IMPLANT FAILURE

BY
Ahmed M Taha
Andrew Reda
Despite the many benefits of dental implants, they do
have the potential to fail. But what happens if and when
?they fail
?Can you get them fixed
?Will you be able to get another implant
Well, let’s take a look at those question. We’ll talk about
how often implants fail, why they fail, and how to
.prevent and care for failed implants
 Definition of implants classified according *
:to radiographic and clinical findings

: Failed implants .1
: An implant that demonstrates
Clinical Mobility-
Peri-Implant Radiolucency-
.Dull Sound When Percussed-

A failed implant is non-functional and must be→

removed
:Failing implants : characterized by .2
Progressive Bone Loss-
Signs of Inflammation-
.No Mobility-

this type of failure is just due to complications of*

either overload or biological and it is reversible upon
.removal of the cause
 Ailing implants .3
An implant that may demonstrate bone loss with
deeper clinical probing depths but appears to be stable
.when evaluated at 3-4 months interval
Radiographic Bone Loss-
No Inflammatory Signs-
.No Mobility-
Parameters evaluating failed implants *

:Clinical Signs of Early Infection-1

Signs of infection occurring during at an early stage -
of healing is MORE CRITICAL than if they occur at
a later stage. This is because; the infection occurring at
an early stage will lead to disturbance in the
Osseointegration of the implant to the surrounding
.bone during the healing period (3-9 months)
 :Pain and Sensitivity-2
Pain or discomfort is often associated with mobility -
and could be one of the first signs which indicate an
.implant failure
occurs also during chewing, percussion, on screw -
.tightening
Not only indicating failure but also due to nerve -
.repositioning or lateralization of the canal
At the same time failed implant can be completely-
asymptomatic
:Clinical Mobility-3
Rotation mobility-
Lateral or horizontal mobility-
.Axial or vertical mobility-
.Mobility is always a clear sign of failure •
Once the clinician has distinguished between the •
mobility of a poorly connected abutment and the
mobility of the underlying implant, the implant must be
.suspected to be surrounded by a fibrous tissue capsule
Occasionally, clinically mobility can be present without •
distinct radiographic bone changes. Therefore, mobility is the
.cardinal sign of implant failure
.’’horizontal mobility’’ diagnosed by the perio test •
Vertical and horizontal mobility’’ shows fibrous tissue •
.’’formation
Rotation mobility ‘’due to weak bone implant interface •
diagnosed by reverse torque test which isn’t recommended
 periotest

The Periotest is the instrument most commonly used for

measuring osseointegration in dental implants. The
Periotest can be employed at all stages of implantological
treatment – from primary stability testing, through the
healing period, and right up to the finished prosthetic
the Periotest values for 1,565 root form implants were 
determined at second-stage surgery and correlated with type,
material, coating, diameter, and length. Hydroxyapatite-coated
implants and increased implant diameter and length produced
Periotest values that indicated a greater extent of stability as
compared with noncoated implants with shorter diameters and
lengths. Hydroxyapatite-coated cylinder-type implants yielded
.the most favorable Periotest readings
THE INFLUENCE OF IMPLANT TYPE, MATERIAL, COATING, DIAMETER, AND
LENGTH ON PERIOTEST VALUES AT SECOND-STAGE SURGERY: DICRG INTERIM
REPORT No. 4.
Ochi, Shigeru PhD; Morris, Harold F. DDS, MS; Winkler, Sheldon DDS Dental Implant Clinical
Research Group
.[Article] Implant Dentistry. 3(3):159-164, Fall 1994
 :Dull Sound on Percussion-4
.Indicates fibrous tissue encapsulation-
Although it is a rather subjective test without a solid-
scientific background, it can provide a useful
.indication to the examiner
A dull tone on percussion can be present before-
.radiographic signs appear
 :Radiographic Signs of Failure-5
X rays taken after abutment connection as baseline-
.value for future marginal bone loss
Since the distinction between the two radiographic •
pictures is not always clear, when a suspected peri-
fixtural radiolucency or excessive marginal bone loss is
observed, it is recommended to remove the prosthetic
construction and check the implants for stability.
Clinically, mobility after bridge removal can confirm the
.presumptive radiographic diagnosis of implant failure
 :There can be two well-distinct radiographic pictures
A thin peri-fixtural radiolucency surrounding the entire implant, •
suggesting the absence of a direct bone-implant contact and possibly a
.loss of stability
An increased marginal bone loss May be also indicating in •
.mechanical failure
 Implant Stability Quotient

