YIJOM-3299; No of Pages 8

Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2015.11.003, available online at http://www.sciencedirect.com

Clinical Paper
Dental Implants

Removal of dental implants: Z. Stajčić1, L. J. Stojčev Stajčić2,

M. Kalanović2, A. Ðinić2, N. Divekar1,
M. Rodić1

review of five different

1
Dental/Medical Clinic of Maxillofacial
Surgery ‘‘Beograd-Centar’’, Belgrade, Serbia;
2
Clinic of Oral Surgery, School of Dentistry,
University of Belgrade, Belgrade, Serbia

techniques
Z. Stajčić, L.J. Stojčev Stajčić, M. Kalanović, A. Ðinić, N. Divekar, M. Rodić:
Removal of dental implants: review of five different techniques. Int. J. Oral
Maxillofac. Surg. 2015; xxx: xxx–xxx. # 2015 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aims of this study were to review five different explantation techniques
for the removal of failing implants and to propose a practical clinical protocol.
During a 10-year period, 95 implants were explanted from 81 patients. Explantation
techniques used were the bur–forceps (BF), neo bur–elevator–forceps (hBEF),
trephine drill (TD), high torque wrench (HTW), and scalpel–forceps (SF)
techniques. The following parameters were analyzed: indications for explanation,
site of implantation, and the type, diameter, and length of the implant removed. The
most frequent indications for implant removal were peri-implantitis (n = 37) and
crestal bone loss (n = 48). The posterior maxilla was the most frequent site of
implant removal (n = 48). The longer implants were more frequently removed
(n = 78). The majority of implants were removed after 1 year in function (n = 69).
The BF/hBEF and SF techniques were found to be the most efficient. Explantation
techniques appeared to be successful for the removal of failing implants. The BF/
Key words: dental implant explantation; dental
hBEF and SF techniques demonstrated 100% success. The hBEF technique enabled implant failure; peri-implantitis; dental implant
safe insertion of a new implant in the same explantation site. The HTW technique complications.
appeared to be the most elegant technique with the highest predictability for
insertion of another implant. An explantation protocol is proposed. Accepted for publication 3 November 2015

The current literature provides ample data on
the high success rates of dental implant
treatment, which range from 90% to 97%.
Failing implants are usually removed either
because of progressive bone loss due to a
peri-implant infection,1,2 frequently associ-
ated with occlusal overload,3 or due to
placement in aesthetically unacceptable
locations.4 Explantation is also performed
on osseointegrated orthodontic implants fol-
lowing the termination of the orthodontic
treatment.5 Furthermore, implants associat-
ed with a good bony and soft tissue condition
are occasionally removed in psychologically
unstable patients.6
Different techniques for dental implant
removal have been proposed in the litera-
ture, such as the use of thin burs or a
trephine drill at low speed under water
cooling,6–8 the use of an electro-surgery
unit to cause thermo-necrosis of the
bone and subsequent weakening of the
bone–implant interface,9,10 and laser-
assisted explantation,11 as well as a removal
torque procedure.12,13
Available data on explantation techni-
ques appear to be inconsistent, therefore
there is no reported unique treatment pro-
tocol for the successful and least traumatic
removal of dental implants. The employ-
ment of less traumatic manoeuvres seems
to be required to create minimal residual
bony defects and spare the soft tissues.

