CLINICAL

Influence of Prognostic Risk Indicators

on Osseointegrated Dental Implant
Failure: A Matched Case-Control Analysis
Rami Alissa, PhD1*
Richard J. Oliver, PhD2

Dental implant treatment is an important therapeutic modality with documented long-term

success for replacement of missing teeth. However, dental implants can be susceptible to
disease conditions or healing complications that may lead to implant loss. This case-control
study identified several risk indicators associated with failure such as smoking and alcohol
consumption. The use of postoperative antibiotics or wide-diameter implants may
significantly reduce implant failure. Knowledge of patient-related risk factors may assist the
clinician in proper case selection and treatment planning.

Key Words: dental implants, risk indicator, case-control, implant failure

INTRODUCTION implant biomaterial and characteristics of

T
he predictability of osseointe-
grated root form implants with
well-documented and long-term
functional and esthetic outcomes
has led to their acceptance as
a practical treatment modality in modern
dentistry for rehabilitation purposes in fully
edentulous and partially dentate patients, or
for single-tooth replacement.
The success of implant treatment and
maintenance of its highly desirable out-
comes are dependent upon several prereq-
uisites to accomplish a dynamic association
of functional and esthetic results. These
factors may include adequacy of bone
quantity and quality, biocompatibility of
1
Oral and Maxillofacial Surgery, School of Dentistry, The
University of Manchester, Manchester, UK.
2
Oral and Maxillofacial Surgery, School of Dentistry, The
University of Manchester, Manchester, UK.
*Corresponding author, e-mail: cloudyeye86@hotmail.
com
DOI: 10.1563/AAID-JOI-D-10-00086
implant surface, absence of surgical compli-
cations, absence of peri-implantitis, and pre-
vention of excessive loading. Moreover,
direct and indirect systemic factors that
influence the host response appear to be
of great relevance to the prediction of risk
groups for implant loss.1
Despite a few contraindications and a
documented long-term success rate, it is
widely recognized that dental implants
sometimes can be susceptible to healing
complications or disease conditions that
eventually may result in implant loss.2 Thus,
the focus of implant research has shifted
from demonstrations of clinical success to
more specific attempts at identification of
factors that may contribute to implant
failure.3
The aim of this study was to identify risk
indicators associated with patients with at
least one implant failure using a case-control
study design.

Journal of Oral Implantology 51

Risk Indicators of Dental Implant Failure
MATERIALS AND METHODS
Strengthening the Reporting of Observa-
tional Studies in Epidemiology (STROBE)
guidelines4 were followed in reporting this
case-control study.
Inclusion and exclusion criteria
All patients who had implants placed and
restored at the University Dental Hospital of
Manchester, Manchester, UK, between Feb-
ruary 2000 and December 2006 were eligible
for inclusion in the study, regardless of
medical health status, age, gender, or race.
Only one inclusion criterion was required for
the study group, namely, that participants
had had at least 1 failed implant that was
removed or lost/exfoliated, although for the
control group, no implant losses should have
occurred during the study period. Exclusion
criteria included inadequate or unavailable
patient records.
Case-control matching criteria
Control subjects were selected so that they
resembled the cases with regard to the
following characteristics:
N Cases and controls had the same number
of implants, which were placed in the same
year.
N Cases and controls were the same age and
gender.
N All cases that had been treated with implants
in combination with bone augmentation
were matched to controls that had under-
gone the same augmentation procedures.
Study variables
General Health Status Variables
The following were recorded: smoking
habits, alcohol consumption or other illicit
drug use, and medical conditions that may
compromise wound healing including im-
munosuppression, diabetes mellitus, system-
ic steroid treatment, osteoporosis, previous
chemotherapy, and radiotherapy treatment.
52 Vol. XXXVIII/No. One/2012
Anatomic variables
These included opposing dentition in rela-
tion to the implant (natural teeth, removable
denture, fixed prosthesis, or implant-sup-
ported prosthesis) and implant location in
the maxilla and mandible (anterior and
posterior sectors: anterior implants were
considered when placed in the region of
incisors and canines, posterior implants were
regarded as those positioned in the region of
premolars and molars).
Antibiotics and Chlorhexidine Use
These included the type, dose, and frequen-
cy of chemotherapeutic agents, such as
antibiotics and analgesics, taken postopera-
tively. A minimum of a 5-day treatment
course recorded on the patient’s prescription
was required for investigators to consider
that the patient had received antibiotics.
Chlorhexidine use was a variable recorded
only if both preoperative and postoperative
use was clearly noted by clinicians.
Implant and abutment-specific variables
The number of placed implants, the implant
system used, and the dimensions of the
implant and abutment (length and diameter)
were recorded.
Prosthetic variables
These were grouped into two main catego-
ries: removable (overdentures) and fixed
(bridge or single-crown restorations).
Clinical events
Any abnormal incidents that had occurred
during implant placement or the healing
period were recorded (cortical plate perfo-
ration, exposed implant surface, lack of
primary stability, and bone graft–related
complications). Whether problems (infec-
tion, pain, paresthesia, dehiscence, and
cover screw loosening) were encountered
before exposure of the implants was also
recorded.

