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REVIEW ARTICLE

Implant failure: A dentist’s nightmare


Madhura Avinash Kate, Sangeeta Palaskar, Prakhar Kapoor

ABSTRACT

Dental implants are commonly used in clinical situations for replacement of natural teeth. Despite
many advances in materials, techniques, and implant design, implant failure is a significant concern
for the dentist and patient. Peri‑implantitis and lack of osseointegration are considered to be the major
factors leading to implant failure. Occlusal overloading, medical status of the patient, smoking, and
implant characteristics are among the other causes for implant failure. The purpose of this concise
review is to discuss the etiology of implant failures by highlighting the various classification put forth
by different authors and formulating a new classification.

KEY WORDS: Classification, fracture, implant failure, osseointegration, overloading, peri‑implantitis,


prosthesis, smoking

INTRODUCTION the prosthesis.[1,2] Implants are placed into the bone either
in 1 stage or 2 stage surgery. In spite of taking many
An implant is “a graft or insert set firmly or deeply precautions and surgical precision, implant failures do
into or onto alveolar process that may be prepared occur attributing to certain factors.
for its insertion.” Implants are used for single tooth
replacements, partially edentulous arches and for REVIEW OF LITERATURE
completely edentulous arches. They are inert, alloplastic
materials most commonly made of titanium or The aim of this article is to study the various causes of
titanium alloy or vitalinium.[1] Alternatively, ceramics implant failure by focusing on the various classifications
such as hydroxyapatite, bioglass, or aluminum given from time to time. Implant failure is caused by
oxides can be used.[2] Depending on their placement a number of factors which include peri‑implantitis,
within the bone, they are classified into epiosteal, absence of osseointegration, and implant fracture. It may
endosteal, and transosteal.[2,3] The most common one also be caused due to surgical trauma, micromotion, and
is endosteal (screw shaped or cylindrical). An implant overloading.[4] Over the years, differed classifications of
consists of an implant body which is placed within the Implant failures have been proposed by various authors
bone, implant screw placed on the superior surface of the [Figures 1-6].
body to which is attached the healing cap. Abutments are
placed over the implant body which provides retention to Working classification
Compiling the various classification systems given
Department of Oral Pathology and Microbiology, Sinhgad Dental College from time to time, we have put forward a new working
and Hospital, Pune, Maharashtra, India classification which divides implant failures broadly into
Address for correspondence: Dr. Madhura Avinash Kate, early and late failures. They are further classified based
150, Anand Avinash Niwas, S.T. Road, Dapodi, Pune ‑ 411 012, on etiology, personnel responsible, failure mode, and
Maharashtra, India.
E‑mail: katemadhura@yahoo.com biological causes [Table 1].

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DOI:
10.4103/0974-6781.202154 How to cite this article: Kate MA, Palaskar S, Kapoor P. Implant failure:
A dentist's nightmare. J Dent Implant 2016;6:51-6.

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Kate, et al.: Classification of implant failures

DISCUSSION success.[3] As implant characteristics are crucial in success


of an implant, the type of bone which receives an implant
Improper selection of patient, poor oral hygiene due is equally significant.
to bacterial plaque accumulation, improper prosthetic
restoration, debris retention, and bone preparation Bone type
without the use of coolants have been contributing factors Dense compact bone and porous compact bone found in
in the breakdown of successfully placed implants.[7] the anterior mandible are more favorable as they hold the
implant firmly in the socket. In contrast to this, porous
Early failures and trabecular bone found in the posterior maxilla
Early failures occur soon after placement of implants decrease the stability of the implant in the bone.[12,13] Jaffin
in the bone which is between few weeks to months. and Berman  (1991), in their 5‑year analysis, reported
They interfere with the healing process or cause altered that as many as 35% of all implant failures occurred in
healing.[2,3,8] porous trabecular bone due to its thin cortex.[14] Placing
the implant in immature bone grafted sites increases the
Implant selection chances of failures.
Etiologically, improper implants such as short implants
cause implant failure due to unfavorable crown root Surgical criteria
ratio.[3,9] In a study carried out by Bahat on treatment Surgical accuracy is an important criterion for a
planning and placement of implants in posterior maxilla successful implant. This depends on axial placement
in the year 1993, 732 placed implants in posterior maxilla of implant, spacing between adjacent implants and its
of partially edentulous patients reported a failure rate of initial stabilization in the bone. Buccally placed implants
9.5% for 7 mm implants as compared to 3.8% for all other jeopardize the buccal cortical plate. Similarly, lingually
lengths.[10] Similarly, implants with a smaller diameter placed implant interferes with tongue movements
are less apt to withstand stresses leading to fracture of the hampering speech.[6] Less space between two implants
implant components. Bahat and Handelsman compared causes injury to interdental bone leading to bone loss.[1]
the clinical outcomes of the placement of different On the other hand, if the spacing is more than required,
combinations of implants at one site in the posterior areas additional cantilevers are placed which increase the
and found the failure rate for all 5  mm implants was stress on supporting implants, leading to fracture of
2%–3%, and that for all double implants was 1%–2%.[11] implants, thereby its failure.[6] Atilla Sertgoz et al. in 1996
The superstructure tends to loosen in the mouth due reported that maximum stresses were concentrated at
to conical screw design.[9] Implant properties such as
surface roughness, impurities help to retain the implant
in the bone, thus playing an important role in implant

