Failures of endosseous dental implants/ laser dentistry courses

Clinical Complications,Clinical Complications,
failures and maintenancefailures and maintenance
of endosseous implantsof endosseous implants
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.co
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ContentsContents
• Introduction
• Clinical complications
- Intraoperative
- Short term complications
- Long-term complications
• Implant care and maintenance
• Conclusion
• References
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IntroductionIntroduction
Current dental implant technologies and
materials continue to develop at a strong
pace. The procedure has become
established as the procedure of choice when
patients are faced with the decision to
replace single or multiple teeth.
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Most restorative and reconstructive dentists can
suggest a variety of treatment plans and
technologies for replacing any number of teeth. In
terms of obtaining optimal restoration of aesthetic
appearances and dental function (bite, occlusion,
eating, speaking, etc), implants tend to be
unsurpassed.
The success rate of implants is in the high ninety
percent range. However, occasionally they do fail.
There are two types of implant failures: Early and
Late: www.indiandentalacademy.co
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Early Failures
• This type of failure occurs shortly after the
implants are placed. They can be caused by:
• overheating the bone
• too much force when they are placed
• contaminated implant
• contaminated osteotomy
• epithelial cells in osteotomy site
• poor quality of bone
• excessive forces during osseointegration
• a myriad of other reasons
Late Failures
• Generally caused by:
• excessive forces
• lateral loading
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Smith and Zarb criteria for implant success:
1. Individual unattached implant is immobile when
tested clinically
2. No evidence of peri-implant radiolucency
3. Mean vertical bone loss is < 0.2 mm annually
after first year of service
4. No persistent pain, discomfort or infection
attributable to the implant
5. Implant design does not preclude placement of
a crown or prosthesis with an appearance that
is satisfactory to the patient
6. 85% success at 5yr post restoration period,
80% at ten years
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Clinical complicationsClinical complications
• Intraoperative complications
• Short term complications [up to six
months of surgery ]
• Long-term complications
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Intraoperative complicationsIntraoperative complications
• Oversized osteotomy
• Perforations of cortical plates
• Fractured buccal of lingual cortical plates
• Inadequate soft tissue flaps for Implant
coverage
• Broken burs
• Hemorrhage
• Poor angulation or Implant position
• Injury to neurovascular bundles
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Oversized osteotomyOversized osteotomy
• Root from implant: if
sufficient width is available
retap and place larger
implant
• Is no large implant is
available place graft
material
• It is a good practice to
stop motor rotations four
to five rotations from final
seating and hand wrench
with counter torquing
device in place
Steri-oss
Calcitek
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HA graft material on implant
Hand wrench
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• Blade and plate
from implants, give
gentle irregular
bands with titanium
tipped pliers to
offer instant
retention or use
0.5mm DFDB
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Cortical plate perforationCortical plate perforation
• It is possible with any
type of implant
• Causes :
 Limited width
 Misdirection of drill
 Unexpected
anatomical
irregularities
e.g. Submandibular
fossa beneath
mylohyoid ridge
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Fractured lingual or buccalFractured lingual or buccal
platesplates
• Seen more in blade form implants
• Also seen in ridge expansion
techniques
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Inadequate soft tissueInadequate soft tissue
flaps for implant coverageflaps for implant coverage
• Undermine the mucosa from the
adjacent buccal muscular surface
and suture flap without tension
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Broken bursBroken burs
• Seen when they
are permitted to
bind
• Removed only if
local reaction
occurs at a later
date
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HemorrhageHemorrhage
• Cause: soft tissue dissection
• Is the vessel is visible clamp and ligate or
electrocoagulate
• The Implant placement may stop the bleeding
• Simple tamponade, bone wax, gelfoam, surgicel,
avitene can also be used
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Simple tamponade
Bone wax
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Poor angulation or implantPoor angulation or implant
positionposition
• Blade and plate form implants, abutment may be
bent into parallel position
• Root from implants :
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“Sleeper “
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Injury to the neurovascularInjury to the neurovascular
bundlebundle
• Remove the implant
and inform patient
about possible
dysesthesia
• Use of infiltration
instead of block to
avoid penetration has
been advocated
• If no recovery occurs
in six weeks consider
exploration and repair
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Short term complicationsShort term complications
• Postoperative infection
• Dysesthesia
• Dehiscent wounds
• Radiolucencies
• Antral complications
• Implant mobility
• Post surgical scar contracture
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Postoperative infectionPostoperative infection
• Manifests by drainage, swollen tissue or pain
• Abscess requires drainage and antibiotic therapy
Infection from retained sutureGingival abscess
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DysesthesiaDysesthesia
• If there is no improvement in six weeks,
exploration and repair is Indicated
• If paresthesia develops in the postoperative
period, Implant removal is indicated
• If pain develops after it has subsided post
operatively, infection should be suspected
of injury from opposing teeth or denture
etc.