Peri-implantitis
Peri-implantitis was recorded when clinical
manifestations of peri-implantitis such as
suppuration, bleeding on probing, redden-
ing of the peri-implant mucosa, pain on
percussion, increased depth of the peri-
implant pocket, mobility, and radiographic
evidence of advanced bone loss around the
implant were noted in the patient’s clinical
records.
Timing of implant removal
The primary outcome in this study was im-
plant failure. Failure was defined as removal
of the implant for any reason.5 Failure was
grouped into five categories according to
timing (failed before exposure, failed at
exposure, failed between exposure and res-
toration, failed during the first year of loading,
failed after the first year of loading).
Sample size calculation
A 2-group continuity corrected x2 test with a
2-sided significance level of .05 would have
80% power to detect a difference in implant
failure between a proportion of 0.390 and a
proportion of 0.100 (odds ratio, 0.174) when
sample sizes were 25 and 73, respectively
(total sample size, 98). The significance of the
association between implant failure and each
potential risk indicator would be determined
by the x2 test at a .05 level of significance. The
appropriate odds ratio would be calculated
for each variable.
Statistical analyses
Data obtained were processed with the
Statistical Package for the Social Sciences
(SPSS) for Windows, version 15 (SPSS Inc,
Chicago, Ill). Basic data analysis including
descriptive statistics (frequency distribution,
cross tabulations, and x2 tests) was used to
produce a table of frequency counts and
percentages for all values associated with
each variable included in this study, and to
examine the association between variables.
Alissa and Oliver
In addition, independent sample t tests were
used to compare the average sizes of im-
plants and abutments between cases and
controls. Logistic regression was used in this
study because the implant failure outcome
variable was binary (yes or no), and predictor
variables were both categorical and contin-
uous. Associations between smoking, alco-
hol consumption, postoperative antibiotics,
chlorhexidine use, peri-implantitis, number
of implants, implant length, implant diame-
ter, abutment height, abutment diameter,
type of prosthesis, opposing dentition, and
implant failure were evaluated by fitting a
univariate logistic regression model for each
variable. Risk factors based on univariate
analyses were then entered into a multivar-
iate logistic regression model that was
adjusted for inclusion of age, sex, number
of implants, and bone grafting, to estimate
odds ratios and corresponding 95% confi-
dence intervals for each variable.
RESULTS
Between February 2000 and December 2006,
a total of 663 patients were provided with
dental implants at the hospital, and 31
patients who had failed implants were
identified. However, only 22 patients were
suitable for inclusion in this study owing to
inadequacy of required data in patient
records, or the fact that it was not feasible
to find matched controls according to
proposed case-control matching criteria.
Twenty-two patients who had experi-
enced a loss of at least one implant (study
group) were matched to 61 patients who did
not lose any implants (control group). Eigh-
teen cases were matched with 54 controls
(ratio, 1:3). Three cases were matched to 6
controls (ratio, 1:2), and 1 case was matched
to 1 control (ratio, 1:1) because it was not
possible to find 3 matching controls.
In the study group, a total of 78 implants
were inserted in 22 patients; of these, 33
Journal of Oral Implantology 53
Risk Indicators of Dental Implant Failure

TABLE 1
Characteristics of case group patients and failed implants*
No. of
Alcohol Failed Implant Length, Diameter,
Case Age, y Sex Smoking Consumption Implants Location System mm mm

