This book is written for any dentist placing and/or restoring implants. Its aim is to identify common and uncommon implant complications, discuss their etiology, and propose methods of prevention. Our hope is that by doing this the clinician will be better able to assess the risks of and avoid, or reduce, many of the complications being seen today. Moreover, the treatments of these complications are discussed in detail, so if the reader experiences a similar or related problem they will be familiar with possible treatment options. Often a minor (and more often a major) complication can result in anguish for the patient, associated with pain, loss of income, and loss of time, and for the clinician loss of a patient and/or referral.
The introduction of the concept of osseointegrated endosseous implants to the field of dentistry in the 1980s resulted in a paradigm shift that affected almost every aspect of dental care. Diagnosis and treatment planning now included an implant option in restorative dentistry, periodontics, oral surgery, endodontics, and orthodontics. High rates of implant survival increased the attractiveness of this option for patients and clinicians alike. The inclusion of implant therapy became part of the undergraduate and graduate dental school curriculum. A significant part of every dental meeting included new research, new equipment, new techniques, and new products related to implant therapy. Technology specific for implant therapy, i.e. diagnostic software, computer axial tomography (CAT), cone beam (CB) scans, and computer-aided systems to place and restore implants, made the implant option easier and more predictable. Associated products including bone grafts, bone substitutes, membrane barriers, machines to measure implant stability, Piezosurgery®, laser systems, and computergenerated guides provided dentists with methods to expedite the placement of implants. New protocols for implant placement and restoration shortened the time required for replacement of an extracted or missing tooth with an implant-supported restoration. However, as more dentists and patients chose the implant option, more complications and adverse events began to be recorded. Some of these complications were minor while others resulted in damage to the patient and failure of treatment. It is the aim of this book to help both the novice and experienced implant clinician avoid these problems and, if they occur, to teach the clinician how to treat or when to refer these complications for treatment.
For the sake of organization, this book has been divided into implant complications associated with the diagnosis, treatment planning, placement, restoration, and maintenance of implants. While this division is arbitrary, and many complications have multifactorial etiology, the intention of this book is to help identify the most common implant complications. Each chapter presents information that will familiarize the clinician with these complications and which will hopefully decrease the number and extent of future complications. Moreover, the management of these complications will be described in depth in an attempt to provide guidance and direction to the clinician when he or she experiences any of these problems.
Each chapter will also provide a detailed analysis of the etiology, prevention, and treatment of specific complications. The reader will find that some chapters will repeat information previously discussed relative to different complications (e.g. three-dimensional implant placement, use of CAT or CB scans for implant planning, prosthetic solutions to implant malposition, esthetic complications, and requirements for a successful implant restoration). However, this repetition, rather than being viewed as redundant, should be considered basic to the prevention or management of several different types of complications. Moreover, the different authors present this information from various aspects of their clinical experience. This results in a more comprehensive understanding of a problem and actually increases knowledge of treatment options. Also included are chapters discussing complications that may occur from various site development procedures designed to augment hard or soft tissue before, or in conjunction with implant placement. Each chapter concludes with “Take-home tips”, serving as helpful reminders in avoiding or treating the complications discussed in the chapter. In addition, there is a chapter on “Medicolegal issues related to implant complications”, discussing implant procedures relative
to the law. Following the format of the book, this chapter discusses methods of avoiding legal ramifications of implant complications and discusses what to do if a clinician is involved in legal action.
Lastly, the chapter on “Management of implant complications by the experts” is a series of case reports by a number of experienced clinicians who review a specific complication, describe how they treated it, and discuss how they may have prevented it from occurring given similar circumstance. Each chapter should serve as a practical clinical guide.
