The surgical treatment of peri‐implantitis is a complex surgical procedure and a clinical challenge in today’s daily practice. The surgical approach seems not to be complicated and a straightforward process for a well‐skilled and competent clinician, but the clinical outcome is not always predictable. A comprehensive review of the literature with the different studies performed for the treatment of peri‐implantitis was recently published [1]. Different etiological factors are associated with the disease and especially the disease progression.

Peri‐implantitis is defined as a biofilm‐associated pathological condition characterized by inflammation in the peri‐implant mucosa and subsequent progressive bone loss of supporting bone [2]. However, biofilm accumulation is dependent on the implant surface characteristics, the implant macro‐geometry [3], the type of the prosthesis as well as other local and systemic factors (smoking, diabetes, metalosis, etc.) contributing to the disease progression [4]. In addition, inadequate maintenance, and oral hygiene (Figure 12.1) are risk indicators for peri‐implantitis.

The non‐surgical treatment, which consists of mechanical debridement, the use of ultrasonics or laser devices, alone or combined with antiseptic and/or antibiotic agents, has not demonstrated the resolution of the disease due to inconsistent results according to the current literature. In contrast to this therapy, surgical therapy, in conjunction with the implant surface detoxification and debridement of peri‐implant tissues, as a regenerative or resective approach, has shown greater effectiveness in terms of disease resolution as demonstrated by preclinical and clinical studies. Surgical augmentative peri‐implantitis therapy resulted in improved clinical and radiographic treatment outcomes compared with the baseline in most studies with six months to 7–10 years of follow‐up [5].

There is no reliable evidence suggesting which could be the most effective intervention for treating peri‐implantitis [6] and no single method can be promoted based on the evidence [7, 8]. Evaluating the different published surgical treatment methods, a recent review of the literature concluded that the available evidence to support the superiority of augmentative surgical techniques for peri‐implantitis management on the treatment outcomes over non‐augmentative methods is limited [9]. There is no “gold standard,” and several techniques have been recommended to treat peri‐implantitis, from non‐surgical to complex resective and regenerative surgical procedures, which aim at preventing inflammation and encouraging the regeneration of hard and soft tissues surrounding the implant [10].

The treatment is focused on detoxification of the implant surface and surrounding tissues with finally the grafting.

Different detoxification methods of the implant surface have been reported in the literature, such as chlorhexidine [11], hydrogen peroxide 3% [12], 24% EDTA [13], tetracycline powder [14, 15] (Figure 12.2), air‐polishing with sodium bicarbonate and glycine [14] and recently the use of an electrolytic cleaning in conjunction with bone grafting [16].

Also, laser irradiation for implant surface detoxification like the use of Er:YAG laser ([17–21]), CO₂ laser [22–25], Er,Cr:YSGG [26], 810 nm diode laser [27] or a high power 980 nm laser [28] have been utilized. Additional options have been reported, like a low‐power 980 nm diode laser [29] and photodynamic therapy [30] (see also chapter 13).

The peri‐implant bone defect debridement, methods of implant surface decontamination, and detoxification have been extensively reported in the literature associated with the treatment of peri‐implantitis. However, the peri‐implant bony defect configuration seems to impact the treatment outcome, and previous experiences reported that the defect morphology dictates the treatment approach [14]. Specifically, contained circumferential defects (Figure 12.3a, b) seem to have favorable outcomes following surgical regenerative therapy using natural mineral in combination with a collagen membrane [31].

Since contained defects have a favorable regenerative potential, any type of bone and bone substitutes can be recommended. Non‐contained defects (one‐ or two‐wall) need the presence of good bone vascularization and stability of the bone particles. Growth factors (Figure 12.4) and/or stabilization of the blood clot, can be performed with the use of CO₂ or high‐power diode lasers (Figure 12.5).

Therefore, autogenous bone (containing autogenous growth factors) or bone substitutes in combination with recombinant growth factors (platelet‐derived growth factor/PDGF, GEM21S) provide an excellent treatment approach.

The strategy for the surgical treatment of peri‐implantitis is presented in the chart below.

Also, the removal of the prosthesis for better access to the defects, to achieve better decontamination and defect debridement has been documented. Preclinical studies in dogs [32] showed that open surgical treatment and submerged healing improved the outcome. Also, clinical studies showed that treatment of peri‐implant defects using a bone graft substitute combined with a resorbable membrane and submerged healing results in defect‐fill and clinically healthier situations [33–35].

