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REVIEW ARTICLE

Implant failure: A dentist’s nightmare

Madhura Avinash Kate, Sangeeta Palaskar, Prakhar Kapoor

ABSTRACT

Dental implants are commonly used in clinical situations for replacement of natural teeth. Despite
many advances in materials, techniques, and implant design, implant failure is a significant concern
for the dentist and patient. Peri‑implantitis and lack of osseointegration are considered to be the major
factors leading to implant failure. Occlusal overloading, medical status of the patient, smoking, and
implant characteristics are among the other causes for implant failure. The purpose of this concise
review is to discuss the etiology of implant failures by highlighting the various classification put forth
by different authors and formulating a new classification.

KEY WORDS: Classification, fracture, implant failure, osseointegration, overloading, peri‑implantitis,

prosthesis, smoking

INTRODUCTION
An implant is “a graft or insert set firmly or deeply
into or onto alveolar process that may be prepared
for its insertion.” Implants are used for single tooth
replacements, partially edentulous arches and for
completely edentulous arches. They are inert, alloplastic
materials most commonly made of titanium or
titanium alloy or vitalinium.[1] Alternatively, ceramics
such as hydroxyapatite, bioglass, or aluminum
oxides can be used.[2] Depending on their placement
within the bone, they are classified into epiosteal,
endosteal, and transosteal.[2,3] The most common one
is endosteal (screw shaped or cylindrical). An implant
consists of an implant body which is placed within the
bone, implant screw placed on the superior surface of the
body to which is attached the healing cap. Abutments are
placed over the implant body which provides retention to
Department of Oral Pathology and Microbiology, Sinhgad Dental College
and Hospital, Pune, Maharashtra, India
Address for correspondence: Dr. Madhura Avinash Kate,
150, Anand Avinash Niwas, S.T. Road, Dapodi, Pune ‑ 411 012,
Maharashtra, India.
E‑mail: katemadhura@yahoo.com
the prosthesis.[1,2] Implants are placed into the bone either
in 1 stage or 2 stage surgery. In spite of taking many
precautions and surgical precision, implant failures do
occur attributing to certain factors.
REVIEW OF LITERATURE
The aim of this article is to study the various causes of
implant failure by focusing on the various classifications
given from time to time. Implant failure is caused by
a number of factors which include peri‑implantitis,
absence of osseointegration, and implant fracture. It may
also be caused due to surgical trauma, micromotion, and
overloading.[4] Over the years, differed classifications of
Implant failures have been proposed by various authors
[Figures 1-6].
Working classification
Compiling the various classification systems given
from time to time, we have put forward a new working
classification which divides implant failures broadly into
early and late failures. They are further classified based
on etiology, personnel responsible, failure mode, and
biological causes [Table 1].

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DOI:
10.4103/0974-6781.202154 How to cite this article: Kate MA, Palaskar S, Kapoor P. Implant failure:
A dentist's nightmare. J Dent Implant 2016;6:51-6.

