Treatment planning/ risk assessment

and prosthodontic risk management

in implant dentistry

Urs Brägger

Department of Reconstructive Dentistry and Gerodontology

School of Dental Medicine
University of Bern, Switzerland 1
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Complications and prosthetic risk management
• Terms, definitions
• Failure rates from systematic reviews
• Complication rates under optimal conditions
• Risk factors
• Risk management

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Definitions
• Risk is a concept that denotes a potential negative impact to some
characteristic of value that may arise from a future event. Exposure to the
consequences of uncertainty constitutes a risk.

• Risk factor: a variable associated with an increased risk of disease or

infection. Risk factors are correlational but not necessarily causal.

• Risk = number of persons experiencing event (food poisoning) / number of

persons exposed to risk factor (food) e.g. chicken 22 / 74 (.297) versus non
chicken 2 / 35 (.057).

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Technical and mechanical risks with implant supported reconstructions

A systematic review

Giovanni Salvi & Urs Braegger

School of Dental Medicine, University of Bern, Switzerland

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Literature search

•3568 titles
•111 full text
•37 included
•Comparative with risk vs without risk
•4 years
•Loading aspects excluded
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Definition of terms

• Mechanical risk: Risk of a complication or failure of a

prefabricated component caused by mechanical
forces

• Technical risk: Risk of a complication or a failure of the

laboratory-fabricated reconstruction or its materials

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Potential risks / Evidence for increased risk 

• Type of retentive elements in OD
• Cantilever extensions
• Use of angled abutments
• Bruxism
• Crown to implant ratio
• Complexity of the reconstruction
• Prosthetic materials
• Number of implants supporting an FDP
• Previous mechanical/technical complications
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Regarding survival rates of implants
and crestal bone loss none of the
above factors had a negative effect

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Definition of terms

•ITI Treatment Guide 8:

Braegger Urs & Heitz-Mayfield Lisa

Hardware-related complications

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Complications and prosthetic risk management
• Terms, definitions
• Failure rates from systematic reviews
• Complication rates under optimal conditions
• Risk factors
• Risk management

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 Survival rate

FDP Type 5 - years 10 - years

Conventional FDPs 93.8% 89.2%

Cantilever FDPs T 91.4% 80.4%*

Cantilever FPDs I 94.3% 88.9%

Implant supported FDPs 95.2% 86.7%

Crossarch perio FDPs 96.4% 92.9%

T-I supported FDPs 95.5% 77.7%*

Implant supported SC 94.5% 89.4%

Resin bonded FDPs 87.8% 65.0%*

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Complications and prosthetic risk management
•Terms, definitions
•Failure rates from systematic reviews
•Complication rates under optimal conditions
•Risk factors
•Economics
•Risk management
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Complication and failure rates with implant-
supported fixed dental prostheses and single
crowns: a 10-year retrospective study

Wittneben J, Buser D, Salvi G, Bürgin W, Hicklin S,

Brägger U.

Clin Implant Dent Relat Res. 2014 Jun;16(3):356-64

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General situation
Midline
Overjet, Overbite
Attrition: 0 no,1 localized, 2 generalised
Guidance: Canine protected, group function, balance
Opposing dentition: Natural, with fillings or reconstructions, implant-
supported reconstructions, RPD, full denture

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Design of the reconstruction
Crown
FDP
-units
Number of abutments
Extension mes/dist
PFM, other
Cemented or screw retained, other

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 The reconstructions were mainly provided by
referring dentists and their dental technicians

1998 1998

1997 1996

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1999 2008

1998 1996

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 N

N patients 303

N reconstructions 397

Impl crowns 268

FDPs 129
(I-I=127; I-T=2)

Maxilla 187

Mandibula 202

Anterior 81

Posterior 308

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 10 year 10 year 10year N compl + 10year
N total N failures failure rate survival rate N compl compl.rate failures success

I crowns and 397 18 4.5 % 95.5 %

FDPs

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9/18 failures were true prosthetic failures. 9 occurred due to other
reasons.
In 6 instances the loss of the supporting implant lead to the loss of the
reconstruction.
In two instances a new reconstruction was made because adjacent
teeth failed.
One FDP was separated and the distal portion removed because of
cheek biting.

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Two crowns had to be redone due to abutment fracture.
In one case, the crown was redone due to esthetic reasons
(step formation, continuous eruption of the adjacent teeth).
2 crowns were redone due to massive chipping.
4 reconstructions were „repaired“ due to massive chipping.
These were also counted as failures.

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 In 2 reconstructions loss of retention and chipping were noted

Mechanical and technical complications over 10 years N %

Loss of retention 7 2.06

Ceramic chipping 79 20.31

Loosening of the occlusal screw 10 2.57

Fracture of the occlusal screw 0 0

Loosening of the abutment 1 0.26

Fracture of the abutment 2 0.52

Wear down to metal framework 1 0.26

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Ceramic chipping

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The most frequent complication was chipping of the veneer ceramic
This affected every 5th reconstruction.
Loss of retention occurred rarely.
Screw loosenings were rarely observed.
Fractures of screws were extremely rare.
Some unprecise crown margins were noted in the radiographic
analyses. This will be further evaluated (effect on tissue conditions?).

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 10 year 10 year 10 year N compl + 10year
N total N failures N compl
failure rate survival rate compl.rate failures success

98
reconstruc
tiones
Implant crowns 397 18 4.5 % 95.5 % (2x2 24.7 % 114(29.2%) 70.8 %
and FDPs compl.
within the
same
Rec.)

