Clinical Oral Investigations (2020) 24:47–60

https://doi.org/10.1007/s00784-019-03127-0

REVIEW

Removal of osseointegrated dental implants: a systematic review

of explantation techniques
Margaux Roy 1 & Lucie Loutan 1 & Giovanni Garavaglia 2 & Dena Hashim 1

Received: 20 April 2019 / Accepted: 16 October 2019 / Published online: 15 November 2019
# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Objectives This systematic review aims to evaluate current literature regarding available techniques for removal of
osseointegrated implants in terms of explantation’s success, complications, and bone loss.
Material and methods Two reviewers conducted a systematic literature search through electronic databases (PubMed and
EMBASE), complimented by manual and grey literature searches. Successful explantation was defined as the primary outcome.
Complications and availability of residual bone for immediate implantation were defined as secondary outcomes.
Results Eighteen articles, comprising 372 implants and 241 patients, were included. Five techniques were identified: reverse
torque, trephines, burs, piezosurgery, and laser-assisted explantation. Peri-implantitis was the most common reason for explan-
tation, followed by crestal bone loss, fracture, and malpositioning. The reverse torque was the most frequently reported technique
(284 implants) with 87.7% success rate. Burs were used for explantation of 49 implants with a 100% success rate, while trephines
were utilized for removal of 35 implants with 94% success. Piezosurgery (11 implants) and Er.Cr:YSGG laser (1 implant)
showed 100% success. One study reported perforation of the sinus floor following trephine explantation, while another reported
fracture of 3 implants following reverse torque application. Further analysis was hindered by the quality of the available studies
and their lack of data.
Conclusions Reverse torque seems the most conservative, and in the authors’ opinion, should be the first choice for explantation
despite its inferior success rate. Additional studies with randomized controlled designs and larger sample sizes are required.
Clinical relevance Dental implants have become the leading choice to replace missing teeth with gradually increasing numbers of
complications and failures. An effective, conservative, and economic explantation technique is necessary to allow a successive
implant placement.