© 2017 Journal of Dental Implants| Published by Wolters Kluwer - Medknow 51

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Kate, et al.: Classification of implant failures
DISCUSSION
Improper selection of patient, poor oral hygiene due
to bacterial plaque accumulation, improper prosthetic
restoration, debris retention, and bone preparation
without the use of coolants have been contributing factors
in the breakdown of successfully placed implants.[7]
Early failures
Early failures occur soon after placement of implants
in the bone which is between few weeks to months.
They interfere with the healing process or cause altered
healing.[2,3,8]
Implant selection
Etiologically, improper implants such as short implants
cause implant failure due to unfavorable crown root
ratio.[3,9] In a study carried out by Bahat on treatment
planning and placement of implants in posterior maxilla
in the year 1993, 732 placed implants in posterior maxilla
of partially edentulous patients reported a failure rate of
9.5% for 7 mm implants as compared to 3.8% for all other
lengths.[10] Similarly, implants with a smaller diameter
are less apt to withstand stresses leading to fracture of the
implant components. Bahat and Handelsman compared
the clinical outcomes of the placement of different
combinations of implants at one site in the posterior areas
and found the failure rate for all 5  mm implants was
2%–3%, and that for all double implants was 1%–2%.[11]
The superstructure tends to loosen in the mouth due
to conical screw design.[9] Implant properties such as
surface roughness, impurities help to retain the implant
in the bone, thus playing an important role in implant
Figure 1: Classification of Implant Failures as stated by
Nallaswamy[1]
Figure 3: Classification of Implant Failures as given by Esposito
et al.[6]
52 Journal of Dental Implants | Volume 6 | Issue 2 | July - December 2016
success.[3] As implant characteristics are crucial in success
of an implant, the type of bone which receives an implant
is equally significant.
Bone type
Dense compact bone and porous compact bone found in
the anterior mandible are more favorable as they hold the
implant firmly in the socket. In contrast to this, porous
and trabecular bone found in the posterior maxilla
decrease the stability of the implant in the bone.[12,13] Jaffin
and Berman  (1991), in their 5‑year analysis, reported
that as many as 35% of all implant failures occurred in
porous trabecular bone due to its thin cortex.[14] Placing
the implant in immature bone grafted sites increases the
chances of failures.
Surgical criteria
Surgical accuracy is an important criterion for a
successful implant. This depends on axial placement
of implant, spacing between adjacent implants and its
initial stabilization in the bone. Buccally placed implants
jeopardize the buccal cortical plate. Similarly, lingually
placed implant interferes with tongue movements
hampering speech.[6] Less space between two implants
causes injury to interdental bone leading to bone loss.[1]
On the other hand, if the spacing is more than required,
additional cantilevers are placed which increase the
stress on supporting implants, leading to fracture of
implants, thereby its failure.[6] Atilla Sertgoz et al. in 1996
reported that maximum stresses were concentrated at
Figure 2: Classification of Implant Failures as stated by
Rosenberg et al.[5]
Figure 4: Classification of implant failures as stated by Truhlar[5]
and Tonetti and Schmid
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Kate, et al.: Classification of implant failures
the most distal bone/implant interface, located on the
loaded side of terminal implant, increasing cantilever
length resulted in increased stress value at bone‑implant
interface.[15] Over preparation of the bone site due to
excessive in and out motion decreases the density of
bone. Use of dense bone drills in low‑density bone
decreases the bone quality.[8] Excess heating of bone
causes bone necrosis[9] (47° for more than 1 min). Salonen
et al. (1993) found that 5.8% of implants were lost due to
failures of osseointegration caused by excessive heating
of bone.[16] Irrigation helps to reduce the chances of bone
necrosis.[9]
Surgical conditions
Maintaining sterile conditions during the surgical
procedure is of utmost importance. Saliva, perioral skin,
unsterile instruments, contaminated gloves, operating
room air, or air expired by the patient, all interfere in
the surgical procedure leading to contamination of the
implant site, causing infection in the implant site.
Prosthetic considerations
Prosthetic rehabilitation and occlusal adjustments
should be taken into consideration for a successful
implant. Fumihiko Watanabe et al. in 2002  reported
that an implant was placed in an incorrect inclination
in spite of cooperation between the surgeon and
prosthodontist. This failure suggested the necessity of
clearly presenting the prosthodontic aspect of treatment
to each member of the team before surgical treatment is