0901-5027/000001+08 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Stajčić Z, et al. Removal of dental implants: review of five different techniques, Int J Oral Maxillofac
Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.11.003
YIJOM-3299; No of Pages 8
2 Stajčić et al.
Ideally, the explantation procedure should
be followed either by the installation of
another implant or by guided bone regen-
eration (GBR), or both at the same sitting,
when indicated.
The aim of this study was to review five
different explantation techniques based on
the authors’ clinical material, in order to
describe their advantages and disadvan-
tages and to offer a practical clinical pro-
tocol for the explantation of failing
implants.
Materials and methods
In this retrospective cohort study, the den-
tal records of 112 patients of both sexes
who had been subjected to the removal of
a total of 129 dental implants over a 10-
year period (2003–2013) were examined.
Seventy patients were referrals. The dental
records of 31 patients from whom 34
implants were removed were excluded
from the study on the basis of the follow-
ing criteria: accidental removal of the
implant (1) at the time of the cover screw
being replaced by the healing abutment
(n = 6); (2) with the tightening force of
35 N cm applied for mounting the abut-
ment (n = 13); (3) as a result of failing
osseointegration without symptoms or
signs of peri-implantitis at routine fol-
low-up (n = 8); (4) becoming loose in
the infected bone (n = 3). All other failing
implants, irrespective of the cause, were
removed using dental forceps and rota-
tional and/or rocking movements only
(n = 4).
The dental records of the remaining 81
patients with a total of 95 implants re-
moved were analyzed with respect to the
effectiveness of the surgical techniques
applied, indications for explantation, the
anatomical distribution of the implants
removed, and the implant types, dia-
meters, and lengths.
Surgical techniques applied in the pres-
ent study are described as the bur–forceps
technique (BF), the neo bur–elevator–for-
ceps technique (hBEF), the trephine drill
technique (TD), the high torque wrench
technique (HTW), and the scalpel–forceps
technique (SF). Apart from the SF tech-
nique, all techniques were used only for
implants indicated for removal with a min-
imum of 1/3 of the threads and that were
well osseointegrated without any mobility.
The bur–forceps technique (BF)
After elevation of a mucoperiosteal flap, a
small sized round and/or fissure bur (Nos.
3–4) is used to remove the bone, usually
from the facial aspect down to the apex of
Please cite this article in press as: Stajčić Z, et al. Removal of dental implants: review of five different techniques, Int J Oral Maxillofac
Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.11.003
the implant, taking care to preserve the
lingual cortex and as much of the bone as
possible mesially and distally (Fig. 1). If
bone resorption is found on the lingual
side (this occurred in two cases), with the
facial cortex intact, then the bony defect is
deepened on the lingual side sparing the
facial cortex. The implant is then grasped
with the dental forceps and an attempt
made to remove it by rotational and slight
rocking movements, similar to tooth ex-
traction. If this is not feasible, more bone
is drilled out until it is possible to either
unwind it or luxate it towards the bone-
removed region, thus creating a three-wall
bony defect.
The neo bur–elevator–forceps technique
(hBEF)
This technique commences with the re-
moval of bone mesially and distally from
the implant, aiming towards the apex.
Round and/or fissure burs (No. 1) are used,
with copious running saline, trying to
maintain a close distance to the implant
surfaces (Fig. 2A). The implant head is
grasped with the corresponding tooth/Lyer
forceps and turned clockwise and anti-
clockwise. When resistant to such
attempted movements, a thin straight ele-
vator (Couplands elevator No. 3) is placed
Fig. 1. Failing implants in the posterior max-
illa removed using the bur–forceps (BF) tech-
nique. (A) Preoperative condition with the
bone loss affecting the buccal aspect of the
implants. (B) Three-sided bone defects fol-
lowing explantation.
into the mesial and distal crevices, inter-
mittently applying small gentle rotating
movements similar to those used for the
extraction of buried roots, until the im-
plant is noted to be slightly tilted to one
side (Fig. 2B). Then, the elevator is placed
into the crevice on the contralateral side
and similar movements performed. The
implant head is then grasped with dental
extraction forceps and gentle rocking
movements applied, pushing it mesially
and distally only, thus preserving both the
facial and the lingual cortical plates
(Fig. 2B). When little resistance is felt,
the implant is removed with a final anti-
clockwise rotation leaving an ovoid defect
(Fig. 2C).
The trephine drill technique (TD)
An appropriate trephine drill with a diam-
eter and length corresponding to the size
of the implant to be removed is selected
(Fig. 3A). The healing abutment or abut-
ment/crown is unscrewed and a mucoper-
iosteal flap raised if necessary. The
trephine drill is sunk over the implant into
the bone using low speed 50–80 rpm dril-
ling and light pressure with running saline
cooling. A hole is drilled taking care that
the trephine has been sunk to the exact
depth by controlling the outside rings on
the drill. For implant systems that do not
provide a guiding cylinder/pin, a healing
abutment of smallest emergence profile
diameter is mounted before using the tre-
phine. For Straumann Standard and Stan-
dard Plus implants, the polished neck is
reduced with a high-speed diamond drill to
correspond to the diameter of the guided
cylinder (Fig. 3B). In the event that the
implant is still firm after the trephine has
been lifted (in cases of insufficient drilling
depth), a Couplands elevator is placed into
the empty space and lightly twisted to
break the bony connections, enabling easy
removal of the implant using the finger-
tips.
The high torque wrench technique (HTW)
For the patients included in this study, the
Neo Fixture Remover Kit (Neobiotech
Co., Korea) was used for this technique.
The compatibility list was consulted first
to determine the correct dimension of the
fixture remover screw and the implant
remover to fit to the implant chamber
and outer diameter, respectively.
The procedure commences with the re-
moval of the cover screw or the abutment
of the implant to be removed. The fixture
remover screw is inserted clockwise
(Fig. 4A) and tightened using the torque
YIJOM-3299; No of Pages 8

