Contemporary Clinical Dentistry
   
  Home | About us | Editorial board | Search
Ahead of print | Current Issue | Archives | Advertise
Instructions | Online submission| Contact us | Subscribe |

 

Login  | Users Online: 679  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size 



 
 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 8  |  Issue : 3  |  Page : 485-489  

Management of broken dental implant abutment in a patient with bruxism: A rare case report and review of literature


Department of Dentistry, Oral Implantology Unit, KFMMC, Dhahran, Saudi Arabia

Date of Web Publication14-Sep-2017

Correspondence Address:
Saad Al-Almaie
King Fahd Military Medical Complex, Medical Administration, P. O. Box 946, Dhahran 31932
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ccd.ccd_426_17

Rights and Permissions
   Abstract 

This rare case report describes prosthodontic complications resulting from a dental implant was placed surgically more distally in the area of the missing mandibular first molar with a cantilever effect and a crest width of >12 mm in a 59-year-old patient who had a history of bruxism. Fracture of abutment is a common complication in implant was placed in area with high occlusal forces. Inability to remove the broken abutment may most often end up in discarding the implant. Adding one more dental implant mesially to the previously placed implant, improvisation of technique to remove the broken abutment without sacrificing the osseointegrated dental implant, fabrication with cemented custom-made abutment to replace the broken abutment for the first implant, and the use of the two implants to replace a single molar restoration proved reliable and logical treatment solutions to avoid these prosthodontic complications.

Keywords: Bruxism, cantilever effect, crest width, custom fabricated titanium abutment, prosthodontics complication


How to cite this article:
Al-Almaie S. Management of broken dental implant abutment in a patient with bruxism: A rare case report and review of literature. Contemp Clin Dent 2017;8:485-9

How to cite this URL:
Al-Almaie S. Management of broken dental implant abutment in a patient with bruxism: A rare case report and review of literature. Contemp Clin Dent [serial online] 2017 [cited 2018 Nov 19];8:485-9. Available from: http://www.contempclindent.org/text.asp?2017/8/3/485/214537




   Introduction Top


Occlusal forces are greatest in the molar region, leading to possible increased stress on the implant components as well as on the surrounding bone.[1] The screw joint for a single implant is susceptible to loosening because the torque relative to the implant axis must be counteracted by the screw joint itself.[2] The clinical feasibility of using two implants to support a molar restoration has been previously reported.[3]

Failures of implant-supported restorations result from technical problems and can be divided into two groups: those relating to implant components, and those relating to the prosthesis.[4],[5],[6] Technical problems related to implant components include abutment screw fracture.[7] Jung et al., 2008, reported that prosthetic screw fracture has an incidence rate of 3.9% and the rate for prosthetic screw loosening is 6.7%.[8] Fracture of the implant abutment in a patient with bruxism was reported as a rare case with prosthodontic complication due to the low incidence rate of 3.9%; this can be a serious problem as the fragment remaining inside the implant prevents the implant from efficiently functioning. The primary reason for screw fracture is undetected screw loosening, which can be due to bruxism, an unfavorable superstructure, overloading, or malfunction.[9]

In the presence of bruxism, most authors recommend the placement of more implants than would have been necessary in the absence of the movement disorder. These authors suggested that bruxism remains a potential risk factor; therefore, clinicians should adopt a cautious approach when planning for implant-assisted prostheses in bruxers and authors also argue that the overloading influence of bruxism on implants and their superstructures yields a higher risk of biological and biomechanical complications than would be the case during physiological masticatory activities.[7],[10],[11] In addition, mechanically connecting the implants leads to better force distribution and a reduced stress on bone around the implants.[12]

Once an abutment fracture has occurred, the fractured screw segment inside of the implant must be removed. Otherwise, the implant will remain osseointegrated but lose its ability to retain the prosthesis; thus, the existing prosthodontic restoration can no longer be used.[6] Methods for retrieving screw fragments within implants in situ have been reported.[6],[9],[10],[13],[14],[15] This rare clinical report presents the management of prosthodontic complication in a patient with bruxism, with reliable and logical treatment solutions.