1 44 F Yes Moderate 1 Ant mand Astra 11 3.5

2 56 M Yes Non 1 Post mand F-II 10 5.5
3 50 M Yes Heavy 1 Post mand F-II 13 3.8
4 24 F No Non 1 Post mand F-II 13 3.8
5 31 F Yes Moderate 1 Ant mand IMZ 10 3.3
6 25 F Yes Moderate 1 Post mand F-II 11 3.4
7 22 F Yes Moderate 1 Ant max F-II 11 3
8 40 M Yes Moderate 1 Ant max F-II 13 4.5
9 55 M Yes Non 2 Ant mand IMZ 11 4
10 56 M Yes Non 2 Ant mand F-II 10 3.4
11 24 F No Non 1 Post mand F-II 13 3.8
12 59 M No Non 1 Ant mand IMZ 15 4
13 62 F No Non 1 Ant mand IMZ 10 3.3
14 87 F No Non 1 Ant mand F-II 10 3.8
15 49 F Yes Heavy 1 Ant mand F-II 13 3.8
16 39 F Yes Moderate 2 Ant mand IMZ 15 4
17 76 F No Non 1 Ant mand Astra 13 3.5
18 62 M Yes Heavy 5 Ant mand IMZ 13 3.3
19 53 F No Non 1 Ant max F-II 13 3.4
20 67 M Yes Moderate 2 Post mand F-II 8 5.5
21 74 M Yes Non 4 Post mand F-II 15 3.8
22 87 F No Non 1 Ant max F-II 10 3.8

*Ant indicates anterior; Astra, Astra Tech, Mölndal, Sweden; F-II, Frialit-II, Friatec, Mannheim,
Germany; Heavy, .5 units daily consumption; IMZ, IMZ, Friedrichsfeld AG, Mannheim, Germany; mand,
mandible; max, maxilla; Moderate, 2–5 units daily consumption; Non, nondrinker; Post, posterior.

(42.3%) implants were lost, whereas in the
control group, 212 implants were inserted in
61 patients and none were lost. Of 83
patients included in the study, 32 (38.6%)
were males and 51 (61.4%) were females,
with a mean age of 51 years (range, 21–
87 years; SD 5 18.7). The largest percentage
of individuals corresponded to the 41–60
year age range. No statistically significant
differences in implant failure between older
(.60 years) and younger patients (P 5 .98),
or between males and females (P 5 .80),
were observed as expected owing to match-
ing of cases and controls. Certain character-
istics of case group patients and of failed
implants are summarized in Table 1.
Most subjects in study group 14 (63.6%)
and control group 44 (72.1%) were healthy,
with no illnesses or medical conditions noted
in the medical records. Although well con-
trolled, diabetes mellitus and cardiovas-
cular conditions were the most frequently
observed conditions, and several conditions
were found in the selected population,
although in small prevalences. A summary
of the medical history of cases and controls
is provided in Table 2. No statistically signif-
icant difference in implant failure was found
between patients with and without systemic
conditions (P 5 .19). On the other hand, a
significant difference in implant failure was
noted between smokers and nonsmokers
(P 5 .004). Similarly, heavy drinkers (.5 units/
d) had a statistically higher percentage of
implant failure compared with nondrinkers
and patients who reported consumption
of a lesser amount of alcohol (,5 units/d)
(P 5 .002).
Jaw site (maxilla and mandible in their
anterior and posterior sectors) was not signi-
ficantly related to implant failure as failure
was considered per patient (P 5 .21).
No significant difference was observed
between groups with respect to bone

54 Vol. XXXVIII/No. One/2012

 Alissa and Oliver

TABLE 2
Summary of the medical history of the study population
General Health Condition Case Control Total

Healthy 14 (63.6%) 44 (72.1%) 58 (69.9%)

Rheumatic disease 0 (0%) 1 (1.6%) 1 (1.2%)
Diabetes mellitus 1 (4.5%) 4 (6.6%) 5 (6%)
Other endocrine disorders 0 (0%) 1 (1.6%) 1 (1.3%)
Irradiation 1 (4.5%) 0 (0%) 1 (1.2%)
Parkinson disease 1 (4.5%) 0 (0%) 1 (1.2%)
Cardiovascular conditions 0 (0%) 5 (8.2%) 5 (6%)
Mandibular fracture 1 (4.5%) 0 (0%) 1 (1.2%)
Oral cancer 2 (9.1%) 1 (1.6%) 3 (3.6%)
Hip replacement 0 (0%) 3 (4.9%) 3 (3.6%)
Sjögren’s syndrome 1 (3.8%) 0 (0%) 1 (1.1%)
Diabetes mellitus and irradiation 1 (4.5%) 0 (0%) 1 (1.2%)
Personal grief and depression 0 (0%) 1 (1.6%) 1 (1.2%)
Bruxism 0 (0%) 1 (1.6%) 1 (1.2%)
Total 22 (100.0%) 61 (100.0%) 83 (100.0%)

