Failures in Implant

Dr ANUSHA D A
3RD YEAR POST GRADUATE

1
 Contents

• Introduction
• Definitions
• Warning signs of implant failure
• Criteria for implant success:
• Implant quality scale:
• Classifications of implant failures
.implant maintenance
.Review of literature
• Conclusion
• Bibliography

2
Introduction
Implant failure is multifactorial.
Any local or systemic factor that
alters healing process can reduce
success.
As dental implants become more
prolific in their use, it is essential
that standardized methods be
developed to provide procedures
to diagnose and treat
deteriorating implant areas that
may not be totally defective.
3
Definitions

IMPLANT FAILURE…
It is defined as total failure of the implant to
fulfill its purpose (functional, esthetic or
phonetic) because of mechanical or biological
reasons.
(Askary et al ID 1999 vol8 no2 173-183)

4
Ailing implants:
Those that show radiographic bone loss without
inflammatory signs or mobility.

Failing Implant:
Characterized by progressive bone loss, signs of
inflammation and no mobility.

5
Failed Implants:
Those with progressive bone loss, with clinical
mobility and that which are not functioning in
the intended sense.

Surviving implants:
Described by Alberktson, that applies to
implants that are still in function but have
been tested against the success criteria.

6
Warning signs of implant failure
(Askary et al ID 1999; vol 8; no2, 173-183)
Connecting screw loosening
Connecting screw fracture
Gingival bleeding and enlargement
Purulent exudates from large pockets
Pain
Fracture of prosthetic components
Angular bone loss noted radiographically
Long-standing infection and soft tissue
sloughing during the healing period of first
stage surgery

7
Criteria for implant success:

…The individual implant is immobile when tested clinically.

…No radiographic evidence of peri-implant radiolucency
…Bone loss no greater than 0.2 mm annually
…Gingival inflammation amenable to treatment
…Absence of symptoms of infection and pain
…Absence of damage to adjacent teeth
…Absence of neuropathies, parasthesia or violation of the
mandibular canal or maxillary sinus

(Albrektson T. :int J. Oral Maxillofac Implants 1986; 1:11-25)

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the James–Misch Health Scale and approved 4 clinical category

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 Classification Of Implant failures

A) E.S Rosenberg, J.P. Torosian and J. Slots

classified as :
1. Infectious Failure:
…Clinical signs of infection 2. Traumatic Failure:
with classic symptoms of …Radiographic periimplant
inflammation
…High plaque and gingival radiolucency
indices
…Pockets …Mobility
…Bleeding, Suppuration
…Attachment loss …Lack of granulomatous
…Radiographic peri-implant tissue upon removal

radiolucency …Lack of increased

…Presence of probing depths
granulomatous tissue upon
10 …Low plaque and gingival
removal indices
B) Marco Esposito, Jan Michael Hirsh, Ulf Lekholm et al
have classified oral implant failures according to the
osseointegration concept.

1)Biological Failures:
• Early or primary (Before loading)
• Late or secondary (After loading)

2)Mechanical failures:
• Fracture of implants, connecting screws,
bridge framework, coatings etc

3)Iatrogenic Failures
• Improper implant angulation and alignment, nerve
damage

4)Inadequate Patient adaptation

• Phonetics, esthetics, psychological problems.
11
C) Kees Heydenrijik, Henny JA Meijer, Wil A Van der et
al classified to occurrence in time as:
1) Early Failures: Causes attributed are:
• Surgical trauma
• Insufficient quantity or quality of bone
• Premature loading of implant
• Bacterial infection

2) Late Failures:
Soon late failures: Implants failing during first year of
loading. Overloading in relation to poor bone quality and
insufficient bone volume.
Delayed late failures: Implant failing in subsequent years.
Progressive changes of the loading conditions in relation
to bone quality, volume and peri -implantitis.

12
E) Abdel Salam el Askary, Roland Meffert and
terrence griffin …
According to etiology

Host Surgical Implant Restorative

factor factor selection factor factor

According to timing of failure

Before stage II After stage II After restoration

According to origin of infection

Peri- implantitis Retrograde peri-implantitis

(Infective process, (Traumatic occlusion origin,
bacterial origin) non infective, forces off the long
axis, premature or excessive
loading)
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 According to failure mode
Lack of Unacceptable Functional Psychological
osseointegration aesthetics problems problems

According to condition of failure

Ailing Implant Failing Implant Failed Implant Surviving Im.

