Review Article Complications in Implants

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1 Review Article Complications in Implants Dr Navjot Kaur, Dr Yashbir Raghav, Dr Amarpreet Kaur, Dinesh Duhan, Dr. Sumit Katoch, Dr. Apurva Sharma Kaur N, Raghav Y, Kaur A, Duhan D, Katoch S, Sharma A. Complications in Implants J Periodontal Med Clin Pract 2016;03:1-10 Affiliation 1. Post Graduate Student, Department of Prosthodontics, Bhojia Dental College and Hospital, Baddi, H.P. 2. Senior lecturer, Department of Periodontology, Swami Devi Dyal Hospital & Dental College, Haryana, India. 3. Post Graduate Student, Department of Prosthodontics, Dr.Harvansh Singh Judge Institute of Dental Sciences & Hospital, Panjab University, Chandigarh, India. 4. Post Graduate Student, Department of Periodontology, Swami Devi Dyal Hospital & Dental College, Haryana, India. 5. Post Graduate Student, Department of Prosthodontics, Bhojia Dental College and Hospital, Baddi, H.P 6. Post Graduate Student, Department of Prosthodontics, Bhojia Dental College and Hospital, Baddi, H.P Corresponding Author: Dr Navjot Kaur Post Graduate Student, Department of Prosthodontics, Bhojia Dental College and Hospital, Baddi, H.P. Conflict of Interest Nil Abstarct Despite the long term predictability of osseointegrated implants, biologic, biomechanical and esthetic complications can occur in small number of cases. Inflammatory complications, operative complications and biomechanical failures can take place after placement of implants. The purposes of this article are to (1) summarize the reported types and frequencies of implant-associated complications, (2) identify risk factors for developing complications associated with the use of dental implants. (3) critically evaluate the etiology of implant biomechanical complications Keywords: Implant, complications, inflammatory conditions, biomechanical, operative Introduction Replacing missing teeth with osseointegrated dental implants is a predictable technique, as evidenced by an overall 5-year implant survival rate that ranges [1 3] between 93% and 97%. Few studies, however, systematically have addressed the frequency or natural history of complications related to the use of [4 7] dental implants. Reported complication rates range so widely (i.e, 1% 40%) as to be rendered 01

2 [4,6,8] clinically meaningless. Differences in reported rates may be attributable to differing definitions of complications. Even less has been written about risk factors for developing surgical complications related to the use of dental implants. A complication is defined in the Glossary of Oral and Maxillofacial Implants as an Unexpected deviation from the normal treatment outcome. It is generally classified as either technical or biological, eg, surgical complication, hemorrhage, damage to the inferior alveolar nerve, infection, delayed [9] wound healing, or lack of osseointegration. Pathologic changes of the peri-implant tissues can be placed in the general category of periimplant disease. Inflammatory changes, which are confined to the soft tissues surrounding an implant, are.[10} diagnosed as peri-implant mucositis Progressive peri-implant bone loss in conjunction with a soft tissue inflammatory lesion is termed peri- [11] implantitis. Technical failures can occur in small percentage of cases in the form of implant, abutment, screw fractures and loosening of fixation screws. Esthetic complications may occur in patients with high esthetic expectations and less than optimal implant placement and restorative treatment results. Materials And Methods The authors have carried out a analytical review of the literature. The authors have identified highquality articles that deal with implant-related complications. They applied expert natural history and prognosis search filters available through PUBMED SEARCH. The authors identified additional articles by hand searching retrieved articles, reviews, and textbooks. All available clinical studies from 1981 to 2015 that presented success data regarding dental implants were evaluated, and type and prevalence of reported complications data were abstracted. A total of 305 study abstracts were identified and reviewed, 90 articles were retrieved and evaluated in detail, and of these articles, 45 were included in this article. Complications were classified as operative or inflammatory. Operative complications occurred during or as a result of an operation and included displacement of the implant, bleeding, nerve injury, fracture, or injury to adjacent teeth. Inflammatory complications occurred at any stage of the implant treatment and included infection, periimplantitis. INCIDENCE The overall reported complication rate averaged 28% and ranged from 1% to 40%. Operative complications averaged 18% and ranged from 1%.[1,4,5,8] to 28% Inferior alveolar nerve (IAN) injury ranged from 1% to 28%. Serious bleeding, implant displacement, mandibular fractures, and injury to adjacent teeth occurred in less than 1% of cases. Inflammatory complications comprised approximately 10% of all complications and ranged from 1% to 32%. The average complication rates reported for periimplant mucositis, periimplantitis, hyperplastic mucositis, and fistula formation were [4,5,7,12, 13] 12%, 8%, 6%, and 4%, respectively.. TPS International Team for Oral Implantology (ITI)- implants demonstrated a mean radiographic change in periimplant bone levels of less than 1.1 [14] mm in the first year of function. However, the percentages of implant sites with bone level changes of more than 0.5 mm between years 1 and 2 was 7% and bone level changes of more than 1 mm were 4%. 02

