RENATA SILVEIRA SAGNORI
ANÁLISE DA PERDA PRECOCE DE IMPLANTES
RELACIONADOS COM A INFECÇÃO PÓS-OPERATÓRIA –
ESTUDO RETROSPECTIVO
A RETROSPECTIVE ANALYSIS OF EARLY DENTAL IMPLANTS
FAILURE ASSOCIATED TO POSTOPERATIVE INFECTION
Piracicaba
2019
RENATA SILVEIRA SAGNORI
ANÁLISE DA PERDA PRECOCE DE IMPLANTES
RELACIONADOS COM A INFECÇÃO PÓS-OPERATÓRIA –
ESTUDO RETROSPECTIVO
A RETROSPECTIVE ANALYSIS OF EARLY DENTAL IMPLANTS
FAILURE ASSOCIATED TO POSTOPERATIVE INFECTION
Dissertação apresentada à Faculdade de
Odontologia de Piracicaba da Universidade
Estadual de Campinas como parte dos
requisitos exigidos para a obtenção do título
de Mestra em Clínica Odontológica, na Área
de Cirurgia e Traumatologia Buco-Maxilo-
faciais.
Dissertation presented to the Piracicaba
Dental School of the University of Campinas
in partial fulfillment of the requirements for the
degree of Master in Clinical Dentistry, in
Surgery and Oral and Maxillofacial
Traumatologia area.
ORIENTADOR: PROF. DR. ALEXANDER TADEU SVERZUT
ESTE EXEMPLAR CORRESPONDE À VERSÃO FINAL DA
DISSERTAÇÃO DEFENDIDA PELA ALUNA RENATA
SILVEIRA SAGNORI, E ORIENTADA PELO PROF. DR.
ALEXANDER TADEU SVERZUT
Piracicaba
2019
Identificação e informações acadêmicas e profissionais da aluna:
- ORCID: https://orcid.org/0000-0002-0483-4833
- Currículo Lattes: http://lattes.cnpq.br/7241195877967731
A Comissão Julgadora dos trabalhos de Defesa de Dissertação de Mestrado, em
sessão pública realizada em 13 de Fevereiro de 2019, considerou a candidata
RENATA SILVEIRA SAGNORI aprovada.
PROF. DR. ALEXANDER TADEU SVERZUT
PROF. DR. MARCELO MAROTTA ARAÚJO
PROF. DR. CLAUDIO FERREIRA NÓIA
A Ata da defesa, assinada pelos membros da Comissão Examinadora, consta no
SIGA/Sistema de Fluxo de Dissertação/Tese e na Secretaria do Programa da
Unidade.
DEDICATÓRIA
Dedico esse trabalho à Deus,
e à minha família, que são a minha fortaleza.
AGRADECIMENTOS
Primeiramente a Deus por estar sempre presente na minha vida me fortalecendo
como ser humano e me permitindo lutar pelos meus sonhos.
À Universidade Estadual de Campinas, em nome do reitor Marcelo Knobel e a
Faculdade de Odontologia de Piracicaba em nome do Prof. Dr. Francisco Haiter Neto
pela oportunidade de formação na Pós-Graduação.
À CAPES pela bolsa concedida e oportunidade de realização e desenvolvido
do projeto do mestrado.
Ao meu orientador Prof. Dr. Alexander Tadeu Sverzut pelo auxilio na
orientação neste trabalho, por todos os conhecimentos teórico-prático transmitidos, e por
sempre se mostrar disponível, colaborando com nossa formação sempre de forma respeitosa e
dedicada.
Ao Programa de Pós-Graduação em Clínica Odontológica em nome do
coordenador Prof. Dr. Valentim Adelino Ricardo Barão e a toda área de Cirurgia Buco-
maxilo-facial pela oportunidade de realização do Mestrado.
À banca examinadora da qualificação Prof. Dr. Renato Corrêa Viana Casarin,
Prof. Dr. Wander José e ao Prof. Dr. Yuri Nejaim pelo aceite do convite e disponibilidade,
e ao Prof. Dr. Marcelo Marotta Araujo, pelos ensinamentos durante a graduação, e por ser
uma referência para mim na profissão, tendo sido fundamental na minha decisão pela
especialidade, e pelo aceite do convite e disponibilidade por estar na minha banca de defesa.
À Profa. Dra. Luciano Asprino por ser um exemplo de professora, cirurgiã, de
sua atenção e carinho com os pacientes e por seu amor pela profissão.
Ao Prof. Dr. Márcio de Moraes pela dedicação e o amor à FOP e à cirurgia, que
tanto serve de inspiração aos alunos que por aqui passam, sou muito grata aos seus
ensinamentos.
Ao Prof. Dr. Claudio Ferreira Noia, por todos os ensinamentos, paciência,
dedicação, e amizade, o senhor é o exemplo de profissional em que nos inspiramos, obrigada
por tudo.
A todos os funcionários da cirurgia: Nathália, Patrícia, e Luciana pela
convivência e por toda ajuda durante o nosso dia-a-dia, e em especial à Didi, que nos acolheu
como filhos, e tornou nossas manhãs sempre mais leves com todo seu carinho e por sempre se
programar, e nos ensinar isso.
