u.Implant complications_YKK_23_24.txt

Implant complications Prof. Young K. Kim, DMD, DMSc, FACP Diplomate & Fellow, American Board of Prosthodontics Clinical Assistant Professor, NYUCD, Dept. of Prosthodontics Editor & Co-leader, NYU Implant Restorative Protocol ’20 Editor & Co-leader, NYU Robotics Surgical Protocol ’21 / ’2...

Implant complications Prof. Young K. Kim, DMD, DMSc, FACP Diplomate & Fellow, American Board of Prosthodontics Clinical Assistant Professor, NYUCD, Dept. of Prosthodontics Editor & Co-leader, NYU Implant Restorative Protocol ’20 Editor & Co-leader, NYU Robotics Surgical Protocol ’21 / ’22 NEW YORK UNIVERSITY COLLEGE OF DENTISTRY UPDATE - Please see the yellow flag under the left corner for its sign of FYI (= NOT on the exam) Prosthodontics Complete dentures, RPD prosthesis, survey crowns, maxilla-facial prosthetics, removable occlusion, oro-facial musculature dynamics, material science Preparation, Remo-Fixed rehab biomechanics, mutually protective occlusion, adhesive dentistry, crown materials PROSTH Implant-retained Implant rehab Bio-compatible substitutes, Osseointegration, wound healing, biology, anatomy, computer-guided surgery Implant Surgical Prosthodontics Complete dentures, RPD prosthesis, survey crowns, maxilla-facial prosthetics, removable occlusion, oro-facial musculature dynamics, material science Preparation, Remo-Fixed rehab biomechanics, mutually protective occlusion, adhesive dentistry, crown materials PROSTH Implant-retained Implant rehab Bio-compatible substitutes, Osseointegration, wound healing, biology, anatomy, computer-guided surgery Implant Implant surgery & Prosthodontics Implant surgery & Prosthodontics Success Photo Credit - Pixabay Complications Success Photo Credit - Pixabay Implant complications S U R G I CA L | B I O L O G I CA L MECHANICAL Implant complications S U R G I CA L | B I O L O G I CA L MECHANICAL • Anatomical complications • Over-heating during the osteotomy • Insufficient insertion torque • Excessive insertion torque Implant complications S U R G I CA L | B I O L O G I CA L MECHANICAL • Success criteria • Risk factors • Microbiological Implant complications S U R G I CA L | B I O L O G I CA L MECHANICAL • Screw dynamics • Prosthetic failure • Emergence profile • Overdenture-related Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Md lingual concavities” (Goodacre CJ & Baba NZ, 2016) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Lateral incisor fossa & Mx concavities” (Goodacre CJ & Baba NZ, 2016) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Lateral incisor fossa & Mx concavities” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Lateral incisor fossa & Mx concavities” Incisive canal Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Sinus-lift” Sinus elevation Residual alveolar ridge height > 5mm + No greater than 5mm of sinus bone elevation needed Advantage Disadvantage Lateral approach (Boyne & James 1980) Large volume Large bony window (morbidity), post-op complications Crestal approach (Tatum 1986; Summers 1994) Less morbidity Smaller volume, limited surgical view (Boyne PJ, 1980; Tatum H, 1986; Summers RB, 1994) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Sinus perforation” A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. • 175 articles resulting in 48 studies that met the inclusion criteria, reporting on 12,020 implants • 3-year implant survival = 90.1% • The annual failure rate : no membrane (4.0%) > window covered (0.7%) • Perforation of the sinus membrane 19.5% the most frequently reported complication (Pjetursson BE et al, 2008) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Anastomosis” Vascular channel • Branches of posterior superior alveolar artery + infraorbital artery → anastomosis in lateral antral wall • Distance between anastomosis and alveolar ridge = ~19mm • Vascular channel containing blood vessels piercing the cortical wall to supply mucous membrane → danger zone (Janner SF. et al, 2011) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Inferior alveolar canal (IAC)” • F-L location of the IAC (Kim ST, 2009) • Type I (70%) - following the lingual cortical plate of the Md ramps and body • IA blood vessels and IAN location (Kim ST, 2009) • 80% - IA blood vessels are above IAN • 20%, IA vessels located buccal to IAN (Goodacre CJ & Baba NZ, 2016) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Mental foramen & anterior loop” • Anterior loop of the inferior alveolar nerve (anterior to the mental foramen) • Incidence = 61% (Killic, 2010) • Each Pt needs to be analyzed using CBCT scan for cases, placing ANTERIOR to mental foramen (Goodacre CJ & Baba NZ, 2016) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Neurosensory disturbance” • Early removal of implants (within 30hrs) may maximize neuropathy resolution, yet the evidence remains weak (Khawaja & Renton, 2009) • Adrenocorticosteroids (Dexamethasone 8-12mg) helps minimizing neuropathy, if administered in high doses within 1 week of injury (Galloway, 2000) • Altered sensation may be due to inflammatory reactions → NSAID (i.e. ibuprofen 600 to 800mg) TID for 3wks is used as soon as possible following any nerve injury (Muller, 1998) (Goodacre CJ & Baba NZ, 2016) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Life-threatening hemorrhage” Sublingual Branch of Lingual Artery • Many reports in literature since 1986 (Krenkel, 1986; Isaacson, 2004) • Md lingual cortex perforation