ISQ, or Implant Stability Quotient, is a scale from 1 to

.100 and is a measure of the stability of an implant
The ISQ scale has a non-linear correlation to micro
,mobility. With more than 1000 scientific references
we now know that high stability means >70 ISQ,
between 60-69 is medium stability and < 60 ISQ is
.considered as low stability
By comparing resonance frequencies, the stability of
a dental implant can be determined as the resonance
frequency changes with different stabilities. A sensor
is mounted on top of the implant and the sensor is
then brought to vibration by gently moving it with
magnetic pulses. The sensor will vibrate for a short
while and then stop. If the implant stability (stiffness
of the bone-implant interface) increases, the
 .vibration frequency of the sensor will increase
implant Stability Quotient (ISQ) is an objective world
standard for measuring implant stability. The clinical
range of ISQ is normally 55-80. Higher values are generally
.observed in the mandible than in the maxilla
If the initial ISQ value is high, a small drop in stability
normally levels out with time. A big drop in stability or
.decrease should be taken as a warning sign
Lower values are expected to be higher after the healing
period. The opposite could be a sign of an unsuccessful
.implant and actions should be considered
The correlation between micro mobility (μm/N) and
ISQ is non-linear and micro mobility is reduced with
  .app. 50 % when ISQ increases from 60 to 70 ISQ
The Osstell technique is an indirect measurement of
osseointgration. It measures the resonance frequency
of the connected SmartPeg which reflects the micro
.mobility of the implant
The same load (N) will give different micro motion 
(μm) in different bone quality. It is well known that too
much micro motion will jeopardize the
osseointegration process. Scientific ISQ data indicates
that implants with high ISQ-values seem to withstand
even high forces in the mouth and still osseointegrate
 Parameters used for Evaluating Failing Implants*
The clinical signs previously discussed emerge only when the -
.failure process reaches an irreversible state
However, the ideal parameter for monitoring implant conditions
should be sensitive enough to distinguish early signs of implant
.failure
Parameters used to evaluate failing implants*
.progressive marginal bone loss-1
Clinical signs of late infections-2
bleeding on probing-3
Absence of keratinized tissues -4
probing pocket depth-5
Radiographically observed progressive marginal-1
bone loss
Progressive marginal bone loss is a pathological sign, •
.which can lead to implant failure
Alberktson et al. have suggested less than 1.5 mm of •
marginal bone loss is seen during the 1st year of loading
and thereafter less than 0.2 mm yearly as success
criteria. Whereas failed implants considered if bone
.loss reach to the apical 1/3
. 
We have three modalities: periapical intraoral radiograph •
(without parallel technique),with parallel technique, digital
.subtraction radiography
Even though it’s difficult to be reproducible but it’s more •
reliable over probing especially in the presence of bony defects
and inflammation
Clinical signs of late infection: In the absence of-2
mobility and radiographic changes, these signs indicate
more a complication (amenable to treatment) than a
.failure
Bleeding on probing: that it can be used to-3
discriminate between a healthy or diseased peri-
.implant state and it does not indicate failing implants
Absence of keratinized mucosa: A relationship and-4
correlation between implant failure and absence of an
adequate band of keratinized mucosa surrounding the
.abutment has been suggested
:Pocket probing depth-5 
Absolute pocket depth alone isn't an indicative to •
failure but progressive probing depth over time could
.be a sign of failing implants
 Classification of implant failures
Biological-1
:Early or primary (before loading)*
.Failure to establish osseointegration→
:Late and secondary (after loading)*
.Failure to maintain the achieved osseointegration→
Inadequate patient adaptation: Phonetical, esthetical-2
problems
.Iatrogenic: Nerve damages, wrong alignment of implants-3
Mechanical: Fracture of implants, connecting screws,-4
.bridge frameworks,lack of passive fit
 Biological
:First stage surgery
 Hemorrhage during drilling
 Nerve injury
 Injury to adjacent teeth
 Flap dehiscence and exposure of graft material
occurs during the first 10 days
 Hemorrhage during sinus lifting
 Loss of the implant or graft materials into the
maxillary sinus
 Hemorrhages in the mandible
Hemorrhage during drilling
A vascular wound may occur after detrimental-
surgical manipulations or tearing of the lingual
periosteum, but in most cases, it is attributed to
perforations of the lingual cortical plate
Nerve injury
:Its types
o Neurapraxia: There is no loss of continuity of the
nerve; it has been stretched or has undergone blunt
.trauma. Feeling will return in days to weeks
o Axonotmesis: Nerve is damaged but not cut; feeling
.returns within 2 to 6 months
o Neurotmesis: Nerve cut; poor prognosis for
.resolution of parasthesia
:Diagnosis
neurodiagnostic tests should always be combined with a -1
directed neurologic examination, in order to identify the
clinical abnormalities and establish a differential diagnosis
Clinical neurophysiological examination is currently the gold
standard for diagnosis and determination of prognosis
it yields key information on the type of involved fibers -2
(sensory vs. motor)
on the underlying pathophysiology (demyelination vs. axonal
loss)
.on axonal loss quantification, and consequently on prognosis
electromyography (EMG)test the integrity and physiological-3
.function of peripheral sensory and motor fibers and the muscles
In order to reveal axonal loss (presence of denervation potentials),-4
the optimal timing of a neurodiagnostic study is 2‑3 weeks after injury
Neurodiagnostic studies should be repeated 3 months or more
following trauma or surgical repair to assess the ratio of denervation
.to reinnervation
High‑resolution ultrasound -5
Its advantages include a bedside, painless study of the nervewith
color‑Doppler analysis integration and dynamic scans. In addition, it
can be utilized in the presence of metal implants, and therefore is
.preferable to a high‑cost, single segment MRI study
MRI -6
Possible causes of nerve injury include poor flap design,→
traumatic flap reflection, compression of the implant body
.into the canal
:The nerve injury may cause one of the following conditions→
 parasthesia (numb feeling)
 hypoesthesia (reduced feeling)
 hyperesthesia (increased sensitivity)
 dysthesia (painful sensation)
 anesthesia (complete loss of feeling) of the teeth, the lower
lip, or the surrounding skin and mucosa
Injury to teeth adjacent to the implant