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Dehiscent wounds andDehiscent wounds and
implantsimplants
• In immediate ten
day postoperative
period, wound
sometimes breaks
down and implant is
exposed.
• Install rigorous oral
hygiene procedures
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RadiolucenciesRadiolucencies
• If at 4 to 8 weeks
postoperative
examination
periapical
radiolucency is seen,
assume that
osseointegration will
not occur.
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Antral complicationsAntral complications
• When sinus is breached
postoperative complications
such as Infection of
maxillary sinus may occur
even if implant has not
entered the sinus
• Facial pain, purulent nasal
discharge, foul smell and
taste, fever, pain and
sensitivity to palpation are
seen
• Confirmation through
Waters projection , CTwww.indiandentalacademy.co
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Implant mobilityImplant mobility
• If implant is mobile
in 3 to 6 months,
assume that no
osseointegration
has occurred,
advise removal
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Post surgical scarPost surgical scar
contracturecontracture
• Surgery in the region of pterygomandibular
raphae may lead to inability to open mouth or
tightness
• Z plasty is done to correct it
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Long-term complicationsLong-term complications
• Definitions:
 Failed implants
 Failing
 Ailing
Roland Meffert defined failed implant as one
with the presence of mobility
Failing implants are firm, osseointegration
develops apically and is responsible for implant
stability
Ailing implants however demonstrate diminished
but static levels of bone on follow-up radiographs
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Causes of bone lossCauses of bone loss
• Bone loss often begins with gingival inflammation
from poor oral hygiene
• Other factors include nutritional and secondary
systemic diseases
• Bruxism and another parafunctional habits
• Traumatic occlusion
• Improperly designed implants supra structure
• Physiologically incompatible implant design
• Cement failure on adjacent natural tooth
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Fixture loss
(Must differentiate between “failing” and
“failed”)
• Failing Implant
– Clinical signs:
• progressive bone loss
• soft tissue pocketing 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.
• Nonpassive superstructures
• inadequate screw joint closure
• functional overload
• periodontal infection (peri-implantitis)
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• Failing Implant
– Treatment:
• Interim: remove prosthesis and abutments
– irrigate with Peridex
– Ultrasonic used to disinfect all components
– reinsert assuring proper screw torque
– recheck passive fit of framework and
occlusion
Failed Implant
– Clinical signs:
• Mobility
– verify fixture mobility by removing any
abutments and superstructures first.
• A “Dull” percussion sound has been associated
with a failed implant
• Peri-implant radiolucency can be a radiographic
finding
– often this is not evident on an X-raywww.indiandentalacademy.co
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• Failed Implant
– Causes
• surgical compromise (overheating bone and
initial lack of stability).
• Nonpassive superstructures.
• Inadequate screw joint closure
• Too rapid initial loading
• Functional overload
• Periodontal infection (“peri-implantitis”)
– Treatment
• removal of the implant
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Implant failuresImplant failures
• Largely classified into four main
categories
1. Loss of integration
2. Positional failures
3. Soft tissue defects
4. Biomechanical failures
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Loss of integrationLoss of integration
• This type of failure occurs mostly before loading
the implant with the definitive restoration
• The major clinical problem in these situations is
delay of completion of treatment and patient
management.
• When non cylindrical implants are used, more
trauma is caused on removal; this can lead to
severe hard and soft tissue loss.
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Implant provisional in place
Soft tissue health
Failed implant removed
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Ailing non-cylindrical implant
Hard and soft tissue defect after implant removal
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Peri-implantitisPeri-implantitis
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Treatment of peri-implantitisTreatment of peri-implantitis
• No difference between more complex procedures and
conventional debridement in light forms of peri-
implantitis.
• The adjunctive use of local antibiotics (doxycycline)
for debridement showed an improvement of about
0.6 mm, after 4 months in patients affected by
severe forms of peri-implantitis (bone loss > 50%).