in canine/1st premolar area during osteotomy • Injury to sublingual or submental artery → submandibular space bleeding → acute airway obstruction (Goodacre CJ & Baba NZ, 2016) Implant complications CR S U R G I CA L | B I O L O G I CA L | MECHANICAL Anatomical complications “Insufficient mouth opening” CO F B R E Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Over-heating during the osteotomy • Bone tissues = highly susceptible to thermal injury • Temperature threshold for tissue survival during osteotomy = 47 °C when drilling is maintained for more than 1 min (Eriksson R & Albrektsson T, 1983, 1984) • Heating in excess of this limit could lead to primary failure to achieve osseointegration (Ercoli C, et al, 2004) • Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Insufficient insertion torque • 35Ncm of insertion torque is recommended for Straumann implants • The true minimum torque that can be employed to attain primary stability for successful osseointegration is undefined (Greenstein G & Cavallaro J, 2017). • Lower insertion torques (lower than 20Ncm) still yield favorable survival rates (Norton MR, 2017) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Excessive insertion torque “Orthopedic perspective” • Bone strain exceeding a certain threshold level → irreversible damage (in the form of micro-cracks and plastic deformation → implant loosening or failure (Windwood K, et al, 2006) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Excessive insertion torque • Compression of bone beyond its physiologic tolerance → ischemia with subsequent necrosis or sequestrum formation → implant failure • Excessive torque placed on an implant → high levels of strain transmitted to the adjacent bone → crestal cortical bone with minimal blood supply becoming susceptible to bone necrosis • (Bashuetski JD, 2009) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Success criteria • Albrektsson 1986 • Clinical immobility • Radiographic absence of per-implant radiolucency • Vertical bone loss < 1.5mm within 12 months and < 0.2mm annually • Absence of pain, infections, neuropathies, paresthesia • Success rate 85% (5yrs), 80% (10yrs) • Smith & Zarb 1989 • Mobility • Peri-implant radiolucency • Marginal bone loss: > 0.2mm annually • Patient comfort • Appearance • Persistent infection Implant complications Implant health findings S U R G I CA L | B I O L O G I CA L | MECHANICAL Success criteria “ICOI Pisa Consensus” Success Satisfactory survival Compromoised survival Failure Clinical No pain or tenderness on function No mobility < 2mm of radiographic bone loss after initial surgery No history of exudates Pt & clinician satisfied with esthetic outcomes No pain on function No mobility 2-4mm of radiographic bone loss after initial surgery No history of exudates May be sensitive on function No mobility Radiographic bone loss > 4mm (less than half the implant body) PD > 7mm May have a history of exudate Pain on function Mobility Radiographic bone loss > half the implant body Uncontrolled exudate No longer in the mouth Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors • Diabetes • Immune-compromised (host factors) • Smoking • Periodontally compromised • Overload, bruxism • Oral hygiene • Anatomy and bone type (quality) • Severe xerostomia • Radiation therapy to implant bone sites • Medications affecting healing • Iatrogenic factors “Etiology” (Bain 1993; Haas 1996; Fiorellini 2000; Nevins 1995; Jaffin 1991; Bass 1991; Heit-Mayfield 2009) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Myocardial infarction (MI)” • Cardiovascular disease (CVD) → compromising blood flow + oxygen tension + nutrient elements to tissues → impairs the process of healing → potential effect on the outcome of the response to osseointegration • CVD may not be a strong risk factor for successful osseointegration (Khadivi V, et al, 1999) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Myocardial infarction (MI)” • Cardiovascular disease (CVD) → compromising blood flow + oxygen tension + nutrient elements to tissues → impairs the process of healing → potential effect on the outcome of the response to osseointegration • CVD may not be a strong risk factor for successful osseointegration (Khadivi V, et al, 1999) • Ischemic heart disease (coronary artery disease) most commonly manifests as angina or myocardial infarction • The greatest risk is ventricular fibrillation and most deaths occur within 12 hours of the event → contraindicated during this period (Cintron H, et al, 1986) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Myocardial infarction (MI)” • Previously, suggested a six-month waiting period for cardiac stabilization (Niwa H, et al, 2000) • Recently, suggesting as early as six weeks after the event if established protocols are followed (Roberts HW, et al, 2001) • PCP consult, Pt consent, Pt assessment • Nitrate premedication, administration of oxygen, achievement of profound local anesthesia, stress reduction measures, perioperative pain medication, and patient monitoring of blood pressure and heart rate • Conscious sedation may be beneficial • Must be aware of any anticoagulant or thrombolytic therapies administered Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Myocardial infarction (MI)” • If angina occurs during dental treatment → the procedure should be stopped • Semi-supine position + 100% oxygen • 0.3 or 0.4 mg tablet of nitroglycerin should be placed sublingually • Repeating at 5-minute intervals if pain persists • Excessive amount may induce hypotension • Pain persisting for longer than 15-20mins + other signs and symptoms of MI → hospital emergency room Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Stroke” • The brain does not store glycogen → requires 60-70mL of perfusion per 100g of tissue per minute for normal function • A drop in the blood flow to 25 mL/100 g/min → neuronal ischemia, energy failure, and neurologic symptoms → irreversible tissue damage (Felberg RA & Naidech AM, 2003) • CVD and stroke do not directly impact on the success or failure of dental implants Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Stroke” • The brain does not store glycogen → requires 60-70mL of perfusion per 100g of tissue per minute for normal function • A drop in the blood flow to 25 mL/100 g/min → neuronal ischemia, energy failure, and neurologic symptoms → irreversible tissue damage (Felberg RA & Naidech AM, 2003) • CVD and stroke do not directly impact on the success or failure of dental implants • Standard evidence-based protocol for dental management of stroke patients = not available • Current recommendations = based primarily on intuitive extrapolations from the medical literature Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Stroke” • The brain does not store glycogen → requires 60-70mL of perfusion per 100g of tissue per minute for normal function • A drop in the blood flow to 25 mL/100 g/min → neuronal ischemia, energy failure, and neurologic symptoms → irreversible tissue damage (Felberg RA & Naidech AM, 2003) • CVD and stroke do not directly impact on the success or failure of dental implants • Standard evidence-based protocol for dental management of stroke patients = not available • Current recommendations = based primarily on intuitive extrapolations from the medical literature • Suggestion - differing the elective dental care for the 6 months following a stroke (Little JW, et al, 2002) • Preoperative assessment of hemostasis is necessary in patients taking oral anticoagulants Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Valvular prosthesis placement” • Critical goal of dental and implant therapy in patients with valvular heart disease = preventing infective endocarditis (Rees TD & Mealey B, 2004) • Valvular heart disease does not directly affect implant outcome; however, risk of infection needs to be recognized Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Valvular prosthesis placement” • Critical goal of dental and implant therapy in patients with valvular heart disease = preventing infective endocarditis (Rees TD & Mealey B, 2004) • Valvular heart disease does not directly affect implant outcome; however, risk of infection needs to be recognized • American Herat Association recommends antibiotic prophylaxis with the following (Khader RN & Rosenberg M, 2007) • Artificial heart valves • Past history of infective endocarditis • Serious congenital heart conditions • Cardiac transplant, developing a problem in a heart valve Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Valvular prosthesis placement” • Critical goal of dental and implant therapy in patients with valvular heart disease = preventing infective endocarditis (Rees TD & Mealey B, 2004) • Valvular heart disease does not directly affect implant outcome; however, risk of infection needs to be recognized • American Herat Association recommends antibiotic prophylaxis with the following (Khader RN & Rosenberg M, 2007) • Artificial heart valves • Past history of infective endocarditis • Serious congenital heart conditions • Cardiac transplant, developing a problem in a heart valve • “for patients with prosthetic joint implants, prophylactic antibiotics are NOT recommended prior to dental procedures to prevent prosthetic joint infection” - ADA Council on Scientific Affairs, 2015 Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Osteoporosis” • Skeletal condition characterized by decreased mineral density (mass/volume unit) of normally mineralized bone • Potential relationship between osteoporosis and decreased oral bone mass or density is controversial (Mori H, et al, 1997) • Concerning assumption: impaired bone metabolism may affect the osseointegration of implants → however, the process of bone remodeling is a non-uniform process (Heersche JN, et al,1998) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Osteoporosis” • Skeletal condition characterized by decreased mineral density (mass/volume unit) of normally mineralized bone • Potential relationship between osteoporosis and decreased oral bone mass or density is controversial (Mori H, et al, 1997) • Concerning assumption: impaired bone metabolism may affect the osseointegration of implants → however, the process of bone remodeling is a non-uniform process (Heersche JN, et al,1998) • Physiologic doses of vitamin D (from 400 to 800 IU/day) and calcium (1500 mg/day) are recommended during the postoperative period (Cooper LF, 2000) • Smoking should be stopped - major risk factor for osteoporosis (Melton LJ, 1997) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Paget’s disease of bone (PDB)” • Localized areas of bone becoming hyperactive → new bone formation with less structural order (Tiegs RD, 1997) • Pagetic bone having 10-fold increase number and larger size (i.e. 100 nuclei, compared to normal 3-10 nuclei) of osteoclast (Meunier PJ, et al, 