occur subsequent to the insertion of implants along an-

.improper axis or after placement of excessively large implants
Adjacent tooth injury by implant placement may cause the tooth
to become non-vital, and the tooth may require subsequent
.endodontic treatment
This will not only result in damage to an adjacent tooth but also
.implant failure
 Flap dehiscence and exposure of graft material
Flap tension, continuous mechanical trauma or irritation,-
incorrect incisions and formation of sequestration of bone
.debris, causing contamination of graft & its eventual loss
.
Hemorrhage during sinus lifting
Although accidental laceration of the vessel is not-
life-threatening because of the small size of the artery,
an impaired visualization may compromise the
elevation of the membrane and interfere with the
.placement of the graft material
Loss of the implant or graft materials into the maxillary sinus
An implant can easily migrate into the sinus without apparent
force in the posterior maxilla, clearly showing a lack of
osseointegration .Various mechanisms have been proposed to
explain the migration of an implant into the maxillary sinus,
:which fall under three main categories
.Changes in Intrasinal and Nasal Pressures *
Autoimmune Reaction to the Implant, Causing Peri-Implant*
.Bone Destruction
Resorption Produced By an Incorrect Distribution of Occlusal*
.Forces
Hemorrhages in the mandible
Injury to the arterial supply of the mandible& perforation-
of the mandibular lingual cortical plate during osteotomy
may compromise the life of the patient. The high risk of
damaging the arteries of the floor of the mouth is
explained by the close proximity of the vessels to the
lingual cortical and the sublingual fossa causing internal
hemorrhage, swelling in the floor of the mouth,
displacement & protrusion of the tongue, may lead to
obstruction of the airway
Second- stage surgery+ Abutment Connection
 Slightly sensitivity and pain
 Fibro-integration
 Infection
 Granulation tissue around the implant head
 Peri-implantitis
 Sinusitis
Slightly sensitivity and pain:The first sign of a failing implant,
before it is evident on a radiograph. If pain is present, the dentist will
.need to evaluate whether this is due to occlusal trauma or infection