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Complications and prosthetic risk management
• Terms, definitions
• Failure rates from systematic reviews
• Complication rates under optimal conditions
• Risk factors
• Risk management

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 Risk factor
Attrition 0 1 2 Ceramic chipping
0 = no
1 = loc. p< .015 (Wald Chi-square)
1.6-29.4 (Confidence interval for
2 = gen. 101(26.3%) 164(42.7%) 119(31.0%)
odds ratios)
11/101 36/164 32/119
(10.9%) (21.9%) (26.9%)

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 Risk factor
0 1

Extension Ceramic chipping

0=no Ext.
1=Ext. 340
(87.4%)
49
(12.6%) n.s (Fisher‘s exact test)
68/340 11/49
(20.0%) (22.5%)

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 Risk factor
crowns >1 unit

-units ceramic fracture

p< .01 (Wald Chi-square)
261(67.1%) 127(32.9%) .3-.83 (Confidence interval
44/261
(16.9%)
36/127
(28.3%) for odds ratios)

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 Risk factor
Cem/ 0 1 2 4

Ceramic chipping
screw ret.
n.s.
311(80%) 68(17.5%) 9(2.3%) 1(0.2%)
64/311 13/68 2/9 0/1
(20.7%) (19.1%) (22.2%) (0%)

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Summary
On SLA implants, the 10-year survival rates with ceramo metal crowns
and FDPs were high
Complications: Ceramic fractures>screw loosening>loss of retention
Mechanical complications with components were extremely rare
The marginal fit of the crowns/FDPs was in some reconstructions
insufficient
„Attrition“ and „number of units“ were a risk factor, other parameters
analyzed were not
Ceramic veneers and their fabrication/resistance need to be
improved
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Retrospective cohort study of 4591 Straumann
implants in private practice setting, with up to 

10-year follow-up. 

Part 1: multivariate survival analysis
French D1,2, Larjava H1, Ofec R3

Clin Oral Implants Res. 2015 Nov;26(11):1345-54. doi: 10.1111/clr.12463. Epub 2014 Aug 19.

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Material and Methods
A total of 4591 Straumann implants were placed in 2060 patients between 1999
and 2012.

Patients were evaluated after 2-3 months, 1, 3, 5, and 7 years and, in some
cases, up to 10 years.

The cumulative survival rate (CSR) was calculated according to the life table
method and illustrated with Kaplan-Meier survival curves.

Univariate analysis was performed to investigate the association between

study variables and time to implant-failure. Variables with P-value < 0.15 were
further selected for a multivariate analysis. Statistical methods which take into
account the fact that some patients have more than one implant (therefore,
dependency between implants within mouth) had been applied.

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Results
At the implant level, the cumulative survival rates at 3, 5, and 7 years were 99.3%,
99.0%, and 98.4%, respectively, and at the patient level, they were 98.6%, 97.7%, and
95.9%, respectively.

After adjustment to possible confounders, the multivariate analysis identified a

relationship between the following risk indicators for implant failure: implant location,
length and design, timing of implantation, bone grafting procedures and gender.

Tissue-Level implants (n = 3863) had a very high survival rate of 99% at 3 years, which
was maintained over the entire study period. Bone-Level implants (n = 600) were as
predictable with a survival rate of 99% up to 3 years, while Tapered Effect implants (n =
128) demonstrated a lower survival rate of 95% at 5 years. Short 6-mm implants in the
mandibular posterior sites had a high survival rate of 100%, while in maxillary posterior
positions a survival rate of only 87% was achieved.

Patient factors such as smoking, autoimmune disease, and penicillin allergy were
tending to associate with higher failure rates. 36
Conclusion
High long-term survival rates were observed for a large cohort of
Straumann implants.

Tissue and Bone-Level implants had higher survival rates than Tapered
Effect implants, and although short implants faired well in the
mandibular posterior sites, they faired less well in the maxillary posterior
sites.

The study represents private practice insight into large-scale, long-term

implant results.

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Complications and prosthetic risk management

•Terms, definitions
•Failure rates from systematic reviews
•Complication rates under optimal conditions
•Risk factors
•Risk management

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Risks with tooth supported reconstructions

• Remaining tooth substance

• Extensions
• Devital abutment: fix<RPD<overdenture
• Combination of T-I
• Ceramic FDP versus ceramometal FDP
• Caries and endodontic events

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Technical/mechanical risk factors for implant supported
reconstructions
• Attachment system
• Extensions
• Screw retention
• Angulation
• Complexity of reconstruction
• Number of I
• C/R ratio
• Materials
• Previous complications
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 (Surface,,Max/mand)

(diameter)
(cumulative events,compl.leading to failures)

(screw,cem,I-T)
(Bruxism,number of I,C:R ratio)

(morse taper,internal,external)

(titanium,acrylic)

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Patient risks in reconstructive dentistry

• Bruxism
• Eating disorders
• Drug controlled mental disorders
• Compliance
• Being dependent

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Multiple combined risks

• Repeated and combined failures and complications

• Statistical evaluations usually end with first event
• Risk mitigation: The process of developing a plan to respond
or deal with risk
• Incomplete data sets

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Survival analysis and clinical evaluation of
implant-retained prostheses in oral cancer
resection patients over a mean follow-up
period of 10 years.

Katja Nelson, Susanne Heberer and Corvin Glazer

J Prosthetic Dent, Vol 98(5) Nov 2007, 405-10

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

Eli E. Machtei, Dan Mahler, Orit Oettinger-Barak,

Otman Zuabi, Jacob Horwitz

Clin. Oral Impl. Res. 19, 2008 / 259-264

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+ professional skills and errors

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Risk management
• Estimate the risks
• Inform about risks
• Reduce known risks
• Use small segments
• Use original components
• Provide retrievability
• Control the technical work
• Collaborate with a quality and service centered laboratory
• Change concept in case of repeated complications
• Apply the service set and complaint system
• Share the risk 62
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Thank you for your attention !
urs|brägger

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