Keywords Explantation . Removal . Implants . Systematic review

Introduction
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00784-019-03127-0) contains supplementary Dental implants have become the leading choice to restore lost
material, which is available to authorized users. function and esthetics for edentulous and partially edentulous
patients. Nowadays, implant-supported reconstructions are
* Margaux Roy considered a reliable treatment option with an overall survival
margaux.roy@unige.ch rate of 97.1% over 5 years [48], 96.5% over 10 years, and
94.6% after 20 years [40]. However, about 34% of complica-
Lucie Loutan
lucie.loutan@unige.ch
tions, whether technical, biological, or esthetic, occur within
the first 5 years [48]. The annual implant failure rate ranges
Dena Hashim from 0.39 to 0.81% [49], with 70% of failures occurring after
dena.hashim@unige.ch
prosthetic loading [40]. Peri-implantitis is the most frequent
1
Division of Periodontology, University Clinics of Dental Medicine, complication impacting 20% of patients and 10% of implants
University of Geneva, 1 Rue Michel-Servet, CH-1211 Geneva [38]. This destructive inflammatory process affects both soft
4, Switzerland and hard tissues, leading to pocket formation and progressive
2
Geneva, Switzerland bone resorption around osseointegrated oral implants.
48
Explantation may be indicated in advanced stages with severe
bone loss when the infection cannot be eradicated. Incorrect
implant position, affecting esthetics or preventing prosthetic
rehabilitation, may also necessitate fixture removal. In addi-
tion, metal fatigue due to overloading, para-functional activi-
ties such as bruxism, and peri-implant bone loss could lead to
implant fracture [9, 13, 50, 59]. The risk of fracture is also
related to the material itself, as well as the implant’s localiza-
tion in the oral cavity, its design, diameter, and length [21, 35,
60]. The type and quality of the prosthetic reconstruction,
including the implant-abutment connection, have significant
effects on the reliability of the different implant components
[6, 60]. Nevertheless, fracture of the implant’s body, or its
prosthetic parts, remains a rare complication, with implant
fracture occurring in 0.02 to 0.5% of cases over a period of
5 years [49]. When feasible, complete explantation of all frag-
ments is recommended. However, mere removal of the mobile
fragments, alteration of the fractured implant or prosthesis,
and even implant apicectomy have been reported [5, 18, 21].
Regardless of the reason for explantation, being able to
safely remove an osseointegrated implant is imperative.
Proper planning is fundamental in order to minimize treatment
time, side effects, and cost. The quantity of peri-implant resid-
ual bone, the proximity of vital anatomical structures, and the
implant’s design should be evaluated [58]. The implant’s sur-
face microstructure also affects the strength of the
osseointegration and hence the forces required for explanta-
tion [8]. Maximal preservation of bone and the feasibility of
future implant placement should be prioritized [1, 11].
Another factor to consider is the retrievability of the prosthetic
suprastructures. Removal of permanently cemented crowns
and bridges may be long and tedious. Their complete destruc-
tion may sometimes be required in order to access the im-
plant’s inner structure. Broken screws or damaged abutments
could also complicate implant removal and limit the choice
between different explantation techniques [52].
Multiple explantation techniques have been reported in the
literature with variable success rates. But thus far, very little is
known regarding the different aspects of each technique with
respect to benefits, limitations, and overall success rates.
Moreover, universal explantation protocols with clear indica-
tions and guidelines are still lacking. Therefore, the aim of this
systematic review was to evaluate the current literature regard-
ing available explantation techniques in terms of success rates,
complications, and bone loss. Success rate was defined as the
percentage of implants that could be removed among a num-
ber of explantation attempts.
Material and methods
This review was performed according to the Preferred
Reporting Items for Systematic Reviews and Meta-analyses
Clin Oral Invest (2020) 24:47–60
Protocol (PRISMA-P) guidelines [36] and the recommenda-
tions of Needleman [42].
The focused question
The focused question was defined according to the PICO
method [42]:
Population: Human subjects with osseointegrated oral im-
plants requiring explantation
Intervention: Removal of osseointegrated endosseous
implants
Comparison: Explantation techniques
Outcomes: Success rate was set as the primary outcome,
which was defined as the percentage of implants that can be
successfully removed using a specific technique.
Complications (intra-operative and/or post-operative) and
availability of sufficient residual bone for immediate implan-
tation were defined as secondary outcomes.
Therefore, the focused question was formulated as: “In
subjects requiring removal of osseointegrated dental implants,
how effective are the current explantation techniques in terms
of success, complications and bone loss?”
Inclusion criteria
Publications were included on the basis of the following
criteria: (i) English language, (ii) human studies, (iii)