   Case Report Top


A 45-year-old male reported to the clinic with the chief complaint of a dislodged crown in relation to an implant placed in the lower posterior region 4 years prior [Figure 1]. The dental history for the surgical and prosthetic treatments for that area was situated outside the town. The clinical and radiographic findings of the patient had a history of bruxing habits and a standard neck, nonsubmerged, screw-type implants of 12 mm height (4.8 mm diameter) (ITI, Straumann, Basel, Switzerland manufacturer) that was inserted more distally in the area of the missing mandibular first molar with a cantilever effect and a crest width of >12 mm [Figure 2]. This clinical report describes a situation, in which a fractured implant abutment screw was not successfully retrieved using the erbium-doped yttrium aluminum garnet laser as an auxiliary tool, which was moved by an explorer or using an ultrasonic scaler tip. Other methods of screw fragment retrieval were employed, which also failed.[15] The apical part of the screw remained threaded into the implant but was fractured at the level of the hexagonal lock. The patient was unwilling to undergo an extensive implant removal procedure; thus, it was decided that the screw hole would be used as a prepared channel for custom fabricated titanium abutment with a passive fit and antirotational device post inside that channel. A recommendation was made to surgically add a narrow neck, nonsubmerged, screw-type, sandblasted, large grit, acid-etched implants of 12 mm height (3.3 mm diameter) (ITI, Straumann, Basel, Switzerland manufacturer) mesial to the previously placed implant [Figure 3]. Informed consent was obtained from the patient after all options for retreatment were explained and before any surgical procedure was conducted. Six weeks after implant placement, it was decided that the fractured portion would be drill out of the abutment screw to make room for fabrication, a custom-fabricated titanium abutment, and the internal threads of the implant were eliminated using a tungsten carbide bur (170 L) in a high-speed air rotor handpiece under copious saline irrigation. The coronal fragment of the fractured segment was removed using an 8 mm round-ended tapered diamond and carbide bur to provide a room for a sufficient length of a passive fit and antirotational device for a post inside that channel capable of resisting the torsional forces. A radiograph was taken to reconfirm the complete room inside the 4.8 mm diameter implant [Figure 3]. The internal threads for the implant were lost. The following steps were followed to fabricate a custom fabricated titanium abutment:
Figure 1: The broken abutment inside the crown

Click here to view
Figure 2: Implant position with fractured implant abutment screw

Click here to view
Figure 3: Implant was added mesially and internal implant preparation

Click here to view


  • The implant body was thoroughly cleaned using the air/water spray from the three-way syringe and then dried with air
  • A regular neck stainless steel solid abutment with a diameter of 4.8 mm, and a height of 5.5 mm (ITI, Straumann, Basel, Switzerland manufacturer) was selected to be sure that it is passively fit into the prepared implant room, otherwise more preparation into that room
  • GC pattern resin low shrinkage (GC Pattern Resin LS, Europe N.V, Interleuvenlaan 33, B-3001, Leuven) was applied on the internal threads of the RN stainless steel solid Abutment to provide a sufficient length of a passive fit and antirotational device for a post inside that channel capable of resisting the torsional forces
  • Impression coping for the solid stainless steel abutment with the GS pattern resin post was taken and sent to the laboratory for fabrication of the titanium abutment
  • A trial fitting of the fabricated abutment in the patient's mouth was conducted.


The impression post for the open tray and the fabricated abutment for the 3.3 and 4.8 mm diameter implants, respectively, were inserted in parallel direction [Figure 4]. A pick-up impression was taken, an Narrow Neck CrossFit (NNC) cementable titanium abutment, with a height of 5.9 mm was selected for 3.3 mm diameter implant, and the fabricated abutment was inserted into the cast and to be sure in a parallel direction. Laboratory procedures as well as fabrication of a single metal framework for porcelain-fused-to-metal cemented crown were conducted [Figure 5]. The NNC cementable titanium abutment screw was tightened into 3.3 mm diameter implant, and the fabricated custom-made abutment was cemented into the 4.8 mm diameter implant using resin cement. Delivery of the final restoration included confirmation that proximal contact allowed the patient to perform normal oral hygiene procedures using dental floss and the occlusal scheme for all molars was evaluated to ensure a firm-centric contact [Figure 6]. A postoperative photograph and radiograph were taken after cementation to confirm the seating of the two-implant supported molar restoration at the time of delivery. Oral hygiene instructions were reinforced, and the importance of periodic recall visits was emphasized. A maxillary acrylic resin occlusal guide was provided for long-term stability in this case due to the patient's history of bruxism. Radiographic evaluation has indicated a stable periodontal condition with little or no bone loss associated with the osseointegrated implants. The patient was followed up after 4 years and showed no signs of failure nor peri-implant radiolucency [Figure 7].
Figure 4: Impression post and fabricated abutment were inserted