According to supporting tissue type

Soft tissue loss Bone loss Combination

According to responsible personnel

Dentist (Oral Dental Laboratory
surgeon, Patient
hygienist Technician
Prosthodontist,
Periodontist)

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According to etiology

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A. Host factor
1. MEDICAL STATUS
a) Bone diseases
- osteoporosis
A skeletal disorder in which there is decrease in bone
density and bone mass

Decreased BIC

Management:
* Longer healing peroid
* Hyperbaric oxygen therapy
* Therapeutic treatment for osteo-
porosis
* HA coated implants
* Increased number of implants 16
-Fibrous dysplasia
Fibrous connective tissue replaces bone

Initial fixation and stability impossible

- Pagets disease

b) Uncontrolled Diabetes
- More infection
- Delayed healing
- Postpone until controlled

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 Etiology : host factor
2. HABITS
a) Smoking:

Significance

• Causes alveolar vasoconstriction and decreased blood flow

• Impaired wound healing due to compromised
polymorphonuclear leucocytes function, increased platelet
adhesiveness as well as vasoconstriction.
• Poor bone quality
• In case of poor oral hygiene, smokers have 3 times more
marginal bone loss then non-smokers

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 Etiology : host factor
b) Parafunctional habits:
Bruxism is the multidirectional nonfunctional grinding of teeth.
Clenching occurs in one direction (vertically).
Bruxism is more aggressive.

Significance
• Most common cause of implant bone loss or lack of rigid fixation
is para functional habits.
• Commonly manifests as connecting screw loosening because of overload.
• Failures are higher in maxilla because of decrease in bone density.

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 Etiology : host factor

Prevention

• Increased number of implants to be placed

• Avoid cantilevers and occlusal contacts in lateral
excursions
• Use of occlusal splint
• Use of wide diameter implant to provide greater surface
area.
• Progressive bone loading and prosthetic design that
improves the distribution of stresses throughout the
implant system.

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3.ORAL STATUS: Etiology : host factor

a) Poor oral hygiene :

Suprabony connective tissue fibers are

oriented parallel to the implant surface

Susceptible to plaque accumulation and

bacterial ingress

Spontaneous loss of the perimucosal seal

Chances of implant failure increases

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 Etiology : host factor
Prevention

• Periodic recall at a minimum of 3 months intervals.

• Periodontal indices, bleeding on probing and radiographic
evaluation

• Soft tissue debridement

• Topical and systematic antimicrobial drugs should be
used

• Provide space beneath the superstructure to allow

cleansing aids

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 Etiology : host factor

4.IRRADIATION THERAPY
Significance
• Xerostomia
• Susceptibility to infection
• Osteoradionecrosis
• Endarteritis of vessels causes decrease in oxygen supply

Management
• Waiting period of 9-12 month between radiation therapy
and implant treatment.
• Hyperbaric oxygen therapy – 20 treatments of 90 min. each
at 2 to 2.4atm before surgery.
• Antibiotic regimen 3 days before (augmentin 500mg every 12
hrs).
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 Etiology : surgical factor

B. SURGICAL PLACEMENT
1. Off-axis placement (severe angulation)
Due to…

A) Alveolar process resorption

B) Unexperienced surgeon
C) Improper surgical stent
Problem…
Occlusal load lie at an angle

Shear & tensile forces increases

Chances of failure increases

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 Etiology : surgical factor

Management

1) Prerestoring the implant position by grafting

2) To place angulated abutments.

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 Etiology : surgical factor
2) Lack of initial stability
Due to oversized osteotomy

Gap develop between implant & bone

Lack of osseointegration

In an experimental investigation, gaps in the range of

0.25 mm around CPTi implants healed, but with less bone
contact than the controls.
When the gap size increased to 0.7mm-1.7mm,
a thin soft tissue layer was found to develop
around the implant.
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 Etiology : surgical factor

Management

• Remove & reinsert the larger size implant.

• if not possible  remove insert HA graft material

reinsert the implant

• loose cancellous bone is involved during the initial steps of

drilling, elimination of mechanical tapping and the placement
of a self tapping implant may be indicted.

