ITI Treatment Guide Volume 8 Biological and Hardware Complications in Implant Dentistry

ITI Treatment Guide
Volume 8

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ITI
Treatment
Guide
Volume 8

Biological and Hardware
Complications in Implant Dentistry
Editors:
D. Wismeijer, D. Buser, S. Chen
Authors:
U. Brägger, L. J. A. Heitz-Mayfield

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Quintessence Publishing Co, Ltd
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Warsaw

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German National Library CIP Data

The German National Library has listed this publication in the German
National Bibliography. Detailed bibliographical data are available at
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© 2015 Quintessence Publishing Co, Ltd
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www.quintessenz.de
All rights reserved. This book or any part thereof may not be
reproduced, stored in a retrieval system, or transmitted in any form or
by any means, whether electronic, mechanical, photocopying, or
otherwise, without prior written permission of the publisher.
Illustrations:
Copyediting:
Graphic concept:
Production:
Printing:

Ute Drewes, CH-Basel,
www.drewes.ch
Triacom Dental, D-Barendorf,
www.dental.triacom.com
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ISBN:
978-3-86867-282-4 (ebook)
978-3-86867-240-4 (print)

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The materials offered in the ITI Treatment Guide are for educational
purposes only and intended as a step-by-step guide to treatment of a
particular case and patient situation. These recommendations are
based on conclusions of the ITI Consensus Conferences and, as
such, in line with the ITI treatment philosophy. These
recommendations, nevertheless, represent the opinions of the
authors. Neither the ITI nor the authors, editors and publishers make
any representation or warranty for the completeness or accuracy of
the published materials and as a consequence do not accept any
liability for damages (including, without limitation, direct, indirect,
special, consequential or incidental damages or loss of profits) caused
by the use of the information contained in the ITI Treatment Guide.
The information contained in the ITI Treatment Guide cannot replace
an individual assessment by a clinician, and its use for the treatment
of patients is therefore in the sole responsibility of the clinician.
The inclusion of or reference to a particular product, method,
technique or material relating to such products, methods, or
techniques in the ITI Treatment Guide does not represent a
recommendation or an endorsement of the values, features, or claims
made by its respective manufacturers.
All rights reserved. In particular, the materials published in the ITI
Treatment Guide are protected by copyright. Any reproduction, either
in whole or in part, without the publisher’s prior written consent is
prohibited. The information contained in the published materials can
itself be protected by other intellectual property rights. Such
information may not be used without the prior written consent of the
respective intellectual property right owner.

Some of the manufacturer and product names referred to in this
publication may be registered trademarks or proprietary names, even
though specific reference to this fact is not made. Therefore, the
appearance of a name without designation as proprietary is not to be
construed as a representation by the publisher that it is in the public

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domain.
The tooth identification system used in this ITI Treatment Guide is that
of the FDI World Dental Federation.

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The ITI Mission is …
“… to promote and disseminate
knowledge on all aspects of implant
dentistry and related tissue
regeneration through education and
research to the benefit of the patient.”

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Preface
While implant dentistry today is well documented and
demonstrates predictable outcomes, a significant proportion of
patients still experience complications. It is therefore a must for

all practitioners to know the causes of implant-related
complications and how to avoid and manage them.
Volume 8 of the ITI Treatment Guide series provides clinicians
with the latest evidence-based information on the origins and
treatment of biological as well as technical and mechanical
complications. An up-to-date analysis of the current evidence is
based in part on the proceedings of the 4th ITI Consensus
Conference held in Stuttgart in 2008 and the 5th ITI Consensus
Conference held in Bern in 2013, as well as on a review of the
current literature. The diagnosis and treatment of biological and
technical complications are examined closely in 16 clinical cases
presented by clinicians from all over the world.
The mission of the ITI “… to promote and disseminate
knowledge on all aspects of implant dentistry to the benefit of
the patient” as always provides the background against which
this volume of the ITI Treatment Guide series has been written.

