Periodontology 2000, Vol. 0, 2017, 1–11 © 2017 John Wiley & Sons A/S.
Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Treatment of pathologic
peri-implant pockets
STEFAN RENVERT & IOANNIS POLYZOIS
The peri-implant mucosa has a number of features
similar to the gingival tissues surrounding teeth. It is
a well-keratinized oral epithelium and creates a cuff-
like barrier that has been proven to adhere to the
implant’s collar by a hemidesmosomal attachment
originating from the junctional epithelium cells (80,
83) (Fig. 1). The collagen fibers, originating at the
level of the crestal bone, are parallel to the implant
surface and as they cannot insert into the body of the
implant, this makes them more susceptible to
trauma. After the installation of titanium fixtures, a
predominantly gram-negative subgingival anaerobic
microflora is established on their surface (36). This
bacterial aggregation in contact with the peri-implant
mucosa leads to inflammation and bone loss. Simi-
larly to the process seen around natural teeth, inflam-
mation and bone loss will eventually lead to
increased probing depths (48).
It has been demonstrated that an inflammatory
lesion develops in the mucosa around teeth and
implants as a reaction to de novo plaque formation
(4). These lesions are localized in the marginal por-
tion of the soft tissue between the keratinized oral
epithelium and the junctional epithelium (4). If no
treatment is provided and the lesion progresses, a
large B-cell lymphocyte infiltrate develops. A number
of studies demonstrated similarities in the host-cell
response at implants diagnosed with peri-implantitis
and at teeth with periodontitis (5, 6, 47). However,
differences exist, and elastase-producing cells have
been reported to be more common in peri-implanti-
tis. This finding suggests that peri-implantitis is a
more acute type of inflammation (23).
Peri-implant lesions progress in an apical direction
and do not seem to be encapsulated by collagen
fibers, as are periodontitis lesions (1, 37) (Fig. 2). His-
tology data acquired from human biopsy specimens
have identified an inflammatory infiltrate consisting
of plasma cells, lymphocytes, macrophages and
PERIODONTOLOGY 2000
numerous polymorphonuclear leukocytes in approxi-
mately 65% of the connective tissue around implants
with peri-implantitis. This finding could explain the
increased amounts of elastase found in peri-implanti-
tis lesions compared with the lesions around teeth.
Further observations suggest that the inflammatory
infiltrate in peri-implantits lesions is in direct contact
with the alveolar bone and can extend into the alveo-
lar bone marrow spaces (37, 82). In periodontal
lesions the inflammatory infiltrate does not spread to
the bone but is separated from it by noninflamed
connective tissue, the thickness of which is about
1 mm. Finally, the cytokine profile differs somewhat
between peri-implant and periodontal sites. Cytoki-
nes with the potential to activate osteoclasts have
been found in both sites but their profile differs in
that interleukin-1alpha appears to be the most preva-
lent cytokine in peri-implantitis, whereas tumor
necrosis factor-alpha is the most common cytokine in
chronic periodontitis (33).
The majority of diagnostic methods conventionally
used in periodontics have been adopted by clinicians
and researchers to diagnose peri-implant diseases as
well as to assess the health status of peri-implant tis-
sues. These methods include clinical, radiographic and
laboratory examinations. The periodontal probe has
been an invaluable tool over the years in assessing the
clinical status and depth of the periodontal pocket and
the level of the marginal crest of the mucosa. Addition-
ally, bleeding on probing or suppuration following
probing have been considered as standard clinical
evaluations (Fig. 3). Concerns about the accuracy of
probing around implants as a result of the design of
the supragingival implant components and the posi-
tion of the implants has led the periodontal commu-
nity to recommend a more flexible plastic probe for
examination of the peri-implant pockets (Fig. 4).
Another reason why it would be prudent to question
the ability of the periodontal probe to lend its
1
Renvert & Polyzois

Fig. 3. Bleeding and suppuration following probing.

Fig. 1. Schematic illustration of healthy tissues around a

tooth and an implant (Copyright Renvert-Giovannoli Peri-
implantitis, Quintessence International, 2012 with permis-
sion) .

