Mechanical and Technical Risks in Implant Therapy

Giovanni E. Salvi, PD, Dr Med Dent1/Urs Brgger, Prof Dr Med Dent2

Purpose: To systematically appraise the impact of mechanical/technical risk factors on implant-supported reconstructions. Material and Methods: A MEDLINE (PubMed) database search from 1966 to April 2008 was conducted. The search strategy was a combination of MeSH terms and the key words: design, dental implant(s), risk, prosthodontics, fixed prosthodontics, fixed partial denture(s), fixed dental prosthesis (FDP), fixed reconstruction(s), oral rehabilitation, bridge(s), removable partial denture(s), overdenture(s). Randomized controlled trials, controlled trials, and prospective and retrospective cohort studies with a mean follow-up of at least 4 years were included. The material evaluated in each study had to include cases with/without exposure to the risk factor. Results: From 3,568 articles, 111 were selected for full text analysis. Of the 111 articles, 33 were included for data extraction after grouping the outcomes into 10 risk factors: type of retentive elements supporting overdentures, presence of cantilever extension(s), cemented versus screw-retained FDPs, angled/angulated abutments, bruxism, crown/implant ratio, length of the suprastructure, prosthetic materials, number of implants supporting an FDP, and history of mechanical/technical complications. Conclusions: The absence of a metal framework in overdentures, the presence of cantilever extension(s) > 15 mm and of bruxism, the length of the reconstruction, and a history of repeated complications were associated with increased mechanical/technical complications. The type of retention, the presence of angled abutments, the crown-implant ratio, and the number of implants supporting an FDP were not associated with increased mechanical/technical complications. None of the mechanical/technical risk factors had an impact on implant survival and success rates. INT J ORAL MAXILLOFAC IMPLANTS 2009;24(SUPPL):6985 Key words: clinical studies, oral implants, prosthodontics, risk factors

edical interventions involving surgical procedures for the insertion of devices such as stents, hip or knee prostheses, orthopedic devices, or dental implants are associated with risk. Before undergoing such interventions, the risks for failure or complications and chances of survival or success need to be carefully weighed by patients and professionals. A qualitative description of risk would relate a greater overall risk to a greater loss and greater likelihood that an event occurs.

In medicine, a risk factor is a variable associated with an increased risk of disease or infection. Risks are correlational and not necessarily causal. Risk factors are evaluated by comparing the risk of those exposed to the potential risk factor to those not exposed. For the purpose of the present review, mechanical and technical risks were defined as follows: Mechanical risk: Risk of a complication or failure of a prefabricated component caused by mechanical forces. Technical risk: Risk of a complication or failure of the laboratory-fabricated suprastructure or its materials. Mechanical and technical risks play a major role in implant dentistry. They may lead to increased rates of repairs and remakes, and to a waste of time and financial resources, and may even affect the patients quality of life. During treatment planning, constellations known to be associated with increased risk should be avoided. Risks associated with different treatment options must also be related to the financial consequences, especially when considerable price differences exist between the prosthetic options.

1Vice

Chairman and Graduate Program Director in Periodontology, Department of Periodontology, School of Dental Medicine, University of Bern, Bern, Switzerland. 2Chairman, Division for Fixed Prosthodontics, School of Dental Medicine, University of Bern, Bern, Switzerland. The authors reported no conflict of interest. Correspondence to: Prof Urs Brgger, Division for Fixed Prosthodontics, School of Dental Medicine, University of Bern, Freiburgstrasse 7, CH-3010 Bern, Switzerland. Fax: +41 31 632 4931. Email: urs.braegger@zmk.unibe.ch This review paper is part of the Proceedings of the Fourth ITI Consensus Conference, sponsored by the International Team for Implantology (ITI) and held August 2628, 2008, in Stuttgart, Germany.

The International Journal of Oral & Maxillofacial Implants 69

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A series of systematic reviews were launched to estimate and compare the failure/complication rates to be expected with various types of fixed reconstructions on teeth and implants.18 With some of the reconstructions, considerably increased rates of failures were estimated to occur over 10 years of function6: fixed dental prostheses (FDPs) with cantilever extensions on teeth (19.6%), combined toothimplant-supported FDPs (22.3%), and resin-bonded FDPs (35.0%). The protocols of the systematic reviews mentioned above were designed to include publications reporting on the prosthetic failure and complication rates with a particular design of a reconstruction, ie, full-arch FDPs on implants/teeth, short-span FDPs on implants and teeth, and single crowns, over at least 5 years. Excluding multiple other factors that may mask a correlation with a particular risk factor seems to be difficult when combining data from cohort studies being performed at various centers. According to the definition of risk factor mentioned above, long-term studies that evaluated and compared the risk of those patients/reconstructions exposed to a certain risk factor to those not exposed to that risk factor in the same environment are of particular interest. Therefore, the aim of this review was to systematically screen the literature for information answering the following focused question: Which mechanical/ technical risk factors have an impact on implant-supported reconstructions?

Selection Criteria
Randomized controlled trials (RCTs), controlled trials, and prospective and retrospective cohort studies with a mean follow-up time of at least 4 years were included. The material evaluated in one study had to include cases with the risk factor and cases without exposure to the risk factor. The following inclusion criteria were used: Mean follow-up time 4 years At least five patients included Studies on fully and partially edentulous patients Studies on fixed and/or removable implant-supported dental prostheses Studies on fixed dental prostheses with cantilever extension(s) Studies on implant-supported single-unit crowns Studies on implant- and/or tooth-implant-supported reconstructions Studies on cylindrical and/or cylindrical-conical solid-screw implants Clinical examination at the follow-up visits Detailed information on the characteristics of the implants and their supported reconstructions The following exclusion criteria were used: Animal studies in vitro studies Studies based on patients records, surveys, questionnaires, or interviews Studies focusing exclusively on finite element analysis (FEA) Studies focusing exclusively on implant length and/or diameter Studies focusing exclusively on patient-centered outcomes Reviews Case reports Abstracts

MATERIALS AND METHODS

Search Strategy
A search in the MEDLINE (via PubMed) database from 1966 up to and including April 2008 was performed. Publications in English, German, French, and Italian in peer-reviewed journals were considered; abstracts were excluded. The search strategy applied was a combination of MeSH terms and free text words, including the following key words: design , dental implants/risk , prosthodontics , fixed prosthodontics , fixed partial denture(s) , fixed reconstruction(s), oral rehabilitation, bridge(s), removable partial denture(s), and overdenture(s). A complementary manual search from 1986 up to April 2008 was carried out in the following journals: Journal of Oral Rehabilitation , Journal of Prosthetic Dentistry, International Journal of Prosthodontics, International Journal of Periodontics & Restorative Dentistry, Clinical Oral Implants Research, and International Journal of Oral & Maxillofacial Implants. In addition, the reference lists of articles selected for inclusion in this review were screened.
70 Volume 24, Supplement, 2009

Validity Assessment
Two reviewers (UB and GES) screened titles and abstracts identified through the search for possible inclusion. The discrepancies were resolved by discussion. Publications of potential interest were obtained in order to evaluate the full text. Both reviewers screened the included publications independently using the inclusion criteria. Again, any disagreement was resolved by discussion between the two reviewers.