However, a clinical study with 32 clinical cases showed no statistically significant differences in response to treatment when removing or keeping the prosthesis after regenerative surgery in peri‐implant defects [36]. In a recent retrospective study, Parma‐Benfenati et al. [37] showed successful long‐term clinical outcomes after regenerative treatment of advanced peri‐implantitis defects (vertical defects). They concluded that a success rate of 70.2% in 40 implants in an average follow‐up period was 6.9 years (range: 2–21 years).

Consecutive case series of 170 treated peri‐implantitis–affected implants in 100 patients with follow‐up measurements from 2 to 10 years were published by Froum et al. [15]. A total of 51 implants in 38 patients previously reported were followed for an additional 2.5 years, and 119 different implants in 62 other patients were treated with the same protocol and monitored for at least 2 years post‐treatment. The results concluded that of the 170 implants treated, 2 were lost, both at six months post‐surgery, yielding a 98.8% survival rate with a mean probing depth reduction (168 implants) of 5.10 mm (range of 2–12 mm) and average bone gain of 1.77 mm (range of 0.4–9.0 mm).

A variety of grafting materials have been tested clinically to evaluate the clinical outcome, with the main goal to get a bone fill and re‐osseointegration (Figures 12.6 and 12.7).

The bone reconstruction was obtained with a variety of bone substitutes like autogenous bone [38–41], deproteinized bovine xenograft (cancellous BioOss®) ([25]), vancomycin and tobramycin impregnated allografts [42] and collagen‐contained grafting materials [13, 43], porous titanium granules [44], and enamel‐matrix derivatives [45].

Comparison between different xenografts (Endobon® and BioOss®; both having bovine origin) did not show any superiority when used in reconstructive surgery of peri‐implant osseous defects [46].

Recent studies from private practices using combination therapy of flap reflection, surface decontamination, use of enamel‐matrix derivative (EMD) or platelet‐derived growth factor (PDGF, GEM21S®), and guided bone regeneration (GBR) with mineralized freeze‐dried bone and/or inorganic bovine bone combined with PDGF or EMD and covered with an absorbable membrane and/or subepithelial connective tissue graft appear to be encouraging [15]. The present evidence does not show any superiority to the specific debridement method (decontamination) and the use of a specific bone substitute. There is no standardized recommendation for submerged or non‐submerged healing after grafting or the adjunctive administration of antibiotics [1].

The effectiveness of the outcome in the treatment of peri‐implantitis after combination therapy with implantoplasty and augmentation was similar, independent if the implants were initially placed in pristine or grafted bone [47].

However, the main topic in any case of peri‐implantitis therapy is the aspect of re‐osseointegration. Studies have also reported that though new bone generation occurs to some extent, a “true” re‐stabilization could not be regained without adjunctive GBR [48–50].

Following preclinical [48, 51, 52] and clinical [53] evidence of the possibility of obtaining re‐osseointegration around dental implants affected by peri‐implantitis, several case reports and studies proposed different reconstructive protocols using autogenous bone and/or various bone substitutes utilizing also barrier membranes to treat peri‐implantitis defects [24, 25, 33, 34,38–40].

Preclinical studies found that while substantial “re‐osseointegration” occurred to an implant with a rough surface (SLA), the bone growth on a previously exposed smooth surface (turned) was minimal [48]. Nevins et al. [54] showed re‐osseointegration after decontamination of the infected implant surface using the Er,Cr:YSGG laser [54].

Fletcher et al. [53] presented human histologic evidence of re‐osseointegration after the use of calcium sulfate and bovine bone as grafting materials and a porcine collagen barrier for connective tissue and epithelial exclusion in conjunction with guided bone regeneration. The implant surface was debrided with a plastic curette, and diluted sodium hypochlorite, hydrogen peroxide, and sterile saline were used for implant surface detoxification.

In a recent systematic review on the topic of re‐osseointegration, Lollobrigida et al. [55] showed in animal studies with induced peri‐implantitis that rough surfaces can enhance re‐osseointegration as compared to smooth surfaces. Submerged healing and barrier membranes have shown a positive effect on re‐osseointegration. Growth factors have been shown to improve re‐osseointegration in animal models, though additional studies are required to confirm the data. Several decontamination treatments have been shown to promote re‐osseointegration compared to control, and no specific procedure has proven superior to others in achieving re‐osseointegration.

The following goals should be achieved in the surgical treatment of peri‐implantitis:

• Removal of the surface pathogens (i.e. biofilm) and de‐granulation in the peri‐implant defect
• Decontamination of the implant surface and surrounding bone
• Creation of an attached keratinized mucosa around the defect to create an adequate width of mechanically stable mucosa
• Decrease the probing pocket depth and bleeding on probing
• Regeneration of the bone
• Access for implant maintenance; if needed, a modification of the implant–supported restoration is required to achieve a sustainable clinical outcome.

