2 Hour Surgical Complications

Complications:How to Treat and Avoid

PART 3 – NONE HOST RELATED FACTORSOPERATOR RELATED – EXPERIENCESURGICAL TECHNIQUE AND PROTOCOL

ADDITIONAL DATA PROVIDED BY DR.PAUL BINON

PROSTHODONTIST ROSEVILLE,CA

Surgical Complications

Contributing

EtiologyNon Host Factors

Biomaterial

Related

(Based on Etiology)

Host Factors

Systemic

Factors

Local

Factors

OperatorRelated

Part III

Surgical Complications:

Non Host Factors

• Operator related

• Experience

• Surgical technique

• Biomaterial related

• Biocompatibility

• Implant surface• Surgical technique

• Surgical protocol

• Implant surface

• Implant shape

Operator Experience

• Higher failure with pioneer Bränemark• Bränemark et al, Hansson, Friberg et al, 1997

• Adell et al, 1981, Parein et al, 1977

• Early failure rates almost twice as high with inexperienced operatorswith inexperienced operators

• Morris et al, Lambert et al, 1997

• Preiskel, Tsolka, 1995

• Meta analysis review is consistent

with the hypothesis of a “learning curve”• Clin Oral Impl Res, 2004

Surgical Complications:

Non Host Factors


• Experience






• Implant surface

• Implant shape

Surgical Technique

• Sterile vs aseptic

• Prophylactic antibiotics

• Surgical incision

• Surgical trauma

• Malpositioned implants

Sterile vs Aseptic

• Infection uncommon clinically with aseptic protocols• Absence of experimental studies

• Equivalent early success: “sterile” vs “clean” • Equivalent early success: “sterile” vs “clean” • Scharf and Tarnow, 1993

• “Experience” has shown importance of asepsis• Unpublished, Arlin, M., Private Practice

Surgical Technique




• Surgical trauma


Prophylactic Antibiotics

• Associated with decreased early losses (multicenter)

• However ; prophylactic protocol was not controlled• Dent et al, JOMI, 1997

• Long-term prophylaxis no advantage over single dosepreoperative antibiotic regimen

• Binahmed et al, JOMI, 2005• Binahmed et al, JOMI, 2005

• No convincing evidence that prophylaxis is effective• Gynther et al, Oral Sg Path Rad En, 1998

• No significant difference in implant survival (Friadent)

• 1,175 implants with prophylaxis 96.3%

• 354 implants without prophylaxis 95.2%• Morris et al, J Oral Implant, 2004

Surgical Technique



• Surgical incision• Surgical incision

• Surgical trauma


Surgical Incision:Mucobuccal vs Crestal

• No effect on early implant failure

• Scharf and Tarnow, 1993

• Hunt et al, 1996

• Casino et al, 1997

• Chou et al, 2004

Surgical Technique




• Surgical trauma


SURGICAL TRAUMA

TOO AGGRESSIVE DEGLOVING OF THE MANDIBLE

SURGICAL TRAUMA

TOO AGGRESSIVE DEGLOVING OF THE MANDIBLE – THE RESULT

Surgical Technique




• Surgical trauma

• GENTLE MANAGEMENT OF TISSUES IS ADVOCATED TO PREVENT POST OP COMPLICATIONS

Surgical Trauma:

Early Implant Failure

• Excess heat generation• Bränemark et al, 1969

• Excess bone compression• Excess bone compression• Arlin, unpublished

• Inadequate implant to bone fit• Schatzker et al, 1975, Carlsson, 1985

• Frieberg, 1991, Ivanoff et al, 1996,

• Orenstein et al 1998, Morris et al 2004,

• Arlin unpublished

Surgical Trauma:








Excess heat generation

dull instrumentation

Implants in place

5 Weeks Post Op

5 Weeks Post Op

5 Weeks Post Op

Surgical Trauma:








Fractured labial plate

Grafted w/ membrane

Result

Surgical Trauma:








Mobility at Placement andSurvival Rate (SR) at Uncovering

Survival Rate Orenstein, Tarnow & Ochi, 1998

81% “Slightly mobile” at placement (all surfaces)

81.5% Titanium (22/27) if slightly mobile at placement

95.0%95.0% Titanium (943/992) if not mobile at placement

100% HA (54/54) if slightly mobile at placement

99.1% HA (53/54) if not mobile at placement

ConclusionTitanium machined implants displayed significantly higher failure rates if mobile initially, but HA implants did not.

Mobility at Placement andSurvival at Uncovering

Survival Rate Arlin, unpublished

1.11% FAILED Slightly mobile at placement (57 / 5,155)

88.2% Titanium (15 / 17) if mobile at placement

94.9%Titanium (1,290 / 1,359) if not mobile at placement

97.5% Rough SURFACE (39 / 40) if mobile at placement

96.9% Rough (3,623 / 3,739) if not mobile at placement

Mobility at Placement andSurvival at Uncovering

MobileNot

Mobile

Titanium 88.2% 94.9%

MobileNot

Mobile

Titanium 81.5% 95.0%Titanium 88.2% 94.9%

Rough 97.5% 96.9%

Titanium 81.5% 95.0%

HA 100% 99.1%

• Orenstein, Tarnow, Morris & Ochi, 1998• Arlin, unpublished

Mobility at Placement andSurvival Rate (SR) at Uncovering and 3 Years

• 1,554 Ankylos roughened titanium Grade 2

• 2.8% “clinically mobile” at placement (2.8%)