Removal of dental implants 3

Fig. 3. The trephine drill (TD) technique. (A)

The trephine drill is selected to match the
diameter of the failing implant. (B) Before
using the trephine drill for the removal of a
Straumann Standard or Standard Plus implant,
the polished neck is trimmed with a diamond
bur to the size of the implant body diameter.

wrench with a torque of 50 N cm

(Fig. 4B). The fixture remover screw,
which features a specific thread design
at the apical tip, is attached to the receiv-
ing implant chamber, while the opposite
end has a fixed constant diameter. The
next instrument, named the implant re-
mover, is manually screwed onto the free
end of the fixture remover screw in an anti-
clockwise direction (Fig. 4C). Once the
implant remover has been seated, the dy-
namometric ratchet is set in an anti-clock-
wise direction and force applied to unwind
the implant (Fig. 4D). It usually takes a
few seconds until less resistance is felt.
During this time, the implant and the
surrounding bone are cooled using saline,
since an increase in bone temperature is
expected as a result of high friction (300–
500 N cm). After one to two turns with the
torque wrench, almost no resistance is
usually felt and the implant is manually
unscrewed (Fig. 4E). If the implant does
not become loose despite maximal torque
Fig. 2. Three failing implants in the mandible. The central implant was planned for implantoplasty
to support the provisional bridge, whereas the lateral ones were indicated for removal. The distant applied, the implant remover is temporar-
one was removed using the high torque wrench (HTW) technique, whereas the mesial implant with ily removed, and a No. 1 round bur used to
the fractured neck was removed with the neo bur–elevator–forceps (hBEF) technique. (A) The remove the bone around the implant neck
distal implant was removed and a new one inserted. The bone was removed mesially and distally down to the second or third thread; the
around the mesial implant using a No. 1 round bur and fissure burs. (B) A No. 3 Couplands elevator implant remover is then mounted again,
was placed into the bone crevice on both sides intermittently and slight rotational movements applying sufficient torque until the implant
applied until the implant was tilted. (C) The defect was of an ovoid shape with well preserved facial becomes loose. Following the termination
and lingual cortices ready for the insertion of a new implant (not shown). of the procedure, when successful, the

Please cite this article in press as: Stajčić Z, et al. Removal of dental implants: review of five different techniques, Int J Oral Maxillofac
Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.11.003
YIJOM-3299; No of Pages 8

4 Stajčić et al.

Fig. 4. The high torque wrench (HTW) technique. (A) The fixture remover screw is mounted onto the failing implant manually. (B) The fixture
screw is tightened with the high torque wrench, with a torque of 50 N cm, clockwise. (C) The implant remover is manually screwed onto the free
end of the fixture remover screw in an anti-clockwise direction. (D) The wrench is set and the force applied in an anti-clockwise direction. (E) After
1–2 turns with the torque wrench, the implant is manually unscrewed.

