failing factors associated with osseointegrated …jrenato.com.br/artigos/001.pdffailing factors...

Failing Factors Associated WithOsseointegrated Dental Implant LossClaudia Cristina Montes, PhD,* Fabiano Alvim Pereira, DDS, PhD,* Geninho Thome, DDS, MS, PhD,*

Edson Durval Menezes Alves, DDS, MS,* Rogeria Vieira Acedo, DDS,* Jose Renato de Souza, DDS, MS,*Ana Claudia Moreira Melo, DDS, PhD,* and Paula Cristina Trevilatto, DDS, PhD†

Dental implants have become animportant therapeutic modalityin the last decade,1,2 mainly af-

ter the works developed by Brånemark(1985),3 in which the direct contactbetween the bone functional tissuesand the biomaterial titanium wastermed osseointegration.4

After the installation of endosse-ous implants, there are three possibleresponses that may occur in host tis-sues: (1) acute or chronic inflamma-tory process, causing early implantfailure; (2) the formation of connec-tive tissue surrounding implant, lead-ing to osseointegration failure, and (3)living and functional bone tissue for-mation around the implants, resultingin osseointegration.5,6

The success rate in patients whoare treated with dental implants, ingeneral, is high for all implant sys-tems.7,8 In prospective and retrospec-tive studies, it varies from 84.9% to100% in longitudinal studies of up to24 years.9–12 However, despite the lownumber, failures occur, most of thetime unexpectedly.13–16 Beyond theimplant loss, early marginal bone lossaround endosseous implants is alsoconsidered a failure aspect.17

Implant loss is divided into earlyfailure, before the occurrence of theosseointegration, and the late failure,after the implant receives occlusalload.4,18–20 Success of osseointegration

is defined as an association of func-tional and aesthetic results,21,22 and de-pends on some factors,23 like implantbiomaterial and superficial properties(topography and roughness sur-face),24–27 appropriate bone quantityand quality,19 nonoccurrence of surgi-cal complications, as bone overheatingand contamination,21,26,28 –30 occlusaloverload,26 and peri-implantitis.22,31

Direct and indirect systemic fac-tors that influence host response seemto be of great relevance in the identi-fication of risk groups for implantloss. In some cases, even when thepatient has had appropriate bone quan-tity and quality, and adequate clinical

indication and recommendations arefollowed, failures in the osseointegra-tion process still do occur. Accordingto Esposito et al,32 implant failure isrelated to immunoinflammatory hostresponse. An intense inflammatoryprocess,33 which compromises os-seointegration,34 can lead to implantloss. Failure in the osseointegrationprocess is a significant cause of im-plant loss.35

The criteria for evaluation of im-plant failure are commonly based onclinical and radiographic alterations,which normally reflect wide patholog-ical conditions, such as mobility, en-capsulation, and local inflammation.33

*Professor at Latin-American Dental Research Institute(ILAPEO), Curitiba, PR, Brazil.†Adjunct Professor at Center for Health and BiologicalSciences, Pontifical Catholic University of Parana (PUCPR),Curitiba, PR, Brazil.

ISSN 1056-6163/07/01604-404Implant DentistryVolume 16 • Number 4Copyright © 2007 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e31815c8d31

Purpose: Dental implants arecurrently the aesthetic and func-tional alternative for tooth replace-ment. Despite the high success rateshown by longitudinal studies, fail-ures do occur, even in patients whopresent appropriate clinical condi-tions. The aim of the present study wasto identify factors related to, or deter-minant of, dental implant loss in pa-tients of the Latin-American DentalResearch Institute, Curitiba, PR, Bra-zil.

Materials and Methods: Retro-spective analysis of 3578 records ofpatients who had implants placed inthis institute during the period of 1996to 2006 was performed. Beyondrecords, panoramic and periapical ra-diographs were analyzed.