Fibro-osseous integration: collagen layer observed between bone

and implant surfaces. This connective tissue zone consists of both
.parallel collagen fibers and supporting blood vascular elements
Surgical trauma and bacterial contamination, heating of bone,
improper fit & stability of dental implants at placement, & the
.negative effect of poor bone quality all play an important role
:Infection
Pathogenic microflora of natural teeth. Contamination of
the implants may be favored by the presence of necrotic
and traumatized bony tissue and/or an impaired host
defense mechanisms. Characteristic clinical features are
edema, swelling, purulent exudate, pain on palpation or
.fistulae, bone resorption may be found on radiographs
Granulation tissue: Caused by traumatic placement of
.implant, compression from transition prosthesis above
 Peri-implant disease Is inflammatory reactions in the
soft tissues
Peri-implant mucositis is a term describing reversible-
inflammatory reactions in the soft tissues surrounding a
.functioning implant
Peri-implantitis refers to inflammatory reaction with loss-
of supporting bone. The clinical signs of such infection
include hyperplastic soft tissues, suppuration, colour changes
of the marginal peri-implant tissues and gradual bone loss,
.oedema of peripheral tissues, bleeding on probing
: Causes
Bacterial Accumulation-1
Overloading-2
or Combination-3
Biomechanical Overload Bone loss at the coronal
aspect of implants can result form biomechanical
overloading and the resultant microfractures at the
coronal aspect of the implant-bone interface. The loss
of osseointegration in this region results in apical down
.growth of epithelium and connective tissue
The role of over loading is likely to increase in four
:clinical situations
The implant is placed in poor quality bone. 2.The.1
implant position or the total amount of implants placed
does not favor ideal load transmisson over the implant
.surface
The patient has a pattern of heavy occlusal function .3
.associated with Para function
The prosthetic superstructure does not fit the .4
.implants precisely
 Other etiologic factors such as
traumatic surgical techniques -1
smoking -2
inadequate amount of host bone resulting in an -3
exposed implant surface at the time of
placement
compromised host response can act as co-factors in-4
.the development of peri implant disease
Bacterial infection
If plaque accumulates on the implant surface, the sub
epithelial connective tissue becomes infiltrated by large
number inflammatory cells and the epithelium appears
.ulcerated and loosely adherent
When the plaque front continues to migrate apically,
the clinical and radiographic signs of tissue destruction
.are seen around both implants and teeth
Peri-implant soft tissue attachment Several authors have
proposed that the maintenance of healthy peri-implant
conditions requires a collar of attached gingival around the
.implant neck
Furthermore, clinical and animal experimental research has
demonstrated that if oral hygiene is sufficient, healthy peri-
implant conditions can be maintained even if mobile oral
.mucosa surrounds the implants
if recurrent inflammation persists around implant surrounded 
by mobile mucosa, it may be prudent to surgically create a
peri-implant zone of attached gingiva, which will also simplify
.implant hygiene
 Management and prevention of peri
implanitis
The first prosthodontic phase
Abutment connection
Avoiding of repeated connection and disconnection-1
of components at fixture head level to promote bone
remodelling
provide a one-time connection of a sterile implant-2
abutment at the time of implant placement or at the
time of second stage implant surgery if at all possible,
such that a definitive abutment is fitted and further
 ,access to the implant
Titanium 'Multiunit' abutments fitted at time of dental
implant surgery for a one-time connection
The use of a preoperative chlorhexidine rinseand the -3
need to begin oral hygiene procedures over the implant
site within a few days of surgery is normal practice for
.the author
Impressions and temporary restorations
Whether restoration of the implant begins at the time of
surgery (if immediate loading is carried out) or following
a conventional healing period, making an impression
with a dental impression material or using resins,
composites or adhesive bonding agents will all put
potentially contaminating dental materials in proximity
to the implant platform or definitive abutment.
Contamination of the implant or abutment surface,
particularly of a high energy, rough surface with a low-
 viscosity dental material
In this case impression material has extruded into an extraction site and onto
the implant surface, motivating the author to remove and replace the
.contaminated implant
Planning for screw or cement-retention
Screw retention of implant crown and bridgework -1
facilitates retrievability, and completely eliminates the
.risk of subgingival cement extrusion
lack of precision can result in poorly fitting bridge -2
substructures, or tight contacts between adjacent
implant restorations, generating high-level standing
loads with the potential to hasten component fracture
 .and possibly contribute to crestal bone loss
CAD CAM design of a zirconia abutment onto which porcelain will be directly
.bonded