• Proper drill grip, Sharp drills, precise preparation

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 Etiology : surgical factor

3) Improper healing & infection

because of improper flap design

No single flap design is optimal for implant surgery.

improper flap design  infection & bacterial ingress 

chances of failure increases

hunt et al: basic surgical procedure, flap design,blood

supply, visibility access,primary
28 closure should be
considered.
 Etiology : surgical factor
4) Overheating the bone and exerting
too much pressure

Excessive pressure Bone cell damage Bone loss

And overheating

Failure increases Connective tissue

interface formed

…Recommended speed- 2000 rpm with graded series

of drill size with external irrigation

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 Etiology : surgical factor

5) Placement of implant in immature bone

grafted site

Minimum waiting period of grafted site…6-9 months

woven bone present before this period, which is fastest

formed bone (partly mineralized &Unorganized)

Not suitable for implant-bone integration

Lamellar bone ideal for

implant prosthetic support
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6) Contamination of implant body before

insertion
Contaminated handling

Alters the surface chemistry

Failure

Causes:
By Manufacture error
By the operator error
By bacteria (oral cavity)
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 Etiology : surgical factor

By autoclaving the contaminated implant

Bake the bacteria on implant surface

Impossible for phagocytic cell to clean the surface

No close adaptation to the bone

Cleaned by a radiofrequency glow discharge unit

or a plasma cleaner

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C. IMPLANT SELECTION FACTOR

.Length of the implant

Longer implants

Increased BIC

Higher success rate

But placement of a short implant where bone permits a longer
length (i.e. an 8mm implant in a 12 mm ridge), would result in
higher stress concentration leading to subsequent failure of the
implant.

The success rate is proportional to the implant length and

the quantity and quality of available bone.
33
 The greater the crown implant
ratio

The greater the amount of the

force with any lateral force.

Therefore, maximum implant

length must be used for the
greatest stability of the overlying
prosthesis.

34
2. Width of the implant

Misch recommended that not less than 1 mm of

bone surrounding the fixture labially and lingually is
mandatory for the long term predictability of
dental implants because it maintains enough bone
thickness and blood supply.

Large- diameter implants:

- greater surface area,
- greater mechanical engagement of the
cortical bone
- initial rigidity.
35
3.Number of implants

Misch stated that the use of more implants

decreases the number of pontics and the associated
mechanics and strains on the prosthesis, and
dissipates stresses more effectively to the bone
structure. It also increases the implant bone
interface and improve the ability of the fixed
restoration to withstand forces.

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 Etiology : restorative factor
D) RESTORATIVE PROBLEMS

1.Excessive cantilevers
Problems associated with cantilevers
supported dental implants: include fracture
of the prosthesis, loss of osseointegration,
and bone fracture.

Cantilever extensions cause load

magnification and overloading of the implant
next to the cantilever extension, which in
turn leads to bone loss

With occlusal forces acting on the

cantilever, the implant becomes a fulcrum
and is subjected to rotational forces

For mandible 15mm or less

For maxilla 10mm or less
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 Etiology : restorative factor

Amount of force increases if

• Length of cantilever
• distance between implants
• crown height
• direction of force

Opposing arch…
…ideally a denture
…no lateral forces on cantilever

Not preferred -moderate to severe

parafunctional habits
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 Etiology : restorative factor

2.No passive fit

One of the most critical elements affecting the long-term
success of a multiple implant restoration is the passive fit
between the framework and the underlying fixtures.

The absence of passive fit : clinically by pain and

discomfort in the short term, and loosening or fracture of
implant components in the long term, because of excessive
strains on the peri-implant bone.

According to Rangert et al, the passive fit should exist at

the 10 um level and is required to achieve an optimum load
distribution

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 Etiology : restorative factor

3.Improper fit of abutment

Improper locking b/w abutment-fixture interface

Increased microbial population &

increased strain on implant component

Bone loss

Rapid screw-joint failure

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 Etiology : restorative factor
4.Improper occlusal scheme
* Important guidelines to follow
*Infraocclusion upto 30 microns of implant supported
restoration
*No balancing contacts on cantilevers.
*No guidance on single implants.
*Freedom in centric.
*Implant length: crown-root ratio ideal – 1:2 , Acceptable
– 1:1 for removable denture.
*Avoidance of cantilever length.
Maximum 10 to 15 mm is advised. 7 mm is optimum .
*Shallow central fossae with tripodal cuspal contacts.

*No contact in lateral excursion.

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 * 5.Premature loading

* Too rapid loading of the implant support system is considered to be

one of the most common causes of prosthetic related failure.
* Branemark stated that strict protocol requires a stress free healing
period of 3-6 months for osseointegration to occur.
* Misch stated that at 16 weeks, the surrounding bone is only 70%
mineralized and still has woven bone as a component. The woven
bone has an unorganized structure that cannot with stand full-scale
stresses.
* Not only bone quality, but also different implant characteristics, (e.g.
roughness, bioactive coatings, surface area) are consider for
immediate loading.
* However, progressive or delayed loading protocol still remains the
treatment of choice.

