Clinical complications of osseointegrated implants

Charles J. Goodacre, DDS, MSD,a Joseph Y.K. Kan, DDS,b and Kitichai Rungcharassaeng, DDSc School of Dentistry, Loma Linda University, Loma Linda, Calif. Statement of problem. There is no comprehensive review of the literature that identifies the complications reported in clinical dental implant studies.

Purpose. This article attempted to determine the types of complications that have been reported and to
provide data regarding their frequency. Methods. All available clinical studies from 1981 to 1997, published in English or with English abstract, that presented success/failure data regarding implant treatment were evaluated to determine the types of reported complications and to quantify implant loss as it relates to type of prosthesis, arch, time, implant length, and bone quality. Results. Greater implant loss occurred with overdentures than with other types of prostheses. There was greater loss in the maxilla than mandible with fixed complete dentures and overdentures, whereas little arch difference was noted with fixed partial dentures. Implant loss increased with short implants and poor bone quality. The time of implant loss (preprosthetic vs postprosthetic) varied with type of prosthesis. Surgical complications included neurosensory disturbance, hematoma, mandibular fracture, hemorrhage, and tooth devitalization. Initial and long-term marginal bone changes were identified. Peri-implant soft tissue complications included dehiscence, fistulas, and gingival inflammation/proliferation. Mechanical complications were screw loosening/fracture, implant fractures, framework, resin base and veneering material fractures, opposing prosthesis fractures, and overdenture mechanical retention problems. Some studies also presented phonetic and esthetic complications. Conclusions. Although the literature presents considerable information on implant complications, variations in study design and reporting procedures limited the available data and therefore precluded proper analysis of certain complications. (J Prosthet Dent 1999;81:537-52.)

CLINICAL IMPLICATIONS
In this literature review, the clinical complications reported in implant studies have been identified along with frequency rates. This information will facilitate treatment planning and enhance communication between dentists and patients regarding the outcomes of dental implant treatment.

nowledge regarding the types of complications that can occur with dental procedures is an important aspect of treatment planning, dentist-patient communication, informed consent, and posttreatment care. Because the design of clinical implant studies has not been standardized, the reporting of clinical complications tends to vary among studies. This variation makes it difficult to determine whether an unreported complication was not evaluated as part of the studys data collection, never occurred in that particular study, or may have occurred but was not reported. Consequently, there are only a small number of studies reporting certain complications. The purpose of this literature review is to identify the types of complications that have been reported in conjunction with dental implant treatment and provide
aProfessor bAssistant

data regarding their frequency. This article is also presented as mean percentages of the available data and statistical analysis are used only when possible. The mean percentage data are intended to reflect trends rather than statistically valid complication rates.

MATERIAL AND METHODS

All available clinical studies from 1981 to 1997 (written in English or with English abstract) that presented success/failure data regarding implant treatment were evaluated to determine the types of reported complications and to quantify implant loss as it relates to type of prosthesis, arch, time, implant length, and bone quality. Also included were patient reports on significant complications arising from osseointegrated implant treatments. Items excluded from this report were the implant studies that involved compromised situations or complex treatments that required bone grafting, subantral augmentation, and so forth. These data will be presented in future articles.
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and Dean. Professor, Department of Restorative Dentistry. cGraduate Student, Advanced Education in Implant Dentistry. MAY 1999

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Table I. Implant loss in patients with implant fixed complete dentures in maxilla
Length of study (y) Range Mean No. of implants placed No. of implants lost (%)

Adell et al1 Cox and Zarb2 Albrektsson et al3 Zarb and Schmitt4 Jemt5 Naert et al6 Jemt7 Branemark et al8 % Failure relative to total number implants placed
*Minimum observation period.

1-9 1-3 1-7 5-9 1* 0.5-6.5 5*

2.5 10

100 12 2464 36 586 269 449 476 4392

22 0 227 1 25 20 34 102

(22.0) (0.0) (9.2) (2.7) (4.3) (7.4) (7.6) (21.4)

431 (9.8)

Table II. Implant loss in patients with implant fixed complete dentures in mandible
Length of study (y) Range Mean No. of implants placed No. of implants lost (%)

Adell et al1 Cox and Zarb2 Albrektsson et al3 Zarb and Schmitt4 Jemt5 Naert et al6 Hemmings et al9 Branemark et al8 % Failure relative to total number implants placed
*Minimum observation period.

1-9 1-3 1-8 5-9 1* 0.5-6.5 6-10

2.5 9 10

124 132 5833 238 1613 320 132 406 8798

14 18 103 38 11 10 15 30

(11.3) (13.6) (1.8) (16.0) (0.7) (3.4) (11.4) (7.4)

239 (2.7)

CLINICAL COMPLICATIONS Implant loss as related to type of prosthesis and arch

Tables I through VII present data1-44 regarding the percentage of implant failure (loss of the implant) associated with each type of implant prosthesis (fixed complete denture, overdenture, fixed partial denture, and single crown). The studies listed in these tables also provided data that permitted a comparison of implant failures between the maxilla and the mandible for each type of prosthesis, except the single crown. Although the length of the studies varied considerably, differences in implant loss between types of prostheses and arches were identified. When data were combined from all the studies related to each prosthesis type and arch and a mean percentage loss calculated, some interesting trends were noted. With implant fixed complete dentures, the mean failure in the maxilla (Table I)1-8 was 9.8%, whereas mandibular mean failure was 2.7% (Table II).1-6,8,9 For implant overdentures (Tables III and IV),9-20 higher
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failure rates were also noted for the maxilla (21.3%) than the mandible (5.0%). The highest failure rate (21.3%) for any type of prosthesis occurred with maxillary overdentures (Table III).10-15 There was little difference between the maxillary and the mandibular failure rates (6.6% and 6.2%, respectively) for implant fixed partial dentures (Tables V and VI).21-32 Implant single crowns had the lowest mean implant failure rate of 2.7% (Table VII).33-44

Implant loss related to type of prosthesis, time after placement, implant length, bone quality
Tables VIII through XI present studies* that identified the total number of implants placed and lost with each type of prosthesis. These studies also included data as to whether the implant losses occurred preprosthetically or postprosthetically. Although the study lengths varied considerably, differences in implant loss between types of prostheses were identified, along with data
*References 1,4-6,9,10,12,13,17,19-23,30,33,38,40,41,45-49. VOLUME 81 NUMBER 5

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Table III. Implant loss in patients with implant overdentures in maxilla

Length of study (y) Range Mean No. of implants placed No. of implants lost (%)

Enquist et al10 Naert et al11 Jemt et al12 Smedberg et al13 Cune et al14 Hutton et al15 % Failure relative to total number of implants placed
*Minimum observation period.