Click here to view
Figure 5: The metal substructure for the porcelain-fused-to-metal crown

Click here to view
Figure 6: Delivery for the final restoration

Click here to view
Figure 7: Four-year postoperative for the implants with good bone pattern

Click here to view



   Discussion Top


Previous studies have shown that prosthesis mobility and screw loosening are the most frequent complications associated with single-implant molar restorations.[16] A high incidence of screw loosening may be a warning sign of potentially more serious complications, including fracture of the implant fixture, which may arise over time with these restorations, as observed by Rangert and others.[17] Zhou et al. were performed the meta-analysis to evaluate the relationship between bruxism and dental implant failure. In contrast to nonbruxers, prostheses in bruxers had a higher failure rate. It suggests that bruxism is a contributing factor of causing the occurrence of dental implant technical/biological complications and plays a role in dental implant failure.[18]

At the onset of treatment, the patient was trying to reduce costs by opting for a single fixture, but in the long term, this was not cost effective for the patient or the treating dentist. Abutment screw fracture, although uncommon, does occur in clinical practice, and its removal can be quite challenging for the clinician.[9],[13],[19] If an abutment screw fracture occurs above the head of the implant, hemostats or artery forceps may be used to grasp the broken screw and remove it successfully. Other methods or systems can be employed to remove the fragment. Most of these systems involve drilling a hole into the center of the broken screw followed by engaging a removal wedge into the broken screw. Reverse torque is then applied with the removal instrument. However, if the methods fail to retrieve the fractured segment or there is damage to the internal threads of the implant screw hole, the implant may be rendered useless. In such a scenario, a fabricated, custom-made, abutment-supported prosthesis can retrieve the near useless implant. Fabrication of custom-made abutment by means of titanium elements for the advantage of titanium's melting point (1670°C) higher than stainless steels melting point (1510°C). Nevertheless, the use of two implants is especially indicated in patients who have been identified as pronounced bruxers or clenchers to overcome the masticatory overload. For a molar, the use of two implants provides more surface area for osseointegration and spreads the occlusal loading forces over a wider area while reducing the potential bending forces that would exist in a single-implant molar restoration.[3],[20],[21],[22] A logical solution to implant overload is the use of two implants to replace the roots of a missing molar.[20]

The postulated advantages of using two implants to support a molar restoration instead of a wide diameter implant are several. First, there is wider support of the restoration in both the mesial-distal and the buccolingual dimensions. In addition, the dentist has greater flexibility to maximize placement in compromised bone receptor sites without perforation of the cortical plates; thus, there is better subsequent retention of the crestal bone levels. The use of two implants also diminishes the potential of the restoration to loosen under normal or parafunctional forces. Furthermore, the double implant may lessen the possibility of occlusal overload. It also allows for greater flexibility in the restorative style used: cement or screw retained. The possibility of increased cost may be outweighed by the reduced likelihood of failure of the implant or the restoration based on the reported complications described earlier. Finally, the double implant does not require special components or procedures that are not normally used in other restorative applications.


   Conclusion Top


The procedures described in this paper to manage prosthodontic complications resulting from a dental implant was placed surgically more distally with a cantilever effect and a crest width of >12 mm in a patient who had a history of bruxism. Adding one more dental implant mesially to the previously placed implant, improvisation of technique to remove the broken abutment without sacrificing the osseointegrated dental implant, fabrication with cemented custom-made abutment to replace the broken abutment for the first implant, and the use of the two implants to replace a single molar restoration proved reliable and logical treatment solutions to avoid these prosthodontic complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Haraldson T, Carlsson GE, Ingervall B. Functional state, bite force and postural muscle activity in patients with osseointegrated oral implant bridges. Acta Odontol Scand 1979;37:195-206.  Back to cited text no. 1
[PUBMED]    
2.
Balshi TJ, Hernandez RE, Pryszlak MC, Rangert B. A comparative study of one implant versus two replacing a single molar. Int J Oral Maxillofac Implants 1996;11:372-8.  Back to cited text no. 2
[PUBMED]    
3.
Balshi TJ. First molar replacement with an osseointegrated implant. Quintessence Int 1990;21:61-5.  Back to cited text no. 3
[PUBMED]    
4.
Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent 2003;90:121-32.  Back to cited text no. 4
[PUBMED]    
5.
Behr M, Lang R, Leibrock A, Rosentritt M, Handel G. Complication rate with prosthodontic reconstructions on ITI and IMZ dental implants. International Team for implantology. Clin Oral Implants Res 1998;9:51-8.  Back to cited text no. 5
[PUBMED]    
6.
Luterbacher S, Fourmousis I, Lang NP, Brägger U. Fractured prosthetic abutments in osseointegrated implants: A technical complication to cope with. Clin Oral Implants Res 2000;11:163-70.  Back to cited text no. 6
    