grafting (P 5 .92). Autogenous bone har-
vested from the iliac crest was most fre-
quently used (90%) for reconstruction of the
atrophic mandible and maxilla.
Although most patients (16; 72.7%) in-
cluded in the study group had implants
opposed by natural dentition or an implant-
supported prosthesis, no significant influence
of type of opposing dentition on implant
failure was found (P 5 .31).
Although a significant difference was ob-
served between patients who had and those
who did not have postoperative antibiotics
with respect to implant failure (P 5 .04),
chlorhexidine use did not significantly influ-
ence implant failure (P 5 .46).
The fixtures were rehabilitated with 11
single crowns and bridges and 11 dentures
in the case group, and with 25 single crowns
and bridges and 36 dentures in the con-
trol group. The type of prosthesis (fixed vs
removable) used to restore implants did not
have a significant effect on implant failure
(P 5 .46).
The number of placed implants did not
influence implant failure (P 5 .99). Approx-
imately two-thirds of cases experienced 1
failure, and only 2 patients lost 4 or 5
implants, respectively.
Whereas the most frequently used im-
plant system in the case group was Frialit-II
(87.5%), the Astra system was used in most
controls (76.7%). Other systems were con-
sidered but were excluded from the final
model as they were rarely used; these
included IMZ (7.2%) and 3i (1.2%).
The mean length of the inserted implants
was 12.2 mm (minimum 10 mm, maximum
15 mm) for the study group, and 12.8 mm
(minimum 9 mm, maximum 15 mm) for the
control group. This means that approximate-
ly 0.6 mm longer implants were inserted in
the control group compared with the study
group. However, this difference between
groups was not statistically significant (t test,
P 5 .17). By contrast, the diameter of the
implant was found to significantly influence
implant failure (t test, P 5 .001); the average
diameter in the case group was 3.7 mm, and
in the control group, 4.1 mm. As far as the
abutment size is concerned, no significant
differences were found between cases and
controls with respect to the height (t test,
P 5 .07) or diameter (t test, P 5 .37) of
abutments.
Statistical analysis of notes made at the
appointment of implant placement or during
the subsequent healing period revealed that
the total frequency of abnormal incidents
registered in the case group (36.4%) was
more than twice that of the control group
(14.8%). However, the difference was not

Journal of Oral Implantology 55

Risk Indicators of Dental Implant Failure

TABLE 3
Abnormal incidents in records
Case Control Total

Nothing recorded 14 (63.6%) 52 (85.2%) 66 (79.5%)

Bone overheating 1 (4.5%) 0 (0%) 1 (1.2%)
Cortical plate perforation 2 (9.1%) 2 (3.3%) 3 (3.6%)
Exposed implant surface 2 (9.1%) 4 (6.6%) 6 (7.2%)
Lack of primary stability 3 (13.6%) 3 (4.9%) 6 (7.2%)
Bone graft–related complications 1 (4.5%) 0 (0%) 1 (1.2%)

TABLE 4
Problems encountered before exposure
Case Control Total

Nothing recorded 11 (50%) 56 (91.8%) 67 (80.7%)

Infection 2 (9.1%) 0 (0%) 2 (2.4%)
Pain 1 (4.5%) 1 (1.6%) 2 (2.4%)
Paresthesia 0 (0%) 2 (3.3%) 2 (2.4%)
Wound dehiscence 1 (4.5%) 1 (1.6%) 2 (2.4%)
Cover screw loosening 3 (13.6%) 1 (1.6%) 4 (4.8%)
Pain and paresthesia 1 (4.5%) 0 (0%) 1 (1.2%)
Paresthesia and cover screw loosening 2 (9.1%) 0 (0%) 2 (2.4%)
Paresthesia and wound dehiscence 1 (4.5%) 0 (0%) 1 (1.2%)

TABLE 5
Association between occurrence of complications before exposure and postoperative
antibiotic use
No Antibiotics Antibiotics Total

No registered complications Case 4 (36.4%) 7 (63.6%) 11 (100%)