Data Extraction
Collectively, the outcome variables included:

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Implant-related mechanical and technical risk factors Abutment-related mechanical and technical risk factors Suprastructure-related mechanical and technical risk factors Depending on the presence or absence of a specific mechanical or technical risk factor, survival and success rates of implants, abutments, and related suprastructures were extracted from the publications. Sur vival was defined as presence of the implant, abutment, and/or its suprastructure in situ in its original extension at follow-up examination with or without complications. Success was defined as presence of the implant, abutment, and/or suprastructure in situ without any mechanical or technical complications during the entire follow-up period. From the included papers, the following information was extracted: the number of patients examined, the mean age of the patients, the mean observation time, the number of implants restored, the implant system used, the designs of the reconstructions under examination, and the study design applied. Finally, the major findings related to harm to the suprastructure, prosthetic components of the implant systems, peri-implant tissues, implants, and results of statistical analyses were noted and grouped according to potential risk factors.

Potentially relevant publications identified from the online search (n = 3,568) Publications excluded on the bases of title and abstract evaluation (n = 3,457) Potentially relevant full-text articles retrieved for detailed evaluation (n = 111) Publications excluded on the basis of full-text evaluation (n = 78) Publications included based on the MEDLINE database search (n = 33) Publications included based on the manual search (n = 2) Publications included in the present systematic review (n = 35) Fig 1 tions. Selection process used to identify the included publica-

Retentive Elements of Overdentures (Tables 1 and 2)

Eight studies dealing with mandibular overdentures in which the allocation of patients to different treatment groups was performed in a randomized manner were identified (Table 1). Naert et al compared 12 patients with Dolder bars to 12 patients with ball attachments and 12 patients with magnets. 9 At 5 years, the highest retention measured by means of a dynamometer amounted to 1,240 g in the bar group, followed by 567 g in the ball attachment group, and only 110 g in the magnet group.9 When questions about prosthesis stability and cleaning comfort were ranked on a scale from very bad (1) to excellent (9), mean rankings were statistically significantly lower in the magnet group compared to the ball and bar groups. Patient satisfaction related to chewing comfort and phonetics did not change significantly over the 5 years. In the magnet group, however, a significant decrease in general satisfaction and in satisfaction with denture stability was noted (P < .03). In a later publication by Naert et al, 10 unfortunately no detailed information related to prosthetic complications over 10 years of observation was presented. Similar failure rates for the implants were noted in the three groups of overdentures. Gotfredsen et al found less frequent events for patients receiving ball attachments (19 cases, 0.6 events per year) than for patients receiving a round

RESULTS
Of the 3,568 titles resulting from the online search, 111 were selected for full text review after reading the abstract. From the 111 full-text articles, 33 were included for data extraction. Two additional articles were included based on a manual search (Fig 1). The data from 35 publications were grouped according to 10 risk factors identified after screening the literature: Type of retentive elements supporting overdentures Cantilever extension(s) on fixed dental prostheses (FDPs) Cemented versus screw-retained FDPs Angled/angulated abutments Bruxism Crown-to-implant ratio Length of the suprastructure Prosthetic materials Number of implants supporting an FDP History of mechanical/technical complications

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Table 1 Randomized Controlled Trials with Edentulous Mandibles Restored with Various Overdenture Designs on Different Implant Systems: Results after 5 and 10 Years of Observation

Study
63.7 (3685) 60 mo 72 Nobel Biocare 12 Dolder bar 12 magnet 12 ball Prospective randomized RCT

Year

No. of patients

Mean Mean age, observation No. of y (range) time implants Implant system Overdenture design Type of study Summary of results

72 Volume 24, Supplement, 2009

64 (5278) 60 mo 52 Astra Tech 11 round bar 19 ball Retention of denture: bar > ball > magnet Reduction of retention in % of original value similar Complications: magnet > ball > bar More hyperplasia with bar More ulcers with ball Satisfaction: comfort with stability significantly reduced with magnet No risk factor for implant loss Complications per year per patient 1.0 for bar, 0.6 for ball No risk factor for implant loss No risk factor for implant loss 60 mo 180 54.0 (3877) 56.6 (3579) 52.8 (3874) 3987 8.3 y 274 Prospective randomized RCT Randomized (envelope) RCT Randomized RCT Satisfaction with retention, stability decreased with ball No difference in change of satisfaction Two implants with bar best solution NR 59 11 5y 122 30 IMZ All Dolder bar 30 Nobel Biocare (90) 30 Straumann Straumann 36 ball 37 bar on 2 implants 37 bar on 4 implants 29 IMZ 61 round bars 32 Nobel Biocare w/ Ackermann clips Computerized balancing NR 60 mo 180 5911 5512 120 mo 122 63.7 (36-85) 120 mo 72 Multiple prosthetic revisions Precision attachment system in the overdenture with frequent fractures and loosenings Implant survival: IMZ 93%; Nobel Biocare 86% IMZ 30 two implants Prospective Tendency for more prosthetic aftercare with two implants and bar and bar, 30 four comparative More soft tissue complications with four implants and bar implants and bar No difference in satisfaction No risk factor for implant loss 29 IMZ 61 round bars Randomized Very high incidences of technical/prosthetic complication and 32 Nobel Biocare w/ Ackermann computer-model failures clips RCT Measured by clinical implant performance score: similar scores for the two systems No risk factor for implant loss Nobel Biocare 12 Dolder bar Prospective No more information on technical prosthetic complications 12 magnet randomized compared to Naert et al 1999 12 ball RCT No risk factor for implant loss

Naert et al10

1999

36

Gotfredsen et al11

2000

26

Meijer et al12

2004

90

Timmerman et al15

2004

110/103

Meijer et al13

2000

61

Visser et al16

2005

60

Meijer et al14

2004

61

Naert et al10

2004

36

NR = not reported; RCT = randomized controlled trial.