0.3-5 0.3-4 1* 1.5-2.5

1.5 1.5 2 2 3

191 12 430 86 106 105 930

58 0 69 12 30 29

(30.4) (0.0) (16.0) (13.5) (28.3) (27.6)

198 (21.3)

Table IV. Implant loss in patients with implant overdentures in mandible

Length of study (y) Range Mean No. of implants placed No. of implants lost (%)

Enquist et al10 Naert et al16 Mericske-Stern17 Naert et al11 Cune et al14 Hemmings et al9 Hutton et al15 Leimola-Virtanen et al18 Versteegh et al19 Wismeyer et al20 % Failure relative to total number implants placed
*Minimum observation period.

0.3-5 0.5-5.5 0.3-4 3-9 3-10 4-9 5.5-10

1.5 2 1.5 2 5 3 5.6 6 6.5

148 87 153 161 1071 68 189 153 135 218 2383

9 1 8 2 29 5 11 13 33 7

(6.1) (1.1) (5.2) (1.2) (2.7) (7.4) (5.8) (8.5) (24.4) (3.2)

118 (5.0)

Table V. Implant loss in patients with implant fixed partial denture in maxilla
Length of study (y) Range Mean No. of implants placed No. of implants lost (%)

van Steenberghe21 Pylant et al22 Naert et al23 Bahat24 Jemt et al25 Nevins and Langer26 Tolman and Laney27 Zarb and Schmitt28(anterior) Zarb and Schmitt29(posterior) Lekholm et al30 Higuchi et al31 % Failure relative to total number of implants placed
*Minimum observation period.

0.5-3 0.2-6 0.4-6.5 5*

2 2.5 5 8 6.5 5 5 3

40 28 304 732 101 652 528 50 41 220 220 2916

5 3 18 35 4 31 58 3 1 17 16

(12.5) (10.7) (5.9) (4.8) (4.0) (4.8) (11.0) (6.0) (2.4) (7.7) (7.3)

191 (6.6)

regarding the timing of the loss. The data were combined from all the studies related to each prosthesis type and an overall percentage loss calculated to determine trends.
MAY 1999

With implant fixed complete dentures, the combined data1,4-6,9,45 (Table VIII) indicated 3742 implants were placed in the 6 studies and 225 were lost, for a 6.0% implant failure rate. Of the 225 implants
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Table VI. Implant loss in patients with implant fixed partial denture in mandible
Length of study (y) Range Mean No. of implants placed No. of implants lost (%)

van Steenberghe21 Gunne et al32 Pylant et al22 Naert et al23 Jemt et al25 Nevins and Langer26 Zarb and Schmitt28(anterior) Zarb and Schmitt29(posterior) Lekholm et al30 Higuchi et al31 % Failure relative to total number of implants placed
*Minimum observation period.

0.5-3 0.2-6 5*

3 2 2.5 5 8 5 5 3

93 69 74 205 158 551 44 64 338 330 1783

7 8 9 12 3 25 5 5 19 17

(7.5) (11.6) (12.2) (5.9) (1.9) (4.5) (11.4) (7.8) (5.6) (5.2)

110 (6.2)

Table VII. Implant loss in patients with implant single crown

Length of study (y) Range Mean No. of implants placed No. of implants lost (%)

Jemt et Babbush and Shimura34 Fugazzotto et al35 Jemt and Pettersson36 Schmitt and Zarb37 Ekfeldt et al38 Laney et al39 Cordioli et al40 Andersson et al41 Haas et al42 Becker and Becker43 Avivi-Arber and Zarb44 % Failure relative to total number of implants placed
*Minimum observation period.

al33

1* 1-4.5 0.5-5 2-3 1-8

5 3 3 3 2.5 3 2 6 2

107 21 136 70 40 93 95 67 65 76 24 49 843

3 0 3 1 0 2 3 3 4 2 1 1

(2.8) (0.0) (2.2) (1.4) (0.0) (2.2) (3.2) (4.5) (6.2) (2.6) (4.2) (2.0)

23 (2.7)

Table VIII. Implant loss and time of loss in patients with implant fixed complete dentures
Length of study (y) Range Mean No. of implants placed No. of implants lost (%) No. of lost preprosthetic (%) No. lost postprosthetic (%)

Adell et al1 Zarb and Schmitt4 Jemt5 Naert et al6 Jemt45 Hemmings et al9 % Failure relative to total number implants lost % Failure relative to total number implants placed
*Minimum observation period.

1-9 5-9 1* 0.5-6.5 3* 6-10

2.5 9

224 262 2199 589 336 132 3742

36 30 36 30 78 15 225

(16.1) (11.4) (1.6) (5.1) (23.2) (11.4)

21 21 24 18 23 9

(9.4) (8.0) (1.1) (3.1) (6.8) (6.8)

15 9 12 12 55 6

(6.7) (3.4) (0.5) (2.0) (16.4) (4.6)

116 (51.6) 116 (3.1)

109 (48.4) 109 (2.9)

225 (6.0)

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Table IX. Implant loss and time of loss in patients with implant overdenture
Length of study (y) Range Mean No. of implants placed No. of implants lost (%) No. of lost preprosthetic (%) No. lost postprosthetic (%)

Enquist et al10 Mericske-Stern17 Johns et al46 Jemt et al12 Smedberg et al13 Hemmings et al9 Versteegh et al19 Wismeyer and van Waas20 % Failure relative to total number implants lost % Failure relative to total number implants placed
*Minimum observation period.

0.3-5 0.5-5.5 1* 1* 1.5-2.5 3-9 4-9 5.5-10

1.5 2 5 6 6.5

339 153 510 430 86 68 135 218 1939

67 7 32 69 12 5 33 7 232

(19.8) (4.6) (6.0) (16.0) (13.9) (7.4) (24.4) (3.2)

46 5 16 27 7 4 17 7

(13.6) (3.3) (3.0) (6.3) (8.1) (5.9) (12.6) (3.2)

21 2 16 42 5 1 16 0

(6.2) (1.3) (3.0) (9.7) (5.8) (1.5) (11.8) (0.0)

129 (55.6) 129 (6.7)

103 (44.4) 103 (5.3)

232 (12.0)

Table X. Implant loss and time of loss in patients with implant fixed partial denture
Length of study (y) Range Mean No. of implants placed No. of implants lost (%) No. of lost preprosthetic (%) No. lost postprosthetic (%)

Jemt et al47 van Steenberghe21 Johansson and Palmqvist48 Pylant et al22 Naert et al23 Jemt et al49 Lekholm et al30 % Failure relative to total number implants lost % Failure relative to total number implants placed
*Minimum observation period.

