Wide use of dental implants has not only assisted the dental profession to simplify many of the difficult treatment planning processes but also reduced the discomfort that is so often difficult to overcome with conventional prostheses. However, with its increased use, clinicians have more unforeseen events. Consequently, more systematic approaches for the recognition of these complications at an early and/or late phase of the reconstruction process, and the treatment of these complications have become important in contemporary implant dentistry. This article will present currently accepted classifications and treatments of various reversible complications commonly encountered during routine implant-related procedures.
Reversible Complications–Recognition and Diagnosis
In general, untoward outcomes of implant placement can be divided into irreversible and reversible complications, depending upon whether the fixture itself can be salvaged or not. A failed implant from irreversible complications is most frequently identified via clinically discernible mobility. Vertical or horizontal movements are highly indicative of the fibrous encapsulation around the fixture. However, rotational movement alone at an early stage of healing may provide insufficient evidence for de-osseointegration as the bone density and mineralization increase over time. Even without implant mobility, bone loss down to 1/3 of the implant fixture length may also be considered “failed.”1 These failures are often associated with pain or sensitivity upon function, signs and symptoms of infection during stage-one surgery, and the complete radiographic perifixtural radiolucency.
Reversible complications on the other hand refer to the increased risk of failure but are either of temporary significance or amenable to treatment.2 Clinical parameters often used in the literature include radiographically observed progressive marginal bone loss exceeding 1.5 mm in the first year and 0.2 mm in the subsequent years.3 However, an accurate detection of the defect morphology could not be made when the radiographic angulation exceeded 9°.4 Consequently, other clinical parameters such as bleeding on probing, sulcus bleeding index, pocket probing depth, mucosal recession, probing attachment levels, crevicular fluid analysis, and microbial composition have been suggested for better identification of the underlying problems. Variations in probing force, hyperplastic state of the gingiva, and different histologic structures of the peri-implant periodontium from that of the natural teeth still result in under or overestimation of the true underlying problems. Therefore, despite the limitations, consensus is that the well-taken intraoral radiographic bitewing view is the most accurate method to detect the perifixtural bone loss compared to any of these clinical parameters.
Reversible complications may occur at various phases of treatment, including intraoperatively (Table 1), early/late postoperatively (Table 2), and during prosthetic reconstruction and/or after functional loading (Table 3). This may further be subclassified into surgical, prosthetic/technique, and esthetic/soft tissue associated complications (Table 4).
Earlier surgical trauma during osteotomy preparation has been associated with an early implant failure. The critical temperature at which bone necrosis may occur has been reported as 47°C for 1 minute beyond which fat cells may replace bone, leading to an unfavorable condition for proper osseointegration.5 Therefore, a high speed accompanied by increased loading in an up-down motion is recommended to minimize the frictional heat.6
Primary stability may be lacking. A wider diameter or longer implant is suggested to re-embrace the stability within anatomic boundaries. However, if this is not possible, the implant is to be removed and its placement delayed until the recipient site is surgically augmented. Malpositioned implants may result from an unexpected deficient ridge, not counting the lingual inclination of 109° in the mandibular molars,7,8 a lack of understanding in the 3-dimensional design of final restorations, an occlusal plane not established before the implant placement, differential bone densities, and an iatrogenic placement without a surgical template. If an improper implant positioning occurs intraoperatively, the implant is relatively easy to torque out manually and/or a side-cutting Lindemann drill (GEBR. BRASSELER GmbH & Co. KG, Lemgo, Germany) may be used to correct the angulation. This process may create a gap between the implant and the bone if the same diameter implant is used. The critical gap reported for ensured bone formation ranged from 0.35 to 1.25 mm.9–11 This suggests that a small gap between the bone and implant surface may not be critical as long as the implant achieves primary stability.
Excessive implant angulation may also compromise the surrounding structures. In case of buccal dehiscence from an excessive buccal angulation, immediate repositioning of an implant with simultaneous grafting is recommended. Collagen membrane and slow resorbing bone particles are preferred. Devitalization of the adjacent teeth from an excessive mesiodistal angulation may occur because of the fact that the biologic distance of 2.0 mm from the adjacent teeth has been violated. To prevent a latent infection of the implant from the potential endodontic lesion, root canal therapy should be performed.12 Thereafter, an implant can be placed immediately in a correct position or delayed until the osteotomy site is completely healed.