A todos os colegas e amigos da Pós-Graduação: aos meus doutorandos Antonio
Lanata, Heitor Fontes, pela paciência e ensinamentos, Andres Cáceres, por ser um exemplo
para todos nós como pessoa e profissional, Zarina Tatia e Breno Nogueira por todos os
conselhos, Luide Marinho, obrigada por sempre estar disponível para me ensinar algo novo e
por tornar os dias mais leves, vou levar sua amizade comigo para sempre. Carolina Ventura
por ser não só minha doutoranda e dividir comigo seus conhecimentos, mas por toda amizade
cumplicidade nos momentos bons e ruins, nas noites de estudo e também de festa durante
esses dois anos, você se tornou minha família aqui em Piracicaba e eu tive muita sorte de ser
presenteada com sua amizade, sou uma grande admiradora e tenho você como exemplo de
cirurgiã e professora, estaremos sempre juntas. Aos novos amigos Anderson Jara e Carlos
Turatto pela troca de boas experiências, por serem tão solícitos e tornarem a convivência
diária algo mais divertido e leve. Aos amigos de mestrado Vitor Fonseca e Erick Alpaca
agradeço pela paciência, amizade, parceira e principalmente por toda contribuição em minha
formação, sempre disponíveis a me ajudar e por cuidarem tanto de mim, levarei vocês comigo
para o resto da vida.
A todos os amigos de Taubaté, em especial às minhas melhores amigas que
mesmo de longe se fizeram presentes todos esses anos, por compreenderem minha constante
ausência e falta de tempo e por serem conselheiras e um porto seguro. Aos amigos que a
Unesp me deu e que sempre me apoiaram em todos os meu sonhos, em especial às Repesadas
e agregadas, vocês fazem muita falta.
À minha família por todo apoio, orações, e reconhecimento. De forma especial
agradeço aos meus pais Mauro Sagnori, e Claudia Sagnori e a minha irmã Juliana por
terem possibilitado não apenas o apoio financeiro, mas também todo apoio emocional e
incentivo para que eu conquistasse todos os meus objetivos. Obrigada por estarem sempre
presentes e serem pacientes nas horas mais difíceis, ouvintes de todos os problemas e fazerem
parte de todas as minhas lutas.
O presente trabalho foi realizado com apoio da Coordenação de Aperfeiçoamento
de Pessoal de Nível Superior - Brasil (CAPES) - Código de Financiamento 001
RESUMO
A Implantodontia tem sido alvo de diversas investigações cientificas na
atualidade, e por isso sua evolução tem sido constante. Pesquisas nessa área envolvem tanto
aspectos mecânicos quanto biológicos e tem dessa maneira melhorado a taxa de sucesso dos
tratamentos. A osseointegração é um dos fatores relacionados ao sucesso da reabilitação com
implantes dentários osseointegráveis, porém esse processo pode apresentar falha resultante de
complicações no período pós-cirúrgico. Diante disso, o objetivo do presente estudo foi avaliar
retrospectivamente a perda precoce de implantes dentários osseointegráveis relacionados com
a presença de infecção pós-operatória e os fatores relacionados com essa perda em pacientes
da área de Cirurgia Buco-Maxilo-Facial da Faculdade de Odontologia de Piracicaba da
Universidade Estadual de Campinas no período de Junho de 1996 a Dezembro de 2017
relacionados à infecção pós-operatória. A amostra do estudo foi composta por 1674 pacientes,
que tiveram 4886 implantes instalados, sendo 3219 instalados em mulheres e 1667 em
homens. Foi realizada análise descritiva e comparativa utilizando os testes qui-quadrado e
regressão binária logística com o objetivo de identificar os fatores relacionados à perda
precoce. Foram obtidos como resultados 164 perdas precoces, totalizando 3,3% da amostra.
Trinta e cinco implantes dentários perdidos estavam relacionados à infecção pós-operatória,
resultando em um percentual de 21,34% das perdas precoces. Fatores como realização de
enxerto prévio, localização dos implantes assim como o tipo de plataforma utilizada também
apresentaram alguma relação com índice de falha. O principal fator de risco identificado na
análise estatística foi a presença de infecção (OR=53,67 com intervalo de confiança de 95%),
assim como o tipo de plataforma do implante, localização de instalação e presença de enxerto
prévio. Concluímos dessa forma que a infecção pós-operatória apresenta-se como um fator de
risco importante relacionado à perda precoce de implantes dentários osseointegráveis.
Palavras-chave: Implantes dentários. Osseointegração. Infecção.
ABSTRACT
Nowadays Implantology has been of the most researched areas of dentistry, thus it
has been in constant development. Researchs in this area involves both mechanical and
biological aspects and has improved the success rate of treatments. Osseointegration is one of
the success criteria for dental implants rehabilitation treatment, and this process can present
failures resulting from complications in the post-surgical period. The objective of the present
retrospective study is evaluate the early dental implants failure related to the presence of
postoperative infection and the relationship with postoperative infection in patients submitted
of dental implants placement in the Department of Oral Diagnosis, Oral and Maxillofacial
Surgery Division at Piracicaba Dental School of University of Campinas, from June 2006 to
December 2017. A sample of the study was made by 1674 patients, who had 4886 implants
installed, 3219 of which were installed in women and 1,667 in men. A descriptive and
comparative analysis was performed using chi-square and logistic binary regression tests to
identify the factors related to early loss. 164 implants were obtained as early results failures,
amounting to 3.3% of the sample. Thirty-five missing dental implants were related to
postoperative infection, resulting in a percentage of 21.34% of early failure. Factors such as
previous alveolar reconstructive procedures, implant placement area and the type of implant-
abutment connection used also had some relationship with early failure index. The main risk
factor identified was the presence of infection (OR = 53.67 with a 99 % confidence are given)
as well as the type of implant platform, location of installation and presence of previous graft.
We concluded that postoperative infection presents as an important risk factor related to the
early fail of osseointegrated dental implants.
Keywords: Dental implants. Osseointegration. Infection.