Implants with progressive bone loss
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Prosthetic management ofProsthetic management of
implant lossimplant loss
• Losing one of several implants mandates a
change in prosthetic strategy
• Options are to shorten bars, eliminate
cantilevers, change location of attachments or
other retention devices from terminal abutment
to pier abutment
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Positional failurePositional failure
• The most common type of failure is caused by
poor treatment planning and/or poor surgical
execution.
• Implant placement must be controlled and
precise in order to support tooth like restorations,
the restoration should guide implant placement
and planning for implant placement must take
into account the form and position of the
restoration.
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• This type of failure can easily
be avoided with proper
treatment planning, proper
site development, use of
surgical guides and a good
understanding of the
restorative aspects of implant
dentistry by the surgeon.
• Malposition of the implant
can lead to biomechanical
problems to the screw joint
or in severe situations to the
implant itself due to overload
Implant axis lingually tilted
Buccally placed implant
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Soft tissue defectsSoft tissue defects
• The soft tissue frames the restoration — careful
management of soft tissue must be considered
from the time extractions take place if the tooth
to be replaced is still present.
• Even a well placed implant will not allow good
aesthetics if the soft tissue is not present or not
managed well with the use of provisional
restorations
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Soft tissue reactions
• Often seen with split thickness skin grafts or lack
of periabutment keratinized tissue
• Soft tissue inflammation most commonly due to
loose screw joints.
– Remove the offending screws, tighten the
abutments and reinsert the prosthesis.
• Poor oral hygiene: soft tissue inflammation often
referred to “peri-implantitis”. Etiology similar to
natural teeth (plaque, lack of attached tissue,
etc.) May result in progressive bone loss.
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PresentationPresentation: Soft: Soft
tissue reactiontissue reaction
Radiographic evaluation:
(A) Within Normal Limits(A) Within Normal Limits (B) Loose or fractured screw(B) Loose or fractured screw
TreatmentTreatment::
1 – treatment for loose or1 – treatment for loose or
fractured screwsfractured screws
1 - Remove abutment1 - Remove abutment
2 - Irrigate area with sterile2 - Irrigate area with sterile
saline or Peridexsaline or Peridex www.indiandentalacademy.co
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TreatmentTreatment: (cont): (cont)
3 - Replace abutment or restoration.3 - Replace abutment or restoration.
4 - Follow up as needed4 - Follow up as needed
Irrigate areaIrrigate area
with sterilewith sterile
saline orsaline or
peridex.peridex.
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Oral HygieneOral Hygiene
• calculus build up can causecalculus build up can cause
areas of soft tissueareas of soft tissue
inflammation.inflammation.
• may result in progressivemay result in progressive
bone loss if left untreated.bone loss if left untreated.
TreatmentTreatment
• remove prostheses, checkremove prostheses, check
implants for mobility,implants for mobility,
retorque abutments.retorque abutments.
• perform maintenanceperform maintenance
cleaning on prosthesis andcleaning on prosthesis and
abutments.abutments.
• reinsert prosthesis with newreinsert prosthesis with new
screws, give oral hygienescrews, give oral hygiene
instructions.instructions.
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Biomechanical failuresBiomechanical failures
• These types of failures range from loosening of
screws to breakage of implant components and
implants.
• These types of failures can be avoided with
proper treatment planning, a good understanding
of screw joint mechanics and knowledge of the
implant system used.
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Screw looseningScrew loosening
-- can have a slot or hex head
- access is usually covered by a
combination of gutta percha and
composite.
- used to retain the prosthesis to the
abutment.
- tightened to 10- 25 Ncm of torque
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Mechanical torquingMechanical torquing
handpiecehandpiece
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Fractured or loosened screws
• Usually results in localized inflammation, loose
restorations and discomfort.
– First suspicion when patient complains of
discomfort or loose implant.
• Prosthetic gold retaining screws have either a
slot or hex head.
• Loose single tooth abutments are true
emergencies. Continued rotation can risk
rounding the corners of the hex on the
implant, causing a loss in anti-rotation.
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Tissue appears swollen and edematous
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Multiple areas exhibit
poor tissue response.
Diagnosis:
– Possible loose or
fractured abutment
screw
Radiographic
evaluation to
determine treatment.
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Radiographic evaluationRadiographic evaluation
of a loose healingof a loose healing
abutment.abutment.