1-20 0.5-3 3-9 0.2-6 1* 5*

5 2 2.5

876 133 286 102 509 430 558 2894

24 12 25 12 29 5 36 143

(2.7) (9.0) (8.7) (11.8) (5.7) (1.2) (6.5)

10 9 23 7 17 5 20

(1.1) (6.8) (8.0) (3.3) (6.9) (1.2) (3.6)

14 3 2 5 12 0 16

(1.6) (2.2) (0.7) (4.9) (2.4) (0.0) (2.9)

91 (63.6) 91 (3.1)

52 (36.4) 52 (1.8)

143 (4.9)

Table XI. Implant loss and time of loss in patients with implant single crowns
Length of study (y) Range Mean No. of implants placed No. of implants lost (%) No. of lost preprosthetic (%) No. lost postprosthetic (%)

Jemt et al33 Ekfeldt et al38 Cordioli et al40 Andersson et al41 % Failure relative to total number implants lost % Failure relative to total number implants placed
*Minimum observation period.

1* 1-4.5 0.5-5 2-3

2.5 2

107 93 67 65 332

3 2 3 4 12

(2.8) (2.2) (4.5) (6.2)

1 1 2 0

(0.9) (1.1) (3.0) (0.0)

2 1 1 4

(1.9) (1.1) (1.5) (6.2)

4 (33.3) 4 (1.2)

8 (66.7) 8 (2.4)

12 (3.6)

lost, 116 (3.1%) were lost preprosthetically and 109 (2.9%) were lost postprosthetically. For implant overdentures (Table IX), 1479 implants were placed in the 8 studies9,10,12,13,17,19,20,46 and 232 were lost for a
MAY 1999

combined 12.0% implant failure rate. More failures (129 of 232) occurred preprosthetically than postprosthetically (103 of 232). The combined implant fixed partial denture data21-23,30,47-49 (Table X) indicates
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Table XII. Time of postprosthetic implant loss

No. of implants lost (%) Type of prosthesis No. of implants placed Total 1st y 2nd y 3rd y

Jemt45* Jemt et al47* Gunne et al50* Andersson et al41* % Failure relative to total number implants lost % Failure relative to total number implants placed

IFCD IFPD IFPD ISC

336 876 521 65 1798

55 10 13 4 82 82 (4.6)

36 7 3 2

(65) (70) (23) (50)

11 3 8 1

(20) (30) (62) (25)

8 0 2 1

(15) (0) (15) (25)

48 (59) 48 (2.7)

23 (28) 23 (1.3)

11 (13) 11 (0.6)

*1, 2, and 3 year data statistically compared using normal approximation to binomial test (P<.05). IFCD = Implant fixed complete dentures; IFPD = implant fixed partial dentures; ISC = implant single crowns.

Table XIII. Effect of implant length

Prostheses Description of failures

Friberg et al51 Jemt and Lekholm52 Jemt et al12 van Steenberghe et al53 Naert et al23 Pylant et al22 Jemt and Lekholm25 Gunne et al50 Higuchi et al31

IFCD IFCD IOD IFPD IFPD IFPD IFPD IFPD IFPD

Higher failure with 7-mm implants. 7-mm implants failed more in maxilla (7%) than mandible (3%). 72 of 298 7-mm implants placed failed (24%). 7 mm failed more than any other implant length in maxilla. 6% failure rate in maxilla with 10-mm implants. 10% failure rate in maxilla with 7-mm implants. 7 and 10 mm were the source of most failures. 7 of 12 failures were 7- and 10-mm implants. 67 of 78 failures were 7 mm implants. 12 of 13 failures were 10-mm implants. Higher failure with 7-mm implants in maxilla (18%).

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture.

Table XIV. Implant length and time of implant loss30,53,54

Implant length (mm) No. implants placed No. of implants lost (%) 0-1 y 1-3 y 3-5 y

7 10 13 15-20 Total

120 245 90 103 558

3 15 5 0

(2.5) (6) (6) (0)

5 4 1 0

(4) (2) (1) (0)

0 3 0 0

(0) (1) (0) (0)

23 (4)

10 (2)

3 (0.5)

2894 implants were placed and 143 were lost for a 4.9% implant failure rate. A larger number of implants were lost preprosthetically (91 of 143) than postprosthetically (52 of 143). Implant single crown studies33,38,40,41 (Table XI) that presented data on the total number of implants placed and lost, along with information on the time when implant loss occurred, were more limited than that available for the other types of prostheses. When this limited data (4 studies) was combined, 332 implants were placed and 12 implants were lost for a 3.6% implant failure rate. More implants were lost postprosthetically (8 of 12) than preprosthetically.
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A limited number of studies41,45,47,50 (Table XII) provide specific data about the time when postprosthetic implant loss occurs. A statistical analysis of the 4 studies presented such data and revealed the following: (1) Implant loss in the second year was significantly lower than in the first year (P<.05); (2) implant loss in the third year was significantly lower than in the first and second years (P<.05); and (3) the data indicate there was a decreasing failure rate at least during the first 3 years after prosthesis placement. Numerous studies have shown higher failure rates with shorter implants (Tables XIII and XIV).12,22,23,25,30,31,50-54 Four of the studies31,51-53 indicated the highest failure rates occurred when 7-mm implants were used in the maxilla. In the available studies,10,13,35,46,53,55 in which data permitted a comparison of the failures rates between different bone qualities (Table XV), significantly higher implant failure rates were noted in type IV bone as compared with types I to III bone. Several retrospective and prospective studies have reported on the incidence of implant failures before and after prosthesis loading.1,4,45 It has been suggested that preprosthetic failures can be caused by the overVOLUME 81 NUMBER 5

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Table XV. Effect of poor bone quality

No. implants in type I-III bone No. failures in type I-III bone (%) No. implants in type IV bone No. failures in type IV bone (%)

Engquist et al10* van Steenberghe et al53* Jaffin and Berman55* Johns et al46* Fugazzotto et al35* Smedberg et al13* % Failure relative to number implants placed

141 491 952 453 851 53 2938

15 19 29 16 12 0 91 (3)

198 67 102 57 512 33 969

52 4 36 16 22 12 142 (15)

*The number of failures in type 4 bone was statistically compared with the number of failures occurring in types 1 to 3 bone using normal approximation to binomial test (P<.0001).