Table 2

Further Studies on Reconstructions of Edentulous Jaws

Study
66 62 mo 115 Nobel Biocare (12106 mo) 8-y life table Round bar/ball 18 maxillary/ 32 mandibular RCT 75 round bar or ball versus 44 rigid bar Consecutive patients Random assignment

Year

Mean No. of age, y patients (range) Implant system Findings Designs of reconstruction Study design

Mean No. observation of time implants

Bergendal and Engquist17

1998

49

Dudic and Mericske-Stern18

2002

119

63 (4090)

9.3 y (515 y)

258

Straumann

Nedir et al19 NR 8-y life table 60 mo 180 Straumann Consecutive patients 145 Straumann 41 ball/14 bar Consecutive patients

2006

55

Oetterli et al20

2001

90/70 67.8 (4189)

Risk of complication: old components, new components Bone anchoragelever arm was a risk factor More denture fractures with bar versus ball (no framework) More implant loss in maxilla (25%) versus mandible (0%) No risk factor for implant loss No significant difference in time to change of retention mechanism between resilient and rigid Rate of prosthetic maintenance service = event per patient per year at 5 years (no significant difference between the 2 retention systems) For resilient: more complications with retainers, more denture base resin fractures, hyperplasia, relining For rigid: fracture of bar extension, retightening of female part Rates at 5 years similar, advantage for rigid related to time needed for service. No risk factor for implant loss Event rate per year: 1.5 with ball, recurrent events 0.9 mm with bar Free of complications 57.1% with bar, 24% with ball (P < .04) Supportive surface and position of implant as well as retention mechanism No risk factor for implant loss

Ferrigno et al21 59.4 (3579) 10-y life table 1286 Straumann

2002

233

Supportive surface, bent clipbars, U-shaped extension bars, mandible o: angle between axis connecting implants and mandibular hinge axis Maxilla: full-arch prosthesis 55; Milled bar 19; Dolder bar 16 Mandible: full-arch prosthesis 40; Milled bar 84 Dolder bar 44

Prospective multicenter

Tinsley et al22 (3780) 46 y 181 Calcitec HA-coated

2001

48

21 FDP vs 27 bar, Prospective mandible (23 bars on 3 implants, 4 on 2 implants)

Survival of prosthesis: Maxilla: full-arch prosthesis 96.4%; Milled bar 94.7%; Dolder bar 87.5% Mandible: full-arch prosthesis 100%; Ball anchor 99%; Dolder bar 98% Implant success: Maxilla: full-arch prosthesis 92.1%; Milled bar 92.2%; Dolder bar 86.9% Mandible: full-arch prosthesis 96.2%; Ball anchor 93.7%; Dolder bar 93.9% Catastrophic results: 50% of overdentures were remade, 30% required a reline Only 83% implant survival HA implants lost a lot of bone

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The International Journal of Oral & Maxillofacial Implants 73

NR = not recorded; FDP = fixed dental prosthesis.

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bar (11 cases, 1.0 events per year).11 Over 5 years, 48 complications/repairs were observed in the ball group and 53 in the bar group. Mainly during the first year of function, there were statistically significantly more complications/repairs in the bar group. However, some of the technical complications were related to the devices needed for radiographic standardization. Meijer et al12 followed overdentures with Dolder bars on three different implant systems (IMZ, Nobel Biocare, and Straumann). Over 5 years, there was no effect on the implants and no information was presented on prosthetic aspects. In an earlier report by the same group comparing overdentures on IMZ and Nobel Biocare implants, multiple prosthetic revisions were noted.13 When the same patients were followed over 10 years,14 the 56 surviving overdentures with round bars and Ackermann clips required 256 prosthetic actions, including replacement of broken abutments and loose clip screws, placement of new bars or gold cylinders and new or fastening clips, relining of maxillary or mandibular dentures, repair of denture bases or teeth, readjustment of occlusion, and provision of new maxillary and mandibular dentureswith no obvious difference between the IMZ and Nobel Biocare groups. A clinical implant performance scale was used to score the events. With a mean score of 1.3 for the IMZ group and 1.2 for the Nobel Biocare group, the clinical outcomes appeared to be similar. Three types of overdenture designs were compared comprehensively using a computerized random allocation procedure.15 Thirty-six overdentures were attached to two ball anchors, 37 to a bar on two implants, and 37 to a bar on four implants. General satisfaction with phonetics, esthetics, and social functioning remained high. The score reflecting satisfaction with retention and stability of the overdenture decreased significantly in the group with two ball attachments. Comparing 30 overdentures with bars on two implants to 30 overdentures with bars on four implants, Visser et al16 found a tendency for more biological complications with four implants but a higher need for prosthetic aftercare on two implants (not statistically significant). Six additional studies were found in which overdentures with different attachment systems were compared longitudinally. In these studies, allocation of the groups was not performed using randomization (Table 2). Forty-nine patients with maxillary and mandibular overdentures were followed over 62 months (range 12 to 106 months).17 When patients received overdentures either on ball anchors or on a round bar, the overdentures that were not reinforced with a metal
74 Volume 24, Supplement, 2009

