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ITI Treatment Guide
Volume 8

Biological and Hardware Complications in Implant Dentistry

Editors:
D. Wismeijer, D. Buser, S. Chen

Authors:
U. Brägger, L. J. A. Heitz-Mayfield

Quintessence Publishing Co, Ltd

Berlin, Chicago, London, Tokyo, Barcelona, Beijing, Istanbul, Milan, Moscow, New Delhi, Paris, Prague, São Paulo, Seoul, Singapore, Warsaw

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Illustrations:	Ute Drewes, CH-Basel, www.drewes.ch
Copyediting:	Triacom Dental, D-Barendorf, www.dental.triacom.com
Graphic concept:	Wirz Corporate AG, CH-Zürich
Production:	Juliane Richter, D-Berlin
Printing:	Bosch-Druck GmbH, D-Landshut, www.bosch-druck.de

ISBN:

978-3-86867-282-4 (ebook)

978-3-86867-240-4 (print)

The materials offered in the ITI Treatment Guide are for educational purposes only and intended as a step-by-step guide to treatment of a particular case and patient situation. These recommendations are based on conclusions of the ITI Consensus Conferences and, as such, in line with the ITI treatment philosophy. These recommendations, nevertheless, represent the opinions of the authors. Neither the ITI nor the authors, editors and publishers make any representation or warranty for the completeness or accuracy of the published materials and as a consequence do not accept any liability for damages (including, without limitation, direct, indirect, special, consequential or incidental damages or loss of profits) caused by the use of the information contained in the ITI Treatment Guide. The information contained in the ITI Treatment Guide cannot replace an individual assessment by a clinician, and its use for the treatment of patients is therefore in the sole responsibility of the clinician.

The inclusion of or reference to a particular product, method, technique or material relating to such products, methods, or techniques in the ITI Treatment Guide does not represent a recommendation or an endorsement of the values, features, or claims made by its respective manufacturers.

All rights reserved. In particular, the materials published in the ITI Treatment Guide are protected by copyright. Any reproduction, either in whole or in part, without the publisher’s prior written consent is prohibited. The information contained in the published materials can itself be protected by other intellectual property rights. Such information may not be used without the prior written consent of the respective intellectual property right owner.

Some of the manufacturer and product names referred to in this publication may be registered trademarks or proprietary names, even though specific reference to this fact is not made. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

The tooth identification system used in this ITI Treatment Guide is that of the FDI World Dental Federation.

The ITI Mission is …

“… to promote and disseminate knowledge on all aspects of implant dentistry and related tissue regeneration through education and research to the benefit of the patient.”

Preface

While implant dentistry today is well documented and demonstrates predictable outcomes, a significant proportion of patients still experience complications. It is therefore a must for all practitioners to know the causes of implant-related complications and how to avoid and manage them.

Volume 8 of the ITI Treatment Guide series provides clinicians with the latest evidence-based information on the origins and treatment of biological as well as technical and mechanical complications. An up-to-date analysis of the current evidence is based in part on the proceedings of the 4th ITI Consensus Conference held in Stuttgart in 2008 and the 5th ITI Consensus Conference held in Bern in 2013, as well as on a review of the current literature. The diagnosis and treatment of biological and technical complications are examined closely in 16 clinical cases presented by clinicians from all over the world.

The mission of the ITI “… to promote and disseminate knowledge on all aspects of implant dentistry to the benefit of the patient” as always provides the background against which this volume of the ITI Treatment Guide series has been written.

We would like to thank Dr. Kati Benthaus of the ITI Headquarters for her invaluable assistance in the preparation of this volume of the Treatment Guide series. We would also like to express our gratitude to Ms. Juliane Richter (Quintessence Publishing) for typesetting and for coordinating the production workflow, Mr. Per N. Döhler (Triacom Dental) for his editing support, and Ms. Ute Drewes for her excellent illustrations. We also acknowledge continuing support from Institut Straumann AG, ITI’s corporate partner.