endosseous osseointegrated dental implants, (iv) explantation
technique described, and (v) reason for explantation clearly
reported.
Exclusion criteria
Publications not fulfilling the eligibility criteria were not in-
cluded in this analysis. Reviews, in vitro and animal experi-
ments, expert opinions, communications, and studies where
full texts could not be obtained were all excluded. Zygomatic,
palatal, pterygoid, non-screw type fixtures, basal, bi-cortical,
and transitional implants were also eliminated.
Search strategy
A systematic literature review was performed using online
electronic databases (PubMed and EMBASE). This was
complemented by manual and grey literature searches, includ-
ing unpublished studies and articles published in non-
academic journals. The publication year was not limited in
order to include the first available study until August 23,
2018. The electronic search was conducted using the follow-
ing terms: “dental implant” OR “oral implant” AND “explan-
tation,” “dental implant” OR “oral implant” AND “implant
removal,” “failing implant” AND “explantation,” “failing
Clin Oral Invest (2020) 24:47–60
implant” AND “implant removal,” “failing implant” AND
“implant extraction.”
Study selection
Titles and abstracts derived from the initial search were inde-
pendently screened by two authors (MR and LL). Studies
were selected for full-text analysis and data extraction after
mutual agreement. Disagreements were resolved by discus-
sion and Cohen’s kappa was used to measure the inter-
reviewer agreement.
Data extraction
Studies selected for inclusion were analyzed and the following
data parameters were extracted: study design, number of pa-
tients, number of implants removed, implant system, reason
for explantation, explantation technique and its success or
failure, complications, flap access, socket grafting, and imme-
diate implant placement.
Quality assessment
The QUADAS-2 tool [69] was utilized for quality assessment.
Studies were evaluated to have high, low, or unclear degrees
of bias by two examiners (DH, MR). Any disagreement was
resolved by discussion.
Results
Literature search
The electronic database search identified 2197 articles. After
removing duplicates, references were screened and 130 titles
were considered eligible for further consideration. One-
hundred nineteen abstracts were evaluated and 86 references
were further excluded. Thirty-three articles were then
reviewed in details resulting in the inclusion of 15 studies.
Three more were selected through a manual research resulting
in the final inclusion of 18 publications (Table 1). The two
reviewers agreed on the classification of 30 out of 33 articles
with an estimated kappa of 0.81 (Fig. 1).
Quality assessment
Table 2 shows the estimated risk of bias for all the included
studies. Five articles were case series, 10 were case reports
describing 1 to 9 cases. Only 3 publications reported on com-
paratively large sample sizes [1, 2, 58]. Moreover, none of the
studies included control groups or any blinding measures.
Descriptive statistical analysis was attempted in 3 studies [1,
49
2, 58]. Therefore, all 18 included publications were consid-
ered at a high risk of bias.
Excluded studies
Out of the 33 studies reviewed in detail, 15 were excluded
from the final analysis (Table 3). The main reasons for exclu-
sion were:
& Review or expert opinion
& Unclear description of the explantation technique
& Studies exclusively describing explantation of non-
osseointegrated, blade or transitional implants
& Implants retrieved for histomorphometric purposes
& Full-text articles could not be obtained.
Description of the included studies
Details of the 18 included studies are presented in Table 1.
Unfortunately, only one was designed as a prospective study
[2], two were retrospective evaluations [1, 58], while the re-
maining 15 were case series or reports evaluating 1 to 9 im-
plants at most. Overall, 241 patients and 372 implants were
included in this analysis, with three studies [1, 2, 58], contrib-
uting 158, 91, and 95 implants, respectively. Five different
explantation techniques could be identified in this review:
the reverse torque technique [1, 2, 33], the utilization of tre-
phine drills [7, 15, 23, 24, 41, 44, 68], diamond or carbide burs
[10, 30], piezosurgery [32, 34], lasers [56], or combinations of
different techniques [16, 28, 58]. The most common reason
for explantation was peri-implantitis followed by crestal bone
loss, reported on 59.9% and 16.7% of implants respectively. A
total of 10.8% of fixtures were removed due to fracture of the
implant or prosthetic components, 8.4% due to malpositioning
and 1.4% due to neurosensory deficit of the jaws.
Bisphosphonate-related osteonecrosis of the jaw (BRONJ)
and osteomyelitis were rarely reported as reasons for explan-
tation (Table 4).
Owing to the studies’ designs, the relatively small sample
sizes reported in most publications and the diversity of the
explanation techniques, meta-analysis could not be per-
formed. Hence, the results will be presented in a narrative
review. Table 5 summarizes the success rate of each
technique.
The reverse torque technique
Three studies reported on techniques exerting torque in a
counterclockwise direction to break the osseointegration, thus
allowing implant removal [1, 2, 33]. Two publications [1, 2]
r e p or t e d u s i n g th e B T I im p l a n t e x t r a c t i o n k i t ®
 50

