Gapski.qxd

Endosseous Implant Failure Influenced by
Crown Cementation: A Clinical Case Report
Ricardo Gapski, DDS, BDS, MS1/Neil Neugeboren, DDS1/Alan Z. Pomeranz, DMD, MMSc1/Marc W. Reissner, DDS1 Implant dentistry has developed predictable treatment outcomes. Nevertheless, there are multiple rea-sons for implant failure. This case report documents a previously unreported type of implant failurethat occurred 1 month after crown cementation. The implant failure is believed to be associated withretained excess subgingival cement. INT J ORAL MAXILLOFAC IMPLANTS 2008;23:943–946 Key words: cement, complication, dental implant, implant loss Titanium endosseous dental implants have been to prosthetic reasons is scarce. This case report increasingly utilized over the past few decades.1 relates to a prosthetic-related implant complication Successful outcomes can be expec ted when that resulted in early implant failure.
implants are placed in bone of good quality andquantity and when proper surgical protocol is fol-lowed.2 Although dental implants are considered a very successful mode of therapy, many factors havebeen associated with the failure of dental implants.3 A 31-year-old Hispanic woman presented to the Complicating factors can be divided into the follow- authors’ periodontal office reporting mobility of the ing categories: surgery-related implant loss; bone maxillary right lateral incisor. The medical history of loss; peri-implant soft tissue disease; mechanical the patient was noncontributor y. The patient problems; and esthetic/phonetic results.4 reported previous orthodontic therapy for 3 years. A In terms of biological implant failure, contributing periapical radiograph revealed severe root resorp- factors reported in the literature include implant tion (Fig 1). The treatment plan was to extract the length and diameter,5 body design,6 smoking,1,5 maxillary right lateral incisor with immediate place- implant location,7 bone quality,8 peri-implantitis,9 ment of an endosseous dental implant. After local and others. In terms of mechanical implant failure, anesthesia was obtained, the maxillary right lateral several investigations have evaluated the most com- incisor was atraumatically extracted. The surgical site mon prosthetic complications associated with dental revealed an adequate amount of alveolar bone for implants. Overall, the majority of these studies focus immediate implant placement. The buccal alveolar on problems associated with the suprastructural bone was intact, and no signs of pathology or bone components and the function/esthetics of the pros- resorption beyond the socket of the remaining tooth thesis. Examples of such complications are abutment fractures and loosening,10 prosthesis fracture,11,12 Subsequently, a narrow, internal platform, parallel- prosthesis retention and comfort,13 and patient satis- walled endosseous implant was inserted (3.25 ϫ 11.5 faction.13 The literature on early implant failure due mm; Biomet 3i, Palm Beach Gardens, FL) using a surgicaltemplate (Fig 2). At the same visit, the healing abut-ment was inserted (3.4 ϫ 4 mm) and a provisionalremovable partial denture was delivered. Postoperativemedication included amoxicillin 500 mg every 8 hours for 10 days, chlorhexidine 0.12% every 12 hours for 7days, and an acetaminophen/hydrocodone-based anal- Correspondence to: Dr Ricardo Gapski, 10200 East Girard gesic as needed for pain. The implant was allowed to Avenue, Building A, Suite 209, Denver, CO 80231. Fax: +303 6956915. E-mail: [email protected] heal for 4 months (Fig 3). Then, a reverse torque of 20 The International Journal of Oral & Maxillofacial Implants COPYRIGHT 2008 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER graph. Note severe resorption of tooth inthe maxillary right lateral incisor.
strating uneventful healing 4 months afterimplant placement.
imately 1 month after crown cementationwas performed. Note the erythematous andcyanotic tissues around the implant. A 9-mm peri-implant pocket with suppurationwas detected on the distal aspect of theimplant.
mately 1 month after crown cementation.
Note the radiopaque material at the distalaspect of the implant in combination withextensive bone loss.