• 6.3% clinically mobile in maxillary posterior• 6.3% clinically mobile in maxillary posterior

• SR=97.7% of initially mobile: stable at uncovering

• SR=84.1% of initially mobile: stable at 3 years

• SR=96.8% of initially stable: stable at 3 years

• Morris et al, J Oral Implant, V. XXX, #3, 2004

Lack of Primary Stability(Spinners)

• Straumann Wide Neck Implants

• Posterior sites (97% molars)

• 7.6% of implants not initially stable (n=20)

• 90% integrated and stable at 5 years (18/20)

• Bischof et al, Clin Oral Impl Res, 2006

Initial 4 Months PostSPINNER - LOADED AT 4 MO. WITH PROGRESSIVE BONE LOSS

6 Months Post 2 Years Post

SPINNER - LOADED AT 4 MO. WITH PROGRESSIVE BONE LOSS

INITIALLY SLIGHT MOBILITY WHEN PLACED

Rotation at uncovering!

Wait additional 6 Months?

Additional 6 MonthsBOTH ARE INTEGRATED

7 Years Post Restoration

Surgical Technique




• Surgical trauma


Malpositioned Implants

Potential Increased Incidence of:

• Implant failure

• Crestal bone loss

• Esthetic complications

• Prosthetic complications

• Other signs and symptoms


• Oro-facially

• Mesio-distally

• Apico-occlusally

• Invasion of anatomic site• Invasion of anatomic site

• Maxillary antrum

• Nasal cavity

• Inferior alveolar canal

• Perforation of alveolar bone

Malpositioned Implants:

Oro-facially

• >Stress with angled implants & abutments• Clelland and Gilat, J Prosth, 1992, 1993, 1995

• Angulated abutments were not associated with increased failure rates (at 3 years)

• Balshi et al, JOMI, 1997

• No studies on angled implant failure rates!

TOO FAR LINGUAL - COMPENSATE WITH TISSUE OVERLAP AND POOR CONTOUR

TOO FAR LABIAL- THIN BONE, RECESSION AND DISCOLORATION

LOOKS GOOD !

REALITY NOT SO GOOD

LOW LIP LINE COMPENSATES


• Oro-facially

• Mesio-distally• Apico-occlusally

• Invasion of anatomic site


• Nasal cavity



MESIO DISTAL MALPOSITION

RESULTING POOR CONTOURS, HYGIENE CHALLENGE and NO PAPPILAE


• Oro-facially

• Mesio-distally




• Nasal cavity



TOO DEEP

TOO DEEPBELOW THE CREST OF THE BONE

TOO DEEP

ATTACHMENT VIOLATION AND POCKET CREATION

LOOK AT GEOMETRY RELATED TO

ADJACENT BONE LEVEL

REQUIRED BONE GRAFT

BEFORE

IMPLANT PLACEMENT

DEEP PROBES, LOOK AT

CERVICAL TISSUE COLOR

CHRONIC INFLAMATION

AND BLEEDING

Another example

Implant platform is at the apical level of adjacent tooth! There is no bone to support soft tissue or a papillae

End result, no papillaeAND

CHRONIC INFLAMMATION

Inadequate interarch space – note occlusal plane -very poor TREATMENT planning!

Required crown elongation

Restorations were severely compromised due to poor planning. Functionally adequate but esthetically

very poor


• Oro-facially

• Mesio-distally




• Nasal cavity



Avoid penetration of the antrum

Malpositioned Implants:

Invasion of Anatomic Site

• Penetration of the maxillary antrum or nasal cavity were associated with:

• A 10% higher failure rate

• Colonization with S. aureus• Casewell, 1998

• Perl & Golub, 1998


• Oro-facially

• Mesio-distally


• Invasion of anatomic site


• Nasal cavity



Obvious intrusion of alveolar canal

Immediately remove offending implant and place

shorter one.

Parasthesia:How to Avoid and How to Treat

• Diagnosis: Radiographs, Surgical Exploration

• Anaesthesia: Infiltration only?

• Surgery:

• Choose implant length 2-3mm short of canal

• Verticle bone augmentation procedures• Verticle bone augmentation procedures

• Lateralization of the inferior alveolar nerve?

• Treatment:

• Remove (replacement with a shorter implant)

• Back off implant several mm (if not integrated)

• *Implant apicoectomy??• * Levitt, D., Implant Dentitry, V 12,#3, page 202, 2003


• Oro-facially

• Mesio-distally




• Nasal cavity



Apical radioluscency

Ct scan shows lingual perforation

COMPLETE APICOECTOMY – NOTE ADJACENT TOOTH HAS RCT

MOLAR REPLACEMENT – MANDIBLE WITH DEEP LINGUAL CONCAVITY

NOTE AXIS OF ANTERIOR IMPLANT

PERFORATION INTO LINGUAL CONCAVITY

Surgical Complications:Non Host Factors


• Experience






• Implant surface

• Implant shape

Surgical Protocol

• One or two stage procedure

• Immediate implant placement

• Early implant placement

• Immediate implant replacement

• Early implant replacement

• Delayed implant replacement

• Early / Immediate loading

• Number of supporting implants

• Connection to natural teeth

One vs Two Stage

• One and two stage Branemark studies yielded similar success rates

• Ericsson et al., 1994, Henry & Rosenberg, 1994

• Bernard et al., 1995, Becker et al., 1997

• Collaert and De Bruyn, 1998• Collaert and De Bruyn, 1998

• One stage Straumann ITI study yielded a 0.6% early failure rate.