SUMÁRIO
1 INTRODUÇÃO 11
2 ARTIGO: A RETROSPECTIVE STUDY OF EARLY DENTAL IMPLANTS
FAILURE ASSOCIATED TO POSTOPERATIVE INFECTION
15
3 CONCLUSÃO 31
REFERÊNCIAS 33
ANEXOS 35
Anexo 1 – Certificado do Comitê de Ética em Pesquisa da Faculdade de
Odontologia de Piracicaba - UNICAMP
35
Anexo 2 – Verificação de originalidade e prevenção de plágio 36
Anexo 3 – Comprovante de submissão do trabalho 37
11
1 INTRODUÇÃO
Atualmente é observada uma melhora da qualidade de vida dos pacientes,
diretamente relacionada com os avanços tecnológicos, aliados à maior acessibilidade aos
tratamentos reabilitadores com implantes dentários, o que têm estimulado a constante busca
por esse tipo de tratamento (Noia et al., 2010). A reabilitação por meio de implantes dentários
osseointegráveis (IDO) oferece um tratamento previsível para a substituição dentária. As
taxas de sucesso do tratamento, na maioria das vezes, são altas. No entanto, algumas falhas
acabam comprometendo a ancoragem do implante ao osso, resultando na necessidade de
remoção do mesmo. Isso alonga e complica o processo de tratamento, bem como compromete
os esforços para alcançar uma função e uma estética satisfatórias. Para o paciente, isso
geralmente envolve mais custos e procedimentos adicionais (Liaw et al., 2015).
O processo de osseointegração pode sofrer interferências que resultam na perda do
implante. Alguns fatores são de grande valia no planejamento do tratamento visando preservar
o osso ao redor dos implantes e evitar a perda precoce dos mesmos. Fatores como o tipo de
osso da região onde o implante será instalado são alguns deles. O processo de integração
(interface osso-implante) pode ser influenciado pela técnica cirúrgica, pelo estado de saúde do
leito ósseo receptor, pela biocompatibilidade do metal, desenho e o tipo de superfície do
implante, bem como as condições de aplicação de cargas transmitidas ao implante. A
estabilidade inicial do implante e um período de reparo livre de cargas são fundamentais neste
processo (Brånemark et al., 1969; Albrektsson et al., 1981; Satomi et al., 1988; Ko et al.,
1992; Sverzut et al., 2008; Sakka et al., 2012).
A seleção dos pacientes para a colocação de implantes dentários é muito
importante para o sucesso do tratamento reabilitador. É papel do profissional identificar os
pacientes que podem se beneficiar da reabilitação por meio de IDO. Smith e colaboradores em
1999, relataram que alguns fatores psicológicos como esquizofrenia e algumas síndromes
neuróticas podem contraindicar o tratamento, demonstrando dessa forma que o estado de
saúde geral do paciente também pode interferir nas taxa de sucesso do tratamento (Smith et
al., 1999).
Alguns Fatores devem ser levados em consideração para o sucesso do tratamento,
e são geralmente divididos em fatores relacionados ao paciente como:
12
Estado geral da saúde
Hábitos como o tabagismo e bruxismo
Quantidade e qualidade do osso
Manutenção da higiene bucal, etc.
Existem ainda características inerentes ao próprio implante como
Dimensões
Tratamento de superfície dos implantes
Carga precoce, etc.
A localização do implante e experiência do cirurgião também acabam sendo de
grande valia durante o planejamento para que o risco de falhas seja menor (Liaw et al. 2015,
Smith et al. 1999).
O sucesso dos implantes é avaliado a partir de uma série de critérios em termos de
função (capacidade de mastigar), fisiologia dos tecidos (presença e manutenção da
osseointegração), ausência de dor e outros processos patológicos, satisfação estética e
acompanhamento a logo prazo, e em caso do não cumprimento de algum desses quesitos
associado à manutenção do mesmo, o implante pode ser considerado apenas como
sobrevivente (Albrektsson et al., 1997).
Por meio de estudos clínicos e revisão de literatura os critérios de sucesso foram
modificados. Esta avaliação preconiza que o implante deve estar imóvel quando testado
clinicamente o exame radiográfico não deve mostrar evidências de radiolucidez peri-
implantar, a perda óssea vertical deve ser menor que 0,2 mm anualmente após o primeiro ano
de instalação dos implantes e ainda, devem estar ausentes sinais e sintomas persistentes e/ou
irreversíveis como dor, infecção, neuropatias ou violação do canal mandibular, sendo que o
índice de sobrevivência deve ser de 85% ao final de cinco anos e 80% ao final de dez anos de
observação (Albrektsson et al., 1997). Pensando na perda precoce, consideramos a falha
quando há presença de dor, sinais de infecção como presença de fístula, eritema, edema,
presença de secreção ativa, e quando o implante apresenta mobilidade.
Segundo Berglundh e Lindhe (1996), outro fator determinante é a espessura de
mucosa periimplantar, que deve ser suficiente para estabelecer uma altura biológica de sulco
periimplantar, epitélio juncional e tecido conjuntivo (Berglundh e Lindhe 1996). Já segundo
13
King et al. (2002) e Buchmann et al. (2003), a presença de “gaps”, entre implante e conexão
protética, pode ser descrita como um dos principais fatores relacionados a saucerização,
devido a micromovimentações e contaminação bacteriana. De maneira geral, estudos como de
Albrektson (1988), Adell et al. (1990) e Cochran et al. (2011) têm demonstrado, ao longo dos
anos, os altos índices de sobrevivência dos implantes dentários no tratamento de pacientes
edêntulos.