framework were at high risk of fracturing. In the bar group, 30 of 36 patients required denture repairs. In the maxilla, 25% of the originally placed implants were lost compared to none in the mandible. The amount of bone anchorage in relation to the lever arm was higher in the lost implants (mean lever armbone anchorage ratio of 1.3) than in all implants placed (a mean lever armbone anchorage ratio of about 1). Over an observation period of 5 to 15 years (mean 9.3 years), 119 patients with implant-supported overdentures were monitored at regular intervals.18 The rate of prosthetic maintenance per patient over 5 years was similar for the resilient and rigid types of fixation applied. However, the characteristics of the complications differed. Whereas resilient attachments had more complications with retainers, more denture base resin fractures, mucosal hyperplasia, and denture relines, the rigid support attachments had more fractures of bar extensions and needed retightening of female parts. It was obvious that rigid fixation was an advantage, since less time was required for services. The time to the first change of a component was not significantly different for resilient versus rigid attachments. The amount of aftercare in patients with overdentures was assessed cumulatively up to 8 years by Nedir et al.19 The percentage of overdentures remaining free from complications was 57% for the bar devices but only 24% for overdentures with ball anchors (P < .04); 1.5 events per year were noted in the ball attachment group, whereas 0.9 events per year per patient occurred in the bar group. Anatomical, morphologic, and prosthetic variables are considered to be of importance when selecting a particular implant position. Oetterli et al20 evaluated the casts and clinical parameters of 90 edentulous patients, each one with two intraforaminal implants supporting an overdenture. The angle between the virtual axis connecting both implants and the mandibular hinge axis was measured on mounted casts. The supporting surface was identified between bent clip bars and U-shaped extension bars. Seventy patients could be evaluated clinically after 5 years. The positions and retention mechanism of mandibular implants supporting an overdenture had little influence on the clinical parameters assessed. No data related to technical/mechanical complications were reported. The long-term function (10-year life table) of overdentures was compared to the clinical outcome with full-arch fixed prostheses in a study including 233 patients receiving 163 overdentures and 95 fixed fullarch prostheses.21 The survival rates for overdentures on Dolder bars were 87.5% for the maxilla and 97.7%

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for the mandible. Survival of full-arch prosthses was 96.4% in the maxilla and 100% in the mandible. Overdentures on milled bars had a 94.7% survival rate in the maxilla, and overdentures on ball anchors in the mandible had a 98.8% survival rate. One study reported a dramatic incidence of implant loss (27% over 4 to 6 years), remakes of overdentures (50%), and relinings (30%).22 Handling such frequent catastrophic events would be highly impracticable in daily clinical practice.

edentulous patients. Fifteen of the FDPs had a distal cantilever extension and 34 a mesial cantilever extension. After a mean follow-up of 4 years, no negative effects related to the presence of the mesial or the distal cantilever extension were found.

Cemented Versus Screw-Retained Dental Prostheses (Table 4)

In a prospective randomized study, 12 cemented and 12 screw-retained crowns were constructed on implants to replace missing lateral incisors.27 Four years after loading, no differences in peri-implant conditions and no prosthetic complications were noted. In two other reports, similar rates of complications were noted over 5 years with cemented and screwretained crowns and FDPs.19,28 It should be noted, however, that the group with cemented reconstructions was considerably larger in both studies. The screw-retained reconstructions in the study by De Boever et al29 demonstrated twice as many complications as the cemented ones: 29/127 cemented (22.8%) and 26/45 screw-retained (57%) reconstructions demonstrated technical/mechanical complications (P < .001). In 21 of the 26 interventions, however, only retightening was required.

Fixed Dental Prostheses (FDP) with Cantilever Extension(s) (Table 3)

In four papers, the presence of a cantilever extension as a potential risk for technical/mechanical complications was assessed. In the oldest report, dramatically higher failure rates with cantilever extensions > 15 mm were noted.23 In 25 patients, 24 edentulous mandibles and four edentulous maxillae were restored with fullarch fixed bilateral cantilever prostheses on five to six implants. The prostheses were grouped into those with a cantilever length of > 15 mm and those with 15 mm (range 5 to 22 mm). The prostheses were followed from 20 to 80 months. Of the 28 prostheses, 12 had to be remade. Practically all of those were originally designed with cantilever extensions > 15 mm. Comparing 24 FDPs with cantilever extensions to 26 FDPs without cantilever extensions over 5 years in 45 consecutive patients, Wennstrm et al24 did not find any negative effect on the peri-implant conditions. The six technical complications noted were not related to the cantilever extensions. Romeo et al25 collected clinical and radiographic data from 42 FDPs with a cantilever extension and 137 FDPs without a cantilever extension. The cumulative survival rates of the implants reached 94.4% with the risk cantilever extension and 96.5% without the risk cantilever extension, as assessed in a 7-year life table analysis. Radiographic success was defined as absence of bone loss > 1 mm during the first year of loading and 0.2 mm/year thereafter. Clinical success, defined as absence of probing pocket depths > 3 mm, was observed in 76.3% of cases with cantilever extensions and in 73.8% of cases without cantilever extensions. Nedir et al 19 presented data on consecutive patients treated with implant-supported removable or fixed prostheses and single crowns on implants. Seventeen of the fixed reconstructions had a cantilever extension and 228 did not. Up to 8 years follow-up, the authors found technical complications in about 30% of the reconstructions with cantilever extensions but in only 8% of the reconstructions without cantilever extensions. Romeo et al26 collected radiographic and clinical information on fixed dental prostheses in 49 partially

Angled/Angulated Abutments (Table 5)

Two studies focusing on the potentially negative influence of nonparallel implants requiring the placement of angled abutments were found. In a report by Sethi et al, 30 misangulations ranged from 0 to 45 degrees. Of 3,101 implants, 264 implants with an abutment angulation of > 15 degrees were compared to 352 implants with a more axial abutment ( 15 degrees). Over 10 years, the angulation had no effect on the probability of survival of the implants. However, no information on mechanical/technical complications was available. A more sophisticated method of analyzing angles was presented by Koutouzis and Wennstrm in 2007.31 Standardized photographs were taken of the maxillary and mandibular study casts in occlusion and then with guide pins in place. Thus, within the superimposed image, the inclination of the implants in relation to the occlusal plane was obtained. Finally, interimplant inclinations in both mesiodistal and buccolingual directions were obtained. Axial implants were defined as ranging from 0 to 4 degrees and nonaxial implants from 12 to 30 degrees. The 36 axial and 33 nonaxial implants yielded similar bone remodeling over 5 years, as assessed in radiographs. Moreover, there was no increased risk of mechanical/technical complications associated with tilted implants.31
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Table 3

Extension

Salvi/Brgger

Study
130 Astra Tech Consecutive patients 5-y survival

Year

Mean No. of age, y patients (range) Implant system Findings

6 complications in 5 y not related to presence of extension No influence on peri-implant condition

Mean observation No. of time implants Designs of reconstruction Study design

Wennstrm et al24

2004

45

76 Volume 24, Supplement, 2009

57 10.3 5 y 62 8.5 mo NR 2080 mo NR Nobel Biocare NR NR Straumann Consecutive Straumann 3.8 y survival 4 y after 379 loading 8-y life table NR 24 FDPs with extension 26 FDPs without extension Short FDPs 28 full-arch prostheses with extensions 1.5 cm and > 1.5 cm 42 FDP with extensions 137 FDP without extensions 17 with extensions 228 without extensions Length > 1.5 cm dramatically more fractures 12/28 remakes No influence on implant loss Implant survival FP with extensions (94.4%) Implant survival FP without extensions (96.1%) 29.4% complications versus 7.9% P < .01

Shackleton et al23

1994

25

Romeo et al25

2004

NR

Nedir et al19

2006

NR

NR = not recorded, FDP = fixed dental prosthesis.

