 cm, exhibited a reddish color, and was partially
covered with fibrin (Fig 1). The implant was part of a
fixed restoration from site 42 to site 32. The mandibular
canines were still in place. Implant 32 exhibited clinical
and radiological signs of peri-implantitis (Figs 2 and 3).
Furthermore, tooth 33 showed progressive attachment
loss and was clinically mobile. The patient did not
experience pain from the growing mass, but felt
464
discomfort from the lesion upon chewing and when
performing oral hygiene.
Fig 1 Initial examination. (a) Buccal view. (b) Occlusal

view showing the extension of the lesion to the lingual
aspect of the alveolar process.
465
Fig 2 Initial panoramic radiograph.
Fig 3 Initial periapical radiograph. Crestal bone loss

around implant 32.
466
The initial surgical step included excision of the PGCG
and debridement of the implant surface using a scalpel
and a CO2laser under local anesthesia (Fig 4). The
removed specimen was sent in for histopathological
evaluation, where the clinical diagnosis of PGCG was
confirmed (Fig 5).
467
Fig 4 After the first removal of the lesion with the CO2
laser. (a) Buccal view. (b) Occlusal view.
Fig 5 Histopathological aspect of the excised specimen.

(a) The overview exhibits a thin epithelial layer with
parakeratosis. Immediately below the epithelium:
highly vascularized connective tissue including multiple
fibroblasts and histiocytes is visible (hematoxylin-eosin
468
staining/HE; original magnification ×10). (b) Detailed
view demonstrated the presence of multinucleated giant
cells in the highly cellular connective tissue (HE;
original magnification ×20).
Initial healing was uneventful, but the lesion recurred

one month after surgery, thusresulting in the fourth
recurrence of the lesion since the initial removal seven
months earlier (Figure 6). After consultations with the
Department of Periodontology, it was decided to extract
tooth 33 and excise the lesion more aggressively,
including a circular revision of the peri-implant bone
(Fig 7). Again, histopathology confirmed the initial
diagnosis (PGCG). Unfortunately, the lesion recurred
yet again, for the fifth time, three weeks after the
surgical intervention (Fig 8).
Fig 6 Recurrence of the PGCG one month after removal

(fourth recurrence).
469
Fig 7 Periapical radiograph after renewed removal of
the lesion and extraction of tooth 33. Further crestal
bone loss around implant 32.
Fig 8 Recurrence of the PGCG one month a
470
fter removal (fifth recurrence) and extraction of tooth
33.
After renewed interdisciplinary consultations, the

following procedure was decided on: Removal of
implant 32; provisional fixed restoration from site
implant 42 to site 34. The patient agreed to that
procedure. After removing implant 32 (Fig 9), a
provisional fixed restoration was fabricated alio loco.
The patient has had no recurrence since then (4.5 years
since explantation).
Fig 9 After removal of implant 32 and before insertion

of the provisional fixed restoration (42–34).
Table 1 Overview of the cases with a PGCG in

association with implant(s) reported in the literature up
to 2014
471
Age/ Implant
Authors Location Treatment (initial) Relapse
sex survival
Yes
31/m Mandible Curettage/excision Yes
Hirshberg and No/
coworkers 69/m Maxilla Curettage/excision Yes explantation
2003
44/f Mandible Curettage/excision Yes No/
explantation
Bischof and
coworkers 56/f Mandible Curettage/excision No Yes
2004
Cloutier and
coworkers 21/m Mandible Excision/explantation No No
2007
Scarano and
Excision/soft-tissue
coworkers 48/f Maxilla No Yes
graft
2008
Özden and
60/f Mandible Curettage/excision No Yes
coworkers2009
45/f Mandible Curettage/excision Yes No/

Hernández and explantation
coworkers 36/f Maxilla Curettage/excision Yes
2009 No/
62/f Mandible Excision No explantation
472
Yes
Olmedo and
coworkers 64/f Mandible Excision No Yes
2010
Hanselaer and
coworkers 33/f Maxilla Curettage/excision No Yes
2010
Peñarrocha-
Diago and
54/f Mandible Curettage/excision No Yes
coworkers
2012
Galindo-
Moreno and
74/m Maxilla Excision No Yes
coworkers
2013
Present case No/

77/f Mandible Excision Yes
2014 explantation
m = male; f = female.
Discussion
In the literature, case series of PGCGs include up to

several hundred cases (Giansanti and Waldron 1969;
473
Katsikeris and coworkers 1988; Mighell and coworkers
1995; Buchner and coworkers 2010), but lesions
associated with the peri-implant mucosa are rare. Only
14 cases of PGCGs located around implants have been
documented in the literature to date (Table 1). Similar
to PGCGs diagnosed around natural teeth, they seem to
be related to chronic local irritation and inflammation.
These irritating factors may include the accumulation of
plaque or calculus and the presence of foreign matter
such as traces of dental cement (Peñarrocha-Diago and
coworkers 2012). PGCGs have also been associated
with trauma from the extraction of teeth prior to implant
placement (Hirshberg and coworkers 2003).
In the present case, trauma and chronic tissue irritation

as a sequela of tooth extraction seem rather unlikely, as
the implants had already been in function for several
years. Peri-implant mucositis and subsequently peri-
implantitis could have been the stimulating factors for
the formation and growth of the PGCG around implant
32. Exposure of the rough surface of implants in the
course of inflammatory disease, such as peri-implantitis
resulting in plaque accumulation and chronic local
irritation, has also been mentioned as a possible
etiological factor for PGCG (Cloutier and coworkers
2007). Furthermore, restorations with ill-fitting margins
have been reported as a potential cause for PGCG
around implants, resulting in plaque accumulation and
chronic soft-tissue irritation (Özden and coworkers
2009).
Recurrences of PGCG around implants after surgical

removal have been reported in 5 of the 14 cases in the
474
literature (Table 1). Therefore, relapses seem more
frequent in PGCGs associated with implants than with
natural teeth, where recurrences are seen in up to 10%
of cases (Mighell and coworkers 1995). This may also
explain the high incidence of implants lost/explanted
due to progressive bone loss in the reports mentioned.
Bone loss around the affected implant in the present
case was most likely already present initially, given the
peri-implantitis reported by the patient and referring
dentist, but progressed further and rather quickly due to
repeated surgical interventions, including osteoplasty
(four interventions before explantation and excision of
the PGCG).
Regarding the diagnostic workflow in cases with

rapidly proliferating tissue on keratinized mucosa, it
seems mandatory to stress the need for a proper
histopathologic examination of the removed tissue to
ensure an accurate diagnosis. Potential differential
diagnoses of PGCGs around implants include lesions
similar to those found in fully dentate patients, such as a
perforating CGCG that may mimic a PGCG, pyogenic
granulomas, fibromas or fibrous hyperplasias,
peripheral ossifying fibromas, metastatic carcinomas of
different origins (breast, lung, prostate), or Kaposi’s
sarcoma (Cloutier and coworkers 2007; Ferrazzini
Pozzi and coworkers 2008). Furthermore, radiographic
features may help determine whether a lesion is of
gingival origin or has arisen centrally from the bone,
with perforation of the cortex and spreading towards the
soft-tissue surface (Frei and coworkers 2012). For cases
with a suspected origin within the jawbone, three-
dimensional imaging using cone-beam computed
475
tomography has been documented as adding diagnostic
value, especially when differentiating benign from
malignant pathoses (Bornstein and coworkers 2008).
Acknowledgments
The author would like to thank Professor Hans Jörg

Altermatt, Pathology Länggasse, Bern, Switzerland, for
his help in establishing a solid histopathological
diagnosis and for preparing the relevant respective
figures for the manuscript.
476
9.2.5 Peri-implantitis Resulting in Bisphosphonate-
related Osteonecrosis of the Jaw
M. M. Bornstein
Introduction
Bisphosphonates are used to treat malignoma-related

osteolysis (such as bone metastases of prostate or
mammary carcinomas, multiple myelomas),
hypercalcemia caused by hyperparathyroidism, Paget’s
disease, or osteoporosis (Migliorati 2003; Hubner and
Houston 2005). Other treatments, such as for giant-cell
lesions of the jaws, osteogenesis imperfecta, fibrous
dysplasia, Gaucher’s disease, or chronic recurrent
multifocal osteomyelitis, have also been described in
the literature (Landesberg and coworkers 2009). A
major complication in patients using oral or intravenous
(i.v.) bisphosphonates is osteonecrosis of the jaw.
Bisphosphonate-related osteonecrosis of the jaw
(BRONJ) was first described in 2003 as a side effect in
patients taking pamidronate or zoledronate (zoledronic
acid), which are bisphosphonates prescribed i.v. to
control bone metastases in patients with breast and
prostate cancer or multiple myelomas (Marx 2003;
Migliorati 2003; Ruggerio and coworkers 2009).
Although there are some differences between clinicians
when diagnosing BRONJ, the common features of a
manifest BRONJ include the following characteristics
(Ruggerio and coworkers 2009): current or previous
treatment with a bisphosphonate (oral or i.v.); exposed
bone in the maxillofacial region that has persisted for
477
more than eight weeks and exhibits no or poor tendency
to heal; no history of radiation therapy to the jaws.
Risk factors for BRONJ include the length of exposure