Editors:

Daniel Wismeijer

DDS, PhD, Professor

Head, Section of Implantology and Prosthetic Dentistry

Department of Oral Function and Restorative Dentistry

Academic Centre for Dentistry Amsterdam (ACTA)

Gustav Mahlerlaan 3004

1066 EA Amsterdam, Netherlands

E-mail: d.wismeijer@acta.nl

Daniel Buser

DDS, Dr med dent

Professor and Chair

Department of Oral Surgery and Stomatology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: daniel.buser@zmk.unibe.ch

Stephen Chen

MDSc, PhD

Clinical Associate Professor

School of Dental Science

University of Melbourne

720 Swanston Street

Melbourne VIC 3010, Australia

E-mail: schen@balwynperio.com.au

Authors:

Urs Brägger

Dr med dent

Professor and Chair

Department of Reconstructive Dentistry and Gerodontology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: urs.braegger@zmk.unibe.ch

Lisa J. A. Heitz-Mayfield

BDS, MDSc, PhD

Professor

International Research Collaborative

University of Western Australia

Nedlands, WA 6009, Australia

E-mail: heitz.mayfield@iinet.net.au

Bilal Al-Nawas

Dr med, Dr med dent, Professor

Johannes Gutenberg-University

Medical Center

Department of Oral and Maxillofacial Surgery

Augustusplatz 2

55131 Mainz, Germany

E-mail: al-nawas@mkg.klinik.uni-mainz.de

Urs C Belser

DMD, Dr med dent, Professor

Department of Oral Surgery and Stomatology

Department of Reconstructive Dentistry and Gerodontology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: urs.belser@unige.ch

Michael M. Bornstein

Dr med dent, Associate Professor

Head, Section of Oral Radiology and Stomatology

Department of Oral Surgery and Stomatology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: michael.bornstein@zmk.unibe.ch

Urs Braegger

Dr med dent

Professor and Chair

Department of Reconstructive Dentistry and Gerodontology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: urs.braegger@zmk.unibe.ch

Daniel Buser

DDS, Dr med dent

Professor and Chair

Department of Oral Surgery and Stomatology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: daniel.buser@zmk.unibe.ch

Agnieszka Frydrych

BDSc(Hons), MDSc, FRACDS(Oral Med), FOMAA

Associate Professor (Oral Medicine)

University of Western Australia

17 Monash Avenue

Nedlands, WA 6009, Australia

E-mail: agnieszka.frydrych@uwa.edu.au

Alexandros Grous

Dr med, Dr med dent

Grous Dental Clinic

2 Vasileos Alexandrou Street

11634 Athens, Greece

E-mail: alex@grousdental.com

Lisa J. A. Heitz-Mayfield

BDS, MDSc, PhD

Professor

International Research Collaborative

University of Western Australia

Nedlands, WA 6009, Australia

E-mail: heitz.mayfield@iinet.net.au

Stefan Hicklin

Dr med dent, Senior Lecturer

Department of Reconstructive Dentistry and Gerodontology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: stefan.hicklin@zmk.unibe.ch

Tim Joda

Dr med dent, MSc, Senior Lecturer

Department of Reconstructive Dentistry and Gerodontology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: tim.joda@zmk.unibe.ch

Janice Kan

BDSc(Hons), DCD Pros

Perth Prosthodontics

Suite 3, Southbank Central

38 Meadowvale Ave

South Perth WA 6151, Australia

E-mail: dr.jkan@perthpros.com.au

Daan Kruger

DDS, MSc Oral Implantology

Section of Implantology and Prosthetic Dentistry

Department of Oral Function and Restorative Dentistry

Academic Centre for Dentistry Amsterdam (ACTA)

Gustav Mahlerlaan 3004

1066 EA Amsterdam, Netherlands

E-mail: d.y.kruger@acta.nl

Peer W. Kämmerer

Dr med, Dr med dent

University of Rostock

Department of Oral and Maxillofacial Surgery

Schillingallee 35

18057 Rostock, Germany

E-mail: peer.kaemmerer@uni-rostock.de

Tomas Linkevičius

DDS, Dip Pros, PhD, Associate Professor

Institute of Odontology,

Faculty of Medicine, Vilnius University

Žalgirio 115/117

LT-08217 Vilnius, Lithuania

E-mail: linktomo@gmail.com

Maximilian Moergel

Dr med, Dr med dent

Johannes Gutenberg-University

Medical Center

Department of Oral and Maxillofacial Surgery

Augustusplatz 2

55131 Mainz, Germany

E-mail: maximilian.moergel@unimedizin-mainz.de

Andrea Mombelli

Dr med dent, Professor

Université de Genève

Section de Médecine Dentaire

Division de Physiopathologie Buccale et Parodontie

Rue Barthélemy-Menn 19

1205 Genève, Switzerland

E-mail: andrea.mombelli@unige.ch

Joris Muris

DDS

Department of Material Science

Academic Centre for Dentistry Amsterdam (ACTA)

University of Amsterdam and VU University Amsterdam

Gustav Mahlerlaan 3004

1066 EA Amsterdam, Netherlands

E-mail: j.muris@acta.nl

Giovanni E. Salvi

Dr med dent, Professor

Department of Periodontology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: giovanni.salvi@zmk.unibe.ch