Nerve trauma and neurosensory disturbance may result from damages to inferior alveolar, mental, incisive, or lingual nerve during osteotomy preparation or flap incisions. This effect may range from an altered sensation (paresthesia), to a complete loss of sensation (anesthesia). These results can be avoided with careful pretreatment imaging. However, if this occurs, implants must be removed, or shorter implants must be placed to relieve the pressure over the injured nerve. A minor injury usually heals spontaneously within days or months. However, prolonged pressure from neuritis may lead to permanent degeneration of the affected nerve. Adjunct drugs such as clonazepam (Rivotril®, Hoffmann La Roche Ltd., Switzerland), carbamazepine (Tegretol®, Novartis Pharmaceutical Inc., NJ), or vitamin B-complex might alleviate neuritis via their known neuronal antiinflammatory actions.
Excessive hemorrhage may occur from an osteotomy preparation in the mandible, frequently involving 3 major arteries supplying the mandible, including inferior alveolar, facial, and lingual artery (Table 5).13 Deep concavities as in the sublingual fossa and lingual cortex of the posterior mandible serve as potential risk sites. Subsequently ruptured artery may lose blood at a rate of 14 ml/min, equivalent to 420 ml of blood loss within 30 minutes.13 Blood loss >500 ml may result in hypotension,14 and even life-threatening airway obstruction may occur if not treated at an early stage.15,16 Gauze should not be packed lingually because there is no hard tissue in the floor of mouth to apply pressure against. The patients are asked to stick out and raise their tongue to bring up the floor of the mouth and to compress vessels against the body of the mandible. After digital palpation of the source of the hemorrhage, extraoral pressure to the submental or submandibular arteries are applied against body of the mandible for 20 minutes. Violation of the intraosseous anastomoses of posterior superior alveolar artery and infraorbital artery during the lateral window preparation during sinus lift procedure may also lead to hemorrhage. These arteries have been located at approximately 19 mm above the alveolar ridge.17 Bone wax or electrocautery may contain the bleeding.
Sinus perforations have been related to the extent of the angle formed by the mediolateral walls of the sinus displayed on computerized tomography.18 The angles <30°, 31°–60°, and >61° resulted in 37.5%, 28.6%, and 0%, respectively, of sinus perforation. Sinus perforation is classified by location: class I, most apical wall of the prepared sinus window; class II, lateral or crestal aspects, with subdivisions of mesial, distal, or crestal extension; and class III, within the body of the sinus window.19 In class I perforation, the Schneiderian membrane folds over itself, so as to seal the perforation. However, collagen tape may be placed over the area. In class IIA perforation where sinus cavity to be augmented extends a minimum of 4–5 mm beyond the position of the membrane perforation, a collagen tape may be used if the diameter of the membrane is <3 mm. Bioabsorbable collagen membrane is preferred if the perforation is >3 mm. Class IIB perforation involves a perforation at the terminal border of the sinus cavity. Because no further reflection can be performed, a bioabsorbable membrane is used to create artificial sinus cavity. The class III perforation is treated in the same way as class IIB. To prevent the subsequent infection, primary wound closure must be achieved, and the patient should be provided with antibiotics, decongestant (e.g., oxymetazoline 0.05%), and 0.12% chlorhexidine. The same approach should be considered in case of a perforation of the nasal floor.
Fracture of the mandible is a severe complication with endosteal implants, especially placed in a severely resorbed mandible with <7 mm of bone height and 6 mm of width. Increased vulnerability was also observed in patients with osteoporosis and osteomalacia.16 Treatment of the fractured mandible is difficult, attributing to a depressed vitality of bone from a higher proportion of dense cortical bone with diminished central blood supply and its dependence upon the periosteal blood supply. Therefore, reduction and immobilization with monocortical miniplates are crucial to avoid any nonunion or malunion healing. Implants in the line of the fracture may not have to be removed if infection and mobility are absent.20 Otherwise, immediate retrieval of implant is advised. During the healing time, the patients are advised to be on a soft diet only.
