Implant failure & its management (Final).pptx

Implant failure & its management Related to perio

1. Implant failure and its management Presented by : DR. NIHAL ABBAS Under the guidance of : Dr. M M DAYAKAR 1

2. CONTENT DEFINATION CLASSIFICATION OF IMPLANT FAILURE CLINICAL INDICATION OF IMPLANT FAILURE ETIOLOGY AND RISK FACTOR PREVENTION OF IMPLANT FAILURE TREATMENT OF IMPLANT FAILURE conclusion 2

3. DEFINITION AND CLASSIFICATION OF IMPLANT FAILURE it is important to define the different terms used when describing implant failure: Implant success – Criteria for implant success were defined by Albrektsson et al. in 1986 and later modified by R oos et al. These criteria for success have been adopted and further modified by the international congress of oral implantologists (ICOI) PISA consensus conference (Table 1). 3 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

4. 2) Implant survival – Esposito in 1998 described implant survival as a situation where the implant may be physically present and functioning yet fails the criteria for being successful . “Surviving” implants exhibit characteristics that may lead to eventual loss of the implant (e.g., Severe osseous defects) (fig.1). Figure 1. Implant and restoration are surviving not successful 4 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

5. 3) Compromised implant - An implant with a compromised survival will present with less than ideal conditions and will be indicated for treatment in order to prevent future failure . This specifically includes peri-implantitis . 4) Implant failure- This refers primarily to the state where the implant has lost integration at any time-point following implant placement. Implant failure is defined as the total failure of the implant to fulfill its purpose (functional, esthetic or phonetic) because of mechanical or biological reasons. 5 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

6. Clinical indications of implant failure Clinical indicators to identify implant failure include pain, mobility , radiographic crestal bone loss, probing depths , and untreatable peri -implant disease 6 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

7. Pain Healed implant, pain should not be associated with the implant. Percussion tests on the implants are used to test for pain. Pain from the implant does not occur unless the implant is mobile and surrounded by inflamed tissue or has osseointegrated and impinges on a nerve. Therefore, pain during function of an implant, unless able to be eliminated by treatment, is a subjective criterion . 7 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

8. Implant mobility A clinically mobile implant indicates the presence of connective tissue between the implant and bone, loss of osseointegration, clinical failure, and the need to remove the implant. 8 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

9. Marginal bone loss A significant indicator of implant health. The most common method to assess marginal bone loss is by conventional periapical radiographs(fig 2). According to international congress of oral implantologists pisa consensus conference in 2007; bone loss more than 50% of the implant length on a radiograph indicates an implant failure . 9 FIG 2(a) shows peri -implant bone level at the time of restoration and 2(b) shows marginal bone loss around implant after restoration. Rokaya D, Srimaneepong V, Wisitrasameewon W, Humagain M, Thunyakitpisal P. Peri-implantitis Update: Risk Indicators, Diagnosis, and Treatment. Eur J Dent. 2020 Oct;14(4):672-682. doi : 10.1055/s-0040-1715779. Epub 2020 Sep 3. PMID: 32882741; PMCID: PMC7536094.

10. Probing depth Probing depths are an excellent proven parameter to assess health or disease A light probing around dental implants (≤ 0.25 N cm ) is a valuable, noninvasive method determine peri -implant disease and whether radiographs are needed. [ Froum and wang et al] Sulcus depths greater than 5 to 6 mm around implants have a greater presence of anaerobic bacteria and may require intervention in the presence of inflammation or exudate. 10 Rokaya D, Srimaneepong V, Wisitrasameewon W, Humagain M, Thunyakitpisal P. Peri-implantitis Update: Risk Indicators, Diagnosis, and Treatment. Eur J Dent. 2020 Oct;14(4):672-682. doi : 10.1055/s-0040-1715779. Epub 2020 Sep 3. PMID: 32882741; PMCID: PMC7536094.

11. Probing depth Together with assessments of bleeding on probing (BOP), suppuration, and radiographs, probing can be used to determine The extent of peri-implant disease, Suggest treatment methods (nonsurgical versus surgical management), And evaluate treatment outcomes. 11 FIG 3 shows probing around healthy implant without bleeding and radiograph shows no marginal bone loss FIG 4 shows B.O.P and deep pocket around implant with peri–implantitis and radiograph shows marginal bone loss

12. Criteria for implant removal According to the Pisa implant health scale, an implant should be removed if any of the following conditions are present : 1. Pain on palpation, percussion, or function 2. Horizontal and/or vertical mobility 3. Uncontrolled progressive bone loss 4. Uncontrolled exudate 5. More than 50% bone loss around the implant 6. Implants surgically placed but unable to be restored 12 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

13. Etiology of (post-loading ) implant failure 13

14. 1. Implant fracture Most of the fractures of implant were in posterior partially edentulous segments , where the generated occlusal forces are greater, as opposed to the anterior segments.[ Rangert et al] Balshi et al, the cause of implant fracture may be broadly divided into : Implant design and manufacturing defects, Lack of passive fit of the prosthetic framework, And physiologic or biomechanical overload. Other possible causes of fracture can also include Failure in the production and design of dental implants, Bruxism or large occlusal forces, Superstructure design, Implant localization, Implant diameter, Metal fatigue, And bone resorption around the implant 14 Sanivarapu S, Moogla S, Kuntcham RS, Kolaparthy LK. Implant fractures: Rare but not exceptional. J Indian Soc Periodontol . 2016 Jan-Feb;20(1):6-11. doi : 10.4103/0972-124X.154190. PMID: 27041830; PMCID: PMC4795137.

