Implants – Post-Surgical Management II – Implant complications immediate, medium and late term implant failures

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Book Chapters

  • Part II Intraoperative Complications in Implant Placement. pp 20-89. Surgical complications in oral implantology: etiology, prevention, and management Louie Al-Faraje. Quintessence Pub., c2011.
  • Part III Postoperative Complications (complications 30-33). pp 96-105. Surgical complications in oral implantology: etiology, prevention, and management Louie Al-Faraje. Quintessence Pub., c2011.
  • Froum, Klokkevold, et al. Implant-Related Complications and Failures. (CH 77). pp 723- Carranza’s Clinical Periodontology; Newman, Takei et al., 2012, 11th edition, Elsevier.



  1. Jemt, T: Failures and complications in 391 consecutively inserted fixed prostheses supported by Branemard implants in edentulous jaws: A study of treatment from the time of prosthesis placement to the first annual check – up. Int J Oral Maxillofac Impls. 6:270-276, 1991
  2. Berglundh, T et al: A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol. 2002; 29 suppl 3:197-212
  3. Devine M, Taylor S, Renton T. Chronic post-surgical pain following the placement of dental implants in the maxilla: A case series.Eur J Oral Implantol. 2016;9(2):179-86.
  4. Esposito, M et al: Differential diagnosis and treatment strategies for biologic complications and failing oral implants: A review of the literature. Int J Oral Maxillofac Impls 14:473-490, 1999
  5. Biglioli F, Chiapasco M. An easy access to retrieve dental implants displaced into the maxillary sinus: the bony window technique. Clin Oral Implants Res. 2013 Sep 30. [Epub ahead of print]
  6. Levine RA. Soft Tissue Augmentation Procedures for Mucogingival Defects in Esthetic Sites. Int J Oral Maxillofac Impls 29 (supplement) 155-185.
  7. Tal, H: Spontaneous early exposure of submerged implants I Classification and clinical observations. J Periodotnol 7o: 213-219, 1999
  8. Asshe, N et al: Correlation between early perforation of cover screws and marginal bone loss: A retrospective study: J Clini Periodontol 2007:35: 76-79
  9. Kim A, Kar K, et al. Subapical osteotomy to correct dental implant malpositioning and vertical ridge deficiency: a clinical report. J Prosthet Dent. 2012 Oct;108(4):204-8.
  10. McCrea SJ. Nasopalatine Duct Cyst, a delayed complication to successful dental implant placement: Diagnosis and surgical management. J Oral Implantol. 2012 Mar 12. [Epub ahead of print]
  11. Givol N, Peleg O, et al. Inferior alveolar neurosensory deficiency associated with placement of dental implants. J Periodontol. 2013 Apr;84(4):495-501.
  12. Walia MS, Arora S, Luthra R, Walia PK. Removal of fractured dental implant screw using a new technique: a case report. J Oral Implantol. 2012 Dec;38(6):747-50.
  13. Boffano P1, Roccia F, Gallesio C, Berrone S. Pathological mandibular fractures: a review of the literature of the last two decades. Dent Traumatol. 2013 Jun;29(3):185-96.

Implant Failures

  1. Rosenberg E, Evian C, et al. Implant failure: prevalence, risk factors, management and prevention. (CH 6) pp 110-118. Dental Implant Complications: Etiology, Prevention, and Treatment. Froum, SJ. 2010. Wiley-Blackwell.
  2. Li CH, Chou CT Bone sparing implant removal without trephine via internal separation of the titanium body with a carbide bur. Int J Oral Maxillofac Surg. 2014 Feb;43(2):248-50. Epub 2013 Oct 28.
  3. Marini E, Cisterna V, Messina AM. The removal of a malpositioned implant in the anterior mandible using piezosurgery. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 May;115(5):e1-5.
  4. Machtei EE. What do we do after an implant fails? A review of treatment alternatives for failed implants. Int J Periodontics Restorative Dent. 2013 Jul-Aug;33(4):e111-9. doi: 10.11607/prd.1505.
  5. Grossman, Y., Levin, L: Success and survival of single dental implants placed in sites of previously failed implants. J Periodontol 2007; 78:1670-1674
  6. Machtei, E et al: Dental implants placed at previously failed sites: Survival rate and factors affecting the outcome. Clin Oral Implants Res 2008:19(3):259-64
  7. Mardinger O, Oubaid S, et al. Factors affecting the decision to replace failed implants: a retrospective study. J Periodontol. 2008 Dec;79(12):2262-6.
  8. Machtei EE, Horwitz J, Mahler D, Grossmann Y, Levin L. Third attempt to place implants in sites where previous surgeries have failed. J Clin Periodontol. 2011 Feb;38(2):195-8
  9. Mardinger O, Ben Zvi Y, et al. A retrospective analysis of replacing dental implants in previously failed sites. Oral Surg Oral Med Oral Path Oral Radiol. 2012 Sep;114(3):290-3.
  10. Vervaeke S, Collaert B, et al. A Multifactorial Analysis to Identify Predictors of Implant Failure and Peri-Implant Bone Loss. Clin Implant Dent Relat Res. 2013 Sep 4. doi: 10.1111/cid.12149.
  11. Froum S, Yamanaka T, Cho SC, Kelly R, St James S, Elian N. Techniques to remove a failed integrated implant. Compend Contin Educ Dent. 2011 Sep;32(7):22-6, 28-30
  12. Implant removal tools: Straumann (explantation tool), Nobel (implant retrieval tool) and Neobiotech (fixture removal kit)—please look up protocols and summarize include pictures if necessary



Topic: Failures of fixed implant prostheses

Authors: Jemt, T

Title: Failures and complications in 391 consecutively inserted fixed prostheses supported by Branemark implants in edentulous jaws: A study of treatment from the time of prosthesis placement to the first annual check – up

Source: Int J Oral Maxillofac Impls. 6:270-276, 1991

Type: Retrospective study

Rating: Good

Keywords: Failure, complication, fixed prostheses, Branemark implants

P: The purpose of the present study was to identify problems and complications related to the prosthetic treatment and the first year of post insertion experience in a large number of edentulous patients provided with fixed prostheses supported by implants.
M&M: A total of 391 edentulous maxillae and mandibles was consecutively treated with routine fixed prostheses, supported by 2,199 implants. The patients were followed for 1 year

Treatment: The edentulous patients were provided with Branemark implants. The mucosa was allowed to heal approximately 10 to 14 days after the second surgical procedure before the final prosthetic treatment was started. Healing caps were delivered.