Control 46 (85.2%) 8 (14.8%) 54 (100%)
Total 50 (76.9) 15 (23.1%) 65 (100%)
Complications Case 10 (90.9%) 1 (9.1%) 11 (100%)
Control 4 (80%) 1 (20%) 5 (100%)
Total 14 (87.5%) 2 (12.5%) 16 (100%)

statistically significant between groups (P 5 .002). The frequency of complications before

.14). Table 3 summarizes the frequencies of
abnormal incidents. On the other hand,
implant failure was significantly related to
the presence of complications that occurred
before exposure (P 5 .001). Although half of
cases experienced 1 or more of the compli-
cations listed in Table 4, only 5 (8.2%)
controls were associated with occurrences
of such problems. Associations between the
frequency of these complications and the
use of postoperative antibiotics were also
studied. It was observed that postoperative
antibiotic administration was significantly
associated with fewer complications encoun-
tered during the early healing period (P 5
exposure in relation to use of postoperative
antibiotics is demonstrated in Table 5.
Fifteen of 22 cases (68.2%) showed signs
of infection and were diagnosed with peri-
implantitis, whereas none of the controls
had peri-implantitis. A highly significant
difference (P , .001) for peri-implantitis
was found between patients with failed
implants and matched controls.
As far as the timing of implant failure is
concerned, the incidence of failure among
cases was 41% before loading (early failures)
and 59% after loading (late failures). More
than half of the late failures (54.5%) occurred
after the first year of function.

56 Vol. XXXVIII/No. One/2012

 Alissa and Oliver

TABLE 6
Logistic regression model analyses for risk factors associated with implant failure*
OR (95% CI)! P Value` OR (95% CI)! P Value`

Smoking 0.14 (0.05, 0.41) ,.001 0.01 (0.03, 0.34) ,.001

Alcohol 0.23 (0.09, 0.59) ,.001 0.19 (0.07, 0.55) ,.001
Postoperative antibiotics 0.36 (0.10, 0.97) ,.001 0.28 (0.09, 0.91) ,.001
Chlorhexidine 0.57 (0.12, 2.59) .46 0.51 (0.10, 2.58) .46
Bone graft 0.95 (0.36, 2.54) .92 0.86 (0.24, 3.13) .92
Implant number 0.97 (0.73, 1.31) .86 0.99 (0.70, 1.39) .86
Prosthesis 1.44 (0.54,3.83) .47 2.94 (0.63,13.68) .46
Opposing dentition 1.73 (0.59, 5.04) .31 2.15 (0.65, 7.12) .31
Implant length 1.24 (0.91, 1.68) .17 1.25 (0.92, 1.76) .14
Implant diameter 13.57 (2.66, 69.22) ,.001 15.41 (2.99, 79.56) ,.001
Abutment height 2.10 (0.91, 4.81) .08 2.25 (0.92, 5.41) .08
Abutment diameter 1.41 (0.62, 3.61) .37 1.75 (0.65, 4.69) .27

*Total number of patients 5 83 patients; total number of implants 5 290 implants.

!OR indicates odds ratio; CI, 95% confidence intervals.
`P value indicates P value from multiple logistic regression analyses with age, sex, number of
implants, and bone grafting included as explanatory.

Univariate logistic regression associations placement, and reconstructive surgery (bone

between study variables and implant failure
indicated that variables associated with im-
plant failure (P , .001) included current tobac-
co use, heavy alcohol consumption, use of
postoperative antibiotics, and implant diame-
ter. Moreover, in the multivariate regression
model with age, gender, bone graft, and
number of placed implants included in the
analysis, all variables already found related
to implant failure in the univariate model
remained statistically associated with implant
failure. A summary of univariate and multivar-
iate logistic regression results can be found
in Table 6.
DISCUSSION
The purpose of this study was to identify
risk indicators associated with implant fail-
ure in a sample of patients treated at the
University Dental Hospital of Manchester. To
reduce bias when case and control groups
were compared, patients in the control
group were matched to the study group.
This indicates that control patients were
identified and then were included in such a
way that both groups were as identical
as feasible with regard to age, gender, num-
ber of placed implants, timing of implant
grafting procedures).
In the study group, 41% of cases lost
their implants before loading (early failures)
and 59% after loading (late failures), with
more than half of late failures occurring
after the first year of function. This is in
accordance with results reported by Esposito
et al6 in a meta-analysis of several studies,
indicating a chronological distribution of
47% as early and 53% as late failures, of
which 55% were detected after the first year
of loading. This observation also supports
several reports indicating that a higher rate
of late implant failure accounted for the
incidence of disease conditions such as peri-
implantitis that eventually may lead to im-
plant loss.3 It is believed that this disease
may require a certain time to reach clinical
significance and an even longer period to
necessitate removal of the implant. There-
fore, it is more likely to predict that the
hazard rate for implant failure may increase
as longer observation times are applied. In
this study, the higher incidence of this
condition for failed implants as compared
with successful implants was positively clear.
Clusterization is a technical term used to
describe the phenomenon in which a few
individuals can concentrate risk for implant