Immediate/Early Implant Postoperative Complications
Spontaneous incision line opening occurring in 4.6%21 to 13.7%22 of submerged implant cases may interfere with the early wound healing around the implant by providing direct communication with the oral cavity. Contributing factors include the flap tension, continuous mechanical trauma or irritation associated with the loosening of the cover-screw, an excessive supracrestal location of the implant head (especially external hex), and formation of the sequestration of bone debris from osteotomy preparation.23,24 In particular, incision line opening with partial implant exposure has been associated with more peri-implant bone loss, likely because of a less favorable environment for oral hygiene access. Therefore, a partial exposure should surgically be converted to a complete exposure at an early stage to facilitate oral hygiene access and to prevent further peri-implant bone loss.23,24
Implant periapical lesion25 may also occur from bacterial contamination,12,25–31 development of undesirable inflammation,26 excessive or premature occlusal loading,28–30,32,33 improper surgical techniques,25,26,30,34 and poor bone quality.34 An acute phase often occurs during the first month of the fixture placement, while chronic form often shows radiographic changes at the third month.35 Systemic antibiotic is reserved only to delay the eventual progression of infection up to one month. Definitive surgical intervention must be performed before infection extends to the neighboring structures. In case half of the fixture still remains osseointegrated in the cortical plate, an apicoectomy of the fixture may be attempted.25 If the apex of the fixture has an easy access, one may attempt to decontaminate the surface without an apicoectomy. However, the implant should be removed in the absence of fixture stability or less than 1/2 fixture remaining within the cortical bone. A wide-diameter implant is recommended to engage into the bone. Demineralized, freeze-dried bone allograft is suggested in defects >5 mm for 2 reasons: (1) it can serve as a carrier for antibiotics and (2) progressive remineralization can be radiographically evaluated when future reentry is not intended.35
Late Implant Postoperative Complications
An implant may get dislodged into the maxillary sinus during the abutment connection in case of incomplete osseointegration or the lack of bone maturation. A short implant <7 mm has been discouraged in the maxillary posterior area with poor bone quality.36,37 Dislodged implants must be retrieved either through the implant preparation site or via a lateral window approach. Primary closure is crucial to prevent an oroantral communication. Today, it is generally recommended to have a sinus lift surgery to accommodate an implant length ≥10 mm.
Correction of the malpositioned implants identified during surgery is relatively easy. However, once osseointegration occurs, a manual or rotary driven de-torque may not be possible. A trephine bur with an inner diameter 1 mm larger than the implant is selected to remove the implant. The site may be grafted for a future implant placement, or an immediate implant placement with a larger diameter implant may be performed.
For infection-related surgical and postoperative complications, the fate of implant is decided upon: fixture stability, remaining osseointegration more than 1/2 fixture length, and/or strategic value of implant. These complications may occur intraosseously or at the soft tissue level. In case of peri-implant mucositis (i.e., reversible inflammation at the gingival level), treatment is identical to the treatment of gingivitis. Mechanical débridement around the implant with a rubber cup polishing with water should suffice. Adjunctive chlorhexidine has had no additional benefit in the clinical outcome.38 For latent onset of implant periapical lesion, the same treatment protocol is followed as previously described. Peri-implantitis is another site-specific infection that may jeopardize the long-term implant survival. For a shallow defect (vertical defect <2 mm) resulting from peri-implantitis, a nonsurgical approach of mechanical débridement combined with systemic antibiotics39–42 or implantoplasty with a high-speed finishing bur36,43,44 may be used. In the defects >2 mm, complete degranulation, antibiotic rinse of the infected site, and implant surface decontamination with sandblasting or tetracycline for a smooth surface and citric acid for a rough surface are recommended before the regenerative procedure. However, a true re-osseointegration still remains a controversial issue.39,41,42,45,46 Treatment of chronic sinusitis, and persistent pain secondary to premature exposure of implants and/or nerve injury requires the careful retrieval of the implants. At the stage II surgery, periosteal reactive bone growth may have occurred over the cover screw, resulting in hyperplasia or chronic irritation of the overlying gingiva. Excess bone should carefully be removed with a bone mill before taking the impression to prevent incomplete seating of the abutment.