7.
Binon PP. Implants and components: Entering the new millennium. Int J Oral Maxillofac Implants 2000;15:76-94.  Back to cited text no. 7
[PUBMED]    
8.
Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5-year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res 2008;19:119-30.  Back to cited text no. 8
[PUBMED]    
9.
Nergiz I, Schmage P, Shahin R. Removal of a fractured implant abutment screw: A clinical report. J Prosthet Dent 2004;91:513-7.  Back to cited text no. 9
[PUBMED]    
10.
Komiyama O, Lobbezoo F, De Laat A, Iida T, Kitagawa T, Murakami H, et al. Clinical management of implant prostheses in patients with bruxism. Int J Biomater 2012;2012:369063.  Back to cited text no. 10
[PUBMED]    
11.
Johansson A, Omar R, Carlsson GE. Bruxism and prosthetic treatment: A critical review. J Prosthodont Res 2011;55:127-36.  Back to cited text no. 11
[PUBMED]    
12.
Guichet DL, Yoshinobu D, Caputo AA. Effect of splinting and interproximal contact tightness on load transfer by implant restorations. J Prosthet Dent 2002;87:528-35.  Back to cited text no. 12
[PUBMED]    
13.
Williamson RT, Robinson FG. Retrieval technique for fractured implant screws. J Prosthet Dent 2001;86:549-50.  Back to cited text no. 13
[PUBMED]    
14.
Gupta V, Prithviraj DR, Muley N. A new restorative technique for the perishing implant due to abutment screw fracture. J Oral Implantol 2014;40:755-7.  Back to cited text no. 14
[PUBMED]    
15.
Maalhagh-Fard A, Jacobs LC. Retrieval of a stripped abutment screw: A clinical report. J Prosthet Dent 2010;104:212-5.  Back to cited text no. 15
[PUBMED]    
16.
Becker W, Becker BE. Replacement of maxillary and mandibular molars with single endosseous implant restorations: A retrospective study. J Prosthet Dent 1995;74:51-5.  Back to cited text no. 16
[PUBMED]    
17.
Rangert B, Krogh PH, Langer B, Van Roekel N. Bending overload and implant fracture: A retrospective clinical analysis. Int J Oral Maxillofac Implants 1995;10:326-34.  Back to cited text no. 17
[PUBMED]    
18.
Zhou Y, Gao J, Luo L, Wang Y. Does bruxism contribute to dental implant failure? A systematic review and meta-analysis. Clin Implant Dent Relat Res 2016;18:410-20.  Back to cited text no. 18
[PUBMED]    
19.
Taira Y, Sawase T. A modified technique for removing a failed abutment screw from an implant with a custom guide tube. J Oral Implantol 2012;38:165-9.  Back to cited text no. 19
[PUBMED]    
20.
Balshi TJ, Wolfinger GJ. Two-implant-supported single molar replacement: Interdental space requirements and comparison to alternative options. Int J Periodontics Restorative Dent 1997;17:426-35.  Back to cited text no. 20
[PUBMED]    
21.
Bahat O, Handelsman M. Use of wide implants and double implants in the posterior jaw: A clinical report. Int J Oral Maxillofac Implants 1996;11:379-86.  Back to cited text no. 21
[PUBMED]    
22.
Shim HW, Yang BE. Long-term cumulative survival and mechanical complications of single-tooth Ankylos implants: Focus on the abutment neck fractures. J Adv Prosthodont 2015;7:423-30.  Back to cited text no. 22
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed744    
    Printed8    
    Emailed0    
    PDF Downloaded109    
    Comments [Add]    

Recommend this journal