Results: Of the 3578 individualsimplant treated, failures occurred in126 (3.5%) patients (mean age 52.2 �10.6 years). Men lost more implants

(4.5%) than did women (3.1%) (P �0.05). Most failure occurred beforeloading (88.2%). Failure was morefrequent when the implant was in-stalled in the posterior jaw (58.5%).The main detectable causes of implantloss were evaluated. Most implantlosses (75%) did not have an apparentclinical cause. Identified causes were17.5% iatrogenic conditions (surgicaltechnique, contamination, and/or oc-clusal trauma), poor bone quality andquantity (3%), peri-implantitis (1%),and 3.5% missing data.

Conclusions: The results ob-tained in this study suggest that hostfactors can be contributing to the fail-ure of implants. (Implant Dent 2007;16:404–412)Key Words: dental implant failure,risk factors, osseointegration, hostfeatures

404 FAILING FACTORS ASSOCIATED WITH OSSEOINTEGRATED DENTAL IMPLANT LOSS

The identification of implant losscausative and related factors can allowearly intervention and minimize in-jury, besides increasing therapeuticalpotential, with the use of mediator an-alogues.33,36 The aim of this study wasto identify, retrospectively, factors as-sociated with osseointegrated implantloss in patients from the Latin-American Dental Research Institute(ILAPEO), Curitiba, PR, Brazil.

MATERIALS AND METHODS

In a retrospective study, 3578 pa-tient records, from the ILAPEO of Cu-ritiba, PR, Brazil, were analyzed.These patients were implant treated(Neodent™, Implante Osteointegravel,Santa Felicidade, Curitiba, PR, Brazil)by postgraduate students at ILAPEObetween 1996 and 2006. The possibleknown factors that led to implant fail-ure were identified by means of recordevaluation and analyses of comple-mentary documentation (panoramicx-rays and periapical radiographs). Pa-tient sex and age, number of teethpresent, number of placed implants,main detectable failure causes, dura-tion of the implants, implant positions,bone quality and quantity, and the pri-mary stability were evaluated.

RESULTS

From the patients who were im-plant treated (N � 3578), most pa-tients (2459; 68.7%) were women and1119 (31.3%) were men (mean age50 � 11.9 years). Most patients werenonsmokers (88.5%). The majority ofpatients (95.5% men and 96.9%women) did not present implant loss.

Failures occurred in 126 (3.5%)patients (mean age 52.2 � 10.6 years).Of these, 76 (60.3%) were women and50 (39.7%) were men. Men lost moreimplants (50 of 1119; 4.5%) thanwomen (76 of 2459; 3.1%) (P �0.05). Among the patients who lostimplants, the average of teeth presentin the moment of surgery was 19 (0–31). The baseline clinical parameterswere determined for the patients withimplant loss (Table 1).

From 875 placed implants in thefailure group (6.9 per patient); 212were lost (1.7 per patient). The per-centage of implant loss in the implantfailure group was 24.2%. Bone quality/

quantity, in most patients, was consid-ered to be adequate [bone type II/IIIand B/C (81.1%)], according to Lekholmand Zarb’s bone type classification.37

Most implants presented reasonableprimary stability (�45 N) (84.8%).Early failure represented 88.2% (187of 212) of cases; only 7.5% (16 of212) occurred after loading, and 4.2%(9 of 212) were missed after immedi-ate load. The survival implant meantime in early failure implants was 30.5weeks (0–179.0), and in late failureimplants was 72.5 weeks (4.0–191.3),and the survival mean time in imme-diate load was 4.4 weeks (1.9–6.0).The restoration procedure in the latefailure implants was divided in: 2.8%(6 of 212) single tooth prosthesis and9.0% (19 of 212) splinted teeth pros-thesis. Clinical characteristics of im-plants placed in patients with implantfailure are shown in Table 2.

The identified causes of implantfailure were iatrogenic conditions, asinadequate surgical technique, con-tamination and occlusal trauma(17.5%; 37 of 212), poor bone qualityand quantity (3%; 6 of 212), and peri-implantitis (1%; 2 of 212). Data weremissing in 3.5% (7 of 212) of cases.The majority of patients (75%; 160 of212) did not present any failure appar-ent clinical cause.

Failure was more frequent whenthe implant was installed in the poste-rior jaw (sextants IV and VI) (124 of212; 58.5%).