Prosthetic (Mechanical/Biologic) Related Complications
For prosthetic-related complications, screw-joint failure such as abutment and prosthetic screw loosening (6% and 7%, respectively) is frequently reported.47 These results are commonly encountered when functional loading exceeds the adaptive capacity or when operators under tighten the screws. If a preload tightening for gold alloy screws (32 Ncm) and titanium screws (20 Ncm) has been achieved previously according to manufacture’s protocol, repeated screw loosening occurring thereafter should not be taken lightly. This process may be a warning sign for potential implant fracture from the framework misfit or biomechanical overload as in patients with a parafunctional habit. Therefore, the screw retightening must be delayed until the cause of the problem is identified. In addition, bending overload with a magnified stress at the alveolar crest may be generated by a large leverage effect from abutment height >7 mm, over-contoured crowns with a large occlusal table, premature contact offset on the buccolingual occlusal surface, and an implant axis >15° deviation in a buccolingual direction.48,49 If complications occur from these occlusal-related problems, occlusal equilibration, use of a bite-splint, removal of any cantilever, or creating intentional stress-breakers may be attempted.
Effect of occlusal loading may also diminish with use of wide diameter implants. Surgical implant placement in a staggered configuration may further reduce stress and strain by as much as 33%.49 Use of an implant system with an inferior antirotational mechanism may minimize screw loosening, especially in posterior single crowns. Moreover, adequate interarch distance ensures enough material thickness to provide sufficient strength under high occlusal stress. Hence, a minimum interarch space of 12 mm and 7 to 10 mm are recommended for removable prostheses and for fixed prostheses, respectively.36 If these guidelines are violated, and the patient experiences discomfort and speech impediment, fabrication of a new prosthesis should be attempted to re-establish proper occlusion and vertical dimension.
Subsequent prolonged metal fatigue may even lead to a fracture at various levels, including the fixture itself.47,51 Implant fixture fracture is often manifested by inflammation at the gingival margin and bone loss down to the fracture line. Depending on the usefulness of the remaining portion of the implant, the fractured implant may be removed with a trephine bur and replacement with new implant and prosthesis, left as a “sleep” implant, or re-faced and modified for adaptation to the preexisting prosthesis.48
Improper therapeutic occlusion and inadequate space for prosthesis may also lead to ceramic fracture, fracture of the acrylic resin base, and/or metal framework fracture. A quick repair of the ceramic fracture may be possible with composite resin. However, most of these problems require a new fabrication of the involved parts.
Biologic-related complications resemble the late postoperative complications because infection appears to be a significant factor. Rigid supra-crestal/sub-crestal structure and diminished biologic resistance against environmental insults from having a “biologic seal” rather than a true “biologic width” and lacking a periodontal ligament complex render implants more susceptible to bone loss from microbial challenges and occlusal disharmony. Therefore, peri-implant bone loss, latent abscess development, and fibrous encapsulation in the presence of micromovement >100–150 μm in various parts of the fixture may be observed.52,53
Even after successful abutment connection, these are at constant risk for peri-implant infections. Therefore, radiographic, probing depth, and mobility assessments must be included in the routine protocol for early diagnosis of peri-implantitis. Nonsurgical, resective, or guided bone regeneration techniques can then be used. No functional loading is recommended for at least 18 weeks in case of the regenerative procedures because bone maturation occurs at this time.54 In general, 6 months of no loading is recommended. Regarding peri-implant soft tissue, Iacono et al55 stated that a lack of attached keratinized gingiva has no adverse effect in implant survival. However, he addressed that a minimum width does exist to establish a “stable epithelial-connective tissue attachment.” Therefore, in the presence of poor oral hygiene, the authors advocate epithelial or connective tissue grafting for enhanced mechanical resistance to bacterial invasion and prosthesis-related mucosal irritation.
Esthetic/Soft Tissue- Related Complications
Esthetic/soft tissue-related complications cannot easily be corrected because underlying causes frequently reside in the treatment planning and surgical phases. Fig. 1 represents a hierarchy of esthetic principles (i.e.,“Esthetic Principle Triangle”) where hard tissue provides the scaffold for the future soft tissue profile. In turn, soft tissue dictates the design of the final prostheses. Therefore, during the patient assessment phase, the failure to assess: patient’s expectation; smile lines; position of gingival scalloping; and biotype of periodontium; and the failure to achieve a buccolingual angulation of the fixture with a mean facial bone thickness of 1.8–2 mm,56 and an inter-implant distance of >3 mm,57 can contribute to gingival recession. These results are associated with exposed metal margins, gingival transillumination of the abutment and fixture, disappearance of inter-implant papilla, and poor emergence profiles. Treatment and prevention of the esthetic complications occurring at different stages of the “Esthetic Principle Triangle” (Fig. 1A) can be achieved based upon the “Esthetic Management Triangle” (Fig. 1B).