Podemos classificar de duas maneiras as complicações relacionadas à perda de
implantes dentários: precoce ou tardia. As complicações precoces normalmente são aquelas
que ocorrem no primeiro estágio cirúrgico ou até o momento da reabertura do implante e
incluem: danos nervosos como parestesia ou disestesia, a falha do implante culminando da
ausência de integração osso implante, posição desfavorável do implante dificultando a
reabilitação protética, infecção pós-operatória, invasão do seio maxilar e hemorragia pós-
operatória. As complicações tardias são aquelas que ocorrem após a segunda fase cirúrgica e
dentre elas temos: a perda do implante não relacionada com a impossibilidade da reabilitação
protética, perda do implante resultando na impossibilidade de reabilitação protética, e grande
perda óssea evoluindo na perda do implante (Givol et al., 2002).
As infecções pós-operatórias são uma das principais preocupações dos pacientes e
cirurgiões, pois podem culminar com a falha de integração do IDO (Camps-Font et al., 2018).
A infecções relacionadas a reabilitação com IDO são raras e geralmente ocorrem no primeiro
mês após instalação do IDO. A prevalência relatada varia entre os estudos publicados, com
números variando de 6 a 11,5%. Como em qualquer infecção de biomateriais, o tratamento
dessas complicações pode ser bastante complexo, e a infecção pode persistir até que o
dispositivo implantado seja removido (Esposito et al., 2008; Figueiredo et al., 2015).
Os IDOs que falham após a inserção são frequentemente caracterizados pela perda
do osso de suporte podendo apresentar uma bolsa peri-implantar, estando associados com
mobilidade. Alguns sinais e sintomas podem estar presentes como: dor espontânea
significativa, dor na torção (torque), percussão ou palpação do implante e dos tecidos ao seu
redor, inflamação local, sangramento, sensibilidade à sondagem e inchaço peri-implantar
(Tanner et al., 1997; Mombelli et al., 2000).
Em seu estudo Camps-Font et al. (2015) avaliaram as infecções pós-operatórias
após instalação IDOs, foram avaliados trezentos e trinta e sete pacientes totalizando 1273
implantes com 42,9 meses de acompanhamento. O estudo apresentou como resultados vinte e
14
duas infecções pós-operatórias (representando 6,5% dos pacientes e 1,7% os implantes), tendo
sido essas complicações geralmente diagnosticadas no primeiro mês após a instalação IDOs, e
destes, doze implantes (54,6%) em 12 pacientes (54,6%) apresentaram perda precoce.
Em 2011 Sakka et al. relataram que a infecção bacteriana que leva a perda do
implante pode ocorrer a qualquer momento durante a reabilitação com IDOs, porém quando
ocorre precocemente, logo após a instalação do implante e antes de sua reabilitação protética,
acaba gerando maior chance de perda precoce.
O presente estudo foi motivado em avaliar retrospectivamente a influência da
infecção com a perda precoce de implantes dentários osseointegráveis instalados na área de
Cirurgia Buco-Maxilo-Facial da Faculdade de Odontologia de Piracicaba da Universidade
Estadual de Campinas no período de Junho de 1996 a Dezembro de 2017.
15
2 ARTIGO: A RETROSPECTIVE STUDY OF EARLY DENTAL
IMPLANTS FAILURE ASSOCIATED TO POSTOPERATIVE
INFECTION
Artigo submetido ao periódico J Oral Maxillofac Surg (Anexo 3)
Renata Silveira Sagnori, Vitor José da Fonseca, Douglas Goulart, Claudio Ferreira Nóia, Luciana
Asprino, Marcio de Moraes, Alexander Tadeu Sverzut
Abstract:
Purpose: There are several causes related to the early dental implants failure,
however infection stands out among the most common cause of negative influence in the
healing process during the initial phase of osseointegration. The aim of this retrospective
study was to evaluate the early dental implant failure associated to postoperative infection and
identify the factors associated to the failure like the factors related to patient or surgical
procedure.
Materials and Methods: A retrospective study was carried out, and the main
predictor variable was the early dental implants failure. The main cause of failure was
postoperative infection, including factors related to early loss due to infection such as
installation site, the type of implant-abutment connection used and the presence of previous
bone graft. The study sample consisted of 1674 patients, who had 4886 implants inserted and
selected for statistical analysis, being of these 3219 implants inserted on women and 1667 on
men. The main outcome variable was early implant failure due to infection. Appropriate
descriptive and multivariate statistics were computed, and Chi-square tests and logistic binary
regression were used to identify the factors related to early failure.
Results: There were 164 early failures in the study, accounting for a total of 3.3%
of the sample; 35 of them were fail as a consequence of a postoperative infection, resulting in
21.34% of early failure. The main risk factor identified was the presence of infection
(OR=53.67, with 95% confidence interval).
Conclusions: The results of this study suggest that infection may be considered a
risk factor for early failure of osseointegrated implants.
Keywords: Osseointegration. Infection. Dental implants
16
INTRODUCTION
Nowadays, the aesthetic concern regarding the improvement of the quality of life
has stimulated research on new treatment options that can satisfy the patients’ needs. One of
the major concerns of patients who have lost dental elements throughout life has been to seek
a treatment option that recovers the functions offered by the teeth before they were failure,
also recovering the aesthetic and avoid negative psychological impact on the quality of life of
the patient1.
Currently, dentistry is in charge of restoring the morphology, function, aesthetics,
comfort and health of the stomatognathic system2. As of the twentieth century, various
authors presented different techniques and new options of materials to be used in oral
rehabilitation through dental implants, with satisfactory results3,4,5,6
. However, it was in 1952
that the physiologist Per-Ingvar Brånemark discovered by chance the osseointegration
process, which was the first big step in modern implantology7.