• Buser et al.,1997 (N=2,359)

• Numerous similar studies

One vs Two Stage

• Patient cooperation

• Initial implant stability

IMPORTANT CONSIDERATIONS

• Initial implant stability

• Bone quality and quantity

• Interim prosthesis type

AVOID LOADING SOFT TISSUE AND HEALING

ABUTMENT VIA TEMPORARY PROSTHESIS

Partially Submerged Implants

• 206 implants

• Buried, partially exposed or fully exposed.

• Prematurely partially exposed, were associated with greater bone lossassociated with greater bone loss

• If partial exposure, fully expose!

•Tal, H., J. Periodontol 1999

•Tal et al., JOMI 2001

•Haim and Zvi, JOMI 2001

•Tal et al Implant Dent, 2002

TYPICAL PARTIAL OR COMPLETE EXPOSURE

RESULTING FROM INADEQUATE RELIEF OF THE INTERIM PROSTHESIS

IT’S BETTER TO REMOVE SOME TISSUE EARLY DURING THE HEALING PERIOD TO

AVOID A FESTERING POCKET AND TO KEEP IT CLEAN AT SECOND STAGE ALL

WERE INTEGRATED

Time Period

Number Followed

Number Failed

Success in Group- %

Cumulative Success- %

0-1 years 100 5 95.0 95.0

1-2 years 90 3 96.7 91.8 (95.0x96.7)

A Sample Life Table THE GOLD STANDARD

2-3 years 75 1 98.7 90.6 (91.8x98.7)

3-4 years 40 0 100 90.6 (90.6x100)

4-5 years 10 1 90.0 81.5 (90.6x90.0)

AT 1 YR 5 FAILED RESULTING IN SUCCESS OF 95%. YEAR 2, YOU MULITIPLY THE SUCCESS RATE OF YEAR ONE WITH THE

SUCCESS RATE EXPERIENCED IN YR 2 (96.7) FOR OVERALL SUCCESS RATE OF 91.8 % FOR 2 YEARS.

THE SAME IS DONE FOR EACH FOLLOW UP YRS TO GET AN ACCURATE CUMMULATIVE SUCCESS RATE.

HOW LIFE TABLES WORK

Time Period Patients Implants Lost Sr-% Csr-%

0 Years 161 435 9 97.9 97.9

0-1 Years 157 419 15 96.4 94.4

1-2 Years 155 403 1 99.8 94.2

2-3 Years 152 395 0 100 94.2

3-4 Years 151 393 0 100 94.2

4-5 Years 143 371 0 100 94.2

5-6 Years 136 352 0 100 94.2

6-7 Years 128 336 0 100 94.2

2 Stage Titanium Screw Vents CORE-VENT ETC.

7-8 Years 111 298 0 100 94.2

8-9 Years 102 274 0 100 94.2

9-10 Years 90 249 0 100 94.2

10-11 Years 79 225 0 100 94.2

11-12 Years 55 166 0 100 94.2

12-13 Years 40 126 0 100 94.2

13-14 Years 32 104 0 100 94.2

14-15 Years 24 80 0 100 94.2

15-16 Years 18 60 0 100 94.2

16-17 Years 13 36 0 100 94.2


0 Years 400 1043 26 97.5 97.5

0-1 Years 351 894 7 99.2 96.7

1-2 Years 262 641 3 99.5 96.3

2-3 Years 196 641 3 99.5 96.1

3-4 Years 145 355 0 100 96.1

1 Stage Straumann ITI Designs

3-4 Years 145 355 0 100 96.1

4-5 Years 118 294 2 99.3 95.4

5-6 Years 82 191 1 99.5 94.9

6-7 Years 64 160 1 99.4 94.3

7-8 Years 48 125 1 99.2 93.6

8-9 Years 32 91 0 100 93.6

9-10 Years 15 47 0 100 93.6

Surgical Protocol










Immediate Implants

• Similar success rates achieved

• Contraindications e.g. acute infection

• Barriers may cause complications

• Better preservation of B-L bone?

