10 Etiology, Management, and Prevention of Hardware Complications with Implant-supported Reconstructions
2Literature Review
L. J. A. Heitz-Mayfield, U. Brägger
2.1Statements and Recommendations Obtained from the 4th and 5th ITI Consensus Conferences
2.1.1Proceedings of the 4th ITI Consensus Conference 2008
International Journal of Oral and Maxillofacial Implants 2009, Vol. 24 (Supplement): Consensus statements and recommended clinical procedures regarding risk factors in implant therapy (Cochran and coworkers 2009)
Introductory remarks
The group was asked to address the available evidence for potential risk factors in implant therapy. The authors were requested to prepare narrative reviews using a systematic approach, and were provided with general topics rather than specific research questions. The four reviews presented for discussion within the group addressed: (1) systemic conditions and treatments as risks for implant therapy, (2) history of treated periodontitis and smoking as risks for implant therapy, (3) mechanical and technical risks in implant therapy, and (4) local risk factors for implant therapy. The group's participants critically reviewed each of the review papers produced by its members, and amendments were made following thorough discussion.
Systemic conditions and treatments
Clinical recommendations
With respect to systemic conditions and treatments as risk factors for implant therapy, the following recommendations can be made:
A thorough medical history is essential to identify potential systemic risks.
Risks for implant failure and risks for medical complications should be differentiated and evaluated. In some instances, conditions and their treatments may pose increased risks for implant failure, whereas the risk for the patient may be minimal. As an example, there are no data to support withholding implant treatment for patients with diabetes or osteoporosis. However, these patients need to be informed of the possibility of implant complications.
Where there is a potential risk of a medical complication-for example, osteonecrosis of the jaw in patients taking oral bisphosphonates and patients undergoing radiotherapy-the option of implant therapy should be chosen restrictively, and the patient should be informed specifically, taking into account the current level of uncertainty with regard to the consequences. For patients with a life-threatening systemic disease, implant placement should be postponed until the patient's medical condition is stabilized and has improved.
History of treated periodontitis and smoking
Clinical recommendations
With respect to a history of treated periodontitis and smoking, the following recommendations can be made:
History of treated periodontitis. A history of treated periodontitis is not a contraindication for implant placement. However, patients with a history of treated periodontitis should be informed of an increased risk of implant failure and peri-implantitis. Patients with a history of periodontitis should receive individualized periodontal maintenance and regular monitoring of peri-implant tissue conditions.
Smoking. Smoking is not a contraindication for implant placement. However, patients should be informed that the survival and success rates are lower in smokers. Heavy smokers should be informed that they are at greater risk of implant failure and loss of marginal bone. Patients who smoke should be informed that there is an increased risk of implant failure when sinus augmentation procedures are used.
History of treated periodontitis and smoking combined. Patients who smoke and have a history of treated periodontitis should be informed that they have an increased risk of implant failure and peri-implant bone loss.
Mechanical and technical risks
Clinical recommendations
With respect to mechanical/technical risks, the following recommendations can be made:
In general, implant reconstructions should be planned to minimize mechanical/technical risks.
Patients receiving implant therapy should receive regular maintenance care in order to detect mechanical/technical complications early, particularly in patients with overdentures.
Both cemented and screw-retained implant-supported reconstructions can be recommended.
Patients should be evaluated for bruxism.
Local risk factors
Clinical recommendations
With respect to local risk factors, the following recommendation can be made:
Special care should be taken in selection of implant diameter and design in areas with limited interdental space.
2.1.2Proceedings of the 5th ITI Consensus Conference 2013
International Journal of Oral and Maxillofacial Implants 2014, Vol. 29 (Supplement): Consensus statements and clinical recommendations for prevention and management of biologic and technical implant complications (Heitz-Mayfield and coworkers 2014)
Introductory remarks
Implant treatment is highly successful, as documented in a wealth of scientific literature. However, patients and clinicians should expect to see complications within their daily practice. The aim of the papers presented by this group was to address the prevention and management of technical and biologic complications in order to make recommendations both for clinical practice and future research. Three topics were chosen within the field of complications of implant treatment, and these addressed prevention and therapy of peri-implant disease and prevention of technical complications.
Three systematic reviews were conducted and formed the basis for discussion of working group 5. The discussions led to the development of statements and recommendations determined by group consensus based on the findings of the systematic reviews. These were then presented and accepted following modifications as necessary at plenary sessions.
Effects of anti-infective preventive measures on biologic implant complications and implant loss
Consensus statements
The aim of the review by Salvi and Zitzmann (2014) was to systematically appraise whether anti-infective protocols are effective in preventing biologic implant complications and implant loss after a mean observation period of at least ten years following delivery of the prosthesis. Out of fifteen included studies, only one comparative study assessed the effects of adherence to supportive periodontal therapy (SPT) on the occurrence of biological complications and implant loss. In view of the lack of randomized trails, observational studies including adherence and lack of adherence to SPT were considered valuable in order to estimate the effects of SPT on implant longevity and the occurrence of biological complications.
Overall, the outcomes of this systematic review indicated that high long-term survival and success rates of dental implants can be achieved in partially and fully edentulous patients adhering to supportive periodontal therapy (SPT).
Long-term implant survival and success rates are lower in patients with a history of periodontal disease adhering to SPT compared with those without a history of periodontal disease.
The findings of this systematic review indicate that pre-existing peri-implant mucositis in conjunction with lack of adherence to SPT was associated with a higher incidence of peri-implantitis.
Treatment guidelines
Preventive measures before implant placement
Residual periodontal pockets are a risk for peri-implant disease and implant loss. Therefore, completion of active periodontal therapy aiming for elimination of residual pockets with bleeding on probing should precede implant placement in periodontally compromised patients.
In cases of residual probing depths (PD) = 5 mm with concomitant bleeding on probing, full-mouth plaque scores > 20%, and associated risk factors, re-treatment and periodontal reevaluation are recommended before implant placement.
In subjects diagnosed with aggressive periodontitis, an SPT program with shorter intervals is a prerequisite.
During implant treatment planning, factors to be considered that may result in biological complications include: insufficient keratinized mucosa and bone volume at the implant recipient site, implant proximity, three-dimensional implant position, and design and cleansability of the prosthesis. Alternative restorative solutions should be considered according to a patient's individual circumstances.
Preventive measures after implant placement
All oral healthcare providers, including undergraduate students, should be trained to recognize clinical signs of peri-implant pathology and maintain or reestablish peri-implant health.
After delivery of the definitive implant-supported prosthesis, clinical and radiographic baseline measurements should be established.
During SPT, an update of medical and dental history and a clinical inspection of the...