to bisphosphonates (Bamias and coworkers 2005) and
the type of bisphosphonate, with a significantly higher
cumulative hazard for zoledronic acid (Boonyapakorn
and coworkers 2008; Walter and coworkers 2008).
Intravenous administration increases the risk of
developing BRONJ as much as 4.4 times (Cartsos and
coworkers 2008). Trauma to the oral mucosa and bone,
such as tooth extractions and oral surgical procedures
including the placement of oral implants, is another
important risk factor and trigger for BRONJ
development (Badros and coworkers 2006;
Boonyapakorn and coworkers 2008; Bornstein and
coworkers 2009; Madrid and Sanz 2009).
This case report describes the development of BRONJ

near implants with peri-implantitis in the maxilla and
mandible in a patient diagnosed with multiple myeloma
and under long-term treatment with i.v. zoledronate and
pamidronate. Furthermore, the clinical and radiological
features, risk factors for BRONJ development in long-
standing implants, and therapeutic concepts in patients
with such systemic risk factors will be critically
discussed.
Case report

University of Bern, Switzerland, for further diagnosis
478
and treatment of growing discomfort in the right
mandible (implant 45) and left maxilla (implant 23).
The patient had had implants of various types inserted
in the mandible and maxilla over the course of the
previous three decades (in the 1980s and 1990s). The
patient had received removable partial dentures on
implants in the maxilla and on natural teeth in the
mandible. The implants in the posterior right mandible
had been restored with two splinted single crowns. The
lower partial denture was not well tolerated by the
patient and therefore had not been worn for over ten
years. After insertion of the implants, there had been no
complications for many years, but implants 45 and 46
as well as 23 had begun to exhibit signs of peri-
implantitis with limited bone loss several years
previously. The infection had been treated by the
private practitioner, and bone loss around the three
implants had not progressed until about half a year
previously (Figs 1 to 3).
Fig 1 Panoramic view of the patient about six
479
months prior to the initial examination at the
department. At this time, the multiple myeloma had
progressed and worsened, and the medication was
switched to i.v. pamidronate (Aredia) using a high dose
protocol. The implants at sites 45, 46, and 23 exhibited
bone loss in the crestal area (peri-implantitis). The
infection had been treated by the private practitioner
and was under control.
480
Figs 2a-b Periapical radiographs of the implants
inserted and restored with splinted crowns at sites 45
and 46 in 1994 (a) and 2005 (b), before deterioration of
the health status and a switch to pamidronate (Aredia)
using a high-dose protocol.
481
Fig 3 Periapical radiograph of implant 23 splinted with
implant 21 half a year before deterioration of the health
status and a switch to i.v. pamidronate (Aredia) using a
high-dose protocol.
The patient had been diagnosed with multiple myeloma

(stage III according to the Durie-Salmon classification;
Sailer and coworkers 1995) eight years previously and
treated by chemotherapy, including melphalan and
prednisone, after establishing the diagnosis. Thereafter,
i.v. bisphosphonates were given, initially pamidronate
(pamidronic acid, Aredia; Novartis, Basel, Switzerland)
for four years, followed by zoledronate (zoledronic
acid, Zometa; Novartis) over the following 3.5 years.
Under this therapy, the progression of the neoplasia was
arrested, and there was even some remission; the patient
had been without symptoms during this time. About
482
half a year prior to the initial visit at the department, the
myeloma had progressed and deteriorated, so the
medication had again been switched to i.v. pamidronate
(Aredia) at a higher dose. Shortly after the deterioration
and the medication switch, the patient began to
complain about growing discomfort in the right
mandible (implant 45) and left maxilla (implant 23).
At the initial visit in our department, pain was more

pronounced in the maxilla. Clinically, both implants (45
and 23) were stable, probably also as a result of being
splinted with implants 46 and 21. The peri-implant
mucosa did not exhibit clear signs of inflammation, and
there was no marked bleeding or discharge upon
probing. Nevertheless, probing depths were clearly
increased around both implants, to up to 10 mm. The
panoramic and periapical radiographs (Figs 4 and 5a-b)
exhibited progressive bone loss around implants 45 and
23 when compared to previous radiographs, including
signs of sequestration. The bony sequesters around the
implants seemed attached to the implant surface, and
the bone surrounding the implants exhibited signs of
osseous sclerosis—presenting themselves very
differently from the classic radiographic features for
peri-implantitis. Based on the anamnestic data, clinical
symptoms, and the radiographs, a diagnosis of BRONJ
around implants 45 and 23 was made.
483
Fig 4 Panoramic radiograph of the patient at the initial
examination at the department. Implants 45 and 23
exhibited progressive bone loss, including signs of
sequestration. The bony sequesters around the implants
seemed attached to the implant surfaces.
484
Figs 5a-b Periapical radiographs exhibiting the status of
the bone disease around the affected implants at sites 45
(a) and 23 (n) in more detail.
The initial treatment concept chosen was a conservative

approach that included regular visits to the dental
hygienist every six to eight weeks and local disinfection
of implants 45 and 23 with chlorhexidine and peroxide
rinses. Subjective symptoms initially decreased, but half
a year after the initial visit, the patient reported growing
pain in the lower right mandible. The treating dentist
separated implants 45 and 46, and removed implant 45
during a follow-up visit. After explantation, the
situation worsened for the patient including growing
pain in the posterior right mandible and increasing
numbness in the chin area (hypoesthesia).
485
At the following visit to our department, explantation
site 45 did not exhibit any clear signs of inflammation,
but exposed bone was detected on probing all along the
former implant socket (Fig 6). The cone-beam
computed tomography (CBCT; Figs 7a-e) exhibited
osseous sclerosis in the area of the former implant 45
and the implant still integrated at site 46. The sclerosis
had enclosed the mandibular canal, and periosteal bone
formation was noted on the buccal aspect of the
mandible. An extended osteolytic area and suspected
sequesters had formed at explantation site 45. In the
regions mesially and distally of the suspected BRONJ,
the radiologic characteristics of the mandible were
markedly different, with a cortical lining of the bone in
the outer aspects, a trabecular network in the bone
marrow, and a mandibular canal delineated by a thin
cortical bone structure.
486
Fig 6 Following explantation of implant 45 two weeks
previously, the area exhibited no signs of inflammation,
but exposed bone was detected upon probing.
487
488
Figs 7a-e CBCT exhibited osseous sclerosis at the site
of the former implant 45 (* = mandibular canal) and the
implant still integrated at site 46 (b, c). The sclerosis
also was enclosing the mandibular canal in this region,
and on the buccal aspect of the mandible periosteal
bone formation was visible (a, d; + = mental foramen).
In the explantation site 45, an extended osteolytic area
and suspected sequestra formation were visible (a, c). In
the region distal to the suspected BRONJ, a regular
cortical lining of the bone in the outer aspects, a
trabecular network in the bone marrow part and a
mandibular canal delineated by a thin cortical bone
structure was visible (d, e).
Based on these findings, progressive BRONJ in the

mandible was suspected that required further surgical
treatment. The patient was referred to the Department
of Cranio-Maxillofacial Surgery at the University
489
Hospital in Bern, where the BRONJ was surgically
treated by sequestrotomy, decortication of the mandible,
and lateralization of the inferior alveolar nerve. Wound
healing was uneventful, and the neurosensory
disturbance in the area of the right mental nerve
regressed. Following this procedure, surgical treatment
of the peri-implantitis and suspected BRONJ in the left
anterior maxilla (23) was planned, which the patient
refused. She was referred to the dental hygienist for
treatment every six to eight weeks, including local
disinfection of implant 23 with chlorhexidine and
peroxide rinses. Control visits at the Department of
Cranio-Maxillofacial Surgery were scheduled at six-
month intervals. The patient has remained stable under
this therapeutic regime for more than six years (Fig 8).
Fig 8 Panoramic view of the patient six years after

surgical revision of the BRONJ at sites 45 and 46. The
bone in the posterior right mandible has regenerated,
and the radiologic situation around the remaining
490
implants in the mandible and maxilla seems to be
stable.
Discussion
Generally, clinical manifestations of BRONJ include