implant is removed together with the fix-
ture remover screw and the implant re-
mover. The implant remover and the
fixture remover screw are dismantled from
the removed implant by simultaneous use
of the torque wrench and the pliers, firstly
turning the implant remover clockwise
and secondly the fixture remover screw
anti-clockwise.
Re-use of the fixture remover screw and
implant remover is possible with caution.
The fixture remover screw may be re-used
once or twice provided that a low unwind-
ing force has been applied. The implant
remover, however, may be re-used more
frequently, until the tips become blunt.
The scalpel–forceps technique (SF)
This technique was used only for implants
with an old-fashioned blade design, as
well as ‘basal osseointegrated implants’
(BOI),14 which are supposed to be an-
chored to the bone by a combination of
osseointegration and connective fibrous
tissue bands, formerly defined as ‘fibro-
osseointegration’.15
The Linkow-type blade vent implant
head is grasped with dental forceps and
a luxation movement started with constant
pulling.16 The scalpel is used to sever the
connective tissue bands all around the
implant. This may take some time, and
despite wobbling and mobility, it is not
possible to extract the implant until the last
connective tissue band is released
(Fig. 5A–C). For BOI, in the event that
the horizontal part is bent, this must first
be straightened with Lyer forceps and the
implant head grasped with dental forceps
with one hand. The scalpel in the other
hand is used to sever the connective tissue
while the implant is pulled constantly
towards the lateral aspect of the jaw until
the least resistance is felt.
Results
A total of 95 implants were removed. Of
these 95 implants, 53 were removed from
the maxilla and 42 from the mandible. The
indications for explantation were recurrent
peri-implantitis not responding to treat-
ment in 37 cases, crestal bone loss in 48
cases, neurosensory deficit of the inferior
alveolar nerve as a result of compression
in two cases, chronic periodontitis of the
neighbouring teeth affecting the implant
in five cases, implant fracture in two cases,
and osteomyelitis in one case. The ana-
tomical distribution of the implants re-
moved and the implant types, diameters,
and lengths are described in Table 1. The
posterior maxilla was the most frequent
site of implant removal (n = 48), followed
by the posterior mandible (n = 35). The
majority of implants (n = 69) were
removed after a minimum of 1 year in
function. The longer implants were more
frequently removed (n = 78) when
compared to implants with a length of less
than 8 mm (n = 17).
It was possible to insert another implant
at the same sitting in 23 explantation sites.
Of these, 17 were inserted following the
use of the HTW technique, five following
the hBEF technique, and one following
the TD technique. Of the 23 inserted
implants, two failed osseointegration (af-
ter 4 and 6 months respectively); new
implants were inserted and are still in
function 2 years after placement. The
remaining 72 explantation sites that were
left open healed uneventfully.
Explantation techniques according to
the implant type and diameter are shown
in Table 2. With regard to the efficacy of
the techniques applied, the BF/hBEF tech-
niques proved to be the most efficient
(Table 3). The TD technique failed in
two out of 19 attempts, whereas the
HTW technique failed in five out of 32
cases. The hBEF technique proved suc-
cessful even when TD and HTW failed
(seven cases). The time scale of the use of
the implant removal techniques is summa-
rized in Table 4.
Discussion
The number of implants placed has in-
creased dramatically over the last decade,
thus the number of failures is expected to
grow accordingly. This necessitates the
involvement of the implant industry in