After Branemark's discovery, scientific researches in the implant dentistry area
has increased significantly, and in this way, an important and much studied aspect is the
complications related to implants failures. Some of the most common
complications associated to the failures are described in the literature include hemorrhage,
infection, angulation or inadequate position of implants, invasion of the maxillary sinus or
mandibular canal, fenestration of the vestibular or lingual bone plate, mandibular fracture,
excessive torque during installation, bone overheating during installation, implant fracture and
dehiscence of the soft tissue wound8,9
.
Dental implant failures can be classified as early or late failures. Early failures
occur before the prosthetic connection rehabilitation, and late failures occur after the
prosthetic connection rehabilitation10
.
Tarnow et al. (1997), and Aparício et al. (2003) identified some risk factors for
the use of immediate loading in dental implants that are also related to early failure, such as
the presence of masticatory overfunction or parafunction, poor bone quality and quantity with
development of local infection11,12
.
17
According to Schnitman & Shulman (1979), the criteria to consider the success of
dental implants are the mobility of less than 1 mm in any direction, with bone loss lower than
one third of the vertical height of the implant. In case of inflammation, it should be treated
properly without symptoms such as pain, paresthesias or phlogistic signs like presence of
secretion. Teeth adjacent to the dental implant should not been demaged due the placement,
and structures such as inferior alveolar neurovascular bundle, maxillary sinus or nasal fossa
should not be impaired13
.
The osseointegration success is connected to a number of variables that are
directly related like: bone characteristics in the recipient site (bone structural quality and
quantity), the macro- and microscopic conformation of the implant, surgical technique
performed, magnitude of the applied force and soft tissue quality around the inserted implants.
Factors related to the patient, such as presence of systemic comorbidities and postoperative
complications (such as infection) have also been described in the literature as possible factors
related to failure of implant osseointegration14, 15
.
Dental implants are currently the best option for dental rehabilitation because of
their various advantages in restoring the health of the stomatognathic system, such as
biomechanical, aesthetic and functional factors. However, despite the high success rate,
osseointegrated dental implants may fail, and the most common reasons for early implant
failures are lack primary stability, surgical trauma and infections16
. In the initial healing
period, infection is the most common complication that lead early implant failure. Clinical
signs (such as the presence of fistulas, edema and active drainage of secretion in the implant
region) may have a much higher risk of early implant failure, due to the negative influence of
the bone healing process17
.
The aim of this retrospective study is investigate influence post-operative
infection in the early dental implant failure performed in the Department of Oral Diagnosis,
Oral and Maxillofacial Surgery Division at Piracicaba Dental School of University of
Campinas, that may help in the understanding of failures as well as their prevention.
18
MATERIALS E METHODS
This retrospective study was approved by the Research Ethics Committee of the
Piracicaba Dental School of University of Campinas, number 91264118.9.0000.5418, on July
30, 2018.
Clinical records of patients treated in the Oral and Maxillofacial Surgery Division
from July 1996 to December 2017 was analysed. Were analyzed 1674 patients, being of these
3219 women and 1667 men, who had 4886 implants inserted.
The inclusion criteria was records of patients submitted of 2 stages
osseointegrated implants placement and submitted to the second surgical stage between July
1996 and December 2017.
The exclusion criteria is incomplete records or data, patients who are undergoing
treatment and have not yet undergone implant placement, patients submitted to implant
placement without continuity of treatment, patients who took over a year to be submitted to
the second stage, implants with diameter smaller than 3.5mm, implants with length smaller
than 9mm (there was a reduced number of these implants in the patient records, so they were
not considered to avoid changes in the statistical evaluation).
The surgical protocol comprised all routine steps for implant placement, including
verification of vital signs, preoperative medication (amoxicillin 1g, dexamethasone 4mg and
sodium dipyrone 500mg given pre-operatively, orally; in patients allergic to penicillin, the
antibiotic of choice was clindamycin 600mg 1 hour before surgery).
After completion of the terminal infiltrative anaesthesia with 2% lidocaine
solution with vasoconstrictor 1: 100.000 (Dfl, Rio de Janeiro-Brazil), the mucoperiosteal flap
was made using a 15 scalpel blade (Solidor, Rio de January-Brazil). All the implants analysed
on the study (Neodent Implantes Osseointegraveis, Curitiba, Paraná, Brazil) were placed
according to the previous prosthetic planning. The implants were placed and subsequently, the
suture was performed in the region with 3-0 silk thread (Shalon, Goiania-Brazil). Patients
were given written guidelines and post-operative care, as well as oral prescription.
The therapeutic medication used was the administration of nonsteroidal anti-
inflammatory drugs for 3 days, sodium dipyrone 500mg every 4 hours (in case of pain) and
mouthwash with chlorhexidine digluconate 0.12%, 2 times a day for 7 days.
19
Data collection
To standardize the data collection, a specific platform was developed through the
software Microsoft Access® 2016 (Microsoft Corporation, Redmond, Washington). This
platform mostly collects the bimodal variable data. Calibration was performed among three
previously calibrated collectors; after collection, the data were transferred to Microsoft
Excel® 2016 (Microsoft Corporation, Redmond, Washington) for statistical analysis.
Selection of variables
Among the variables related to the patients, the following were selected: gender
(male or female); age; patient medical conditions, which was considered systemic arterial
hypertension (SAH), (which were considered suitable to the treatment, patients being treated
with antihypertensive medication or with an arterial pressure ≤ 140/90 mmHg); controlled
diabetes mellitus (which were considered suitable to the treatment patients with previous
diagnosis and using diabetes medication and patients who presented capillary blood
glucose ≤ 140mg/dL during the initial assessment); smoking patients (smoking patients or
non-smoker patients).