DISCUSSION

Epidemiologic and retrospectivestudies are important for clinicalknowledge that constitutes a referencepoint for specialists to plan, execute,

and evaluate implant procedures. Thechallenge for the future in the treat-ment with osseointegrated implantswill be the professional ability to de-tect and classify risk. The professionalteam must be able to select therapeuticprocedures taking into considerationindividual features,38 and trying tominimize injury and failure.

The technique of installation of os-seointegrated implants presents previs-ible and replicable results, with levels ofsuccess over 90%.39 Randomized clini-cal trials comparing different implanttypes or systems with a follow-up of atleast 1 year, reporting results of 512patients showed no significant differ-ences concerning implant failures andminor statistically significant differencesfor peri-implant bone level changes.40

In the present study, the numberof patients who presented implant loss

Table 1. Baseline Clinical Parametersof Patients Who Presented ImplantFailure (n � 126)

n (%)

GenderMale 50 (39.7)Female 76 (60.3)

Age, mean (�standarddeviation)

Male 50.1 (10.8)Female 53.2 (10.5)

SmokingYes 19 (15.1)No 107 (84.9)

Table 2. Number of Successful andFailed Implants in Patients WithImplant Loss (n � 126) and ClinicalCharacteristics of Failed Implants inThese Patients

n (%)

Failed and successfulimplants

Success 663 (75.8)Failure 212 (24.2)

Primary stability�40 N 180 (84.8)�40 N 32 (15.2)

Bone quantity/qualityAdequate 172 (81.1)Nonadequate 40 (18.9)

Bone graftYes 29 (13.7)No 183 (86.3)

Implant designCylindrical 184 (86.8)Conical 28 (13.2)

Implant hexagonInternal 164 (77.3)External 48 (22.7)

Implant lossEarly 187 (88.2)Late 16 (7.5)Immediate loading 9 (4.3)

Restoration typeImplants before

restoration187 (88.2)

Single toothprosthesis

6 (2.8)

Splinting toothprosthesis

19 (9.0)

*Quantity II or III/quality B or C.

IMPLANT DENTISTRY / VOLUME 16, NUMBER 4 2007 405

was 126 (3.5%), which is in accor-dance with published data from longi-tudinal studies.41,42 It was observedthat implant loss was influenced bysex. Men were more prone to developimplant failure (P � 0.05), which is inaccordance with the study by Mau.43 Itis possible that men are at a higher riskfor implant failure by the fact that theyseem to be less cooperative for post-operative medication use and hygienecare. No statistically significant differ-ence among patients was observed forage. A lack of association betweenimplant failure and age was also ob-served by other authors.19,38,44–49

It was observed in this study thatthe group of patients with implantloss was partially edentulous at thetime of surgery. The success rate hasbeen considered higher in partialthan in total edentulous patients.41 Thiscontroversial result can partially be ex-plained by a more favorable load distri-bution32 and lack of remaining teethbacterial reservoirs.14,50

Early failure results from a distur-bance in the initial steps of the os-seointegration mechanisms.4,41,44 Themajority of failures occurred in thepreload phase (88.2%). After the oc-currence of osseointegration, 7.5% ofthe implant failures occurred afterloading, and only 4.2% occurred inimmediately loaded implants. This ob-servation points to a host responserole within the individual healingprocess.33–35,45

Iatrogeny was the identified causeof implant failure in 17.5% of cases.Other studies have evidenced a similarfailure prevalence caused by iatro-genic factors,45–47,51 such as contami-nation,48,52–54 overheating,49,55 occlusaltrauma,56 inadequate surgical tech-nique,55 overloading forces.45,49

Poor bone quality and quantityhave also been considered a determi-nant influence in implant fail-ure.19,45,52,57,58 Studies suggest thatmost failures occur in places of poorbone quantity and quality.52,56–60 How-ever, in this study, bone quality andquantity were considered adequate inthe great majority of patients (81.1%)[bone type II/III and B/C]. Only 3% ofthe implant failures were related topoor bone quantity and quality. Theprimary stability in this study was con-sidered to be reasonable (84.8%) for

most patients. This indicates that thesurgical technique was performed inan adequate way.61 This still corrobo-rates with other studies, which affirmthat combined B and C bone quantity,together with II and III quality,37 al-lows a satisfactory stabilization and anadequate osseointegration.9,62–68