Please cite this article in press as: Stajčić Z, et al. Removal of dental implants: review of five different techniques, Int J Oral Maxillofac
Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.11.003
YIJOM-3299; No of Pages 8
Fig. 5. The scalpel–forceps (SF) technique.
(A) Preoperative radiographic image of a
failing Linkow-type blade implant in the up-
per jaw. (B) The implant-supported crown is
grasped with the dental forceps after the fi-
brous bands around the implants have been
severed with a scalpel. (C) The removed
implant with the soft tissue capsule around it.
providing the required equipment, as well
as implant surgeons to develop new sur-
gical techniques that can be used not only
to remove a failing implant with very little
damage, but also to insert another one at
the same implant site when indicated.
Changes in the implant industry have
led us to modify our surgical technique
dramatically (Table 4). Until 2010, BF/
hBEF and TD were used almost exclu-
sively for the removal of failing implants,
whereas within the last 3 years, the HTW
technique has become the first choice
treatment (71%) because of its simplicity
and elegance, as well as predictable inser-
tion of another implant at the same osteot-
omy site.
It has been reported that the following
occurrences can contribute to an increase
Please cite this article in press as: Stajčić Z, et al. Removal of dental implants: review of five different techniques, Int J Oral Maxillofac
Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.11.003
in the implant failure rate: a low insertion
torque of implants that are planned to be
loaded immediately or early, an inexperi-
enced surgeon inserting the implants, im-
plant insertion in the maxilla, implant
insertion in the posterior regions of the
jaws, implants in heavy smokers, implant
insertion in bone quality of types III and
IV, implant insertion in places with small
bone volumes, the use of shorter length
implants, a greater number of implants
placed per patient, lack of initial implant
stability, use of cylindrical (non-threaded)
implants and prosthetic rehabilitation with
implant-supported overdentures, the use
of the non-submerged technique, immedi-
ate loading, and implant insertion in fresh
extraction sockets, as well as the use of
smaller diameter implants.17 However,
crestal bone loss and peri-implantitis were
the most frequent causes of implant re-
moval in the present study, although the
sample was too small for definite conclu-
sions to be drawn.
This study showed that explantation
techniques are generally efficient, with a
low failure rate; BF/hBEF proved to be
100% successful and can be recommended
as a safe and reliable technique should
others fail. The SF technique was applied
for old-fashioned blade vent implants,
which have not been in use in the last
three decades, as well as for BOI, which
have been employed sporadically; thus it
is expected that this technique will be used
rarely and is not a matter of further dis-
cussion.
Irrespective of the efficacy of explan-
tation techniques, two patients with neu-
rosensory deficit of the inferior alveolar
nerve did not improve following success-
ful removal of the implants causing symp-
toms.
When the BF, hBEF, TD, and HTW
techniques are compared on the basis of
technical requirements, the time required
for their execution, and on patient and
surgeon compliance, it should be empha-
sized that the BF and hBEF techniques
proved to be the most reliable, versatile,
and predictable; however, they are not
well accepted by patients because of the
drilling noise, force applied, and the
length of time needed. The HTW and
TD techniques have been shown to be
quick, elegant, and well accepted by both
patients and surgeons; however they have
limitations that need further elaboration.
With regard to the HTW technique,
specially designed instruments or kits
are needed, which vary from company
to company (the Straumann 48 h explan-
tation device (Straumann), the Neo Fix-
ture Remover Kit (Neobiotech), BTI
Removal of dental implants 5
Implant Extraction System (Biotechnolo-
gy Institute S.L.), Implant Retrieval Tool
(Nobel Biocare)). In essence, two types of
instrument are used, one of a screw-type to
engage the implant and the other a high-
torque dynamometric ratchet to unwind
the implant. These kits have recently been
brought to the dental market and therefore
data on their use in the literature are
scarce.12 The use of removal torque for
explantation of orthodontic mini-implants
has already been documented in the liter-
ature.13,18,19 Since orthodontic mini-
implants have a diameter not larger than
2 mm and length of 7–17 mm, the reported
removal torque values have been smaller
than those required for unscrewing dental
implants of a standard diameter and
length.13,18 A more recent retrospective
longitudinal study described the Biotech-
nology Institute extraction kit for explan-
tation, which consists of a wrench that
allows a 200 N cm counter-torque force,
an internal connection extractor, an ex-
tractor for external connection, and a set of
ratchet handle extension pieces. This tech-
nique appears to be the least traumatic and
biologically acceptable, since after it has
been used there is almost no bony defect
left except an empty implant bed prepara-
tion site.12 These findings correlate with
the results found in the present study.
However, HTW has its limitations.
Open systems such as the Neobiotech
Fixture Remover Kit, which was used
for patients included in the present study,
despite versatility and a compatibility list,
lack a perfect fit for less known implants;
in such cases, trial-and-error often has to
be used to determine the corresponding
diameter of the fixture remover screw.
Fracture of the fixture remover screw is
likely should high torque be applied. In the
case of vertical implant fracture during
installation when excessive torque is ap-
plied (as has happened in our patients
using narrow platform NobelReplace or
NobelActive implants), this explantation
technique has not been feasible. With
regard to osseointegrated Straumann Stan-
dard or Straumann Standard Plus implants
in the mandible, the implant remover may
dig into the polished neck of the implant
damaging it without being able to unwind
it, as occurred in two cases in the present
study (Table 2). In these two cases, hBEF
was used successfully following failed
HTW.
The TD technique, despite its simplicity
in use, has been shown to be unpredictable
when utilized without a guiding cylinder/
pin, since it may be difficult to follow
the implant axis; either a considerable
distortion of the drill and the implant
YIJOM-3299; No of Pages 8

