Restorative Dentistry

Enhanced CPD DO C

Vanessa Sousa

Víctor Beltrán, Nikos Mardas, Lochana Nanayakkara and Nikolaos Donos

Treatment of Peri-implantitis:
Fiction or Reality?
Part 1: Non-surgical and
Surgical Management
Abstract: Peri-implantitis is a biological complication characterized by an inflammatory process affecting the soft and hard tissues around
an osseo-integrated load-bearing implant. Clinically, it results in progressive bone loss, pocket formation, bleeding and/or suppuration and
leads to implant loss. Although the main aetiological factor is bacterial biofilms, the clinical presentation and progression of peri-implantitis
is exacerbated by several local, systemic and iatrogenic factors. Treatment protocols of peri-implantitis include various decontamination
procedures of the exposed implant surface. In this two-part series, we will review the available evidence for the non-surgical and surgical
management of peri-implantitis (Part 1), and then we will discuss various modalities for implant surface decontamination (Part 2).
CPD/Clinical Relevance: The pre-operative risk identification and management at both patient and site level, early diagnosis and regular
supportive peri-implant care are fundamental for long term implant success and survival.
Dent Update 2023; 50: 731–738

A classification for peri‐implant health

Vanessa Sousa, DDS, MJDFRCS, CertPerio, MS, MPerioRCS, MA, FHEA, FCGDent, FDSRCS,
and diseases was published in 2018 and
PhD, Clinical Lecturer and Honorary Consultant in Periodontology, Periodontology Unit,
subsequently modified in 2023 (Table 1).1,2
Centre for Host–Microbiome Interactions, Faculty of Dentistry, Oral and Craniofacial
Peri‐implant health is characterized by the
Sciences, King’s College London, Guy’s and St Thomas’ NHS Foundation Trust; Specialist
absence of: erythema; bleeding on probing;
Practitioner, Private Practice, London. Víctor Beltrán, DDS, MS, PhD, Associate Professor
swelling; and/or suppuration. However, it
in Periodontology and Implant Dentistry, Postgraduate Academic Dean, Director of
is not possible to define a range of probing
Clinical Investigation and Dental Innovation Center, Institute of Dentistry, Universidad
depths compatible with health.1
de La Frontera, Temuco, Chile; Specialist Practitioner, Private Practice, Temuco,
Peri‐implant mucositis is mainly
Chile. Nikos Mardas, DiplDS, MS, PhD, Clinical Reader and Honorary Consultant in
characterized by bleeding on gentle
Periodontology, Undergraduate Periodontology Lead, Centre for Immunobiology probing, a decrease in probing resistance,
and Regenerative Medicine, Centre for Oral Clinical Research, Institute of Dentistry, erythema, swelling, and/or suppuration.1
Queen Mary University of London; Specialist Practitioner, Private Practice, London. Peri‐implantitis was defined as a plaque‐
Lochana Nanayakkara, BDS, MJDFRCS, MS, FDSRCS, Consultant in Restorative Dentistry, associated pathological condition occurring
Director of Dental Education, Royal London Hospital, Barts Health NHS Trust; Honorary in tissues around dental implants, which
Senior Lecturer, Co-Lead for DClinDent Programme in Prosthodontics, Institute of Dentistry, is characterized by inflammation and
Queen Mary University of London; Specialist Practitioner, Private Practice, London. progressive loss of supporting bone.1
Nikolaos Donos, DDS, MS, FHEA, FDSRCS, PhD, Professor of Periodontology and Implant Peri‐implantitis sites show clinical signs of
Dentistry, Honorary Consultant in Periodontology, Director of Research, Director of Centre inflammation, bleeding on probing and/or
for Oral Clinical Research, Institute of Dentistry, Queen Mary University of London; Royal suppuration, increased probing depths and/or
London Hospital, Barts Health NHS Trust; Specialist Practitioner, Private Practice, London. recession of the mucosal margin, in addition
email: [email protected] to radiographic bone loss.1,3

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Peri-implant health Peri-implant mucositis Peri-implantitis