• Gelb, 1993 , Becker et al, 1994, Cordioli et al, 1994

• Dahlin et al, 1995, Haas et al, 1995, Rosenquist et al, 1996

• Arlin, 2000, Schwartz-Arad et al., 2000, Paolantons et al., 2001

• Covani et al, J. Periodontol, Dec. 2004, Quirynen et al, SSID, JOMI, 2007

TYPICAL EXAMPLE

COMPLETED BAR VERY OLD FASHION DESIGN

TYPICAL BONE LEVELS FOR IMMEDIATE PLACEMENT

FAILING CENTRAL INCISOR – IMMEDIATE PLACEMENT– AND ADJACENT

EDENTULOUS RIDGE

LARGER DIAMETER IMPLANT FOR IMMEDIATE PLACEMENT AND

STANDARD 3.75 FOR THE DELAYED PLACEMENT


0 Years 955 1570 38 97.6 97.6

0-1 Years 810 1332 33 97.5 95.2

1-2 Years 532 895 2 99.8 94.9

2-3 Years 408 688 3 99.6 94.5

3-4 Years 323 558 1 99.8 94.4

4-5 Years 253 435 0 100 94.4

5-6 Years 198 351 0 100 94.4

6-7 Years 151 278 1 99.6 94.0

All Immediate Implants

7-8 Years 121 228 0 100 94.0

8-9 Years 82 161 1 99.4 93.4

9-10 Years 60 116 0 100 93.4

10-11 Years 53 100 0 100 93.4

11-12 Years 37 65 0 100 93.4

12-13 Years 24 44 0 100 93.4

13-14 Years 15 32 0 100 93.4

14-15 Years 12 22 0 100 93.4

15-16 Years 6 12 0 100 93.4

16-17 Years 3 4 0 100 93.4


0 Years 2459 6840 140 98 98.0

0-1 Years 2157 5954 128 97.9 95.8

1-2 Years 1576 4382 26 99.4 95.3

2-3 Years 1271 3559 10 99.7 95.0

3-4 Years 1040 2908 14 99.5 94.6

4-5 Years 854 2411 9 99.6 94.2

5-6 Years 690 1906 15 99.2 93.5

6-7 Years 537 1505 5 99.7 93.1

All Implants

7-8 Years 434 1239 4 99.7 92.8

8-9 Years 339 985 1 99.9 92.8

9-10 Years 243 727 1 99.9 92.6

10-11 Years 195 584 4 99.0 91.7

11-12 Years 134 392 2 99.5 91.2

12-13 Years 92 265 0 100 91.2

13-14 Years 44 133 0 100 91.2

14-15 Years 32 99 0 100 91.2

15-16 Years 22 61 0 100 91.2

16-17 Years 14 42 0 100 91.2

BY LOCATION IN THE DENTAL ARCH

Surgical Protocol










EXTRACTION AND DELAY ON IMPLANT PLACEMENT UNTIL SOCKET FILLS

< THAN 3 MO.

POST OP

POST OP


0 Years 105 128 4 96.9 96.9

0-1 Years 93 115 1 99.1 96.0

1-2 Years 75 96 0 100 96.0

2-3 Years 63 84 0 100 96.0

3-4 Years 50 65 0 100 96.0

4-5 Years 44 59 0 100 96.0

5-6 Years 36 48 0 100 96.0

6-7 Years 23 31 0 100 96.0

Early Post Extraction Implants < 3 MO

6-7 Years 23 31 0 100 96.0

7-8 Years 20 28 0 100 96.0

8-9 Years 16 24 0 100 96.0

9-10 Years 9 11 0 100 96.4

10-11 Years 7 7 0 100 96.0

11-12 Years 4 4 0 100 96.0

12-13 Years 1 1 0 100 96.0

13-14 Years 1 1 0 100 96.0

14-15 Years 1 1 0 100 96.0

15-16 Years 1 1 0 100 96.4

Surgical Protocol










3i IMPLANT PLACED 4MM

2ND STAGE W/ HEALING ABUTMENT IN PLACE

First Stage

Second Stage

REVERSE TORQUE TEST LOOSENED IMPLANT

ONLY TIP END WAS INTEGRATED

LARGER DIAMETER IMPLANT PLACED AND THE PROXIMAL OF THE MOLAR WAS REDUCED TO ELIMINATE

THE MESIAL OVERHANG

FLOSS CHECK TO BE SURE THERE WAS NO CONTACT

WIDE DIAMETER IMPLANT IN

PLACE


Surgical Protocol










FAILING IMPLANT

WAIT > 4 MONTHS FOR OSTEOTOMY FILL

REPLACEMENT IMPLANT

FRACTURED IMPLANT WITH

SCREW REMNANT INSIDE

FRACTURED IMPLANT WITH

SCREW REMNANT INSIDE

IMPLANTS ARE TREPHINED OUT AND AREA GRAFTED

NEW IMPLANTS ADDED


0 Years 37 44 7 84.1 84.1

0-1 Years 25 32 5 84.4 71.0

1-2 Years 14 17 0 100 71.0

2-3 Years 13 16 0 100 71.0

3-4 Years 10 12 0 100 71.0

Immediate Replacement Implants

3-4 Years 10 12 0 100 71.0

4-5 Years 9 11 0 100 71.0

5-6 Years 7 9 0 100 71.0

6-7 Years 7 9 0 100 71.0

7-8 Years 6 8 0 100 71.0

8-9 Years 4 6 0 100 71.0

9-10 Years 2 2 0 100 71.0


0 Years 9 12 1 90.7 91.7

0-1 Years 8 9 0 100 91.7

1-2 Years 7 7 0 100 91.7

2-3 Years 5 5 0 100 91.7

Early Replacement Implants(less than 3 months)

2-3 Years 5 5 0 100 91.7

3-4 Years 5 5 0 100 91.7

4-5 Years 2 2 0 100 91.7

5-6 Years 1 1 0 100 91.7

6-7 Years 1 1 0 100 91.7


0 Years 56 71 6 91.5 91.5

0-1 Years 45 56 0 100 91.5

1-2 Years 16 20 0 100 91.5

2-3 Years 14 18 0 100 91.5

3-4 Years 7 11 0 100 91.5

4-5 Years 5 8 0 100 91.5

5-6 Years 2 4 0 100 91.5

Delayed Replacement Implants (more than 3 months)