R: the overall success rate was 99.5% and 98.1% for the prostheses and implants, respectively. The number of severe complications was low, but it was possible to identify a significantly higher ratio of problems in the maxillae throughout the observation period than for the mandibles. While many problems occurred in both the maxillae and mandibles, there were also problems more typical for each jaw. Diction and fractures of resin teeth were more common problems in maxillae; cheek and lip biting was a more frequent post insertion complication in the treatment of mandibles. Most problems were easily resolved, and the retrievability of the prostheses was of great advantage.

C: Most of the problems have been observed in maxillae, but few of the problems have jeopardized the continuous stability of the fixed prostheses. Most problems were easy to resolve, and their relatively simple management was facilitated by the retrievability of the implant system.

Topic: Dental implant complications

Authors: Berglundh, T

Tittle: A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years.

Source: J Clin Periodontol. 2002; 29 suppl 3:197-212

Type: Systemic review

Rating: Good

Keywords: Complications, survical, success

Purpose: To systematically review the incidence of biological and technical complications in implant therapy reported in prospective longitudinal studies of at least 5 years.

Methods: A MEDLINE search was conducted for prospective longitudinal studies with follow-up periods of at least 5 years. Screening and data abstraction were performed independently by multiple reviewers. The types of complications assessed were as follows: implant loss, sensory disturbance, soft tissue complications, peri-implantitis, bone loss >or=2.5 mm, implant fracture and technical complications related to implant components and suprastructures.

Results: The search provided 1310 titles and abstracts, out of which 159 were selected for full-text analysis. Finally, 51 studies were included. Meta analysis of these studies indicated that implant loss prior to functional loading is to be expected to occur in about 2.5% of all implants placed in implant therapy including more than one implant and when routine procedures are used. Implant loss during function occurs in about 2-3% of implants supporting fixed reconstructions, while in overdenture therapy >5% of the implants can be expected to be lost during a 5-year period. Few studies (41% of those included) reported data on the incidence of persisting sensory disturbance >1 year following implant surgery. Most of the studies that provided such data reported on the absence or a low incidence (1-2%) of this complication beyond this interval. A higher incidence of soft tissue complications was reported for patients treated with implants supporting overdentures. There is limited information regarding the occurrence of peri-implantitis and implants exhibiting bone loss >or=2.5 mm. Implant fracture is a rare complication and occurs in <1% of all implants during a 5-year period. The incidence of technical complications related to implant components and suprastructures was higher in overdentures than in fixed reconstructions.

Conclusion: Implant loss was most frequently described (reported in about 100% of studies), while biological complications were considered in only 40-60% and technical complications in only 60-80% of the studies. This observation indicates that data on the incidence of biological and technical complications may be underestimated and should be interpreted with caution.

Topic: Chronic pain from dental implants

Authors: Devine M, Taylor S, Renton T.

Title: Chronic post-surgical pain following the placement of dental implants in the maxilla: A case series

Source: Eur J Oral Implantol. 2016;9(2):179-86.

Type: Case review

Rating: Fair

Keywords: chronic pain, dental implant, neuropathic pain, postoperative complications

Purpose: Present 10 cases of post-surgical neuropathic pain after placement of maxillary dental implants

Methods: Data collected from patients presenting to orofacial pain clinic, with neuropathic pain arising

after placement of maxillary dental implants

Results: 9/10 patients were female with avg age 55. Six patients had significant medical history including depression, peripheral neuropathic pain, irritable bowel syndrome, and fibromyalgia). Four of the patients had experienced pain during the implant placement. Nine of the patients had immediate pain post-surgery. Average pain on 1-10 scale was 5.6. Pain was constant in all patients. Potentially exacerbating factors were stress, tiredness, low mood, and cold weather. Two patients had implants removed but the pain persisted. Pain management varied and included medication (anti-epileptics and TCAs), botox, and cognitive behavioral therapy. Pain still remained in 9 of the patients despite therapy.

Conclusion: Chronic pain following dental implant placement may occur in patients with no apparent cause and without neurosensory deficits. Practitioners must be aware of chronic post-surgical neuropathic pain as a complication. Certain patients may be more susceptible to this based on medical history and should be considered whether they are suitable for implants. Patients reporting severe and prolonged postoperative pain following surgery should be considered high risk patients for post-surgical neuropathic pain and referred to a specialist in orofacial pain.

Topic: Implant Complications

Authors: Esposito, M et al

Title: Differential diagnosis and treatment strategies for biologic complications and failing oral implants: A review of the literature

Source: Int J Oral Maxillofac Impls 14:473-490, 1999

Type: Discussion

Rating: Good

Keywords: complication, dental implant, evidence-based treatment, failing implants, guided bone regeneration, infection, peri-implantitis, therapy

Purpose: The aim of this article was to review the literature on differential diagnosis and treatment of biologic complications and failing implants.

Method: All types of publications, with the exception of abstracts, published in English up to December 1998, were included. A multi-layered search strategy was used. Controlled clinical trials (CCTs) were searched in the Cochrane Oral Health Group’s Specialized Register of Trials. This database contains all CCTs identified in MEDLINE and EMBASE. PubMed was searched using various key words and the “related articles” feature. All identified publications were obtained and none were excluded.

Result: Infection, impaired healing, and overload are considered the major etiologic factors for the loss of oral implants. Only a few clinical and animal investigations were found that tested the validity of the proposed therapeutic approaches. The treatment of failing implants is still based mainly on empirical considerations, often derived from periodontal research, from data extrapolated from in vitro findings, or from anecdotal case reports performed on a trial-and-error basis.

