10.

5005/jp-journals-10019-1065
Smita Vaidya et al
REVIEW ARTICLE

Complications and their Management in Implantology

Smita Vaidya, Arun Khalikar, Shankar P Dange, Rujit Desai

ABSTRACT Mechanical Factors

Implant prosthodontics will become straightforward if the fixture • Implant shape, surface
position and angulation are ideal. But the prosthetic treatment
– Titanium implants with different shapes and surface
may be complicated by component and framework breakage,
inadequate tissue support, poor implant position and angulation. preparations have similar success rates, but that
Complications during maintenance of implant supported smooth implants, compared to rough implants,
prostheses have considerable clinical and laboratory appear to be less prone to peri-implantitis.5
implications. It is important for the practitioner who uses implants
to have an understanding of the type and frequency of • Implant length and diameter
complications that may arise. – Implants more than >4 mm in diameter showed better
This paper focuses on the common complications in success rate than those with lesser diameters.5
treatments involving the use of implants and also considers the
modalities for its management. The practitioner should be fully
– Shorter implants also showed more failure rates.
aware of any possible complications prior to treatment and inform
the patient accordingly. In most cases it is possible to avoid Anatomic and Osseous Factors
complications by careful attention to diagnosis, treatment
planning and good surgical and prosthodontic planning. • Significant determinants for implant failure were poor
bone quality (type 4), a resorbed jaw, and short implant
Keywords: Complications, Management, Implant, Prosthodontics.
length (7 mm).5
How to cite this article: Vaidya S, Khalikar A, Dange SP, Desai
R. Complications and their Management in Implantology. Int J
• It has been found that neither jaw site (maxilla vs
Prosthodont Restor Dent 2012;2(4):150-155. mandible) nor implant position (anterior vs posterior)
Source of support: Nil
had any significant effect on implant survival.5

Conflict of interest: None Factors related to Occlusal Loading

INTRODUCTION • Parafunctional habits and excessive occlusal loadings
are often a risk factor for implant failure.
The field of implantology is progressing very rapidly with
• The opposing occlusion or dentition may also be a
a wide variety of applications in various interdisciplinary
relevant determinant of implant success. Patients with
branches. These include prosthodontics (for replacing
implants opposing unilateral occlusal support showed
missing tooth and maxillofacial prosthesis), orthodontics
the highest rate of implant failure (43.8%).5
(for the purpose of growth studies 1 and anchorage 2),
periodontics (for bone preservation and augmentation3) and
Systemic Risk Factors
oral surgery. Proper case selection and treatment planning
are the keys to success of implants. The focus of implant • The most common systemic risk factors leading to
research is shifting from descriptions of clinical success to implant failure are smoking, radiation treatment, diabetes
the identification of factors associated with failure.4 A (resulting in increased bone loss).
detailed knowledge regarding the complications and failures • Other common systemic conditions acting as risk factors
is a must. Prompt management of these complications holds for implant failure include chemotherapy, osteoporosis,
the key to the success of the implants. hormone replacement therapy, scleroderma, Sjogren’s
This article reviews the various complications that one syndrome, Parkinson’s disease, multiple myeloma and
faces during implant therapy. It also throws light on the HIV-positive individuals.
management of the complication. It is necessary to have
knowledge regarding the complication as it is the operator Microbial and Host Immune-inflammatory Factors
to be blamed in case of implant failure. • Peri-implantitis, defined as infection and inflammation
affecting implant supporting tissues, is leading causes
RISK FACTORS
of late implant failures.
Risk factors require an indispensible attention as they are • Organisms commonly involved are Porphyromonas
often responsible for implant failures. The risk factors may gingivalis, Actinobacillus actinomycetemcomitans,
be stated as: Prevotella nigrescens, Staphylococcus aureus,