Bruno Schmid

Dr med dent

Private Office

Bayweg 3

3123 Belp, Switzerland

E-mail: info@brunoschmid.ch

Sandro Tettamanti

Dr med dent

Department of Reconstructive Dentistry and Gerodontology

University of Bern, School of Dental Medicine

Freiburgstrasse 7

3010 Bern, Switzerland

E-mail: tettamanti@hispeed.ch

Hans-Peter Weber

DMD, Dr med dent

Professor and Chair

Department of Prosthodontics and Operative Dentistry

Tufts University, School of Dental Medicine

One Kneeland Street, Rm. 220

Boston, MA 02111

United States of America

E-mail: hp.weber@tufts.edu

Philipp Wick

Dr med dent

Weststrasse 4

3005 Bern, Switzerland

E-mail: philipp.wick@gmx.ch

Daniel Wismeijer

DDS, PhD, Professor

Head, Section of Implantology and Prosthetic Dentistry

Department of Oral Function and Restorative Dentistry

Academic Centre for Dentistry Amsterdam (ACTA)

Gustav Mahlerlaan 3004

1066 EA Amsterdam, Netherlands

E-mail: d.wismeijer@acta.nl

1Introduction

L. J. A. Heitz-Mayfield, U. Brägger

The replacement of missing teeth with implant-supported prostheses is a well-documented, predictable treatment method. High five- and ten-year survival rates of both the implants and the implant-supported prostheses have been reported (Pjetursson and coworkers 2014). However, both the clinician and patient should be aware that a significant percentage of patients treated with dental implants will experience a complication requiring a dental visit within the first 5 years. Given the steady growth in the number of implants placed and restored over recent years, the number of complications may also be expected to increase in the future. Therefore, the diagnosis, management, and prevention of implant-related complications are important issues to consider as a part of everyday practice.

Complications may be categorized as biological or hardware-related.

Biological complications are associated with the surrounding peri-implant tissues (peri-implant mucosa or bone).

Hardware complications may be associated with the implant or with the prosthetic components. Following the definitions by Salvi and Brägger (2009), a technical complication is defined as a complication that affects the laboratory-fabricated components of the prosthesis, while a mechanical complication is one associated with the manufacturer-fabricated components. Thus, hardware complications include both technical and mechanical complications, as well as other types of complications, for example fracture of the luting cement or loss of the occlusally screw-retained restoration.

Furthermore, complications may be classified as minor (those that can be rectified at chairside with minimal intervention and minimal cost) or major (those that require numerous visits or are associated with considerable cost). Major complications may result in either implant loss, or failure of the prosthesis, or both. Compromised esthetics may be a consequence of either biological or hardware complications.

The present Volume 8 of the ITI Treatment Guide series addresses etiology, management, and prevention of biological and hardware complications that occur following successful osseointegration, with the implant in function. Biological complications described in this volume include complete loss of osseointegration (implant failure); peri-implant infections (peri-implant mucositis and peri-implantitis); bisphosphonate-related osteonecrosis of the jaw (BRONJ) in relation to osseointegrated dental implants; peri-implant oral mucosal disorders; material allergies; and carcinomas/tumors.

Hardware complications outlined in this volume include implant fracture; abutment or screw fracture; abutment or screw loosening; prosthesis framework fracture; prosthesis veneering material fracture; loss of the occlusally screw-retained restoration; and—in the case of cemented prostheses—fracture of the luting cement (loss of retention). Reasons for ill-fitting restoration margins are also discussed, as well as complications arising from insufficient space for restorative components due to inadequate treatment planning.

While various complications may appear similar in their clinical presentation, the clinician must be able to make the correct diagnosis and understand the underlying cause of the complication in order to implement the appropriate treatment strategy. Furthermore, some hardware complications, such as an abutment-screw fracture or prosthesis-screw loosening, may present clinically as a biological complication (e.g. a draining sinus). For the successful management of both hardware and biological complications, an accurate diagnosis and evaluation of the cause of the complication is therefore the first important step.

In this treatment guide, step-by-step procedures for the management of various complications are outlined and illustrated by individual case descriptions. The important topic of how to prevent complications is also discussed in detail.

Volume 8 of the ITI Treatment Guide series aims to provide the clinical and laboratory team with valuable information concerning the etiology and risk factors, management and prevention of biological and hardware complications occurring after the implant has been restored.

2Literature Review

L. J. A. Heitz-Mayfield, U. Brägger