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According to timing of failure
Before stage II

AT stage II

After restoration

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a. After stage ii

• Dental implants are less likely to fail at this point in time (ie,
between implant placement and the first 2 months of the healing
period).

• It usually occurs as a result of implant malplacement (eg,

placement of the implant in an infected socket, pathological
lesion, or immature bone or placement of a contaminated
implant in the osteotomy),

• infection or soft tissue complications, lack of biocompatibility,

excessive surgical trauma, and / or lack of primary stabilization
of the implant.

• The failed dental implant may appear to be an exfoliating fixture

that is sometimes accompanied by a purulent exudate.

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B.Second stage surgery
Problem Possible causes Solutions
Slightly sensitive but Imperfect Cover the implant for 2-
perfectly immobile osseointegration 3 months and test again
implant
Slightly painful and Lack of integration Remove the implant
mobile implant
Inability to perfectly misfit replace the abutment
connect the
abutment to the
implant
Granulation tissue Traumatic Open the area and
around the implant placement of the disinfect with
head implant; compression chlorhexidine. If the
from the transition lesion is too large,
prosthesis, bacteira consider a bone
45 regeneration or grafting
technique
C.Prosthetic problems

Problem Possible causes Solutions

Loosening of one Occlusal problem Retighten, verify the

or more occlusion, and recheck
prosthetic screws after two weeks.
at the first
inspection after
two week
Occlusal problem Verify the occlusion
Loosening of or misfit and/ or the prosthetic
prosthetic between fit
screws at the prosthesis and Change the prosthetic
second check abutments design. In all cases,
or later Unfavourable46 change the prosthetic
prosthetic screws
Fracture of a Occlusal problem, If the occlusion or the
prosthetic lack of fit between adaptation of the prosthesis
screw or an the prosthesis and seems right, modify the
abutment screw the abutment or prosthetic design (reduce or
unfavourable eliminate extensions,
prosthetic design reduce the width of occlusal
surfaces, reduce cuspal
inclination, add implants,
etc)

47
 Fractured abutment screw
Tip of the explorer is placed on the top
portion of the fractured abutment
screw.
With slight apical pressure and a
counterclockwise circular motion, the
fragment can be unscrewed.
Care must be taken not to damage
the internal threads of the implant.

When Screw Fragment removed ,replace with

appropriate new abutment and screw. Verify seating
with a radiograph prior to final torque.
Replace prosthesis and secure with new retention
screws. 48
Fracture of Weak metal Remake the prosthesis;
the frame end or modify the prosthetic design
framework too large (reduce or eliminate
extension extensions, reduce width and
Bruxism or height of occlusal surfaces,
parafunction reduce cusp inclination, add
implants, etc).
Make a nightguard

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 Loose restoration

Radiographic Evaluation: Small

opening at abutment-implant
interface

Diagnosis: screw Loosing and

screw fracture

Treatment:
Reinsert: intact screw
Removal of screw and
Small
replacement 50
opening
 Implant fracture

Fractures occurs due to

Fatigue Trauma

The most frequent area of fracture is just below the

abutment level.
Treatment includes removal of the fragments
Usually apical portion of the implants is
osseointegrated and should be left behind, if not to
be replaced, to prevent further osseous loss (Maeglin
1988)
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 FAILING IMPLANT

Clinical signs:progressive bone loss

:soft tissue pockets and crestal bone loss

:bleeding on probing with possible purulence

:tenderness to percussion or torque forces
Causes:overheating of bone at the time of surgery
or lack of initial stability.
:inadequate screw joint closure
:functional overload
:periodontal infection (peri-implantitis)

Treatment: remove prosthesis and abutments

:disinfect all components
:reinsert assuring proper screw torque
:recheck passive fit of framework and occlusion
52
 failed implant
Clinical signs:
• pain
• Mobility
• A “Dull” percussion sound
• Peri-implant radiolucency

Causes:
:surgical compromise (overheating bone and
initial lack of stability).
:Inadequate screw joint closure
:Too rapid initial loading
:Functional overload
:Periodontal infection (“peri-implantitis”)