1980) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Paget’s disease of bone (PDB)” • Localized areas of bone becoming hyperactive → new bone formation with less structural order (Tiegs RD, 1997) • Pagetic bone having 10-fold increase number and larger size (i.e. 100 nuclei, compared to normal 3-10 nuclei) of osteoclast (Meunier PJ, et al, 1980) • Resorptive phase characterized by radiolucency (ground glass appearance) & appositional phase by irregular radiopacity (cottonwool appearance) (Smith BJ & Eveson JW, 1981) • Unlike other systemic diseases, PDB has compromised bone density & may be contraindicated for dental implant surgery Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Paget’s disease of bone (PDB)” • Localized areas of bone becoming hyperactive → new bone formation with less structural order (Tiegs RD, 1997) • Pagetic bone having 10-fold increase number and larger size (i.e. 100 nuclei, compared to normal 3-10 nuclei) of osteoclast (Meunier PJ, et al, 1980) • Resorptive phase characterized by radiolucency (ground glass appearance) & appositional phase by irregular radiopacity (cottonwool appearance) (Smith BJ & Eveson JW, 1981) • Unlike other systemic diseases, PDB has compromised bone density & may be contraindicated for dental implant surgery • Treatment agent = bisphosphonates (Altman RD, et al, 2000) → drug side effects Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Bisphosphonates” • Established category of drug inhibiting bone resorption by depressing osteoclastic function • Side-effect complication risk in osteonecrosis of the jaws (ONJ) (Ruggiero SL & Drew SJ, 2007) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Bisphosphonates” • Established category of drug inhibiting bone resorption by depressing osteoclastic function • Side-effect complication risk in osteonecrosis of the jaws (ONJ) (Ruggiero SL & Drew SJ, 2007) • IV bisphosphonates used for tumor-induced, osteoclast-mediated bone resorption (Body JJ, et al, 1998) • Oral bisphonates used for osteoporosis and osteopenia → considerably lower risk for ONJ compared to IV bisphosphonates due to a relatively short period of Tx (Marx RE, et al, 2005) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Bisphosphonates” • Established category of drug inhibiting bone resorption by depressing osteoclastic function • Side-effect complication risk in osteonecrosis of the jaws (ONJ) (Ruggiero SL & Drew SJ, 2007) • IV bisphosphonates used for tumor-induced, osteoclast-mediated bone resorption (Body JJ, et al, 1998) • Oral bisphonates used for osteoporosis and osteopenia → considerably lower risk for ONJ compared to IV bisphosphonates due to a relatively short period of Tx (Marx RE, et al, 2005) • In case of any oral surgery, healing must be complete before IV bisphosphate use (Ruggerio S, 2006) • Guideline for oral bisphosphates (AAOMS, 2007), • For less than 3yrs w/o clinical risk factors • No alteration or delay in the planned surgery • For less than 3yrs + taking corticosteroids • Physician should be contacted + discontinuation for 3months before the surgery + resuming after osseous healing • For more than 3yrs w/o any steroid or prednisone • Physician should be contacted + discontinuation for 3months before the surgery + resuming after osseous healing Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Anticoagulants” • Platelet aggregation inhibitors (antiplatelets) such as aspirin prevent aggregation of platelets, which reduces blood viscosity and prevents clot formation • Potential risk of bleeding after dental extractions • Should not be routinely stopped or changed because the risk of thrombosis formation outweighs the risk of bleeding for most patients (Ferraris VA & Swanson E, 1983) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Anticoagulants” • Platelet aggregation inhibitors (antiplatelets) such as aspirin prevent aggregation of platelets, which reduces blood viscosity and prevents clot formation • Potential risk of bleeding after dental extractions • Should not be routinely stopped or changed because the risk of thrombosis formation outweighs the risk of bleeding for most patients (Ferraris VA & Swanson E, 1983) • Vitamin K antagonists (warfarin) inhibits synthesis of vitamin K-dependent clotting factors • Can be continued with low or moderate risk for bleeding procedures • High bleeding risk procedures require a consultation w/ PCP + measuring the international normalized ratios (INRs) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Anticoagulants” • Minimally invasive surgery is recommended • Utilization of epinephrine (adrenaline) • Recommending the buccal mucoperiosteal flap, not lingual in the lower molar regions (endangering the airway) (Scully C & Cawson RA, 1997) • Oxidized regenerated cellulose, resorbable gelatin sponge, collagen (synthetic or microcrystalline or porcine), cyanoacrylate, or fibrin glues may be utilized Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “International normalized ratio (INR)” • Warfarin taking patients should be evaluated with INR level before the surgery • INR (Prothrombin time or PT ratio) = patient PT / control PT Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “International normalized ratio (INR)” • Warfarin taking patients should be evaluated with INR level before the surgery • INR (Prothrombin time or PT ratio) = patient PT / control PT • World Health Organization recommends Prothrombin time < 1.3 2 - 4.5 < 2.5 Thrombotest 70% 