3 Patients with a history of periodontitis may represent a group of individuals with an elevated risk of developing periimplantitis. This view is based on the evident susceptibility to periodontitis, and the potential for transmission of periodontal [15] pathogens from teeth to implants. Inflammatory Complications Inflammatory complications can occur at any time during implant treatment. Inflammatory complications are divided into acute and chronic categories. Acute inflammatory conditions include cellulitis, perioperative infection and abscess formation. [16-18] Chronic inflammatory conditions include soft tissue periimplantitis (mucosal erythema and edema) and hard tissue periimplantitis (periimplant radiolucent lesions or progressive bone [1,3] loss ). Acute Inflammatory Conditions Perioperative infection after implant placement ranges from 1% to 3% and increases the risk for [19,20] implant failure. Among the risk factors for developing this complication is overheating of the bone during site preparation. The use of aseptic technique and avoidance of implant placement into previously infected sites may reduce the risk for infection. Prophylactic antibiotics administered before implant placement reportedly decreased [21] early failure rates twofold to threefold. Chronic Inflammatory Conditions Chronic inflammatory complications occur with a reported frequency of 1% to [1,3,12,22,23] 34%. Chronic inflammatory complications are classified as soft tissue periimplantitis and hard tissue periimplantitis. Soft tissue periimplantitis is an inflammatory process that involves soft tissue surrounding an implant without signs of bone loss. Soft tissue periimplantitis occurs most commonly in association with implant-supported overdentures, with a reported frequency ranging from 10% to [24,25,26] 30. Rates of soft tissue periimplantitis associated with implant-supported fixed prostheses [1,2,27,23] range from 8% to 22%. Risk factors include unstable overdentures that result in mucosal ulceration and hyperplasia, misaligned implants that traverse non attached gingival tissue, improper use of the abutment or healing caps, poor oral hygiene,, and presence of dead space under the superstructures. The frequency of hard tissue periimplantitis and progressive bone loss is low. Several studies have reported on the average marginal bone loss that occurs during the first year after implant [1,29] placement. Mean bone loss was 0.93 mm (range 0.4 mm 1.6 mm). The mean loss during subsequent [27] years was 0.1 mm per year (range 0 mm 0.2 mm. Risk factors for hard tissue periimplantitis include early implant exposure and poor oral hygiene, infection located at the apical area of the implant. Apical implant lesions may be completely asymptomatic or present with tenderness, persistent pain or swelling, and fistula formation. The risk factors for apical periimplantitis include excessive heating of the bone during insertion, residual bone cavities created by the placement of implants that are shorter than the prepared surgical site, and bacterial contamination from either extracted teeth or a seeding mechanism from the remaining natural teeth. Fistula formation at the abutment implant 03

4 interface may be one of manifestations of hard tissue periimplantitis. It was reported in the literature with an incidence of 0.02% to 25%.[1,2,28] Risk factors for developing chronic fistulas include a gap between the implant components that creates a nidus for infection and poor oral hygiene. Operative Complications: Bleeding And Hematoma Hematoma formation and bleeding after implant placement reportedly occurs in 0% to 29% of cases. [27,30] Bleeding is commonly controlled with local measures and is considered a minor complication. Hematoma formation after placement of dental implants usually resolves completely with minimal [27,30] sequelae. Life-threatening bleeding is rare, and [31,32] only seven cases are reported in the literature. Sublingual, submental, or submandibular swelling in conjunction with tongue elevation was observed in all seven of these cases. Suggested risk factors for bleeding include location, perforation of the lingual cortex, and implant length. A CT-guided prefabricated surgical splints guides the osteotomy bur to its proper position while avoiding perforation of the lingual cortex, especially in the presence of extensive sublingual fossae. Using implants smaller than 16 mm also may reduce the risk of lingual perforation and reduce the chances of this problem. Nerve Injury The incidence of neurosensory disturbance after placement of dental implants ranges from 0.6% to [3,27,30] 36%. Inferior alveolar nerve injury during implant placement may result from direct mechanical damage to the nerve, compression of the nerve and vessels, damage to vessels with bleeding into the canal that results in a compartment-like syndrome, or the formation of a traumatic neuroma.[33] The risk factors for IAN injury during implant placement include the use of nerve repositioning or lateralization procedures and implant placement in the severely atrophic mandible.[34] Early postoperative anesthesia suggests that direct, significant injury to the IAN and removing the implant promotes early decompression of the nerve and may improve outcome. Mandible Fractures Mandible fractures after implants placement are [2] rare (reported frequency of V0.2%). Etiologically, fractures may occur because implant site preparation creates an area of stress concentration and weakness in the bone. The major risk factor for [7,35] fracture is a severely atrophic mandible. Other risk factors include lateralization of the IAN in association with implant placement, osteoporosis, and trauma to the mandible after implant [36] placement. To prevent fractures, imaging the severely atrophic mandible to evaluate better the three-dimensional anatomy of the proposed site. Avoidance of wide implants in cases of nerve lateralization also may decrease this risk. In cases of severe resorption, bone grafting to increase mandibular volume and bulk may be indicated. Implant Displacement During implant placement or abutment connection, there is a risk for displacing the implant from its site to adjacent anatomic structures (eg, the maxillary [37,38] sinus, nasal floor, or mandibular canal). Risk 04