Table XVI. Percentage of patients experiencing paresthesia over time

No. of patients with paresthesia (%) Type of prosthesis Total no. patients treated Stage I surgery Stage II surgery Prosthesis placement

1st y

2nd y

3rd y

4th y

5th y

Johns et al46 Wismeyer et al20 van Steenberghe et al53 Henry et al54 Lekholm et al30 Astrand et al62 Higuchi et al31 Avivi-Arber and Zarb44 Jemt et al33 Albrektsson63 Ellies and Hawker64 Lazzara et al65 Allen et al66 Total (mean%)

IOD IOD IFPD IFPD IFPD IFPD IFPD ISC ISC IFCD/IOD Multiple Multiple Multiple

98* 57 159* 139 132 46* 117* 49* 92 761* 87* 625* 60* 2002

19 (19) 16 (10) 17 (39) 16 (14) 2 (4) 4 (0.6) 31 (36) 8 (1) 11 (18) 124 (6.1)

7 (5) 3 (3)

3 (3)

1 (1) 6 (4) 6 (5) 11 (13)

9 (19)

5 (4) 5 (4)

4 (7) 2 (2)

IOD = Implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown; IFCD = implant fixed complete denture. *Represents studies included in calculation of mean paresthesia after stage I surgery.

heating of the bone during osteotomy, infection, patients health status, or micromotion during the healing phase.56,57 Proposed causes of postprosthetic failures have included poor oral hygiene, unfavorable load situations, and framework misfits.45,58,59 Implant length and bone quality have also been proposed as factors affecting implant success, and this data also found higher implant failure rates in the maxilla, which often is comprised of type IV bone (Tables XIII through XV).* Data from this literature review12,22,23,25,30,31,50-54 indicated a higher failure rate with short implants (Tables XIII and XIV) that relates to only 1 type of implant (threaded, nonsurfacecoated screw), and recent studies60,61 suggest that surface characteristics may influence the success outcome of short implants. The 5-year data from these

2 studies reported a 4% to 6% failure rate with 8-mm hydroxyapatite-coated implants in the posterior mandible.

Surgical complications
Implant surgical complications that have been reported include neurosensory disturbance, mandibular fracture, life-threatening hemorrhage, hematoma and devitalization of adjacent teeth. Neurosensory disturbance rates as high as 39% and as low as 0.6% (6.1% mean) have been reported after stage I surgery (Table XVI). Four studies31,46,53,64 provided data that indicated significantly lower neurosensory disturbance when comparisons were made at stage I surgery and after 1 year (Table XVI). Although the incidence rates seem to be high, the number and size of the areas
References

*References 10,12,13,22,23,25,30,35,46,50-55. MAY 1999

References

20,30,31,33,36,44,46,47,53,54,62-77. 20,30,31,33,44,46,53,54,62-66. 543

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Table XVII. Mandibular fracture

Description of incidence

Table XX. Devitalization of adjacent teeth

No. devitalized teeth

Albrektsson63 Mason et al67 Tolman and Shonberg et al69 Rothman et al70 Neyt et al71 Kan et al72 Keller68

1 patient of 508 (0.2%) 3 patients, all female, fractured before loading 7 patients; 6 female, 1 male (due to trauma) 1 patient, male, severly atrophic mandible 2 of 886 (0.2%); female, suggested link with osteoporosis 2 patients 1 patient, male, in conjunction with inferior alveolar nerve transposition

Prosthesis

No. implants

Jemt et Jemt and Pettersson36 Rubenstein and Taylor77

al47

IFPD ISC IFPD

876 1 70 3 Patient treatment report about devitalization of a tooth caused by apical nerve transection from implant placement.

IFPD = Implant fixed partial denture; ISC = implant single crown.

Table XXI. Bone loss over time Table XVIII. Life-threatening hemmorhage for implant placement
No. of patients Type of prosthesis Length of study (y) Mean loss in 1st year (mm) Subsequent loss per year (mm)

Laboda73 Mason et al74 ten-Bruggenkate et al75 Mordenfeld et al76

1 1 2 1

Table XIX. Hematoma

Type of prosthesis Incidence rate (%)

Adell et al1 Adell et al78 Cox and Zarb2 Quirynen et al79 Naert et al11 Johns et al46* Quirynen et al80* Gunne et al32 Pylant et al22 Jemt and Lekholm25 Lekholm et al30 Laney et al39* Andersson41 Mean of all studies

IFCD IFCD IFCD IFCD IOD IOD IOD IFPD IFPD IFPD IFPD ISC ISC

1-15 3 1-3 6 0.3-4 1 4 2 2 5 5 3 2-3

Johns et al46 van Steenberghe et al53 Jemt et al33

IOD IFPD ISC

13 29 5

IOD = Implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown.

1.2 0.9 1.6 0.8 0.75 0.4 1.0 3.2 0.4 1.5 0.4 0.4 N/A 1.3 0.93

0.1 0.05 0.1 0.1 0 N/A 0.05-0.1 N/A 0.1 0.1 0.1 0.12 0.1 0.2 0.1

with affected sensation usually diminishes over time.30,31,46,53,62 A small group of patients still exhibit persistent neurosensory disturbance after 5 years.20,30 Mandibular fracture after implant placement is a rare complication and has been reported in conjunction with severely resorbed edentulous mandibles (Table XVII).63,67-72 Of the 7 studies, 2 reported fractures that occurred only in female patients, 2 only in male patients, and 1 in both male and female patients; 2 were not identified by sex. A link with osteoporosis in the female patients has been suggested.67,70 The site of an implant that was not yet osseointegrated represents an area of stress concentration and weakness; thus, routine oral activities could cause a fracture without any trauma to the mandible.67,72 Mandibular trauma is another factor that has been linked to fractures.68 Perforation of the mandibular lingual cortex in the canine and first premolar region during implant osteotomy can possibly injure the lingual artery or its branches (Table XVIII).73-76 This occurrence may lead to extensive bleeding into the submandibular space, creating a hematoma with life-threatening acute airway obstruction within the first few hours after surgery. Securing and maintaining an adequate airway
544

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown. *Not included in mean of combined data. Mandible; implants were connected. Maxilla; implants were not connected.

should be given the highest priority. Exploration of the bleeding area and management of arterial hemorrhage is the treatment of choice.75 Knowledge, recognition, and effective treatment of this complication are essential. Hematomas have been reported after implant surgery and/or second stage surgery, which usually resolved completely during the normal healing phase (Table XlX).33,46,53 Implant placement in close proximity to an adjacent tooth with or without perforating the root apex may cause devitalization of that tooth, warranting endodontic therapy (Table XX).36,47,77

