FEATURED ARTICLE Hong Kong Dental Journal 2008;5:79-83

HK
DJ
Prosthodontic complications in dental implant
therapy
Edmond Ho-Nang Pow *, BDS, MDS (Prosthetic Dent), PhD, FRACDS, FCDSHK (Prosthodontics), FHKAM (Dental Surgery)
Katherine Chiu-Man Leung *, BDS, MDS (Prosthetic Dent), PhD, FRACDS,
FCDSHK (Prosthodontics), FHKAM (Dental Surgery)

ABSTRACT Implant therapy is popular in dental practice. However, prosthetic complications in implant-supported
prostheses are common. Although most of the problems can be prevented by careful case selection and treatment
planning, failures do occur and their management can sometimes be very demanding. This article discusses the common
prosthodontic problems encountered during and after implant therapy. Special emphasis is placed on how to avoid and
solve the late mechanical complications of implant-supported prostheses.

Key words: Dental implants; Dental prosthesis, implant-supported; Osseointegration

Introduction

Implant therapy is becoming popular in dental practice,

and is now regarded as a predictable treatment option for
replacing missing teeth (Figure 1) 1. Long-term follow-
up studies have revealed that it is very successful. Meta-
analyses 2,3 indicate impressive results. Thus, the 5-year
survival for an implant replacing a single missing tooth is
95.6%, while for implants replacing multiple teeth using
a bridge it is 97.7%. In edentulous patients rehabilitated
with fixed implant prostheses, the 5-year survival rate in
the maxilla is 87.7% while in the mandible it is 96.7%.
In edentulous patients rehabilitated with removable
prostheses, the 5-year survival rate in the maxilla is 76.6% Figure 1 Implant-supported crown to replace 22
while in the mandible it is 95.7% 2,3.

Prosthodontic complications Table Cumulative 5-year occurrence of technical

complications in implant-­supported fixed partial dentures
(FPD) and single crowns (SC) 5,6
Although implant survival rates across-the-board are
Veneer Screw Screw Framework Implant
high, prosthetic complications in implant-supported fracture loosening fracture fracture fracture
prostheses are not uncommon 4. They can be classified
FPD 13.2% 1.5% 5.8% 0.8% 0.4%
SC 4.5% 12.7% 0.3% 3.0% 0.1%
* Oral Rehabilitation, Faculty of Dentistry, The University of Hong
Kong, Hong Kong

Correspondence to: as: veneer fracture, screw loosening, screw fracture,

Dr. Edmond Ho-Nang Pow framework fracture, implant fracture, and problems
Oral Rehabilitation, Faculty of Dentistry, The University of Hong
related to overdentures.
Kong, 34 Hospital Road, Hong Kong
Tel : (852) 2859 0309
Fax : (852) 2858 6114 Two systematic reviews 5,6, based on the data from over
E-mail : [email protected] 40 clinical studies, have estimated the 5-year cumulative

Hong Kong Dent J Vol 5 No 2 December 2008 79

Pow and Leung

Figure 3 Weak framework leading to cracking of acrylic

resin
Figure 2 Fractured acrylic veneer
Porcelain fractures, however, usually need to be repaired
in the laboratory to achieve better results.
incidence of technical complications in implant-
­supported fixed partial dentures and single crowns Screw loosening
(Table). However, there are no such systematic reviews on
implant-supported overdentures. Goodacre et al. 7 reported Screw joint stability in implant prostheses is determined
that the mean incidence of overdenture retention loss by a number of factors such as adequate preload,
requiring adjustment was 30%; for overdenture relines it the precision of the fit between the mating implant
was 19%; for overdenture clip/attachment fracture it was components and the antirotational characteristics of the
17%, and for overdenture fracture it was 12%. Technical implant-to-abutment interface 8. Preload is the clamping
complications do not necessarily lead to implant loss but force on a screwed joint produced by tension in the screw
maintenance and repair can be a burden for both the patient as a result of its being tightened. Screw loosening occurs
and the dentist and influence their level of satisfaction. when the clamping force is overcome by forces acting
Complications can also lead to additional costs and time to separate the fastened components. Higher preload
investment during the follow-up years. values can be achieved using newly designed screws with
enhanced surfaces (compared to earlier gold or titanium
Veneer fracture alloy designs) 9. To achieve optimum preload, a mechanical
torque device should be used instead of tightening the
Mechanical failures are not uncommon and of these, veneer screw manually.
fracture is the most frequent (Figure 2). They are often due
to insufficient support from the underlying framework. A Regarding connections between the implant and
full contour wax-up of the final prosthesis followed by abutment, those having an external (or sometimes
the cut-back technique can greatly minimize the problem. internal) antirotation feature between the implant body
Veneer failure can also be caused by technical errors, such and connecting component (abutment) can undergo
as: incompatibilities between an alloy and ceramic, poor relative rotation around the joint due to machining
alloy surface preparation or surface contamination, and tolerances. This can lead to micro-movement during
improper ceramic buildup or firing techniques. In addition, functional loading and subsequent joint failure. It has
the design of the framework also plays an important role. been shown that some implant systems using external
It should be rigid enough to resist significant deformation hex connections had rotational movement in excess of
under occlusal loads (Figure 3). Retentive features such as 4 degrees 10. On the other hand, the Morse taper design
beads or pins can be incorporated to enhance bonding connection provides a mechanical friction grip which is
between the veneer material and the framework. In cases significantly more resistant to rotation. This design can
of foreseeable heavy occlusal load, a metal occlusal also distribute forces to the implant more evenly.
surface is preferred. Acrylic/composite veneer fractures
can be repaired intraorally under proper moisture control. Screw loosening or fracture can also be due to