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Peptostreptococcus micros, Fusobacterium nucleatum, A brief review of complications can be stated as:
ss vincentii, F. nucleatum and ss nucleatum.
A. Complication associated with Systemic
COMPLICATIONS Disorders and Medications
A complication is defined as a secondary condition that The disease often leading to complications are:
developed during or after implant surgery or prosthesis i. Myocardial infarction: Alteration in blood and oxygen
placement.6 It does not indicate that a substandard treatment supply interferes with the process of osseointegration.
was provided and also that an implant has failed. Prompt ii. Cerebrovascular disease (stroke): No direct role on
management of the complications is the key to implant failure of implants has been documented.8
success. iii. Osteoporosis: The impaired bone metabolism as it
In 1999, Charles Goodacre et al,6 had classified implant occurs in osteoporosis may affect osseointegration of
complications as implant loss as related to type of prosthesis implants.
and arch, time after placement, implant length, bone quality, iv. Paget’s disease: Paget’s disease has compromised
surgical complications, marginal bone loss, peri-implant soft bone density and may be contraindicated for dental
tissue complications, mechanical complications, and implant surgery.
phonetic and esthetic complications. v. Parkinson’s disease: Poor motor control, often a cause
In 2008, Kelly Misch7 et al, had classified implant as: of improper oral hygiene maintenance.
• Treatment plan related (wrong angulation, improper vi. Diabetes: Studies of implants in the anterior mandible
implant location, lack of communication), have shown 5-year survival rates of 88 to 94% in
• Procedure related (lack of primary stability, mechanical subjects with type II diabetes.8
complications, mandibular fracture, ingestion/ vii. Smoking: Smoking increases the rate of implant
aspiration), complications.
• Anatomy related (nerve injury, bleeding, cortical plate viii. Immunodeficiency: Long-term systemic steroids can
perforation, sinus perforation, devitalization of adjacent induce osteoporosis, which should be considered in
teeth) and others (iatrogenic, human error). the risk–benefit assessment for implant therapy.
ix. Cancer therapy – radiation: When implants are placed
In 2010, Stuart J Froum,8 stated implant complications as:
following irradiation, the failure rate may be higher.
• Associated with systemic disorders and medications
• Associated with implant planning
B. Complication associated with Implant Planning
• Implant fractures
• Implant failures a. Lack of proper diagnosis, patient history especially of
• Peri-implantitis the systemic conditions is often responsible for the
• Esthetic complications due to implant malposition complications of implants.
• Related to immediate implant placement into extraction • Using too few implants can lead to occlusal overload
sites and ultimate failure of the prosthesis. Patient’s
• Related to immediately loaded dental implants motivation for cleanliness and implant maintenance
• Complications can also be described as those occurring also plays a vital role as poor oral hygiene can often
during first stage surgery, second stage surgery, result in peri-implantitis.
abutment connection, prosthetic procedure, control after b. Proper implant planning of treatment is of utmost
prosthesis placement (Table 1). importance. Improper planning may result in:

Table 1: Implant complications

1st stage (during surgery) 2nd stage (abutment connection) 3rd stage (prosthetic phase)
1. Hemorrhage during drilling 1. Sensitivity 1. Loosening of abutment screws
2. Implant mobility after placement 2. Mobile implant (slight) and painful 2. Fracture
3. Exposed implant threads 3. Difficulty in insertion i. Abutment screw
4. Lingual swelling 4. Formation of granulation tissue ii. Veneering material
5. Postoperative pain around implant iii. Frame work
6. Lower lip insensitivity 3. Bleeding on probing
7. Exposed cover screw after few days 4. Implant fracture
8. Abscess around cover screw 5. Bone loss around implant

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Smita Vaidya et al

• Tooth or root proximity to a planned implant site

can cause adjacent tooth devitalization (Fig. 1).
• An adjacent tooth with an undiagnosed periapical
lesion could lead to implant failure, when the
infection spreads and reaches the implant surface.
• Implant fenestration or dehiscence may occur due
to improper placement of implant.
• Another factor of prime importance concerns vital
anatomic structures. Structures of importance to note
before beginning treatment are the proximity of the
inferior alveolar canal, mental foramen, sinus, nasal
floor, and incisive canal. Anatomic variations can
lead to perforations of the alveolar bone during Fig. 3: Implant fracture
treatment. This could lead to soft tissue and/or artery
damage, with the ensuing complications (Fig. 2). b. Incidence: 0.6% of all implant placements, with a lower
incidence in edentulous jaws (0.2%) and more frequent
C. Implant Fractures occurrence in partially edentulous jaws (1.5%).8
a. Implant fracture is an infrequent and late biomechanical c. Etiology:
complication (Fig. 3). i. Bone loss may be a factor that is associated with
implant fracture.
ii. Manufacturing defects: Defects in the raw materials
and in the manufacturing process are certainly
possible when implants are made.
iii. Biomechanics: Excessive occlusal load can lead to
implant fracture. Typically, fractured implants are
found in the molar areas where this force potential
is quite high.
iv. Patient-related habits.