Treatment :removal of the implant

53
According to failure mode
Lack of Osseointegration

Unacceptable Aesthetics

Functional Problems

Psychological Problems

54
A. Lack of Osseointegration

Adell et al proposed that lack of osseointegration can be

due to:
-Surgical trauma
-Perforation through covering mucoperiosteum during
healing
-Repeated overloading with microfractures of the bone
at early stages

Characterized by:
*Mobility
*Easy to remove by a mere
counter torque movement
*A thin radiolucent zone is
seen around the implant 55
B.AESTHETIC PROBLEM

Aesthetic outcome is affected by four factors:

• Implant placement
• Soft tissue management
• Bone grafting consideration
• Prosthetic consideration

• improper placement of the implant: not allowing enough space for

the transition from the implant head cross section to the natural
tooth cervical cross section
• and improper soft tissue management: leading to absence of normal
gingival contours.
• fabrication of a preoperative prototype: helpful information about
the final prosthesis and facilitates proper implant positioning.
56
C.FUNCTIONAL PROBLEMS

Proper function of the implants is dependent on two main

types of:

Anchorage related Prosthetic related

* Osseo integration * Prosthetic design
* Marginal bone height * Occlusal scheme

D.PSYCHOLOGICAL PROBLEMS

-high expectations of the patient

57
 According to supporting tissue type
…Soft tissue problems

…Bone loss

…Both soft tissue and bone loss

58
A.SOFT TISSUE PROBLEMS
Gingival loss leads to continuous recession around the implant with
subsequent bone loss. This will lead to a soft tissue type of
failure.

B. BONE
LOSS
Bone functions as a support for the implant and that any
disturbance in its function may lead to eventual loss of the implant.

Loss of marginal bone occurs both during the healing period and
after abutment connection

Bone loss in mandible is higher during the healing period.

In maxilla, bone loss is higher after abutment connection

59
Factors that contribute to
marginal bone loss:
• Surgical trauma such as detachment of
the periosteum and damage cased during
drilling

• Improper stress distribution caused by

defective prosthetic design and occlusal
trauma
• Physiological ridge resorption

• Gingivitis, which if allowed to progress

will lead to ingression of bacteria and
their toxins to the underlying osseous
structures.
60
C. BOTH SOFT TISSUE AND BONE LOSS

If failure starts from soft tissue, then it usually is

considered to be due to a bacterial factor.

However, if failure starts at the bone level, then it is

considered to be due to a mechanical factor. Both bone
and soft tissue may be involved together.

61
 According to origin of infection
Peri- implantitis Retrograde peri-implantitis

(Infective process, (Traumatic occlusion origin,

bacterial origin) non infective, forces off the long
axis, premature or excessive
loading)

PERI- IMPLANTITIS
Acc to meffert defined as: the Progressive peri-implant
bone loss in conjunction with a soft tissue
inflammatory lesion is termed peri-implantitis.

62
 Classification of peri-implantitis

Slight Horizontal bone loss with

minimal Peri-implant defects.
Class I
TREATMENT
• Initial therapy for removal of
etiological factors.
• Surgical therapy includes cleaning
the implant surface

63
 Moderate horizontal bone loss with
Class II isolated vertical defects.

TREATMENT
• Initial therapy for removal of
etiological factors
• Surgical therapy includes cleaning
the implant surface
• Pocket elimination and adjunctive
treatment using systemic
antibiotics

64
Class III Moderate to advanced
horizontal bone loss with broad,
circular bony defects.

TREATMENT
• Initial therapy for removal
of etiological factors
• Surgical therapy includes
cleaning the implant
surface
• pocket elimination via osseous
regeneration and adjunctive
antibiotic treatment

65
 Advanced horizontal bone loss
with broad circumferential
vertical defects as well as loss
Class IV of buccal and lingual bony wall.

TREATMENT
• Initial therapy for removal of
etiological factors
• Surgical therapy includes
cleaning the implant surface,
• pocket elimination via bone
regeneration techniques,
possibly autologous bone
transplants with adjunctive
antibiotic therapy.
66
Implant maintenance

67
The following factors must be evaluated at
each maintenance appointment……
• oral hygiene
• implant stability (evaluate mobility)
• peri-implant tissue health
• crevicular probing depths
• Bleeding on probing
• radiographic assessment (serial)
• proper torque on screw joints
• occlusion
• Patient comfort and function

68
 * Hygiene aids
Super - floss
End tufted brushes
Proxy brushes
Tartar control dentrifices
Mechanical instruments

69
Super - Floss
Excellent for all types
of implant restorations

Butler Post Care

Floss Aid
Excellent for
implant bars and
fixed hybrid
prostheses.
70
 Proxy brushes

End tufted
71
brushes
 Plastic scalers

Plastic scalers are appropriate

for cleaning around standard
abutments supporting implant
bar substructures, hybrid
prostheses and implant
supported splinted
restorations.