6 Stajčić et al.
Table 1. Characteristics of implants removed and the anatomical site of insertion according to the type of implant and the implant diameter.
Implant Anatomical region
Implant type and diametera
Length Time span in function Mandible Maxilla
!8 mm "10 mm <3 months 3–12 months >12 months Anterior Posterior Anterior Posterior
Narrow diameter
Straumann
Standard 5 5 1 2 2
Bone level 1 1 1
Nobel Biocare
Replace Select Tapered 2 1 1 1 1
NobelActive 3 1 1 1 1 1 1
Regular diameter
Straumann
Standard 9 9 5 4
Hollow Screw 2 2 2
Nobel Biocare
Replace Select Tapered 2 12 2 2 10 1 4 9
Brånemark MKIII 3 17 1 3 16 2 6 2 10
NobelActive 1 6 3 4 2 5
Osstem 1 1 1
Wide diameter
Straumann
Standard 4 4 4
Nobel Biocare
Replace Select Tapered 2 4 3 3 2 4
NobelActive 1 3 1 1 2 2 2
Miscellaneous
Linkow blade vent 2 2 2
BOI implantb 4 4 2 2
Unknown 4 7 3 2 6 5 6
Total 17 78 8 18 69 7 35 5 48
a
Narrow diameter 3.0–3.5 mm; regular diameter 3.75–4.3 mm; wide diameter "4.8 mm.
b
Basal osseointegrated implant.
Table 2. Explantation techniques according to the implant type and the diameter.a
Implant type and diameterb BF/hBEF TD HTW SF Total
Narrow diameter
Straumann
Standard 3 2 (2)c 5
Bone level 1 1
Nobel Biocare
Replace Select Tapered 1 1 2
NobelActive 1 2 3
Regular diameter
Straumann
Standard 5 4 9
Hollow Screw 1 1 2
Nobel Biocare
Replace Select Tapered 8 6 14
Brånemark MKIII 4 11 (2) 5 (1) 20
NobelActive 1 6 7
Osstem 1 (1) 1
Wide diameter
Straumann
Standard 4 4
Nobel Biocare
Replace Select Tapered 3 3 6
NobelActive 1 3 (1) 4
Miscellaneous
Linkow blade vent 2 2
BOI implantd 4 4
Unknown 5 3 3 11
Total 38 19 32 6 95
a
BF: bur–forceps technique; hBEF: neo bur–elevator–forceps technique; TD: trephine drill technique; HTW: high torque wrench technique;
SF: scalpel–forceps technique.
b
Narrow diameter 3.0–3.5 mm; regular diameter 3.75–4.3 mm; wide diameter "4.8 mm.
c
The figure in brackets denotes the number of unsuccessful attempts.
d
Basal osseointegrated implant.

Please cite this article in press as: Stajčić Z, et al. Removal of dental implants: review of five different techniques, Int J Oral Maxillofac
Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.11.003
YIJOM-3299; No of Pages 8

Removal of dental implants 7

Table 3. Success rate of explantation techniques used for the removal of implants.
Explantation techniquea
Successful removal
BF/hBEF TD HTW SF Total
Yes 38 17 27 6 88
No 0 2 5 0 7
Total 38 19 32 6 95
a
BF: bur–forceps technique; hBEF: neo bur–elevator–forceps technique; TD: trephine drill technique; HTW: high torque wrench technique;
SF: scalpel–forceps technique.