Clinical Cases

Case 1 Peri‐implantitis Therapy and Implant Surface Decontamination with Hydroxen Peroxide

Case 2 Peri‐implantitis Therapy in a Heavy Smoker

Implants were placed in a heavy smoker (heavy cigar smoker for more than 10 years) with type 2 diabetes (HbA1c: 7.2%). One year after implant placement the patient developed peri‐implantitis. The defects were debrided with titanium curettes (a). The decontamination occurred with 3% H₂O₂ irrigation for one minute. A non‐resorbable PTFE membrane was used without the use of any grafting material. The membrane was adapted around the implants (b), stabilized with titanium tacks (Frios^®, Dentsply, Mannheim, Germany), and the flap was sutured without tension (c, d). The membrane was exposed after six weeks (e). Chlorhexidine mouth rinses were recommended and the membrane including the tacks was removed carefully after eight weeks (f). The bone regeneration after two years with the prosthetic restoration showed a significant improvement and new bone fill (g).

The following clinical cases present laser‐assisted peri‐implantitis therapy based on the cases published in the recent book: Romanos GE. Advanced Laser Surgery in Dentistry (Wiley, 2021).

Case 4 Peri‐implantitis Treatment Before Functional Loading

The case presents a peri‐implantitis clinical case before delivery of the final prosthesis. The patient complained for acute pain and swelling in the mesial implant (#21 area). After irrigation with chlorhexidine solution to clean up the acute infection, a mucoperiosteal flap was elevated and the peri‐implant bony defect was de‐granulated with curettes. The maximum depth of the infrabony defect was 12 mm. The decontamination with a CO₂ laser (4 W; pulsed mode) was performed and the entire defect was irradiated in an ablative mode. Bone grafting with a bovine mineral was finally used to fill the defect and a collagen membrane covered the augmented site. The healing was uneventful and the clinical and radiological condition improved over the 3‐years of follow‐up (Figure 12.9).

Case 6 Laser‐Supported Treatment of Severe Peri‐implantitis Defect

The present case demonstrates a severe bone loss of an implant, splinted with additional implants in the fixed maxillary restoration. The female 84‐year‐old patient asked me to try to do my best to save her implant, which was the terminal (distal) implant of the restoration and was an additional anchorage for a partial prosthesis. The patient signed the informed consent to harvest autogenous bone from the tuberosity (#1) and to use this particulate graft with allograft as a composite graft (b, c) after debridement and detoxification of the implant surface using the pulsed CO₂ laser in a non‐contact mode. The detoxification occurred for 30 seconds around the entire exposed implant surface (Figure 12.11d). The defect was filled with the composite graft and a collagen membrane was used to cover the augmented site (Figure 12.11e, f). The flap was advanced coronally and closed with silk sutures (Figure 12.11g, h). The patient presented a significant reduction of the probing pocket depth and a recession of the soft tissue (Figure 12.11i). She asked for a new surgical procedure to improve the clinical outcome. The probing was reduced without bleeding on probing or suppuration (Figure 12.11j). A new flap was elevated and presented significant bone fill. The defect was filled with a combination of BioOss collagen® and BioOss® 1–2 mm large granules were used to augment the site. A collagen membrane was used to cover the grafted site (Figure 12.11k–m). The two‐year radiological evaluation showed a complete bone fill without resorption (Figure 12.11n) compared to the preoperative radiograph (Figure 12.11o) (Surgery performed together with the periodontal resident: D. Papadimitriou, Rochester, NY)

Case 7 Laser‐Supported Treatment of Peri‐implantitis

A 55‐year‐old patient was diagnosed with peri‐implant inflammation (Figure 12.12a) associated with pain and suppuration and presented radiological findings of an advanced peri‐implant osseous lesion (Figure 12.12b). The implant prosthesis was a screw‐retained restoration, which was fabricated 10 years ago. The prosthesis and the abutment of the failing implant were removed. Under local anesthesia, a mucoperiosteal flap was elevated, the peri‐implant granulation tissue was conventionally removed with plastic curettes (Figure 12.12c) and subsequently, the implant surface and the surrounding bone were decontaminated with the CO₂ laser (average power: 4 W, c.w.). The laser‐assisted decontamination permits good hemostasis (Figure 12.12d). The osseous defect was filled with bovine mineral bone grafting material (Figure 12.12e) and covered with an absorbable collagen membrane, based on the principles of the Guided Bone Regeneration for submerged healing (Figure 12.12f). After four months the implant was uncovered, the previous abutment was placed in the same position and the older prosthesis was delivered. Healing succeeded with no complications and after four months the clinical situation (as well as the radiological examination showed excellent peri‐implant conditions. The clinical situation was stable for four years (Figure 12.12g, h). However, 13 years later the patient decided to replace the bridge for esthetic reasons and mesial migration of the anterior teeth. The peri‐implant condition showed after 21 years a stability of the peri‐implant bone, proof of the long‐term success of the peri‐implantitis treatment concept (Figure 12.12i–k).