A still lower percentage of pa-tients (1%) presented peri-implantitis.A number of studies have reportedperi-implantitis as an important causeof implant failure.19,22,31,52,53

In the present study, 58.5% of thepatients who presented failure had lostimplants installed in the posterior re-gion of the jaw (sextants IV and VI).Once most failures occurred beforeloading (88.2%), this maybe is due tolocal bone quality and quantity. Thejaw cortical layer generally is denseand thick and tends to become narrowerand porous in the posterior region. Thesame occurs with the trabecular por-tion. Moreover, the presence of themandibulary canal limits the availablebone volume in the posterior jawregion.32,69

Despite several studies reportingvarious clinical causes in associationwith osseointegrated implant failures,some questions on risk factors, whichpredispose to implant loss, remain tobe clarified.7,15,56

The great majority of patients (75%)with lost implants did not present apparentdeterminant clinical causes,9,10,70 suggest-ing an inefficient host immunoinflam-matory response.56 Besides, a smallgroup presented failure (126 of 3578patients; only 3.5%). Within this group(126 patients) the percentage of lost im-plants increased from 3.5% to 24.2%.These data suggest that few individu-als can concentrate risk for implantloss. This phenomenon has beentermed clusterization.4,71–73

From this observation, severalquestions should arise in the searchfor implant loss susceptibility. Ge-netic predisposition could be sug-gested, including the adding effectof gene polymorphisms.

CONCLUSION

Most patients presented no appar-ent clinical cause for implant failure.These results suggest that host factors,

not identified clinically, can contributeto an increased risk for implant loss.

Genetic studies should be pro-posed in order to better understandhost response to implant failure.

Disclosure

All authors claim to have a finan-cial interest in ILAPEO, whose prod-uct, Neodent implant, is mentioned inthis article.

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Reprint requests and correspondence to:Paula Cristina Trevilatto, DDS, PhDCenter for Health and Biological SciencesPontifıcia Universidade Catolica do Parana(PUCPR)Rua Imaculada Conceicao1155 Curitiba, PRBrazil 80215-901Phone: �55(41) 3271-2618Fax: �55(41) 3271-1657E-mail: [email protected]

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Claudia Cristina Montes, PhD, Fabiano AlvimPereira, DDS, PhD, Geninho Thome, DDS, MS, PhD, EdsonDurval Menezes Alves, DDS, MS, Rogeria Vieira Acedo,DDS, Jose Renato de Souza, DDS, MS, Ana Claudia MoreiraMelo, DDS, PhD, Paula Cristina Trevilatto, DDS, PhD.Schriftverkehr: Paula Cristina Trevilatto, DDS, PhD, Zen-trum fur Forschungen im Bereich Gesundheitswesen undBiologie (Center for Health and Biological Sciences), Pon-tifıcia Universidade Catolica do Parana (PUCPR), RuaImaculada Conceicao, 1155, Curitiba, PR, Brasilien 80215-901. Telefon: �55 (41) 3271-2618, Fax: �55 (41) 3271-1657, eMail: [email protected] Verbindung mit dem Verlust Knochengewebsintegrier-ender Zahnimplantate zu sehende Versagensfaktoren

ZUSAMMENFASSUNG: Zielsetzung: Aktuell stellen Zah-nimplantate die aus asthetischer sowie funktionaler Sichtbeste Alternative fur einen Zahnersatz dar. Trotz der in langsverlaufenden Studien ausgewiesenen hohen Erfolgsquotetreten nichtsdestotrotz auch Versagensfalle auf und dies sogarbei Patienten, die optimale klinische Voraussetzungen mit-bringen. Die vorliegende Studie zielte darauf ab, die mit demVerlust von Zahnimplantaten in Verbindung stehenden oder