Marginal bone loss

Thirteen studies* have reported on the average marginal bone loss occurring during the first year (Table XXI). Mean loss was 0.93 mm, with a range from
*References 1,2,11,22,25,30,32,39,41,46,78-80. VOLUME 81 NUMBER 5

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Table XXII. Change in marginal bone level over time

% Patients with marginal bone change Bone loss Study length (y) >2 mm 1-2 mm 0.6-1.0 mm 0.1-0.5 mm No change 0 mm Bone gain >0 mm

van Steenberghe et Henry et al54* Quirynen et al,80 FCD (mandible) Quirynen et al,80 FCD (maxilla)

al53*

0-1 1-3 0-1 1-2 2-3 0-1 1-2 2-3

2.0 0.4 0.5 1.5 0 4.5 0 3.4

9.5 4.4 5.8 2.1 2.0 20.1 3.9 13.7

20.0 10.4 41.5 5.0 5.9 23.5 6.8 5.2

26.5 25.0 29.9 23.4 25.5 24.0 25.7 6.9

27.0 25.8 20.5 55.3 49.0 22.3 37.1 31.0

15.0 34.0 1.8 12.7 17.6 5.6 26.5 37.8

FCD = Fixed complete denture. *Same group of patients. Data did not equal 100%.

0.4 to 1.6 mm. The mean loss that occurred per year in subsequent years was 0.1 mm, with a range from 0 to 0.2 mm. Three studies53,54,80 present data that helps quantify the amount of bone loss patients experienced over time and the number of patients who had no bone loss or gained bone (Table XXII). Only a small percentage of patients experience bone loss exceeding 2 mm. A greater percentage of patients had 1 to 2 mm of bone loss and the highest percentage of patients experienced 0.5 to 1.0 mm of bone loss. A substantial percentage of patients exhibited no bone loss or had bone gain. Furthermore, the percentage of patients experiencing bone gain increased over time (Table XXII).53,54,80 Slight marginal bone loss after implant placement has been reported as a common phenomenon.2,30,78,81 It is thought to be the result of several contributing factors: remodeling after the countersinking process,21 inadvertent stress distribution to the marginal bone by forced tightening of the implant during placement,82 or excessive loading force.1 The third criteria of implant success proposed by Smith and Zarb81 is that vertical bone loss must be less than 0.2 mm annually after the first year of service. Quirynen et al80 suggested that bone loss only be considered a complication when a progressive excessive amount of bone loss is observed.

Table XXIII. Implant dehiscence before stage II surgery

Type of prosthesis Incidence rate (%)

Adell et al1 Naert et al6 Jemt et al33 Cordioli et al40 Avivi-Arber and Zarb44

IFCD IFCD ISC ISC ISC

4.6 12 2 3 11

IFCD = Implant fixed complete denture; ISC = implant single crown.

Peri-implant soft tissue complications

Peri-implant complications have included dehiscence, fistulas, and gingival inflammation/proliferation.* The exposure of implants before stage II surgery was reported in 5 studies,1,6,33,40,44 and ranged between 2% and 11% (Table XXIII). Dehiscence in highly esthetic areas may lead to a soft tissue deficit that compromises the final esthetic outcome and may necessitate soft tissue grafts.84
*References 1,5,6,9,10,12,14,16,27,33,36,38,40,41,44,46,63,65, 66,83. MAY 1999

An adverse tissue response leading to inflammation and/or gingival proliferation was reported in many studies with an incidence range of 1% to 32% (Table XXIV). An adverse tissue response is considered the most common peri-implant complication with implant overdentures.10,85 Soft tissue changes usually occur around abutments and under bars, often because of poor oral hygiene, improper use of abutments and healing caps, presence of dead spaces under the superstructure, and the lack of attached mucosa.4,10,12,44 Multiple surgeries may be needed to correct this problem.12 The rate of soft tissue complications and postplacement maintenance with overdentures is reportedly higher than with fixed complete dentures.1,5,10,12 It has been reported that the implant overdenture demands more frequent recall examinations to ensure good, long-term results.10 A number of studies reported on the incidence rate of fistulas at the abutment-implant connection level (Table XXV); the range for the 10 studies was 0.002% to 25%. This peri-implant complication is often associated with poor oral hygiene and/or gaps between components caused by loose abutment screws or framework misfits, which occur more frequently with single crown replacement.33,36,40,44 A good seal through crown cementation on firmly connected abutments has been
References References

l,5,9,l0,12,14,16,27,44,63,65,66. 1,33,36,38,40,41,44,46,63,83. 545

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Table XXIV. Gingival inflammation and proliferation

Type of prosthesis Length of study (y) Incidence rate (%)

Table XXVI. Abutment screw loosening

Type of prosthesis Length of study (y) % Loosening

Adell et al1 Jemt5 Hemmings et al9 Engquist et al10 Naert et al16 Jemt et al12 Cune et al14 Hemmings et al9 Avivi-Arber and Zarb44 Albrektsson63 Tolman and Laney27 Lazzara et al65 Allen et al66

IFCD IFCD FCD IOD IOD IOD IOD IOD ISC IFCD/IOD IFCD/IOD Multiple Multiple

1-15 1 9 1.5 2 1 2 5.3 1-8 1-7 6.5 5 6

7 6 20 25 11 21 16 32 2 1 25 6 27

IFCD = Implant fixed complete denture; IOD = implant overdenture; ISC = implant single crown.

Naert et al6 Hemmings et al9 Naert et al11 Jemt et al12 Hemmings et al9 Naert et al87 van Steenberghe et al53 Lekholm et al30 Gunne et al32 Gunne et al50 Jemt et al33 Jemt and Pettersson36 Ekfeldt et al38 Laney et al39 Andersson et al41 Haas et al42 Lazzara et al65

IFCD IFCD IOD IOD IOD IOD IFPD IFPD IFPD IFPD ISC ISC ISC ISC ISC ISC Multiple

2.5 9 1.5 1 5.3 1 1 5 2 3 1 3 2.5 3 2-3 6 5

6 1 2 2 6 18 6 5 2 3 26 45 43 11 2 16 2.4

Table XXV. Fistula at implant-abutment level

Type of prosthesis Length of study (y) Incidence rate (%)

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown.