5-6 Years 2 4 0 100 91.5

6-7 Years 2 4 0 100 91.5

7-8 Years 2 4 0 100 91.5

8-9 Years 2 4 0 100 91.5

9-10 Years 1 3 0 100 91.5

10-11 Years 1 3 0 100 91.5

11-12 Years 1 3 0 100 91.5

12-13 Years 1 3 0 100 91.5

13-14 Years 1 3 0 100 91.5

14-15 Years 1 3 0 100 91.5

Immediate Replacement ofFailed Implants

• 51 immediate implants replaced failed implants

• 2 failed (3.9% failure rate)• 2 failed (3.9% failure rate)

• Failure rate was not significantly differentfrom the 1,195 immediate implants in the study

• Wagenberg and Froum, JOMI 2006

“Effect of Implant Surface in the

(Delayed) Replacement of Failed

Implants”• 58 failed, “delayed” replacement (4-6 mo.)

• 29 machined replaced with machined:

• 19 machined replaced with TiUnite • 19 machined replaced with TiUnite

• 10 TiUnite replaced with TiUnite

• Delayed Replacement Survival Rate:

• Machined (79.3%) vs TiUnite (96.6%)

• Alsaadi, Quirynen and van Steenberghe, JOMI 2006

Surgical Protocol










Early/Immediate Loading

• Traditional healing times based on Bränemark

“developmental group”• Adell et al, 1990

• Initial Bränemark immediate loaded studies

experienced a >10% early failure rate• Balshi & Wolfinger, (N=60),1997

• Schnitman et al, (N=233), 1997

• Tarnow et al, (N=232),1997


• 100% success immediate loading

• Bränemark system MKII fixtures

• 16 patients (88 implants)• 16 patients (88 implants)

• Fixed prosthesis within 20 days

• At 18 months, 0.4mm bone loss

• Randow et al, 1999


• Early and immediate loading can be successful

if micromotion is controlled• Salama et al., 1995, Chiapasco et al., 1997,2001

• Tarnow et al., 1997, Schnitman et al.,1997

• Randow et al., 1999, Gatti et al., 2000, Romanos et al., 2001

• Rough surface implants may have lower early failure rates vs “turned” surfaces

• Esposito et al, J Mat Sci: Mater Med, 1997


• Threshold of “early” micromotion ranging

50 to <150 microns, consistent with osseointegrationosseointegration

• Cameron et al, J Biomater Res, 1973

• Maniatopoulos et al, J Biomater Res, 1986

• Pilliar et al, Clin Orthop Relat Res, 1986

• Pilliar et al, Symposium Italy, 1995

• Szmukler-Moncler et al, J Biomater Res, 1998


• Early loading may lead to successful osseointegration

and may increase the quality of the direct bone contact with the implant surface. (animal

and human studies) and human studies)

•Piatelli et al, J Oral Implant 1993

•Piatelli et al, Int J Perio and Impl Dent, 1997

•Piatelli et al, J Periodontol, 1997 and 1998

•Testori et al, Int J Perio and Rest Dent, 2002

•Rocci et al, Clin Oral Impl Res 2003

Early / Immediate Loading

• Good bone quality

• Primary stability (>35 Ncm)

• Rigid splinting

• Threaded implant design• Threaded implant design

• Implant length >10mm

• Rough implant surface

• Control occlusion

• Compliant patient

• Informed consent

Proceedings of the Third ITI Consensus Conference:JOMI, Vol. 19, Supplement 2004

• Objectives:

• Critique current peer reviewed implant literature (to 2003)

• Establish a concensus and make recommendations

• 4 groups, each with a leader and 15 to 20 “experts”• 4 groups, each with a leader and 15 to 20 “experts”

• Group I: Implants in Extraction Sockets

• Group II: Esthetics in Implant Dentistry

• Group III: Loading Protocols for Implant Dentistry

• Group IV: Implant Survival and Complications

Immediate Loading: Clinical GuidelinesITI Consensus Conference-2004

• Edentulous Mandible:

• Minimum of 4 interforaminal implants

• Overdenture or fixed prostheses

• Edentulous Maxilla:• Edentulous Maxilla:

• Not routine

• Partially Edentulous Mandible / Maxilla:

• Not routine

• Proceedings of the Third ITI Consensus Conference: JOMI, Vol. 19, Supplement 2004 Group III: Loading Protocols for Implant Dentistry

• IV: “Concensus Statements and Recommended Clinical Procedures Regarding Loading Protocols for Endosseous Implants”

• David Cochran, Dean Morton and Hans-Peter Weber

Early Loading (6 weeks): Clinical Guidelines ITI

Consensus Conference-2004

• Edentulous Mandible:

• 2 or more implants rigidly splinted

• Rough surface implants at 6 weeks if unsplinted

• Edentulous Maxilla:• Edentulous Maxilla:

• 4 or more rough splinted implants at 6 weeks with an overdenture or fixed prosthesis

• Partially Edentulous Mandible or Maxilla:

• Fixed prosthesis, rough surface, at 6 weeks

• Proceedings of the Third ITI Consensus Conference: JOMI, Vol. 19, Supplement 2004 Group III: Loading Protocols for Implant Dentistry

• IV: “Concensus Statements and Recommended Clinical Procedures Regarding Loading Protocols for Endosseous Implants”