Figure 5: Classification of implant failures given by Matukas[5]
Figure 6: Classification of implant failures as given by El Askary et al.[5]
Journal of Dental Implants | Volume 6 | Issue 2 | July - December 2016 53
rendered.[17] Distribution of forces enhances the success
of implant. Increased force on one implant leads to
prosthetic component breakage.[3,8] Hence, excessive
load on single implant should be avoided. Misfit of the
implant leads to constant tension in the components
which leads to screw loosening or fracture.[3,8] Robert L.
Simon in 2003 concluded that the implant failure rate
was 4.6% with complications of abutments screw
loosening (7%).[18] Poor implant design and excessive
loading of implant (especially cantilever abutments)
increase the failure chances.[8] Greater the cantilever
distance, greater the chances of failure.[1,8]
Late failures
As certain factors are responsible for causing early
failures, there are a different set of factors which cause
delayed failures. These failures arise from pathologic
processes in previously osseointegrated implants. These
are mostly associated with medical status of the patient.
They are categorized as host factors.
Host factors
Patients with diabetes experience delayed wound
healing which impairs osseointegration process.[4,9,13]
Uncontrolled diabetes leads to implant failure. Fiorellini
et al. (2000)[19] demonstrated a lower success rate of only
85% in patients with diabetes, while Olson et al. (2000) [20]
found that the duration of diabetes had an effect on
implant success: more failures occurred in patients who
had diabetes for longer periods.[13] In osteoporotic and
arthritic conditions, density of bone is adversely affected.
This leads to porous bone. Such bone is unsuitable for
implant success.[4,13] John C. Keller et al. in 2004  have
reported that osteoporosis‑like bone conditions affect the
osseointegration characteristic of implant.[21] Overweight
is a metabolic syndrome which leads to increase in
peri‑implant inflammations which in turn affect implant
prognosis.[4] A study carried out on implants, and relative
risk factors stated that increasing age was also a major
risk factor.[13] Compared to patients younger than 40,
patients in the range of 60–70 years had a higher risk of
implant failure.[22]
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Kate, et al.: Classification of implant failures
Table 1: Working classification
Early failures (intraoperative or within 3 months)
1. According to Etiology:
• Implant selection: improper Implant type or bone type, length • Host factors: systemic factors diabetes, arthritis, obesity,
and diameter of implant, surface impurity, surface roughness.
• Surgical placement: off axis placement, lack of initial
stabilization, overheating of bone, minimal space between
implants, contamination of implants during placement.
• Restorative problems: Improper design, occlusal scheme,
improper fit, excessive loading , implant fractures.
2. Due to Personnel Responsible
• Dental expertise: oral surgeon, prosthodontist, periodontist
• Laboratory technician:improper design of prosthesis.
3. Accroding to failure mode
• Lack of osseointegration
4. Due to biological causes: peri• implantitis
Tissue abuse and parafunctional habits
Tissue abuse habits, parafunctional habits, and
psychological disorders have a detrimental effect
on implant success. [3] Smoking is associated with
significantly higher levels of bone loss. It reduces the
density of bone which interferes with osseointegration,
leading to increase the failure rate.[4,13] A longitudinal
study by Lambert et al.  (2000) found more failures
in patients who smoked, and Bain and Moy  (1993)
observed that a significantly greater percentage of
failures implant occurred in smokers  (11.3%) than in
nonsmokers  (4.8%).[13] Based on the studies carried
out by Dror Twito and Paul Sade between the years
1999 and 2008 in Israel, it has been proved that 4.2%
of implants, i.e., 321 out of 7680 implants failed due to
smoking which included passive smoking as well.[23]
Parafunctional habits such as bruxism increase the
occlusal stress on implants. It leads to fracture of
implants causing failures.[9] Glauser et al., evaluated
41  patients who received 127 immediately loaded
implants. Their results showed that implants in
patients with a parafunctional habit  (bruxers) were
lost more frequently than those placed in patients with
no parafunction (41% vs. 12%).[24] Cognitive difficulty,
mental retardation, and lack of support interfere with
surgical procedures. Implant success is adversely
affected due to psychological disorders.[3]
Radiation
Radiotherapy is provided to patients suffering
from maxillary and mandibular tumors. It causes
osteoradionecrosis of bone which decreases the volume
of bone, thus interfering with osseointegration.[4,13]
Reported success rate is only about 70%, long‑term
studies are limited, but Jacobsson et al. (1988) showed
increasing implant loss over time due to radiation.[25]
54 Journal of Dental Implants | Volume 6 | Issue 2 | July - December 2016