Removal of healingRemoval of healing
abutment indicates aabutment indicates a
distorted screwdistorted screw
Replace with new healingReplace with new healing
abutmentabutment
Initial PresentationInitial Presentation::
Loose HealingLoose Healing
AbutmentAbutment
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Area ofArea of
concernconcern
Radiograph confirms poorRadiograph confirms poor
seating abutment.seating abutment.
DiagnosisDiagnosis::
- possible loose or- possible loose or
fractured abutmentfractured abutment
screwscrew
Clinical evaluation afterClinical evaluation after
removal of bar indicatesremoval of bar indicates
loose abutment screw.loose abutment screw.
1 - Retorque abutment screw.1 - Retorque abutment screw.
Initial PresentationInitial Presentation: Loose: Loose
barbar
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Abutment screw driver.Abutment screw driver.
Treatment: continuedTreatment: continued
2 - Abutment screw is2 - Abutment screw is
tightened with abutmenttightened with abutment
driver.driver.
3 - Bar is then replaced3 - Bar is then replaced
and prosthetic screws areand prosthetic screws are
torqued with appropriatetorqued with appropriate
screw driver.screw driver.
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Clinical ExamClinical Exam: Loose: Loose
restorationrestoration
Radiographic EvaluationRadiographic Evaluation::
Small opening at abutment-Small opening at abutment-
implant interfaceimplant interface
Small
opening
DiagnosisDiagnosis::
- Loose abutment screw- Loose abutment screw
1 - Loosen screw and1 - Loosen screw and
remove restorationremove restoration
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continuedcontinued
2 - inspect the implant hex2 - inspect the implant hex
for damagefor damage
3 - inspect the restoration3 - inspect the restoration
for damagefor damage
Implant hex
Abutment hexAbutment hex
(A) No Damage to fixture of restoration(A) No Damage to fixture of restoration
- replace restoration and secure with- replace restoration and secure with
the appropriate new screw. Verifythe appropriate new screw. Verify
seating with radiograph prior to finalseating with radiograph prior to final
torque. Recheck occlusion withtorque. Recheck occlusion with
shimstock.shimstock.
(B) Damaged fixture hex and or restoration(B) Damaged fixture hex and or restoration
- replace restoration and secure with- replace restoration and secure with
same screw. Refer to Commandsame screw. Refer to Command
Implant Coordinator.Implant Coordinator.
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Fractured Abutment ScrewFractured Abutment Screw
TreatmentTreatment
PlanPlan::
1 - Remove prosthetic1 - Remove prosthetic
restoration.restoration.
2 - Remove fractured2 - Remove fractured
abutment.abutment.
3 - Remove fractured3 - Remove fractured
abutment screw.abutment screw.
- Intraoral fractured- Intraoral fractured
abutment screws canabutment screws can
often be teased out withoften be teased out with
the tip of an explorer.the tip of an explorer. www.indiandentalacademy.co
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Fractured Abutment ScrewFractured Abutment Screw
- the tip of the explorer is- the tip of the explorer is
placed on the top portion of theplaced on the top portion of the
fractured abutment screw.fractured abutment screw.
- with slight apical pressure- with slight apical pressure
and a counterclockwise circularand a counterclockwise circular
motion, the fragment can oftenmotion, the fragment can often
be unscrewed.be unscrewed.
- care must be taken not to- care must be taken not to
damage the internal threads ofdamage the internal threads of
the implant. Requires extremethe implant. Requires extreme
patience.patience.
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Fractured AbutmentFractured Abutment
ScrewScrew
- rotary instruments have been- rotary instruments have been
used by skilled practitionersused by skilled practitioners
utilizing magnification.utilizing magnification. (not(not
recommended)recommended)(A) Screw Fragment(A) Screw Fragment
removedremoved
- replace with appropriate- replace with appropriate
new abutment and screw.new abutment and screw.
Verify seating with aVerify seating with a
radiograph prior to finalradiograph prior to final
torque.torque.
- replace prosthesis and- replace prosthesis and
secure with new retentionsecure with new retention
screws.screws.
Treatment :Treatment : continuedcontinued
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Fractured Abutment Screw
((B) Screw fragment unable to be removed
- Replace prosthesis on existing abutments and secure
with prosthetic retention screws or place healing caps on
all abutments.
On request Nobel Biocare will send you a tool kit to help
retrieve broken abutment screws.
Refer to Command Implant Coordinator.
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Broken Attachments
• Plastic bar clip
– damaged or broken
• cut along long axis with sharp knife and
remove.