Table 1 Description of included studies (n = 18)

Technique Study Study type No. of No. of Implant system Reason for explantation (n implants) Explantation technique
patients implants

Reverse [2] Prospective 81 158* Nobel Biocare, Astratech, Peri-implantitis (131) Malposition (22) Reverse torque device (BTI) If RT > 20 Ncm — > Trephine (3–4 mm)
torque study Biomet 3i Fracture (1) Transitional (2) BRONJ (2) then BTI
Anitua Retrospective 42 91 31, Nobel, Straumann, Peri-implantitis Fracture Malposition Reverse torque device (BTI) If RT > 20 Ncm — > trephine (2–3 mm)
et al. longitudinal Biomedics, Importacion dental, then BTI
[1] study Pitt-Easy, TRS, Astra, Defcon,
Osteoplus
[33] Case report 1 1 NR Malposition Reverse torque device (Implant Retrieval Tool, Nobel)
Trephine [7] Case report 1 2 NR Fracture of implant or prosthetic components Trephine
drills [15] Case report 1 2 NR Fracture of prosthetic components Trephine (using a 3D-printed surgical guide)
[23] Case series 4 4 NR Fracture Trephine
[24] Case series 2 3 NR Malposition (in the alveolar nerve canal, Trephine
hypesthesia and dysesthesia) (1) Fractured
prosthetic components and malposition
(2)
[44] Case report 1 2 AstraTech Fracture Trephine
[68] Case report 1 1 IMZ Malposition Trephine
Muroff Case report 1 1 Branemark Fracture Trephine
et al.
[41]
Bur Li et al. Case report 1 1 Ankylos Prosthetic component fracture Removal of 2–3 mm of coronal bone using a diamond fissure bur.
[30] Diamond and carbide burs were used to separate the implant in two
pieces. Elevators and forceps were used to remove the implant.
[10] Case series 9 9 NR Fracture Thin bur
Piezosurgery [32] Case report 1 1 NR Malposition (in the lingual cortical) Piezosurgery
[34] Case series 10 NR NR Fracture Piezosurgery
Laser Smith Case report 1 1 Branemark Damage of the connection + peri-implantitis Er,Cr:YSGG laser
et al.
[56]
Combined [58] Retrospective 81 95 Straumann (21), Nobel (56), Crestal bone loss (48) Peri-implantitis (37) Bur-forceps technique Neo bur-elevator-forceps technique Trephine
tech- cohort study Osstem (1), other (11), Neurosensory deficit (2) drill High torque wrench (Neo Fixture Remover Kit)
niques blade (2), BOI (4) Chronic periodontitis of neighboring teeth
affecting implant (5) Implant fracture (2)
Osteomyelitis (1)
[16] Case report 1 4 NR Fracture Piezosurgery (2), Trephine bur (1) Rose-head bur (1)
[28] Case series 2 4 NR Prosthetic component fracture (1) Trephine (1) Reverse torque device (NeoBiotech) (3)
Peri-implantitis (3)

Technique Success/failure Flap access Socket grafting Complications Immediate

implant
placement

Reverse Yes 139/158 : BTI 19 implants removed with trephine + Yes, only when immediate implants are PRGF clot covered with fibrin plug Fracture of 3 implants 13/156
torque BTI placed Post-operative pain
Yes 78/91 : BTI 13 implants removed with trephine + For peri-implantitis cases: yes, No NR 32/91
BTI For malpositioned implants: no
Clin Oral Invest (2020) 24:47–60
Table 1 (continued)
Yes No No NR Yes
Trephine Yes Yes Autogenous bone blocks + particulate NR No
drills autogenous bone graft
Yes No No NR Yes
Yes Yes (2) NR (2) J-block + Tutoplast + pericardium membrane NR No
(1) J-block (1) No graft (1) NR (1)
Yes Yes Allogenic bone block (Ostis) + allogenic No No
bone (Allomatrix) (1) Allogenic bone
Clin Oral Invest (2020) 24:47–60

block (Ostis) (1)