The screw channel would emerge through the incisal edge of the tooth (a) without angle 

correction (b) which makes it possible to re-angulate the channel to emerge on the palatal surface
of the abutment where use of a special screwdriver (c) allows the crown to be screw-retained (d)
A CAD CAM zirconia abutment designed to have supragingival margins
palatally, with the buccal margin just beneath the buccal gingival margin so as to
minimise the potential for cement extrusion
Sinusitis
The clinical diagnosis of sinusitis is characterized by a -
triad of symptoms: nasal congestion, secretion or
.obstruction, and headache
 Causes: Maxillary sinusitis can occur as a result of
contamination of the maxillary sinus with oral or nasal
. pathogens
. Lack of asepsis during sinus augmentation
 Drainage disturbances, mainly as a result of septal
deviation and allergies combined with oversized inferior and
.middle turbinates
1- . Screw and Fracture
• frequent in screw-retained FPDs
• screw loosening in 6% to 49% of cases at the first annual
check-up.- Jemt et al. 1994
it is due to long standing loose screw.
• in the patient with a prosthesis retained by multiple
implants, the ability to detect a loose screw is greatly
diminished
• biomechanical support (and resistance) for the
restoration must be evaluated
screw loosening -2
Abutment screw stability can be affected by preload, the effect of
settling, and screw geometry . Preload is the force, measured in volts
and later transferred to newton, that is generated when a screw is
tightened within a given torque
Preload is that after u screw the abutment and 25 N wait for 5-10 min
then we screw again for a quarter to half a turn. This will undergo
tension and elongation (stretching) of the screw inside the screw
channel and increase its resistance to unscrewing
Screw should be tightened at 25N
Only 10% of the initial torque is transformed into preload, where the  
remaining 90% is used to overcome the friction between the surface
 irregularities
Another important phenomenon experienced by the screw
joint is the settling effect. This occurs because neither the
interior torque nor the screw is perfectly fabricated without
irregularity, and therefore these rough areas are smoothed out
causing a loss of 2-10% of the initial preload. It is known that
the preload should not be too high and should be lower than
75-80% of the elastic limit of the material . If the forces
applied onto the system are greater than the preload, screw
.loosening takes place
From a clinical point of view, it is thought that screw
loosening is greater in an external connection than in an
,internal connection
Preload must be maintained as little as possible to
prevent joints from separating
Torque loosening causes micromovements in the interface
to appear that generate both mechanical problems
increased loosening and failure of the screw, abutment(-1
)and implant body
biological problems. In the case of biological-2
problems, microspaces that form within the interface
permit the colonization of bacteria that can cause
mucositis, peri-implantitis and finally implant loss,
especially when the implant-prosthesis are subjected to
cyclic loads
Dental implant screw retrieval methods
No. 1—Cavitron and instrumentation
Artery forceps, explorers, spoon excavators, and Cavitrons have
been used when the screw fracture occurs in the coronal third of
the implant chamber. The oscillations from an ultrasonic scaler
can gradually reverse out the screw by placing the thin tip of an
ultrasonic scaler directly on the top of the screw. Adding a
lubricant, such as eugenol or mineral oil, can decrease friction
.and ease clamping to assist in screw retrieval
When screw fractures occur in the coronal third of the dental implant
chamber, artery forceps, explorers, spoon excavators, and Cavitrons
are useful for screw retrieval
No. 2—Screw retrieval kit
There are many different types of screw/implant retrieval and
rescue kits made by different companies. Nobel Biocare,
Neobiotech, Osstem (OssVK), BTI Biotechnology Institute,
and Salvin Dental Specialties all make these types of kits.
The author has found great success with screw retrieval using
the Implant Rescue Kit from Salvin Dental This kit is
especially useful when the broken screw is fractured in the
apical 50% of the implant chamber. Following are the steps
involved in using this implant screw retrieval kit
• 
Salvin Dental Implant Rescue Kit, particularly useful for fractured screws in the apical
.50% of the implant chamber
Insert the appropriate drill guide onto the implant platform. Use a contra-angle
handpiece with the pilot drill at 1,000–1,250 RPM in reverse with a pumping motion
and copious irrigation to create a 1–2 mm deep dimple into the fractured screwhead.
.This creates a purchase point for the next drill tap
.Suction the metal shavings and irrigate the area •
While still in reverse, use the tap drill at 70–80 rpm, which will reverse out the •
.broken screw from the screw chamber
VID-20200417-WA0002.mp4
• 3- implant fracture
• fatigue of implant materials and weakness in prosthetic
design or dimension are the usual causes of implant
fractures
• Balshi listed three categories of causes
(1) design and material,
(2) nonpassive fit of the prosthetic framework, and
(3) physiologic or biomechanical overload.
Lack of passive fit-4
Unlike the natural teeth which can move in their
sockets about 100 microns, the implant has limited
range of movement around 10 microns. Thus, the
misfit in case of implant-supported prosthesis will be
more destructive in contrast to the teeth-supported
prosthesis
misfit should be not more than 10 microns
The implant superstructure misfit is a result of accumulative distortions during
,the whole procedure of final prosthesis fabrication
Impression procedure contributing factors are mandibular flexure, )1
impression technique/material, and machining tolerance of the impression
.copings
Master cast fabrication contributing factors are machining tolerance of the )2(
.implant replica, master cast pouring technique, and die materials used
 Wax pattern fabrication )3(
Framework fabrication contributing factor is the conventional casting )4(
.distortion
Definitive prosthesis fabrication: contributing factor is Addition of acrylic )5(
.or porcelain
Definitive prosthesis delivery contributing factors are machining tolerance, )6(
fit detection variability between clinicians, and the mandibular flexure
:prosthetic fracture -5
Failures of implant-supported restorations result from technical
problems and can be divided into two groups: those relating to
implant components, and those relating to the
prosthesis.Technical problems related to implant components
.include abutment screw fracture
Jung et al., 2008, reported that prosthetic screw fracture has an
incidence rate of 3.9% and the rate for prosthetic screw loosening
is 6.7%. Fracture of the implant abutment in a patient with
bruxism was reported as a rare case with prosthodontic
complication due to the low incidence rate of 3.9%; this can be a
serious problem as the fragment remaining inside the implant
prevents the implant from efficiently functioning
bruxism remains a potential risk factor; therefore,
clinicians should adopt a cautious approach when
planning for implant-assisted prostheses in bruxers and
authors also argue that the overloading influence of
bruxism on implants and their superstructures yields a
higher risk of biological and biomechanical
complications than would be the case during
physiological masticatory activities
The broken abutment inside the crown
• The risk for esthetic complications is increased for
patients with high esthetic expectations and less than-
optimal patient-related factors (e.g., high smile line, thin
periodontal soft tissues, or inadequate bone quantity and
quality)