Plastic scaler tips are also

available for metal handle
scalers.
72
Prophy paste and a
rubber cup can be used
to polish implant bars
when removal is not
indicated

73
 Influence of Diameter and Length of Implant on
Early Dental Implant Failure

Purpose: To relate diameter and length of implants with early

implant failure.

Methods:
Implants with a cylindrical design and surface treatment by removal
of titanium via acidification from 3 different manufacturers were
used.
The length of the implants was classified as short (6-9 mm), medium
(10-12 mm), or long (13-18 mm),
and the diameter was classified as narrow, regular, or wide.
The statistics were analyzed

Journal of Oral and Maxillofacial Surgery Volume 68, Issue 2, February 2010,
Pages 414-419 74
Results:
In this retrospective study,

The early survival rate for all 1,649 implants was 96.2%.

Regarding diameter, the largest loss was observed in narrow

implants (5.1%), followed by regular (3.8%) and wide (2.7%) implants.

Regarding length, the largest loss was observed in short implants

(9.9%), followed by long (3.4%) and medium (3.0%) implants.

Early loss occurred in 50 implants, 31 (4.3%) of which were installed

in anterior areas and 19 (2.8%) in posterior areas.

According to analyses,
short implant (P = .0018) and anterior installation of implant (P
= .0013) showed associations with early loss.
75
 Influence of the implant abutment types and the
dynamic loading on initial screw loosening
J Adv Prosthodont 2013 Feb;5(1):21-8.

PURPOSE: This study examined the effects of the abutment types and
dynamic loading on the stability of implant prostheses with three types of
implant abutments prepared using different fabrication methods by
measuring removal torque both before and after dynamic loading.

MATERIALS AND METHODS:

Three groups of abutments were produced using different types of
fabrication methods; stock abutment, gold cast abutment, and CAD/CAM
custom abutment.
A customized jig was fabricated to apply the load at 30° to the long axis.
The implant fixtures were fixed to the jig, and connected to the abutments
with a 30 Ncm tightening torque. A sine curved dynamic load was applied
for 105 cycles between 25 and 250 N at 14 Hz. Removal torque before
loading and after loading were evaluated.
statistical analysis was done. 76
RESULTS:
Removal torque value before loading and after loading was the highest in
stock abutment, which was then followed by gold cast abutment and
CAD/CAM custom abutment, but there were no significant differences.

CONCLUSION:

The abutment types did not have a significant influence on short term screw
loosening.
On the other hand, after 105 cycles dynamic loading, CAD/CAM custom
abutment affected the initial screw loosening, but stock abutment and gold
cast abutment did not.

77
 Conclusion

Although dental implant therapy is extremely

successful as an alternative to conventional
complete dentures, it is not without risk of
complications and failures.

The practitioner must be familiar with the

potential complications, however the risk of
prosthodontic complication should not
preclude a patient from seeking implant
treatment.

78
REFERENCES

Misch : Contemporary implant dentistry

Atlas of implant dentistry, Cranin
Why do dental implants fail: part I : Askary et al
ID 1999 vol8 no2 173-183
Why do dental implants fail: part II : Askary et al
Id 1999 vol 3 : 265-275
Porter JA. Success or failure of dental implants? A
literature review with treatment considerations.
General dentistry. 2005;53(6):423-32.
A.S.Sclar; Soft tissue & esthetic considerations in
implant dentistry.
Myron Nevins; Implant therapy.

79
Torosian J, Rosenberg ES.  The failing and failed
implant: a clinical, microbiologic, and treatment
review.  J Esthet Dent.  1993.
Failures in implant dentistry.W. Chee and S. Jivraj.
British Dental Journal 202, 123 - 129 (2007)
Yoav Grossmann. Prosthetic treatment for severely
misaligned implants: A clinical report. J Prosthet
Dent 2002;88:259-6.
Goodacre C J, Bernal G, Rungcharassaeng K, Kan J
Y. Clinical complications with implants and implant
prostheses. J ProsthetDent 2003; 90: 121–132.
Effect of implant size and shape on implant
success rates: A Literature review JPD
2005;94:377-81
80