exposed bone, which may be painful in up to 69% of
cases (Ruggerio and Woo 2008). Radiographically,
BRONJ presents with thickening of the lamina dura,
widening of the periodontal ligament space, osteolysis,
diffuse sclerosis, and poor or non-healing in extraction
sockets (Phal and coworkers 2007; Arce and coworkers
2009). In the present case report, there was no visible
exposure of necrotic bone, but the patient experienced
variable episodes of pain, and the radiological features
observed in the CBCT scan were typical for BRONJ as
described in the literature (Stockmann and coworkers
2010). Overlapping clinical and radiographic features
sometimes make it difficult to differentiate BRONJ
from osteolysis due to neoplasias in patients with an
underlying or metastatic or malignant bone disease
(Arce and coworkers 2009; Frei and coworkers 2010).
The presence of actinomyces and other bacteria in the
affected jaws is a characteristic feature in patients with
BRONJ and demonstrates that bacterial infection plays
a significant role in the pathogenesis of BRONJ
(Hansen and coworkers 2007).
There is a clear risk for implant failure related to oral or

i.v. intake of bisphosphonates. Failure may occur
following placement in patients taking bisphosphonates,
or in existing and well osseointegrated implants when a
patient begins taking bisphosphonates for either bone
491
cancer or osteoporosis. In a large sample of 16,000
patients with 28,000 implants, Goss and coworkers
(2010) identified 7 cases of implant failures associated
with oral bisphosphonate intake due to osteoporosis
with 3 cases of failures after surgery, and 4 cases of
implants that had been successful before patients were
diagnosed as having osteoporosis and commencement
of bisphosphonate use, resulting in subsequent loss of
integration. The authors calculated that—based on the
assumption that 5% of the patients were taking oral
bisphosphonates—1 out of 114 treated patients (0.89%)
would exhibit implant failure including BRONJ.
BRONJ that develops in the first weeks or months after

the placement of implants is regarded as a surgical
complication (Kwon and coworkers 2014). If BRONJ
occurs more than six months after surgery, implant
placement (surgery) is not considered an etiological
factor. Interestingly, a case series of implant-related
BRONJ showed that the average time between implant
placement and the onset of bone necrosis was 20.9
months (Jacobsen and coworkers 2012). Furthermore,
only one case of BRONJ out of 14 clearly triggered by
surgery was identified: a female patient after sinus floor
elevation with simultaneous implant placement. The
authors also stated that the location of the implant could
be an influencing factor for BRONJ development and
loss of the implant. Most cases were diagnosed in
posterior regions, and no patient exhibited BRONJ in an
implant placed in the anterior maxilla. The authors
speculated that posterior implants were more difficult
for patients to clean and therefore there were at risk for
peri-implantitis development and initiation of BRONJ.
492
The present case report showed two implant failures in
a patient with a known history of peri-implantitis and
long-term bisphosphonate intake due to multiple
myeloma. The situation was exacerbated following
deterioration of the health status and a switch in the
type of i.v. bisphosphonate including an increase in the
dose. Both implants (45 and 23) exhibited a bone
destruction pattern recently described and termed as
“en-bloc type” of sequestration (Kwon and coworkers
2014), where a considerable amount of bone-to-implant
contact is actually maintained and bone destruction
continues peripherally to the bone immediately
surrounding the implant. Sometimes the implant and
attached bone become sequestrated as a block (Figs
5a-b). This pattern of BRONJ around implants has also
been described in other case reports (Shirota and
coworkers 2009; Favia and coworkers 2011; Sverzut
and coworkers 2012) and case series (Lazarovici and
coworkers 2010; López-Cedrún and coworkers 2013;
Kwon and coworkers 2014).
Based on the findings of the present case and also the

data from the literature, not only the placement of
implants, but also long-standing implants and especially
the condition of peri-implant tissues appear to be pose a
continuous risk factor for BRONJ development in
patients under oral or i.v. bisphosphonate therapy
(Shirota and coworkers 2009; Jacobsen and coworkers
2013; Kim and Kwon 2014; Kwon and coworkers
2014). Thus, in patients receiving either oral or i.v.
bisphosphonates, implants must be planned and inserted
carefully, ideally using a minimally invasive approach.
Furthermore, in patients with implants already in
493
function, the intake of bisphosphonates increases the
risk for peri-implant infections potentially resulting in
BRONJ with subsequent loss of the implant. Therefore,
these patients should get regular follow-ups and
maintenance at short intervals (every three to six
months).
Acknowledgments
The author would like to thank Professor Tateyuki

Iizuka, Department of Cranio-Maxillofacial Surgery,
University Hospital of Bern, Switzerland, for his help in
establishing the diagnosis and treatment of the patient.
494
9.2.6 Metal Allergy
D. Wismeijer, D. Kruger, J. Muris
In 2004, the patient, a smoker, began dental treatment at

the ACTA graduate clinic. She was a TV producer
exposed to a lot of stress in her job and had a sick
husband. Her maxillary teeth had been extracted, as had
the mandibular canines, premolars, and molars, with the
exception of tooth 34.
She received a complete maxillary denture and a

mandibular skeleton denture. In October 2007, her
maxilla was augmented by an oral and maxillofacial
surgeon; in March 2008, implants (Biomet 3i, Palm
Beach, Florida, USA) were inserted at that same clinic.
In 2008, the patient was presented at the Department of

Oral Implantology and Prosthetic Dentistry to request
restorations for her implants. An implant-supported
overdenture was planned. She also asked if we could
restore her occlusion with fixed prosthetics. To that end,
we inserted four mandibular implants (35, 44:
Straumann SP, diameter 4.1 mm, length 10 mm; 36, 46:
Straumann SPWN, diameter 4.8 mm, length 10 mm;
Institut Straumann AG, Basel, Switzerland) and fit
these with a three-unit fixed partial denture and two
single crowns.
The mandibular implants were inserted at the ACTA

postgraduate implant clinic in August 2008. To prepare
for the prosthetic phase and to evaluate the
495
augmentation of the maxilla, the second-stage surgery
was carried out by the oral and maxillofacial surgeon.
In October 2008, the patient reported pain and irritation
around the healing caps in the maxilla. The soft tissue
around the healing caps had begun to show symptoms
of inflammation (Fig 1a). The soft tissue was resected
but the inflammation and proliferation returned (Fig
1b). The patient had also started to develop signs and
symptoms of an allergy. Her hands and face developed
skin problems (Figs 2a-b).
Fig 1a The soft tissue around the healing caps showing

signs of inflammation.
496
Fig 1b It was resected but the inflammation and
proliferation returned.
497
Figs 2a-b Skin problems on the face and both hands.
We replaced the healing caps with titanium healing caps

(Figs 3a-b). One week later, the problems had
disappeared. Differential diagnosis pointed to
hypersensitivity to the metal of the healing caps. The
material was examined by our material sciences
department.
498
Figs 3a-b The healing caps were replaced with caps
made of titanium.
Several samples were taken of the healing abutments

using an Arkansas stone and analyzed by energy-
dispersive X-ray spectroscopy (EDX). The analysis
showed that the healing caps contained palladium. A
superstructure (Fig 4) and a resin-based denture (Figs
5a-b) were inserted. The mandibular implants were
restored with metal-ceramic crowns and a bridge.
499
Fig 4 Superstructure on eight 3i implants.
500
Figs 5a-b Three-unit fixed partial denture (44–46) (a)
and 2 single crowns (35–36) (b).
Table 1 ADX analysis, new restorations (% w/w).
Au Pt Cu Zn Ag Pd Cr Mo Co
Superstructure 86 11 2 1
Clips 68 4 12 3 10 3
Maxillary denture, metal

28 10 62
part
Metal-ceramic crown 35 96 1 2 2
501
Metal-ceramic crown 36 84 11 1 2
Metal-ceramic crowns 45/

83 14 2 1
46
After the maxillary superstructure, the mandibular

crowns, and the overdenture had been inserted, some
irritation reoccurred in the maxilla. We analyzed the
materials used in the dental restorations and found that
the clips used in the overdenture contained a small
amount of palladium. Once the clips were removed and
replaced with a nickel-free and palladium-free alloy, the
complaints disappeared.
Discussion
The anamnesis of this patient contained several “red

flags.” She reported being allergic to adhesive
bandages, plastic watch straps, some brands of
deodorant, bell pepper, nickel, and other metals but not
to silver and gold. She also wore an intrauterine
contraceptive device made of copper, to which she
reported no allergic reactions; she did report additional
allergi
es to ammonia and several brands of detergents.
Given the patient’s known allergy to nickel, we

considered this the probable explanation for her specific
reaction when exchanged the primary healing caps for
titanium caps. On the other hand, it would seem
advisable for a patient with multiple signs of allergy to
502
undergo comprehensive allergy testing. It was not until
after specific allergy testing that we discovered her
hypersensitivity to palladium and found that the initial
healing caps had also contained palladium.
503
9.3.1 Management of a Fractured Implant Supporting a