15. Etiology of implant fracture The incidence of implant body fracture dramatically increases when force conditions are greater. Cantilevers, angled loads, and parafunction increase the risk for fracture. The endurance limit or fatigue strength is the level of highest stress a material may be repetitively cycled through without failure. The endurance limit of a material is often less than half of its ultimate tensile strength. Therefore fatigue and ultimate strength values are related, but fatigue is a more critical factor, especially for patients with parafunction because they impose higher stress magnitude and greater cycles of load. 15 Sanivarapu S, Moogla S, Kuntcham RS, Kolaparthy LK. Implant fractures: Rare but not exceptional. J Indian Soc Periodontol . 2016 Jan-Feb;20(1):6-11. doi : 10.4103/0972-124X.154190. PMID: 27041830; PMCID: PMC4795137.

16. Etiology of implant fracture The risk for fracture also increases over time . Typical mechanical failures are due to : Static load (i.e., One load cycle) failures cause the stress in the material to exceed its ultimate strength after one load application. Fatigue load failures occur if the material is subjected to lower loads but repeated cycles of that load. Implant The fatigue strength of titanium alloy is four times greater ( and safer ) than grade 1 titanium and almost two times greater than grade 4 titanium. Long-term fracture of implant bodies and components may be dramatically reduced with the use of titanium alloy rather than any grade of commercially pure titanium. 16 Sanivarapu S, Moogla S, Kuntcham RS, Kolaparthy LK. Implant fractures: Rare but not exceptional. J Indian Soc Periodontol . 2016 Jan-Feb;20(1):6-11. doi : 10.4103/0972-124X.154190. PMID: 27041830; PMCID: PMC4795137.

17. Dental implant fractures may be one of the major causes of late implant failures ; Studies by Goodacre et al . relate the risk for implant body fracture in the early to intermediate period for implants 3.75 mm in diameter to be approximately 1%, the abutment screw fracture risk at 2%, and the prosthetic screw risk at 4% (fig. 5 ). 17 FIG 5 (a)shows Mid-implant fracture (b& c)shows implant neck #(crestal implant #) (e)clinical image of implant neck # Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent. 2003 Aug;90(2):121-32. doi : 10.1016/S0022-3913(03)00212-9. PMID: 12886205.

18. Prevention A titanium alloy implant should ideally be used to reduce the possibility of implant body fracture. Parafunctional habits should be addressed with occlusal guards, narrow occlusal tables, no lateral contacts, and an ideal occlusal scheme. 18 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

19. Treatment of fractured implants S uggested by Balshi , there are three methods for treating fractures of dental implants: Removal of the fractured implant (replace the implant and manufacture a new prosthesis), Alteration of the existing prosthesis and submergence of the osseointegrated fractured part , [fig 6] And alteration of the fractured implant and replacement of the prosthetic portion . 19 FIG 6 shows three fracture implant before and after definitive restoration [in which they were submerged] Sanivarapu S, Moogla S, Kuntcham RS, Kolaparthy LK. Implant fractures: Rare but not exceptional. J Indian Soc Periodontol . 2016 Jan-Feb;20(1):6-11. doi : 10.4103/0972-124X.154190. PMID: 27041830; PMCID: PMC4795137 .

20. 2. Apical (retrograde) peri-implantitis Implant periapical lesions (IPLs) are defined as an infection located at the apex of an implant. Three possible etiologies: ( 1) implant factors, which include contamination of the implant surface ; (2) patient factors , which include the presence of a preexisting or adjacent bone pathology (of endodontic or periodontal origin); and (3) iatrogenic factors , which include overheating of the bone and excessive tightening or overloading of the implant . 20 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

21. Sussman called the problem endodontic implant pathology (EIP) and described two types. Type 1 EIP is implant-to-tooth , which occurs when a tooth with a vital pulp adjacent to an implant becomes devitalized after implant placement (fig 7). 21 FIG 7 shows implant contact with natural tooth Laird, B. S., Hermsen , M. S., Gound , T. G., Al Salleeh , F., Byarlay , M. R., Vogt, M., & Marx, D. B. (2008). Incidence of Endodontic Implantitis and Implant Endodontitis Occurring with Single-tooth Implants: A Retrospective Study. Journal of Endodontics, 34(11), 1316–1324. doi:10.1016/j.joen.2008.08.010