The introduction of the concept of osseointegrated endosseous implants to the field of dentistry in the 1980s resulted in a paradigm shift that affected almost every aspect of dental care. Diagnosis and treatment planning now included an implant option in restorative dentistry, periodontics, oral surgery, endodontics, and orthodontics. High rates of implant survival increased the attractiveness of this option for patients and clinicians alike. The inclusion of implant therapy became part of the undergraduate and graduate dental school curriculum. A significant part of every dental meeting included new research, new equipment, new techniques, and new products related to implant therapy. Technology specific for implant therapy, i.e. diagnostic software, computer axial tomography (CAT), cone beam (CB) scans, and computer-aided systems to place and restore implants, made the implant option easier and more predictable. Associated products including bone grafts, bone substitutes, membrane barriers, machines to measure implant stability, Piezosurgery®, laser systems, and computergenerated guides provided dentists with methods to expedite the placement of implants. New protocols for implant placement and restoration shortened the time required for replacement of an extracted or missing tooth with an implant-supported restoration. However, as more dentists and patients chose the implant option, more complications and adverse events began to be recorded. Some of these complications were minor while others resulted in damage to the patient and failure of treatment. It is the aim of this book to help both the novice and experienced implant clinician avoid these problems and, if they occur, to teach the clinician how to treat or when to refer these complications for treatment.
For the sake of organization, this book has been divided into implant complications associated with the diagnosis, treatment planning, placement, restoration, and maintenance of implants. While this division is arbitrary, and many complications have multifactorial etiology, the intention of this book is to help identify the most common implant complications. Each chapter presents information that will familiarize the clinician with these complications and which will hopefully decrease the number and extent of future complications. Moreover, the management of these complications will be described in depth in an attempt to provide guidance and direction to the clinician when he or she experiences any of these problems.
Each chapter will also provide a detailed analysis of the etiology, prevention, and treatment of specific complications. The reader will find that some chapters will repeat information previously discussed relative to different complications (e.g. three-dimensional implant placement, use of CAT or CB scans for implant planning, prosthetic solutions to implant malposition, esthetic complications, and requirements for a successful implant restoration). However, this repetition, rather than being viewed as redundant, should be considered basic to the prevention or management of several different types of complications. Moreover, the different authors present this information from various aspects of their clinical experience. This results in a more comprehensive understanding of a problem and actually increases knowledge of treatment options. Also included are chapters discussing complications that may occur from various site development procedures designed to augment hard or soft tissue before, or in conjunction with implant placement. Each chapter concludes with “Take-home tips”, serving as helpful reminders in avoiding or treating the complications discussed in the chapter. In addition, there is a chapter on “Medicolegal issues related to implant complications”, discussing implant procedures relative
to the law. Following the format of the book, this chapter discusses methods of avoiding legal ramifications of implant complications and discusses what to do if a clinician is involved in legal action.
Lastly, the chapter on “Management of implant complications by the experts” is a series of case reports by a number of experienced clinicians who review a specific complication, describe how they treated it, and discuss how they may have prevented it from occurring given similar circumstance. Each chapter should serve as a practical clinical guide.