Table 4. Explantation techniques used for the removal of implants according to the time scale of
use.
Explantation techniquea
Time scale of implant removal
BF/hBEF TD HTW SF Total
2003–2010 29 19 0 2 50
2010–2013 9 0 32 4 45
Total 38 19 32 6 95
a
BF: bur–forceps technique; hBEF: neo bur–elevator–forceps technique; TD: trephine drill
technique; HTW: high torque wrench technique; SF: scalpel–forceps technique.
has occurred or an unwanted quantity of The BF technique has been used for
bone removed. We have abandoned the many years in implant dentistry, long be-
use of TD in narrow alveolar ridges where fore HTW and TD were introduced into
narrow platform implants are usually clinical practice. In this study it was re-
inserted and in cases where the cortical served for the removal of failing implants
thickness around implants has been less without a gap to the neighbouring tooth/
than 1.5 mm, irrespective of the alveolar implant and in cases of HTW failure. It has
bone width. In such instances either a very been shown to be a time-consuming and
thin cortical plate remains or a through- occasionally tedious procedure, especially
and-through bony defect can be created. when drilling out implants of considerable
Furthermore TD is not indicated in cases length (14–16 mm). When thick cortical
where there is no gap between the failing bone has to be removed over the implant
implant and the neighbouring tooth/im- length, a bur can slip and dig into the
plant, since they can be damaged during implant surface, thus the wound becomes
the procedure. contaminated by metal dust or particles.
Fig. 6. Explantation protocol for a failing implant in relation to the proximity of the
neighbouring tooth/implant. BF: bur–forceps technique; hBEF: neo bur–elevator–forceps
technique; TD: trephine drill technique; HTW: high torque wrench technique.
During the removal of fully osseointe-
grated implants in the mandible, substan-
tial damage to the implant surface can
occasionally be expected as a result of
laborious attempts to remove the cortical
bone around it. This metal contamination
may interfere with GBR procedures in
cases where this is planned as an immedi-
ate treatment. It has proved feasible to
insert a new implant into the explantation
site, however with complex manoeuvres
that require soft tissue management, GBR,
and lateral augmentation. We are of the
opinion that it would be more predictable
to perform GBR alone and postpone im-
plant placement following the use of the
BF technique.
The hBEF technique has been devel-
oped as a novel approach resulting from
the increased interest of patients with fail-
ing implants to receive a new implant
immediately after the failing one has been
removed. The trigger was the difficulty
unwinding a failing implant despite the
fact that only small portion of it was
osseointegrated. It was observed by
chance that it is feasible to dislodge failing
implants by pushing them either with an
elevator or with dental forceps. This tech-
nique has demonstrated its predictability,
especially in preserving facial and lingual
cortices, thus enabling the insertion of a
new implant, occasionally of the same
length and diameter. It is certainly more
predictable to use a slightly larger diame-
ter when feasible. In such cases, the avail-
ability of different implants systems,
diameters, and lengths can be of great
assistance. Thus, the diameters of failing
implants removed using this technique of
3.3 mm, 3.5 mm, 3.75 mm, 4.0 mm, and
4.1 mm have been replaced successfully
with implants of 3.5 mm, 3.75 mm,
4.0 mm, 4.1 mm, and 4.3 mm diameters,
respectively; this can be achieved using
Straumann and Nobel implants, as was the
case in the present study. It can be specu-
lated that the preservation of the facial/
lingual cortex, as well as minimal bone
loss mesial and distal to the implant
and the creation of an ovoid crestal defect
that can easily be grafted (Fig. 2C), are
responsible for the predictability of this