Gingival recession and subsequent display of the metal abutment or fixture are, in particular, serious esthetic concerns. Gingival recession may occur at 2 stages: (1) from the time of the second stage surgery to the abutment removal and (2) from the time of the prosthesis installation. During the healing around the abutment, a total mean recession on the mid buccal portion reached 1.05 mm.58 A burst of recession interestingly occurred during the first 3 months of abutment connection. From the prosthesis insertion, reported gingival recession ranged from 0.4 to 1.75 mm over 9 years.58–61 The first 6 months of prosthesis connection is another critical period when most recession occurs (approximately 0.5 mm). It is agreed that the variations in gingival recession are caused by variations in the thickness and amounts of the keratinized gingival and underlying bone. As a general rule, 1.0-mm gingival recession is expected after the prosthesis is connected; and the prosthesis should be delayed for 3 months if optimal esthetic results are desired.
Loss of the interdental papilla poses another esthetic concern, especially when it creates asymmetry within the smile display. Tarnow57,62 and Choquet63et al showed that a minimum of 3.0-mm inter-implant distance is required to preserve the inter-implant papilla. In particular, the crestal bone to contact distance less than 5 mm showed a full papilla in all cases. However, the mean height of the papilla height was still 3.4 mm because the epithelial and connective tissue attachment around the implant are below the abutment connection, not supporting the papilla.
To treat esthetic-related complications, soft tissue grafting such as the roll technique,64 modified roll technique,65 or conventional connective tissue or free gingival grafting offer immediate resolutions. However, hard tissue augmentation achieves a more predictable long-term result. According to the authors,66 autogenous bone layered with a long-lasting mineralized allograft over the exposed implant surface (“Sandwich technique”) are preferred. Inner autogenous bone layer may facilitate wound healing near the implant surface, while outer layer resorption-resistant layer may help maintain the space more effectively. For papillae treatment, various papillae regeneration incision designs can be adopted during the second stage surgery.6,67–69 However, the long-term maintenance of the regenerated papillae is possible only if an adequate interproximal bone height exists. A slow orthodontic extrusion before extraction may help bring up adjacent bone height before the implant placement for more predictable papilla regeneration.70,71
In edentulous sites with compromised bone volume, a vertical bone augmentation with either guided bone regeneration or block graft should be performed before the implant placement to establish the proper interproximal bone height. A conventional ovate pontic after soft tissue grafting may also be an option.63 If soft/hard tissue manipulations are difficult, missing soft tissue can be prosthetically camouflaged with pink porcelain. Distance between crown contact point and crestal bone can also be reduced to <5 mm, to create an illusion of a papilla reestablishment.72 Use of an angled or customized abutment may also prove extremely useful when the malpositioned implants are either correctable or difficult to remove surgically.
Reversible complications may occur at any stage, including intraoperatively, postoperatively, during prosthetic, and after prosthetic phases. However, if these complications are not recognized at an early stage, ultimate failure at both fixture and prosthetic levels may occur. Therefore, prevention by the careful use of imaging tools, a diagnostic wax-up, use of surgical template, and a good understanding of the surgical anatomy and principles are essential. Early recognition of problem etiology and prompt treatment may prove to be invaluable to clinicians.
The authors claim to have no financial interest in any company or any of the products mentioned in this article.
This work was partially supported by the University of Michigan Periodontal Graduate Student Research Fund.