Fig. 4. Probing using a flexible plastic probe.

Fig. 2. Schematic illustration of a lesion at a tooth and an

implant (Copyright Renvert-Giovannoli Peri-implantitis,
Quintessence International, 2012 with permission).
diagnostic ability well to the peri-implant environment
is the nature of the peri-implant soft tissues, which are
different from the periodontal soft tissues. The orien-
tation of the supracrestal gingival fibers of the connec-
tive tissue around implants, which are parallel to the
implant surface, could influence the interpretation of
probing measurements, particularly in sites where the
resistance to probing is low.
Peri-implant mucositis presents as inflammation,
with erythema, swelling and bleeding on probing
around a fixture (38) (Fig. 5). The prevalence of peri-
Fig. 5. Peri-implant mucositis demonstrating swelling and
redness of the peri-implant mucosa.
implant mucositis has been reported in 80% of
subjects and for 50% of implants (59, 60).
Untreated peri-implant mucositis can progress to
peri-implantitis and lead to failure of a dental
implant. Peri-implantitis has been reported in
16–47% of subjects and in 6–36% of implants,
depending on the diagnostic criteria used (32, 59). A
number of factors have been implicated in the

2

etiology of peri-implantitis over the years and
although there has been some evidence for and
against these factors, it is now accepted that this dis-
ease is caused by a microbial infection. As a result,
the primary objective for treatment of both peri-
implant mucositis and peri-implantitis is elimination
of biofilm from the implant surface. Similarly to the
diagnostic tools, therapies proposed for the manage-
ment of pathologic peri-implant pockets are primarily
based on the evidence available from studies related
to the treatment of periodontitis.
Most modern implants have a medium rough sur-
face structure in order to increase the bone–implant
contact area, and this feature has worked very well
when it comes to the amount and quality of osseoin-
tegration. However, this same feature can complicate
the management of infections deep inside the peri-
implant pocket as the increased surface area and sur-
face roughness may facilitate microbial colonization
and enhance biofilm formation. Recent evidence sug-
gests that the surface roughness and the chemical
composition of the implant surface can have an
impact on plaque accumulation and thus contribute
to the difficulty in reducing the bacterial load to a
level necessary for resolution of the peri-implant
inflammation (80).
Elimination of biofilm from the implant surface
can be challenging. Biofilm formation is partially
controlled by an interbacterial communication
mechanism that is dependent on bacterial popula-
tion density, otherwise called quorum sensing (13).
Attempting to treat peri-implant infections with
antibiotics usually fails because antibiotic therapy
can control the acute phases but cannot resolve the
basic biofilm infection (14). Only one study recently
assessed the efficacy of combined mechanical
debridement and systemic antibiotics (azithromycin)
in the treatment of peri-implant mucositis. The
results suggested that the use of systemic antibiotics
as an adjunct to mechanical therapy had no impact
on bacterial counts after 6 months and limited clini-
cal effect (24). The primary objective for treatment
of peri-implant mucositis and peri-implantitis is to
alter the microbiota in such a way that the resident
microbiota at the implant surface is compatible with
the host. By doing so, the host’s immune system has
the potential to eliminate putative pathogens effec-
tively.
Efficient mechanical debridement is difficult but
critical in the management of dental implant infec-
tions. The prosthetic supra-structure often prevents
effective cleaning around the implant neck by the
patient, and conventional mechanical therapies
Treatment of peri-implant pockets
adopted from the treatment of periodontal disease
have their limitations because getting good access to
the relevant area can be difficult (74) (Fig. 6). Data
also suggest that the intracoronal compartments of
screw-retained fixed restorations, as well as the inter-
nal implant cavities, are heavily contaminated and
that the restorative margin in the implant/abutment
interface may be an important source of bacterial
leakage (15, 27). As a result, modifying the prosthetic
supra-structure in a way that allows the clinician and
the patient to access and clean around the implant is
an essential component in the treatment of peri-
implant mucositis and peri-implantitis. Nonsurgical
adjunctive therapies for peri-implant mucositis and
peri-implantitis, such as antibiotics, antiseptics and
laser treatments, have been proposed (52). Surgical
therapies have also been proposed to enhance the
healing and/or regeneration of the defects in cases of
peri-implantitis (12). Overall, the basic steps in peri-
implant infection therapy include: infection control;
nonsurgical debridement; corrective or regenerative
surgical procedures where necessary; and supportive
therapy.
Treatment of peri-implant pockets
diagnosed with peri-implant
mucositis
Current evidence indicates that peri-implant mucosi-
tis is the precursor of peri-implantitis in the same
way that gingivitis is the precursor of periodontitis.
Furthermore, we now have enough evidence to sug-
gest that peri-implant mucositis, like gingivitis, is
reversible when effectively treated with the indicated