Adell et al1 Johns et al46 Quirynen et al83 Jemt et al33 Jemt and Pettersson36 Cordioli et al40 Ekfeldt et al38 Andersson et al41 Avivi-Arber and Zarb44 Albrektsson63

IFCD IOD IFPD ISC ISC ISC ISC ISC ISC IFCD/IOD

1-15 1 2.5 1 3 2 2.5 2-3 1-8 1-7

2 3 1.4 10* 25 4 2 1.5 6 0.002

Mechanical complications
Mechanical complications include screw loosening, screw fractures, implant fractures, framework/resin/ veneering material fractures, implant prosthesis fractures, opposing prosthesis fractures, and overdenture mechanical retention problems.* Abutment screw loosening was reported in a large number of studies and ranged from 2% to 45% of the abutments (Table XXVI). A difference in the incidence of loosening was noted between types of prostheses. The highest rate was found with single crowns followed by overdentures. Prosthesis screw loosening ranged from 1% to 38% in the 13 studies reporting this complication (Table XXVII). Only 1 single crown study43 reported prosthesis screw loosening that was comparable to the high abutment screw loosening found with single crowns.33,36,38,39,41,42 In contrast, prosthesis screw loosening with overdentures tended to be lower than abutment screw loosening.9,11,12,87 Abutment screw fractures (Table XXVIII) occurred less frequently than prosthesis gold screw fractures|| (Table XXIX). The most common complication reported with single crowns was abutment and/or prosthetic screw loosening.38,42,43 A higher frequency of screw loosening has been reported for single crown replacements in the pre-

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown. *6% with mobile abutment screws. All in maxilla; 7% with mobile abutment screws.

proposed as an obstacle to bacterial migration and a hindrance to this type of complication.41 These soft tissue problems could be related to the depth of the subgingival location of the implant, which Cordioli et al40 described as the mucosal canal, for anterior single tooth replacements. The correct depth of the mucosal canal around implants is still controversial. It has been suggested that maxillary anterior implants be placed 2 to 3 mm apical to the adjacent cementoenamel junction to facilitate esthetics and proper emergence profile. 86 Some studies reported no significant clinical increases in gingival inflammation associated with implant restorations with subgingivally placed margins when good oral hygiene was maintained.33,42 A thick and long mucosal canal promotes better esthetics, which may result in difficulties in component seating and maintenance of peri-implant hygiene.40
546

*References 1,5,6,9,11-13,17-20,22,23,27,29,30,32,33,36,38,39, 41-44,46,48-50,53,54,63,65,66,83,87-89. References 6,9,11,12,30,32,33,36,38,39,41,42,50,53,65,87. References 6,9,11,12,23,30,43,49,50,53,54,65,88. References 1,6,0,11,27,32,44,63,66,81,89. ||References 1,6,9,11,23,27,30,50,66,81,89. VOLUME 81 NUMBER 5

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Table XXVII. Prosthesis gold screw loosening

Type of prosthesis Length of study (y) % Loosening

Table XXIX. Prosthesis gold screw fracture

Type of prosthesis Length of study (y) % Fracture

Naert et al6 Kallus and Bessing88 Hemmings et al9 Naert et al11 Jemt et al12 van Steenberghe et al53 Henry et al54 Lekholm et al30 Naert et al23 Gunne et al50 Jemt et al49 Becker and Becker43 Lazzara et al65

IFCD IFCD IFCD IOD IOD IFPD IFPD IFPD IFPD IFPD IFPD ISC (molar) Multiple

2.5 >5 9 1.5 1 1 2 3 5 6 3 1 2 5

5* 24* 7* 5 1 6 5 4 4 6* 9 14* 38* 3*

Adell et al1 Zarb and Smith81 Naert et al6 Hemmings et al9 Zarb and Schmitt89 Allen et al66 Naert et al11 Hemmings et al9 Zarb and Schmitt89 Naert et al23 Tolman and Laney27 Gunne et al50 Lekholm et al30

IFCD IFCD IFCD IFCD IFCD IFCD IOD IOD IOD IFPD IFPD IFPD IFPD

1-15 0-9 2.5 9 9-15 6 1.5 5.3 13 6 6.5 3 5

1.5 19 1 4 7 1 5 6 3 1 5.5 7 3

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown. *Per implants; per patients; reported at both 2 and 3 y in the same article.

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown.

Table XXX. Fractured implants Table XXVIII. Abutment screw fracture

Type of prosthesis Length of study (y) % Fracture Type of prosthesis Length of study (y) No. implants No. fracture (%)

Adell et al1 Zarb and Smith81 Naert et al6 Hemmings et al9 Zarb and Schmitt89 Allen et al66 Naert et al11 Gunne et al32 Allen et al66 Avivi-Arber and Zarb44 Albrektsson63 Tolman and Laney27

IFCD IFCD IFCD IFCD IFCD IFCD IOD IFPD IFPD ISC IFCD/IOD IFCD/IOD

1-15 0-9 2.5 9 9-15 6 1.5 2 6 1-8 1-7 6.5

3 3 0.6 8 5 2 2 2 2 4 0.5 5

Adell et al1 Naert et al6 Naert et al6 Pylant et al22 Quirynen et al83 Lekholm et al30 Gunne et al50 Tolman and Laney27 Allen et al66 % Fracture relative to total number implants placed

IFCD IFCD IFPD IFPD IFPD IFPD IFPD IFCD/IOD Multiple

15 7 7 2 6 5 3 6.5 6

1997 564 465 102 509 558 521 1778 66 6560

69 3 5 1 5 5 3 3 2

(3.5) (0.5) (1) (1) (1) (1) (1) (0.2) (3)

96 (1.5)

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown.

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture.

molar and molar area than in the anterior region.33,43 One suggested reason for the high incidence of screw loosening from early studies is that the abutment screws were made of titanium, and devices capable of providing countertorque during tightening were not available. This problem seems to be solved through the use of gold alloy abutment screws that yield a higher screw preload when properly torqued.36,38,41,44 Since the introduction of gold alloy screws, single implant crowns have been placed with fewer screw loosening problems.38,44 Possible causes of screw loosening and/or fracture (Tables XXVIII and XXIX)* have included poorly fitting frameworks, bone remodeling and release of pretension in the screw joint, reduced clamping force and screw joint movement, and heavy occlusal forces.4,6,20,73,75,78
*References 1,6,9,11,23,27,30,32,44,50,63,66,81,89. MAY 1999

Implant fracture is an uncommon but significant complication that occurred in 96 of 6560 implants (1.5%) followed for 3 to 15 years in 9 studies (Table XXX). Most fractures occurred between the third and fourth implant thread, which corresponds to the last thread of the abutment screw.23,83 Framework misfit and occlusal overload have been suggested as the primary causes.30 Removal of fractured implants, more often than not, leaves a large bony defect that required additional healing and treatment time. A higher incidence of implant fractures has been reported in fixed partial dentures supported by only 2 implants.25,30,49,50,53 In a survey by Rangert et al,90 most fractured implants occurred in single or double implantsupported restorations in posterior partially
References

