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SUMMARY One hundred and seventy-two fixed recon- sion (44%). Of the necessary clinical repair, 36% was
structions (317 prosthetic units), made on 283 ITI recementing and 38% tightening the screws. Of all
implants in 105 patients (age range 25–86 years) with interventions, 14% were classified as minor (no
a minimum follow-up period of 40 months, were treatment or <10 min chair time), 70% as moderate
taken into the study to analyse technical complica- (>10 min but <60 min chair time) and 14% as major
tion rate, complication type and costs for repair. The interventions (>60 min and additional costs for
mean evaluation time was 62Æ5 25Æ3 months. replacement of parts and/or laboratory). For seven
Eighty were single crowns and 92 different types of patients the additional costs ranged from €28 to €840.
fixed partial dentures (FPDs). In 45 cases the con- Bruxing seemed to play a significant role in the
struction was screw retained and in 127 cases frequency of complications. Longer constructions
cemented with zinc phosphate cement or an ac- seemed to be more prone to complications. The
rylic-based cement. Complications occurred after a relatively high occurrence of technical complications
minimum period of 2 months and a maximum should be discussed with the patient before the start
period of 100 months (mean: 35Æ9 21Æ4 months). of the treatment.
Fifty-five prosthetic interventions were needed on KEYWORDS: complications, fixed partial dentures,
44 constructions (25%) of which 88% in the molar/ oral implants, costs for repair
premolar region. The lowest percentage of compli-
cations occurred in single crowns (25%), the highest Accepted for publication 28 January 2006
in 3–4 unit FPDs (35%) and in FPDs with an exten-
complications can also lead to additional costs and time per implant. The clinical and radiographic data of the
investment during the follow-up years. whole group will be reported elsewhere. The project
Pjetursson et al. (10) stressed in their comprehensive was approved by the Ethics Commission of the Univer-
review that little is known about the type and number sity Hospital, Gent University, Belgium.
of events of technical complications per time interval as
well as the costs required.
Prosthethic treatment protocol
Recently, Attard et al. (11) reported on long-term
costs in 90 edentulous patients treated with mandibular After 3–6 months of undisturbed healing, an impres-
implant-supported prostheses. They found that main- sion was taken with polyaether impression material
tenance costs for implant-borne fixed reconstructions (Impregum Penta†) in a full impression tray using a
were higher than for overdenture prostheses. one-stage impression method or with the help of
The present study describes the prosthetic technical accessories as developed by the Straumann company.
complications, the possible risk factors involved and the For FPDs, all models were mounted on a semi-adjust-
type and costs of the interventions to repair the able articulator Dentatus ARH‡ or Whipmix§ using a
complications of fixed restorations on non-submerged facebow to mount the upper model. For single crowns
ITI implants* after an observation period of at least no articulator was used. Before cementation occlusion
40 months. and articulation were carefully checked using thin
We hypothesized that technical complications were occlusion paper (Okklusionsprüffolie Hanel¶). In
more frequent in longer FPDs than in single crowns, in maximal intercuspation, there was a very slight contact
cemented than in screw-retained reconstructions and on closing and more contact on the natural teeth or on
that complications were more frequent in patients with the occlusal surfaces of the bridges and crowns on
bruxing habits. natural teeth. Contact was avoided on the crowns on
implants on lateral excursions and anterior guidance
was on natural dentition in all patients. If all lateral
Materials and methods
teeth were replaced by an FPD on implants, group
contact was aimed at during lateral excursions. In
Patient selection
accordance with recommendations made in the litera-
Patients for the present study were selected from a ture, a narrowed occlusal table and a reduced cusp
larger group of 312 consecutive patients with 522 inclination were preferred (12, 13). None of the
endosseous implants installed ad modum ITI Strau- patients exhibited a cross-bite occlusion.
mann. They were selected on the following premises: All reconstructions were either screwed or cemented.
(i) having implant-borne single crowns, FPD or tooth- Two types of cement were used: zinc phosphate cement
implant-borne restorations (ii) regular follow-up and (Harvard**) or acryl/urethane cement (Improv††)
maintenance for at least 40 months. One hundred and especially developed as cement for prosthetic work on
seventy-two reconstructions in a total of 283 ITI implants.
implants in 105 patients (48 males, 46%; 57 females,
54%) were analysed. This represented a total of 317
Evaluation of prosthetic complications
prosthetic units available for analysis.
The age range of the patients was 25–86 years (aver- The following variables were recorded:
age: 59Æ1 years; s.d. ¼ 13Æ5 years; median: 62 years). 1 gender and age of the patients
All implants were at the time of evaluation in 2 bruxing habits based on clearly visible facets on the
function, fully osseointegrated with no or minimal occlusal surfaces and based on the self-report of the
signs of bone resorption. Only when complications patients and his or her partner.
occurred, suprastructures were removed at control
†
sessions. ‘Implant osseo-integration’ was based on the 3M Espe AG, Seefeld, Germany.
‡
Dentatus AB, Stockholm, Sweden.
lack of visual bone resorption on the peri-apical ¶
Hanel GHM, Nürtingen, Germany.
radiographs and on the probing depths at four sites §
Whipmix Corporation Louisville, KY, USA.
**Harvard Dental GmbH, Berlin, Germany.
††
*Straumann, Basel, Switzerland. Sterioss Nobelbiocare, Yorba Linda, CA, USA.