5 - 20% 15% INR Normal level Therapeutic range Levels at which minor oral procedures can be carried out 1 2.5 < 3.5 Implant complications • Major risk factor for periodontal disease S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Diabetes” • Hyperglycemic environment → decreased osteoblast differentiation and proliferation → decreased collagen production + increased osteoblast apoptosis → negatively impacts bone metabolism (Mealey BL & Oates TW, 2006) Implant complications • Major risk factor for periodontal disease S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Diabetes” • Hyperglycemic environment → decreased osteoblast differentiation and proliferation → decreased collagen production + increased osteoblast apoptosis → negatively impacts bone metabolism (Mealey BL & Oates TW, 2006) • Animal models of type 1 diabetes → decreased bone-to-implant contact + decreased trabecular bone volume + unaffected cortical bone (Nevins ML, et al, 1998) • Animal models of type II diabetes → no difference in osseointegration or trabecular bone volume (Casap N, et al, 2008) Implant complications • Major risk factor for periodontal disease S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Diabetes” • Hyperglycemic environment → decreased osteoblast differentiation and proliferation → decreased collagen production + increased osteoblast apoptosis → negatively impacts bone metabolism (Mealey BL & Oates TW, 2006) • Animal models of type 1 diabetes → decreased bone-to-implant contact + decreased trabecular bone volume + unaffected cortical bone (Nevins ML, et al, 1998) • Animal models of type II diabetes → no difference in osseointegration or trabecular bone volume (Casap N, et al, 2008) • Good glycemic control in diabetic animal models → significantly improves bone-to-implant contact (Kwon PT, et al, 2005) • Glycemic control is evaluated through the glycosylated hemoglobin assay (HbA1c) (Mealey BL & Ocampo G, 2007) • Normal HbA1c = less than 5.7% • ADA recommendation = less than 7% • If greater than 8% = physician intervention necessary Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Smoking” • Numerous deleterious effects on tissues & host immuno-inflammatory response • Nicotine + carbone monoxide + hydrogen cyanide → decreasing proliferation of fibroblasts + other reparative cells → vasoconstriction + increasing platelet adhesion → alter wound healing (Johnson GK & Guthmiller JM, 2007) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Smoking” • Numerous deleterious effects on tissues & host immuno-inflammatory response • Nicotine + carbone monoxide + hydrogen cyanide → decreasing proliferation of fibroblasts + other reparative cells → vasoconstriction + increasing platelet adhesion → alter wound healing (Johnson GK & Guthmiller JM, 2007) • Most of the studies do not clearly delineate the degree of smoking exposure such as the number of cigarettes smoked or the duration of smoking (Klokkevold PR, et al. 2007) • Systematic reviews demonstrate that implant failure is higher in smokers compared with non-smokers (Klokkevold PR, et al, 2007; Hinode D, et al, 2006; Strietzel FP, et al, 2007) • Not an absolute contraindication Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Radiation” • Has numerous factors affecting the risk for implant failure or complications (Barasch A & Coke JM, 2007) • Lower implant survival rates in previously irradiated bone than in non-irradiated (Chambrone L, et al, 2013) • More vulnerable in irradiated maxilla compared with the mandible Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Radiation” • Has numerous factors affecting the risk for implant failure or complications (Barasch A & Coke JM, 2007) • Lower implant survival rates in previously irradiated bone than in non-irradiated (Chambrone L, et al, 2013) • More vulnerable in irradiated maxilla compared with the mandible • No significant difference of implant failure rate whether radiation was received before / after the implant placement (Colella G, et al, 2007) • Relatively lower implant failure in the total radiation dose of below 45 Gray • No correlation with increasing radiation dose (5.4% at 46-55 Gy; 5.1% at above 61 Gy) • Interestingly, higher implant failure in the studies prior to 2007 (Schiegnitz E, et al, 2014) → possible improvement of implant survival in irradiated bones with newer implant designs and surfaces Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Osteoradionecrosis (ORN)” • Radiation inducing tissue hypoxia in normal cells → resulting in an imbalance where cell death and collagen lysis exceed the homeostatic mechanisms of cell replacement and collagen synthesis → a wound that will not heal, in which the metabolic demands exceed the oxygen and vascular supply (David LA, 2001) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Hyperbaric oxygen (HBO)” • HBO therapy is intended for providing an increased oxygen tension at the tissue level to promote angiogenesis + better wound healing, especially in wounds with a compromised vasculature (David LA, 2001) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Hyperbaric oxygen (HBO)” • HBO therapy is intended for providing an increased oxygen tension at the tissue level to promote angiogenesis + better wound healing, especially in wounds with a compromised vasculature • Lack of high quality studies → still need further research and consensus (David LA, 2001) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Risk