Journal of Oral Implantology 57

Risk Indicators of Dental Implant Failure
failure and subsequently experience multiple
losses. In the present study, the prevalence
of clustered failure was observed in 6 (27.8%)
of the cases. A combination of the presence
of peri-implantitis or illness (diabetes melli-
tus) and heavy smoking habits could explain
implant failure in these subjects. These obser-
vations suggest the existence of systemic
factors that may affect the survival of all
implants within a given patient, leading to
multiple implant failures. This finding is con-
sistent with those of other studies.7,8
No statistically significant difference
among patients was observed for age. Lack
of association between implant failure and
age was previously reported.9 Although
males were more prone to lose implants in
previous investigations,10,11 female gender
was considered by other authors to be a risk
factor for implant failure.12,13 Consistent with
other reports in the literature,14,15 no signif-
icant association was found between patient
gender and implant failure in the selected
sample of patients.
Several medical conditions that were
recorded in the study group such as diabetes
mellitus and Sjögren’s syndrome were found
by some authors to play an important role
in early implant failure.16,17 However, general
health conditions did not significantly influ-
ence implant failure observed in the present
study. This observation is in accordance with
the findings of 2 larger studies18,19 and a
consensus review of the literature.1
The adverse effect of smoking on the
peri-implant tissue condition has been de-
scribed in a number of studies.20,21 In the
present study, a statistically significant dif-
ference was noted between smokers and
nonsmokers with regard to implant failure.
This may be explained by the detrimental
effect of smoking on the wound healing
process, particularly in the early stage of
osseointegration.
As far as alcohol consumption is con-
cerned, individuals who routinely consume
58 Vol. XXXVIII/No. One/2012
alcohol may experience a delay in the
healing of surgical wounds, as consumption
of alcohol was found to be associated with
deficiencies in the complement system and
suppression of activation and proliferation
of T lymphocytes, as well as with adher-
ence, mobility, and phagocytic activity of
monocytes, macrophages, and neutrophils.22
Moreover, certain substances contained in
alcoholic drinks such as ethanol and nitro-
samines may cause bone resorption and
interfere with the stimulation of new bone
formation.23 In the present study, it was
observed that alcohol consumption was
significantly associated with implant failure.
Characteristics of bone quality and quan-
tity at the implantation site in relation to
anatomic location are among those factors
that seem to significantly influence implant
failure.24 However, several authors25,26 ob-
served no significant differences when com-
paring the failure rates of both jaws, or of
the anterior and posterior zones. In contrast,
other authors27,28 reported different results,
indicating higher failure rates for implants
placed in the maxilla and in posterior seg-
ments of both jaws. In this study, no signifi-
cant differences in failure rate were recorded
between the maxilla and the mandible.
The effectiveness of the prophylactic use
of antibiotics in conjunction with implant
surgery and its correlation with success or
failure rates are poorly investigated in the
literature; a lack of randomized controlled
clinical trials is documented. It has been
suggested that little or no benefit is derived
by providing antibiotic coverage for implant
placement.29 On the other hand, Dent et al30
reported that significantly fewer failures
occurred when preoperative antibiotics were
used. Although evidence-based support is
still missing, a recent Cochrane review31
reported that some evidence suggests that
a single oral dose of 2 g of amoxicillin given
preoperatively an hour before implant place-
ment can significantly reduce failure of