22. Type 2 EIP is tooth-to-implant , which occurs shortly after implant placement when there is an exacerbation of a preexisting apical lesion associated with an adjacent tooth (fig 8). 22 FIG 8(a) shows periapical lesion around lateral incisor adjacent to implant site (b) shows failed implant was removed. Laird, B. S., Hermsen , M. S., Gound , T. G., Al Salleeh , F., Byarlay , M. R., Vogt, M., & Marx, D. B. (2008). Incidence of Endodontic Implantitis and Implant Endodontitis Occurring with Single-tooth Implants: A Retrospective Study. Journal of Endodontics, 34(11), 1316–1324. doi:10.1016/j.joen.2008.08.010

23. Treatment The primary goal of IEP treatment is to eliminate any infection , and the secondary objective is implant and/or tooth survival . The treatment guidelines are based on four phases : 23 Laird, B. S., Hermsen , M. S., Gound , T. G., Al Salleeh , F., Byarlay , M. R., Vogt, M., & Marx, D. B. (2008). Incidence of Endodontic Implantitis and Implant Endodontitis Occurring with Single-tooth Implants: A Retrospective Study. Journal of Endodontics, 34(11), 1316–1324. doi:10.1016/j.joen.2008.08.010

24. Force overload Implant overload has been defined as occlusal forces that exceed the mechanical or biologic tolerance capacity of the osseointegrated implants or the prosthesis, causing either mechanical or osseointegration failure. If the bone surrounding implants is in the “ mild overload” range (1,500–3,000 microstrain ), There appears to be biologic apposition of bone . If strain in the bone is beyond this range , at some point fatigue fracture and bone resorption will occur . 24 FIG 9 (c)shows marginal bone loss caused by implant overload Laird, B. S., Hermsen , M. S., Gound , T. G., Al Salleeh , F., Byarlay , M. R., Vogt, M., & Marx, D. B. (2008). Incidence of Endodontic Implantitis and Implant Endodontitis Occurring with Single-tooth Implants: A Retrospective Study. Journal of Endodontics, 34(11), 1316–1324. doi:10.1016/j.joen.2008.08.010

25. Implant malposition compromising esthetics Esthetic complications can be caused either by malpositioned implants or by an inappropriate number and/or size of implants . Importance of correct 3D implant placement is now recognized, from which the term restoration-driven implant placement was derived . 25 Mistry A, Ucer C, Thompson JD, Khan RS, Karahmet E, Sher F. 3D Guided Dental Implant Placement: Impact on Surgical Accuracy and Collateral Damage to the Inferior Alveolar Nerve. Dent J (Basel). 2021 Sep 2;9(9):99. doi : 10.3390/dj9090099. PMID: 34562973; PMCID: PMC8470513.

26. Proper 3D implant placement has been described as p lacement of the implant shoulder such that there is 26 Mistry A, Ucer C, Thompson JD, Khan RS, Karahmet E, Sher F. 3D Guided Dental Implant Placement: Impact on Surgical Accuracy and Collateral Damage to the Inferior Alveolar Nerve. Dent J (Basel). 2021 Sep 2;9(9):99. doi : 10.3390/dj9090099. PMID: 34562973; PMCID: PMC8470513.

27. THE THREE TYPES OF IMPLANT MALPOSITION IN ESTHETIC AREAS INCLUDE THE FOLLOWING: 1 . Mesiodistal malposition: Implant is placed too close to an adjacent natural tooth or implant. Caused by an oversized implant with a platform that is too large for a single-tooth gap. Risk of a reduced papilla height at the adjacent tooth due to crestal bone resorption and remodeling during the healing phase (fig 10). 27 FIG 10 (a) show implant placed too close to each other (b) missing papilla and soft tissue Chen ST, Buser D, Sculean A, Belser UC. Complications and treatment errors in implant positioning in the aesthetic zone: Diagnosis and possible solutions. Periodontol 2000. 2023;92:220-234

28. 2. Apicocoronal malposition: Implant placed too shallow or too deep. 28 Chen ST, Buser D, Sculean A, Belser UC. Complications and treatment errors in implant positioning in the aesthetic zone: Diagnosis and possible solutions. Periodontol 2000. 2023;92:220-234

29. 3. Orofacial malposition: Implant placed too far palatally / lingually or labially . 29 FIG 11 shows ridge lap design Chen ST, Buser D, Sculean A, Belser UC. Complications and treatment errors in implant positioning in the aesthetic zone: Diagnosis and possible solutions. Periodontol 2000. 2023;92:220-234

30. Prevention of implant malposition Depend on The experience and surgical skills of the clinician, Thickness of the facial bone, Contour of the ridge, Anatomy of the nasopalatine canal, Evaluation of the extraction sites, Preoperative planning using radiographic assessment, and the Use of surgical guides. 30 Chen ST, Buser D, Sculean A, Belser UC. Complications and treatment errors in implant positioning in the aesthetic zone: Diagnosis and possible solutions. Periodontol 2000. 2023;92:220-234