Figure 2: Classification of Implant Failures as stated by


Rosenberg et al.[5]
Figure 1: Classification of Implant Failures as stated by
Nallaswamy[1]

Figure 3: Classification of Implant Failures as given by Esposito Figure 4: Classification of implant failures as stated by Truhlar[5]
et al.[6] and Tonetti and Schmid

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Kate, et al.: Classification of implant failures

the most distal bone/implant interface, located on the rendered.[17] Distribution of forces enhances the success
loaded side of terminal implant, increasing cantilever of implant. Increased force on one implant leads to
length resulted in increased stress value at bone‑implant prosthetic component breakage.[3,8] Hence, excessive
interface.[15] Over preparation of the bone site due to load on single implant should be avoided. Misfit of the
excessive in and out motion decreases the density of implant leads to constant tension in the components
bone. Use of dense bone drills in low‑density bone which leads to screw loosening or fracture.[3,8] Robert L.
decreases the bone quality.[8] Excess heating of bone Simon in 2003 concluded that the implant failure rate
causes bone necrosis[9] (47° for more than 1 min). Salonen was 4.6% with complications of abutments screw
et al. (1993) found that 5.8% of implants were lost due to loosening (7%).[18] Poor implant design and excessive
failures of osseointegration caused by excessive heating loading of implant (especially cantilever abutments)
of bone.[16] Irrigation helps to reduce the chances of bone increase the failure chances.[8] Greater the cantilever
necrosis.[9] distance, greater the chances of failure.[1,8]

Surgical conditions Late failures


Maintaining sterile conditions during the surgical As certain factors are responsible for causing early
procedure is of utmost importance. Saliva, perioral skin, failures, there are a different set of factors which cause
unsterile instruments, contaminated gloves, operating delayed failures. These failures arise from pathologic
room air, or air expired by the patient, all interfere in processes in previously osseointegrated implants. These
the surgical procedure leading to contamination of the are mostly associated with medical status of the patient.
implant site, causing infection in the implant site. They are categorized as host factors.

Prosthetic considerations Host factors


Prosthetic rehabilitation and occlusal adjustments Patients with diabetes experience delayed wound
should be taken into consideration for a successful healing which impairs osseointegration process.[4,9,13]
implant. Fumihiko Watanabe et al. in 2002  reported Uncontrolled diabetes leads to implant failure. Fiorellini
that an implant was placed in an incorrect inclination et al. (2000)[19] demonstrated a lower success rate of only
in spite of cooperation between the surgeon and 85% in patients with diabetes, while Olson et al. (2000) [20]
prosthodontist. This failure suggested the necessity of found that the duration of diabetes had an effect on
clearly presenting the prosthodontic aspect of treatment implant success: more failures occurred in patients who
to each member of the team before surgical treatment is had diabetes for longer periods.[13] In osteoporotic and
arthritic conditions, density of bone is adversely affected.
This leads to porous bone. Such bone is unsuitable for
implant success.[4,13] John C. Keller et al. in 2004  have
reported that osteoporosis‑like bone conditions affect the
osseointegration characteristic of implant.[21] Overweight
is a metabolic syndrome which leads to increase in
peri‑implant inflammations which in turn affect implant
prognosis.[4] A study carried out on implants, and relative
risk factors stated that increasing age was also a major
risk factor.[13] Compared to patients younger than 40,
patients in the range of 60–70 years had a higher risk of
Figure 5: Classification of implant failures given by Matukas[5] implant failure.[22]

Figure 6: Classification of implant failures as given by El Askary et al.[5]