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Acknowledgment
We would like to thank Dr. Kati Benthaus of the ITI Headquarters for
her invaluable assistance in the preparation of this volume of the
Treatment Guide series. We would also like to express our gratitude to
Ms. Juliane Richter (Quintessence Publishing) for typesetting and for
coordinating the production workflow, Mr. Per N. Döhler (Triacom
Dental) for his editing support, and Ms. Ute Drewes for her excellent

illustrations. We also acknowledge continuing support from Institut
Straumann AG, ITI’s corporate partner.

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Editors and Authors
Editors:
Daniel Wismeijer
DDS, PhD, Professor
Head, Section of Implantology and Prosthetic Dentistry
Department of Oral Function and Restorative Dentistry
Academic Centre for Dentistry Amsterdam (ACTA)
Gustav Mahlerlaan 3004
1066 EA Amsterdam, Netherlands
E-mail:
Daniel Buser
DDS, Dr med dent
Professor and Chair
Department of Oral Surgery and Stomatology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Stephen Chen
MDSc, PhD
Clinical Associate Professor
School of Dental Science
University of Melbourne
720 Swanston Street

Melbourne VIC 3010, Australia
E-mail:
Authors:

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Urs Brägger
Dr med dent
Professor and Chair
Department of Reconstructive Dentistry and Gerodontology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Lisa J. A. Heitz-Mayfield
BDS, MDSc, PhD
Professor
International Research Collaborative
University of Western Australia
Nedlands, WA 6009, Australia
E-mail:

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Contributors
Bilal Al-Nawas
Dr med, Dr med dent, Professor
Johannes Gutenberg-University

Medical Center
Department of Oral and Maxillofacial Surgery
Augustusplatz 2
55131 Mainz, Germany
E-mail:
Urs C Belser
DMD, Dr med dent, Professor
Department of Oral Surgery and Stomatology
Department of Reconstructive Dentistry and Gerodontology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Michael M. Bornstein
Dr med dent, Associate Professor
Head, Section of Oral Radiology and Stomatology
Department of Oral Surgery and Stomatology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Urs Braegger
Dr med dent
Professor and Chair

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Department of Reconstructive Dentistry and Gerodontology
University of Bern, School of Dental Medicine

Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Daniel Buser
DDS, Dr med dent
Professor and Chair
Department of Oral Surgery and Stomatology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Agnieszka Frydrych
BDSc(Hons), MDSc, FRACDS(Oral Med), FOMAA
Associate Professor (Oral Medicine)
University of Western Australia
17 Monash Avenue
Nedlands, WA 6009, Australia
E-mail:
Alexandros Grous
Dr med, Dr med dent
Grous Dental Clinic
2 Vasileos Alexandrou Street
11634 Athens, Greece
E-mail:
Lisa J. A. Heitz-Mayfield
BDS, MDSc, PhD
Professor
International Research Collaborative
University of Western Australia
Nedlands, WA 6009, Australia

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E-mail:
Stefan Hicklin
Dr med dent, Senior Lecturer
Department of Reconstructive Dentistry and Gerodontology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Tim Joda
Dr med dent, MSc, Senior Lecturer
Department of Reconstructive Dentistry and Gerodontology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Janice Kan
BDSc(Hons), DCD Pros
Perth Prosthodontics
Suite 3, Southbank Central
38 Meadowvale Ave
South Perth WA 6151, Australia
E-mail:
Daan Kruger
DDS, MSc Oral Implantology
Section of Implantology and Prosthetic Dentistry
Department of Oral Function and Restorative Dentistry

Academic Centre for Dentistry Amsterdam (ACTA)
Gustav Mahlerlaan 3004
1066 EA Amsterdam, Netherlands
E-mail:
Peer W. Kämmerer

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Dr med, Dr med dent
University of Rostock
Department of Oral and Maxillofacial Surgery
Schillingallee 35
18057 Rostock, Germany
E-mail:
Tomas Linkevičius
DDS, Dip Pros, PhD, Associate Professor
Institute of Odontology,
Faculty of Medicine, Vilnius University
Žalgirio 115/117
LT-08217 Vilnius, Lithuania
E-mail:
Maximilian Moergel
Dr med, Dr med dent
Johannes Gutenberg-University
Medical Center
Department of Oral and Maxillofacial Surgery
Augustusplatz 2
55131 Mainz, Germany
E-mail:

Andrea Mombelli
Dr med dent, Professor
Université de Genève
Section de Médecine Dentaire
Division de Physiopathologie Buccale et Parodontie
Rue Barthélemy-Menn 19
1205 Genève, Switzerland
E-mail:
Joris Muris
DDS
Department of Material Science

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Academic Centre for Dentistry Amsterdam (ACTA)
University of Amsterdam and VU University Amsterdam
Gustav Mahlerlaan 3004
1066 EA Amsterdam, Netherlands
E-mail:
Giovanni E. Salvi
Dr med dent, Professor
Department of Periodontology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Bruno Schmid
Dr med dent
Private Office

Bayweg 3
3123 Belp, Switzerland
E-mail:
Sandro Tettamanti
Dr med dent
Department of Reconstructive Dentistry and Gerodontology
University of Bern, School of Dental Medicine
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail:
Hans-Peter Weber
DMD, Dr med dent
Professor and Chair
Department of Prosthodontics and Operative Dentistry
Tufts University, School of Dental Medicine
One Kneeland Street, Rm. 220
Boston, MA 02111

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United States of America
E-mail:
Philipp Wick
Dr med dent
Weststrasse 4
3005 Bern, Switzerland
E-mail:
Daniel Wismeijer
DDS, PhD, Professor

Head, Section of Implantology and Prosthetic Dentistry
Department of Oral Function and Restorative Dentistry
Academic Centre for Dentistry Amsterdam (ACTA)
Gustav Mahlerlaan 3004
1066 EA Amsterdam, Netherlands
E-mail:

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Table of Contents
1 Introduction
L. J. A. Heitz-Mayfield, U. Brägger

2 Literature Review
L. J. A. Heitz-Mayfield, U. Brägger

2.1 Statements and Recommendations Obtained
from the 4th and 5th ITI Consensus Conferences
2.1.1 Proceedings of the 4th ITI Consensus Conference 2008
2.1.2 Proceedings of the 5th ITI Consensus Conference 2013

2.2 Literature Review: Biological Complications
L. J. A. Heitz-Mayfield

2.3 Literature Review: Hardware Complications and
Failures
U. Brägger
2.3.1 Mechanical and Technical Risks
2.3.2 Effect of Improved Components on Complications and Failure

Rates
2.3.3 Complication and Failure Rates with Cemented versus Screwretained Reconstructions
2.3.4 Complication and Failure Rates with Metal versus Ceramic
Abutments
2.3.5 State of the Art of CAD/CAM-assisted Production of Implantsupported Reconstructions
2.3.6 Overdentures

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2.3.7 Survival Rates of Reconstructions Obtained from Systematic
Reviews

3 Etiology and Risk Factors: Biological
Complications
L. J. A. Heitz-Mayfield

3.1 Peri-implant Infections
3.1.1 Peri-implant Biofilms
3.1.2 Risk Factors for Peri-implant Infection
3.1.3 Hardware Complications Presenting as Biological Complications

3.2 Non-plaque-related Biological Complications
3.2.1 Complete Loss of Osseointegration and Occlusal Overload
3.2.2 Other Theories for the Etiology of Loss of Osseointegration
3.2.3 Non-plaque-related Oral Mucosal Disorders

4 Etiology and Origin of Hardware Complications
U. Brägger

4.1 Materials and Interfaces
4.2 Absorption of Kinetic Energy and Biomechanical
Risks
4.3 Hardware-related Complications and Failures
4.3.1 Implant Body
4.3.2 Implant Body/Abutment Interface
4.3.3 Abutment Screw
4.3.4 Abutment Body
4.3.5 Retention of Superstructures: Screw-retained and Cemented
4.3.6 Closure Screws, Healing Abutments, Mucosa Formers
4.3.7 Attachment System for Overdentures
4.3.8 Mesostructures
4.3.9 Reconstruction

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5 Management of Biological Complications
L. J. A. Heitz-Mayfield

5.1 Treatment of Peri-implant Mucositis
5.2 Treatment of Peri-implantitis
5.2.1 Pre-treatment Phase
5.2.2 Non-surgical Debridement
5.2.3 Early Reassessment
5.2.4 Surgical Intervention
5.2.5 Immediate Postsurgical Care
5.2.6 Maintenance
5.2.7 Implant Removal
5.2.8 Concluding Remarks