• David Cochran, Dean Morton and Hans-Peter Weber

Immediate Loading: Host Risk Factors

• Group A: 82 patients, 411 implants, 94.65% success

• Bruxers: 16, patients, 88 implants, 88.64%

• Smokers: 35 patients, 184 implants, 95.11%

• Diabetes: 8 patients, 42 implants, 88.10%

• Immediate: 51 patients, 262 implants, 96.56%

• Bone Grafting: 22 patients, 120 implants, 93.33%

• Nozawa et al, Abstract Clin Oral Impl Res, Aug 2006

GROUP A – NORMAL PATIENTS

Early / Immediate Loading:( Systematic Literature Review)

• Pubmed search up to May 2005

• Of 1,882 only 22 papers met criteria

• Most studies: no significant difference

• Trend to favor Delayed Loading• Trend to favor Delayed Loading

• Immediate or Early can be safe

• Jokstad and Carr, “What is the Effect of Time-to-Loading of a Fixed

or Removable Prosthesis on Implant(s)?”, JOMI, (Suppl), SSID, 2007

¾ OF LOWER ARCH TO BE RESTORED WITH IMPLANTS

6 ITI IMPLANTS PLACED

PROVISIONAL FIXED PARTIAL DENTURE

INSERTED IMMEDIATELY


Consensus Conference on Immediate Loading:

Single and Partial Edentulous

“Extreme caution”“Extreme caution”

“Strict protocol”

Implant Dentistry, 2006

Immediate and Delayed Load(Unsplinted: Mandibular Overdenture)

• 20 patients, TiUnite 15mm length

• Immediate (1 week) vs Delayed (12 weeks)• Immediate (1 week) vs Delayed (12 weeks)

• 100% success, no differences

• Turkyilmaz et al, Clin Oral Impl Res, Oct 2006

Immediate Single Restorations:

• 111 implants, (7 systems), 5 years

• Minimum insertion torque of 25 Ncm

• 5 lost implants, in first 4 months in D4 bone

95.5%• Survival rate all sites: overall: 95.5%

• Survival rate in healed sites: 100%

• Survival rate in extraction sites: 92.5%

• Degidi et al, Implantology, 2006

Immediate Provisional of Immediate Implants

• Immediate “intact” extraction sockets

• Good initial stability (>40 Ncm)

• Mean 15.6 months follow-up

• Survival rate:163 splinted: 99.6%

• Survival rate: 47 single: 92.5%

• Schwartz-Arad et al, J. Periodontol, 2007

Immediate Provisional of an Immediate Implant

Provisional

5 Years Restored

Immediate Provisional of Immediate Implants:

OBJECTIVE!

• Immediate implant for:

BONE PRESERVATION

• Immediate provisionalization for:

SOFT TISSUE PRESERVATION

Esthetic Outcome -Immediate Implants:

Delayed vs Immediate Restoration

Staged surgery and restoration resulted in

approximately 1mm facial recession from

abutment connection to 1 year post restoration.abutment connection to 1 year post restoration.

Gelb, JOMI, 1993

Bengazi et al, Clin Oral Impl Res, 1996

Small and Tarnow, JOMI 2000

Grunder, Int J Perio Rest Dent, 2002

Cardaropoli et al, Clin Oral Impl Res, 2003

Esthetic Outcome -Immediate Implants:

Delayed vs Immediate Restoration

�Immediate Restoration: optimizes esthetics (?)

��Wohrle, Prac Perio Aesth Dent, 1998�Hui et al, Clin Impl Dent Relat Res, 2001 �Garber and Salama, Comp Cont Educ Dent, 2001�Kan & Rungcharassaeng, Int J Perio & Rest Dent, 2003�Cornelini et al, Int J Perio & Rest Dent, 2005�Ingeborg et al, JOMI 2006,�Dedi & Duarte, Clin Oral Impl Res abst., 2006

Surgical Protocol










Number of Supporting Implants:

Clinical Applicability ?

• Biomechanical theories

• Mathematical models

WHAT DO YOU USE AS CRITERIA ?

• Finite element analysis

• Animal studies

• Methodological limitations

• Biological variations

16 Years

ORIGINAL BRANEMARK HEX /FLAT-TOP ABUTMENT INTERFACE SUPPORTED THIS CANTILEVER

MESIAL CANTILEVERS ARE BETTER TOLERATED THAN DISTAL CANTILEVERS DUE TO THE

DISTRIBUTION OF FORCE BEING LESS ANTERIORLY THAN POSTERIORLY

NARROW DIAMETER IMPLANT WALLS

SPREAD OPEN DUE TO DISTAL

CANTILEVER OVERLOAD

DISTAL CANTILEVER MAGNIFIES THE LOAD

IT ALSO HELPS TO HAVE A STRONG

IMPLANT WALL TO RESIST DEFORMATION

IMPLANT DESIGN FLAWS –IMPLANT DESIGN FLAWS –THIN WALLS; USE OF Grade 1

Titanium = weakest; PROGRESSIVE FAILURE AND OVERLOAD RESULTED IN A

DOMINO EFFECT AND CATASTROPHIC FAILURE

TREPHINE THE IMPLANT OUT OR USE IMPLANT REMOVAL

TOOL TO DE- INTEGRATE THE FRACTURED IMPLANTS

IMPLANT REMOVAL TOOL FRICTION LOCKS WITH ITS THREADS INTO THE IMPLANT BODY AND THEN COUNTER ROTATE TO

UNSCREW IT FROM THE BONE.