The variables related to the implants selected for the study were: type of
prosthetic platform (external hexagon, internal hexagon and morse taper implants); implant
diameter N - Narrow (3-3.5mm), R - Regular (3.75-4.5mm), and L - Large (4.8-5.5mm);
implant length Short (6-9mm), Medium (10-12mm) and Long (13-18mm).
The variables related to the treatment selected for the study were region of
implant placement: anterior maxilla (region of incisor and upper canine), posterior maxilla
(region of premolars and upper molars), anterior mandible (region of incisors and lower
canines), posterior mandible (region of premolars and lower molars; need alveolar bone
reconstruction prior to implant placement.
The variables related to the to the complications: postoperative infection in the
region of implant placement, dehiscence of cortical bone walls in the trans-operative surgery
and dehiscence of the soft tissue. It was considered as infection, the presence of secretion or
fistula, pain, swelling, presence of tissue dehiscence, redness and fever, detected through
clinical evaluation.
20
The variables related to the failure criterion it was adopted the removal of the
implant prior to or during the surgical reopening.
Stastistical analysis
The data collected in the Microsoft Acess (Microsoft Corporation, Redmond,
Washington) were transferred to a spreadsheet using the software Microsoft Excel® 2016
(Microsoft Corporation, Redmond, Washington). A descriptive and comparative analysis was
performed using the computer software Statistical Package for the Social Sciences, version
18.0 (SPSS Inc., Chicago, IL, USA). Chi-square tests and logistic binary regression were used
to identify the factors related to early implant failure.
RESULTS
In this study, we analysed 4886 implants placed in 1674 patients between July
1996 and December 2017, with an average of 2.9 implants per patient, and minimal follow-up
time until the second surgical stage (installation of healing caps). Regarding gender, a greater
number of females (65.8%) were found when compared to males (34.3%). In the anamnesis,
16.8% of the patients reported controlled hypertension, 4.7% reported being diabetic and
12.3% reported being smokers (Table 01).
Table 01 - Characteristics of the patients analyzed.
Total of 4886 implants installed
N
%
Gender
Female 3219 65.88%
Male 1667 34.12%
Hypertension
Yes 823 16.84%
No 4063 83.16%
Diabetes
Yes 233 4.76%
No 4653 95.24%
Smoking
Yes 602 12.32%
No 4284 87.68%
It was observed that 25%, 27%, 18% and 30% of the implants were installed in
the anterior maxillary, posterior maxillary, and anterior mandibular and posterior mandibular
regions, respectively (Chart 1).
21
Chart 1 - Implants installed by region.
A statistically significant difference was observed for grafting reconstructives
procedures according to the anatomical region (p<0.01), and the anterior region of the maxilla
was more affected than the posterior one (p<0.01); and for the anterior and posterior regions
of the mandible there was no statistical difference (p=0.07). When the maxillary and
mandibular anterior regions were compared, the mandibular anterior region had a higher value
(p<0.01), and the maxillary anterior region was more affected than the posterior one (p<0.01),
and the maxillary posterior region was more affected than the mandibular anterior and
posterior regions (p<0.01).
Table 2 shows the correlation between the early implants failures and other
variables present in the study, and we can see that 164 patients (3.3% of the sample) had early
failures, and only 35 of them had associated postoperative infection, accounting for a total of
21.34% of the early failures. A statistical difference is demonstrated in the early failures
associated to the type of implant abutment connection, and 108 early failures occurred in the
group of implants with the external hexagon (EH) platform. In the morse taper (MT) implants,
45 early failures were observed. After a Chi-Square statistical test, a statistically significant
difference was observed in the early failure between EH and MT groups (p<0.001). Men
presented proportionally more early failure than women, with a statistically significant
Maxila anterior (1195)
25%
Maxila posterior (1312)
27%
Mandíbula anterior (893)
18%
Mandíbula posterior (1486)
30%
Posterior mandible (1486) 30%
Anterior Maxilla (1195) 25%
Posterior Maxilla (1312) 27%
Anterior Mandible (893) 18%
22
difference (p = 0.02), as well as preoperative reconstructive grafting procedures increased the
incidence of early implants failures (p = 0.01). The other variables did not present statistical
difference. (Table 2)
Table 2 - Assessment of the relationship between the early loss of osseointegrated
implants and the variables studied using the Chi-Square test.
Early
Yes No p
Infection Yes 35 24 <0.01
No 129 4698
Implant type Type 1 108 2430
<0.01* Type 2 11 190
Type 3 45 2102
Gender Female 95 3124 0.02
Male 69 1598
Diabetes Yes 11 222 0.236
No 153 4500
Smoking Yes 21 581 0.848
No 143 4141
Preoperative
graft
Yes 34 662 0.01
No 130 4060
Maxilla Anterior 43 1152
0.01** Posterior 37 1275
Mandible Anterior 19 874
Posterior 65 1421
Type 1: External hexagon (EH), Type 2: Internal hexagon (IH), Type 3: Morse taper (MT)
Regarding infection and associated variables, the only variable analyzed that
showed statistical difference was the implant region of implant placement, the posterior
mandible region being the most expressive like is demonstrated in Table 3:
23
Table 3 - Assessment of the relationship between the infection and the variables studied
using the Chi-Square test.