31. TREATMENT OF IMPLANT MALPOSITION Implant removal and new implant placement: [ When esthetic complications caused by a severe implant malposition cannot be corrected with soft tissue grafting, the only solution is the removal of the implant or submerging the implant and replacing it with a pontic where applicable ] ( Fig 12). Soft tissue grafting : [Performed in cases of recession of the labial marginal mucosa . 31 Fig 12( a,b,c )show malpositioned implant with esthetic poor outcomes and (e) shows radiograph with new implant placed at ideal position Chen ST, Buser D, Sculean A, Belser UC. Complications and treatment errors in implant positioning in the aesthetic zone: Diagnosis and possible solutions. Periodontol 2000. 2023;92:220-234

32. IMPLANT FAILURES ASSOCIATED WITH VITAL ANATOMICAL STRUCTURES Implant failures can also occur when an implant contacts or disturbs an anatomical vital structure ( eg , maxillary sinus, inferior alveolar canal) or an adjacent tooth or implant. 32 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

33. Implant displacement/ migration into the maxillary sinus, resulting from 33 Figure 13 shows implant migration after bone augmentation

34. Prevention of implant displacement/migration into maxillary sinus Good primary stability Sufficient bone quality and quantity at implant placement . 34 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

35. There are three ways of treating dental implant displacement into the maxillary sinus: 35 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

36. Inferior alveolar nerve (IAN) injury can result from trauma due to : Local anesthetic injections, Dental implant site preparation or placement, Or poor surgical technique . Most serious complications is the alteration of sensation after implant placement in the posterior mandible & the prevalence of such complications has been reported to be as high as 13%. 36 Juodzbalys G, Wang HL, Sabalys G. Injury of the Inferior Alveolar Nerve during Implant Placement: a Literature Review. J Oral Maxillofac Res. 2011 Apr 1;2(1):e1. doi : 10.5037/jomr.2011.2101. PMID: 24421983; PMCID: PMC3886063.

37. Damage to the IAN can occur When the twist drill or implant encroaches on, transects, or lacerates the nerve . Positioning the implant close to the canal and the subsequent formation of an adjacent hematoma that presses against the nerve . 37 FIG 15 shows displacement of implant into IAN canal Juodzbalys G, Wang HL, Sabalys G. Injury of the Inferior Alveolar Nerve during Implant Placement: a Literature Review. J Oral Maxillofac Res. 2011 Apr 1;2(1):e1. doi : 10.5037/jomr.2011.2101. PMID: 24421983; PMCID: PMC3886063.

38. TREATMENT 38

39. PERI-IMPLANTITIS Peri-implantitis has been defined as an inflammatory disease of the soft tissues surrounding an implant accompanied by bone loss that exceeds normal physiologic remodeling. The etiology of this disease has been considered to be related to the bacterial biofilm forming on the implant surface, which interacts with the host tissue, leading to the destruction of supporting bone. 39 Rokaya D, Srimaneepong V, Wisitrasameewon W, Humagain M, Thunyakitpisal P. Peri-implantitis Update: Risk Indicators, Diagnosis, and Treatment. Eur J Dent. 2020 Oct;14(4):672-682. doi : 10.1055/s-0040-1715779. Epub 2020 Sep 3. PMID: 32882741; PMCID: PMC7536094.

40. Perez- chaparro et al . identified three commonly occurring pathogens associated with peri-implantitis: porphyromonas gingivalis , treponema denticola , and tannerella forsythia . Prevalence of peri-implantitis has been shown to vary from 6 % to 54%. Two systematic reviews and a meta-analysis of the literature reported that the prevalence of peri-implantitis was approximately 10% of implants and 20% of patients 5 to 10 years after implant placement. 40 Rokaya D, Srimaneepong V, Wisitrasameewon W, Humagain M, Thunyakitpisal P. Peri-implantitis Update: Risk Indicators, Diagnosis, and Treatment. Eur J Dent. 2020 Oct;14(4):672-682. doi : 10.1055/s-0040-1715779. Epub 2020 Sep 3. PMID: 32882741; PMCID: PMC7536094.

41. consensus report of the Sixth European Workshop in PeriOdontology listed seven risk factors associated with peri -implant disease. These included : Poor oral hygiene , History of periodontitis , Cigarette smoking , Diabetes with poor metabolic control, Alcohol consumption , Genetic traits , And the implant surface itself. 41 Rokaya D, Srimaneepong V, Wisitrasameewon W, Humagain M, Thunyakitpisal P. Peri-implantitis Update: Risk Indicators, Diagnosis, and Treatment. Eur J Dent. 2020 Oct;14(4):672-682. doi : 10.1055/s-0040-1715779. Epub 2020 Sep 3. PMID: 32882741; PMCID: PMC7536094.

42. Additional risk factors not included Poor prosthetic fit/ micromotion , Poor implant positioning, Malocclusion, Retained cement, Hypertension, Inadequate keratinized mucosa (KM), Growth and development, Reuse of healing abutments, foreign particles/titanium, and abutment disconnection/reconnection. 42 Rokaya D, Srimaneepong V, Wisitrasameewon W, Humagain M, Thunyakitpisal P. Peri-implantitis Update: Risk Indicators, Diagnosis, and Treatment. Eur J Dent. 2020 Oct;14(4):672-682. doi : 10.1055/s-0040-1715779. Epub 2020 Sep 3. PMID: 32882741; PMCID: PMC7536094.