die diesen verursachenden Faktoren bei Patienten des “Latin-American Dental Research Institute” (ILAPEO), Curitiba,PR, Brasilien, zu bestimmen. Materialien und Methoden: Eswurde eine retrospektive Analyse von insgesamt 3.578 Kran-kenblattern durchgefuhrt. Diesen Patienten wurden im Zeitraumvon 1996 bis 2006 im oben genannten Institut Zahnimplantateeingesetzt. Zusatzlich zu diesen Unterlagen wurden auch Pan-oramaaufnahmen und periapikale Rontgenbilder analysiert.Ergebnisse: Von den insgesamt 3.578 mittels Implantierungbehandelten Patienten verzeichneten 126 (3,5%) ein Fehlschla-gen der Implantierungsbehandlung. Das durchschnittliche Alterder Patienten lag dabei bei 52,2 � 10,6 Jahren). Vom Verlustder Implantate betroffen waren mehr Manner (4,5%) als Frauen(3,1%) (p � 0,05). Am haufigsten tritt ein Versagen bereits vorBelastung des Implantats auf (88,2%). Ebenfalls wurde einhaufigeres Fehlschlagen bei Implantierung im hinteren Kieferbeobachtet (58,5%). Die herausstehenden Begrundungen fur dasVersagen eines Implantats wurden herausgefiltert undbeurteilt. Dabei schienen die meisten Fehlschlage (75%)keinen direkt ableitbaren klinischen Grund zu haben. Unterden zu bestimmenden Begrundungen fanden sich: zu 17,5%iatrogene Bedingungen (Operationstechnik, Verunreinigungund/oder okklusales Trauma); schlechte Qualitat sowie Quan-titat des Knochengewebes zu 3%; Periimplantitis (1%) und


fehlende Daten zu 3,5%. Schlussfolgerungen: Die innerhalbdieser Studie gewonnenen Erkenntnisse lassen den Schlusszu, dass Wirtsfaktoren zum Versagen einer Implantierungs-behandlung beitragen konnen.

SCHLUSSELWORTER: Versagen von Zahnimplantaten,Risikofaktoren, Knochengewebsintegration, Wirtsfaktoren

SPANISH / ESPAÑOLAUTOR(ES): Claudia Cristina Montes, PhD, Fabiano AlvimPereira, DDS, PhD, Geninho Thome, DDS, MS, PhD, EdsonDurval Menezes Alves, DDS, MS, Rogeria Vieira Acedo,DDS, Jose Renato de Souza, DDS, MS, Ana Claudia MoreiraMelo, DDS, PhD, Paula Cristina Trevilatto, DDS, PhD.Correspondencia a: Paula Cristina Trevilatto, DDS, PhD,Center for Health and Biological Sciences, Pontifıcia Uni-versidade Catolica do Parana (PUCPR), Rua ImaculadaConceicao, 1155, Curitiba, PR, Brazil 80215-901. Tele-fono: �55 (41) 3271-2618, Fax: �55 (41) 3271-1657,Correo electronico: [email protected] de fallas asociados con la perdida de implantesdentales oseointegrados

ABSTRACTO: Proposito: Los implantes dentales son actu-almente la alternativa estetica y funcional para el reemplazode un diente. A pesar de la alta tasa de exito demostrada porlos estudios longitudinales, ocurren fallas, incluso en pacien-tes que presentan condiciones clınicas apropiadas. El objetivode este estudio fue identificar factores relacionados con, odeterminantes de, la perdida del implante dental en paci-entes del Latin-American Dental Research Institute(ILAPEO), Curitiba, PR, Brasil. Materiales y Metodos: Serealizo un analisis retrospectivo de 3.578 historiales depacientes que recibieron implantes colocados en este in-stituto durante el perıodo 1996 a 2006. Ademas de loshistoriales, se analizaron radiografıas periapicales y pan-oramicas. Resultados: De los 3.578 implantes individualestratados, ocurrieron fallas en 126 (3,5%) pacientes (edadmedia de 52,2 � 10,6 anos). Hombres perdieron masimplantes (4,5%) que mujeres (3,1%) (p � 0,05). Lamayorıa de las fallas ocurrieron antes de la carga (88,2%).Las fallas fueron mas frecuentes cuando se coloco elimplante en la mandıbula posterior (58,2%). Se evaluaronlas causas detectables principales de la perdida del im-plante. La mayorıa de las perdidas de los implantes (75%)no tuvieron una causa clınica aparente. Las causas identi-ficados fueron: 17,5% condiciones iatrogenicas (tecnicaquirurgica, contaminacion y/o trauma oclusal); pobre cali-dad y cantidad de hueso (3%); periimplantitis (1%), y 3,5%datos que faltan. Conclusiones: Los resultados obtenidosen este estudio sugieren que factores de recepcion puedencontribuir a la falla de los implantes.