Screw-retained Metal-ceramic Restoration
H. P. Weber, A. Grous
The fracture of an
implant after it has been restored is one of the most
severe complications. It most frequently occurs in
partially edentulous jaws (1.5%). Most implant
fractures involve implants with a diameter of 3.75 mm
made of commercially pure titanium (Eckert 2010).
Unfortunately, many cases are not reported or
documented by the clinicians involved in resolving the
problems created by the fracture.
This case report describes the management of an

implant fracture at site 36 in a middle-aged male
patient. The implant had been restored with a screw-
retained metal-ceramic crown (Fig 1).
504
Fig 1 Panoramic radiograph. Fractured rough-surfaced
external-hex implant, diameter 3.75 mm, length 11 mm.
Fig 2 CT scan of site 36. Bone loss around the fractured

implant.
505
Fig 3 CT scan of site 36. Buccolingual orientation and
relation of the implant to the mental nerve.
An external-hex rough-surface implant (diameter 3.75

mm, length 11 mm) had been immediately placed in
2000, following the extraction of the fractured natural
tooth 36. After twelve years of service (February 2012),
the patient presented with slight mobility of the implant
and discomfort upon mastication. The periapical
radiograph revealed signs of bone loss advancing past
the engagement of the abutment screw at the distal
aspect of the implant (Fig 4). This area seems to be
most vulnerable to cyclic fatigue, as it is the thinnest
portion of the implant. The titanium alloy may undergo
fatigue and ultimately failure under the bending forces.
Microstructural analysis has demonstrated that
fragments from fractured implant showed patterns
compatible with failure due to fatigue (Rangert and
coworkers 1995).
506
Fig 4 Periapical radiograph. Implant 36 with signs of
bone loss on the distal aspect.
The fractured implant was exposed under local

anesthesia using a conservative mucoperiostal flap to
facilitate the application of a 4-mm trephine drill to
retrieve the fractured apical part (Froum and coworkers
2011; Anitua 2010).
Figure 5 shows the bony attachment around the implant

below the fracture level. The fracture line is located
between the third and fourth threads and coincides with
the end of the prosthetic retention screw.
507
Fig 5 Coronal part of the fractured implant with the
screw-retained metal-ceramic crown. The retrieved
apical portion of the implant shows the remaining
attached bone.
The fractographic analysis of the two pieces at the

fracture line (Figs 6a-b) documented the strain induced
by bending forces. A lack of osseointegration or peri-
implantitis were excluded as causes of this implant
failure. The fracture resulted from problems related to
prosthesis cantilever and the implant’s design and
dimensions (diameter 3.75 mm).
508
Figs 6a-b Stereomicroscopic imaging of the fracture
area.
The implant fracture may have a multifactorial etiology.
509
The fracture presumably occurred gradually, starting
with cracks developing when some bone was lost
around the neck of the implant. This resulted in a
fatigue-induced fracture of the implant body, which
might have been enhanced by corrosion (Reclaru and
coworkers 1994; Olmedo and coworkers 2009; Adya
and coworkers 2005) and overload due to the
unfavorable implant position distal to the center of site
36 with an evident mesial cantilever effect (Pjetursson
and coworkers 2004; Romeo and Storelli 2012).
Although the removal of an implant with a trephine drill

is somewhat invasive, the surrounding bone in this
particular case was intact for at least two-thirds of the
height of the implant. Taking into consideration the
patient’s desire for immediate replacement of the
implant and subsequent restoration, the treatment plan
called for placing of an implant with a wider diameter
of 5 mm and a length of 11.5 mm immediately after
removing the fractured implant. This new implant was
of the tapered type with a microrough surface and an
external hex (NanoTite; Biomet 3iPalm Beach Gardens,
Florida, USA).
Four months after surgery, a new screw-retained metal-

ceramic crown was connected and tightened to 32 Ncm
using a titanium hex screw (Figs 7a-d).
510
Figs 7a-b New metal-ceramic crown, occlusal view, on
the master cast (a) and in situ (b).
511
Figs 7c-d New metal-ceramic crown, buccal view, on
the master cast (c) and in situ (d).
512
Fig 8 Twelve-month postoperative panoramic
radiograph of the replacement implant and restoration.
Fig 9 Twelve-month postoperative occlusal view.
513
Fig 10 Two-year postoperative periapical radiograph.
Osseous steady state around the implant.
Fig 11 Two-year postoperative clinical follow-up with

implant-supported restoration in centric occlusion.
514
Discussion
The etiology of implant fractures is multifactorial, and

many of the factors leading up to them are “interactive.”
The evidence-based literature related to the etiology of
implant fractures is inconclusive. From the limited
studies available, it appears that implant fractures occur
more frequently in partially dentate than in edentulous
patients. Most fractures occur below the level of
engagement of the abutment screw. In this area, where
stress is concentrated, implants are generally hollow.
Danger signs such as screw loosening and bone
resorption should be taken seriously during follow-up
visits. Unsupported cantilever extensions in molar areas
should be avoided. Patients with parafunctional habits
should be provided with occlusal guards and strongly
advised to wear them. Clinicians must carefully
consider the prosthetic design and the choice of
implants in terms of diameter and length, especially in
areas of high masticatory loads.
Conclusion
The fracture of an osseointegrated implant is a severe

complication that often requires the removal of the
implant fragments. This procedure calls for extreme
caution, as there is substantial risk for further damage.
Action should be taken in accordance with evidence-
based methods of treatment and material selection,
aiming at perfection through careful clinical
implementation and including the necessary recall and
follow-up.
515
9.3.2 Retreatment of a Patient with Multiple Biological
and Technical Complications and Failures
S. Hicklin, S. Tettamanti, U. Brägger
A 66-year-old patient presented because of retention

loss of the tooth-supported FDP in the right maxilla
(x-13-x-11). The mandibular full-arch implant-
supported reconstruction (x-i34-i33-x-x-x-x-i43-i44-x)
had suffered extreme wear.
His medical history revealed high blood pressure,

controlled with anti-hypertensive medication. The
patient was a light smoker (2 to 3 cigarettes per day).
The existing reconstructions had been performed alio
loco about five years previously. That treatment had
taken an extensive amount of time, and as early as
during the fabrication of the reconstructions, multiple
complications had occurred with the provisionals.
Clinical diagnoses and findings
A comprehensive clinical and radiographic examination

revealed the following findings and diagnoses (Figs 1a-
b to 3):
516
Fig 1a Pretreatment occlusal view of the maxilla.
Fig 1b Pretreatment occlusal view of the mandible.
517
Fig 2 Pretreatment frontal view.
Fig 3 Pretreatment panoramic radiograph.
Intraoral conditions
• Multiple missing teeth
• Root tips 13, 11, and 25
518
• Tooth 26 with a deep carious lesion and periapical
radiolucency (non-vital)
• FDP on implants 21 and 23, single crown on implant

24
• Severe wear of the fixed mandibular implant-

supported acrylic prosthesis with a metal framework
due to a parafunctional habit
Function and occlusion
• Reduced occlusal vertical dimension due to attrition

and pronounced wear of the mandibular prosthesis
Periodontal/peri-implant condition
• Peri-implant mucositis at implant 21, 24, 34, 33, 43,

and 44
• Peri-implantitis at implant 23 with a bone defect
Compromised esthetics
• Inadequate vertical dimensions and facial height
• Several missing teeth in the maxilla
Treatment plan
519
General considerations
Due to caries in the root canal and only minimal tooth
substance remaining, the extraction of teeth 13, 11, and
25 was unavoidable. A removable maxillary
reconstruction was planned. The existing implants 21,
23, and 24 were to be incorporated into the new
reconstruction. To obtain an adequate vertical
dimension of occlusion, a new prosthesis was planned
on the existing mandibular implants. Tooth length in the
maxilla was adequate, so the bite had to be raised in the
mandible (Fig 4). For a less expensive alternative
compared to a new reconstruction, the repair of the
existing fixed implant-supported prosthesis was
proposed.
520
Fig 4 The smile line before the loss of the FDP in the
right maxilla revealed that the maxillary teeth had been
appealingly visible.
The prosthodontic rehabilitation was planned with an

increased vertical dimension of occlusion of 4 mm. This
approach was necessary to provide adequate interarch
space, an ideal occlusal plane, and correct facial
proportions.
521
Hygienic phase
• Delivery of a provisional removable prosthesis in the

maxilla
• Extraction of root tips 13, 11, 25 and tooth 26;

establishing an optimized level of oral hygiene
(instruction and motivation)
• Removal of deposits at the implants by a dental

hygienist and regular application of disinfectants
(chlorhexidine)
Surgical phase
• Presurgical assessments: centric mounting and

diagnostic set-up/mock-up at an increased occlusal
vertical dimension
• Peri-implant GBR at implant 23 by a periodontist or

explantation
• Implant placement according to the set-up in the

right maxilla at sites 12 and 14
Reconstructive phase
• Reconstruction with a maxillary removable bar-

supported acrylic prosthesis with metal framework on
four implants (14, 12, 21, 24)
• Repair of the existing mandibular full-arch fixed