Table 4

Cemented Versus Screw-Retained

Study
NR 4 y after loading 50.8 mo Straumann 40 I-I 58 T-T 18 I-T 24 Biomet 3i 12 cemented

Year

Mean No. of age, y patients (range) No. of implants Implant system Designs of reconstruction

Mean observation time

Study design
12 screw-retained

Findings

Vigolo et

al27

2004

12

Brgger et al28 55.7 (2383)

2001

85

Retrospective cohorts

Prospective randomly assigned No complications at all No influence on bone and soft tissue 13/79 cemented with complications 3/26 screw-retained with complications (ns) No influence on implant loss 8-year life table Consecutive

Nedir et al19 NR 2586 283 8-y life table 62.5 25.3 mo

2006

NR

130 implants 142 teeth NR Straumann Straumann

De Boever et al29

2006

105

189 cemented 32 screw-retained FDP/Crown 45 screw-retained versus 127 cemented

No significant difference in complication rate No influence on implant loss 29 complications out of 127 (22.8%) 26 complications out of 45 (57%) P < .001 No influence on implant loss

NR = not recorded; ns = not significant; FDP = fixed dental prosthesis; I-I = implant-to-implant FDP; I-T = implant-to-tooth FDP; T-T = tooth-to-tooth FDP.

Table 5
Observation No. of time implants Factors No information on prosthetic complications No increased risk of technical complications Finding for reconstruction Finding for implants Survival probability for implants NS 10 y 3,101 Ankylos Implant system

Angulation Versus No Angulation

Study

Year

No. of patients

Sethi et al30

2002

NR

Koutouzis and Wennstrm31

2007

38

5y

69

Astra Tech

From 045 degrees; 264 implants > 15 degrees, 352 implants 15 degrees 36 axial (04 degrees inclination) versus 33 nonaxial (1230 degrees)

No influence on bone loss around implants

NR = not recorded; NS = not significant.

Table 6

Bruxism

Study
55.7 (2383) NR NR 301 Nobel Biocare 56.8 mo 103 (142 teeth) Straumann FDPs: 40 I-I; 58 T-T; 18 I-T

Year

No. of patients

Mean observation Mean age, time y (range) (range) No. of implants Implant system Design of reconstructions Type of study
Retrospective cohorts Clustered failures as test group versus matched control group

Findings

Brgger et

al28

2001

85

Ekfeldt et al32

2001

54

13/75 nonbruxers (17.3%) had technical complications and 6/10 bruxers (60%) had complications P < .01 No influence on implant loss In the test group with clustered losses, there were 7 patients with bruxism Heavy influence on implant loss

De Boever et al29 2006 2586 65.2 25.3 mo 283 Straumann

105

Consecutive

17/43 (39%) had complications in the bruxing group 29/126 (23%) had complications in the non-bruxing group; P < .001 No influence on implant loss

Tawil et al33 53.6 (2280) 53 (12108) NR mo

2006

109

Nobel Biocare

Consecutive patients

22.6% of the patients were defined as bruxers; they had 50% of the veneer fractures; however, ns No significant influence on implant loss Straumann Consecutive No statistically significant increase in complication rate for FDPs and overdentures NS

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The International Journal of Oral & Maxillofacial Implants 77

NR 8-y life table 72 Edentulous maxillary FPD or overdenture; 27 with clustered implants loss (50%) vs 27 with no such loss (control) 23 bruxers, 80 nonbruxers 43 reconstructions at risk in bruxers 126 reconstructions at risk in non-bruxers 123 FPDs: 22.6% bruxers, 5.9% occasional bruxers, 71.4% nonbruxers 26 bruxers/ 189 nonbruxers

Nedir et al19

2006

26 bruxers 189 nonbruxers

NR = not recorded; FDP = fixed dental prosthesis; NS = not significant; I-I = implant-to-implant FDP; I-T = implant-to-tooth FDP; T-T = tooth-to-tooth FDP.

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Bruxism (Table 6)
Based on clinical experience, probably every dentist would group bruxers into a high-risk category for technical and mechanical complications and failures. Even implant fractures seem to occur more frequently in bruxers according to case reports. The present literature search indicated five studies in which bruxers were compared to nonbruxers. In two of the clinical reports, statistically significantly higher rates of mechanical/technical complications (ie, 17.3% and 23%) and failures (ie, 60% and 39%) were found in bruxers compared with nonbruxers.28,29 In two additional publications, trends toward more frequent mechanical/technical complications and implant losses were observed in bruxers.32,33 Nedir et al,19 however, found no increased rate of complications in FDPs and overdentures in bruxers compared to nonbruxers.

Prosthetic Materials (Table 9)

In addition to gold alloys, other metal alloys have been used to fabricate prosthetic frameworks. A longitudinal study was carried out to compare two cast framework alloys with different mechanical properties: gold alloy and silver-palladium.36 Fixed implantsupported mandibular prostheses were constructed in 26 edentulous patients. The frameworks in group A were cast with Chicago IV gold alloy, and those in group B were cast with Palliag M silver-palladium alloy. Acrylic resin teeth were used and heat cured onto the frameworks. Frameworks had a distal cantilever extension of 10 mm, and the patients received maxillary complete dentures with acrylic teeth. The number of screw loosenings (11 in group A and 13 in group B) as well as other technical complications were similar in the groups over 5 years of observation. In another study, after random assignment, conventional ceramometal cast frameworks were fabricated for FDPs on one side of the jaw in 21 patients, while 21 laser-welded titanium frameworks with lowfusing porcelain were constructed for FDPs on the other side of the jaw.37 An additional cohort of 21 cases with laser-welded titanium frameworks with low-fusing porcelain was added. Fifteen events of fractured porcelain veneer were noted over 5 years with the combination titanium/low-fusing porcelain, compared to three events with the conventional ceramometal FDPs. In a study by Hedkvist et al, 36 patients were provided with 46 FDPs on 207 implants.38 While 37 prostheses used the conventional implant/abutment configuration, 19 prostheses were placed directly at the implant level (Cresco Ti Precision, Astra Tech). Thirty-three patients with 43 prostheses could be reexamined after 5 to 8 years of function. Technical complications included six resin fractures and one porcelain fracture. These were not related to the type of framework used. Andersson et al conducted a multicenter study in 32 patients with 105 implants.39 Nineteen short-span FDPs were seated on 53 ceramic abutments (Ceradapt alumina ceramic, Nobel Biocare) and 17 were mounted on 50 titanium abutments. After 5 years, 30 patients with 29 FDPs could be re-examined. Only one of the ceramic abutments failed. In all four of the above-mentioned studies, no effects on the peri-implant conditions of the different materials used for frameworks or abutments were detected.