• If the amount of available bone is not ideal… unesthetic

emergence profile.
• Benefits of Gingiva colored materi als
• Improved lip support :
• Masking interproximal spaces
• Restoration of gingival symmetry

• Phonetic problems:
• More common with full arch implant supported
prosthesis
• Unusual palatal contours
• Space between implant and superstructures
 The predictability of the aesthetic outcome of an implant
restoration is dependent on many variables including but not
limited to the following:

1) Patient selection and smile line

2) Tooth position

3) Root position of the adjacent teeth

4) Biotype of the periodontium and tooth shape

5) The bony anatomy of the implant site

6) The position of the implant.

Tooth position
The tooth needs to be evaluated in three planes of space: apicocoronal, faciolingual
and mesio-distal.

The existing tooth position will signifi-cantly influence the presenting gingival
architecture. In many

instances teeth with a poor prognosis are thoughtlessly extracted. These teeth can
significantly influence both the hard and soft tissue configuration.
Facio-lingual

In this dimension the tooth position may present with different concerns:

Too far facially this often results in very thin or non existent labial bone.

A tooth positioned more lingually would benefit from the presence of an

increased amount of facial bone
2-Mesio-distal
Ideally the mesiodistal tooth width should be equal to that of the contra
lateral tooth so that an aesthetic outcome can be achieved.