implant-supported metal-acrylic prosthesis using the
522
existing framework; increased occlusal vertical
dimension by modification of the reconstruction in the
mandible
Maintenance phase
• Supportive periodontal care and maintenance at

three-months intervals
Treatment
Hygienic phase
Two alginate impressions and a bite registration in
habitual occlusion were taken during the first
emergency treatment. To rapidly establish function and
esthetics, a provisional partial denture was made (Figs
5a-b).
523
Figs 5a-b Provisional partial denture.
After this immediate provisional rehabilitation, the

patient underwent a comprehensive clinical and
radiographic examination. The hygienic phase included
motivation and instruction in tooth-brushing techniques
and the use of interdental brushes (mandible) to
establish adequate oral hygiene. The patient was
instructed to rinse with a chlorhexidine solution twice a
day for one minute. Plaque and calculus were removed
by a dental hygienist.
Root tips 13, 11, and 25 were extracted. Tooth 26 was

extracted during the hygienic phase because of the large
cavity, periapical lesion, and poor prognosis.
After soft-tissue healing at sites 13, 11, 15, and 26, the
cemented implant-supported FDP (i21-x-i23) and the
single crown on implant 24 were removed using the
CORONAflex® device (KaVo, Biberach, Germany).
Spherical attachments were inserted on implants 21, 23,
524
and 24 (Fig 6a) and a polyether impression was taken
with the provisional denture in occlusion. The
removable prosthesis was relined and modified to an
overdenture with retention on the three ball attachments
(Fig 6b).
Figs 6a-b After soft-tissue healing and modification of

the provisional prosthesis.
525
Surgical phase
A wax wall was adapted on an acrylic record base and a

bite registration in centric occlusion was performed.
Acrylic teeth were selected and arranged on the record
base for a trial arrangement. After the try-in, the set-up
was duplicated and a radiographic stent was produced
for a CBCT to evaluate the ideal implant sites in the
first quadrant.
Having obtained the CBCT data, the patient was

referred to a periodontist for evaluation of implant 23.
According to the specialist, a guided bone regeneration
(GBR) procedure around that implant was impossible
because of the large bone defect and missing buccal
bone wall. Therefore, implant 23 had to be explanted
prior to implant placement in the right maxilla.
According to the prosthetic planning and the CBCT,

two implants (RN; Institut Straumann AG, Basel,
Switzerland) were placed at sites 12 and 14. After ten
weeks of healing, the abutments were connected (Fig
7).
526
Fig 7 Occlusal view of the maxilla after abutment
connection.
Four weeks later, a polyether impression (Impregum®;

3M ESPE, Seefeld, Germany) was taken at the implant
level using an open custom impression tray. To check
the accuracy of the master cast, a verification jig was
used intraorally to ensure the passive fit of the planned
titanium bar (Figs 8a-b).
527
Figs 8a-b Verification jig on the master cast and the
intraoral try-in.
A composite-resin record base with a wax occlusion rim

was used to determine the occlusal vertical dimension
and to record the maxillomandibular relationship. A set-
up for the maxilla and a mock-up on the mandibular
prosthesis was constructed. Several try-ins with an
528
increased vertical dimension of occlusion (group
function in lateral movements), phonetics, esthetics, the
occlusal plane, and the facial height were performed
(Figs 9a-d).
Figs 9a-b Try-in of the maxillary set-up with the mock-

up in the mandible to increase the vertical dimension of
occlusion (freeway space and centric relation).
529
530
Figs 9c-d Smile line and facial height with the set-up/
mock-up.
The implant-supported titanium bar was CAD/CAM-

designed and milled based on the set-up/mock-up. The
passive fit of the bar was examined on the master cast
as well as intraorally using the Sheffield test. After
verifying the fit of the CAD/CAM bar, the maxillary
denture was produced in the dental lab with a cobalt-
chromium framework.
531
The maxillary prosthesis was tried in when the denture
base was still in its raw phase t
o confirm esthetics, the occlusal plane, phonetics, and
function. The mock-up was bonded to the existing
mandibular prosthesis with composite and a bite
registration was taken in centric relation (Figs 10a-b).
532
Figs 10a-b Bite registration with the new removable
prosthesis in the maxilla and the mock-up bonded to the
existing mandibular prosthesis.
The maxillary prosthesis was finished at the dental

laboratory, including characterization of the buccal
acrylics (Figs 11a-c).
533
534
Figs 11a-c Final reconstructions in the articulator.
The teeth and acrylic were removed from the

mandibular framework. It had been designed as
cleansable with all pontics convex and showed adequate
contact to the oral mucosa, so there was no need for any
modifications. With this bite registration (Fig 10), the
occlusion and the mandibular denture were rebuilt with
new denture teeth and acrylic (Figs 12a-j).
535
Figs 12a-b Final maxillary prosthesis and titanium
CAD/CAM bar.
536
Figs 12c-d Repaired mandibular prosthesis.
537
Fig 12e CAD/CAM bar.
Fig 12f Maxillary bar and final mandibular prosthesis.
538
Fig 12g Final Maxillary and mandibular prostheses.
539
Figs 12h-i Lateral view of final prostheses.
540
Fig 12j Smile line and facial height with final
prostheses.
Maintenance phase
Supportive periodontal care and maintenance was

planned at three-month intervals. To prevent attrition,
the patient was provided with a night guard.
Acknowledgments
541
Dental laboratory procedures
Elias Bühler – Bühler Dental Aesthetik, Zurich,

Switzerland
542
9.3.3 Management of a Technical Complication Caused
by a Fractured Zirconia Abutment
T. Joda, U. Brägger
A 24-year-old female patient was treated with an

implant-supported crown for single-tooth replacement
at site 11. A Straumann Bone Level RC implant
(Institut Straumann AG, Basel, Switzerland) was placed
with simultaneous bone augmentation (Fig 1), and the
peri-implant emergence profile was conditioned with a
fixed implant-supported provisional crown. After
finalization of the mucosal architecture, the clinical
situation was transferred by means of a custom
impression post for fabrication of an implant-supported
screw-retained one-piece crown consisting of a
CARES® zirconia abutment (Straumann) with a direct
ceramic veneer.
543
Fig 1 Periapical x-ray after surgical placement of a
Straumann Bone Level RC implant at site 11.
During the first clinical try-in of the final restoration, a

fracture in the apical portion of the pristine CARES®
zirconia abutment became evident. The zirconia
remnant was trapped in the implant and could not be
removed (Figs 2a-b).
544
Fig 2 (a) Fractured CARES® zirconia abutment. (b)
Occlusal view of the clinical situation with a zirconia
remnant trapped in the implant at site 11.
Complication management aimed at removing the ring-

like shaped zirconia remnant without surgical
intervention and without damaging the internal
configuration of the implant. Due to its ring shape,
545
however, the zirconia remnant could not be removed
with the classical manufacturer’s service set, which
contains drills designed to remove components trapped
in the central screw-access canal (Luterbacher and
coworkers 2000).
A compatible extraction bolt was used to detach the

fractured component. Despite meticulous caution, the
apex of the extraction bolt fractured within the zirconia
ring and blocked the screw access hole (Fig 3).
Fig 3 Fractured extraction bolt.
Furthermore, neither the provisional implant crown nor

the fractured crown could be placed in their intended
position and connected to the implant for
provisionalization. Therefore, a custom wire
construction was used to bond the crown to the adjacent
teeth, so that the shape of the mucosa around the
implant could be maintained (Figs 4a-c).
546
547
Figs 4a-c Modified fractured implant crown (a)
provisionally bonded to the adjacent teeth to maintain
the mucosal architecture around the implant (b-c).
In a first attempt, the double-fractured zirconia ring plus

the fragment of the extraction bolt was meant to be
removed with the manufacturer’s service set. Once
again, however, the blocked implant could not be
released.
Ultimately, a custom-made tungsten carbide round bur

had to be manufactured (Jota AG, Rüthi, Switzerland).
Tungsten carbide is characterized by a Young’s
modulus of approximately 550 GPa and a stiffness two
times higher than steel. The custom round bur had the
same shaft design as the drills of the manufacturer’s
service set (Figs 5a-c). This was necessary to determine
the shaft’s length for the protection of the internal
configuration of the implant. The tip of the custom
small-diameter round bur created a centralized access to
the fractured extraction bolt.
548
Figs 5a-b (a) Detailed view of a customized small-
diameter round bur (Jota AG, Rüthi, Switzerland). (b)
Bur placed in the appropriate bracket of the
manufacturer’s service set.
During intermediate drilling combined with permanent

water-cooling, the custom round bur could be placed in
the implant axis with the specific drilling guide for
549
Straumann Bone Level implants (Brägger and
coworkers 1995). After repeated drilling, the round bur
was able to engage the trapped remnant and remove it
from the screw canal (Figs 6a-c).
550
Figs 6a-c (a) The first treatment sequence with the
inserted system-specific drilling guide in the screw
canal. (b) Custom round bur. (c) The bur was used
under irrigation.
In the second step, the drill of the manufacturer’s