1,6,22,23,27,30,50,66,83. 547

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Table XXXI. Metal framework fracture

Type of prosthesis Length of study (y) % Fracture

Table XXXII. Acrylic resin base fracture

Type of prosthesis Length of study (y) No. prostheses No. fractures (%)

Adell et al1 Zarb and Smith81 Jemt and Lekholm25 Naert et al6 Zarb and Schmitt89 Naert et al11 Jemt et al12 Johns et al46 Zarb and Schmitt89 Albrektsson63 Tolman and Laney27

IFCD IFCD IFCD IFCD IFCD IOD IOD IOD IOD IFCD/IOD IFCD/IOD/IFPD

1-15 0-9 1 2.5 9-15 1.5 1 1 13 0-8 6.5

5 27 1 5 6 1 1 2 4 2.5 0.5

Jemt5 Hemmings et al9 Jemt et al12 Hemmings et al9 Zarb and Schmitt89 Allen et al66

IFCD IFCD IOD IOD IOD IOD

1 9 1 5 13 6

380 25 92 25 47 37

13 (3) 6 (24) (11) 1 (4) 1 (2) 5 (14)

IFCD = Implant fixed complete denture; IOD = implant overdenture.

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture.

Table XXXIII. Facial/occlusal veneer material fracture

% Fracture Type of prosthesis Length of study (y) Denture teeth Denture teeth and acrylic resin Acrylic resin Acrylic resins and composites

Composite

Porcelain

Metal

Naert et al23 Allen et al66 Allen et al66 Jemt et al49 Zarb and Schmitt29 Johansson and Palmqvist48 Gunne et al50 Lekholm et al30 Allen et al66 Andersson et al41 Avivi-Arber and Zarb44

IFPD IFCD IOD IFPD IFPD IFPD IFPD IFPD IFPD ISC ISC

2.5 6 6 1 5.2 5.2 3 5 6 2-3 1.8

22

23 13 6

14

20 4 30

5 17 11 6 4

20

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture; ISC = implant single crown.

edentulous jaws where occlusal loads were higher. Thus, it was suggested that implant fixed partial dentures be supported by 3 implants placed in a tripod alignment to minimize stress and torque distribution.30,90 Metal framework fracture* (Table XXXI) has been attributed to inadequate metal thickness, poor solder joints, excessive cantilever length, alloys with inadequate strength, patients parafunctional habits, and improper framework design.81,91,92 Acrylic resin base fractures5,9,12,66,89 for implant overdentures (Table XXXII) are usually caused by inadequate space for resin between the framework and the denture teeth, thereby, weakening the denture. The use of metal-reinforced overdenture bases can minimized this complication.93 Acrylic and composite fractures comprised the majority of facial/occlusal veneer material failures (Table XXXIII).23,29,30,41,44,48-50,66 With fixed partial dentures, acrylic resins and composites fractured more
*References 1,5,6,11,12,27,46,63,81,89. 548

often than porcelain.30,50 Recent studies where porcelain was used instead of resin are also reporting fractures, but they occur less frequently than with resin.44,50 Because studies have not been able to identify a single superior occlusal material, porcelain has been used more frequently in recent years for esthetic reasons.94,95 Four studies12,17,20,46 indicated that a small number (6% mean) of implant overdentures fractured (Table XXXIV). Fractures of conventional removable prostheses have also been reported9,11,66 when they oppose an implant prosthesis (Table XXXV). Relatively high overdenture complication rates have been reported in conjunction with clips/attachments (Tables XXXVI and XXXVII).9,12,13,20,46,66,87,89 Most of the bar and clip overdenture complications were found to be the result of clip loosening or fracture.9,11,12 This outcome is recognized as a nuisance problem,11,12 but was judged by 1 author88 to be a less demanding complication than the problems associated with magnets or ball attachVOLUME 81 NUMBER 5

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Table XXXIV. Fracture of implant overdenture

Length of study (y) No. prostheses No. fractures (%)

Table XXXVII. Overdenture clip/attachment fracture and replacement

Length of study (y) % Incidence

Meriscke-Stern17 Jemt et al12 Johns et al46 Wismeyer et al20 % Fracture relative to total number of prostheses

0.5-5.5 1 1 6.5

62 92 127 57 338

3 3 7 4

(5) (3) (6) (7)

21 (6)

Jemt et al12 Johns et al46 Smedberg et al13 Hemmings et al9 Wismeyer et al20 Zarb and Schmitt89 Allen et al66

1 1 2 5 6.5 13 6

22 13 33 12 9 13 22

Table XXXV. Fracture of opposing prostheses

Type of prosthesis Length of study (y) No. prostheses % Fracture

Table XXXVIII. Postplacement reline required with implant overdentures

Length of study (y) Incidence rate (%)

Allen et al66 Naert et al11 Hemmings et al9 Allen et al66

IFCD IOD IOD IOD

6 1.5 5.3 6

20 86 25 37

40 10 4 5

IFCD = Implant fixed complete denture; IOD = implant overdenture.

Merickse-Stern17 Naert et al11 Jemt et al12 Johns et al46 Smedberg et al13 Hemmings et al9 Wismeyer et al20

0.5-5.5 1.5 1 1 2 5 6.5

6.5 18 24 13 44 32 28

Table XXXVI. Overdenture clip/attachment loosening and activation

Length of study (y) Incidence rate (%)

Table XXXIX. Phonetic problems

Type of prosthesis Incidence rate (%)

Jemt et al12 Johns et al46 Smedberg et al13 Naert et al87 Hemmings et al9 Allen et al66

1 1 2 2 5 6

17 36 56 75 40 5

Jemt5 Jemt et al12 Naert et al23

IFCD IOD IFPD

8% postplacement, 3% at 1 y 4% phonetic resonance 8% (2 of 25 patients with Kennedy Class IV arches)

IFCD = Implant fixed complete denture; IOD = implant overdenture; IFPD = implant fixed partial denture.

ments. It has been noted that a relatively high number of relines were required in conjunction with the placement or postplacement care of implant overdentures (Table XXXVIII).9,11,12,13,20,46

shade, and exposure of implant components from gingival recession (Table XL).