3. Root position of the adjacent teeth

4.Biotype of periodontium and tooth shape The position of the gingival
tissue around a tooth is determined by the connective tissue attachment
and by the bone level. Two different periodontal biotypes
thin scalloped periodontium:
characterised by a delicate soft tissue curtain,scalloped underlying osseous
form and often has dehiscence and fenestrations and a reduced quantity
and quality of keratinised mucosa.
thick flat periodontium
characterised by a denser more fibrotic soft tissue curtain, a flat thicker
underlying osseous form and an increased quantity and quality of attached
keratinised gingiva.
5. Bony anatomy of the implant site
For successful aesthetic restoration of implants the bony housing must have
a three dimensional configuration that permits
placement of an implant in arestoratively ideal position.
Several key analyses need to be performed
A diagnostic wax up highlighting tissue deficiencies and final tooth
positioning can assist in the planning process.
Facio-lingual ridge anatomy should be evaluated to determine if there is
sufficient crest width to house the implant.
Mesio-distal space should be equal to that of the contra lateral tooth
excess or deficiencies in this dimension need to
be addressed through orthodontics, enameloplasty or restoration either
prior to or after implant placement.
Apicocoronal dimension: is the most critical factor
deficiencies in this dimension can result from periodontal disease,
trauma, atrophy and infection. Vertical grafting is
complex and the site may require several surgeries to achieve an optimal
configuration.
6. Implant position
Aesthetic implant placement is driven by both a restorative and
biological philosophy. Aesthetically the
implant should be placed to satisfy the parameters of contour
so that the restoration is pleasing
6. Implant position
Aesthetic implant placement is driven by both a restorative and biological
philosophy. Aesthetically the
implant should be placed to satisfy the parameters of contour so that the
restoration is pleasing
 Phonetic failure
All speech sounds result from air being obstructed or modified •
within the vocal tract

:This involves 3 processes •

The airstream process: the source of air used in making sound -

The phonation process: the behavior of the vocal cords in the -
glottis during the production of sound
Oro-nasal process: the modification of flow of air in the vocal -
track
The articulation is done by the contact of two articulators: lips, •
teeth, alveolar ridge, tongue tip
Phonetic failure depand on well design prosthesis to facilitate
acceptbable phonetics
Correct inclination of maxillary anterior teeth in relation to
changes in phonetics
Particularly letter S is distorted when inclination of anterior
teeth is increased, in both labial and palatal direction. This is the
.mostfrequently distorted letter
Bilabial: b, m, w
Labiodental: f, v-
Interdental: t, d-
Apico-dental: tip of the tongue and back of the teeth-
-1 immediate implant placement
• Poor implant position,
• marginal bone loss,
• periimplant soft tissue recession,
• compromised esthetics,
• Failure to attain primary stability and
• Implant failure
-2 immediate loading
• failure to achieve primary stability
• To avoid complication
• long and wide implants
• Thread design
• for full edentulous arches, mininum 4-6
implants
• Cross-arch stabilization
• Minimizing cantilever
• 3-Flapless approach
• Complications due to:
• Lack of operator visualization
• Improper positioning
• It is technique sensitive that requires surgical
experience,
• Proper Case selection
• an accurate surgical guide and
• knowledge of the anatomy surrounding the implant site
• Severe peri-implant bone loss (> 50% of implant length(.
• Bone loss involving implant vents or holes.
• Unfavorable advanced bone defect.
• Rapid, severe bone destruction (within 1 yr of loading(.
• Nonsurgical or surgical therapy ineffective.
• Esthetic area providing implant surface exposure
 Management of biological implant failures

I- First stage surgery*

Hemorrhage during drilling .1
Possible cause: Lesion or detrimental surgical technique
.during osteotomy preparation
.Management: Implant placement will stop bleeding
Swelling lingually directly after implant placement .2
at the mandibular symphesis (Emergency)
Possible cause: Incision of an artery branch sublingually
Management: Hospitalization for Securing air way and
.coagulation of artery under G.A
Insensitivity of the lower lip .3
Possible cause: Incision or compression of Inferior Alveolar nerve
Management: If sensitivity persists after a week removal of the implant
.causing the problem
Abscess around the cover screw-4
Possible cause: Implant is not integrating
Management: Remove the implant
Infection around cover screw (which is often a little loose)
Make a flap )a(
Remove the granulation tissue )b(
Disinfect with chlorhexidine )c(
Change the cover screw )d(
Resuture )d(
:Nerve Injury .5
A) Radiographs must be taken to confirm whether it has been caused by
the implant. If the implant is impinging on the nerve, it should be
removed or at least unscrewed a few threads to relieve the pressure on
.the nerve
B) If the implant causing the problem is already osseointegrated, it can
be removed by a trephine drill. As an alternative, an apicoectomy of the
.implant can be done, if feasible
C) To control inflammatory reactions in the injured nerve, a course of
steroids can be prescribed. An alternative would be a large dose of
nonsteroidal anti-inflammatory drugs (eg, 800 mg ibuprofen) 3 times
daily for 3 weeks. If the situation improves, the clinician can prescribe
another course of anti-inflammatory drugs. Perceptions of pain and
temperature are usually the first 2 sensations to recover, whereas other
.sensations may take longer
C) Many patients respond well to this line of treatment. Any
improvement in the patient's condition should be recorded, along
with results of a neurosensory examination and the patient's
description. If the condition fails to improve within 2 months,
referral to a microneurosurgeon is indicated. Early referral will allow
for early management before distant degeneration of the nerve
takes place. This degeneration usually occurs within 4–6 months of
nerve injury.This is the reason why many authors recommend that
microsurgery be performed within the first months after injury
D) Strauss et al concluded that 50% of the patients who underwent
microsurgical repair of the IAN reported significant improvement,
42.9% reported slight improvement, and only 7.1% reported no
improvement. They also reported that highly significant
improvements were achieved after 1 year of microsurgical
.intervention
II- Second stage surgery (Abutment
Connection)