D. Peri-implantitis
a. Peri-implant mucositis is a term used to describe
reversible inflammatory reactions in the mucosa adjacent
to an implant. Peri-implantitis is defined as an
Fig. 1: Improper implant angulation inflammatory process that (i) affects the tissues around
an osseointegrated implant in function and (ii) results
in loss of supporting bone.
b. Diagnostic aspects:
i. Mobility
ii. Bleeding on probing
iii. Increased probing death and loss of attachment
iv. Pus formations.

E. Esthetic Complications due to Implant Malposition

a. Malposition of implant can lead to significant and
permanent loss of hard and soft tissue support with
extremely adverse esthetic outcomes.
b. Coronoapical malposition (Fig. 4)
– A coronoapical malposition can cause two different
Fig. 2: Perforations of the inferior alveolar canal complications

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Complications and their Management in Implantology

• Superficial implant placement—unesthetic • Implant failure

display of metal • Unacceptable esthetic outcomes.
• Deep apical malposition of implant can cause
recession of the facial mucosa, if the implant only G.Complications related to Immediately Loaded
has a thin facial bone wall at implant placement. Dental Implants (Fig. 7)
c. Orofacial malposition (Fig. 5): Complications addressed in this chapter that are associated
– An orofacial malposition of an implant can also cause with the immediate implant loading protocol include:
two different complications: • Failure of the implant to osseointegrate
• Palatal placement may result in tongue • Surgical complications
interference • Esthetic complications
• Facial placement may cause recession of the • Implant malposition
facial mucosa. • Restorative complications
• Complications with guided surgery and prefabricated
F. Implant Complications related to Immediate
restorations.
Implant Placement into Extraction Sites (Fig. 6)
Most common complications that occur with immediate H. Implant Failures
implant placement after extraction of the natural tooth a. Criteria for implant success were defined by Albrektsson
include: and Zarb9 in 1986, followed and modified later by Roos
• Poor implant positioning et al.10 These criteria for success include:
• Membrane exposure during healing • No mobility,
• Inadequate bands of keratinized tissue after healing • No radiographic evidence of peri-implant
• Gingival recession translucency,