5 factors for implant displacement are placement of implants in soft (type IV) bone and in close proximity to the maxillary sinus or mandibular canal. To avoid this complication, a thorough preoperative evaluation of the bone quality, especially in posterior maxillary cases must be done. Evaluation of the implant site with a probe before insertion of the fixture is helpful to detect bony perforations. Early, Unplanned Implant Exposure Early, unplanned implant exposure Premature exposure of a staged dental implant because of wound breakdown occurs with a reported frequency [1, 37] of 2% to 11%. Early exposure of two-stage dental implants may be associated with an increased risk for inflammatory complications, including crestal bone loss and periimplant soft tissue inflammation.a meticulous closure of the wound without tension after reconstructive procedures is valuable for avoiding this complication. [38] placement is a rare, but reported, complication. Adequate preoperative imaging and use of a prefabricated splint when placing implants help prevent inadvertent injury to adjacent teeth. Biomechanical Complications Biomechanical complications include acrylic resin veneer fracture, overdenture attachment fracture, early implant failure, porcelain fracture, acrylic base fracture of overdentures, prosthesis/abutment screw loosening, prosthetic framework fracture, prosthesis/abutment screw fracture, implant body fracture, and marginal bone loss around the [30] implant. Miyata and coworkers demonstrated that excessive occlusal forces led to bone resorption around implants, even if the peri-implant tissue was clinically healthy. In addition, it was found that once peri-implantitis has progressed, the efficacy of the.[31] healing mechanism was compromised Damage To Adjacent Teeth Injury to adjacent teeth associated with implant 05

6 Occlusal overload may cause prosthesis/abutment screw loosening and fracture of the implant body and abutment screw. Comparatively, screw loosening has a higher incidence (6% versus 1% to [32] 2%). Implant fracture, in contrast, is rare, with an [33] incidence of 1.2%. Fractures of prosthesis components, eg, attachments, the metal framework, or an acrylic resin base, occur relatively often. The mean percentages of acrylic resin base and metal framework fractures are 7% and 3%, respectively. Fractures of retentive devices, such as attachments, are by far the most common complication, with an i n c i d e n c e o f 1 7 %. T h e m o s t c o m m o n biomechanical complications related to fixed prostheses supported by implants are [34] resin veneer and porcelain fracture. Severe wear or fracture of resin veneers is relatively more common than other biomechanical complications reported, this was clearly demonstrated in a 15-year study that had a 90.6% survival rate of implant- supported prosthesis. [ 3 5 ] Another common complication is ceramic fracture. It was found that implant-supported fixed partial dentures (FPDs) had a significantly higher 5-year risk of porcelain fracture or chipping compared with tooth s u p p o r t e d F P D s ( 8. 8 % v e r s u s 2. 9 %, [36] respectively). Similarly, Kreissl and colleagues found that fracture of ceramic veneers occurred in [37] 5.7% of 112 FPDs supported by 205 implants. In comparison, fracture of [38,39,40] the metal framework of FPDs was rare (0.5%). Therefore, fracture of a veneer material (acrylic, porcelain, or resin) is undeniably the most common technical complication for implant-supported fixed reconstructions. [40] Management of Biomechanical Complications Possible factors resulting in Implant overload 06

7 Summary This article identifies the operative and longitudinal and biomechanical complications associated with the placement of dental implants and discusses predisposing conditions and risk factors. Surprisingly, the most common surgical complications are neurosensory disturbances and hematoma formation. Inflammatory complications (both soft and hard tissue) are most commonly associated with implant failure. A thorough clinical and radiographic examination can be helpful in determining morphologic abnormalities and reducing the incidence of operative complications, such as perforation of the lingual cortex, associated bleeding, and damage to contiguous structures. Careful implant site selection, appropriate angulation, and soft tissue handling may decrease mucosal inflammatory complications. Longitudinal follow-up and assessment of bone and soft tissue health 07 surrounding implants should promote longevity and minimize these complications. There is no doubt that prevention is the best way to manage possible biomechanical complications. With a better understanding of implant occlusion, such as the use of more implants when shorter lengths and smaller diameters are required, splinting of implants in areas of heavy occlusal loading, provision of occlusal splints for bruxers, and selection of the proper occlusal scheme, implant overloading can be prevented and the long-term stability of implant-supported prostheses can be ensured. References: 1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study on osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Maxillofac Surg 1981;10: Alberktsson T, Zarb G, Worthigton P, Eriksson A. The long-term efficacy of

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