Infection
Yes No P
Implant type Type 1 36 2502
0.373 Type 2 2 199
Type 3 21 2126
Gender Female 38 3181 0.810
Male 21 1646
Diabetes Yes 4 229 0.466
No 55 4598
Smoking Yes 8 584 0.771
No 51 4233
Preoperative
graft
Yes 9 687 0.823
No 50 4140
Maxilla Anterior 6 1189
<0.01** Posterior 12 1300
Mandible Anterior 12 881
Posterior 29 1457
As for the infection related to early failure (specifically), 94 of all implants
installed had postoperative infection, of which 35 implants were early failure (37.23%), and
for the early implant failures due to infection it was 21.34% as previously mentioned and
demonstrate in the chart 2.
24
Chart 2: Relationship between early loss and infection.
A binary logistic regression was performed to assess the role of the factors
analyzed in the early implants failures; males had more risk of (OR=1.44, with 95%
confidence interval), however the main risk factor identified was the presence of infection
(OR=53.67, with 95% confidence interval). Preoperative grafting was also a risk factor
(OR=1.61, with 95% confidence interval). The mandibular posterior region was identified as
a risk factor for implant failure when compared to the maxillary posterior region (OR=1.34,
with 95% confidence interval) and between the mandibular anterior region and the posterior
mandibular region (OR=2.16, with 95% confidence interval of 1.23-3.78). Regarding the type
of implant, type 3 had a lower probability of when compared to type 1 (OR=2.22, with 95%
confidence interval) and type 2 (OR=2.87, with 95% confidence interval).
In Table 4 we can observe the demographic analysis and clinical characteristics
predominant in the patients who had early dental implants failure associated to postoperative
infection, and we can see that there was a greater number of losses in men (57.14%) when
compared to women. The presence of a previous graft wasn’t present in most patients who
experienced early implant loss associated to infection, as well as the presence of hypertension
and diabetes, or smoking, which were also not present in most of these patients. Regarding the
location of the implant, the posterior mandible presented the largest number of early implants
lost (51.42%), followed by posterior maxilla, anterior maxilla and anterior mandible.
4827
59
129
35
Pacientes sem infecção
Pacientes com infecção
Perda precoce TotalEarly loss
Pacients with infection
Pacientes without infection
25
Table 4 - Quantitative analysis of demographic and clinical
characteristics of patients affected by postoperative infection who had
early implant loss.
Characteristic n %
Gender Male 20 57.14% Female 15 42.86%
Hypertension Yes 6 17.14%
No 29 82.86% Diabetes Yes 3 8.57%
No 32 91.43% Smoking Yes 6 17.14%
No 29 82.86%
Preoperative graft
Yes 5 14.28% No 30 85.72%
Antomical Location Maxilla – Anterior 6 17.14%
Maxilla - Posterior 7 20.0% Mandible – Anterior 4 11.42%
Mandible – Posterior 18 51.42%
A logistic binary regression was performed to evaluate which factors could influence the
incidence of infection and it was found that the only variable with a statistically significant difference
was location, the mandibular region presented a greater chance (OR = 2.60) of developing infection
compared to jaw. Table 5 presents the logistic regression results.
Table 5 – Evaluation of the incidence of infection according to clinical and
demographic characteristics assessed by binary logistic regression.
Variables evaluated p OR
Gender 0,756 1,090
Hypertension 0,844 0,932
Diabetes 0,471 1,475
Smoking 0,713 1,152
Preoperative graft
0,182 1,680
Location – Mandible
and Maxilla
0,002 2,602
Location – Anterior
and posterior
0,111 1,578
26
DISCUSSION
This study aimed to assess the early dental implants failures related to
postoperative infection and tried to identify the variables associated. Several reports addressed
the prevalence and described some of the clinical characteristics and risk factors for
postoperative infections, however, this study evaluates the direct relation of infection as the
main risk factor for implant failure before the prosthetic rehabilitation stage, comparing it
with other predisposing variables, thus alerting the surgeons on the care needed at this stage to
increase the success rate of rehabilitations.
In this way, the treatment with dental implants for rehabilitation of edentulous
regions has been increasingly, because it is a treatment with great predictability and
introduced a significant change in the planning and treatment of patients totally and partially
edentulous in the last 10 to 20 years17
.
Despite the great predictability, there are some factors correlated with failures and
postoperative complications that increase the rates of early or late implant failures18,19
. The
Tonetti literature review (1999) finding that failures in implants are not randomly distributed
between the treated populations and that the sets of implant failures occur in specific high-risk
groups and individuals. And these causes may be related to both patient-related risk factors
and trans- and postoperative complications18,19,20,21
.
Infection and the area where the implant was placed are the commonest causes of
early dental implant failure. A study by Devorah Schwartz-Arad et al. (2008) assessed failed
implants placed from 1997 to 2004, and 99 of the 3609 implants installed failed, and the most
common cause were inflammation and mobility of the implant in the post-surgical period21
.
The present study assessed a total of 1674 patients with 4886 implants installed,
and 164 of them were early failure, and the most prevalent cause was infection with 21.34%
of the early failures, proving to be the major risk factor with odds ratio (OR)=53.67. A
retrospective study conducted by Camps-font (2018) was carried out to determine factors that
may increase the failure rate of dental implants with postoperative infection during healing
period. In such study, postoperative infections were defined as the presence of pus or fistula in
the surgical area, with pain or tenderness, swelling, redness and heat or fever, before the
27
prosthetic load, and with a proportional risk regression analysis, and the prevalence of
postoperative infections based on the patient after implant placement was 2.80%1.
Rui Figueiredo et al. (2015) evaluated 474 patients, comprising a total of 1,625
implants for a 3 years follow-up period, and as a risk analysis. Postoperative infections during
the period of osseointegration considerably increased the risk of dental implants early failure
(odds ratio=78.0, 95% confidence interval), as well as the male gender. When compared to
the values found in this study (which had a n = 4886 patients), and a follow-up period of 21
years, the risk of early failures due to infection was found to be unrelated to gender and
showed a statistically similar rate23
.