Conclusion: The treatment strategy for complications and failing implants is influenced by the identification of the possible etiologic factors. In particular, the therapy of infected failing implants should be immediate, aggressive, and combined (prolonged systemic or local antibiotics and surgical debridement). Antibiotic administration alone is unlikely to be successful because of the difficulties in eradicating bacterial colonies from surfaces of biomaterials. If no improvement occurs, removal of the implant is indicated.

Topic: Iatrogenic complications

Authors: Biglioli F, Chiapasco M.

Title: An easy access to retrieve dental implants displaced into the maxillary sinus: the bony window technique.

Source: Clin Oral Implants Res. 2013 Sep 30

Type: Discussion

Rating: Good

Keywords:lateral window, maxillary sinus, displaced implants

Purpose:To present the authors’ experience concerning the removal of dental implants displaced in the maxillary sinus via an intraoral approach consisting of the creation of a bony window pedicled to the maxillary sinus membrane.

Methods and Materials: Thirty-six systemically healthy patients, presenting with oral implants displaced into the maxillary sinus, but with no signs of acute or chronic sinusitis, were consecutively treated between 2002 and 2012 via an intraoral approach with the bony window technique.

Results:Removal of oral implants from the maxillary sinus was achieved in all patients, and postoperative recovery was uneventful in all of them. Computed tomographies performed after surgery showed no signs of residual sinus infection in all patients and a complete ossification of the bony window margins. Twelve of the 36 treated patients were treated with a sinus grafting procedure 12-18 months after in the same areas previously treated with the bone lid technique. Seventeen implants were placed in the grafted areas 6-9 months later and, after a further waiting period needed for osseointegration, the treated patients were rehabilitated with implant-supported prostheses. The survival rate of implants was 100%, and no complications related to the sinuses and implants were recorded.

Conclusion: Results from this study seem to demonstrate that the bony window technique is a safe and easy way to remove oral implants from the maxillary sinus under local anesthesia. The surgical access is hardly visible 6-12 months after surgery, and maxillary sinuses appeared free from residual pathology in all treated patients. Finally, this procedure allows a second-stage sinus grafting procedure via a lateral approach as in a previously untreated maxillary sinus, thus allowing an implant-supported prosthetic restoration.

Topic: Post Surgical Management

Authors: Levine RA.

Title: Soft Tissue Augmentation Procedures for Mucogingival Defects in Esthetic Sites.

Source: Int J Oral Maxillofac Impls 29 (supplement) 155-185.

Type: Systematic Review

Rating: Fair

Keywords: soft tissue deficiencies, maxillary anterior implants

P: This systematic review was performed to address the focus question: “In adult patients with soft tissue deficiencies around maxillary anterior implants, what is the effect on esthetic outcomes when a soft tissue procedure is performed?” In addition, this paper reviews the importance of presurgical esthetic risk assessment (ERA) starting with comprehensive team case planning prior to surgical intervention and a restorative-driven approach.

M&M: A thorough Medline database search performed on related MeSH terms yielded 1,532 titles and selected abstracts that were independently screened. Out of the 351 abstracts selected, 123 full-text articles were obtained for further evaluation. At each level, any disagreements were discussed until a consensus was reached.

R: 18 studies were included. A preliminary analysis of the included studies showed that the vast majority were case series studies with most not providing objective outcomes of their results. Moreover, only one randomized controlled trial was identified. Therefore, quantitative data analysis and subsequent meta-analysis could not be performed. The included studies were grouped according to the intervention on the peri-implant soft tissue performed and six groups were identified. The periodontal procedures performed around dental implants gave initial good results from the inflammation involved in wound healing, but in virtually all cases significant recession occurred as healing resolved and the tissues matured.

C: Although success of implant therapy is similar in the anterior maxilla and other areas of the mouth, the majority of studies evaluating this therapy in the esthetic zone are lacking literature support, few in number, devoid of long-term follow-up and number of patients, and are subject to inclusion bias. The use of the ERA tool for all esthetic zone cases can benefit both the clinician and the patient to avoid any miscommunication and problems of expectation upon completion. All the available knowledge on this topic, including the approaches described in this paper, is based on a very limited literature support and thus should be addressed with caution. These concerns should encourage long-term good clinical trials for better assessment of those issues.

Topic: spontaneous early exposure

Authors: Tal H,

Title:Spontaneous early exposure of submerged implants: I. Classification and clinical observations.

Source: J Periodontol. 1999 Feb;70(2):213-9. DOI:10.1902/jop.1999.70.2.213

Type: case series

Rating: good

Keywords: Dental implants; classification; infection; prevention and control; osseointegration.

Background: It is believed that complete mucosal coverage and isolation of the implant from the oral cavity avoids trauma and infection and establishes favorable conditions for osseointegration.

Purpose:Toclinically classify spontaneous early exposure and to describe and analyze this complication.

Methods:a group of 148 patients treated with 372 submerged implants: 216 in the mandible and 156 in the maxilla. Edentulous sites were exposed by mid-crestal incisions and full thickness gingival flaps. Implants’ shoulder leveled with the bone crest. Incisions were closed in an attempt to achieve complete closure and healing by primary intention. Measurements were taken to avoid mechanical trauma to the mucosa over the implants. Patients were followed up weekly and examined to identify early exposures. At Perforations were classified according to the degree of exposure from 0 (no perforations) to 4 (complete exposure). At 8-10 weeks post-op, implants were exposed with a biopsy punch.

Results:Of the implants, 51 (13.7%) presented spontaneous early exposure, 28 (13%) in the mandible

and 23 (14.7%) in the maxilla. Class 2 perforation was the most frequent, followed by Class 3, Class 1 and Class 4. nine implants (17.6%) were associated with loose cover screws (P value <0.01). Inflammation at the mucosal orifices of the perforations was minimal, but no objective index (bleeding, probing) was taken in order to avoid morphological changes of the lesions that were biopsied for histological examination.