Fig. 4: Coronoapical malposition Fig. 6: Loss of labial plate

Fig. 5: Facial placement of implant Fig. 7: Extensive facial resorption

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Smita Vaidya et al

• 1 mm bone loss 1 year following implant loading c. Patient instructions should be given prior to surgery
and 0.2 mm annually thereafter, d. Manufacturing instructions regarding implant placement
• Absence of pain and pathology around the implant, should be followed.
• Functional survival for 5 years in 90% and 10 years
in 85%, of cases respectively. C. Implant Fractures
b. Classification of implant failure: There are two Three management options have been described in the event
commonly used periods to assess an implant failure that of implant fracture.12
relate to the time of occurrence: i. Complete removal of the fractured implant using
• Early failures: Failures before osseointegration, explantation trephines.
primarily the result of surgical and/or postoperative ii. Removal of the coronal portion of the fractured implant
complications. with the purpose of placing a new prosthetic post.
• Late failures: Failures after the osseointegration iii. Removal of the coronal portion of the fractured
period, usually arising during and after the restorative implant, leaving the remaining apical part integrated
phase. in the bone.
c. Incidence: Rosenberg and Torosian11 reported an overall
failure rate of 7.0% in a 7.5-year investigation that aimed D. Peri-implantitis
to identify clinical and/or microbiological differences
a. Cumulative interceptive supportive therapy (CIST):
associated with failure in five different implant systems.
Four-step procedure, along with antibiotics.
d. Etiology and risk factors: Implant failure can be caused
1. Mechanical debridement
by several factors, including:
2. Antiseptic treatment
• Infection
3. Antibiotic treatment
• Tissue trauma (e.g. overheating of bone, pressure
4. Regenerative or resective therapy.
necrosis)
b. Removal of implant if mobile, entire length and
• overload (e.g. transmucosal loading, occlusal
circumference of implant involved.
trauma)
c. Proper plaque control measures.
• Iatrogenic and improper angulations.
E. Improper Angulations (Fig. 4)
MANAGEMENT
a. Correct any implant malposition at the time of implant
A detailed knowledge of the complication is essential. This
placement
will enable its prompt management and thereby ensuring
b. Removal of implant if necessary (if angulation is not
implant success. Management of the stated complication is
possible to correct)
as follows:
c. Proper oral hygiene
A. Systemic Disorder and Medication-related d. In case of recession or membrane exposure, adequate
Complications bands of keratinized tissue can be created by flap
positioning or connective tissue grafting at the time of
a. Proper case history and systemic evaluation or after implant placement.
b. Stop the procedure, in case of complication, during
surgery and seek medical help. It is wise to have F. Implant Complications related to Immediate
nitroglycerine, adrenaline and oxygen handy Implant Placement into Extraction Sites
c. Proper postoperative antibiotic course
a. Correct any implant malposition at the time of implant
d. Regular recalls
placement
e. Abstaining from habits – smoking.
b. Removal of implant if necessary (if angulation is not
B. Complication associated with Implant possible to correct)
Planning c. Proper oral hygiene
d. In case of recession or membrane exposure, adequate
a. Proper diagnosis, evaluation of patient and treatment bands of keratinized tissue can be created by flap
planning positioning or connective tissue grafting at the time of
b. Necessary investigations should be thoroughly or after implant placement.
performed

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Complications and their Management in Implantology

G.Complications related to Immediately loaded 3. Newman MG, Takei HH, Curranza FA. Advanced implant
Dental Implants surgery and bone grafting techniques. In: Clinical periodontology
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the implant should be removed immediately. term efficacy of currently used dental implants: A review and
d. Replacement of failed implant. proposed criteria of success. Int J Oral Maxillofac Implants
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10. Roos J, Sennerby L, Leckholm U, Jemt T, Grodahl K,
IMPLANT MAINTENANCE
Albrektsson T. A qualitative and quantitative method for
One of the key factors for long term success of implants is evaluating implant success: A 5-year retrospective analysis of
the Brånemark implant. Int J Oral Maxillofac Implant
the maintenance of the healthy tissues around it. Implant
1997;12:504-14.
should have accessible embrasure widths for maintenance 11. Rosenberg ES, Torosian J. An evaluation of differences and
with polished collars for prevention of plaque formations. similarities observed in fixture failure of five distinct implant
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irrigant.
Patient must be asked to maintain plaque control. A soft
ABOUT THE AUTHORS
or extrasoft toothbrush must be used. Use of floss and
interdental aids may be encouraged. Smita Vaidya (Corresponding Author)
Associate Professor, Department of Prosthodontics, Government
CONCLUSION Dental College, Aurangabad, Maharashtra, India, e-mail:
[email protected]
The ultimate success of implants is not only based on
diagnosis, evaluation, treatment planning but also on having Arun Khalikar
a knowledge regarding the complications of implants and
Professor and Head, Department of Prosthodontics, Government
their fruitful management. In short it is always better to
Dental College, Nagpur, Maharashtra, India
remember: ‘Prevention is better than cure’ and ‘a stitch in
time saves nine.’ Shankar P Dange

REFERENCES Professor and Head, Department of Prosthodontics, Government

Dental College, Aurangabad, Maharashtra, India
1. Bjork A. The use of metallic implants in the study of facial
growth in children: Method and application. Am I Phys Rujit Desai
Anthropol 1968;29:243.
2. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics Postgraduate Student, Department of Prosthodontics, Government
(4th ed). Mosby, 2007;298. Dental College, Aurangabad, Maharashtra, India

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