5.3 Non-plaque-related Biological Complications
6 Management of Hardware Complications
U. Brägger

6.1 Hardware Complications
6.1.1 Fracture and Loss of Implants
6.1.2 Unfavorable Three-dimensional Position of the Platform
6.1.3 Complications Related to Abutments
6.1.4 Complications Related to Abutment Screws
6.1.5 Complications Related to Retention
6.1.6 Complications Related to Healing Abutments
6.1.7 Complications Related to Systems for Overdentures

6.2 Superstructure-related Complications
6.2.1 Denture Teeth and Acrylic
6.2.2 Wear and Attrition
6.2.3 Ceramic Chipping

6.3 Iatrogenic Reasons

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7 Prevention of Biological Complications
L. J. A. Heitz-Mayfield

7.1 Prevention of Peri-implant Infections
7.1.1 Treatment Planning
7.1.2 Preparation of the Patient

7.1.3 Preparation of the Recipient Site
7.1.4 Implant Placement
7.1.5 Prosthesis Design
7.1.6 Supportive Care
7.1.7 Diagnostic Monitoring of the Peri-implant Tissues
7.1.8 Frequency of Recall

7.2 Prevention of Loss of Osseointegration Due to
Occlusal Overload
7.3 Prevention of Non-plaque-related Oral Mucosal
Disorders
7.4 Concluding Remarks
8 Prevention of Hardware Complications
U. Brägger

8.1 Prevention of Complications Related to
Components and Reconstructions
8.1.1 Implant Body
8.1.2 Implant/Abutment Connection
8.1.3 Abutment Body and Abutment Screw
8.1.4 Third-party Components
8.1.5 Retention: Screw-retained and Cemented
8.1.6 Closure Screw, Healing Abutment, Mucosa Formers
8.1.7 Attachment Systems for Overdentures
8.1.8 Mesostructures
8.1.9 Superstructures

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8.2 Risk Management
9 Clinical Case Presentations
Biological Complications
9.1.1 Iatrogenic Complications Managed by Replacing
Prosthetic Components: Non-surgical Approach
B. Schmid

9.1.2 Peri-implantitis Treated with Access-Flap
Surgery
L. J. A. Heitz-Mayfield

9.1.3 Excess Cement Resulting in Peri-implant
Infection Presenting as a Draining Sinus Tract
T. Linkevičius

9.1.4 Peri-implantitis Modified by Submucosal Excess
of Cement: Regenerative Peri-implantitis
Therapy and Six-year Follow-up
G. E. Salvi

9.1.5 Peri-implantitis Treated by an Antimicrobial and
Regenerative Approach
A. Mombelli, P. Wick

9.1.6 Recurrent Peri-implantitis Leading to Implant
Removal
L. J. A. Heitz-Mayfield

Biological Complications (Other than Infections)
9.2.1 Removal of a Malpositioned Implant and Direct

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New Implant Placement with Simultaneous
Contour Augmentation using GBR
D. Buser, U. Belser

9.2.2 Oral Lichen Planus Associated with the Periimplant Mucosa
A. Frydrych

9.2.3 Peri-implant Carcinoma
M. Moergel, P. W. Kämmerer, B. Al-Nawas

9.2.4 Peripheral Giant-cell Granuloma Associated with
Peri-implant Tissues
M. M. Bornstein

9.2.5 Peri-implantitis Resulting in Bisphosphonaterelated Osteonecrosis of the Jaw
M. M. Bornstein

9.2.6 Metal Allergy
D. Wismeijer, D. Kruger, J. Muris

Hardware Complications
9.3.1 Management of a Fractured Implant Supporting
a Screw-retained Metal-ceramic Restoration
H. P. Weber, A. Grous

9.3.2 Retreatment of a Patient with Multiple Biological

and Technical Complications and Failures
S. Hicklin, S. Tettamanti, U. Brägger

9.3.3 Management of a Technical Complication
Caused by a Fractured Zirconia Abutment

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