A 60-year-old Caucasian woman was referred to a private practice specializing in periodontics, dental implants and advanced restorative techniques to replace a 'failed' implant. The author informed the patient that the soft and hard tissues around her implant (tooth position 34 according to the World Dental Federation notation) showed evidence of peri-implantitis. The implant had been placed 20 months prior to her visit (to the current practice), and the crown fitted 4 months after the implant surgery. She reported a problem-free implant surgery and subsequent healing period; however, she reported that from the day the crown was fitted, the crown and adjacent gum had never felt 'comfortable.' The patient completed normal hygiene visits during her dental check-ups, but since the crown was fitted onto the implant in position 34, she had visited a hygienist every 3 months for help with this implant site. During visits to the hygienist, topical antibiotics were inserted on several occasions into the pocket to treat infections and pocket/implant surface debridement was carried out. The referring dentist had already warned the patient that the implant should be removed. Upon visiting our office, the patient described feeling very unsatisfied with the loss to her buccal tissue and bone at the implant site and asked if the implant could be replaced. Additionally, the tooth anterior to the implant (position 33) had also suffered extreme recession, which she felt was attributed to the development of peri-implantitis at position 34. The patient had no contraindicating medical condition. Clinical examination showed a very pronounced loss of attachment at positions 33 and 34 (Fig. 1A and B). The patient was diagnosed as having a mixed 'thin and thick' gum phenotype. The width of keratinized gingivial tissue (KGT) in the lower arch varied between 0 and 6 mm. We performed a radiographic examination that produced periapical, panoramic and linear tomograms (Fig. 1C-E). The initial diagnosis was controlled chronic adult periodontitis with horizontal bone loss affecting both the upper and lower dental arches. Peri-implantitis was also present at implant position 34 with no buccal KGT present. The aetiology of the problem was described to the patient, and a suggested treatment plan that involved the elective removal of the implant affected by peri-implantitis was suggested. In addition, we explained that bone loss was present at not only the implant site but also the anterior tooth and that both teeth should be removed to allow for the re-establishment of normal crestal bone at the site. With the elective removal of both the affected implant and anterior tooth, we had to create a stable peri-implant gingival apparatus. As a result, the width of the KGTs required reestablishing. The advantages of using a free split gingival graft was explained to the patient. Advantages included the presence of a stable, wide band of KGT conducive to ease of surgical handling and the carrying out of oral hygiene techniques. Because of the extreme bone loss suffered at site 34, new implants had to be placed at positions 33 and 35. The surgery was divided into three separate interventions as follows:

One hour prior to surgery, the patient received systemic coverage of 2-g amoxicillin, 400-mg ibuprofen and 2-mg dexamethasone. Additionally, a mouth rinse of 2% chlorhexidine gluconate was administered 20 minutes before surgery. The surgery was carried out under intravenous sedation (midazolam) and local anaesthesia (4% articaine, Septodont, Saint-Maur-Des-Fosses, France). The mucoperiosteal flap was raised and tooth 33 and implant 34 were removed with periotomes to preserve the socket walls (Fig. 1F and G). The sockets were debrided of all inflammatory and granulation tissue, but the remaining sulcular epithelium from the soft tissue margin was left intact (Fig. 1H). The lingual soft tissue was then reflected to allow the submucosal placement of a resorbable membrane (Bio-Gide, Geistlich Pharma, Wolhusen, Switzerland) (Fig. 1I). The vacated sockets were then packed with xenograft Bio-Oss (Geistlich Pharma, Wolhusen, Switzerland) with a particle size of 0.25-1.0 mm and covered with Bio-Gide (Fig. 1J and K), thus attempting to re-establish a normal height in the crestal hard tissue. Last, 4.0 Prolene sutures were used to close the wound (Fig. 1L).

Four months postoperatively, a periapical radiograph was taken to display the newly augmented crestal bone (Fig. 1M). Afterward, the second stage of surgery was carried out under the same surgical protocol. The free split gingival graft was carried out using donor tissue from the left palatal vault (Fig. 2A), and the wound was covered with an eugenol-free pack for 7 days. Preparation of the recipient site involved the removal and apical reflection of the supraperiosteal mucosa, and this was sutured into the sulcus with 6.0 Prolene sutures (Ethicon, Johnson and Johnson, Wokingham, Berks, UK). Next, the 'free-graft' from the donor was sutured into the recipient site with 6.0 Prolene sutures (Fig. 2B).