Absence of clinical signs of soft Signs of inflammation Signs of inflammation
tissue inflammation, and no Line or drop of bleeding within 30 seconds following Increased probing depth compared with
increase in probing pocket depth probing probing depth values collected after
compared to previous examinations placement of the prosthetic reconstruction
No BoP BoP BoP
No bone loss* No bone loss* Bone loss*
Following the ID-COSM initiative Following the ID-COSM initiative consensus,2 this In the absence of baseline and/or previous
consensus international consensus definition has been updated to: presence of bleeding examination records:
report,2 this definition has been (more than one spot at a location around the  BoP ± S
slightly modified and allows for the implant or presence of a line of bleeding or profuse  PPD ≥6 mm
presence of a single bleeding spot bleeding at any location) and/or suppuration on  BL ≥3 mm apical of the most coronal
around the implant gentle probing, in the absence of bone loss beyond portion of the IO part of the implant (IP
crestal bone level changes resulting from initial reference for epidemiological studies)
bone remodelling4
Table 1. Peri-implant diseases and conditions: case definitions in clinical practice.1 *Beyond crestal bone-level changes resulting from initial healing. Baseline
radiograph with supra-structure in place. Changes ≥2 mm at any time point during, or after, the first year of function are regarded as pathological. BoP:
bleeding on probing; S: suppuration; PPD: probing pocket depth; BL: bone levels; ID-COSM: Implant Dentistry Core Outcome Set and Measurements; IO:
intra-osseous; IP: implant platform.

Considerations

Patient-specific Periodontal disease (susceptibility/active/Hx), SPC compliance, Applied treatment modalities for peri-
OH self-care, plaque control, smoking, systemic disorders, implantitis1 have hitherto been based on
genetics, DM, medications, stress, Hx radiotherapy in the the assumption of its aetiological similarity
jawbone, craniofacial growth, Hx bruxism to periodontitis, and therefore, anti-infective
protocols, which aim mainly at resolving
Site-specific Percentage of sites with BoP, prevalence of PPD ≥5 mm, inflammation and arresting the disease
periodontal BL in relation to age, endodontic infections, loss progression by controlling the subgingival
of periodontal support, longitudinal root fractures, thin buccal
bacterial biofilm,7 have been adopted for
bone morphotype, gingival tissue thickness, tooth position in
its treatment. For instance, peri-implant
the arch, traumatic XLA, pneumatization of the maxillary sinus
mucositis, a reversible inflammatory
Clinician/procedure DH OH education, motivation, process of peri-implant soft tissues without
monitoring of habits and supporting bone loss,1 can be successfully
lifestyle, SPC treated by supra/submucosal mechanical
debridement, in conjunction with the
Surgeon Professional expertise
administration of local antiseptics and
Prosthodontist Planning, execution and long- preventive measures to reinforce oral
term follow-up hygiene.8,9 Although peri-implant mucositis
Implant/prosthesis Implant prosthesis-related factors (design, contours, shares certain similarities with gingivitis,
restorative margins, fit, excess cement), distance from experimental peri-implant mucositis leads
restorative margin to the bone to a greater increase in bleeding sites
compared with experimental gingivitis, and
Table 2. Risk factors and other considerations for peri-implant diseases and conditions. Hx: history; OH:
oral hygiene; DM: diabetes mellitus; BoP: bleeding on probing; PPD: probing pocket depth; BL: bone
may take longer than 3 weeks for clinical
loss; XLA: extraction; DH: dental hygienist skills and devices; SPT: supportive periodontal care. reversibility.10 Peri-implantitis treatment often
consists of a combination of non-surgical,
submucosal instrumentation, followed by
surgical flap procedures to provide access for
The successful management of peri- pocket depth (PPD) of 5 mm with no BoP debridement and decontamination of the
implantitis is based on the evaluation of may predict the cessation of bone loss and exposed implant surface and, in some cases,
composite therapeutic endpoints that the successful outcome of peri-implantitis with the reconstruction of the resulting
correspond to disease resolution. These therapy.6,7 In addition, secondary outcome osseous defects by means of bone grafting
include the presence of shallow pockets measures such as inflammatory biomarkers and barrier membranes.12 The mechanical
with no bleeding on probing (BoP) or in peri-implant crevicular fluid (PICF) and disruption of the biofilm in both non-surgical
suppuration, and the maintenance of microbiological assessment of subgingival and surgical approaches has been combined
radiographic bone levels. As clinical signs mucosal plaque samples may be used. with the adjunctive use of antibiotics (local/
of pathology are more frequent in implants Currently the treatment of peri- systemic),13 local chemical agents, laser or air-
with progressive bone loss,5 a probing implantitis remains a clinical challenge.6 powder abrasives.14