Case 8 Treatment in a Heavy Smoker using CO2 Laser Decontamination and Bone Mineral as a Grafting Material (see Figure 12.13)

Case 9 Peri‐implantitis Treatment with a Diode Laser

The clinical case presents a female patient with endosseous dental implants placed almost 4 years ago and loaded with a fixed prosthesis (Figure 12.14a). The patient complained about sub‐acute pain, especially during tooth brushing. The clinical examination showed bleeding on probing and suppuration in conjunction with peri‐implant intrabony defects at #19–20 (Figure 12.14b). After local anesthesia and mucoperiosteal flap elevation with meticulous degranulation of the peri‐implant defects (Figure 12.14c), a 980 nm diode laser with a 300 μm glass fiber was used, in a non‐contact mode and 2 W power settings for 3 x 20 seconds irradiation period. (Figure 12.14d).

Autogenous, particulate bone grafting material was used (patient decision) to fill the defects (Figure 12.14e), and a collagen membrane was applied and fixated with titanium tacks (Figure 12.14f). The flap was closed with interrupted silk sutures. The sutures were removed after one week. The healing was uneventful and after one year the clinical and radiological evaluation (Figure 12.14g, h) showed a significant increase of the bone fill around the failing implants and no clinical symptoms of inflammation.

Case 11 Treatment of Peri‐implantitis Using a Pulsed 980 nm Diode Laser

Peri‐implantitis defect before implant loading was debrided by titanium curettes and the implant was decontaminated with a pulsed 980 nm diode laser for 20–30 seconds (320 micron glass non‐initiated fiber) and 2‐w average power in a non‐contact mode (Figure 12.16a).

A composite graft (allograft – Puros® and autogenous bone from the ramus) was used to fill the vertical two‐wall defect (Fig. 12.16b). The bone particles were compressed under a collagen membrane (Fig. 12.16c, d), which was stabilized with titanium tacks (Fig. 12.16c, d). The flap was advanced and closed with vertical mattress sutures. The implant was healed in submerged mode (Fig. 12.16e). Nine months later, the implant was uncovered (Fig. 12.16 f). The complete bone fill is presented in Figures 12.16f, g when the flap was elevated for the removal of the titanium tacks. The final restoration was delivered 7 months later. The follow‐up radiograph 14 months later shows the crestal bone stability (Fig. 12.16h). (The patient was treated with the residents E. Rexha and N. Estrin, Stony Brook University, NY)

Case 12 Peri‐implantitis Therapy in Conjunction with Growth Factors

Peri‐implant subacute swelling in #14 under antibiotic treatment before drainage (Fig. 12.17a–d). Peri‐implant defect due to excess of cement after flap elevation demonstrating the severe bone loss. A long fracture was diagnosed at the tooth #13 and required a tooth extraction (Fig. 12.17e, f). After debridement of the defect and decontamination with H2O2 3% for one minute the defect was filled with a composite graft of allograft and platelet‐derived growth factor, covered with a collagen membrane (Fig. 12.17g). The membrane was stabilized with titanium tacks and the flap was closed (Fig. 12.17h, i). The clinical outcome was improved over this healing period (Fig. 12.17j–l) After a full‐thickness flap elevation for implant placement at the site #13, a significant defect closure was demonstrated at the area #14 and complete bone regeneration palatally. However, new grafting was required for complete bone regeneration. Eight months later implant uncovering (#13) and removal of the tacks shows a complete bone fill around the implants #13 and #14 (Fig. 12.17m). The implant was restored two months later representing good clinical and esthetic outcome and radiographically crestal bone stability (Fig. 12.17n‐p). Postoperatively, the patient was rinsing the oral cavity 3–5×/day with the herbal‐based mouth rinse StellaLife, which supports the wound healing and has also beneficial effects in the tissue regeneration (Fig. 12.17q, r).

The following clinical cases have been treated by different clinicians and included here to provide further information about various concepts of surgical treatment of peri‐implantitis. These cases show multiple decontamination methods of the implant surface as well as grafting materials including growth factors to contribute to the bone growth around implants and possibly re‐osseointegration (implant long‐term success).

Peri‐implantitis case presentation utilizing air abrasion using glycine powder, hydrogen peroxide 3% chemical detoxification and mineralized cancellous allograft in conjunction with rhPDGF (Fig. 12.21).