Conclusion: spontaneous early exposure can be due to:

  • Failure of the mucosal incision to heal by primary intention due to tension in the flaps.
  • Acute mechanical trauma or continuous pressure
  • Loosening of the cover screw
  • Bone debris from the osteotomy

Early perforation and partial exposure of the implant’s covering device are a focus for plaque accumulation which, if left untreated, may result in inflammation, damage to the peri-implant mucosa, and possible peri-implant loss.

Topic: Cover screws

Author: Asshe N, et al.

Title: Correlation between early perforation of cover screws and marginal bone loss: A retrospective study

Source: J Clini Periodontol 2007:35: 76-79

Type: Retrospective study

Rating: Good

Keywords: bone loss; cover screw; exposure; implant; perforation

Purpose: The purpose of this retrospective study was to determine the consequence of early screw exposure on peri-implant marginal bone level.

Methods: 60 Astra Tech MicroThread implants were placed in 34 patients with partially edentulous jaws. 20 implants were placed following a two-stag procedure and were unintentionally exposed to the oral cavity (two-stage exposed), 20 implants were placed following a two-stage procedure and were surgically exposed after a subgingival healing time of 3-6 months (two-stage submerged), and 20 implants were placed following a one-stage surgical protocol (one-stage). Digital radiographs were taken at time of implant placement for all implants, and after abutment surgery (for two staged groups) and at 3 months for the one-stage group. Bone loss was measured on the mesial and distal of implants with an on-screen cursor.

Results: The mean bone re-modelling around each protocol was recorded

Group Mean bone re-modeling (range)
Two-stage submerged 0.01mm (0.0-0.3 mm)
Two-stage exposed 1.96 mm (0.2-3.2 mm)
One stage 0.14mm (0.0-1.2mm)

This amount of bone loss was significantly higher in the two-stage exposed group compared with the other two groups.

Discussion: This study indicates that when soft tissue integrity isn’t maintained during the healing of two stage implants, there will be significantly more bone loss. Bone loss after unintentionally exposed implants in the oral cavity could be explained by a bacterial infection that arises almost instantly.

Conclusion: The unintentional perforation of two-stage implants resulted in significant bone destruction.

Topic: implant repositioning

Authors: Kim A, Kar K, Noxzari H, Kang-Min A, Cha H

Title: Subapical osteotomy to correct dental implant malpositioning and vertical ridge deficiency: a clinical report

Source: J Prosthet Dent. 2012 Oct;108(4):204-8

Type: Case report

Rating: Good

Keywords: osteotomy, reposition, implants, malpositioning

Purpose: The technique of subapical osteotomy involves separating the teeth containing bone segment and repositioning it. This report describes using this technique to simultaneously correct a vertical ridge deficiency and reposition the implants with a segmental down fracture.

Method: A patient presented with definitive implant prosthesis with gingiva-colored porcelain to mask a vertical ridge deficiency of approximately 7 mm. The patient was not pleased with the esthetics due to a high smile line. Subapical osteotomy was performed under general anesthesia. A mucosal vestibular incision was made approximately 5-8 mm apical to the MGJ. Subapical osteotomy was performed with small carbide round burs and microsaws. The bone segment containing the implants was down fractured with chisels. Bone block graft was used for stabilization.

Results: Healing was uneventful. Implants were successfully repositioned and remained stable for 3 years.

Conclusion:Subapical osteotomy is a viable treatment option than can be considered for select patients requiring correction of implant position.

Topic: Nasopalatine Duct
Authors: Shane Josef McCrea
Title: Nasopalatine Duct Cyst, a Delayed Complication to Successful Dental Implant Placement: Diagnosis and Surgical Management
Source: Clin Implant Dent Relat Res. 2013 Apr 22. doi: 10.1111/cid.12074.
Type: Case Report
Rating: Good

Keywords:implantology, nasopalatine duct cyst, symphyseal graft

Purpose: To report a case history of the late manifestation of a nasopalatine duct cyst (NPDC) in close proximity to a dental implant and its subsequent surgical management.

Method:62-year old white man presented to private practice for implants on asymptomatic fractured teeth #4 and #5. However, he had successful rehabilitation of tooth #9 with dental implants three years ago. The clinical exam revealed a grey-blue soft/fluctuant translucent mucosal 1 cm swelling on the palatal aspect of the implant. The mass was depressible without bony resistance. Also, a fluctuant swelling was noted at tooth #8.

Conclusion:The presence of the nasopalatine cyst remains a chance finding due to its largely asymptomatic nature. Its unchecked expansion will result in destruction of the palatal and/or buccal cortical walls and sometimes even the nasal floor. The presence of dental implants in the direction of expansion will certainly endanger those implants. The annual review of dental implants in the anterior maxilla (4th to 6th decade of age) must be strongly reinforced to allow the early diagnosis of the NPDC and its ease of excision.

Topic: Implant Complications –paresthesia

Authors: Givol N, Peleg O, Yarom N, Blinder D, Lazarovici T

Title:Inferior alveolar neurosensory deficiency associated with placement of dental implants

Source: Journal of Periodontology, 2013.84: 495-501.

Type: Case Series

Rating: Good

Keywords:Chin, dental implants, legal liability, mandibular nerve, trigeminal neuropathy.

Background:This study reports and analyzes a large series of patients with neurosensory deficiency related to the placement of dental implants (Dis) resulting in liability claims (LCs) in an Israeli population.

Materials and methods:

From 1998 to 2009 a total of 92 LCs associated with persistent altered sensation following placement of DIs was reported to Medical Consultants International Company (MCI). The data were analyzed according to patient demographics, year of LC report to MCI, source of report (patient, practitioner or legal representative), interval between the operation that resulted in a neurosensory deficiency and reporting MCI, qualifications of the practitioner, preoperative imaging modality, DI placement site, DI length, whether DI ws placed immediately after tooth extraction or after the socket had healed, treatment administered after neurosensory deficiency was detected.