43. poor  oral  hygiene Partially edentulous patients with very poor and poor oral hygiene are at statistically significantly higher risks of developing peri‐implant mucositis and peri‐implantitis compared with patients with proper plaque control ( ferreira et al. 2006). (Van steenberghe et al. 1993). Based on evidence, postulated that, if left untreated, peri ‐implant mucositis may lead to progressive destruction of peri ‐implant marginal bone (i.e. Peri‐implantitis ) and, eventually, implant loss 43 Serino G, Ström C. Peri-implantitis in partially edentulous patients: association with inadequate plaque control. Clin Oral Implants Res. 2009 Feb;20(2):169-74. doi : 10.1111/j.1600-0501.2008.01627.x. Epub 2008 Dec 1. PMID: 19077152.

44. HISTORY OF TREATED PERIODONTITIS Periodontitis ‐susceptible patients treated for their periodontal conditions may ex perience more biologic complications and implant losses compared with non‐periodontitis patients and also be more susceptible to peri‐ implant infections . Patients with one or more residual ppd of ≥6mm displayed a significantly greater mean peri‐implant ppd and radiographic bone loss compared with both periodontally healthy and periodontally compromised patients without residual ppd , respectively ( lee et al. 2012 ) Residual PPD of ≥5 mm at the end of active periodontal therapy represented a significant risk for the onset of peri‐ implantitis and implant loss over a mean follow‐up period of 7.9 years ( pjetursson et al. 2012 ) 44 Pjetursson BE, Helbling C, Weber H-P, Matuliene G, Salvi GE, Brägger U, Schmidlin K, Zwahlen M, Lang NP. Peri-implantitis susceptibility as it relates to periodontal therapy and supportive care. Clin . Oral Impl . Res .  23 , 2012; 888-894. doi : 10.1111/j.1600-0501.2012.02474.x

45. diabetes mellitus Potential risk factor for implant loss and peri -implant infections is diabetes mellitus Chronic infection of the periodontal and peri-implant pocket can lead to an increased release of pro inflammatory mediators with subsequent tissue loss in altered glycosylated cells of the diabetic patient. HbA1c level is a suitable measure for observation of patients with diabetes mellitus. It is concluded that patients with periodontitis, diabetes, and poor oral hygiene are more prone to develop peri-implantitis . 45 Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, Makrilakis K, Taylor R. Periodontitis and diabetes: a two-way relationship. Diabetologia . 2012 Jan;55(1):21-31. doi : 10.1007/s00125-011-2342-y. Epub 2011 Nov 6. PMID: 22057194; PMCID: PMC3228943.

46. diabetes mellitus Normal values for a healthy individual or a patient with diabetes under good metabolic control are HbA1c of <6–6.5% . Patients with diabetes with HbA1c values of of 8% are under poor control and have an elevated risk of encountering wound‐healing problems and infection if dental implants are placed. 46 Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, Makrilakis K, Taylor R. Periodontitis and diabetes: a two-way relationship. Diabetologia . 2012 Jan;55(1):21-31. doi : 10.1007/s00125-011-2342-y. Epub 2011 Nov 6. PMID: 22057194; PMCID: PMC3228943.

47. Genetic trait Polymorphisms of interleukin- 1 (IL-l a, IL-l b) and its natural specific receptor antagonist IL-l RA have a significant influence on the incidence of peri -implant bone loss during the early healing phase. 47 Laine ML, Leonhardt A, Roos-Jansåker AM, Peña AS, van Winkelhoff AJ, Winkel EG, Renvert S. IL-1RN gene polymorphism is associated with peri-implantitis . Clin Oral Implants Res. 2006 Aug;17(4):380-5. doi : 10.1111/j.1600-0501.2006.01249.x. PMID: 16907768.

48. smoking smoking can have a synergizing effect on the marginal bone loss in the positive IL-1 genotype. 48 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

49. Cigarette smoking must be considered as a potential risk factor with a strong influence on the maintenance of endosseous dental implants (fig 2.8). Avoidance of chemotaxis and phagocytosis, polymorphic cellular granulocytes, a stimulation of proinflammatory cytokines and direct encouragement of subgingival anaerobics found in early and late complication . Nicotine and its metabolites influence the metabolism of connective tissue and bone through the inhibition of collagen synthesis and a reduction of the intestinal absorption of ca++ . 49 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

50. alcohol Limited evidence also suggests that alcohol consumption of > 10 g daily may induce a greater amount of marginal bone resorption than cigarette smoking. 50 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

51. 51 Stacchi C, Berton F, Perinetti G, Frassetto A, Lombardi T, Khoury A, Andolsek F, Di Lenarda R. Risk Factors for Peri-Implantitis: Effect of History of Periodontal Disease and Smoking Habits. A Systematic Review and Meta-Analysis. J Oral Maxillofac Res. 2016 Sep 9;7(3):e3. doi : 10.5037/jomr.2016.7303. PMID: 27833728; PMCID: PMC5100643.