Contents
List of contributors xi
Foreword xv
Ray C. Williams
Introduction xvii
Stuart J. Froum
1 Implant complications: scope of the problem 1
Stuart J. Froum
Introduction 1
Etiology 1
Prevention and treatment 5
Acknowledgment 6
References 6
2 Implant complications associated with systemic disorders and medications 9
Louis F. Rose and Brian L. Mealey
Introduction 9
Etiology 9
Prevention 22
Treatment 34
Take-home hints 39
References 39
3 Complications associated with implant planning: etiology, prevention, and treatment 46
Nicolas Elian, Brian Ehrlich, and Geon U. Kim
Diagnosis and treatment planning 46
Prevention of complications with proper planning 54
Avoiding implant complications 64
Take-home hints 66
References 66
4 Implant complications associated with two- and three-dimensional diagnostic imaging technologies 71
Scott D. Ganz
Introduction 71
Case 1: Complications due to scanographic templates 71
Case 2: Long-term complications due to nerve perforation 74
Case 3: Sinus augmentation complications diagnosed by three-dimensional imaging 82
Case 4: Complications in the mandibular symphysis related to diagnostic imagery 89
Conclusions 96
Take-home hints 97
References 97
5 Implant fractures: etiology, prevention, and treatment 100
Steven E. Eckert and Thomas J. Salinas
Introduction 100
Incidence 100
Etiology 100
Prevention 104
Treatment 107
Conclusion 108
Take-home hints 108
References 109
6 Implant failure: prevalence, risk factors, management, and prevention 110
Edwin S. Rosenberg, Cyril I. Evian, J. Kobi Stern, and Jonathan Waasdorp
Introduction 110
Etiology and risk factors 112
Treatment 115
Clinical recommendations for prevention of implant failures 117
Take-home hints 117
References 117
7 Peri-implantitis: etiology, pathogenesis, prevention, and therapy 119
Niklaus P. Lang and Maurizio S. Tonetti
Etiology: microbiologic aspects 119
Diagnostic aspects 123
Prophylactic procedures 126
Therapeutic strategies 127
Conclusions and clinical implications 130
Take-home hints 131
References 131
8 Esthetic complications due to implant malpositions: etiology, prevention, and treatment 134
Stephen T. Chen and Daniel Buser
Introduction 134
Esthetic complications due to implant malpositions 135
Prevention of implant malposition 140
Treatment of esthetic complications due to implant malposition 148
Conclusions 154
Take-home hints 154
References 154
9 Prosthodontic complications related to non-optimal dental implant placement 156
John S. Cavallaro Jr. and Gary Greenstein
Introduction 156
Three-dimensional determinants for correct implant placement 156
Positional issues 158
Angulation issues 163
Apico-occlusal issues (sink depth) 164
Take-home hints 170
References 170
10 Prosthetic-related dental implant complications: etiology, prevention, and treatment 172
Charles J. Goodacre and Mathew T. Kattadiyil
Introduction 172
Etiology and timing of complications and failure 172
Mechanical complications 173
Phonetic complications 183
Esthetic complications 184
Biologic complications attributable to the prosthesis 191
Conclusions 194
Take-home hints 195
References 195
11 Complications associated with single-implant esthetics: prevalence, etiology, prevention, and treatment
Dario Adolfi and Oswaldo Scopin de Andrade
Introduction 197
Prevalence of complications 197
Etiology of complications related to single implants 198
Prevention and treatment of complications 201
Prevention of complications 202
Prevention of single-implant complications 204
Conclusions 213
Take-home hints 213
Acknowledgments 214
References 214
12 Esthetic complications with adjacent implant restorations 216
Dennis P. Tarnow, Sang-Choon Cho, and Stuart J. Froum
Complications 216
Etiology 216
Prevention 218
Treatment 219
Conclusions 224
Take-home hints 225
References 225
13 Complications of autogenous bone grafting 227
Craig M. Misch
Introduction 227
Donor sites 227
Recipient site complications: early healing complications 238
Recipient site complications: late healing complications 244
Patient habits/systemic disease 248
Take-home hints 251
References 252
14 Complications in guided bone regeneration 256
Filippo Fontana, Isabella Rocchietta, and Massimo Simion
Introduction 256
Literature review 256
Prevention of complications: surgical technique 257
Clinical management of guided bone regeneration complications 264
Conclusion 270
Take-home hints 271
References 271
15 Avoiding complications for alveolar distraction osteogenesis and osteoperiosteal flaps 273
Ole T. Jensen
Introduction 273
Alveolar distraction osteogenesis 273
Major orthognathic distraction procedures 281
Take-home hints 283
References 283
16 Complications in lateral window sinus elevation surgery 284
Stephen S. Wallace
Introduction 284
Intraoperative complications 284
Postoperative complications 298
Conclusion 307
References 307
17 Complications with the bone-added osteotome sinus floor elevation: etiology, prevention, and treatment 310
Paul S. Rosen
Incidence 310
Etiology 311
Prevention 317
Management of complications 321
Take-home hints 322
Acknowledgment 323
References 323
18 Implant complications related to immediate implant placement into extraction sites 325
Barry D. Wagenberg and Stuart J. Froum
Introduction 325
Etiology and prevention 325
Treatment of complications 338
Take-home hints 339
References 339
19 Complications associated with flapless surgery 341
Thomas G. Wilson, Jr.