Ncm was utilized to ensure the implant was osseointe- extensive bone loss (Fig 6). It was decided to remove grated and a follow-up radiograph was obtained (Fig 4).
the crown and prosthetic abutment and re-insert the The peri-implant sulcus was within normal range.
healing abutment and provisional partial denture The patient returned to the periodontal office 1 prior to exploration of the site. After local anesthesia month after final cementation of the implant pros- was obtained, the area was surgically explored, thesis reporting soreness and swelling in the area revealing extensive bone loss distal and buccal to (Fig 5). Clinically, a 9-mm pocket with suppuration the implant (Figs 7a and 7b). There was a mixture was present on the distal aspect of the implant, while resembling granulation material and temporary a shallow sulcus was present on the mesial aspect of cement involving up to 70% of the implant length.
the maxillary right canine. A radiograph at the same The implant was surgically removed, and guided appointment revealed radiopaque material at the bone regeneration was performed at the site for a distal aspect of the implant in combination with COPYRIGHT 2008 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER defect revealed extensive bone loss at thedistal and buccal aspects of the implantand material resembling temporary cementat the thread of the implant. (b) A mixture ofgranulation tissue with large amount ofmaterial resembling temporary cement wasremoved from the defect. retrieval and excess cement removal can be experi-enced with cemented restorations.17 When properly Numerous studies show that abutment loosening restored, the intracrevicular position of the restora- constitutes one of the known implant postsurgery tion margin does not appear to adversely affect peri- complications requiring clinical intervention.4 A implant health and stability.18 However, it can be review of the literature demonstrated that abutment speculated that excess cement is more difficult to loosening is the most common prosthetic complica- remove or identify when implants are restored with tion in implant dentistry (2% to 45% depending on deep subgingival margins. These situations are more the study and type of prosthesis).4 In a prospective commonly seen in anterior restorations, where preclinical study, 27% of loosened screws were pre- esthetic demands are higher. In such cases, the mar- sent with use of screwed abutments, in comparison gins are usually placed further subgingivally, leading to no abutment loosening with cemented restora- to an increased risk of leaving additional cement in tions.14 The authors speculated that screwed abut- the peri-implant tissues. In a recent 8-year private ments are often submitted to nonaxial loads that practice study, the authors did not notice different determine screw and abutment loosening.14 Screw complication rates for cemented and screw-retained loosening not only becomes an inconvenience to prostheses.10 However, the authors recommended clinicians and patients due to the increase in mainte- screw-retained prostheses in the esthetic zone to nance, but also there are biological detrimental avoid problems associated with excess cement irri- effects in the surrounding tissues when this condi- tion occurs. An in vivo study has demonstrated an One of the reasons for such a complication possi- increase in expression of vascular endothelial growth bly relates to the supracrestal soft tissue micro- factor and microvessel density (markers of inflamma- anatomy around dental implants. In contrast to nat- tion) in loosely screwed abutments compared to ural teeth, implants do not develop perpendicular screw-tight and cement-retained restorations.15 In fiber attachment.19,20 Instead, the gingival connec- addition, microbial leak age through the gap tive tissue fibers are closely adapted to the titanium between the suprastructure and the abutment plays layer but in an orientation approximately parallel to an important role in the bacterial colonization of the the implant surface.20 This anatomic condition may internal part of screw-retained crowns and partial not provide enough protection if excess cement is pushed into the peri-implant sulcus. In fact, probing Despite all the advantages related to cement- measurements around healthy osseointegrated oral retained implant restorations, some disadvantages implants and teeth differ.21 Histologic studies have can be clearly seen. For instance, difficult prosthesis demonstrated that a probe has a tendency to pene- The International Journal of Oral & Maxillofacial Implants COPYRIGHT 2008 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER trate deeper into the peri-implant tissues compared 7. Hutton JE, Heath MR, Chai JY, et al. Factors related to success to the counterpart teeth.21–23 In addition, it has been and failure rates at 3-year follow-up in a multicenter study of demonstrated that peri-implant probing depth mea- overdentures supported by Brånemark implants. Int J OralMaxillofac Implants 1995;10:33–42.
surements are more sensitive to force variation than 8. Khang W, Feldman S, Hawley CE, et al. A multi-center study periodontal pocket probing.22 Hence, it could be fur- comparing dual acid-etched and machined-surfaced implants ther speculated that implants may be more sensitive in various bone qualities. J Periodontol 2001;72:1384–1390.
to excess cement pressed into the peri-implant tis- 9. Esposito M, Hirsch JM, Lekholm U, et al. Biological factors con- sue than tissue around natural teeth.
tributing to failures of osseointegrated oral implants. (II).
Etiopathogenesis. Eur J Oral Sci 1998;106:721–764.
