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3 Implant Surgery
Raza A. Hussain, BDS DMD, FACS
Pooja Gangwani, DDS, MPH
Michael Miloro DMD, MD, FACS
INTRODUCTION
It is clear that, since the introduction of the principles of osseointegration by Branemark and its worldwide acceptance, the clinical practice of dental implantology has completely changed the prosthodontic, surgical, and orthodontic rehabilitation of partially edentulous, fully edentulous, and, in some cases, fully dentate patients. Although there is a low incidence of integration failure of an implant fixture, and the clinical and radiographic features of implant condition are well known (Table 3.1), an implant that has achieved success or satisfactory osseointegration may be considered a failure from a restorative or functional standpoint. Fortunately, many complications that are associated with dental implant placement are considered salvageable, even if the plan would include implant removal and replacement. However, certain types of dental implant failures may have devastating consequences on the physical, psychosocial, and financial well‐being of a patient, and may also impact negatively upon surgeon confidence. This chapter will focus on the more common complications associated with dental implant surgery, in the preoperative, intraoperative, and postoperative phases of treatment, with strategies for avoidance as well as management of these implant‐related complications. Consideration will be given to (i) preoperative planning and the avoidance of complications during the treatment planning phase; (ii) intraoperative contributions to integration failure and acute intraoperative complications; (iii) early postoperative failures; and (iv) late postoperative failures including peri‐implantitis (Table 3.2).
PRE‐OPERATIVE PLANNING
Patient Assessment
There are many critical factors that are important to assess when evaluating a patient for implant reconstruction. Even before the actual clinical assessment is performed, the clinician should have a reasonable idea whether the patient is a candidate for a successful implant treatment outcome. The patient's ability to cooperate with treatment, and subsequent hygiene and maintenance requirements, should be of primary concern when evaluating a patient for dental implant and prosthetic reconstruction. A short‐term successful implant surgical outcome (osseointegration), while important, does not ensure long‐term success of implant rehabilitation if the patient does not possess the understanding, dexterity, and skills to perform ongoing implant maintenance. Additionally, an assessment of patient expectations is key in determining whether the patient is able to consider their own treatment a success, and also the ability to deal with failure and complications if, and when, they may occur.
Table 3.1. Co‐relationship between implant condition and clinical and radiographic findings
| Implant condition | Clinical and radiographic examination |
|---|---|
| Success | No pain/tenderness upon functionNo mobility<2 mm of radiographic bone loss from initial surgeryNo exudate |
| Satisfactory state | No pain on functionNo mobility2–4 mm of radiographic bone loss from initial surgeryNo exudate |
| Compromised state | May have sensitivity on functionNo mobility>4 mm of radiographic bone loss from initial surgery or less than half length of an implantProbing depths >7 mmMay have exudate |
| Failure | Pain upon functionPresence of mobilityRadiographic bone loss less than half length of an implantPresence of continuous exudateNo longer present in the oral cavity |
Table 3.2. Stages of implant failure
| At implant placementBone overheatingImplant surface contaminationLack of primary implant stabilityInfectionEccentric loading |
| Delayed (1–2 years)Poor soft tissue healthLack of keratinized tissuePeri‐implantitisPoor oral hygieneSystemic issues (e.g., smoking)Excessive biomechanical loadsProsthodontic issuesImplant and component fractures |
| Late (>2 years)Progressive steady‐state bone lossPoor hygiene maintenanceProsthodontic issues |
There have been a variety of systemic conditions described in the literature that traditionally have been accepted as risk factors for implant integration failure, and a number of studies cite specific conditions that are considered to be absolute or relative contraindications to dental implant placement. Typically, these comorbid conditions have included diabetes mellitus, osteoporosis, corticosteroid use, tobacco smoking, bisphosphonate use, chemotherapy, and head and neck radiation (Table 3.3). Recently, several outcome studies have alluded to the fact that each of these indeed may not be absolute, or even relative, contraindications, and that other factors, not generally included in this list, may be more significant contributors to implant failure. One study [1] analyzed data from 35 other studies that included implant failure rates in diabetics and smokers. The findings suggest that while smoking contributed significantly to implant failure, there was no effect for diabetes. However, a contradictory study reviewing 4680 implants [2] found that there was indeed a significant increase in implant failure in both the diabetic and smoker. Also, additional conditions related to an increased risk for implant failure include patient age greater than 60 years, head and neck radiation, and postmenopausal estrogen use. Conversely, gender, hypertension, coronary artery disease, pulmonary disease, steroid therapy, chemotherapy, and not receiving hormone replacement therapy (in postmenopausal women) were all not associated with an increased incidence of implant failure.
Table 3.3. Factors affecting implant success
| Condition | Recommendations |
|---|---|
| Diabetes mellitus | Glycemic control (HBA1c < 8), antibiotic prophylaxis |
| Jaw irradiation | Consider dose and field, avoid implants, HBO prophylaxis |
| Smoking | Smoking cessation or nicotine holiday, avoid implants |
| Corticosteroids | Controversial, steroid holiday |
| Periodontal disease | Correct prior to implant, oral hygiene instructions |
| Advanced age | Accepted risk |
| Parafunctional habits | Address before implants, bite appliances, physical therapy, medicines (Botox) |
| Osteoporosis | Controversial |