Introduction 341
Definition of flapless surgery 341
Goals of therapy 341
Etiology of complications 341
Prevention of complications 342
Treatment of complications 348
Summary 353
Take-home hints 353
Potential conflicts of interest 353
References 353
20 Complications related to immediately loaded dental implants 355
Jeffrey Ganeles and David Grossberg
Introduction 355
Failure to achieve osseointegration: etiology 355
Surgical complications related to immediate loading 359
Esthetic complications 361
Implant malposition 364
Restorative complications 368
Guided surgery and prefabricated restorations 371
Summary 375
Take-home hints 375
References 376
21 Prosthodontic treatment of the malpositioned implant and implant occlusal complications 379
Thomas D. Taylor
Introduction 379
Scope and frequency of problems 379
Etiology 379
Prevention 381
Treatment 382
Etiology of occlusal complications 382
Prevention of occlusal complications 384
Conclusion 386
Take-home hints 386
Acknowledgment 387
References 387
22 A potpourri of surgical complications associated with dental implant placement: 35 case reports – common problems, avoidance, and management 388
Gary Greenstein and John S. Cavallaro Jr.
Introduction 388
Diagnosis and treatment planning 388
Involved tissues: soft tissue, bone, and nerves 398
Implant placement 403
Postoperative problems 407
Sinus issues 409
Fractured mandible 412
Take-home hints 413
References 413
23 Implant complications related to maintenance therapy 415
Robert N. Eskow and Valerie Sternberg Smith
Introduction 415
Inflammatory peri-implant disease 415
Loss of stability of restorative components 424
Peri-implant mucosal hyperplasia 426
Conclusion 426
Take-home hints 427
References 427
24 Medicolegal issues related to implant complications 429
Edwin J. Zinman
Etiology of malpractice litigation 429
Prevention of litigation 431
Litigation risk management 436
Take-home hints 437
References 437
25 Management of implant complications by the experts 441
Introduction 441
Cases 441
Case 1: Treatment of midbuccal recession in the esthetic zone 441
Pamela K. McClain
Case 2: Treatment of buccal soft-tissue recession on a restored central incisor implant 444
Jeffrey R. Lemler
Case 3: Repair of failed esthetic implant case 447
Bobby Butler
Case 4: Treatment of an osseous defect associated with an immediately placed implant 450
Donald S. Clem
Case 5: Treatment of bone loss from an acute abscess around a dental implant 454
Bradley S. McAllister
Case 6: Replacement of a failed implant in the esthetic zone 458
Abd Elsalam Elaskary
Case 7: Treatment and replacement of a malpositioned implant in the esthetic zone 461
Scott H. Froum
Case 8: Corrective treatment for a malpositioned implant in the esthetic zone 468
J. Daulton Keith
Case 9: Treatment of implant malposition in the esthetic zone 473
Burton Langer and Laureen Langer
Case 10: Treatment of a malpositioned implant in the esthetic zone 476
Stuart J. Froum and Jeffrey R. Lemler
Index 481
List of contributors xi
Foreword xv
Ray C. Williams
Introduction xvii
Stuart J. Froum
1 Implant complications: scope of the problem 1
Stuart J. Froum
Introduction 1
Etiology 1
Prevention and treatment 5
Acknowledgment 6
References 6
2 Implant complications associated with systemic disorders and medications 9
Louis F. Rose and Brian L. Mealey
Introduction 9
Etiology 9
Prevention 22
Treatment 34
Take-home hints 39
References 39
3 Complications associated with implant planning: etiology, prevention, and treatment 46
Nicolas Elian, Brian Ehrlich, and Geon U. Kim
Diagnosis and treatment planning 46
Prevention of complications with proper planning 54
Avoiding implant complications 64
Take-home hints 66
References 66
4 Implant complications associated with two- and three-dimensional diagnostic imaging technologies 71
Scott D. Ganz
Introduction 71
Case 1: Complications due to scanographic templates 71
Case 2: Long-term complications due to nerve perforation 74
Case 3: Sinus augmentation complications diagnosed by three-dimensional imaging 82
Case 4: Complications in the mandibular symphysis related to diagnostic imagery 89
Conclusions 96
Take-home hints 97
References 97