Results: Study cohort consisted of 92 patients who fulfilled inclusion criteria of permanent damage to inferior alveolar nerve due to placement of dental implants (58 LCs submitted by females). There were 21 cases during first 5 years of the study and 63 cases over the following 5 years. Most LCs involved procedures that were planes according to radiographs and computes tomography. 65% of LCs was performed by general dental practitioners, and 35% by specialists. More than one DI was performed during surgery that resulted in a neurosensory deficiency in 73 LCs (79.3%) and the DI was greater than 10mm in 55 (59.8%) cases.

Conclusion: Liability claims for DIs that result in a neurosensory deficiency pose a legal risk t the practitioner long after the injury has occurred.

Topic:Post surgical management, screw loosening, prosthetic complications Fractured Dental Implant Screw

Authors: Manpreet S. Walia, Saryu Arora, Reena Luthra, Prabhjot Kaur Walia

Title: Removal of Fractured Dental Implant Screw Using a New Technique: A Case Report

Source:Journal of Oral Implantology. 2012;38(6):747-750.

Type:clinical case report

Rating:low level evidence; Potentially high clinical value

Keywords:dental implant, screw loosening, osseointegration

Background: Many methods have been reported for retrieving screw fragments within the implant. Two common approaches are the use of a self-made screwdriver or the use of a service set available for the specific implant system. If the fragment is not jammed, an attempt to unscrew it using an explorer or a straight probe might be successful. The tip of the instrument is moved carefully in a counterclockwise direction over the surface of the screw segment until it loosens.

An implant repair kit (ITI Dental Implant System, Institut Straumann, Waldenburg, Switzerland) is also available and consists of drills, 2 drill guides, and 6 manual tapping instruments. One drill is 1.6 mm in diameter and is used counterclockwise at a speed of at least 600 rpm, together with the respective drill guide. Once the fragment has been perforated, the 6 manual tapping instruments are used successively with the second drill guide in a clockwise direction to remove the retained fragment and to section the threads. This procedure will not unscrew the fractured fragment. It will cut it into splinters while cutting the threads at the same time, leading to the misfit of the new abutment screw. The method is complex for routine application and involves the risk of damaging the internal threads of the implant. The use of the repair system may not be successful in different situations.

Screwing out the fragment is a better method as it will leave the implant threads intact. It is essential not only to retrieve the fractured screw but also to determine the reason for failure and to modify the prosthesis if necessary.

Purpose: procedure used for removal of the fractured screw portion is described.

Materials and Methods: One clinical case presented of single implant crown in molar region. Previously Been in function for 6 years. Presented with chipped porcelain, and marginal bone loss. Access hole was made through occlusal of crown; it and abutment were removed leaving the screw fragment in the screw access of the fixture. Explorer tip and US tip in CCW direction were unsuccessfully attempted. Screw was notched notched, off-center, taking care not to damage the screw channel threads. US tip on low power placed in notch and rotated in CCW direction until removed.

Results: screw successfully removed

Conclusions: Screw loosening and fracture can happen for a number of reasons and is one of the most common reported implant complications. Several screw removal systems are available but are expensive, have many components, are complex for routine application, and can damage screw channel threads impeding use of another abutment. A simpler method for screw fragment retrieval is presented. Morse taper systems (Ankylos) eliminate the need for screws for retention.


Topic: Mandibular Fractures

Authors: Boffano P1, Roccia F, Gallesio C, Berrone S.

Title: Pathological mandibular fractures: a review of the literature of the last two decades.

Source: Dent Traumatol. 2013 Jun;29(3):185-96.

Type: Review

Rating: Good

Keywords: Mandibular fractures, pathology

Intro: Pathological mandibular fractures are rare, accounting for fewer than 2% of all fractures of the mandible. They could be defined as fractures that occur in regions where bone has been weakened by an underlying pathological process. Treatment of pathological can be challenging, and it should differ according to presented etiology;

Mandibular fractures following tooth removal

  • A rare event with a reported incidence between 0.0034% and 0.0075%
  • Several risk factors can be associated with this type of pathological fracture, such as age (over 40 years of age), gender, types of impaction, existing infection or bony lesions, surgical technique, and patient’s compliance (in particular, chewing of hard foods after extraction).
  • 71% of postoperative pathological occurred during chewing. A soft diet should be recommended for 4 weeks postoperatively, especially in patients with full dentition

Mandibular fractures following implant placement

  • This rare event is most likely to occur in severely resorbed mandibles with an anterior mandibular bone lower than 12 mm, when the ratio between implant length and the distance to the occlusal plane is compromised, resulting in unfavorable biomechanics
  • Marginal bone loss around a dental implant may be an area of stress concentration and weakness, thus representing a predisposing factor for a fracture in the atrophic mandible too
  • it should be remembered that both the use of wide-diameter implants and bicortical penetration may jeopardize the integrity of severely atrophic mandibles, as inadequate remaining bone volume after placement of implants may increase stress concentration from functional loading

Mandibular fractures associated with benign cystic pathology

  • Very rarely reported
  • Different benign cystic lesions were involved in pathological mandibular fractures, such as aneurismal bone cysts, follicular cysts, residual cysts, radicular cysts, and odontogenic keratocysts

Mandibular fractures associated with a malignant pathology/benign tumors

  • The treatment of pathological mandibular fractures associated with malignant or benign neoplasms has to be directed toward the disease process that must be considered the first priority
  • Pathological fractures are more frequently associated with metastatic tumors or primary oral squamous cell carcinoma
  • The aim of the treatment is the maintenance of oral function and pain control to maintain quality of life
  • Primary radical surgery (with segmental resection of the mandible and selective or radical neck dissection) is the gold standard treatment if the tumor is resectable.
  • For secondary metastatis, treatment depends on the tumor type and patient’s general condition: frequently radiation therapy or chemotherapy is administered as palliation

Mandibular fractures associated with osteomyelitis

  • Osteomyelitis of the mandible may develop if a primary infection is not eliminated by proper treatment or if concurrent immunodeficiencies are present.
  • The first step of treatment is antibiotic therapy, a minimum of 6 weeks of intravenous therapy is recommended.
  • Treatment of the fracture should depend on how much viable bone is present following sequestrectomy or resection, on a case-by case-basis

Mandibular fractures associated with ORN and BRONJ

  • Often are elderly and they may frequently present comorbidities or swallowing and nutritional problems because of previous surgery and/or radiotherapy
  • First of all, surgeons should deal with the patient’s systemic problems, ruling out recurrent cancer and nutritional issues before managing the fracture.
  • In such patients, the aim of the treatment is to restore the function of the mandible, allowing food processing, swallowing and speech production, and if possible to restore the appearance of the lower face

Topic: Implant removal

Authors: Li CH, Chou CT

Title: Bone sparing implant removal without trephine via internal separation of the titanium body with a carbide bur.