service set was able to reach the defined insertion depth.
Continuous rinsing with chlorhexidine digluconate
solution helped remove the last remnants of the trapped
components (Figs 7a-c).
551
552
Figs 7a-c Second treatment sequence with intermediate
use of the Straumann-specific drills until the final depth
was reached.
As a final step, the implant screw thread was re-tapped

with the Straumann tap guides I to III; followed by
thorough rinsing with chlorhexidine digluconate
solution (Figs 8a-c).
553
Figs 8a-c Third treatment sequence with re-tapping the
implant screw thread (guides I–III).
The fractured remnants of the CARES® zirconia

abutment and extraction bolt could thus be removed
successfully without requiring a surgical intervention.
Neither the implant connection nor the bone-to-implant
interface was damaged (Fig 9).
554
Figs 9a-b Screw canal and persisting peri-implant
mucosal architecture after minimally invasive removal
of all fractured remnants.
The incremental approach using a customized round bur

and the system-specific drills of the manufacturer’s
service set saved the blocked implant, so that it could be
555
successfully restored with a new crown (Figs 10a-c and
11).
556
Figs 10a-c (a) New implant-supported crown with
CARES® zirconia abutment and direct veneer. (b)
Rehabilitated patient with crown at site 11, buccal view.
(c) Occlusal view.
557
Fig 11 Final periapical x-ray of the new implant-
supported crown at site 11.
558
9.3.4 Repeated Acrylic Fractures on a MandibularFixed
Full-arch Implant-supported Metal/Acrylic Prosthesis
J. Kan
A 77-year-old male patient was referred for the

management of frequent and repeated acrylic fracture of
his existing mandibular fixed full-arch implant-
supported metal/acrylic prosthesis. He also complained
about soft-tissue soreness and the lack of retention and
stability of his maxillary removable partial metal/acrylic
prosthesis. Both prostheses had been delivered two
years previously as part of his full-mouth rehabilitation
(caries, tooth wear, tooth fracture).
His medical history revealed high blood pressure,

controlled with the use of antihypertensive medication.
Clinical diagnoses and findings
A comprehensive clinical (extraoral and intraoral) and

radiographic examination yielded the following clinical
findings and diagnoses (Figs 1 and 2a-c):
Fig 1 Pre-treatment dental charting.
559
Fig 2a Pre-treatment occlusal view of the maxillary
arch.
Fig 2b Pre-treatment occlusal view of the mandibular

arch.
560
Fig 2c Pre-treatment frontal view in maximum
intercuspation.
Functional and restorative challenges
• Multiple missing teeth. Maxillary teeth 13, 12, 11,

21, 23, 27 remaining.
• Severe tooth attrition leading to reduced clinical

crown lengths of teeth 13, 12, 11, 21
• Severe wear and fractures on the acrylic teeth of the

maxillary removable prosthesis and the mandibular
fixed prosthesis
• Potential etiological factors: Parafunctional habits,

acid erosion of extrinsic dietary genesis
Occlusal challenges
• Reduced interarch space
561
• Compromised length and curvature of the maxillary
incisal plane
• Compromised vertical dimension of the mandibular

prosthesis
• Crossbites in the maxillary and mandibular right

quadrants
Periodontal/peri-implant challenges
• Attachment loss
• Generalized moderate to advanced periodontitis
• Clinical mobility grade I (teeth 13, 12, 11, 21, 23)

and grade II (tooth 27)
• Peri-implant tissue mucositis at sites 36, 33, 43, 46

and the midline
Esthetic challenges
• Inadequate tooth dimension, contour, symmetry, and

discoloration
Other
• Maxillary dental arch: Acceptable arch shape,

moderate ridge resorption, normal palatal vault and
normal vestibular depth
562
• Mandibular dental arch: Acceptable arch shape,
moderate ridge resorption, normal vestibular depth
Treatment considerations and treatment planning
Patient preferences. Based on the patient’s wishes to

retain all his remaining teeth despite poor to guarded
prognoses and to address his primary concern of
mechanical wear and fracture, several treatment options
were considered with the intention to provide a short-
term solution for his maxillary restoration and a long-
term result for his mandibular restoration. It was agreed
that a maxillary removable implant-retained
overdenture or a fixed full-arch implant-supported
prosthesis would be considered should his maxillary
dentition fail.
Rehabilitation at an increased vertical dimension of

occlusion. The prosthodontic rehabilitation was
performed at an increased vertical dimension of
occlusion (VDO) of 4 mm (interincisal distance). This
was necessary to provide adequate interarch space for
an ideal occlusal plane as well as adequate soft-tissue
clearance and dimension to ensure a strong metal
framework and acrylic base for the mandibular fixed
prosthesis. The dentofacial effect of the VDO increase
was acceptable in terms of facial height, proportion, and
profile and the establishment of a class I occlusal
relationship.
The following treatment plan was outlined:
Control and holding phases
563
• Dietary analysis and formulation of a preventive
oral-hygiene regime
• Periodontal and peri-implant tissue management

with a periodontist
• Centric mounting and diagnostic wax-up at an

increased occlusal vertical dimension
• Composite core build-up for teeth 13, 12, 11, 21 and

acrylic modifications to the occlusion of the existing
prostheses
• Prosthodontic assessment: Monitoring of the

patient’s functional adaptation (mastication, phonetics),
esthetics, and comfort
• Construction of a maxillary removable partial metal/

acrylic prosthesis
• Construction of a mandibular fixed full-arch

implant-supported metal/acrylic prosthesis
Maintenance phase
• Continued periodontal and prosthodontic recall and

maintenance
Prosthetic design and configuration
564
Maxillary removable metal/acrylic partial prosthesis.
The framework design of the existing maxillary partial
prosthesis had involved the use of a horseshoe-shaped
major connector. Thus, support was derived from the
alveolar ridge as the primary load-bearing area. Under
high functional and parafunctional loads, this had
resulted in soft-tissue trauma on the alveolar ridge,
especially the edentulous site 22 and the palatal gingiva
of the remaining abutment teeth 13, 12, 11, 21, 23. The
existing cobalt-chrome metal framework design had to
be modified to improve support for the new prosthesis,
which was achieved by adding occlusal or cingulum
rests on teeth 13, 23, 27 and a posterior palatal strap
made of metal (Fig 3a).
Fig 3a Maxillary dental arch restored with a removable

partial metal/acrylic prosthesis. Post-treatment occlusal
view.
It was accepted that the stability of the VDO

contributed by the maxillary restoration, being a short-
565
term solution, was questionable due to the poor
prognosis of abutment 27, anticipated continued ridge
resorption, and the wear on composite restorations
(Filtek™ Supreme XTE; 3M ESPE, St. Paul,
Minnesota, USA) and acrylic teeth (SR Phonares® II;
Ivoclar Vivadent, Schaan, Liechtenstein).
Mandibular full-arch fixed hybrid implant-supported

metal/acrylic prosthesis. Implants placed at sites 36, 33,
43, 46 and midline (Neoss Dental Implants, North
Yorkshire, UK) had previously been restored with a
full-arch fixed metal/acrylic prosthesis retained by
direct-to-fixture abutment screws. The vertical
dimension of the existing prosthetic design was limited
and did not allow adequate soft-tissue clearance for oral
hygiene. The height and width of the metal framework
were also minimal, and the framework was visible
through the thin and fractured acrylic. Hence, a decision
was made to make modifications to address these
fundamental issues in the new prosthesis.
For soft-tissue clearance, the framework was designed

to allow light tissue contact on the edentulous ridge,
whilst having embrasure areas around implants for oral
hygiene maintenance (Fig 3b).
566
Fig 3b Gingival contours of the mandibular fixed full-
arch implant-supported metal/acrylic prosthesis.
To maximize the stability of the VDO contributed by

the mandibular restoration, the posterior occlusion was
designed in metal as part of the implant-supported
titanium-vanadium-aluminum-milled framework (Nobel
Procera; Nobel Biocare, Quebec, Canada). The
mandibular anterior segment and the buccal aspect of
the posterior segments were realized with acrylic teeth
(SR Phonares® II; Ivoclar Vivadent) secured to the
framework with tooth-colored polymethyl methacrylate
(Telio Lab; Ivoclar Vivadent) and pink polymethyl
methacrylate (IvoBase High Impact; Ivoclar Vivadent)
(Fig 3c).
567
Fig 3c Mandibular arch restored with a fixed full-arch
implant-supported metal/acrylic prosthesis, Post-
treatment occlusal view.
Prosthetic phase
After the diagnostic wax-up in centric occlusion at the