dental implants. In the present study, a
significant difference was found, with fewer
patients experiencing implant losses when
prescribed antibiotics postoperatively as com-
pared with patients who had not received any
antibiotics. This was further supported by the
finding of a significant decrease in occurrence
of complications during the early healing
period when patients had received postoper-
ative antibiotics.
A review of the literature6 found that the
success rates of implants placed in the
setting of reconstructive grafting proce-
dures ranged from 60%–100%. Based on
the inconsistency of these reported esti-
mates of implant survival, it is reasonable to
doubt whether the bone graft itself is an
independent risk factor for implant failure.
Similar to other studies,14,32 no negative
influence for bone grafts on implant failure
was observed in the present study. In con-
trast, in a retrospective investigation,33 a
possible correlation between multiple implant
failures in bone-grafted patients and relative
bone mass density was observed. Further-
more, it was suggested that implant failure
might be related to the complexity of the
procedure and to the presence of bone graft–
related complications.6 These complications
were recorded in only 1 of 37 patients (44.6%)
who underwent reconstructive procedures. In
addition, the delayed approach used in the
present study, which allowed for at least
3 months of healing time before implant
placement, was believed to provide time for
graft maturation and might have resulted in
greater predictability of the treatment, espe-
cially when the residual ridge was insufficient
for initial implant stability. Moreover, it could
be hypothesized that delayed implant inser-
tion in a 2-stage surgical approach might have
permitted implant placement in more ideal
positions and angulations after reconstruction
of the deficient implant site.
It is generally agreed that greater implant
length and diameter may increase the contact
Alissa and Oliver
surface area at the bone-to-implant inter-
face, subsequently resulting in better survival
rates.34 Nevertheless, several authors17,35,36
failed to observe this association. In the pres-
ent study, implant failure was significantly
associated with implant diameter but not
with implant length. Moreover, no associa-
tions were found between abutment size
(height and diameter) and implant failure. The
correlations between implant or abutment
size and implant failure in relation to qualities
of the specific implant placement site (thick-
ness, height, density) and prosthetic needs
were not studied. Also, several implant sys-
tems with different surface characteristics
were included. These factors should be kept
in mind when results of this study are
interpreted.
Outcomes derived from well-designed
retrospective studies are important for clin-
ical knowledge that constitutes a reference
point for specialists in planning, performing,
and subsequently evaluating dental implant
procedures. However, retrospective studies
rely on the completeness and validity of data
entered into patient records.37 Although
data in patient records may be misfiled,
misplaced, discarded, or simply missing, this
lack of information was not a major restrict-
ing issue in this study. Fortunately, note
entries were made by a small number of staff
members at the implant clinic, where a
standardized and efficient approach is put
in place to ensure appropriate registration of
information included in the patient notes.
Nevertheless, the possibility of incomplete
recording of information persists but is
thought not to be statistically significant
owing to the availability of key variables of
interest in this study of risk factors related to
implant failure.
With regard to statistical data analyses in
this study, an appropriate multivariate re-
gression analysis was necessary for better
control of confounding factors with a great
emphasis on a sound study design and
Journal of Oral Implantology 59
Risk Indicators of Dental Implant Failure
appropriate case-control matching criteria.
Despite robust statistical analyses of dental
implant failure data, conclusions that can be
drawn from retrospective studies may be
limited in terms of generalization to a larger
population. A limitation of this study is the
descriptive definition of implant failure used
in this study, that is, implant removal for
any reason. Although definite, this did not
address situations such as the nonfunctional
implant, the nonrestorable implant, the
failing implant, the implant associated with
progressive subtle bone loss without clini-
cally detectable mobility, or patient satisfac-
tion. Unfortunately, in the setting of this
study and given its retrospective design, it
was not feasible to consistently ascertain
implant failure in terms other than implant
removal. The retrospective nature of this
report should be taken into consideration
when its results are interpreted; prospective
case-control studies may be more appropri-
ate and are needed to assess the risk of
implant failure in conjunction with identified
predictors.
CONCLUSIONS
Improving knowledge about the risk factors
associated with implant failure is of clinical
value in improving implant treatment out-
comes. Knowledge of patient-related factors
may help the clinician in patient selection,
treatment planning, and obtaining appropri-
ate consent of a patient for treatment. Equally
important, careful preoperative assessment of
implant-based risk could be useful in confi-
dently selecting the type, size, location, and
number of implants and in precisely design-
ing the prosthesis according to individual
prosthetic requirements. In summary, this
study identified smoking and alcohol con-
sumption as risk factors for implant failure. It
was also found that the use of postoperative
antibiotics or wide-diameter implants may
reduce implant failure.
60 Vol. XXXVIII/No. One/2012
ABBREVIATIONS
STROBE: Strengthening the Reporting of
Observational Studies in Epidemiology
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