PALABRAS CLAVES: falla del implante dental, factores deriesgo, oseointegracion, factores de recepcion

PORTUGUESE / PORTUGUÊSAUTOR(ES): Claudia Cristina Montes, PhD, Fabiano AlvimPereira, Cirurgiao-Dentista, PhD, Geninho Thome, Cirurgiao-Dentista, Mestre em Ciencia, PhD, Edson Durval MenezesAlves, Cirurgiao-Dentista, Mestre em Ciencia, Rogeria VieiraAcedo, Cirurgia-Dentista, Jose Renato de Souza, Cirurgiao-Dentista, Mestre em Ciencia, Ana Claudia Moreira Melo,Cirurgia-Dentista, PhD, Paula Cristina Trevilatto, Cirurgia-Dentista, PhD. Correspondencia para: Paula CristinaTrevilatto, DDS, PhD, Center for Health and Biological Sci-ences, Pontifıcia Universidade Catolica do Parana (PUCPR),Rua Imaculada Conceicao, 1155, Curitiba, PR, Brazil 80215-901. Telefone: �55 (41) 3271-2618, Fax: �55 (41) 3271-1657,e-Mail: [email protected] de Fracasso Associados com Perda de ImplanteDentario Osseointegrado

RESUMO: Objetivo: Os implantes dentarios sao atualmentea alternativa estetica e funcional para substituicao de dentes.Apesar da alta taxa de exito mostrada por estudos longitudi-nais, fracassos realmente ocorrem, mesmo em pacientes queapresentam condicoes clınicas apropriadas. O objetivo dopresente estudo foi identificar fatores relacionados ou deter-minantes de perda de implante dentario em pacientes doInstituto Latino Americano de Pesquisa e Ensino Odon-tológico (ILAPEO), Curitiba, PR, Brasil. Materiais e Meto-dos: Foi realizada analise retrospectiva de 3.578 prontuáriosde pacientes que tiveram implantes colocados neste institutodurante o perıodo de 1996 a 2006. Alem de prontuários,radiografias panoramicas e periapicais foram analisadas. Re-sultados: De 3.578 indivıduos tratados, perdas ocorreram em126 (3,5%) pacientes (idade media 52,2 � 10,6 anos). Oshomens perderam mais implantes (4,5%) do que as mulheres(3,1%) (p � 0,05). A maior parte dos perdas ocorreu antes dacarga (88,2%). Os perdas foram mais frequentes quando oimplante foi instalado na mandıbula posterior (58,5%). Asprincipais causas detectaveis de perda de implante foramavaliadas. A maior parte das perdas de implante (75%) naotinha causa clınica aparente. As causas identificadas foram:17,5% de condicoes iatrogenicas (tecnica cirurgica, contami-nacao e/ou trauma oclusal); qualidade e quantidade deficientede osso (3%); periimplantite (1%), e 3,5% de dados faltantes.Conclusoes: Os resultados obtidos neste estudo sugerem quefatores do hospedeiro podem estar contribuindo para o fra-casso dos implantes.

PALAVRAS-CHAVE: fracasso de implante dentario, fatoresde risco, osseointegracao, caracterısticas do hospedeiro

RUSSIAN /��: Claudia Cristina Montes, ��†, Fabiano Alvim Pereira, �� , �� †,Geninho Thomé, �� ,�� , �� †, Edson Durval Men-


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