chosen VDO, composite-core restorations were
provided for teeth 13, 12, 11, 21, temporary acrylic was
added to improve the occlusal plane of the existing
mandibular prosthesis, and a new maxillary removable
partial metal/acrylic prosthesis was fabricated.
Construction of the new mandibular prosthesis began

with implant-level impressions using splinted open-tray
impression copings and light- and heavy-body
polyvinylsiloxane impression materials (ImprintTM 3
VPS; 3M ESPE) in a custom tray.
A lab-processed verification jig was used intraorally to

verify the accuracy of the working cast. A maxillary
568
cast with the newly constructed maxillary removable
metal/acrylic partial prosthesis in place was mounted in
a semi-adjustable articulator using a facebow record
(Whip Mix 2000 series; Whip Mix, Louisville, USA).
Using the existing mandibular prosthesis, which had
been modified to the ideal vertical dimension, the
working cast was mounted against the maxillary
working model at chairside. At an acrylic try-in, aided
by temporary titanium cylinders, the accuracy of the
tooth set-up in centric occlusion, the planned group
function in lateral excursive movements, as well as
esthetics and phonetics were verified. This was then
provided to the laboratory for the copymilling process
(Jemt and coworkers 1999) for designing and
fabricating an implant-supported framework using the
CAD/CAM scanning and milling method.
At the framework try-in and the insertion of the finished

mandibular fixed full-arch metal/acrylic prosthesis (Fig
3d), direct vision, tactile sensation, and alternative
finger pressure testing on alternating terminal
abutments helped investigate any misfit that may
manifest itself as a mechanical fulcrum or in the form of
saliva movement at the framework-implant interface
(Kan and coworkers 1999). Parallel-view radiographic
evaluation complemented the clinical assessment (Figs
4a-c).
569
Fig 3d Post-treatment frontal view in maximum
intercuspation.
570
Figs 4a-c Parallel-view radiographs of implants 36, 33,
43, 46, and midline.
CAD/CAM titanium frameworks have shown a superior

and consistent passive fit across many studies thanks to
the omission of conventional casting steps (Torsello and
571
coworkers 2008; Örtorp and coworkers 2003; Al-Fadda
At the one-year review, the patient continued to report

complete satisfaction with the functional and esthetic
outcome. The mandibular restoration presented no
biological or mechanical complications. The patient
was reminded to consider long-term treatment options
available for the restoration of his failing dentition in
the maxillary arch.
Acknowledgments
Laboratory procedures
Michael Standish – Michael Standish Dental

Laboratory, Perth, WA, Australia
572
Table 1 presents a comprehensive overview
summarizing the topics concerning hardware
complications and failures with implant supported
reconstructions, which were discussed in the previous
chapters.
The table is structured by the site of origin of hardware-

related problems. The key biomechanical parameters
involved in the etiology are listed along with the
resulting observed complication/failure, its
management, and preventive measures to be taken.
The locations of the observed problems start with the

implant, proceed from the apical to occlusal aspect, and
end with the superstructure, as indicated in Chapter 4.1
(Figs 1a-f).
The table presents guidelines related to management

and prevention of hardware-related complications and
failures and attempts to structure the complexity of
clinical findings in patients with implant-supported
reconstructions.
Table 1 Hardware-related failures and complications in

different positions along an implant/abutment/
reconstruction complex, key biomechanical parameters
involved, management, and prevention.
573
Implant/
Key Complication/
reconstruction Management Prevention
parameters failure
complex
574
1. Implant Materials’ • Deformation • Remove • Optimized
body physical implant physical material
properties and design
properties
• Fracture: • Remove
Small diameter implant • Resistant
– Fatigue fragment materials for
fracture small diameter
Design of • Leave implants
platform, neck – Disruption fragment
(trauma) sleeping • Correct
indication
• Sufficient
dimensions
• Reduce stress
peaks by
optimized design
achieved by
simulation,
testing, e.g.
Finite-Element
Analysis (FEA)
Surface • Scratches, pits • Polish • Avoid

damage when
• Traces from • Smoothen handling
instrumentation components
• Avoid
damage during
maintenance
procedures
• Damage to • Explantation • Use adequate

platform, neck instruments
• Avoid
damage when
removing old
reconstructions
575
Osseointegration • Spinner • Stop • Give enough
manipulation time for healing
• Wait • Slow
increase of
• If persistent, torque when
remove removing
healing
abutments
• Observe
patient reaction
• Use ISQ as
indicator
3D position of • Malpositioned • Prosthetic • Prosthetically

platform platform compromise driven planning
and implant
• Remove or placement
leave the
implant
sleeping
Implant/
Key Complication/
parameters failure
complex
576
2. Implant Materials’ • Loosening • Remove, • Use well-
body/ physical of abutment/ clean documented
Abutment properties abutment screw components, systems
interface and design rinse,
(connection) retorque • Correct
torque
Clamping,
settling, • Matching
• Fracture of • Remove,
tolerance components
abutment base rinse, use new
component,
• Use original
retorque
abutments
• Fragment • Remove
blocks access to fragment,
bore in the retap, rinse,
implant use new
component,
torque
Index • Misfit of • Find • Clean the

position (index) correct interface
position
• Gap • No foreign
• Retake bodies while
impression inserting
abutments
• New
reconstruction • Correct
indexing
• Radiographic
control of
position before
definitive torque
Tribology • Wear of • Remove • Use

implant abutment optimized
material causing wear components
causing a
titanium tattoo • Replace
577
Bore • Damage by • Use • Avoid
non-guided service set damage when
attempt to removing
remove • Retap fragments
fragments
Seal • Colonization • Treat • Use correct

by bacterial infection components,
plaque torque, index
• Insert
• Fistulas perfectly • Precision of
fitting components
abutments
and
reconstruction
Implant/
Key Complication/
parameters failure
complex
578
3. Abutment Materials’ • Loosening • Remove • Use
screw physical screw or correct
properties, • Fracture fragment, abutment
dimensions clean, rinse, screw
and design use new
screw, • Apply
retorque correct
torque
• Use
original
abutment
screw and
original
screwdriver
Access to • Insert • Clean • Clean

insert for damaged due with probe abutment
screwdriver to handling of screw
the • Apply
screwdriver or axial pressure • Clean
while drilling on insert before
out covering screwdriver use of intact
restoration while screw driver
detorqueing
• Protect
• Apply screw head
ultrasound with Teflon
and a
• Freeze covering
restoration
• Remove
with service
set if insert
damaged
Screw-head • E.g. • Remove • Use

seating on fracture of fractured correct
abutment ceramic component abutment
body abutment with service screw from
(clamping) because of set the
wrong beginning
579
abutment • Remake • No
screw with correct inadvertent
screw exchange of
screws
Fracture • Fracture • Easy or • Systems

mode occurring at complicated with built-in
different levels removal of predictable
screw fracture
fragment mode for
easy
removal of
fragments
Implant/
Key Complication/
parameters failure
complex
580
4. Abutment Materials’ • Deformation • Remove • Correct
body physical and replace indications
properties • Fracture component
• Correct
handling
• Original
component
Design: wide • Loss of • Recement • Use plan

choice of retention abutment
prefabricated (cementable) • If
components repeatedly, • Enough
or custom remake but retention for
CAD/CAM change cementation
components, concept
dimensions,
height
AntirotationaI • Rotation • New • Use

stop (“spinning abutment rotational stop
crown”)
• New • Use correct
crown copings
Access for • Access too • Change • Use plan

screw, axis labialy for abutment or abutments
screw-retained change to
reconstructions cementation • Prosthetically
driven implant
placement
Surface of • Scratches, • Polish • Avoid

emergence pits damage during
profile aspect • Smoothen maintenance
• Traces from procedures
instrumentation • Change
abutment • Use adequate
instruments
581
Implant/
Key Complication/
parameters failure
complex
582
5. Interface Retention by • Loss of • Recementation • Use correct
between cementation retention height of
reconstruction components
and abutment
• Choose
among more or
less retentive
cements
Cement • Cementing • Remove • Careful

residue error cement residues cementation
• Cement • Remove
residue cement residues
• Radiographic
control
• Place implant
at favorable
depth
• No
Interface cementation if
between submucosal
implant cement margin is
platform and not accessible
cemented or
screw- • Remove
retained immediately if
reconstruction cement mistake
has occurred
Index for • Misfit • Find index • Controlled

single crowns transfer/index
and tolerance • Gap • Repositioning
for multiunit of abutment • Precise
reconstructions • Leakage laboratory
• Remake procedures
• Cement
Precision residue • Correct try-in
procedure
583
• Fistula • Radiographic
control
• Mucositis/
peri- • Transfer aid
implantitis
Torque, • Loosening • Remove, clean • Correct screw

preload, component, rinse,
clamping with retorque • Original
occlusal screw screw
• No lab screw
Materials • Fracture • Remove, • Correct

physical rinse, use new handling of
properties of screws screw driver,
occlusal screw apply correct
torque at correct
position (index)
Insert of • Insert • Remove with • Protect