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 Prosthodontic complications in implants

(a)

(b)
Figure 5 Fractured prosthetic screw

cantilevers should be avoided. Parafunctional habits

such as bruxism should be diagnosed and a hard acrylic
protective night guard can be prescribed after implant
therapy.

Screw fracture

Implant-supported prostheses can be either screw- or

Figure 4 (a) Cast cobalt-chromium bar fixed on one cement-retained. Screw-retained ones are popular because
impression coping. (b) All impression copings are linked with they are easily retrieved for maintenance. In the traditional
cobalt-chromium bar by autopolymerizing acrylic resin
implant prosthesis, the prosthetic screw was intentionally
designed as the weakest link within the system. If there
was any mechanical stress challenging the prosthesis, the
framework misfits. Attempts have been made to minimize screw took up the stress without endangering the bone-
errors during impression taking. They include: splinting implant interface.
the impression copings with impression plaster, and using
autopolymerizing resin possibly in combination with If a fractured gold screw is encountered, it can often
dental floss 11,12. Another alternative is first to fabricate be removed by counterclockwise rotation with a dental
a cast cobalt-chromium bar in the laboratory, and then explorer or probe. On the other hand, an abutment screw
connect it with the impression copings at chairside, fracture is more difficult to manage. If the remaining
using autopolymerizing resin (Figure 4). However, in abutment screw fragment is above the implant head, that
the literature there is conflicting evidence about these fragment can often be gripped by an artery forceps and
approaches. In some studies, splinting improved the rotated out of the fixture (Figure 5). If the abutment
accuracy of the working cast but in others there was no screw has fractured at or below the implant head, it can
advantage compared to non-splinted techniques 13,14. To sometimes be rotated out with a probe as for a gold
minimize casting discrepancy and misfits, cementation of screw. A small round drill can be used as a screwdriver
prostheses can be considered instead of screw retaining 15. to engage the head of the fragment (Figure 6). Some
Other techniques such as double casting 16, computer- clinicians suggest using the smallest possible drill to cut
aided design/computer-aided manufacturing (CAD/ a small groove in the screw fragment and then rotate the
CAM) or welding are also available to fabricate passively fragment out of the fixture by a screw driver of the same
fitting frameworks. size, but it is very difficult to achieve at the chairside. On
the other hand, retrieval kits for different implant systems
Heavy or unfavorable occlusal loading also contributes are also available. When using the latter, damage to the
to failure of implant components. Prostheses with long internal threads of the implant should be avoided lest the

Hong Kong Dent J Vol 5 No 2 December 2008 81

Pow and Leung

(a) (b) often well osseointegrated, a rotary trephine instrument

must be used to remove it. If necessary the same site can
be reused (following adequate healing) to install another
implant.

Technical problems related to overdentures

Overdenture retention loss requiring adjustment is the

most frequent post-insertion problem. It partly reflects
the tendency of attachments to wear over a period of
time, due to cyclic occlusal loading. On the other hand,
denture-bearing areas which are not close to the implant
Figure 6 (a) Retrieval of fractured abutment screw by open region resorb over years and relining of the denture may
flap surgery. (b) Fractured abutment screw retrieved
be required to improve denture stability. Bar-clip, ball-stud
and magnet attachments are common retention systems.
However it is still unclear as to which type is most suited
to a given application. In terms of frequency of aftercare
and total costs, an 8-year randomized clinical trial on
mandibular implant-retained overdentures showed that
a bar on two implants was preferable to a triple bar on
four implants or ball attachments on two implants 18.
Notably, the stability or success of the implant-retained
overdenture should not rely solely on the attachments. In
such matters, the quality of the denture (fit, extension,
vertical dimension, jaw relationship and tooth setting)
should not be overlooked.
Figure 7 Fractured implant

Conclusions
implant cannot be used again 17. Most implant complications can be prevented by careful
case selection and treatment planning. New implant
Framework fracture connection designs, ceramic materials and CAD/CAM
technology facilitate the fabrication of prostheses with
Properly designed frameworks should not fracture. much enhanced longevity. However, no matter how
Common parts to fracture are the solder joints and just sophisticated the implant technology, failures do occur.
distal to the distal-most fixture. Because of the cantilever, Dentists should always be prepared for failures, and
this region is subjected to a higher force, and an adequate inform patients about this possibility well before treatment
cross-sectional dimension is needed to resist fracture. is commenced 19.
Improperly soldered joints are also subject to fracture.
Fractured solder joints may be reindexed intraorally and References
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