THERE HAS TO BE SUFFICIENT INTERNAL ACCESS TO LOCK ON TO THE IMPLANT

DEPENDING ON THE CIRCUMSTANCES AND LOCATION IT

MAY BE MORE PRUDENT TO LET THE FRACTURED REMNANT

“SLEEP”

Number of Supporting Implants:

Clinical Guidelines• Bone quality / quantity

• Implant type, size, position

• Prosthetic design and fit• Prosthetic design and fit

• Restorative materials

• Cantilever length

• Occlusal patterns

• Parafunction

Number of Supporting Implants: Clinical Studies

• Partial fixed bridges/splints

• 2 vs 3 or more implants

• More losses and complications with 2 implant • More losses and complications with 2 implant

per case • Gunne et al., Int J Prosthodont 1994

• Lekholm et al., JOMI 1994

• Parein et al., J Prosth Dent 1997

• Duyck and Naert, Clin Oral Invest,1998

• Sennerby and Roos, Int J Prost, 1998

• Wenneberg and Jemt, Cl Dent, 1999

• Snauwaert et al, Clin Oral Invest, 2000

• *“no differences”-Eliasson et al, JOMI, 2006?

Cantilever Length

• Increased biomechanical stress

• Contradictory publications relating clinical

failure to cantilever length

• Clinical complications?• Yes - Shackleton et al., 1994

• No - Naert et al., 1992

• No - Linquest et al., 1996

• No- Magalbaes et al (Abst), COIR, 2006

IN FUNCTION SINCE 1984 - CANTILEVER BY DEFINITION BUT NOT BY FUNCTION WEAR IS EXTENSIVE AND OCCLUSAL CONTACTS ARE

QUESTIONABLE

IN FUNCTION SINCE 1984 - CANTILEVER BY DEFINITION BUT NOT BY FUNCTION WOULD NOT CONSIDER THIS AN

EXCELLENT EXAMLPE OF CANTILEVER SUCCESS

10 Years Post Restoration. .

..

Implants placed by Dr. P.I.B. (Toronto, 1984)

NOTE BONE LOSS AND POOR FIT OF PROSTHESIS

One Implant Supporting 2 Crowns• 50 patients, 50-3i implants

• Screw retained, cantilevered

• Up to 5 year follow up

• 1 pre prosthetic failure

• 100%prosthetic success

NEED TO ASK WHAT TEETH WERE REPLACED? Laterals ? Bicuspids? Cuspids? Not impressive data.

• Magalhaes et al, Abstract, Clin Oral Impl Res, Aug 2006

Number of Supporting Implants:Occlusal Guidelines

• “It must be emphasized that currently there is no evidence based, implant-specific concept of occlusion.”

• “Future studies in this area are needed to clarify the relationship between occlusion and implant success”

• “Occlusal considerations in implant therapy: Clinical guidelines with biomechanical rationale”, Kim, Y., Oh, T-J., Misch, C.E., Wang, H-L.

Clinical Oral Implants Research, 16, 2005 / 26-35

Surgical Protocol










Connection to Natural Teeth:Considerations

• Mobility of implants is less than teeth

• Increased proprioception of teeth?

• Implant overload? / Tooth underload ?

• Prognosis of teeth vs implants?

• Most authors feel it is contraindicated

• Klinge, B., J Clin Perio, 1991

• Ericsson et al, Implant Dent, 1995

• Velasquez-Plata et al, Int J Perio Rest Dent, 2002

• Pjetursson et al, Clin Oral Impl Res, ITI Concensus, 2004

• Misch, CE, Text, St. Louis, Elsevier-Mosby, 2005

Over 20 years

The exception – but it’s very unpredictable

TYPICAL RESULTS !

FRACTURED IMPLANT

RETAINER SEPARATED FROM

ABUTMENT

POST LOOSENED, CARIES AND

ROOT FRACTURE

FRACTURED IMPLANT

RESULTING FAILED BRIDGE

ANOTHER FPD FAILED – ABUTMENTS 2, 3, 6 AND IMPLANT CO ABUTMENT ON 4/5

CAN SEE BRIDGE SEPERATING FROM ABUTMENTS AND IMPLANT

IMPLANT BODY FRACTURED

BRIDGE WAS REMOVED AND REPLACED FOR X RAY

BRIDGE SECTIONED, IMPLANT AND

ABUTMENT REMOVED

Connection to Natural Teeth (5-10 years)

Combined FPD’s Combined FPD’s-ITI

Implant Survival:8 studies, 5 years-90.1%

4 studies, 10 years-82.1%

FPD Survival:5 studies, 5yrs, 114 FPD’s-94.1%

3 studies, 10 yrs, 60 FPD’s 77.8%

ITI Implant Survival:1 study, 5 yr-94.8%

1 study, 10 yr-77.3%

FPD Survival:5 studies, 5 yrs, 114 FPD’s-94.5%

studies, 10 yrs, 60 FPD’s 79.3%

“elevated rates of technical complications”

“additional biological complications leading to abutment loss”

“implant supported FPD’s appear to be preferable to combined”

•Proceedings of the Third ITI Consensus Conference: JOMI, V. 19, Supp. 2004

•Group IV: Implant Survival and Complications: Consensus Statements and Recommended Procedures

Regarding Implant Survival and Complications: Combined Tooth/Implant-supported FPD’s.