therapeutic regimens (35, 48). When inflammation is
identified around the implant head, mechanical
Fig. 6. Prosthetic constructions hampering the oral
hygiene procedures.
3
Renvert & Polyzois
therapy, with or without adjunctive use of antiseptic
rinses, is usually employed as the treatment of choice.
For effective mechanical debridement of the implant
surface, specially designed hand instruments have
been developed and are made of pure titanium or
ceramics. Their design helps in reducing the damage
to implant surfaces and in achieving efficient plaque
removal.
The combination of professional irrigation of the
sulci with chlorhexidine and professional administra-
tion of local delivery antimicrobials as an adjunct to
mechanical therapy did not show any advantage over
mechanical therapy alone in the treatment of peri-
implant mucositis (49, 65). In one study by Schenk
et al. (65), little effect was observed from the sub-
mucosal placement of tetracycline fibers. However,
the standard of oral hygiene was low in this study,
which makes it difficult to reach firm conclusions. In
a study by Felo et al. (22), patients with moderate
mucositis and shallow probing depths were used to
compare two different regimes for the treatment of
peri-implant mucositis. Self-administration of
chlorhexidine irrigation was shown to be significantly
more effective in reducing signs of peri-implant
mucositis compared with rinsing alone with
chlorhexidine. Additionally, less staining and less cal-
culus was observed in patients who used irrigation as
the mode of therapy (22). Finally, the use of phos-
phoric acid as an adjunct to mechanical maintenance
therapy was evaluated and some advantages were
reported (76).
Tho^ ne-Mu€ hling et al. (81) tested the hypothesis
that within one session, improved clinical and
microbiological results can be achieved when
patients receive nonsurgical mechanical debride-
ment and additional full-mouth disinfection com-
pared with those receiving mechanical treatment
alone. Clinical examination was performed and
microbiological samples were taken at baseline, and
at 1, 2, 4 and 8 months after treatment, and addi-
tional microbial samples were taken 24 h after
treatment. No significant differences were detected
between the two groups (81). A clinical trial, con-
ducted recently, concluded that nonsurgical
mechanical debridement can effectively control
peri-implant mucositis and that the adjunctive use
of a glycine powder air-polishing device did not
seem to have a significant effect (28). The PERIO-
FLOWâ device, which is a nonsurgical, air-abrasive
method that has been developed to debride teeth
and implant surfaces, employs a small, thin dispos-
able plastic nozzle in order to gain access into the
peri-implant pocket. The biofilm is removed by
4
irrigation with a water/glycine powder mix. This
treatment has been recognized as safe and provides
clinical results similar to the results achieved by
hand instruments following subgingival debride-
ment (41) In vitro data have, however, demon-
strated that the use of an air-abrasive device may
alter the surface characteristics of titanium implant
surfaces (10).
The effectiveness of two different disinfection proto-
cols for the treatment of peri-implant mucositis was
evaluated in a randomized controlled double-blind
clinical study. Participating patients received mechani-
cal treatment at the implant sites and were subse-
quently instructed to use a gel with the aid of a
manual toothbrush to clean around the implants twice
daily, for a period of 4 weeks. One group received a
chlorhexidine gel (0.5%) and the other group received
a placebo gel. The patients were asked to stop using
the gel 4 weeks following the mechanical debridement
and to continue with routine oral hygiene. The para-
meters measured at baseline were also measured at 1
and 3 months following treatment. At 1 month and
also from 1 to 3 months, there were statistically signifi-
cant reductions in the mean number of sites with
bleeding on probing and mean probing depths in both
groups but interestingly no statistically significant dif-
ferences were observed between the two groups (26).
In the literature it is suggested that mechanical
therapy, with or without the adjunctive use of
antiseptic rinses, can be effective in the treatment of
peri-implant mucositis if the patient maintains a sat-
isfactory level of oral hygiene. Ciancio et al. (11)
demonstrated the beneficial results of rinsing with an
antiseptic mouthrinse without initial mechanical
therapy as reduced plaque levels and inflammation
were observed in patients using this regime when
compared with a placebo group of patients. The clini-
cians should dedicate time to ensure that oral
hygiene instructions are delivered properly and that
the patient understands the importance of effective
plaque control, for which a large number of different
oral hygiene tools have been suggested. Supra-struc-
tures should be adjusted in such a way that allows
accessibility for performing optimal oral hygiene. If,
for technical reasons, this is not possible, the restora-
tions should be replaced. For the interdental area,
interdental brushes of appropriate size or dental tape
should be used. Patients should also be advised to
use dental tape under pontics. Finally, repeated self-
irrigation of the inflamed areas diagnosed with peri-
implant mucositis around implants seems to be an
effective adjunct to mechanical treatment (11, 22, 26,
40, 49, 65, 76, 79, 81).
 Treatment of peri-implant pockets