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a
Peri-implant Endpoints Recommendations for clinicians4
condition (at implant
(treatment phase) level)
Peri-implant ≤1 point of BoP Evaluate these endpoints 2–3 months after the
mucositis and absence intervention, and in presence of ≥2 BoP sites,
treatment of S or ≥1 sites with profuse BoP, or presence of
suppuration, re-treatment should be rendered
Repeat PMPR if the endpoints of therapy have
not achieved within 3 months after PMPR.
Modify endpoints/evaluation times based on
patient's OH, risk factor profile, and prosthesis
b cleansability
Peri-implantitis Residual Evaluate outcome after 6–12 weeks. Monitor
(non-surgical probing depths cases frequently during healing. If goals are not
step) ≤5 mm with achieved: consider additional treatment
no BoP at
Note: Peri-implantitis therapy starts with a non-
more than one
surgical step, followed by re-evaluation and,
point and no
depending on the outcomes, progress to the
suppuration
surgical step or to SPIC
Peri-implantitis ≤1 point of Record clinical parameters 6 months post-
(surgical BoP, absence treatment. Obtain radiographs at 12 months.
treatment) of S, PPD ≤5 Include complication-free survival of the implant
mm, absence and prosthesis and patient satisfaction in long-
of progressive term evaluation
bone loss
Figure 1. (a) Clinical appearance of an implant Note: If non-surgical therapy endpoints (PPD
compared to
affected by peri-implantitis after raising a ≤5 mm and ≤1 point of BoP) are not achieved:
pre-treatment
mucoperiosteal flap. Advanced bone resorption perform surgical therapy
can be observed. Trephine explantation was
performed in order to obtain a small portion
Dental teams providing implant therapy should have the professional expertise
of bone adjacent to the implant. (b) Technical to manage peri-implantitis. Given the complexity of surgical treatment for peri-
histology of plastic inclusion (with x40 toluidine implantitis, it is advisable for it to be conducted by dentists with specialized
blue staining). Inflammatory invasion (TCF: training or by qualified specialists4
fibrous connective tissue) is observed around Table 3. Summary of recommended endpoints and evaluation strategies for the treatment of peri-
a thread of the implant (I) deep in the peri- implant mucositis and peri-implantitis. BoP: bleeding on probing; PMPR: professional mechanical
implant intra-osseous defect (TO: bone tissue). plaque removal; OH: oral hygiene; S: suppuration; PPD: probing pocket depth; SPIC: supportive peri-
Reproduced from Sousa et al.11 implant care.

A recent consensus statement9 has introduced the S3 level clinical practice reconstruction of osseous defect with
indicated that prosthetic overcontouring guideline for the prevention and treatment a bone graft substitute with or without
(emergence angle >30° combined with a of peri-implant diseases, which outlines a membrane.
convex emergence profile of the abutment/ specific therapeutic guidelines and  Post-operative anti-infective control,
prosthesis) is associated with an increased establishes objectives for treatment e.g. chlorhexidine rinses as adjuncts to
risk for peri-implantitis.15 Furthermore, it (Table 3).4 routine oral hygiene practices.
appears that reconstructive peri-implantitis For example, systematic reviews7,19 have  Maintenance care on a regular basis.
treatment may facilitate the maintenance suggested a four-phase treatment strategy
Finally, when faced with the clinical
of post-operative peri-implant soft-tissue for peri-implantitis:
challenge of the failure of a surgical or
levels (Table 2).16  Pre-treatment phase to include regenerative treatment (Figure 1) or with
Therapeutic strategies for the oral hygiene and risk management,
cases of severe bone loss coupled with
management of peri-implant diseases prosthesis assessment, adjustment
possible complications, such as unfavourable
have been described in the literature.17,18 and removal if required, and non-
implant position or prosthetic failures, then
Historically, literature has delineated surgical debridement with or
a cumulative interceptive supportive explantation is recommended.20–22
without antimicrobials.
therapy protocol17 for the prevention and  If resolution is not achieved, surgical Given the complexity of peri-implantitis
management of peri-implant diseases. access is indicated by means of a treatment, it is fundamental to:
Recently, the European Federation mucoperiosteal flap for implant surface  Perform a risk estimation and
of Periodontology (EFP) has recently decontamination and modification or management at patient and site level;23