Late failures(postoperative after 3 months)
1. According to Etiology:
osteoporosis.
• Tissue abuse:smoking, para functional habits, alcoholism.
• Radiotherapy
2. Due to Personnel Responsible
• Patient: inadequate post• operative maintenance
3. Accroding to failure mode:
• functional and psychological problems
4. Due to biological causes:
• Infections: retrograde perimplantitis, due to traumatic
occlusion, overloading.
Personnel responsible (early failures)
Placement of an implant is a surgical procedure carried
out cumulatively by a periodontist, prosthodontist, and
an oral surgeon.[3] Extraction of natural tooth, assessment
of bone quality and quantity, periodontal health as well
as systemic condition of the patient are all assessed by
periodontist and an oral surgeon. Prosthodontist takes
care of the implant design, prosthesis, and occlusal
scheme. Any discrepancy in any of these steps decreases
the success of implant. Inaccurate design of the implant
increases the occlusal loading on the implants resulting
in implant failure. Russell A. Wick in 1994 reported that
thoughtful design selection is crucial for the perpetual
success of any dental implant restoration.[26] Hence,
laboratory technician also plays a significant role.[9]
Personnel responsible (late failures)
After successfully placing the implant, it is the
patient’s duty to take care of its maintenance in the oral
cavity. Inadequate postoperative care, carelessness in
maintaining oral hygiene leads to infection in the implant
site causing peri‑implantitis.[27] More bone resorption
was noted around fixtures in edentulous patients with
poor oral hygiene than in participants with good hygiene 
(Lindquist et al. 1988).[28] This proves that in addition to
surgical precision, personnel involved in its procedure
and maintenance are responsible for the fate of implant.[3]
Failure mode
The mode in which failure is caused is different
in early and delayed failures. In early failures, it
is due to lack of osseointegration, whereas in late
failures, it is due to functional and psychological
attributes of the patient.[3] Osseointegration is direct
communication between implant surface and bone.[29‑32]
Lack of osseointegration causes loosening of implant in
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Kate, et al.: Classification of implant failures
the bone which decreases the success rate of implant.
[3]
Failure rates are high due to fibrous union of tissues
instead of osseointegration.[30] Mobility of implants due
to lack of osseointegration results in implant failure.[31,32]
Infection of implant site, poor bone quality, and improper
design of the implant interfere in osseointegration process.
Unacceptable esthetics, psychological problems such as
emotional instability, emotional disturbances, dementia,
and lack of support affect implant success.[3] Failure of
implants is also caused by infections in the oral cavity.
These mostly include peri‑implantitis in early stages that
is during or immediately after implant placement. In
late stages, retrograde infection is the primary causative
agent. These infections are broadly grouped into biological
causes.[8] Peri‑implantitis is an inflammatory process
which affects the tissues around an osseointegrated
implant.[3,13,27,32] It results in loss of supporting bone along
with bleeding, suppuration, increased probing depth,
and mobility. Bacterial infection is the prime reason for
peri‑implantitis.[3,13,27.32] Bacterial flora at failing implant site
consists of Gram‑negative anaerobic bacteria including
Porphyromonas gingivalis, Prevotella intermedia, and
Actinobacillus.[7,27,32] Studies by Mombelli et al. (1987)[33] and
Rosenberg et al. (1991)[34] showed the presence of periodontal
microorganisms around failing implants.[13] Retrograde
peri‑implantitis is also known as apical peri‑implantitis
or periapical implant lesion, occurring in the later stage
of implant placement.[3,7] It develops shortly after implant
insertion while coronal portion of implant achieves a
normal implant bone interface. However, very few failures
have been reported due to retrograde infection.[3,9]
CONCLUSION
Failure of implant is a multifactorial occurrence.
A combination of causes leads to ultimate failure of
implant. Every dentist needs to identify the cause to
treat the present condition. Proper data collection,
patient feedback, and accurate diagnostic tools will help
point out the reason for failure. An early intervention is
always possible if regular checkups are undertaken. The
treatment strategy for complications and failing implants
is influenced by the identification of the possible etiologic
factors. When a diagnosis is established and possible
etiologic factors identified, the causative agent should be
eliminated and treatment attempted as soon as possible.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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56 Journal of Dental Implants | Volume 6 | Issue 2 | July - December 2016