Treatment of peri-implant pockets

diagnosed with peri-implantitis

Nonsurgical therapy
The peri-implant pocket becomes deeper as the dis-
ease progresses and the bone resorbs. This increased
probing depth, in combination with the surface structure
of the implant’s screw design and the supra-structure,
may hinder effective nonsurgical debridement of the
infected implant. Nevertheless, nonsurgical therapy
should always be performed before any surgical
intervention as this gives time for the clinician to Fig. 8. Nonsurgical therapy using a titanium scaler.
evaluate the healing response of the tissues as well as
the patient’s ability to perform effective oral hygiene
or a manual carbon-fiber curette, and probing depths
measures (Fig. 7). Additionally, as demonstrated in a
either did not improve or became deeper. Similar
study by Renvert et al. (56), there is always the
results were obtained from a randomized controlled
possibility that the nonsurgical therapy will resolve the
trial comparing the use of either titanium curettes or
problem without any further surgical intervention
an ultrasonic device designed for implants. Although
being necessary.
significant reduction in bleeding tendency and pla-
In most of the studies conducted over the last few
que scores was noted after 6 months, probing depths
years, nonsurgical therapy was performed using spe-
did not improve (55). Recently, another randomized
cially designed scalers (Fig. 8) or ultrasonic devices
controlled clinical trial compared the effectiveness of
with plastic- or TeflonTM-coated tips. These instru-
an air-abrasive device on clinical parameters with
ments were designed with the aim of reducing dam-
that of mechanical debridement using carbon cur-
age to the implant surface. Current evidence suggests
ettes and chlorhexidine digluconate as an adjunct.
that using these instruments to decontaminate
Excluding mean bleeding on probing reductions,
between the treads and within the irregularities of
which were statistically significant and in favor of the
modern implants is rather ineffective. In a study by
air-abrasive device, limited improvements were noted
Karring et al. (29), only minor changes in bleeding
both at 3 and at 6 months, and for both modalities
tendency were observed 6 months following therapy
(63). Laser therapy has also been suggested as a non-
with either the Vector system using a carbon-fiber tip
surgical approach for decontaminating the implant
surfaces deep in the peri-implant pocket (20). The use
of Er:YAG lasers could offer an advantage over tradi-
tional mechanical treatment as they have a bacterici-
dal effect (34, 67, 69, 77). Better clinical results have
been reported using laser treatment compared with
traditional mechanical debridement (56, 66). Earlier
studies demonstrated that decontamination using
nonsurgical photodynamic therapy (diode soft laser
and dye) can effectively reduce the levels of certain
bacteria, such as Aggregatibacter actinomycetemcomi-
tans, Porphyromonas gingivalis and Prevotella inter-
media but cannot eliminate them completely (18). In
a clinical evaluation comparing an Er:YAG laser and
the air-abrasive PERIO-FLOWâ for the treatment of
advanced peri-implantitis, the results demonstrated
similar reductions in probing pocket depths, fre-
quency of suppuration and bleeding at implants (56).
Fig. 7. Decision tree illustrating the process of patient man-
agement before the decision to intervene surgically (Copy- Nonsurgical mechanical therapy, in combination
right Renvert-Giovannoli Peri-implantitis, Quintessence with antimicrobials, has resulted in reduced bleed-
International, 2012 with permission). ing on probing and shallower probing depths (9,