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Update to inform patients of their individual risk

profile during the consent process. The
Medical, social, dental, history, risk assessment and presenting complaints Implant Disease Risk Assessment (IDRA)
is a risk stratification tool that helps to
Access and record estimate the risk of a patient developing
peri-implantitis.23 Therefore, the decision
Full mouth plaque and bleeding scores, probing pocket depths, presence of calculus whether implant treatment should
and/or cement, bleeding and/or suppuration, recession, presence of wear facets, be performed should be based on an
prosthetic supra-structure, light occlusion, contacts, percussion, mobility (implant and/or assessment of the patient’s risk profile at
prosthesis), behaviour, lifestyle the patient level, as well as at the site level
(Figure 2).25
Compare
Clinical and radiographic records (baseline, previous appointment and current) Non-surgical treatment
of peri-implantitis
Motivate and reinforce Non-surgical mechanical plaque control
could be effective in the treatment of peri-
Primordial, primary, secondary, and tertiary prevention. Promotion of health and
implant mucositis through the reduction
protection from risk, procedures to identify and eliminate early stage of disease and
of bacterial load and inflammation
address the damage caused by disease and to maintain or improve residual function
within peri-implant soft tissues. In peri-
implantitis therapy, non-surgical treatment
Instrumentation protocols are considered the first step of
management, which also serves to optimise
Evidence-based following EFP S3 level clinical practice guidelines, and depending on patient’s oral hygiene, risk factor profile
clinical need4 and marginal tissues for the next phase of
treatment.26 However, various instruments
and approaches, aimed at removing both
Recall intervals
supra- and subgingival biofilm, such as
Based on specific risk factors (patient, systemic, local, implant, prosthesis), ranging from plastic, carbon or titanium curettes, sonic
3 up to 6 months. The higher the risk, the shorter the recall. Post non-surgical treatment or ultrasonic scalers, rubber polishers, and
of peri-implantitis, it is proposed that SPIC be administered every 3–4 months during the air-powder flows, have been proven to be
initial 12 months, beginning at 3 months post-treatment. Following surgical intervention insufficient to ensure complete removal
for peri-implantitis, it is advised that SPIC be administered every 3–4 months during the of bacteria on implant surfaces, and have
first 12 months, beginning at 3 months post-surgery4 only a moderate short-term effect on the
Figure 2. Framework for supportive periodontal and peri-implant care in patients with dental improvement of clinical parameters (such
implants. SPIC: supportive peri-implant care. as a reduction in PPD),9,27,28 radiographic
or microbiological outcomes (Figure 3).9
a b
In addition, the effect of the cleaning
methods on different implant surfaces,
such as the use of plastic scalers, titanium
brushes and air-abrasive systems, may lead
to surface topography modifications on
rough and smooth titanium implants.
Despite evidence that some specific
surface decontamination protocols may
be effective in reducing bacterial load,
Figure 3. Scanning electron microscopy images showing (a) microcosm biofilms grown on top of clinical pocket depths and peri-implant
machined titanium discs (scale bar: 5 µm, magnification ×5000), and (b) machined titanium surfaces mucosal inflammation, non-surgical
following decontamination employing titanium brushes (scale bar: 2 µm, magnification ×10,000). treatment of peri-implantitis has often
Reproduced from Sousa et al.30 been reported as insufficient for disease
resolution. Moreover, one study reported
that 11% of patients had at least one
implant removed during surgical treatment
 Discuss relevant information on the  Highlight the importance of regular
of peri-implantitis or at some time point
periodontal status of the remaining and thorough maintenance (supportive after surgery because peri-implantitis had
dentition and patient-reported periodontal and peri-implant care). reached its terminal stage, and implant
outcomes with patients;24 The above reinforces the need loss was unavoidable.29 Notably, no single
 Highlight the importance of prevention, for clinicians to identify and optimise method of non–surgical implant surface
early diagnosis and early management modifiable risk factors prior to implant instrumentation decontamination has been
of peri-implant mucositis; placement, and to use this information found to be superior.30 Part 2 of this series