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Kate, et al.: Classification of implant failures

Table 1: Working classification


Early failures (intraoperative or within 3 months) Late failures(postoperative after 3 months)
1. According to Etiology: 1. According to Etiology:
• Implant selection: improper Implant type or bone type, length • Host factors: systemic factors diabetes, arthritis, obesity,
and diameter of implant, surface impurity, surface roughness. osteoporosis.
• Surgical placement: off axis placement, lack of initial • Tissue abuse:smoking, para functional habits, alcoholism.
stabilization, overheating of bone, minimal space between • Radiotherapy
implants, contamination of implants during placement.
• Restorative problems: Improper design, occlusal scheme, 2. Due to Personnel Responsible
improper fit, excessive loading , implant fractures. • Patient: inadequate post• operative maintenance
2. Due to Personnel Responsible 3. Accroding to failure mode:
• Dental expertise: oral surgeon, prosthodontist, periodontist • functional and psychological problems
• Laboratory technician:improper design of prosthesis. 4. Due to biological causes:
3. Accroding to failure mode • Infections: retrograde perimplantitis, due to traumatic
• Lack of osseointegration occlusion, overloading.
4. Due to biological causes: peri• implantitis

Tissue abuse and parafunctional habits Personnel responsible (early failures)


Tissue abuse habits, parafunctional habits, and Placement of an implant is a surgical procedure carried
psychological disorders have a detrimental effect out cumulatively by a periodontist, prosthodontist, and
on implant success. [3] Smoking is associated with an oral surgeon.[3] Extraction of natural tooth, assessment
significantly higher levels of bone loss. It reduces the of bone quality and quantity, periodontal health as well
density of bone which interferes with osseointegration, as systemic condition of the patient are all assessed by
leading to increase the failure rate.[4,13] A longitudinal periodontist and an oral surgeon. Prosthodontist takes
study by Lambert et al.  (2000) found more failures care of the implant design, prosthesis, and occlusal
in patients who smoked, and Bain and Moy  (1993) scheme. Any discrepancy in any of these steps decreases
observed that a significantly greater percentage of the success of implant. Inaccurate design of the implant
failures implant occurred in smokers  (11.3%) than in increases the occlusal loading on the implants resulting
nonsmokers  (4.8%).[13] Based on the studies carried in implant failure. Russell A. Wick in 1994 reported that
out by Dror Twito and Paul Sade between the years thoughtful design selection is crucial for the perpetual
1999 and 2008 in Israel, it has been proved that 4.2% success of any dental implant restoration.[26] Hence,
of implants, i.e., 321 out of 7680 implants failed due to laboratory technician also plays a significant role.[9]
smoking which included passive smoking as well.[23]
Parafunctional habits such as bruxism increase the Personnel responsible (late failures)
occlusal stress on implants. It leads to fracture of After successfully placing the implant, it is the
implants causing failures.[9] Glauser et al., evaluated patient’s duty to take care of its maintenance in the oral
41  patients who received 127 immediately loaded cavity. Inadequate postoperative care, carelessness in
implants. Their results showed that implants in maintaining oral hygiene leads to infection in the implant
patients with a parafunctional habit  (bruxers) were site causing peri‑implantitis.[27] More bone resorption
lost more frequently than those placed in patients with was noted around fixtures in edentulous patients with
no parafunction (41% vs. 12%).[24] Cognitive difficulty, poor oral hygiene than in participants with good hygiene 
mental retardation, and lack of support interfere with (Lindquist et al. 1988).[28] This proves that in addition to
surgical procedures. Implant success is adversely surgical precision, personnel involved in its procedure
affected due to psychological disorders.[3] and maintenance are responsible for the fate of implant.[3]

Radiation Failure mode


Radiotherapy is provided to patients suffering The mode in which failure is caused is different
from maxillary and mandibular tumors. It causes in early and delayed failures. In early failures, it
osteoradionecrosis of bone which decreases the volume is due to lack of osseointegration, whereas in late
of bone, thus interfering with osseointegration.[4,13] failures, it is due to functional and psychological
Reported success rate is only about 70%, long‑term attributes of the patient.[3] Osseointegration is direct
studies are limited, but Jacobsson et al. (1988) showed communication between implant surface and bone.[29‑32]
increasing implant loss over time due to radiation.[25] Lack of osseointegration causes loosening of implant in

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Kate, et al.: Classification of implant failures

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Conflicts of interest
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