5
Renvert & Polyzois

16, 43, 46, 50, 51, 53, 64). The rationale behind Surgical treatment
their use is that peri-implantitis can be viewed as a
Mechanical nonsurgical therapy alone is insufficient
polymicrobial infection and their action could com-
in the treatment of the majority of advanced peri-
plement mechanical nonsurgical therapy (45). A
implantitis lesions and in such cases a surgical
number of different local antimicrobials, such as
approach is indicated. The major objective for such
tetracycline-containing fibers, a slow-release doxy-
cycline-containing gel or minocycline microspheres, an approach is to provide access for removal of the
biofilm and calcified deposits from the implant sur-
have been used over the years. The adjunctive use
face in order to allow healing and reduce the risk for
of a slow-release doxycycline-containing prepara-
further disease progression. The decision of whether
tion was evaluated in a controlled study in which
to use a resective or a regenerative surgical technique
the supra-structure was removed before nonsurgical
therapy, including mechanical cleaning and irriga- depends on the clinical situation.
When surgical intervention is necessary, an inverse
tion with 0.2% chlorhexidine. It was concluded that
bevel incision is recommended to facilitate flap eleva-
the local application of this antimicrobial signifi-
tion and preserve soft tissue (Fig. 10). Following
cantly improved the results (9). Furthermore, in a
removal of the soft-tissue collar from the infected tis-
series of randomized controlled studies, clinical
sue around the implant, mechanical decontamina-
benefits were reported after the adjunctive use of
tion to remove plaque and mineralized deposits from
minocycline-containing microspheres (3, 50, 51, 53,
the implant surface (Fig. 11) should be performed
73) (Fig. 9). A number of case series and clinical tri-
and, for this task, instruments made of pure titanium
als performed over the last decade have reported
are recommended (Fig. 12). The use of a titanium
similar results (16, 39, 46, 64). Overall, and although
rotary brush makes this procedure easier than use of
the lesions were not resolved in all cases, improve-
ments in bleeding on probing and in probing conventional curettes (Fig. 12). Airborne-particle
abrasion devices have also been recommended for
depths were common findings. From a clinical per-
spective, this combined therapy may serve as an
alternative therapy in cases where access is difficult
and the area or the patient is not suitable for a
surgical intervention.
There is a lack of controlled studies evaluating
the efficacy of systemic antimicrobial treatment on
peri-implantitis. Data from case series suggest clini-
cal improvements following a combination of
mechanical and antimicrobial treatments (7, 8, 30,
42). However, caution should be exercised when
interpreting these results in light of the observation
that the case series includes both local irrigation
Fig. 10. An inverse bevel incision used to facilitate flap
with antimicrobials and systemic administration of
elevation.
antimicrobials.

Fig. 9. Application of slow-release minocycline micro- Fig. 11. Plaque and mineralized deposits on the titanium
spheres into a peri-implant pocket. surface.