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discusses in detail the evidence in relation to consideration should be given to this surgical a
adjuvant antimicrobial and decontamination approach, as implantoplasty procedures can
modalities following non-surgical and/or lead to implant mechanical complications
surgical treatment of peri-implantitis. (implant fracture), and to the release of
In order to potentiate the effectiveness of nanometre-sized particles that can trigger
mechanical plaque control, several clinicians local-level reactions, and the full systemic
have suggested the adjunctive use of other effect is not fully understood at present.37,41
antimicrobial therapeutics or approaches. As previously described for non-surgical
Currently, there is limited evidence regarding treatment of peri-implantitis, many implant
the use of systemic antimicrobial protocols surface decontamination procedures
as adjuncts to mechanical therapy, which have been suggested as part of surgical
hinders robust conclusions regarding treatment, through the use of carbon or
their effectiveness considering possible plastic curettes, ultrasonic scalers, titanium b
side effects (e.g. antibiotic resistance) and brushes, air-polishing devices using
increased cost (e.g. laser equipment).31 sodium bicarbonate or glycine powder,
Larger randomized controlled clinical trials irradiation with hand or soft laser light,
are still required to assess their effect on photodynamic therapy or the application
clinical outcomes. Specifically, FGDP (UK) and of acids or various antimicrobial agents.18,42
European Federation of Periodontology (EFP) While these studies report on the efficacy
S3 level clinical practice guidelines do not of these procedures, the role of implant
recommend systemic or local antimicrobials surface characteristics may also influence
for peri-implant mucositis. However, local treatment outcomes.43
measures to improve self-care oral hygiene One study evaluated the effect of
are strongly recommended. Similarly, surgical treatment of peri-implantitis in Figure 4. (a) Surgical access and (b) debridement
FGDP (UK) does not recommend the use a preclinical setting, using different anti- using diamond piezosurgical tips on a maxillary
of antimicrobials as an adjunct to local infective procedures, such as surgical implant (UL1) affected by peri-implantitis.
management of peri-implantitis.4,32 debridement of the implant sites, in Reproduced from Sousa et al.11
conjunction with either normal saline or
0.2% chlorhexidine, comparing different
Surgical treatment implant surfaces.44 It was shown that:
of peri‑implantitis  The local use of chlorhexidine has minor Regenerative procedures
Current surgical treatments for peri- effects on treatment outcomes; A meta-analysis of treatment outcomes12
implantitis, such as access flap,  Resolution of peri-implantitis was identified the main surgical procedures that
reconstructive, resective, and combination possible without the use of adjunctive are predominantly performed in the surgical
approaches, include the removal of the peri- local and systemic antibiotics; access phase:
implant inflammatory granulation tissue and  The results were influenced by implant
 Access flap debridement;
the decontamination of the exposed implant surface characteristics.
 Surgical resection;
surface.3,12,33,34 According to the current EFP A randomized controlled clinical trial  Regeneration with bone grafts;
S3 level clinical practice guideline for the has suggested that treatment outcomes  Guided tissue regeneration.
prevention and treatment of peri-implant for implants with a modified surface had
diseases,4 there is insufficient evidence to The outcomes of regenerative therapy
significantly lower odds for treatment
recommend the use of implantoplasty. are reported to be the most variable.12 It
success.13 They mentioned that the use of
However, the use of implantoplasty has been adjunctive systemic antibiotics, such as oral is important to emphasize that, overall,
considered in specific cases, in conjunction amoxicillin 750 mg twice daily for 10 days, peri-implantitis lesions do not respond
with regenerative or resective surgery. 35–37 was likely to yield positive effects in patients predictably to either non-surgical or
The modification of the implant surface with implants with modified surfaces.13 surgical treatments.
by implantoplasty (Figure 4), along with However, more recently, this study reported In terms of regenerative therapy,
a resective surgical approach (performed 3-year follow-up results that indicated that autogenous bone, allogenic decalcified
on supracrestal/horizontal, infrabony and the potential benefits of systemic antibiotics freeze-dried bone, xenogenic de-proteinized
some combined defects), has also been are not sustained over this period, although bone mineral, phytogenic calcium carbonate,
proposed as an effective treatment for the surgical treatments were still deemed to hydroxyapatite or tri-calcium phosphate
peri-implantitis.39 Clinical improvements be effective.13 and porous titanium granules (PTGs),47 with
following the surgical treatment of peri- Further studies are needed to clarify the or without employing e-PTFE, collagen
implantitis are usually measured against effect of implant surface characteristics on or resorbable synthetic membranes, have
clinical parameters, such as reduction of treatment outcomes45 and the influence of been used in an attempt to reconstruct peri-
PPDs, absence of BoP and radiographic bone adjunctive use of antibiotics on treatment implant defects and attain bone regeneration.
fill of bony defects indicating long-term outcome is still unknown. Furthermore, A meta-analysis demonstrated higher
stability.3,38,39 However, 2 years after therapy, adequately powered randomized controlled reduction in PPDs and BoP when using bone
50% of patients continued to exhibit signs of trials in this area of research are of grafts and barrier membranes, in comparison
peri-implantitis.29,40 Notwithstanding, careful high priority.46 to employing grafts alone.12 However, as