Please cite this article in press as: Stajčić Z, et al. Removal of dental implants: review of five different techniques, Int J Oral Maxillofac
Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.11.003
YIJOM-3299; No of Pages 8
8 Stajčić et al.
technique. With the introduction of the
HTW technique it has been used less
frequently and is reserved for cases of
HTW failure or for the removal of frac-
tured implants.
All five explantation techniques
reviewed, namely BF, hBEF, TD, HTW,
and SF, appeared to be successful in re-
moving failing implants. The BF/hBEF
and SF techniques demonstrated 100%
success. The hBEF technique enabled safe
insertion of a new implant at the same
explantation site. SF is reserved for blade-
type implants. The HTW technique
appears to be the most elegant, with the
highest predictability of insertion of an-
other implant during the same sitting with-
out the need for additional procedures.
The TD technique is a straightforward
technique when used with a guiding pin;
the indication for this technique is limited
to cases with thin crestal cortical bone, as
well as cases where there is no gap be-
tween the failing implant and the adjacent
tooth/implant.
An explantation protocol is proposed.
The selection of the explantation tech-
nique, as far as screw-type implants is
concerned, depends on two factors: the
proximity of the failing implant to the
neighbouring tooth/implant and the corti-
cal thickness around it. Taking these into
consideration and based on the simplicity
of the procedure as well as the possibility
of insertion of a new implant in the ex-
plantation site, the explantation protocol
shown in Fig. 6 is proposed.
Funding
None.
Competing interests
None.
Please cite this article in press as: Stajčić Z, et al. Removal of dental implants: review of five different techniques, Int J Oral Maxillofac
Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.11.003
Ethical approval
Ethical approval was obtained (Eticki
komitet Drustva privatnih doktora stoma-
tologije Srbije, No. 1/2015).
Patient consent
Not required.
References
1. Albrektsson T, Buser D, Sennerby L. Crestal
bone loss and oral implants. Clin Implant
Dent Relat Res 2012;14:783–91.
2. Fransson C, Wennstrom J, Berglundh T.
Clinical characteristics at implants with a
history of progressive bone loss. Clin Oral
Implants Res 2008;19:142–7.
3. Heckmann SM, Linke JJ, Graef F, Foitzik C,
Wichmann MG, Weber HP. Stress and in-
flammation as a detrimental combination for
peri-implant bone loss. J Dent Res
2006;85:711–6.
4. Duyck J, Naert I. Failure of oral implants:
aetiology, symptoms and influencing factors.
Clin Oral Investig 1998;2:102–14.
5. Favero LG, Pisoni A, Paganelli C. Removal
torque of osseointegrated mini-implants: an
in vivo evaluation. Eur J Orthod
2007;29:443–8.
6. Ten Bruggenkate CM, Sutter F, Schroeder A,
Oosterbeek HS. Explantation procedure in
the F-type and Bonefit ITI implant system.
Int J Oral Maxillofac Surg 1991;20:155–8.
7. Covani U, Barone A, Cornelini R, Crespi R.
Clinical outcome of implants placed imme-
diately after implant removal. J Periodontol
2006;77:722–7.
8. Covani U, Marconcini S, Crespi R, Barone
A. Immediate implant placement after re-
moval of a failed implant: a clinical and
histological case report. J Oral Implantol
2009;35:189–95.
9. Cunliffe J, Barclay C. Removal of a dental
implant: an unusual case report. J Dent
Implants 2011;1:22–5.
10. Massei G, Szmukler-Moncler S. Thermo-
explantation. A novel approach to remove
osseointegrated implants. Eur Cell Mater
2004;7(Suppl. 2):48.
11. Smith LP, Rose T. Laser explantation of a
failing endosseous dental implant. Aust Dent
J 2010;55:219–22.
12. Anitua E, Orive G. A new approach for
atraumatic implant explantation and imme-
diate implant installation. Oral Surg Oral
Med Oral Pathol Oral Radiol 2012;113:
e19–25.
13. Chen YJ, Chen YH, Lin LD, Yao CC. Re-
moval torque of miniscrews used for ortho-
dontic anchorage—a preliminary report. Int
J Oral Maxillofac Implants 2006;21:283–9.
14. Besch KJ. A consensus on basal osseointe-
grated implants (BOI). The Implantoral-
Club Germany (ICD). Schweiz Monatsschr
Zahnmed 1999;109:971–2.
15. Oleinick AJ. Osseointegration versus fibro-
osseointegration: review of endosseous
dental implant systems. Gen Dent 1993;41:
406–8.
16. Linkow LI, Mahler MS. Validating the end-
osteal blade-vent implant. Oral Health
1975;65:16–23.
17. Chrcanovic BR, Albrektsson T, Wennerberg
A. Reasons for failures of oral implants. J
Oral Rehabil 2014;41:443–76.
18. Simon H, Caputo AA. Removal torque of
immediately loaded transitional endosseous
implants in human subjects. Int J Oral Max-
illofac Implants 2002;17:839–45.
19. Okazaki J, Komasa Y, Sakai D, Kamada A,
Ikeo T, Toda I, et al. A torque removal study
on the primary stability of orthodontic tita-
nium screw mini-implants in the cortical
bone of dog femurs. Int J Oral Maxillofac
Surg 2008;37:647–50.
Address:
Zoran Stajčić
Dental/Medical Clinic of Maxillofacial
Surgery ‘‘Beograd-Centar’’
Kraljice Natalije 35
Belgrade 11 000
Serbia. Fax: +381 11 3610 764
E-mail: beogradcentar@icloud.com