52. prevention HOME CARE An effective oral hygiene program is paramount to minimize peri -implant disease . PROFESSIONAL CARE Thorough periodontal charting and review is essential. Patients with periodontitis must have this pathologic condition controlled before implant placement . 52 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

53. Prosthetic Design A thoroughly evaluated cone beam computed tomography scan study with favorable biomechanical design for prosthetics is mandatory . Ideal implant position is paramount to allow for a properly designed prosthesis that is cleansable . 53 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

54. Cementation Technique The meticulous use of cements when delivering a prosthesis is imperative , or the clinician can choose to use a screw retained prostheses. If a cementable prosthesis is utilized, the clinician must take precautions to prevent retainment of cement . Conventional cementable techniques that are normally used for natural teeth are not recommended . 54 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

55. Control of Parafunctional Forces An occlusal guard is crucial in preventing unfavorable occlusal stress . The night guard is adjusted to be on a flat plane occlusion to disperse stress . 55 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

56. Cumulative interceptive supportive therapy [CIST] Depending upon the clinical, radiographic, diagnosis ,protocols for preventives therapeutic measures were designed to intercept the development of peri -implant lesions. This system of CIST has four steps procedures 56 Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156.

57. 57 Mombelli A, Lang NP. The diagnosis and treatment of peri‑implantitis . Periodontol 2000 1998;17:63‑76

58. CIST protocol A : Mechanical debridement Implants with plaque and calculus deposits and surrounded by a mucosa that is BOP positive but suppuration negative and with a ppd <= 4 mm are to be subjected to mechanical debridement . 58 Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156.

59. CIST protocol A+B : Antiseptic therapy At implant sites which are bop positive , exhibit an increased probing (4- 5 mm) and may or may not demonstrate supuration ), antiseptic therapy is delivered in addition mechanical debridement. A 0.2% solution of chlorhexidine digluconate is prescribed for daily rinsing , or a 0.2% gel of the same antiseptic is recommended for application to the affected site Generally, 3-4 weeks of antiseptic therapy are necessary to achieve positive treatment results. 59 Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156.

60. CIST protocol A+B+C : Antibiotic therapy At BOP-positive sites with deep pockets ( ppd >=6 mm ) , suppuration may or may not be present), also radiographic signs of bone loss. Such pockets represent an ecologic habitat which is conducive for the colonization of gram-negative and anaerobic putative periodontal pathogens ( M ombelli et al. 1987). Anti-infective treatment must include the use of antibiotics to eliminate or reduce the pathogens in this habitat. This, in turn, will allow soft tissue healing as demonstrated in a clinical study by M ombelli and L ang (1992 ). 60 Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156.

61. Prior to administering antibiotics the mechanical (CIST A) and the antiseptic (CIST B) protocols have to be applied. During the last 10 days of the antiseptic treatment regimen, an anti- Antibiotic directed against bacteria ( Eg . Metronidazole or O rnidazole ) 61 Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156.

62. The antibiotic must thus remain at the site of action for at least 7—10 days and in a concentration high enough to penetrate the submucosal biofilm ( mombelli et al. 2001). Example of such a controlled-release device Tetracycline-containing Periodontal fiber ( actisite ). The therapeutic effect of this controlled-release device appears to be identical to the effect obtained by the systemic use of Antibiotics ( mombelli et al. 2001). 62 Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156.

63. In a more recent development, minocycline micro- Spheres (1 mg arestin ) have been used as a controlled-release Device in a similar manner to the application of tetracycline fibers ( mombelli et al. 2001). These micro-spheres are easily applied into the peri -implant Pocket by means of a syringe. The antibiotic is contained in very small beads that stick to the lateral walls of the pocket and to the implant surface providing enough concentration f or up to 14 days ) to penetrate the biofilm . Microspheres are adjunctive to the cist protocols a+b . Represents a valuable alternative to the administration of systemic antibiotics for the treatment of incipient peri -implant infections. 63 Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156.

64. CIST Protocol A+B+C+D : Regenerative or resective therapy It is imperative to understand that regenerative or resective therapy is not performed until the peri -implant infection is under control . Thus, before surgical intervention is planned, the previously diseased site should have become bop negative, exhibit no suppuration, and have a reduced probing depth . Depending on the extent and severity of the local bone loss, a decision is made whether regenerative or resective measures are to be applied. 64 Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156.

65. Treatment of peri-implantitis Systematic literature reviews on this subject concluded that no specific recommendation for the therapy of peri-implantitis . Few of these reviews reported that the regenerative procedures that included bone graft techniques with and without the use of barrier membranes resulted in an increased degree of success. Three decision trees and a prognosis table have been published to guide clinicians in the treatment of peri-implantitis . 65 Mordini L, Sun N, Chang N, De Guzman JP, Generali L, Consolo U. Peri-Implantitis Regenerative Therapy: A Review. Biology (Basel). 2021 Aug 13;10(8):773. doi : 10.3390/biology10080773. PMID: 34440005; PMCID: PMC8389675.