Crown-to-Implant Ratio (Table 7)

Adopted from perioprosthetic concepts, the crown-toimplant (C:I) ratio might also be a negative biomechanical factor to be considered in implant-supported reconstructions. If the ratio of the supracrestal leverage increases, unfavorable forces and load may be transmitted to the implant. If the crown and the supracrestal implant components have the same length as the osseointegrated part of the implant, the crown-to-implant ratio is 1. It may be logical to expect less favorable load conditions with a crown that is twice as long as the implant, and vice versa. Three clinical studies were found in which implants and their fixed reconstructions were grouped into ranges of C:I ratios. In 123 FDPs, no significant influence of the parameter C:I on the periimplant conditions was found over a mean observation period of 53 months.33 Similar results were obtained by Rokni et al 34 over 4 years and Blanes et al35 over 5 years. However, all three studies were restricted to radiographic analyses and did not report mechanical/technical complications.

Length of the Suprastructure (Table 8)

In 105 partially edentulous patients, 283 implants were placed and restored with 80 single crowns, 39 double crowns, and 38 three- to four-unit FDPs.29 Over 5 years, 25% of the single crowns, 35% of the double crowns, and 44% of the three- to four-unit FDPs demonstrated a complication. Of the necessary clinical repairs, 36% were solved by recementation and 30% by retightening the screws. Longer reconstruc tions seemed to be more prone to complications.

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Table 7

Crown-to-Implant Ratio

Study
59.6 (2280) 53 mo 262 Nobel Biocare Consecutive patients Consecutive patients Consecutive patients

Year

No. of patients Type of study Findings

Mean age, y (range)

Mean observation time (range) No. of implants Implant system Crown-to implant ratio
No influence on bone loss No risk factor for implant loss No influence on bone loss No risk factor for implant loss No influence on bone loss No risk factor for implant loss

Tawil et

al33

2006

109

Rokni et al34 53 (2076) 46 mo 199 Endopore

2005

74

Blanes et al35 NR 6 (510) y 192 Straumann

2007

83

123 FDPs ranged from C:I < 1 to > 2 for 234 implants 30 were < 1, 8 > 2 22: 1.0 157: 1.12.0 20: > 2.0 8: 00.99 133: 11.99 51: 2

NR = not recorded; C:I = crown-to-implant ratio; FDP = fixed dental prosthesis.

Table 8

Length of Reconstruction

Study
2586 62.5 25.3 mo 283 Straumann

Year

No. of Mean age, patients y (range)

Mean observation time (range) No. of implants Implant system

Type of study
Consecutive patients

Design of reconstruction
80 SC 39 two connected crowns 38 3- to 4-unit FDP

Findings
25% of SC had complications 35% of two connected crowns had complications 44% of 3- to 4-unit FDP had complications, P < .04

De Boever et

al29

2006

105

SC = single crowns; FDP = fixed dental prosthesis.

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Number of Implants Supporting an FDP (Table 10)

In the early days of osseointegration, the number of implants used per reconstruction to replace teeth was preferably kept high. Already by 1995, however, it was reported that the function of full-arch prostheses over 10 years was the same when 14 cases with FDPs on four implants were compared to 70 cases with FDPs on six implants in the maxilla and 13 prostheses on four implants were compared to 59 on six implants in the mandible. 40 The survival rates for individual implants and prostheses were similar in the groups at the end of a 10-year observation period. As a concept for the restoration of free-end situations with FDPs on implants, it was advocated to preferably place three implants not aligned but rather offset. The distribution of load would thus prevent implant failures and complications with screw loosening. In a report by Eliasson et al,41 63 FDPs were fixed on two implants and 83 FDPs on three implants. Over 9.5 years (range 5 to 18 years), the survival rates of the FDPs were similar: 96.8% and 97.6%, respectively. FDPs on two implants had more screw loosening (P < .05); in FDPs on three implants, more porcelain fractures (P < .05) were observed. Farzad et al42 applied measurements of implant stability and found somewhat higher ISQ (Implant Stability Quotient) values assessed by means of Osstell readings at implants supporting threeimplant prostheses compared to two-implant prostheses. Apart from that, no differences were observed in the 30 FDPs on two implants and the 74 FDPs on three implants followed over 4 years.

DISCUSSION
Data Extraction
The main objective of this report was to extract published evidence related to mechanical/technical risk factors for any kind of damage to an implant-supported reconstruction. We searched for technical and/or biological complications or failure rates experienced with or without exposure to a certain mechanical/technical characteristic. Studies related to implant sur faces, loading protocols, toothimplantsupported reconstructions, implant length, and width of the platform were excluded.