occlusal screw damaged by service set occlusal screw
incorrect head with teflon
handling of and a cover
screwdriver, restoration
by wear, or by
previous
drilling
Access for • Screw does • Position with • Prosthetically

occlusal screw not engage correct indexing driven implant
planning and
• Soft-tissue • Remove placement
pressure excessive tissue
• Provide
• Access for sufficiently wide
screwdriver access channel
blocked
584
• Access • Use angulated
with abutment
screwdriver
not
manageable
• Access • Use
located too far customized
labially abutment
Screw-retained • Esthetics • Screw-access • Consider pros

versus cover restauration and cons from
cemented • Non- the ITI
retrievability • Use Consensus
of provisional Conference 2013
superstructure cement related to
recommendations
for cementation/
screw retention
Implant/
Key Complication/
parameters failure
complex
585
6. Closure Materials’ • Component • Surgical • Provide
screw, healing physical covered by removal of access to
abutment, properties bone/graft graft/bone implant
mucosa
former • Choose
optimal
Design, abutment
height,
width
• Overgrowth • Replace • Soft-
of soft tissue with tissue
component management
with optimal at second-
configuration stage
surgery
• Surgical
soft-tissue • Soft-
correction tissue graft
in cases with
thin mucosa
• Mucosal • Change to • Avoid

recession smaller long-lasting
component in blanching
case of thin
mucosa
Insert • Insert filled • Clean • Instruct

with deposits insert patient for
cleaning
• Remove
deposits
before using
screwdriver
• Damaged • Use • Careful

insert service set handling of
screwdriver
586
and ratchet
(axis)
Implant/
Key Complication/
parameters failure
complex
587
7. Attachment Materials’ • Loosening • Remove, • Use correct
system for physical clean component
overdentures properties, component,
torque, rinse, • Correct
clamping retorque torque
• Fracture • Remove • Established

fragment systems
with service
set, clean,
rinse
• Replace
fractured
component
Attrition • Wear of • Replace • Protective

inserts and/or worn parts splint
abutments
• Implant axes
not too divergent
Reduction • Loose fit • Replace • Respect

of retention and reduced with inserts tissue height
function with better
retention • Respect
prosthetic
• Change to principles for
components overdentures
with better such as distances
retention between
implants, axes
• Prosthetically
driven implant
placement
588
Activation • Patient • Use • Start with
cannot handle inserts with low retention
insertion or less retention
removal of • Adapt
overdenture retention
individually
• Instruct
handling
Maintenance • Repeated • Change • Correct

service service need attachment prosthetic
needs system, position
• Hardware- concept
related • Support
mucositis, • Improve polygon, axes,
peri- domestic oral required space
implantitis, hygiene
hyperplasia • Prefer
• Treat durable
infection materials, easy
replacement
• Correct
surgically • Instruct on
careful insertion
of overdenture
• Regular
maintenance
Implant/
Key Complication/
parameters failure
complex
589
8. Materials’ • Fracture • Remove • Choose
Mesostructure physical cemented resistant
properties of • Loosening of reconstruction materials and
substructure material
prefabricated (abutment) • If combinations
or custom- successful,
made recement • Retrievable
components after cleaning final
and reconstruction
retightening
• Remake
Correction • Overcontouring • Reduce • Avoid the

of axes or overcontour need for
vertical • No access for mesostructures
levels cleaning with
prosthetically
driven implant
• Plaque • Instruct in placement
accumulation oral hygiene
• Avoid
• Calculus overcontour
and concave
• Biological surfaces
complications blocking the
access for
hygiene
Implant/
Key Complication/
parameters failure
complex
590
9. Materials’ • Aging of • Polish • Reduce
Reconstruction physical materials rough known risk
properties/ surfaces factors as
Dimension • Different described in
for degrees of Chapter 8
framework/ wear • Remove
veneer stain, deposits
• Change in • Optimize
color laboratory
procedures
• Different
Chairside severity of • Polish • Meticulous
corrections ceramic polishing after
fractures • Repair corrections to
avoid crack
• Remake formation
• Avoid crack
formation in the
laboratory
• Retrievability
Connector • Framework • Remake • Choose

dimension fractures sufficient
dimensions
Parafunction • Wear • Repair • Splint

protection
• Remake
Access for • Mucositis/ • Modify • Design

hygiene peri- access leaves access for
implantitis hygiene and
• Remake maintenance
591
Maintenance • Combined • Remake • Apply a
and/or but change reasonable
service repeated concept occlusal concept
needs complications/
failures • Regular
supportive care
for early
diagnosis
Allergenic • Allergic • Remake • Avoid Ni and

potential reaction with Pd
biocompatible
• Fibrotic material • Protection by
lung disease of exhaust
dental ventilation
technician
592
10 Etiology, Management, and Prevention of Hardware
Complications with Implant-supported Reconstructions
U. Brägger, S. Hicklin
593
This volume of the ITI Treatment Guide series has
presented the etiology, risk factors, and strategies for
the treatment and prevention of biological and hardware
complications in implant dentistry.
As more implants are placed throughout the world by

an increasing number of practitioners with varying
levels of expertise, it is likely that the cumulative
number of patients who experience complications will
also increase. Hence, the skills for an accurate diagnosis
and management plan are important.
With careful treatment planning and patient assessment,

in order to identify systemic, local or site-related, and
lifestyle-related risk factors, the occurrence of
complications can be minimized.
Meticulous preparation of the patient and the implant-

recipient site, followed by precision in both implant
placement and restorative aspects of treatment, will also
minimize the risks for future complications.
Careful selection of appropriate materials and

techniques, which have all been tested and well
documented, can reduce the incidence of complications.
A thorough understanding of the technical requirements
of the restorative components used is important, as well
as good communication between the implant surgeon,
the restorative clinician, and the laboratory technician.
Patients should be informed of the possibility of future

complications arising at the outset of treatment during
594
the treatment planning stage. Furthermore, the
importance of regular maintenance care and monitoring
should be reinforced. An individualized supportive-care
program for each patient should be planned and
implemented, in order to maintain healthy peri-implant
tissues.
Finally, clinicians should be aware of their own

experience level and limitations and adopt a team
approach to patient care where appropriate.
595
11 Conclusions
596
597
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ITI Treatment Guide, Vol 8 - Biological and Hardware Complications in Implant Dentistry - U. Brägger (2015)

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ITI Treatment Guide

Biological and Hardware Complications in Implant

Berlin, Chicago, London, Tokyo, Barcelona, Beijing,

The German National Library has listed this publication

© 2015 Quintessence Publishing Co, Ltd

Ifenpfad 2–4, 12107 Berlin, Germany

All rights reserved. This book or any part thereof may

Illustrations: Ute Drewes, CH-Basel,

The inclusion of or reference to a particular product, method,

All rights reserved. In particular, the materials published in the ITI

Some of the manufacturer and product names referred to in this

The tooth identification system used in this ITI Treatment Guide is

“… to promote and disseminate knowledge on all

While implant dentistry today is well documented

Volume 8 of the ITI Treatment Guide series

The mission of the ITI “… to promote and

We would like to thank Dr. Kati Benthaus of the ITI

DDS, PhD, Professor

Head, Section of Implantology and Prosthetic Dentistry

Department of Oral Function and Restorative Dentistry

Academic Centre for Dentistry Amsterdam (ACTA)

Gustav Mahlerlaan 3004

1066 EA Amsterdam, Netherlands

DDS, Dr med dent

Professor and Chair

Department of Oral Surgery and Stomatology

University of Bern, School of Dental Medicine

3010 Bern, Switzerland

Clinical Associate Professor

School of Dental Science

720 Swanston Street

Melbourne VIC 3010, Australia

Professor and Chair

Department of Reconstructive Dentistry and

University of Bern, School of Dental Medicine

3010 Bern, Switzerland

BDS, MDSc, PhD

International Research Collaborative

University of Western Australia

Nedlands, WA 6009, Australia

Dr med, Dr med dent, Professor

Department of Oral and Maxillofacial Surgery

55131 Mainz, Germany

DMD, Dr med dent, Professor

Department of Oral Surgery and Stomatology

Department of Reconstructive Dentistry and

University of Bern, School of Dental Medicine

3010 Bern, Switzerland

Dr med dent, Associate Professor

Head, Section of Oral Radiology and Stomatology

Department of Oral Surgery and Stomatology

University of Bern, School of Dental Medicine

3010 Bern, Switzerland

Professor and Chair

Department of Reconstructive Dentistry and

University of Bern, School of Dental Medicine

3010 Bern, Switzerland

DDS, Dr med dent

Professor and Chair

Department of Oral Surgery and Stomatology

University of Bern, School of Dental Medicine

3010 Bern, Switzerland

BDSc(Hons), MDSc, FRACDS(Oral Med), FOMAA

Associate Professor (Oral Medicine)