– Missing
• replace by inserting a new clip into
denture base receptacle
• if unavailable, contact Command Implant
Coordinator
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• Metal bar clip
– damaged or broken (replacement clip
available)
• remove the clip and perforate the denture
base carefully for intraoral pick up
replacement.
• Block out under the bar with wax, seat the
denture and position a new clip through
access in denture base.
• Use autopolymerizing acrylic resin with
“bead brush” technique to fill in access and
connect clip to denture base. Polish ,
disinfect and deliver.
• Always confirm seating of denture after
repair and evaluate occlusion.
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• Metal bar clip
– Damaged or broken (replacement clip not
available)
• remove all remnants of the clip from the
denture base.
• block out under the bar with wax
• reline the clip area of the denture with a
resilient chairside reline material
(viscogel).
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– Intact clip with no retention
• carefully bend the leaves of the clip toward
the bar with a thin instrument.
• Reseat the denture to confirm increased
retention.
• Recheck occlusion.
• Stud attachments
– treatment is similar to clips
• tease out “O” ring with an explorer and
replace as needed.
• Fractured housing can be treated like a clip
replacement.
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Lost clipLost clip
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Clip RepairClip Repair
1 - Block out bar with1 - Block out bar with
waxwax
2 - Remove all remnants2 - Remove all remnants
of the clip from theof the clip from the
denture base.denture base.
3 - reline clip area of3 - reline clip area of
denture with resilientdenture with resilient
chairside reline material.chairside reline material.
(Viscogel)(Viscogel)
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Clip RepairClip Repair
4 - Reseat prosthesis and4 - Reseat prosthesis and
verify occlusion.verify occlusion.
5 - Remove after 10 to 155 - Remove after 10 to 15
minutes, trim excessminutes, trim excess
material, polish,material, polish,
disinfect and deliverdisinfect and deliver
back to patient.back to patient.
3 - reline clip area of3 - reline clip area of
denture with resilientdenture with resilient
chairside reline material.chairside reline material.
(Viscogel)(Viscogel)
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Fractured components
• Screw retained prosthesis
– Fractured resin or prosthetic tooth
• remove prosthesis and repair as if a conventional
prosthesis.
• If the prosthesis is a hybrid, remove in the same
manner as for a maintenance appointment.
• Cemented Prosthesis
– Multiple unit restoration
• carefully tap off the restoration with crown remover
and repair as indicated.
– Single unit restoration
• if no screw access, drill an access through the
occlusal surface to the abutment screw and remove
the restoration.
• Repair or fabricate provisional as indicated.
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Fracture and breakage ofFracture and breakage of
prosthesisprosthesis
Fractured cast framework
Fractured overdentures
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Fractured InfrastructureFractured Infrastructure
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Implant - Soft TissueImplant - Soft Tissue
InterfaceInterface
• Normal gingival
architecture
• Minimal inflammatory
infiltrate
• Connective tissue closely
adapted to the implant
HealthyHealthy
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Bone Maturation
• Pre-existing bone (PB) extends into
threads providing stability.
• New Bone (NB) in close apposition to
the implant
• New Bone deposition approximately
1um/day
NB
PB
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Soft Tissue RelationshipSoft Tissue Relationship
• Similar to teeth
• No Sharpeys fibers
• Hemidesmosomal
attachments
• Circumferential and
perpendicular
connective tissue
• Fibres run parallel to
the surface
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Plastic probes are used whenPlastic probes are used when
checking for evidence ofchecking for evidence of
disease.disease.
Implants are similarImplants are similar
to the natural tooth.to the natural tooth.
Implantitis vs. PeriodontalImplantitis vs. Periodontal
disease have similar clinicaldisease have similar clinical
presentationspresentations
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Maintenance and RecallMaintenance and Recall
• Annually
– periapical radiographs should be taken to
monitor the crestal bone levels. (crestal bone
can be at the level of the first thread in one year
with 0.1mm continued loss to approximately 1.5
mm total bone loss)
– remove and reinsert screw retained implant
prostheses every 2 years unless indicated
otherwise.
• Replace prosthesis with new retaining screws
if removed.
– Cemented restorations are usually permanent
(nonretrievable).
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– Recall focus
• Occlusion - verify there are no excursive
contacts. Should not hold shimstock.
Better to be out of occlusion
• Oral hygiene - same requirements as for
natural teeth.
• Soft tissue health - periodontal probing for
evidence of disease.
• Screw joint torque - check for loosened
screws (most common problem).