factors “Lifelong craniofacial growth” • Potential estehtic, occlusal and periodontal ramifications of continued adult craniofacial growth → teeth migration → changes in occlusion, opened contacts, changes in the esthetic results • Continued adult craniofacial growth w/ clinical problems = not predictable (Daftary F, et al, 2013) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Biofilm formation” • Endosseous implants are consisted of hard, nonshedding surfaces in a fluid system, as do teeth → subject to bio-film formation • Glycoproteins rapidly wraps around the implant surfaces exposed in oral environment → Single bacterial colonies adhering to the pellicle coat (few mins ~ hours) → Further aggregation of larger bacterial colonies • Early colonization of gram-positive coccoidal and rod microbiota → more complex microbiota (Gristina AG, 1987) Implant complications • Peri-implant mucositis S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Pathogenesis of peri-implant diseases” • Reversible inflammatory reactions of mucosa adjacent to an implant • Peri-implantitis • An inflammatory process that (i) affects the tissues around an osseointegrated implant in function and results in loss of supporting bone (1st European Workshop on Periodontology, 1993) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Peri-implant mucositis” • Production of inflammatory mediators and the expression of cytokines → highly similar to the local defense mechanisms in peri-implant soft tissue seal & dentogingival unit • Erythematous • Increased probing depths (PDs) due to increased plaque accumulation (Tonetti M, 1994) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Peri-implant mucositis” • “Recent reports revealed that peri-implant mucositis was present in 48% of implants followed from 9 to 14 years after placement (AAP report, 2013) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Peri-implantitis” • Diagnostic aspects • Mobility • Bleeding on probing • Modified gingival index • Loss of attachment • Radiographic crestal bone loss • Pus formation Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Treatment” • Peri-implant mucositis • Mechanical debridement + antimicrobial rinse (Chlorhexidine for 30 sec for 3-4 wks) + antibiotics (Metronidazole 250mg TID for 10 days) • Peri-implantitis • Non-surgical route is not effective • Mechanical debridement + decontamination • Regenerative or surgical intervention • Bone graft / membrane (Lindhe J & Meyle J, 2008) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Explantation” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Explantation” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Cement sepsis” • Mostly seen with pre-fabricated abutments • Undetected Bucco-palatal remnant cement • Causing cement-associated peri-implantitis • Solution - use of custom abutments or screw-retained Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Occlusion & biological outcomes” • Controversy persists as to the role of occlusal overload in peri-implantitis • No controlled studies evaluating the effect of occlusion on implants in humans, following the Helsinki accords (Graves CV et al, 2016) (Sadowsky SJ, 2019) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Occlusion & biological outcomes” • Controversy persists as to the role of occlusal overload in peri-implantitis • No controlled studies evaluating the effect of occlusion on implants in humans, following the Helsinki accords (Graves CV et al, 2016) • Available body of evidence → broad and heterogenous • Lacking a study that reveals the link between specific mechanical loads and histological changes (Sadowsky SJ, 2019) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Occlusion & biological outcomes” • Evidence-based fact - increased mechanical stress (below a certain threshold) → increasing bone density or bone apposition → following the “Wolff’s law” strengthening the bone (Frost HM, 2003; Frost HM, 1994) • Non-evidence-based expert opinion - mechanical stress + fatigue micro-damage → biological bone resorption (Isidor F, 2006) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Occlusion & biological outcomes” “In uences of forces on peri-implant bone (Isidor F, 2006)” fl • Randomized controlled + prospective cohorts studies - NOT FOUND • Only animal studies (no human studies) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Microbiological “Occlusion & biological outcomes” “In uences of forces on peri-implant bone (Isidor F, 2006)” fl • Randomized controlled + prospective cohorts studies - NOT FOUND • Only animal studies (no human studies) • The impact of occlusal overload in biological outcomes remains UNKNOWN Implant complications • Survival rate - 95.5% S U R G I CA L | B I O L O G I CA L | MECHANICAL Prosthetic failure “10-year study” • Mean observation period - 10.75 yrs • Most frequent complications • Ceramic chipping (20.31%) • Occlusal screw loosening (2.57%) • Loos of retention (2.06%) (Wittneben et al, 2013) Implant complications • Survival rate - 91% • Most frequent complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Prosthetic failure “20-year study” • Veneer material fractures • Component loosening and abutment (Lekholm U, et al, 2015) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Prosthetic failure “Late implant failure” • Local factors: poor OH/maintenance, previous/current periodontitis, cement, foreign body, occlusion • Systematic factor: smoking, diabetes, alcohol, Ti allergy (Daubert DM et al, 2015) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Prosthetic failure “Is cement-retained evil?” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Prosthetic failure “Is cement-retained evil?” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Prosthetic failure “Is cement-retained evil?” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Prosthetic failure • Misfit + premature contacts and/or eccentric excursive interferences (i.e. non-axial forces) → major etiology of mechanical prosthetic complication • Biological complication (i.e. peri-implantitis), resorbing the crestal bone around implant platform, may further enhance the mechanical complications Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Prosthetic failure • Misfit + premature contacts and/or eccentric excursive interferences (i.e. non-axial forces) → major etiology of mechanical prosthetic complication • Biological complication (i.e. peri-implantitis), resorbing the crestal bone around implant platform, may further enhance the mechanical complications Non-destructive equilibrium • Proper hygienic & occlusal rehabilitation/maintenance Kim YK, Under Review Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Flexure fatigue” Preload • Tightening force = preload → generating clamping force (i.e. compressive stress) Maximum stress • Clamping force shields the abutment screw from flexure • Maximum stress strain concentrated at the implant-abutment interface (via off-axial forces) Clamping force (N) Torque (Ncm) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw loosening” • Common prosthetic complication in implant dentistry • Non-axial force serves as a critical factor affecting screw loosening (i.e. prematurity, eccentric excursive interferences, and bruxism) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw loosening” • Common prosthetic complication in implant dentistry • Non-axial force serves as a critical factor affecting screw loosening (i.e. prematurity, eccentric excursive interferences, and bruxism) • Wide diameter implants → reducing the screw loosening and component fracture (Boggan, 1999) • Crown height magnifies the force on the abutment screw (Boggan, 1999) • Narrowing the occlusal table is critical for a single unit to prevent screw loosening (Bakaeen, 2001) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw loosening” • Retightening abutment screws 10 min after the initial torque applications improve the tightening of screw and to decrease screw loosening (Siamos, 2002) • Repeated opening and closing of implant abutment screws → progressive loss of torque retention with variations between systems → decrease in the coefficient of friction of the screw head and threads (Weiss, 2000) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw loosening” • Retightening abutment screws 10 min after the initial torque applications improve the tightening of screw and to decrease screw loosening (Siamos, 2002) • Repeated opening and closing of implant abutment screws → progressive loss of torque retention with variations between systems → decrease in the coefficient of friction of the screw head and threads (Weiss, 2000) • Preventing the misfit through proper impression & laboratory workflows and verification = the key ! Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” • Screw loosening → Loss of preload → increasing the bending load of the screw Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” • Screw loosening → Loss of preload → increasing the bending load of the screw • During the insertion, passivity is an absolute critical pre-requisite (i.e. DO NOT FORCE) Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” • Screw loosening → Loss of preload → increasing the bending load of the screw • During the insertion, passivity is an absolute critical pre-requisite (i.e. DO NOT FORCE) If fractured, what now? Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” • Cavitron or piezo to vibrate the broken screw out • Round bur with slow-speed + counter clockwise • Creating a tiny notch → reverse rotation with a tip instrument Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” • Cavitron or piezo to vibrate the broken screw out • Round bur with slow-speed + counter clockwise • Creating a tiny notch → reverse rotation with a tip instrument What if torqued and tightened ? Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” What if still not coming out? Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” Implant complications Or … S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Screw fracture” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Implant fracture” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Implant fracture” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Screw dynamics “Implant fracture” “Hoop stress” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Implant complications S U R G I CA L | Prosthesis Free gingival groove Critical contour Sub-critical contour B I O L O G I CA L | MECHANICAL Emergence profile “Emergence profile” Schoenbaum TR, Kim YK, Khalifa F, Emergence contours for single-unit implant provisionals in the esthetic zone, Compendium, 42:7, 2021 Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Farid E, Chang A, Lucretia DC, Kim YK, Predictable Implant Crown Emergence Profile Extra-Oral Composite (EPEC) Technique, NYU ARD, 2022. Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Farid E, Chang A, Lucretia DC, Kim YK, Predictable Implant Crown Emergence Profile Extra-Oral Composite (EPEC) Technique, NYU ARD, 2022. Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Farid E, Chang A, Lucretia DC, Kim YK, Predictable Implant Crown Emergence Profile Extra-Oral Composite (EPEC) Technique, NYU ARD, 2022. Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Farid E, Chang A, Lucretia DC, Kim YK, Predictable Implant Crown Emergence Profile Extra-Oral Composite (EPEC) Technique, NYU ARD, 2022. Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Farid E, Chang A, Lucretia DC, Kim YK, Predictable Implant Crown Emergence Profile Extra-Oral Composite (EPEC) Technique, NYU ARD, 2022. Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Photo credit - Tareen F Cox M, Tareen F, Paranhos K, De Bartolo A, Kim YK, Emergence Profile Intra-Oral Composite (EPIC) Technique and its Advantages, NYU ARD, 2022. Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Photo credit - Tareen F Cox M, Tareen F, Paranhos K, De Bartolo A, Kim YK, Emergence Profile Intra-Oral Composite (EPIC) Technique and its Advantages, NYU ARD, 2022. Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Emergence profile Photo credit - Tareen F Cox M, Tareen F, Paranhos K, De Bartolo A, Kim YK, Emergence Profile Intra-Oral Composite (EPIC) Technique and its Advantages, NYU ARD, 2022. Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Denture stomatitis” • Small, painful mucosal lesions that most commonly develop in the first days after insertion of a new denture that are caused by dentures with overextended borders, unbalanced occlusion, small excess of material related to direct pick up of overdenture attachment procedure. Kim YK, et al, NYU Predoctoral Implant Manual – Restorative. NYUCD, 2021 Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Denture stomatitis” • Small, painful mucosal lesions that most commonly develop in the first days after insertion of a new denture that are caused by dentures with overextended borders, unbalanced occlusion, small excess of material related to direct pick up of overdenture attachment procedure. • Clinical features: the painful mucosal ulcerations are tender, have a yellowish floor and red margins. Kim YK, et al, NYU Predoctoral Implant Manual – Restorative. NYUCD, 2021 Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Denture stomatitis” • Small, painful mucosal lesions that most commonly develop in the first days after insertion of a new denture that are caused by dentures with overextended borders, unbalanced occlusion, small excess of material related to direct pick up of overdenture attachment procedure. • Clinical features: the painful mucosal ulcerations are tender, have a yellowish floor and red margins. • Management: denture base and occlusion adjustments need to be made. Traumatic ulcers usually heal fast, in about a week, after removal of the cause. Kim YK, et al, NYU Predoctoral Implant Manual – Restorative. NYUCD, 2021 Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Attachment system” • Attachment system (loss of retention): most frequent attachment system complications, with overdentures, are: decreased prosthesis retention due to distortion or detachment of retentive nylon, or damage or loss of the retentive metal housing part Kim YK, et al, NYU Predoctoral Implant Manual – Restorative. NYUCD, 2021 Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Attachment system” • Attachment system (loss of retention): most frequent attachment system complications, with overdentures, are: decreased prosthesis retention due to distortion or detachment of retentive nylon, or damage or loss of the retentive metal housing part • Management: simply replace with new nylon insert. Kim YK, et al, NYU Predoctoral Implant Manual – Restorative. NYUCD, 2021 Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Attachment system” • Attachment system (loss of retention): most frequent attachment system complications, with overdentures, are: decreased prosthesis retention due to distortion or detachment of retentive nylon, or damage or loss of the retentive metal housing part • Management: simply replace with new nylon insert. • If damaged housing is still embedded in the denture, remove it completely with an acrylic bur from the tissue side of a denture and provide enough space for new Housing (attachment Compartment). Once enough space has been created for a new housing component, pick up the component with the auto-polymerizing acrylic resin material. Kim YK, et al, NYU Predoctoral Implant Manual – Restorative. NYUCD, 2021 Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Denture base fracture” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Denture base fracture” “Bilateral-balanced occlusion” Centric occlusion R. laterotrusion R. mediotrusion Protrusion Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Denture base fracture” “Primary stress bearing area” Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Denture base fracture” “Improper force distribution” Fulcrum Implant complications S U R G I CA L | B I O L O G I CA L | MECHANICAL Overdenture-related “Denture base fracture” “Improper force distribution” “Frequent maintenance visits are CRITICAL !” Complications Success Photo Credit - Pixabay Thank you Instagram Youtube Linkedin YKK Website [email protected] @ykk_pros YKP r o s t h o d im s tonti