This is the first case report demonstrating that 10. Nedir R, Bischof M, Szmukler-Moncler S, et al. Prosthetic com- excess cement can lead to severe clinical conse- plications with dental implants: From an up-to-8-year experi- quences, including implant failure. However, it is diffi- ence in private practice. Int J Oral Maxillofac Implants 2006; cult to be certain of the cause-effect cited in this report; other factors should be considered. First, 11. Krennmair G, Piehslinger E, Wagner H. Status of teeth adjacent to single-tooth implants. Int J Prosthodont 2003;16:524–548.
there were no apparent signs of peri-implant pathol- 12. Gothberg C, Bergendal T, Magnusson T. Complications after ogy prior to the insertion of the crown. Second, the treatment with implant-supported fixed prostheses: A retro- crown was not in occlusal trauma, which could justify spective study. Int J Prosthodont 2003;16:201–207.
the severe bone loss. Finally, there was a large 13. Naert I, Alsaadi G, Quirynen M. Prosthetic aspects and patient amount of temporary cement in the vertical defect satisfaction with two-implant-retained mandibular overden-tures: A 10-year randomized clinical study. Int J Prosthodont around the implant. It is imperative to note that it is difficult to speculate whether local factors such as an 14. Assenza B, Scarano A, Leghissa G, et al. Screw- vs cement- undermining bone fenestration influenced the sever- implant-retained restorations: An experimental study in the ity of the infection. Further controlled studies are Beagle. Part 1. Screw and abutment loosening. J Oral Implan- necessary to unravel all possible variables associated 15. Assenza B, Artese L, Scarano A, et al. Screw vs cement-implant- with excess cement and implant failure.
retained restorations: An experimental study in the beagle.
Part 2. Immunohistochemical evaluation of the peri-implanttissues. J Oral Implantol 2006;32:1–7.
16. Keller W, Bragger U, Mombelli A. Peri-implant microflora of implants with cemented and screw retained suprastructures.
Clin Oral Implants Res 1998;9:209–217.
Cementation of implant-supported crowns is com- 17. Rajan M, Gunaseelan R. Fabrication of a cement- and screw- mon in the esthetic zone. It is recommended that the retained implant prosthesis. J Prosthet Dent 2004;92:578–580.
restorative dentist be especially vigilant to remove 18. Giannopoulou C, Bernard JP, Buser D, et al. Effect of intracrevic- excess subgingival cement following cementation of ular restoration margins on peri-implant health: Clinical, bio- the crowns to avoid the potential for implant failure.
chemical, and microbiologic findings around estheticimplants up to 9 years. Int J Oral Maxillofac Implants 2003; The biologic process by which the cement is found within the intraosseous defect requires further study.
19. Cochran DL, Hermann JS, Schenk RK, et al. Biologic width around titanium implants. A histometric analysis of theimplanto-gingival junction around unloaded and loaded non- submerged implants in the canine mandible. J Periodontol1997;68:186–198.
20. Listgarten MA, Buser D, Steinemann SG, et al. Light and trans- 1. Schwartz-Arad D, Samet N, Mamlider A. Smoking and compli- mission electron microscopy of the intact interfaces between cations of endosseous dental implants. J Periodontol 2002;73: non-submerged titanium-coated epoxy resin implants and bone or gingiva. J Dent Res 1992;71:364–371.
2. Brånemark P-I, Hansson BO, Adell R, et al. Osseointegrated 21. Schou S, Holmstrup P, Stoltze K, et al. Probing around implants implants in the treatment of the edentulous jaw. Experience and teeth with healthy or inflamed peri-implant mucosa/gin- from a 10-year period. Scand J Plast Reconstr Surg 1977; giva. A histologic comparison in cynomolgus monkeys (Macaca fascicularis). Clin Oral Implants Res 2002;13:113–126.
3. Tolstunov L. Dental implant success-failure analysis: A concept 22. Mombelli A, Muhle T, Bragger U, et al. Comparison of peri- of implant vulnerability. Implant Dent 2006;15:341–346.
odontal and peri-implant probing by depth-force pattern 4. Goodacre CJ, Bernal G, Rungcharassaeng K, et al. Clinical com- analysis. Clin Oral Implants Res 1997;8:448–454.
plications with implants and implant prostheses. J Prosthet 23. Ericsson I, Lindhe J. Probing depth at implants and teeth. An experimental study in the dog. J Clin Periodontol 1993; 5. Bain CA, Moy PK. The association between the failure of dental implants and cigarette smoking. Int J Oral Maxillofac Implants1993;8:609–615.
6. Karoussis IK, Bragger U, Salvi GE, et al. Effect of implant design on survival and success rates of titanium oral implants: A 10-year prospective cohort study of the ITI Dental Implant Sys-tem. Clin Oral Implants Res 2004;15:8–17.
COPYRIGHT 2008 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER

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