• Integrity of attachments - applies to
overdentures
• Stability of implants - must be stable (non
mobile) to be successful
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• Screw retained prosthesis
– Remove prosthetic retention screws
• Screw access holes are usually sealed
with a layer of cotton pellet, silicone plug
or gutta percha the acrylic or composite
resin.
• Expose the screw by drilling carefully
through the resin.
• Remove the screw (slot or hex) with the
appropriate screw driver.
• Throat drapes are highly recommended.
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– Check for implant mobility and retorque
abutments to 20 Ncm. (hand tighten as
much as possible with finger abutment
driver if no torque control device is
available)
– Clean and polish abutments (Do not
remove)
– Reseat restoration using new gold retaining
screws.
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• Screw retained prosthesis (cont.)
– Temporary reinsertion
• fill access holes with small cotton pellet and
polyvinylsiloxane impression material or
putty.
– Long-term reinsertion
• fill access hole with small cotton pellet over
the head of the screw, followed by warm
gutta percha and only 1-2 mm of acrylic or
composite resin.
• ..
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• Cemented restorations
– Single unit
• usually nonretrievable and not removed for
maintenance.
– Multiple unit (usually not indicated)
• carefully tap off with crown remover, check
for mobile implants and retorque abutment
screws.
• Replace restoration with provisional luting
media, and recheck occlusion
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Hygiene Aids
• Super - floss
• End tufted brushes
• Proxy brushes
• Tarter control dentrifices
• Mechanical instruments
• Peridex
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Super - FlossSuper - Floss
- Excellent for all types of- Excellent for all types of
implant restorationsimplant restorations
Butler Post Care FlossButler Post Care Floss
AidAid
- Excellent for implant- Excellent for implant
bars and fixed hybridbars and fixed hybrid
prostheses.prostheses. www.indiandentalacademy.co
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Use of super flossUse of super floss
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Fixed Hybrid Prosthesis
- Hygiene care with a
proxy brush
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Patient presents with a maxillary RPD with an
implant bar/clip component to the anterior
edentulous area.
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Butler Floss Aid is used
to clean the bar
including the area
contacting the tissue..
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The bar may be removed with the
appropriate screw driver, polished and the
torque of all the abutments checked prior to
replacement.
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Prophy paste and a rubberProphy paste and a rubber
cup on a prophy head /cup on a prophy head /
handpiece can be used tohandpiece can be used to
polish implant bars whenpolish implant bars when
removal is not indicatedremoval is not indicated
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Plastic scalers arePlastic scalers are
appropriate for cleaningappropriate for cleaning
around standardaround standard
abutments supportingabutments supporting
implant bar substructures,implant bar substructures,
hybrid prostheses andhybrid prostheses and
implant supported splintedimplant supported splinted
restorations.restorations.
Plastic scaler tips arePlastic scaler tips are
also available for metalalso available for metal
handle scalers.handle scalers.
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Implant supported
fixed partial
denture
Scaler tips are designed to fit the curvature of
the standard abutment.
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ConclusionConclusion
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ReferencesReferences
• Atlas of implant dentistry, Cranin
• Contemporary implant dentistry, Misch CE,
second edition
• Dental implant art and science, Charles
Babbush
• Implants in clinical dentistry, Palmer RM
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JournalsJournals
• Goodacre C J, Bernal G, Rungcharassaeng K, Kan
J Y. Clinical complications with implants and
implant prostheses. J Prosthet Dent 2003; 90:
121–132.
• Rosenberg E S, Cho S C, Elian N et al. A
comparison of characteristics of implant failure
and survival in periodontally compromised and
periodontally healthy patients: a clinical report.
Int J Oral Maxillofac Implants 2004; 19: 873–
879.
• Garber D A. The esthetic dental implant: letting
restoration be the guide. J Am Dent Assoc 1995;
126: 319–325.
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JournalsJournals
• Winkler S, Ring K, Ring J D, Boberick KG. Implant
screw mechanics and the settling effect:
overview. J Oral Implantol 2003; 29: 242–245.
• Alkan I, Sertgöz A, Ekici B. Influence of occlusal
forces on stress distribution in preloaded dental
implant screws. J Prosthet Dent 2004; 91: 319–
325.
• Failures in implant dentistry.W. Chee and S.
Jivraj. British Dental Journal 202, 123 - 129
(2007)
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Recently uploaded (20)

Failures of endosseous dental implants/ laser dentistry courses