Slightly painful and mobile implant .5

.Possible cause: lack of Osseointegration
.Management: Remove implant
Slightly sensitive but immobile implant .6
Possible cause: Imperfect integration
Management: Cover implant for 2-3 months and test again
Granulation tissue around implant head .7
:Possible cause
 Traumatic placement of implant
 Compression from provisional prosthesis
 Lid above cover screw

:Management
Open the area )a(
Disinfect with chlorhexidine )b(
If the lesion is too large, consider Bone Regeneration or Grafting )c(
technique
 :III- prosthetic procedure

Pain when tightening Gold screw (during try-in -8

of the prosthesis)
Possible cause: Misfit between the prosthesis and the abutment
:Management
Sectioning of the prosthesis )a(
Re-soldering the prosthesis in lab (after solder index) )b(
Retry the prosthesis )c(
Abscess close to an implant .9
Possible cause: Poor fit of the abutment to the implant
:Management
.Verify abutment fit with an x ray )a(
.Remove the abutment, sterilize it )b(
.Remove granulation tissue )c(
.Disinfect with chlorhexidine )d(
.Replace the abutment )d(
Development of pain after placement of the .10
prosthesis
.Possible cause: Disintegrated implant
.Management:Remove implant
:Peri-implant infection
Remove etiologic factors (poor plaque control) )a(
Look for bacterial pockets around natural teeth )b(
Cut open lesion )c(
Adjust peri-implant tissues (gingival graft) )d(
Consider bone regeneration procedure )e(
Continuing bone loss around one or more .11
implants
Possible cause: Infection (peri-implantitis)
Occlusal Overload (Biomechanical)
Management: Modify prosthetic design
Reducing or eliminating extensions -
Reducing width of occlusal surfaces -
Reducing cuspal inclination -
Adding implants -
Bleeding on probing .12
Possible cause: Mucositis or peri- implantitis
Management: (a) Remove etiologic factors (poor plaque
control)
Look for bacterial pockets around natural teeth )b(
Cut open lesion )c(
Adjust peri-implant tissues (gingival graft) )d(
Consider bone regeneration procedure )e(
Oro-antral fistula ‘’Schneiderian membrane .13
’’perforation
Avoid by using Piezoelectric surgery
Management: Collagen or a fibrin adhesive
.membrane
In severe perforations, some investigators have even
suggested abandoning the procedure for 6 to 9 months
while the membrane regenerates (Karabuda et al.,
.2006)
:lack of passive fit -14
a) Splinting concept
splinting of impression copings during impression procedure using rigid material, to
stabilize and prevent the rotational, horizontal and vertical movement of the impression
coping. Since then, various splinting techniques and materials used to hold rigidly the
.impression copings have been studied

b) The Impression Procedure

both polyether and addition silicone impression materials produced similarly accurate
casts. However, in the presence of parallel implants, polyether impression material
performed better in terms of accuracy. On the other hand, addition silicone
impression material produced better accuracy in cases where angled implant
situations were simulated. Lee et al. also found that addition silicone was more
accurate than the polyether in situations where the implants were placed at deeper sub
.gingival levels
prosthetic fracture -15
Management: Adding one more dental implant
mesially to the previously placed implant,
improvisation of technique to remove the broken
abutment without sacrificing the osseointegrated dental
implant, fabrication with cemented custom-made
abutment to replace the broken abutment for the first
.implant
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