Complications 50
Upper front Lower front Upper premolar Lower premolar Upper molar Lower molar Total
and 44% of the three-to-four-unit FPDs (Table 2). group, 29 of the 126 reconstructions needed some
There were significantly less complications on single repair (23%). The difference was statistically significant
crowns than on three-to-four-unit FPDs and FPDs with (P < 0Æ001) (Fig. 2).
an extension (P < 0Æ048). Of the clinical interventions, 14% were classified as
Fifty-six per cent of screw-retained constructions minor interventions, 71% as moderate and 14% as
needed some repair and 22% of the cemented restora- major interventions. Of the major interventions, four
tions (Table 3). Screw-retained reconstructions had were for single crowns, one on a two-unit FPDs and
significantly more complications than cemented resto- three on three-to-four-unit FPDs. If therapy was nee-
rations (P < 0Æ001). However, in 21 of the 26 interven- ded, the minimum time required was 5 min; the
tions necessary in screw-retained reconstructions, the maximum time was 120 min (mean: 47Æ4 25Æ0 min).
treatment consisted of only tightening the screw. The type of necessary interventions is given in Table 4.
No difference in complication rate was found The type and duration of repair was not different
between the different types of antagonistic occlusion between the bruxing and non-bruxing group
(P < 0Æ687). (P < 0Æ688).
Of the reconstructions made in the bruxing group, 17
of the 43 had a complication (39%). In the non-bruxing
100
Complication
80 No complication
Table 2. Number and percentages (%) of complications in
different groups of reconstructions
60
Complications
In one patient, two-connected crowns on the central in material and surface characteristics of metal abut-
upper incisors were made on two implants. After ments and natural teeth, results of studies using teeth as
6 months the patient had a severe car accident and abutments cannot be applied to implant dentistry. They
the two crowns were broken and had to be replaced. concluded that at present conclusive data were not
The implants stayed intact. No complications were available and that it is at the clinician’s discretion to
observed over the next 60 months. In five patients, the choose a certain type of cement based on the clinical
construction became loose twice. These five patients situation.
were all classified as bruxers. In one patient, several In contrast to other studies implant fracture was not
complications occurred from retention loss to fracture observed.
of the porcelain crown. Difference was made between minor, major and
In addition to the chair time costs, in seven cases, moderate complications based on the necessary chair
additional costs had to be charged to the patients. No time and extra laboratory costs to resolve the problem.
additional costs were charged for polishing or rece- Only 14Æ5% of the complications could be classified as
menting tightening of the screws and abutment. Addi- major. The larger the construction, the more frequent
tional costs were new screws, new abutments, new complications occurred.
octa-abutments or dental laboratory costs for new FPDs, It has been reported that the incidence of technical
new porcelain on the frames. The costs ranged from €28 complications is higher in combined tooth/implant-
to €840. Two patients had to pay €120, one patient supported FPDs (10). This was not found in the present
€201, one patient €210 and another €420. The high cost study but the number of such type of construction is too
of €840 for one patient was due to the remake of two limited to draw any conclusion. In the present study,
porcelain crowns in the patient who had a car accident intrusion of the natural abutment teeth has not been
some months after cementation. observed.
In the present study, all reconstructions were single
crowns and FPDs. McDermott et al. (5) reported a
Discussion
statistically significant difference in prosthetic compli-
The incidence of all technical complications on the cation rate between removable reconstructions and
prosthetic unit level (17%) and on the construction fixed restorations and between anterior versus posterior
level (25%) in the present study is higher than what location of the FPDs. Payne & Solomons (7) reported a
has been found in the literature (14–16). McDermott high rate of prosthetic complications over a 3-year
et al. (5) reported over a median duration of follow-up period in implant-borne removable dentures: fracture
of 13Æ1 months, a complication rate of 14% of which of retention clips (30%), relining of the denture (40%)
3% were classified as prosthetic complications. The and remake of the denture (21%). FPDs have a smaller
incidence of suprastructures-related complications has complication rate than removable dentures on im-
been reported at 14% after 5 years (10). In the present plants.
study, screw or abutment loosening amounted to 12%. Overload because of a faulty occlusal design has often
The incidence of connection related complications as been mentioned as an important factor in technical
screw loosening has been reported at 2Æ9% after 5 years complications and in peri-implant bone loss in implant-
(10). Eckert & Wollan (17) found the probability of supported FPDs (23–25). On small FPDs and single
5-year no occurrence of screw loosening at 83Æ8%. Loss crowns, the occlusion should be designed to minimize
of retention was reported at 7% after 5 years and 16% occlusal forces and to maximize force distribution to
after 10 years (18, 19). The higher percentage of loss of adjacent natural teeth (26, 27). In the present study,
retention (20%) in the present study cannot be attrib- great care was taken to the occlusal design and to follow
uted to the use of a semi-temporary cement generally accepted guidelines (12, 13).
(Improv††) which was chosen because of the easy Bruxism has often been mentioned a major cause
retrievability if complications occurred. The choice of for implant fracture and technical complications (23,
an adequate cement providing enough tensile strength 28–30). This is confirmed in the present study with a
still allowing some retrievability is not easy. In vitro significantly higher complication rate in bruxers. This
studies provided controversial results (20–22). Mansour is also in accordance with the study by Tosun et al.
et al. (21) stressed the fact that because of the difference (31) who, in six patients diagnosed as bruxers by
means of a polysomnographic analysis, found more University, Gent, Belgium, for their clinical contribu-
mechanical and implant fractures than in non-bruxers. tion to the study.
In the present study, the patients were classified as
bruxers based on the presence of occlusal wear facets
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