Assessment of Complications and Failures

To compare the outcomes with implant-supported reconstructions achieved in different patient populations, useful parameters for statistical analyses should be provided. Standardization of the criteria used in the assessment of the frequency, the kind of events observed, and the severity of the damage is required. Of particular interest were, therefore, the various attempts of authors to score and describe the outcomes related to experiences with implant-supported reconstructions. According to Dudic and Mericske-Stern,18 categories of prosthetic problems with overdentures included: Complications and failures of implant-related parts (abutments, bars and anchors, retainers, occlusal screws) Mechanical and structural failures of prostheses (denture base, teeth, prosthetic design, fabrication of new dentures) Prosthesis-related adjustments (relining, occlusion, esthetics, hyperplasia) The rates of prosthetic maintenance services (events per patient) were calculated for comparable periods of time (per year, per 2 years, per 5 years) and according to the three categories.18 The rates of prosthetic maintenance per patient over 5 years were similar for resilient and rigid types of fixation; however, the characteristics of the complications were different. An additional useful parameter for statistical analyses was also assessed by calculating the time to the first event for resilient and rigid attachment systems. In other reports, a clinical implant performance scale (CIP) was used.14 This included scores from 0 to 4, as follows:

History of Complications (Table 11)

In two studies, odds ratios for reconstructions with previous complications ending in failure were statistically significantly increased compared to reconstructions that had not had previous complications (Table 11).43,44 Of 30 failed reconstructions, 15 had already had major so-called retrievable complications (odds ratio 3.55, P < .001). Altogether, 214 crowns or FDPs were observed over 4.2 years. 43 When 69 single crowns, 33 FDPs on implants, and 22 tooth-implantsupported FDPs were followed over 10 years (range 8 to 12 years), the odds ratio for technical failure of those reconstructions with a previous loss of retention reached 17.6 (95% CI: 3.6 to 86.4). The odds ratio for a suprastructure failure was 11.0 (95% CI: 2.1 to 57.9) for reconstructions with a history of porcelain fractures (P < .01).44

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Table 9

Material Aspects

Study
60 5y NR Astra Tech 13 FDP mandible Chicago IV gold alloy A 13 FDP Palliag M silver palladium B Not randomized

Year

No. of patients Type of study Findings

Mean Mean age, observation No. of y (range) time (range) implants Implant system Design of reconstruction/ materials used

Murphy et

al36

2002

26

Jemt et al37 56 11 50 12 5y 170 Nobel Biocare Groups arranged at random, split mouth

2003

42

Hedkvist et al38 NR 58 y 207 Nobel Biocare

2004

36

Consecutive

Andersson et al39 NR 5y 105/103 Nobel Biocare

2003

32/30

21 FDP ceramometal cast framework left 21 FDP ceramometal cast framework right with low-fusing porcelain 21 with titanium framework prosthesis with low-fusing porcelain 27 prostheses with abutment 19 at implant level, Cresco Ti Precision 53 ceramic abutments (Ceradapt alumina ceramic) 50 titanium abutments 19 FDP on ceramic abutments 17 FDP on titanium abutments/29 left Short FDP Consecutive

Similar number of events for technical complications No influence on bone loss; no risk factor for implant loss No difference in prosthesis survival, more porcelain chips with titanium 19% versus 10% (P > 0.3) No risk factor for implant loss No more bone loss No difference in complication rates No difference in bone loss around implants Patients satisfied with esthetics Only one ceramic abutment failed No influence on implant bone loss

NR = not recorded, FDP = fixed dental prosthesis

Table 10

Number of Implants

Study
65 (3291) 9.5 (518) y 375 Nobel Biocare

Year

No. of patients

Mean Mean age, observation No. of y (range) time (range) implants Implant system

Design of reconstruction/ materials used

63 FDP on 2 implants 83 FDP on 3 implants Free-end situations

Type of study
Not randomized

Findings

Eliasson et

al41

2006

178

Farzard et al42 62 (43-80) 3.9 y 210

2004

34

Nobel Biocare

30 FDP on 2 implants 74 FDP on 3 implants Nobel Biocare Maxilla: 14 FDP on 4 implants 70 FDP on 6 implants Mandible: 13 FDP on 4 implants 59 FDP on 6 implants

Not randomized Age- and gendermatched groups

Brnemark et al40 NR 10 y

1995

156

882

Salvi/Brgger

The International Journal of Oral & Maxillofacial Implants 81

Survival rate 96.8%/97.6% More screw loosening with 2 implants; P < .05 More porcelain fractures with 3 implants; P = .05 No influence on implant loss and bone loss Small difference in ISQ value No influence on reconstruction No influence on implant loss Function of prostheses over 10 y was same All mandibular prostheses stable 1/14 on 4 implants lost 6/70 on 6 implants lost in the maxilla Survival of implants 88.4%/ 93.4% Higher risk to lose an implant if only 4 were placed

NR = not recorded; ISQ = implant stability quotient; FDP = fixed dental prosthesis.

Salvi/Brgger

0: Success, no complications 1: Minor complications, such as: gingival hyperplasia, relining of maxillary or mandibular dentures, readjustment of occlusion, clip loosening, coping/ screw loosening, broken abutment, a slight disturbance of the mental nerve, probing depth = 6 mm, or x-ray score 1 with PPD 5 mm 2: Complications with a chance of recovery or stabilization of the present situation, such as: correction of a non-fitting superstructure, fracture of the superstructure, a severe disturbance of the mental nerve, x-ray score 1 with PPD 6 mm, or x-ray score 2 with PPD 5 mm 3: Serious complications that may lead to failure of the implant system: X-ray score 2 with PPD 6 mm or x-ray score 3 4: Failure of the implant system: removal of one or two implants after placement of the suprastructure The x-ray score 0 related to no apparent bone loss; 1, to a reduction < 1/3 of the length of the implant; 2, to a reduction between > 1/3 and < 1/2 of the implant length; and 3, to a reduction > 1/ 2 of the implant length. Pooling wide ranges of biological and technical complications in the same category may mask clinically important differences between groups.43 In 2006, Nedir et al grouped prosthetic complications of overdentures into foreseeable and nonforeseeable events. 19 Change of female parts of the spherical attachment, change of the clip, and relining were categorized as foreseeable. Mechanical retention problems, repair and replacement of the overdenture, and complications of the opposing complete denture were unforeseeable complications in the overdenture group. For the fixed restoration group, complications were graded as minor or major. A fracture was considered major if it affected esthetics, caused the metal framework to be visible, resulted in a missing interproximal contact point, or caused the patient to complain of tongue- or masticatory-related discomfort. Major fractures resulted in a prosthesis remake; minor fractures did not lead to remakes. In a series of systematic reviews on complication and failure rates reported with various types of reconstructions on teeth and implants, the extracted data were listed as the estimated event rates per 100 reconstructions per year, considering the actual exposure time and assuming no change in the longterm risk intensity. 6 Statistically significantly increased failures rates were calculated for cantilever FDPs on teeth and tooth-implantsupported FDPs compared to FDPs on teeth without extension, implant-supported FDPs, and single crowns on implants over 10 years. In addition, statistically signifi-

Type of study

Consecutive

Design of reconstruction/ materials used

56 SC on implants 168 FDP on implants

69 SC on implants 33 FPDs I-I 22 FPDs I-T

Prospective

Of 30 failures with reconstructions, 15 had major so-called retrievable complications before Odds ratio 3.55; P < .001 Loss of retention leading to technical failure; Odds ratio 17.6 (3.686.4); P < .001 Fracture of porcelain leading to technical failure; Odds ratio 11.0 (2.157.9); P < .004 Brgger et al44
SC = single crowns; FDP = fixed dental prosthesis; I-I = implant-to-implant FDP; I-T = implant-to-tooth FDP.