6

Fig. 12. Mechanical cleaning of the implant using a rotary
brush.
the decontamination of implant surfaces during sur-
gery but because of the risk of developing subcuta-
neous emphysema, care must be taken during their
use (78). A number of other methods for decontami-
nation, such as the use of lasers or abrasive devices,
and implantoplasty of the exposed part of the
implant, have been suggested as adjuncts to surgical
resective or regenerative surgery but the clinical
improvements reported when using these techniques
are limited and the evidence is weak (18, 58, 72).
In general, mechanical decontamination should be
followed by application of chemical agents onto the
exposed surface of the affected implants. In this
respect, the substances that have been recommended
are hydrogen peroxide, citric acid, sodium chloride,
chloramines, tetracycline hydrochloride and
chlorhexidine gluconate. From the evidence available,
no single method has been proven superior (12).
Owing to its availability, efficiency and safety, hydro-
gen peroxide applied on the implant surface for
2 min has been the substance most widely used for
chemical decontamination. However, irrespective of
the agent used, the implant and the peri-implant
wound area should be thoroughly rinsed with a sterile
solution following decontamination.
Surface modification in the form of implanto-
plasty, and in conjunction with a resective surgical
approach, has been proposed as an effective way
of treating peri-implantitis, but only about 50% of
the patients treated had no signs of peri-implanti-
tis 2 years following therapy. Forty-two per cent of
the implants that were treated using the protocol
mentioned above demonstrated peri-implantitis,
and seven implants with bone loss of less than
7 mm were removed during the follow-up period.
The authors observed that peri-implantitis pro-
gressed around the implants that demonstrated
Treatment of peri-implant pockets
signs of the disease following therapy and con-
cluded that disease resolution depends mainly on
the initial bone loss (58, 75). Clinically, this treat-
ment protocol can be implemented in nonesthetic
areas, as exposed threads would be a highly unde-
sirable complication in the esthetic zone. Interest-
ingly, a recent study suggested that although
implant surface decontamination following access
flap surgery leads to greater suppression of anaero-
bic bacteria in the short term, it does not lead to
better clinical results (17).
Clinical decisions regarding the most suitable sur-
gical approach are usually made depending on the
position of the affected implant. In nonesthetic
areas, where exposure of the titanium components
is not a major complication, resective surgery and
apical positioning of the flap are preferable in order
to reduce the pocket depth and improve access for
home care. In esthetic areas, the decision for the
appropriate intervention is usually based on the
morphology of the defect and the degree of bone
loss. Radiographic and clinical examinations may
provide an indication of the morphology of the bony
defect but are not sensitive enough to give us the
complete picture. This can only be determined fol-
lowing elevation of the flap and removal of the gran-
ulation tissue. In the presence of a crater-like four-
wall bony defect or a three-wall defect, regenerative
techniques are recommended and the use of autoge-
nous bone or bone substitutes can be used to obtain
bone fill (Fig. 13). A resorbable membrane can also
be used in combination with the above-mentioned
grafting materials. For two-wall defects, regenerative
procedures are usually not indicated as the mor-
phology of the alveolar bone does not allow the
grafting material to be properly maintained in the
required area.
Fig. 13. Application of a bone substitute (porous titanium
granules; Tigran Technologies, Malmo € , Sweden) in a four-
wall defect.
7
Renvert & Polyzois
Several studies (61, 62, 68, 70, 71) have investigated
the effect of grafting materials as well as the effect of
the combination of barrier membranes and grafting
materials on treatment success. Based on the results
of these studies, the use of these barrier membranes
does not seem to improve the healing process and
often results in postoperative complications as a
result of membrane exposure. A recent randomized
controlled clinical trial (2) investigated the difference
in healing between subjects receiving antibiotics, sur-
gical debridement and either autogenous bone or
bovine-derived xenograft covered by a resorbable col-
lagen membrane. Twenty-two subjects were included
in the autogenous bone group and 23 subjects in the
bovine-derived xenograft group. Following
12 months of healing, significantly better results were
obtained in the bovine-derived xenograft group for
bone levels, bleeding on probing and suppuration,
but the success for both procedures was limited.
In some studies (30, 62, 85), a submerged approach
was employed to allow undisturbed healing and to
reduce the risk of infection, and although the amount