66. Peri -Implant Disease Treatment Regimen [ Suzuki- resnik peri -implant disease protocol ] Treatment Regimen A: Mechanical Closed Debridement ( Acceptable Instrumentation) Resin, titanium, graphite, carbon-fiber, and gold-tipped instruments can be used to remove deposits Prophy cup/brush Air-polisher with glycine powder ( hu-friedy ), prophy jet ( dentsply ) Cavitron (use blue implant tip) Rx: chlorhexidine (0.12%, 0.2%) or cetylpyridinium chloride Check occlusion 66 Mordini L, Sun N, Chang N, De Guzman JP, Generali L, Consolo U. Peri-Implantitis Regenerative Therapy: A Review. Biology (Basel). 2021 Aug 13;10(8):773. doi : 10.3390/biology10080773. PMID: 34440005; PMCID: PMC8389675.

67. Treatment Regimen B: Antiseptic Therapy Subgingival antiseptic irrigation (0.12%, 0.2% chlorhexidine ) is added to the mechanical therapy Irrigate intracrevicularly to disrupt and dislodge the biofilm , then thoroughly debride the implant surface with a curette. Irrigate a 2nd time to rinse out the debris and further detoxify the subgingival area . Pressure is then applied for one minute to obtain intimate soft tissue/restoration contact. Alternative antiseptic ; diluted sodium hypochlorite ( NaoCl ). Diluted (.25%) NaoCl solution = one teaspoon (5ml) of standard 6% household bleach ( clorox ) and diluting it with 4 oz (125ml) of water. Check occlusion, possible occlusal guard 67 Mordini L, Sun N, Chang N, De Guzman JP, Generali L, Consolo U. Peri-Implantitis Regenerative Therapy: A Review. Biology (Basel). 2021 Aug 13;10(8):773. doi : 10.3390/biology10080773. PMID: 34440005; PMCID: PMC8389675.

68. Treatment Regimen C: ANTIBIOTICS Add systemic and/or local antibiotic treatment Systemic : amoxicillin, metronidazole (500 mg, 3 times/daily for 8 days) Alternative: clindamycin , augmentin , tetracycline , bactrim , ciprofloxacin Local : tetracycline Alternative: , doxycycline, minocycline spheres ( arestin ) 68 Mordini L, Sun N, Chang N, De Guzman JP, Generali L, Consolo U. Peri-Implantitis Regenerative Therapy: A Review. Biology (Basel). 2021 Aug 13;10(8):773. doi : 10.3390/biology10080773. PMID: 34440005; PMCID: PMC8389675.

69. Treatment Regimen D: SURGERY (Access, Open Debridement, Bone Graft, Closure) Step 1: access flap, open debridement with hand instruments, implantoplasty ( salvin bur kit) Step 2: detoxify with: 1. Apply 0.12% or 0.2% chlorhexidine with cotton pellet for 60 sec. (Rinse with saline) + 2a. Apply 20-40% citric acid with cotton pellet or spatula or titanium brushes ( salvin ) for 60 sec.(Rinse with saline) OR 2b. Apply tetracycline paste with titanium brushes ( salvin ) for 60 sec. (Rinse with saline) Other detoxification agents: EDTA, hydrogen peroxide, 0.25% naocl - Er:yag laser (diode laser alone results in an unacceptable increase in implant body temperature) 69 Mordini L, Sun N, Chang N, De Guzman JP, Generali L, Consolo U. Peri-Implantitis Regenerative Therapy: A Review. Biology (Basel). 2021 Aug 13;10(8):773. doi : 10.3390/biology10080773. PMID: 34440005; PMCID: PMC8389675.

70. Step 3: bone graft with mineralized/demineralized (70:30) + autograft (if indicated) Step 4: cross-linked collagen (extended collagen) Step 5: tension-free closure with vicryl (PGA) or PTFE sutures Treatment Regimen E: IMPLANT REMOVAL 70 Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753.

71. three decision trees differ on their recommendations for when an implant affected by peri-implantitis should be removed 71

72. Methods of implant removal: A moveable implant can be easily removed using forceps , the counter-torque ratchet technique (CTRT), or by rotating the implant counterclockwise . The counter-torque ratchet technique ( CTRT ) and the reverse screw technique ( RST) may be helpful where damage to the surrounding tissues is to be avoided .   Both of these procedures engage the implant and reverse screw it out of the bone with a counterclockwise force . 72 Froum S, Yamanaka T, Cho S C, Kelly R, St James S, Elian N. Techniques to remove a failed integrated implant. Compend Contin Educ Dent 2011; 32: 22–26: 28–30

73. 73

74. 74

75. Conclusions THE USE OF IMPLANTS IS WIDESPREAD AND LIKELY TO INCREASE OVER THE NEXT YEARS, WHICH SUGGESTS THAT DENTAL PROFESSIONALS WILL DEAL WITH IMPLANT FAILURE AND ASSOCIATED CONSEQUENCES MORE FREQUENTLY. ONE MUST IDENTIFY THE CAUSE TO TREAT THE CURRENT CONDITION AND GAIN KNOWLEDGE FOR FUTURE THERAPIES. 75