Source: Int J Oral Maxillofac Surg. 2014 Feb;43(2):248-50. Epub 2013 Oct 28.

Type: Case study

Rating: Fair

Keywords: osseointegrated, implant removal, immediate replacement

Purpose: To describe a novel technique to remove osseointegrated implants without enlarging the bony socket and immediately replacing it with an implant of the same size.

Methods: A 42 year old healthy male patient with a betel nut chewing habit and a heavy bruxer had to have an osseointegrated implant removed after being loaded for 13 months. Bone covering the implant shoulder was removed using a diamond coated fissure bur creating a 2-3 mm gap in depth around implant shoulder. A carbide surgical round bur was used to perforate both buccal and lingual titanium walls to split the implant into two. Cutting was relatively easy on the hollow 2/3 of the implant however the apical third was solid and vibrations made it difficult to section. Next and was wedged into the distal space created and forced away from the socket wall. Forceps were then used to flex and fatigue the metal until the section separated and was removed. The elevator was then used on the other side of the socket and was removed with forceps. This took approximately 45 min. The osteotomy was reangulated in order to place a straight abutment and the same size implant was placed with good stability and healing was uneventful.

Results: Six months later, at second stage, new bone was found to have grown over the shoulder and a restoration was placed. Good bone stability was observed for 12 months.

Conclusion: Compared to the socket before drilling, the size was almost unchanged after implant removal with this new technique. The surrounding bone was not significantly compromised and a larger implant as not necessary for immediate replacement.

Topic: Implant Failures

Authors: Marini E, Cisterna V, Messina AM

Title: The removal of a malpositioned implant in the anterior mandible using piezosurgery.

Source: Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 May;115(5):e1-5

Type: Case Report

Rating: Good


Purpose: To report the removal by means of piezosurgery of a malpositioned osseointegrated implant that had previously caused a sublingual hematoma during its insertion.

Method: 85-year-old woman with a significant medical history for cerebral ischemia presented at the office of her dentist for placement of dental implants in the anterior region of the mandible. Four 1-piece implants were placed with ball attachments to attach to removable prosthesis. 5 hours after the implant surgery, the patient’s tongue began to swell, protrude, and become elevated. The patient began to have difficulty in swallowing and breathing, so she called her dentist and was then referred to a nearby local hospital. The upper-airway obstruction was caused by the development of a delayed hematoma within the floor of the mouth. Oral intubation was performed, and prophylactic antibiotics and steroids were administered. The swelling began to steadily resolve during the next 4 days and the patient was discharged from the hospital 1 week after implant surgery.

3-months later the patient presented for implant removal. The radiological study included a panoramic X-ray and computed tomography (CT) to assess the position of the 4 implants and their relationship to neighboring structures. A circumferential osteotomy was performed with piezosurgery. The insert was use working at the bone-implant interface so as to break it down by means of the ultrasonic waves. After removal of the implant, attention was focused on hemostasis, the residual perforation was sealed with fibrin glue, then the site was reconstructed using hydroxyapatite plus fibrin glue. The flap was closed using a 4-0 polyester suture with an interrupted suturing technique. Patient was given antibiotics and pain meds.

Result: Clinical evaluation was carried out 2 days, 7 days, 4 weeks, and 12 weeks after implant removal to assess complications at the surgical site, hematoma formation, and the integration and resorption of the graft. The postoperative course was uneventful, no bleeding, infection, or hematoma formation was noted and the patient reported 100% resolution of all symptoms.

Conclusion: Recommend CT or cone-beam examination to visualize the mandibular lingual foramina before the implant removal; furthermore, piezosurgery may reduce the risk of postsurgical life-threatening complications.

Topic: Implant Failures

Authors: Machtei EE.

Title: What do we do after an implant fails? A review of treatment alternatives for failed implants.

Source: Int J Periodontics Restorative Dent. 2013 Jul-Aug;33(4):e111-9. doi: 10.11607/prd.1505.

Type: Discussion

Rating: Good

Keywords:alternative treatment, implant failure, treatment planning

Purpose: The purpose of this paper is to explore treatment alternatives for failed implants and their strengths and shortcomings.

Methods and Materials: A comprehensive literature search was performed using PubMed and a manual search. Only five studies were identified that explored treatment in sites where implants had failed. In all five studies, the treatment alternative tested was the placement of a new implant in the failed site.

Results: The overall survival rate for such implants ranged from 71% to 92.3%. Four other alternatives are also discussed in light of data derived from other studies on the survival of various treatment strategies. These include: a continuation of the original plan using the remaining implants, modification of treatment to a tooth-supported fixed partial denture (FPD) or to a hybrid tooth-implant supported FPD, or modification to a removable prosthesis.

Conclusion: The selection of an appropriate alternative for failed implants is complex and involves biologic, mechanical, and psychological considerations along with financial aspects. This should be a team decision with the patient’s opinion included.

Topic: Post Surgical Management

Authors: Grossman, Y., Levin, L:

Title: Success and survival of single dental implants placed in sites of previously failed implants.

Source: J Periodontol 2007; 78:1670-1674

Type: Clinical study

Rating: Fair

Keywords: soft tissue deficiencies, maxillary anterior implants

B: The aim of this study was to assess the clinical effectiveness of single dental implants placed in sites of previously failed implants.

M&M: The study consisted of a consecutive cohort of 1,215 patients who received 1,387 single implants for single-tooth replacement during a 6-year period (1999 to 2005). Inclusion criteria were a single implant replacing a previously failed implant and follow-up data > or =6 months. Data were recorded and analyzed regarding implant survival and location, need for bone augmentation, and implant dimensions.