SUMMARY AND CONCLUSIONS

This article identifies the types of complications that have been reported in clinical studies of dental implant treatment. Because of variations in the reporting of complications, only a small number of studies present data about certain complications, and, thus, limits the ability to analyze statistically many of the reported complications. On the basis of available data, the following conclusions are offered relative to dental implant complications: 1. More implants were lost with overdenture prostheses than with fixed complete dentures, fixed partial dentures or single crowns. More implants were lost in the maxilla than mandible with fixed complete dentures and overdentures but not with fixed partial dentures. The highest implant loss occurred with maxillary overdentures. 2. With fixed complete dentures, the number of
549

Phonetic and esthetic complications

Phonetic problems were reported in 3 implant studies5,12,23 and involved fixed complete dentures, overdentures, and fixed partial dentures, but have not been reported in conjunction with single crowns (Table XXXIX). These problems are encountered more frequently in the maxilla than in the mandible.5 Fixed implant-supported prostheses in the resorbed anterior maxilla often allow an airway escape passage that causes a problem with speech.5,6,96 Some authors claim this is a time-related problem and patients usually adapt by increasing lip pressure to prevent air leakage.5,96 Esthetic problems have been reported with fixed complete dentures, fixed partial dentures, and single crowns, but not with overdentures.33,38,52,49,66 These problems included improper restoration contour, poor
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Table XL. Esthetic problems

Type of prothesis Incidence rate Incidence rate (%) Reasons

Allen et al66 Jemt et al49 Allen et al66 Jemt et al33 Ekfeldt et al38 Haas et al42

IFCD IFPD IFPD ISC ISC ISC

3/20 9/121 2/9 9/92 15.93 3/76

15 7 22 10 16 4

Contour modification Difficult to create harmonious prostheses due to significant amount of bone loss Contour modification Poor shade; gingival recession exposing metal margin Parts of implant or abutment were visible Gingival recession exposing implant/abutment junction

IFCD = Implant fixed complete denture; IFPD = implant fixed partial denture; ISC = implant single crown.

implants lost preprosthetically was comparable to the number lost postprosthetically. More failures occurred preprosthetically with overdentures and fixed partial dentures, whereas more postprosthetic failures were found in conjunction with single crowns. 3. When comparing the times at which postprosthetic implant loss occurred, significantly fewer implants were lost in year 2 than year 1. Likewise, implant loss in year 3 was significantly lower than both year 1 and year 2. 4. Higher failure rates occurred with shorter implants (7 and 10 mm lengths). Significantly higher failure rates were found with implants placed in type 4 bone compared with those in types 1 to 3 bone. 5. Neurosensory disturbances and hematomas were the 2 most commonly reported surgical complications. After stage I surgery, the neurosensory disturbance rates ranged from 0.6% to 39% (6.1% mean). After 1 year, the disturbance rates ranged from 1% to 13%. The hematoma incidence ranged between 5% and 29%. Other less common surgical complications included mandibular fracture, life-threatening hemorrhage, and devitalization of adjacent teeth. 6. The mean marginal bone loss around dental implants in the first year ranged from 0.4 to 1.6 mm (mean 0.93 mm) for all studies. Subsequent bone loss per year ranged from 0 to 0.2 mm, with a mean of 0.1 mm per year. However, many patients evaluated over periods from 1 through 3 years experienced no bone change or gain. 7. Three peri-implant soft tissue complications were reported. Gingival inflammation/proliferation was the most frequent complications, with the range of 1% to 32%. Implant dehiscence before stage II surgery ranged between 2% and 11%. A range of 0.002% to 25% was reported for fistulas that occurred at the implant-abutment level. 8. Screw loosening was the most frequently reported mechanical complication. The incidence of abutment screw loosening ranged from 1% to 45% with a comparable 1% to 38% incidence range for prosthesis gold screw loosening. More screw loosening occurred with single crowns than with any other types of prosthesis. 9. Prosthesis gold screws fractured more often (range of 1% to 19%) than the abutment screws (range
550

of 0.5% to 8%). Implant fractures were reported in 9 studies with a mean incidence of 1.5%. 10. Other mechanical complications included fractures of the metal framework, resin base, facial/occlusal veneer material, overdenture prosthesis, and opposing prosthesis. Clip/attachment loosening and fracture were reported with overdentures as well as the need for postplacement relines. 11. Phonetic and esthetic problems were reported in a limited number of studies. Phonetic problems were reported with all prostheses, except single crowns and esthetic problems, involved all prostheses, except overdentures.
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1. Adell R, Lekholm U, Rockier B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416. 2. Cox JF, Zarb GA. The longitudinal clinical efficacy of osseointegrated dental implants: a 3-year report. Int J Oral Maxillofac Implants 1987;2:91100. 3. Albrektsson T, Dahl E, Enbom L, Engevall S, Engquist B, Eriksson AR, et al. Osseointegrated oral implants. A Swedish multicenter study of 8139 consecutively inserted Nobelpharma implants. J Periodontol 1988;59:28796. 4. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental impiants: the Toronto study. Part I: surgical results. J Prosthet Dent 1990;63:451-7. 5. Jemt T. Failures and complications in 391 consecutively inserted fixed prostheses supported by Branemark implants in edentulous jaws: a study of treatment from the time of prosthesis placement to the first annual checkup. Int J Oral Maxillofac Implants 1991;6:270-6. 6. Naert I, Quirynen M, van Steenberghe D, Darius P. A study of 589 consecutive implants supporting complete fixed prostheses. Part II: prosthetic aspects. J Prosthet Dent 1992;68:949-56. 7. Jemt T. Fixed implant-supported prostheses in the edentulous maxilla. A five-year follow-up report. Clin Oral Implants Res 1994;5:142-7. 8. Branemark PI, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prostheses on four or six implants ad modum Branemark in full edentulism. Clin Oral Implants Res 1995;6:227-31. 9. Hemmings KW, Schmitt A, Zarb GA. Complications and maintenance requirements for fixed prostheses and overdentures in the edentulous mandible: a 5-year report. Int J Oral Maxillofac Implants 1994;9:191-6. 10. Engquist B, Bergendal T, Kallus T, Linden U. A retrospective multicenter evaluation of osseointegrated implants supporting overdentures. Int J Oral Maxillofac Implants 1988;3:129-34. 11. Naert I, Quirynen M, Theuniers G, van Steenberghe D. Prosthetic aspects of osseointegrated fixtures supporting overdentures. A 4-year report. J Prosthet Dent 1991;65:671-80. 12. Jemt T, Book K, Linden, Urde G. Failures and complications in 92 consecutively inserted overdentures supported by Branemark implants in

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