5 Implant fractures: etiology, prevention, and treatment 100
Steven E. Eckert and Thomas J. Salinas
Introduction 100
Incidence 100
Etiology 100
Prevention 104
Treatment 107
Conclusion 108
Take-home hints 108
References 109
6 Implant failure: prevalence, risk factors, management, and prevention 110
Edwin S. Rosenberg, Cyril I. Evian, J. Kobi Stern, and Jonathan Waasdorp
Introduction 110
Etiology and risk factors 112
Treatment 115
Clinical recommendations for prevention of implant failures 117
Take-home hints 117
References 117
7 Peri-implantitis: etiology, pathogenesis, prevention, and therapy 119
Niklaus P. Lang and Maurizio S. Tonetti
Etiology: microbiologic aspects 119
Diagnostic aspects 123
Prophylactic procedures 126
Therapeutic strategies 127
Conclusions and clinical implications 130
Take-home hints 131
References 131
8 Esthetic complications due to implant malpositions: etiology, prevention, and treatment 134
Stephen T. Chen and Daniel Buser
Introduction 134
Esthetic complications due to implant malpositions 135
Prevention of implant malposition 140
Treatment of esthetic complications due to implant malposition 148
Conclusions 154
Take-home hints 154
References 154
9 Prosthodontic complications related to non-optimal dental implant placement 156
John S. Cavallaro Jr. and Gary Greenstein
Introduction 156
Three-dimensional determinants for correct implant placement 156
Positional issues 158
Angulation issues 163
Apico-occlusal issues (sink depth) 164
Take-home hints 170
References 170
10 Prosthetic-related dental implant complications: etiology, prevention, and treatment 172
Charles J. Goodacre and Mathew T. Kattadiyil
Introduction 172
Etiology and timing of complications and failure 172
Mechanical complications 173
Phonetic complications 183
Esthetic complications 184
Biologic complications attributable to the prosthesis 191
Conclusions 194
Take-home hints 195
References 195
11 Complications associated with single-implant esthetics: prevalence, etiology, prevention, and treatment
Dario Adolfi and Oswaldo Scopin de Andrade
Introduction 197
Prevalence of complications 197
Etiology of complications related to single implants 198
Prevention and treatment of complications 201
Prevention of complications 202
Prevention of single-implant complications 204
Conclusions 213
Take-home hints 213
Acknowledgments 214
References 214
12 Esthetic complications with adjacent implant restorations 216
Dennis P. Tarnow, Sang-Choon Cho, and Stuart J. Froum
Complications 216
Etiology 216
Prevention 218
Treatment 219
Conclusions 224
Take-home hints 225
References 225
13 Complications of autogenous bone grafting 227
Craig M. Misch
Introduction 227
Donor sites 227
Recipient site complications: early healing complications 238
Recipient site complications: late healing complications 244
Patient habits/systemic disease 248
Take-home hints 251
References 252
14 Complications in guided bone regeneration 256
Filippo Fontana, Isabella Rocchietta, and Massimo Simion
Introduction 256
Literature review 256
Prevention of complications: surgical technique 257
Clinical management of guided bone regeneration complications 264
Conclusion 270
Take-home hints 271
References 271
15 Avoiding complications for alveolar distraction osteogenesis and osteoperiosteal flaps 273
Ole T. Jensen
Introduction 273
Alveolar distraction osteogenesis 273
Major orthognathic distraction procedures 281
Take-home hints 283
References 283
16 Complications in lateral window sinus elevation surgery 284
Stephen S. Wallace
Introduction 284
Intraoperative complications 284
Postoperative complications 298
Conclusion 307
References 307
17 Complications with the bone-added osteotome sinus floor elevation: etiology, prevention, and treatment 310
Paul S. Rosen
Incidence 310
Etiology 311
Prevention 317
Management of complications 321
Take-home hints 322
Acknowledgment 323
References 323
18 Implant complications related to immediate implant placement into extraction sites 325
Barry D. Wagenberg and Stuart J. Froum
Introduction 325
Etiology and prevention 325
Treatment of complications 338
Take-home hints 339
References 339
19 Complications associated with flapless surgery 341
Thomas G. Wilson, Jr.