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reported in a recent systematic review and decontaminated dental implants into particular reconstructive surgical
meta-analysis, it is important to highlight that freshly prepared osteotomies in dogs.52 approach. The routine use of adjunctive
there is lack of evidence suggesting improved Similar results were reported in another antibiotics in the surgical treatment of
aesthetic or patient-reported outcomes preclinical study where electrolytic cleaning peri-implantitis is not recommended
following reconstructive therapy at peri- of previously infected implant surfaces by current guidelines. Given the
implantitis-related bone defects.40 promoted their re-osseo-integration in complexity of surgical treatment for
A recent randomized multicentre fresh osteotomies.53 However, there was peri-implantitis, it is recommended
trial demonstrated the benefits of bone considerable variability within and between for it to be conducted by dentists with
grafting in combination with an open studies, where histological evidence of specific training or by specialists.
flap debridement (OFD) procedure for the re-osseo-integration was unpredictable, and  Reconstruction of peri-implant bone
treatment of advanced peri-implant osseous may not have been achieved for the entire defects with new bone formation and
defects compared with OFD alone.47 Both (previously) contaminated implant surface.12 re-osseo-integration has been reported
surgical treatment approaches included Re-osseo-integration might be with various degrees of success,
the use of a titanium brush for implant influenced by a number of factors, which may be influenced by various
surface decontamination and adjunctive including the implant material, design and factors including defect morphology,
systemic antibiotics. Although no significant surface characteristics, exhibited bacterial material selection and implant
differences were observed regarding BoP communities and host state, surgical site surface characteristics. Furthermore, it
and PPD reduction between the groups, and technique, loading conditions and has been suggested that reconstructive
the radiographic bone fill was superior time.54 As such, direct comparison of bone- procedures should be preferably be
in the group including the bone grafts. to-implant contact figures between studies applied at intra-osseous defects with a
The challenge of achieving a successful can be difficult. depth of ≥3 mm.
regenerative therapy in peri-implantitis Following the treatment of peri- A substantial knowledge gap persists
will greatly depend also on the patient’s implantitis by employing a regenerative regarding the optimal implant surface
systemic conditions and the morphological approach, large variations in the amounts decontamination protocol. To date, none of
configuration of the peri-implant bone of re-osseo-integration, from 1% to the clinically described methodologies has
defect, in relation to the number of bone 84% have been reported.55 The implant demonstrated total biofilm elimination.
walls that determine its configuration.3,13,34,48 surface characteristics could be one of the Further research is required in the
Furthermore, it has been reported that good factors responsible for this variability.56 development of biomaterials with
oral hygiene plays a pivotal role in long-term It is well known that bacterial adherence antibacterial potential and osteo-
stability (4-year follow up) after regenerative is enhanced by the micro-irregularities inductive properties that can be used in
treatment of peri-implantitis (combining of implant surfaces, and as long as the context of regenerative treatment
a xenograft and a collagen membrane).49 contamination is present, wound healing of peri‑implantitis.
Regardless of the chosen surgical method will be variably compromised.55
and biomaterial use, attaining resolution Acknowledgements
of peri-implantitis remains challenging. The authors thank everyone who has
Over the long term, several implants might Conclusions
provided their time and input in the
experience disease recurrence, requiring It is advised to adhere to the EFP S3 development of these articles, in particular
further surgical interventions or potentially level clinical practice guidelines for peri- to Dr A Yogarajah, for his feedback on
resulting in implant loss.50 implant disease prevention and treatment, both manuscripts.
implementing a standardized protocol for
peri-implantitis management. The following
Re-osseo-integration factors merit consideration:
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
The ultimate goal of surgical regenerative
 Patients’ risk profile at an individual they have no conflict of interest.
treatment of peri-implantitis should be
and site level should be evaluated prior Informed Consent: Informed consent was
re-osseo-integration: the growth of new
to the commencement of a treatment obtained from all individual participants
bone in direct contact with the previously
plan, with specific attention to medical included in the article.
contaminated implant surface.50,51 Therefore,
and lifestyle risk factors for peri-implant VS was supported by the NIHR (CL).
regenerative surgical treatment should aim to:
and periodontal diseases. VB and VS were supported by Project
 Ensure substantial regeneration of bone  Non-surgical implant surface REDI170658, ANID.
from the walls of the defect; instrumentation with or without
 Decontaminate the implant surface to adjunctive chemotherapeutics, or other References
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