R: A total of 75 patients experienced the failure of 96 implants. Of those, 31 implants in 28 patients were replaced by a similar implant placed in the same location. Nine of the replacement implants failed, resulting in an overall survival rate of 71%. Follow-up ranged from 6 to 46 months (mean, 19.4 +/- 11.4 months). Replacement of maxillary and mandibular failed implants was similar. All failures occurred during the first year after implant replacement. On average, implant replacement occurred 5.8 +/- 5.2 months after original implant removal; three implants were placed immediately after implant removal. A third attempt for single implant replacement was made in two patients. However, one failed.

C: Replacement of a failed implant presents a challenge to achieve osseointegration in a healed bone site and may result in a decline in the survival rates. Patients and clinicians should be aware of these results before a replacement attempt is considered. The success of replacement may be increased by the use of wider implants or with improved surfaces.

Topic: implants in previously failed sites

Authors: Machtei EE, Mahler D, Oettinger-Barak O, Zuabi O, Horwitz J.

Title: Dental implants placed in previously failed sites: survival rate and factors affecting the outcome.

Source:Clin Oral Implants Res. 2008 Mar;19(3):259-64. doi: 10.1111/j.1600-0501.2007.01466.x.

Type: retrospective

Rating: good

Keywords: dental implants; failures; modifying factors; redo; replacement; success rate.

Purpose: to evaluate the survival rate of dental implants in previously failed implant sites, and to explore factors that might affect the outcome of these redo procedures.

Methods: Patients that had failed dental implants, which were replaced with the same implant type at the same site, were included. Data on the failed implants were collected. The same parameters, along with the interval between retrieval and re-implantation, were collected for the second set of implants. Descriptive statistics were used to describe the patients and implants. The effect of systemic, environmental and local factors on the survival of the redo dental implants was evaluated.

Results: 56 patients with a total of 79 redo implants were included in this study. Implants were followed for 7-78 months (mean 29.9 ±2). Thirteen implants failed that resulted in an overall survival rate of 83.5%. Successful implants had greater diameter (4.05 ±0.52 mm) than failed implants (3.72 ±0.56 mm); however, these differences were only marginal (P=0.06). Conversely, smoking habits, implants length and location, mode of placement and spontaneous exposure did not have a significant effect on the outcome of this procedure.

Conclusion: Redo of dental implants has a lesser survival rate compared with previous reports for implants in pristine sites. These results were not associated with most implant- and/or patient-related factors. Thus, a possible negative effect that is associated with the specific implant’s site might account for this phenomenon.

Topic: Failed implants

Author: Mardinger O, Oubaid S, et al

Title: Factors affecting the decision to replace failed implants: a retrospective study

Source: J Periodontol. 2008 Dec;79(12):2262-6

Type: Retrospective study

Rating: Good

Keywords: Decision-making; dental implants; failures; reimplantation; replacement

Purpose: The purpose of this study was to explore the major factors that can affect the decision to replace failed implants.

Methods: A restrospective cohort study was conducted on 194 patients who presented following dental implant failure during a 6-year period. The data collected at this time, included patient characteristics, failed implant characteristics, anatomic status of the alveolar ridge after failure, and factors affecting the decision to avoid reimplantation. The control group in this study was the patients were no reimplantation was completed. In the experimental group, the failed implants were replaced.

Results: Seventy-four patients (135 implants) made up the control group, and 120 patients (157 implants) made up the study group. The mean patient age was higher and the medical status worse in the control group. The number of failed implants per patient was higher in the control group. The time between the diagnosis of failure and removal and between implant placement and removal were greater in the control group. The chances of a patient with minor bone loss undergoing reimplantation was 20 times greater than a patient with severe bone loss. The main patient related reasons for avoiding reimplantation were the additional costs (27%), fear of additional pain (17.7%), and fear of second failure (16.2%)

Discussion: There is a lack of available studies reporting the outcome of dental implants placed in previously failed sites is scarce. Those studies have concluded that redone dental implants have a lower survival rate compared to initial implant placement.

Bottom Line: Removal of failing implants as soon as it is diagnosed as hopeless will improve the chances for reimplantation.

Topic: implant failure

Authors: Machtei EE, Horwitz J, Mahler D, Grossmann Y, Levin L

Title: Third attempt to place implants in sites where previous surgeries have failed

Source: J Clin Periodontol. 2011 Feb;38(2):195-8

Type: Retrospective case study

Rating: Good

Keywords: dental implants; implant failure; implant replacement; implant success; reimplantation; survival

Purpose: To evaluate the survival rate of dental implants that were performed in sites that previously had two failing attempts to place implants.

Method: Healthy subjects who underwent a third attempt at implant placement at the same site were included in this study. Time between implant placements were recorded, along with implant lengths and diameters.

Results: 12 patients with 15 implants were placed at the same site 3 times. 6 out of the 15 second reimplantation attempt implants failed, leading to an overall success rate of 60%.

Conclusion:The placement of dental implants in sites where 2 implants had failed resulted in poor survival rate (60%, first year survival). This information may be valuable to clinicians and patients when considering treatment alternatives.

Topic: Implant Failures
Authors: Mardinger et al.
Title: A retrospective analysis of replacing dental implants in previously failed sites
Source: Oral Surg Oral Med Oral Path Oral Radiol. 2012 Sep;114(3):290-3
Type: Retrospective Study
Rating: Good
Keywords: N/A

Purpose: to evaluate the survival rate of dental implants that were performed in sites where failed implants were previously removed and to evaluate the factors associated with outcome.

Methods: Three certified oral and maxillofacial surgeons replaced implants in previously failed sites of 144 fixtures in 144 patients (60 men and 84 women) between 1994 and 2009. Patients’ ages ranged from 31 to 73 years (mean 56.5 9 years). Patients were followed for 12-180 months (mean 48 1.27 months).

Results: Survival rate of the implants replacing previously failed ones was 93% (133/144). A third placement in the same site was performed in 7 of 11 patients with a survival rate of 85% (6/7) up to the last follow-up.