of bone fill following a submerged approach was
reported to be good, it is important to remember that
no human clinical studies have compared submerged
with nonsubmerged surgical treatment of peri-
implantitis. Even though the approach preferred is
the submerged approach, it should be highlighted
that, clinically, is not always possible to remove the
prosthetic supra-structure in order to submerge the
treated implants following surgery.
A number of regenerative treatment modalities
involving placement of autogenous bone or bone
substitutes have been reported and animal studies
have demonstrated that re-osseointegration may
occur on previously contaminated implant surfaces
(54). Recently, in a human case series, it was demon-
strated that re-osseointegration is possible. In this
study, the peri-implantitis lesions were mechanically
treated using titanium curettes and the implant sur-
face was then chemically cleansed using a 24% EDTA
gel. The defects were filled with porous titanium
granules, 700–1000 lm in diameter and with a pore
size of 50 lm in diameter, as a bone substitute (84).
It has been suggested in the past that the stability
of the membrane can influence the success of
guided tissue regeneration, especially in areas where
the bony morphology is unfavorable (44). Often, the
clinicians come across the presence of a bony dehis-
cence where the morphology of this defect might
not allow for retention of the augmentation material
(86). In cases like these, it is recommended to use
micropins to stabilize the membrane, which in turn
8
will keep the grafting material in place. These
micropins can be removed at a later stage. As in
most cases the primary treatment objective is bone
regeneration, having enough soft-tissue coverage of
the surgical site can significantly increase the suc-
cess of the regenerative procedures. In cases where
the peri-implant mucosa is thin, additional surgery
is indicated before grafting to increase the amount
of keratinized tissue (31, 57).
Conclusions
Although the scientific evidence on the efficacy of
nonsurgical and surgical therapies in the treatment of
peri-implantitis is limited, clinical evidence suggests
that it is predictable when the diagnosis is made early
and when the intervention is not delayed. In one
recent meta-analysis that included 11 randomized
controlled clinical trials, it was concluded that all the
studies were at unclear or high risk of bias (21).
Although the meta-analysis identified that surgical
procedures in peri-implantitis treatment produce
better results than nonsurgical approaches, these
results should be interpreted with caution because of
the limited number of studies included and their low
methodological quality. As for risk indicators for peri-
implant disease, poor oral hygiene, history of peri-
odontitis and cigarette smoking have been identified
as those with the strongest amount of evidence (25).
This highlights the necessity to perform proper risk
assessments before implant placement and to pro-
ceed with treatment only when the response is satis-
factory. Susceptible patients should be monitored on
a regular basis (19). Even if under these controlled
conditions peri-implant mucositis is detected, the
prosthetic design should be examined for accessibility
for oral hygiene measures. If considered appropriate,
the suprastructure should be modified or replaced
and the infected area treated to avoid disease pro-
gression.
If peri-implantitis is already established in the peri-
implant pocket, the proposed treatment suggestions
should be recognized as empirical. From the existing
evidence, we can conclude that nonsurgical therapy
is of limited value in advanced cases but should
always be employed before surgical treatment. In
these advanced cases, surgical techniques provide us
with the necessary access in order to remove the
inflamed tissues in the peri-implant pocket effectively
and to decontaminate or modify the implant surface.
To prevent relapse, regular maintenance appoint-
ments are essential.
 Treatment of peri-implant pockets

When it comes to regenerative procedures, the lim- 14. Costerton JW, Montanaro L, Arciola CR. Biofilm in implant
ited histological evidence from human studies makes infections: its production and regulation. Int J Artif Organs
2005: 28: 1062–1068.
it difficult to reach any conclusions regarding their
15. Cosyn J, Van Aelst L, Collaert B, Persson GR, De Bruyn H.
efficiency and the capability of the exposed implant The peri-implant sulcus compared with internal implant
surfaces to re-osseointegrate. Clinically, it seems that and supra-structure components: a microbiological analy-
the configuration of the bone defect and its position sis. Clin Implant Dent Relat Res 2011: 13: 286–295.
in the maxillary and mandibular arch can play a sig- 16. De Arau  jo Nobre M, Capelas C, Alves A, Almeida T, Car-
valho R, Antunes E, Oliviera D, Cardador A, Malo  P. Non-
nificant role for a predictable outcome.
surgical treatment of peri-implant pathology. Int J Dent Hyg
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