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Abstract Translations [German, Spanish, Portugese, Japanese]
AUTOR(EN): Sang-Hoon Park, DDS*, und Hom-Lay Wang, DDS, MSD**. *Assistenzarzt mit universitärem Abschluss, Orthodontie, Prävention, Geriatrie, zahnmedizinische Fakultät, Universität von Michigan, Ann Arbor, MI, USA. **Professor und Leiter des Graduiertenkollegs für Orthodontie, Abteilung für Orthodontie, Prävention, Geriatrie, zahnmedizinische Fakultät, Universität von Michigan, Ann Arbor, MI, USA. Schriftverkehr: Hom-Lay Wang, DDS, Professor und Leiter des Graduiertenkollegs für Orthodontie (Professor and Director of Graduate Periodontics), Universität von Michigan (University of Michigan), zahnmedizinische Fakultät (School of Dentistry), 1011 N. University Ave., Ann Arbor, Michigan 48109-1078, USA. Telefon: (734) 763-3383, Fax: (734) 936-0374. eMail:[email protected]
Implantatreversible Komplikationen: Einteilung und mögliche Behandlungsansätze
ZUSAMMENFASSUNG: Versagt die Implantierungsbehandlung von Zahnimplantaten, ist dies sowohl für den Patienten wie auch für den Hersteller bzw. Lieferanten der zahnärztlichen Implantierungsprodukte von Nachteil. Diesen fehlgeschlagenen Behandlungen gehen häufig Komplikationen in den unterschiedlichsten Behandlungsphasen voraus. Die frühzeitige Entdeckung derartiger Komplikationen, die sofortige Abhilfsmaβnahmen zur eventuellen Rettung des Implantats erforderlich machen, könnte über Erfolg oder Fehlschlagen der Implantierungsbehandlung entscheiden. Die vorliegende Prüfungsunterlage setzt sich kritisch mit Diagnoseverfahren, Einteilungsmechanismen sowie Behandlungsaspekten der allgemein bei Routineverfahren unter Implantateinsatz beobachteten Komplikationen auseinander.
SCHLÜSSELWÖRTER: Zahnimplantate, Fehlschlagen der Implantierung, Behandlung, Einteilung
AUTOR(ES): Sang-Hoon Park, DDS* y Hom-Lay Wang, DDS, MSD**. *Residente Graduado, Periodóntica/Prevención/Geriátrica, Facultad de Odontología, Universidad de Michigan, Ann Arbor, MI, EE.UU. **Profesor y Director de Periodóntica Graduada, Departamento de Periodóntica/Prevención/Geriátrica, Facultad de Odontología, Universidad de Michigan, Ann Arbor, MI, EE.UU.. Correspondencia a: Hom-Lay Wang, DDS, MSD, Professor y Director of Graduate Periodontics, University of Michigan, School of Dentistry, 1011 N. University Ave., Ann Arbor, Michigan 48109-1078, U.S.A. Teléfono: (734) 763-3383, Fax: (734) 936-0374. Correo electrónico:[email protected]
Complicaciones reversibles de los implantes: Clasificación y tratamientos
ABSTRACTO: Las fallas de los implantes dentales son perjudiciales para los pacientes y los profesionales dentales. Estas fallas a menudo se ven precedidas por complicaciones a distintos niveles de las fases del tratamiento. La detección temprana de las complicaciones que pueden solucionarse con terapias de rescate pueden invertir el destino del implante. Esta revisión explica el diagnóstico, clasificación y aspectos de atención de las complicaciones reversibles que se encuentran comúnmente durante los procedimientos relacionados con los implantes dentales de rutina.
PALABRAS CLAVES: implantes dentales, fallas, atención, clasificación
AUTOR(ES): Sang-Hoon Park, Cirurgião-Dentista e Hom-Lay Wang, Cirurgião-Dentista, Médico**. *Residente Graduado, Periodontia/Prevenção/Geriatria, Escola de Odontologia, Universidade de Michigan, Ann Arbor, MI, USA. **Professor e Diretor de Periodontia Graduada, Departamento de Periodontia/Prevenção/Geriatria, Escola de Odontologia, Universidade de Michigan, Ann Arbor, MI, USA. Correspondência para: Hom-Lay Wang, DDS, MSD, Professor and Director of Graduate Periodontics, University of Michigan, School of Dentistry, 1011 N. University Ave., Ann Arbor, Michigan 48109-1078, USA. Telefone: (734) 763-3383, Fax: (734) 936-0374. E-mail:[email protected]
Complicações Reversíveis de Implante: Classificação e Tratamentos
RESUMO: As falhas nos implantes são prejudiciais tanto aos pacientes quanto aos dentistas. Essas falhas são freqüentemente precedidas de complicações em diferentes níveis das fases de tratamento. A detecção precoce das complicações que são receptivas a terapias de resgate pode reverter o destino do implante. Esse artigo de revisão discute aspectos de diagnóstico, classificação e gestão das complicações reversíveis comumente encontradas durante os procedimentos de rotina relacionados a implantes dentários.
PALAVRAS-CHAVE: implantes dentários, falhas, gestão, classificação
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