Findings

No. of implants

Brnemark

Mean observation time (range)

Complications Leading to Failures

Mean age, y (range)

No. of patients

152

1997

82 Volume 24, Supplement, 2009

Parein et al43

Table 11

Study

2005

Year

89

58.9 (2888)

55.7 (1490)

10 (812) y

4.2 y

160 (24 teeth)

392

Straumann

Implant system

Salvi/Brgger

cantly increased complication rates were calculated for loss of vitality and loss of retention when comparing cantilever FDPs with conventional FDPs. The 5year complication rates were similar for the implant-supported FDPs and single crowns.

Risk Factors Affecting the Implants

The most obvious and clinically relevant finding in this review is that almost none of the technical/ mechanical risk factors extracted seemed to affect the implant per se or the surrounding bone. This is very surprising, since for many years overload, nonaxial loading, and biomechanical stress were considered the main reasons for implant losses.

Risk Factors Affecting the Suprastructures

Eight studies presented comparisons of prosthetic outcomes with overdentures using different attachment systems and implant components in the edentulous mandiblethe best model in prosthodontics to perform RCTs. The groups compared, however, were so diverse that an analysis of the combined data was not feasible. Some of the overdenture designs, however, indicated clinically relevant increased risks. Satisfaction of the patients with the retention of an overdenture was affected by the attachment mechanism and seemed to be best with bar devices. The amount of aftercare was higher with spherical attached systems in most of the reports. Fractures of dentures occurred frequently if no metal frameworks were constructed, especially with bar devices. In two of four included reports, the presence of a cantilever extension in an FDP on implants did not lead to increased failure or complication rates.24,25 The reported higher rate of failures with FDPs on implants was restricted to very long cantilever extensions (> 15 mm).23 The small number of FDPs with cantilever extensions in the report by Nedir et al may not be representative.19 Findings from a meta-analysis of a systematic review on implant-supported short-span FDPs with cantilever extensions yielded estimated survival rates of 94.4% (95% CI: 87.0 to 97.6) after 5 years and 89.1% (95% CI: 75.7 to 95.3) after 10 years.45 The lack of a negative effect of cantilever extensions in FDPs on implants is in contrast to the increased complication and failure rates reported with cantilever extensions in FDPs on teeth. 4 For treatment-planning aspects, this mechanical/technical advantage of implant-supported reconstructions is of considerable importance. In three of four publications comparing complications/failures with screw-retained versus cemented FDP crowns, the retention mechanism could not be

identified as a risk factor. Both of two extracted papers on angled abutments did not indicate that angulations > 15 degrees for the abutments and the prosthesis had any effect on the outcome. The patient risk factor bruxism resulted in significantly increased event rates in two studies, in trends for higher rates in two studies, and in no difference in one report. From a retrospectively assessed cohort of 368 patients with 838 endosseous implants, 19 cases were selected in which there were technical/ mechanical complications such as implant fractures, abutment fractures, screw loosening, occlusal wear, or damage to the prosthesis.46 The 19 patients were evaluated for sleep bruxism using polysomnographic analysis. Most of the bruxism episodes occurred during light sleep and did not cause arousal, and the patients were unaware of the nocturnal parafunctional habits. Bruxism was reported to have continued despite the fact that all these patients were provided with a nightguard. Crown-to-root ratio, material aspects, and the number of implants placed were not identified as risk factors for increased failure/complication rates. The complexity of a reconstruction, expressed as the number of units, was identified as a risk in only one study, and having had a previous complication was identified as a risk in two. The implant length in relation to the height of the suprastructure as well as the number of implants needed to physically support an FDP and assure its function are risk factors related to the quality and quantity of the osseointegration and the torque needed to disrupt the chemical and histologic bonding between the supporting bone and the implant surface. Efforts to improve osseointegration in implant dentistry by modifying the surface characteristics, such as the topography and chemistry, have led to much more reliable clinical results compared to the original machined implants when using shorter and fewer implants.47,48

Limitations/Critical Remark
The fact that some of the mechanical/technical characteristics evaluated were not identified as true risk factors in this review does not mean that they are not, in fact, risks. Limitations of the study designs, too many uncontrollable variables, small number of subjects, etc, may have hidden the actual facts in some of the studies.

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CONCLUSIONS
Mandibular overdentures: Independent of the retentive element system used, patients required multiple prosthetic services during the observation period (six RCTs). Technical/mechanical complications occurred more frequently with a ball attachment than with a bar retentive system (one RCT). With respect to retention, patients were most satisfied with a bar retentive system, followed by ball anchors, and least satisfied with magnets (one RCT). Metal frameworks protected overdentures from fractures (one consecutive case study). The presence of cantilever extensions was not associated with increased mechanical/technical risks for implants supporting short-span FDPs (three consecutive case studies). The presence of cantilever extensions > 15 mm was associated with an increased risk of full-arch FDP fracture compared with the presence of cantilever extensions 15 mm (one consecutive case study). No increased mechanical/technical risks for FDPs were observed in three of four studies (one prospective, one retrospective, and one consecutive case study) comparing screw-retained versus cemented reconstructions. The presence of angled/angulated abutments was not associated with increased mechanical/technical risks for implant-supported FDPs (one consecutive case study). Increased mechanical/technical risks for FDPs were observed in bruxers in four of five studies (two retrospective and two consecutive case studies) comparing bruxers and nonbruxers. The crown-to-implant ratio was not associated with implant loss and marginal bone loss of implants supporting FDPs (2 consecutive case studies). Increased mechanical/technical risks for FDPs were observed in 1 study (consecutive cases) comparing 3- to 4-unit FDPs with single crowns and double crowns. Increased mechanical/technical risks for FDPs were observed in two studies (consecutive case studies) comparing FDPs with and without a history of complications. Regarding the survival/success rate of the implant, none of the 10 listed mechanical/technical risks had an influence.

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