When we try to correlate the failure of implants with the area of installation, the
literature often shows that the maxillary posterior region represents an area of greater
difficulty for the placement and maintenance of osseointegrated implants, since it has a lower
quality bone (type IV) and (in some cases) the pneumatization of the maxillary sinus and bone
resorption of the alveolar ridge. In these areas, prior alveolar bone reconstruction would be
indicated24
. Studies such as those by ASHLEY et al. (2003) and BAIN (2003) indicate high
failure rates for implants placed in the posterior maxillary region. In the present study, the
presence of postoperative infection was observed in the posterior mandible region in 29 cases
followed by the anterior mandible and posterior maxilla regions (with equal values of 12
cases each) and finally the anterior maxilla region with 6 cases. We believe that what would
justify the highest number of early losses in this region would be the highest rate of soft tissue
dehiscence during healing in the posterior mandible region25,26
.
Camps -Font in 2015 assessed the prevalence and described the clinical
characteristics and possibilities of treatment of patients with early infections after implant
placement. In this study, 337 participants were included (total = 1273 implants), 22 of them
had postoperative infections (6.5% of patients and 1.7% of implants), and 12 of the infected
implants had early failure, at a follow-up of 42.9 months; the authors conclude the study with
an average rate of 4-10% failure per implant infection, lower than that observed in this
study19
.
Ata-Ali et al. (2013) assessed the use of antibiotic therapy as a factor reducing
failure due to postoperative infections in dental implant placement, through a meta-analysis
with 4 randomized clinical trials comprising a total of 2063 implants and 1002 patients.
Although the antibiotic reduced implant failures, the study concludes that antibiotic therapy
28
did not reduce significantly the incidence of postoperative infection (P=0.754), which is the
main cause of early failure. In our study, even with prophylactic antibiotic therapy, we found
a considerable rate of sites that progressed with infection. Faced with this fact, although our
study did not indicate correlation between infection or early failure with systemic conditions
(such as diabetes or smoking), as observed in the Tables 3 and 4, the application of a protocol
of short-term postoperative antibiotic therapy in patients undergoing more invasive surgical
procedures or having systemic alterations, such as diabetes mellitus, or with habits such as
smoking should be a factor to be considered in order to reduce the postoperative infection
rates 27
.
Through binary logistic regression to assess the role of the factors analyzed of
dental early implants failure, our study identified postoperative infection as the main risk
factor for early implant failure. When the clinical and demographic factors that could have
influence on the early loss of dental implants due to infection were evaluated by logistic
binary regression, location was the only factor that presented a statistical difference, the
posterior jaw region being the one with the greatest influence, and in the literature we find
studies that affirm that sites with tissue dehiscence are more likely to accumulate impurities,
bacteria and would probably justify the greater risk of infection in a region with dehiscence28
.
CONCLUSION
According to the results observed, we conclude that the postoperative infection
can be considered as a high risk (53% of risk) factor related to the dental implants early
failures.
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3 CONCLUSÃO
Segundo a metodologia aplicada podemos concluir que as infecções pós-
operatórias aumentam em 53 vezes o risco de perda precoce de implantes dentários.
33
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35
ANEXOS
Anexo 1 – Certificado do Comitê de Ética em Pesquisa da Faculdade de Odontologia de
Piracicaba - UNICAMP
36
Anexo 2 – Verificação de originalidade e prevenção de plágio
37
Anexo 3 – Comprovante de submissão do trabalho
Elsevier Editorial System(tm) for Journal of
Oral and Maxillofacial Surgery
Manuscript Draft
Manuscript Number:
Title: A RETROSPECTIVE STUDY OF EARLY DENTAL IMPLANTS FAILURE
ASSOCIATED
TO POSTOPERATIVE INFECTION
Article Type: Full Length Article
Section/Category: Dental Implants
Corresponding Author: Miss Renata Silveira Sagnori, DDS
Corresponding Author's Institution:
First Author: Renata Silveira Sagnori, DDS
Order of Authors: Renata Silveira Sagnori, DDS; Vitor Fonseca, DDS;
Douglas Goulart, DDS, PhD; Luciana Asprino, DDS, PhD; Marcio Moraes,
DDS,
PhD; Claudio Noia, DDS, PhD; Alexander Sverzut, DDS, PhD
Abstract: Purpose: There are several causes related to the early dental
implants failure, however infection stands out among the most common
cause of negative influence in the healing process during the initial
phase of osseointegration. The aim of this retrospective study was to
evaluate the early dental implant failure associated to postoperative
infection and identify the factors associated to the failure like the
factors related to patient or surgical procedure.
Materials and Methods: A retrospective study was carried out, and the
main predictor variable was the early dental implants failure. The main
cause of failure was postoperative infection, including factors related
to early loss due to infection such as installation site, the type of
implant-abutment connection used and the presence of previous bone
graft.
The study sample consisted of 1674 patients, being of these 3219 women
and 1667 men, who had 4886 implants inserted and selected for
statistical
analysis. The main outcome variable was early implant failure due to
infection. Appropriate descriptive and multivariate statistics were
computed, and Chi-square tests and logistic binary regression were used
to identify the factors related to early failure.
Results: There were 164 early failures in the study, accounting for a
total of 3.3% of the sample; 35 of them were fail as a consequence of a
postoperative infection, resulting in 21.34% of early failure. The main
risk factor identified was the presence of infection (OR=53.67, with
95%
confidence interval).
Conclusions: The results of this study suggest that infection may be
considered a risk factor for early failure of osseointegrated implants.