76. REFERENCES Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P, Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. doi : 10.1097/ID.0b013e3181676059. PMID: 18332753 . El Askary , Abdel Salam BDS*; Meffert , Roland M. DDS**; Griffin, Terrence DMD***. Why Do Dental Implants Fail? Part II. Implant Dentistry 8(3):p 265-278, Fathima , Maliha & Sinha, Nikita & Ali, Shaik . (2017). Failures in Dental Implants: A Review. 4. Rokaya D, Srimaneepong V, Wisitrasameewon W, Humagain M, Thunyakitpisal P. Peri-implantitis Update: Risk Indicators, Diagnosis, and Treatment. Eur J Dent. 2020 Oct;14(4):672-682. doi : 10.1055/s-0040-1715779. Epub 2020 Sep 3. PMID: 32882741; PMCID: PMC7536094 . Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent. 2003 Aug;90(2):121-32. doi : 10.1016/S0022-3913(03)00212-9. PMID: 12886205. Sanivarapu S, Moogla S, Kuntcham RS, Kolaparthy LK. Implant fractures: Rare but not exceptional. J Indian Soc Periodontol . 2016 Jan-Feb;20(1):6-11. doi : 10.4103/0972-124X.154190. PMID: 27041830; PMCID: PMC4795137 . Serino G, Ström C. Peri-implantitis in partially edentulous patients: association with inadequate plaque control. Clin Oral Implants Res. 2009 Feb;20(2):169-74. doi : 10.1111/j.1600-0501.2008.01627.x. Epub 2008 Dec 1. PMID: 19077152 . Pjetursson BE, Helbling C, Weber H-P, Matuliene G, Salvi GE, Brägger U, Schmidlin K, Zwahlen M, Lang NP. Peri-implantitis susceptibility as it relates to periodontal therapy and supportive care. Clin . Oral Impl . Res .  23 , 2012; 888-894. doi : 10.1111/j.1600-0501.2012.02474.x Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, Makrilakis K, Taylor R. Periodontitis and diabetes: a two-way relationship. Diabetologia . 2012 Jan;55(1):21-31. doi : 10.1007/s00125-011-2342-y. Epub 2011 Nov 6. PMID: 22057194; PMCID: PMC3228943 . Stacchi C, Berton F, Perinetti G, Frassetto A, Lombardi T, Khoury A, Andolsek F, Di Lenarda R. Risk Factors for Peri-Implantitis : Effect of History of Periodontal Disease and Smoking Habits. A Systematic Review and Meta-Analysis. J Oral Maxillofac Res. 2016 Sep 9;7(3):e3. doi : 10.5037/jomr.2016.7303. PMID: 27833728; PMCID: PMC5100643 . Passi D, Singh M, Dutta SR, Sharma S, Atri M, Ahlawat J, Jain A. Newer proposed classification of periimplant defects: A critical update. J Oral Biol Craniofac Res. 2017 Jan-Apr;7(1):58-61. doi : 10.1016/j.jobcr.2017.01.002. Epub 2017 Feb 7. PMID: 28316924; PMCID: PMC5343156 . Mombelli A, Lang NP. The diagnosis and treatment of peri‑implantitis . Periodontol 2000 1998;17:63‑76 76

77. REFERENCES Laird, B. S., Hermsen , M. S., Gound , T. G., Al Salleeh , F., Byarlay , M. R., Vogt, M., & Marx, D. B. (2008). Incidence of Endodontic Implantitis and Implant Endodontitis Occurring with Single-tooth Implants: A Retrospective Study. Journal of Endodontics, 34(11), 1316–1324. doi:10.1016/j.joen.2008.08.010 Mistry A, Ucer C, Thompson JD, Khan RS, Karahmet E, Sher F. 3D Guided Dental Implant Placement: Impact on Surgical Accuracy and Collateral Damage to the Inferior Alveolar Nerve. Dent J (Basel). 2021 Sep 2;9(9):99. doi : 10.3390/dj9090099. PMID: 34562973; PMCID: PMC8470513. Chen ST, Buser D, Sculean A, Belser UC. Complications and treatment errors in implant positioning in the aesthetic zone: Diagnosis and possible solutions. Periodontol 2000. 2023;92:220-234 Juodzbalys G, Wang HL, Sabalys G. Injury of the Inferior Alveolar Nerve during Implant Placement: a Literature Review. J Oral Maxillofac Res. 2011 Apr 1;2(1):e1. doi : 10.5037/jomr.2011.2101. PMID: 24421983; PMCID: PMC3886063 . Mordini L, Sun N, Chang N, De Guzman JP, Generali L, Consolo U. Peri-Implantitis Regenerative Therapy: A Review. Biology (Basel). 2021 Aug 13;10(8):773. doi : 10.3390/biology10080773. PMID: 34440005; PMCID: PMC8389675 . Froum S, Yamanaka T, Cho S C, Kelly R, St James S, Elian N. Techniques to remove a failed integrated implant. Compend Contin Educ Dent 2011; 32: 22–26: 28–30 77