Introduction 341
Definition of flapless surgery 341
Goals of therapy 341
Etiology of complications 341
Prevention of complications 342
Treatment of complications 348
Summary 353
Take-home hints 353
Potential conflicts of interest 353
References 353
20 Complications related to immediately loaded dental implants 355
Jeffrey Ganeles and David Grossberg
Introduction 355
Failure to achieve osseointegration: etiology 355
Surgical complications related to immediate loading 359
Esthetic complications 361
Implant malposition 364
Restorative complications 368
Guided surgery and prefabricated restorations 371
Summary 375
Take-home hints 375
References 376
21 Prosthodontic treatment of the malpositioned implant and implant occlusal complications 379
Thomas D. Taylor
Introduction 379
Scope and frequency of problems 379
Etiology 379
Prevention 381
Treatment 382
Etiology of occlusal complications 382
Prevention of occlusal complications 384
Conclusion 386
Take-home hints 386
Acknowledgment 387
References 387
22 A potpourri of surgical complications associated with dental implant placement: 35 case reports – common problems, avoidance, and management 388
Gary Greenstein and John S. Cavallaro Jr.
Introduction 388
Diagnosis and treatment planning 388
Involved tissues: soft tissue, bone, and nerves 398
Implant placement 403
Postoperative problems 407
Sinus issues 409
Fractured mandible 412
Take-home hints 413
References 413
23 Implant complications related to maintenance therapy 415
Robert N. Eskow and Valerie Sternberg Smith
Introduction 415
Inflammatory peri-implant disease 415
Loss of stability of restorative components 424
Peri-implant mucosal hyperplasia 426
Conclusion 426
Take-home hints 427
References 427
24 Medicolegal issues related to implant complications 429
Edwin J. Zinman
Etiology of malpractice litigation 429
Prevention of litigation 431
Litigation risk management 436
Take-home hints 437
References 437
25 Management of implant complications by the experts 441
Introduction 441
Cases 441
Case 1: Treatment of midbuccal recession in the esthetic zone 441
Pamela K. McClain
Case 2: Treatment of buccal soft-tissue recession on a restored central incisor implant 444
Jeffrey R. Lemler
Case 3: Repair of failed esthetic implant case 447
Bobby Butler
Case 4: Treatment of an osseous defect associated with an immediately placed implant 450
Donald S. Clem
Case 5: Treatment of bone loss from an acute abscess around a dental implant 454
Bradley S. McAllister
Case 6: Replacement of a failed implant in the esthetic zone 458
Abd Elsalam Elaskary
Case 7: Treatment and replacement of a malpositioned implant in the esthetic zone 461
Scott H. Froum
Case 8: Corrective treatment for a malpositioned implant in the esthetic zone 468
J. Daulton Keith
Case 9: Treatment of implant malposition in the esthetic zone 473
Burton Langer and Laureen Langer
Case 10: Treatment of a malpositioned implant in the esthetic zone 476
Stuart J. Froum and Jeffrey R. Lemler
Index 481