Two months later, the third stage of surgery was performed under the same surgical protocol. The implants were placed by centralizing them to the 'bony ridge' (MIS, SEVEN, Tel Aviv, Israel). The primary stability of all of the inserted implants was high; both implants had an initial seating torque of 50 Ncm as calibrated on the seating apparatus (Implantmed, W&H Dentalwerk, Buermoos, Germany). The final placement of the implants (torque value>50 Ncm) was carried out using a hand wrench. The crestal bone was further augmented with the xenograft (Fig. 3A and B), and periapical radiographs were taken immediately postoperation (Fig. 3C and D).

Five months later, the implants were exposed via a crestal incision displaced to the lingual side, and healing abutments were fitted. The final fixed bridge was fitted eight weeks later (Fig. 4A-C). Periapical radiographs were taken systematically at the bridge fitting and one, six and 12 months postloading (Fig. 4D). All treatments proceeded uneventfully, and the results showed a marked improvement in marginal gingival tissue levels and bone levels (Fig. 5A and B). Every six months, the patient has been examined and radiographs taken, which will continue for two years. After two years, observational radiographs will be taken every 12 months. The patient remains in supportive periodontal therapy.

A 44-year-old Caucasian man was referred to our office to replace implants that were expected to be imminently lost. Over the past five years, the patient reported receiving multiple implant therapies where many of the implants were removed and replaced. There were sites where the implants had been replaced on three occasions during that period. The patient did not understand the aetiology of the loss, had never received oral hygiene instruction or other forms of long-term supportive periodontal therapy and had no concept of peri-implantitis. The initial diagnosis was uncontrolled chronic adult periodontitis with horizontal bone loss affecting both the upper and lower dental arches. Additionally, peri-implantitis was present in varying degrees of aggression at all implant positions. Multiple photographs and radiographs were included in the initial diagnosis. The aetiology of the problem was described to the patient. Supportive periodontal therapy was initiated, and various surgical designs for implantotomywere applied with great success. Because of the degree of bone loss associated with the implant in position 42 (Fig. 6A), the corrective surgical therapy was complicated and divided into two stages as follows:

The same surgical protocol as in the preceding case was followed.

A mucoperiosteal flap was raised to allow full visualization of the affected site (Fig. 6B and C). The site was partially debrided and implant 42 was removed by luxation, which minimizes trauma to the socket walls (Fig. 6D). The socket was debrided of all inflammatory and granulation tissue, but any remaining sulcular epithelium was kept intact in the soft tissue margin (Fig. 6E). The lingual soft tissue was then reflected to allow the submucosal placement of the Bio-Gide membrane (Geistlich Pharma, Wolhusen, Switzerland). The vacant void was then packed with xenograft Bio-Oss (Geistlich Pharma) with a particle size of 0.25-1.0 mm and covered with Bio-Gide. These efforts attempted to re-establish a crestal hard tissue of a normal height. Last, 5.0 Prolene sutures were used to close the wound (Fig. 6F).

Five months postoperatively, a periapical radiograph was taken to display the newly augmented crestal bone (Fig. 7A and B). After that, the implants (MIS, SEVEN) were placed by centralizing them to the 'bony ridge' and following the same surgical protocol (Fig. 7C). The primary stability of both inserted implants was high; both implants had an initial seating torque of 50 Ncm as calibrated on the seating apparatus (Implantmed). Final seating of the implants (torque value>50 Ncm) was carried out using a hand wrench (Fig. 7C). The crestal bone was further augmented with the xenograft and covered with Bio-Gide. Connective tissue was harvested from the right palatal vault and sutured to the underside of the extended, reflected labial mucosal flap (Fig. 7D-F).

Five months later, the implants were exposed via a crestal incision displaced to the lingual side, and healing abutments were fitted. The final fixed bridge was fitted four weeks later (Fig. 8A-D). All of the treatments proceeded uneventfully, and the results showed a marked improvement in marginal gingival tissue levels and bone levels (Fig. 9A and B). To date, the patient has received periodic examinations and radiographs over two years. After two years, observational radiographs will be taken every 12 months. The patient remains in supportive periodontal therapy.