Systematic Review of Fixed Partial Dentures: Minimum 5 years Duration

• I: Implant-supported FPD’s• Pjetursson et al Clin Oral Impl Res, V 55 #6, Dec. 2004

• II: Combined tooth-implant-supported FPD’s• II: Combined tooth-implant-supported FPD’s• Intrusion-5 studies, 5.2% with non rigid connections.

• Lang et al, Clin Oral Impl Res, V 55 #6, Dec. 2004

• III: Conventional FPD’s• Tan et al Clin Oral Impl Res, V 55 #6, Dec. 2004

Connection to Natural Teeth

• Intuitive solutions

• Non-rigid attachments (complications)

• Intramobile elements (not proven)

• Resilient supra-structure (not proven)

• Rigid connection (equally successful?)• Rigid connection (equally successful?)

• Ericsson et al., J Clin Periodontol 1986

• Van Steenberghe, J Prosthet Dent 1989

• Naert et al., J Prosthetic Dent 1992

• Olsen et al., Clin Oral Implants Res 1995

• Nickenig et al, COIR, 2006

Tooth-Implant Fixed Bridge

• 19 subjects, fixed bridges, 3 years

• “Fully functional successful restorations with

no evidence of tooth intrusion and with stable no evidence of tooth intrusion and with stable

bone levels at both teeth and implants”.

• Palmer, Howe and Palmer, Clin Oral Impl Res, 2005

Tooth-Implant Fixed Restorations

• 84 restorations, 132 teeth, 142 implants

• No difference Branemark vs Straumann

• 100 % implant survival, median 4.73 years

• 10% non rigid: with technical complications

• 0% rigid: lack of significant complications

• Nickenig et al, Clin Oral Impl Res, Oct 2006


• Implant success rates (> 72 months):

• 97.1%-implant supported splints

• 94.3%-single implant restorations

• 89.2%-implant / tooth combined

• Implant survival rates (>72 months):

• 97.7%-implant supported splints• 97.7%-implant supported splints



• Prosthesis success (>72 months):

• 89.7%-implant supported splints



Weber and Sukotjo, SSID, JOMI, 2007


• Differences were not statistically significant

CONCLUSION

• *“After review of the limited available evidence it appears that connecting evidence it appears that connecting

implants to teeth may lead to a higher rate of complications/failures”.

Weber and Sukotjo, SSID, JOMI, 2007

*concensus report


Contributing


Biomaterial

Related

Summary:(Based on Etiology)

Host Factors

Systemic

Factors

Local

Factors

Operator

Related

Summary: Operator Related Factors

• Experience: strong evidence for a “learning curve”

• Sterile vs Aseptic: equivalent early success rates

• Surgical incision: no apparent effect on early success

• Surgical trauma:

• Excess heat generation associated with early failure• Excess heat generation associated with early failure

• Excess bone compression may be associated with

increased bone loss & implant failure (lack of studies)

• Inadequate bone fit associated with:

• Increased early and late implant failure

• Rough surface implants have a higher “re-osseointegration” rate

• Apparent “early re-osseointegration” may demonstrate late failure

• Insufficient data on fate of unstable implants at second stage


• Implant malposition may lead to complications with:• Implant failure, crestal bone loss, esthetics, prosthetics,

and neurosensory disturbances (e.g. parasthesia)

• Surgical Protocols:• I vs 2 stage surgery yield similar success rates• I vs 2 stage surgery yield similar success rates

• 2 stage protocol should be considered for “at risk” cases

• Partially submerged implants should be fully exposed

• Replacement of Failed Implants:• Immediate replacement requires careful case selection, and despite

risk may be of indicated, due to minimal intervention involved

• Delayed replacement survival rates similar to conventional

• Replacement survival rates may improve with rough surfaces

Summary: Operator Related Factors:(Surgical Protocols – Continued)

• “Early/Immediate Loading”

• Can be successful if micro motion controlled

• May actually increase the % of bone to implant contact

• Rough surface implants may display improved survival

• “Immediate Loading”-Clinical Guidelines• Edentulous mandible:-4 interforaminal splinted implants

• Maxilla and Partially edentulous- not routine-EXTREME CAUTION!

• “Early Loading”-Clinical Guidelines (6 weeks or less)

• Edentulous mandible:• 2 or more splinted implants, unsplinted if roughened surface

• Edentulous Maxilla:• 4 or more splinted rough surface implants

• Partially Edentulous• Fixed splinted prostheses with rough surface implants


• Number of Supporting Implants-Variables:

• Bone quality & quantity, Implant: type, size & position

• Prosthetic design and fit, Restorative materials

• Cantilever length, Occlusal patterns, Parafunction

• Cantilever Length:• Cantilever Length:

• Creates increased biomechanical stress

• No publications relating failure to cantilever length

• Few publications investigating clinical complications?

• Connection to natural Teeth:

• >Complications (long term, non rigid) most studies


Contributing


Biomaterial

Related

(Based on Etiology)

Host Factors

Systemic

Factors

Local

Factors

Operator

Related

NEXT SEGMENT (4) BIOMATERIALS RELATED

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