  1. No correlation was found between ASA groups and failure rate of the replaced implants (85.4% ASA I, 14.6% ASA II).
  2. No correlation was found between smoking habits and failure rates (23.6% smoked less than 10 cigarettes per day).
  3. There was no significant difference among the diameter and length of the first implant, the replaced implant and the third. Most of the replaced implants were from the same manufacturer as the first implant.
  4. Time interval between failure and replacement was 1-36 months (mean 4.8 – 5.45 months).
  5. No correlations were found between replaced implant failures and : gender, jaw, site, early/late failure, implant diameter and length, age, and type of restoration.
  6. Correlation was found between amount of bone loss to the need for local augmentation, but after site augmentation, correlation was not found between the previous site bone loss and failure of the replaced implant.

Conclusion: Within the limits of the present study, it can be concluded that a previous implant failure should not discourage practitioners from a second or even a third attempt.

Topic: Implant Failure

Authors: Vervaeke S, Collaert B, Cosyn J, Deschpper E, De Bruyn H.

Title:A multifactorial analysis to identify predictors of implant failure and peri-implant bone loss.

Source: Clinical Implant Dentistry and Related Research, 2015.17(1): 298-307.

Type: Retrospective Cohort Study

Rating: Good

Keywords:dental implant, implant survival, multifactorial, peri-implant bone loss, predictor.

Purpose:Primary aim: Evaluate implant survival and peri-implant bone loss of surface modified implants with minimum follow up of 2 years. Secondary aim: identify predictors affecting implant treatment outcome.

Materials and methods:

All patients treated between November 2004 and December 2007. No patients excluded based on risk factors, history of periodontitis or smoking habits. Patients were partially dentate and fully edentulous with indications for implant rehabilitations. All patients treated by the same surgeon using the same implant system (Osseospeed, Astra Tech). Implants were placed using either one-stage or two-stage surgery technique, and different loading protocols were used, either immediate or delayed loading. Three different treatment protocols were analyzed: immediate loading (IL) , one-stage delayed loading (1-DL), and two-stage delayed loading (2-DL). In immediate loading, an impression was made and a provisional acrylic, metal reinforced, screw-retaines restoration, was placed after surgery. Immediate full occlusal loading with balanced occlusion was applied for all cases, except single tooth where nonocclusal load was applied. Final restorations were made after 3 months. Peri-implant bone loss was assessed by comparing digital radiographs of baseline and recall visits.

Results:Total of 1,320 implants of which 21 implants failed in 19 patients, this results in an absolute survival rate of 98.4%. In the IL group, 0.5% of implants failed, 3.9% in 1-DL, and no failures occurred in 2-DL. Only smoking and recall compliance had a significant influence on implant failure. More peri-implant bone loss was observed in smokers and in the maxilla (0.42 mm vs. 0.28 in mandible). The overall mean bone loss was 0.36 mm. Neither implant length, diameter, nor design, had a significant impact on implant survival.

Conclusion: Multivariate analysis demonstrated that implant related factors did not affect the clinical outcome, but smoking was identified as a predictor for implant failure. Predictors for peri-implant bone loss were smoking and jaw treatment (maxilla or mandible).

Topic: implant removal

Authors: Froum S, Yamanaka T, Cho SC, Kelly R, St James S, Elian N

Title:. Techniques to remove a failed integrated implant.

Source: Compend Contin Educ Dent. 2011 Sep;32(7):22-6, 28-30

Type:literature and clinical review

Rating: decent


Background: Based on specific clinical factors such as anatomical conditions, implant design, condition of implant connection, bone quality, and remaining amount of bone integrated to the implant body, a decision tree is proposed to help clinicans determine the most appropriate minimally invasive technique.

Purpose: to present a clinical and literature review of various techniques for removing failed, fractured, or peri-implantitis-affected nonmobile implants.

Materials and Methods: Total of 2,333 articles from peer-reviewed journals published in English published from January 1986 –August 2010; 2,066 articles for “dental implant and failure; 281 for “dental implant and fracture” 31 for “hopeless and dental implant; and 114 for displacement and dental implants; 54 for “remove and dental implant” Only use of human clinical studies were evaluated and only those that looked at the advantages and disadvantages of various implant removal techniques.


Counter-torque Ratchet technique (CTRT)is the least invasive technique for removing an implant without damaging surrounding structures. Cases amenable to removal with a counter-torque ratchet depend on an intact implant connection (external, internal hex), implant diameter, implant geometry, implant location and the amount of osseointegration remaining. This method is the option of choice if the implant is able to be engaged and reverse torqued until mobile. Care must be taken with narrow-diameter implants that <4mm in dense cortical bone to avoid implant fracture. Internal connections are much more easily removed using this technique than external connections. However, for tri-lobed internal connections, more complications are seen than with other internal connection designs. Square implant thread designs are harder to reverse torque out. Consider another technique with square, small diameter,

Reverse screw technique: is another less invasive method that uses a screw removal device.This is used when the implant is fractured implant when connection is damage or in the removal of an external connection when the ratchet cannot be engaged to use the CTRT.

Bone Removal Techniques (BRTs)

Piezo Tips:allow for better intraoperative control than high-speed burs during bone-cutting by preventing damage to surrounding tissue. Companies providing such tips are listed as Piezosurgery, inc. www.piezosurgery .com; Bone healing is better in response following piezosurgery versus bone removal with burs.

High-speed Burs:using FG burs under copious irrigation are efficient but come with the risk of air embolism and also create more particles that may enter the wound and impede healing.

Trephine burs: several sizes are available corresponding to various implant diameters. The smallest effective size should be selected to limit damage to adjacent structures. The internal diameter of the trephine needs to be slightly larger than the implant to avoid engaging the implant body. The preferred speed is 1,200-1,500 rpm with copious irrigation. This is one of the most invasive options. Fatigue fracture of mandible after trephination has been reported. Osteomyelitis is other complication. Only Indicated when ABSOULTELY NECESSARY.