Yes Yes Osteobiol Gen Os + Osteobiol Evaluation NR No
Yes Yes No NR Yes
Yes Yes No No Yes, Summers
osteotomes +
BioOss
Bur Yes Yes No Titanium particles in surrounding Yes
tissues
Yes Yes No No 9.9
Piezosurgery Yes Yes Hydroxyapatite + fibrin glue No No
Yes Yes Not specified. Bone grafting was done in the No No
case described
Laser Yes No No No No
Combined Bur-forceps and neo-bur-elevator-forceps techniques : Bur-forceps and NR NR 23/89
tech- yes (38/38) neo-bur-elevator-forceps techniques
niques Trephine drill : yes (17/19) : yes
High torque wrench : yes (28/32) Trephine drill : NR
High torque wrench : no
Yes Yes No No No
Reverse torque: Yes (3/4) A trephine drill was required Yes Osteon II (alloplastic) + collagen membrane Perforation of the alveolar bone of No
for removal of 1 implant after failure of the reverse the sinus. Scheiderian
torque device membrane intact
51
52
(Biotechnology Institute, Spain), which includes a wrench that
opens whenever the applied torque is greater than 200 Ncm. In
these cases, a trephine bur was utilized for removal of the
coronal 3–4 mm of bone. The explantation procedure was
consequently completed using reverse torque. Out of the 247
implants explanted using the BTI® system, 215 (87.7%)
could be successfully explanted using reverse torque alone.
Trephines were required for the removal of the remaining 32
implants. The use of trephine drills was indicated in cases with
fractured implants or prosthetic components as well as when
torque values exceeded 200 Ncm.
In the first study [1], 91 implants were explanted in 42
cases. However, trephine drills were required for extrac-
tion of 13 (14.29%) of these implants. Mucoperiosteal
flaps were reflected in all cases but immediate implants
could only be installed in 35 instances (38.5%). The au-
thors did not further elaborate on reasons for delaying
implant placement.
In the second study [2], the main reason for explantation
was peri-implantitis affecting 131 (82.9%) out of the 158 im-
plants, followed by malpositioning (22 implants, 13.9%).
They also reported removal of one fixture with fractured pros-
thetic components and two transitional implants; the latter
were excluded from analysis in this review. Two more im-
plants were diagnosed with BRONJ and were therefore
explanted. Three implants fractured after reverse torque appli-
cation and explantation were terminated using trephine drills.
Fixture removal in cases affected with peri-implantitis was
performed following flap elevation, while malpositioned im-
plants could be explanted in a flapless manner. Immediate
implant placement was successfully achieved in 13 cases
(8.3%). Defects with extensive bone resorption or those lack-
ing buccal bone plates were grafted for delayed implant place-
ment. However, no further details were provided regarding
failed implantation attempts or their association with the use
of trephine burs.
Finally, Matsumoto et al. [33] reported removal of one
malpositioned fixture using an Implant Retrieval Tool®
(Nobel Biocare, Kloten, Switzerland) without flap
reflection. The authors reported flap elevation and
immediate implant placement following the explantation
procedure.
Trephine drills
Seven studies [7, 15, 23, 24, 41, 44, 68] reported utilizing
trephine drills for implant removal. Thirteen implants could
be removed following flap reflection while 2 implants were
removed using a flapless approach [15]. Immediate implant
placement was only planned and successfully performed in 4
cases [15, 41, 68], while a delayed approach was selected for
13 patients [23, 24, 28, 44]. Aiming for a non-invasive ap-
proach with minimal bone loss, the authors used cone beam–
Clin Oral Invest (2020) 24:47–60
computed tomography (CBCT) to construct a resin splint in
order to guide the explantation drills and facilitate placement
of the new implants with simultaneous bone augmentation in a
flapless approach.
The use of trephines for removal of four fractured implants
with different degrees of vertical bone resorption was reported
by Jin et al. [23]. However, despite clinical images showing
flap reflection, details regarding surgical access and compli-
cations were not clearly reported.
Jo et al. [24] reported explantation of three implants in two
cases. One implant was removed due to signs of hyposthesia
and dysthesia caused by invasion of the alveolar nerve canal.
The second patient presented with two fractured abutments
and malpositioned implants. All three implants were success-
fully extracted using trephine drills with simultaneous bone
augmentation and delayed implant placement
Four articles reported on single cases. Cardoso et al.
showed flap elevation and removal of two fractured implants
with simultaneous bone augmentation [7]. New implants were
placed 6 months post-operatively. Oguz et al. [44] also de-
scribed explantation of two fractured implants but despite
bone grafting, one of the two sites was unsuitable for re-
implantation 6 months post-operatively. Watanabe et al. [68]
reported removal of a malpositioned implant with immediate
implant placement and simultaneous guided bone regenera-
tion without providing further details. Finally, Muroff et al.
[41] described explantation of a single fractured implant after
flap elevation. Summers’s osteotome technique and bone
grafting were performed with immediate successful implant
placement.
Burs
Two studies reported using different types of burs to success-
fully remove osseointegrated implants [10, 30]. One [10] de-
scribed flap access followed by the utilization of a thin bur to
isolate the apical part of 9 fractured implants. The authors
reported successful removal and immediate implant place-
ment in all 9 patients. Four implants required simultaneous
bone augmentation using cortico-cancellous bone grafts and
bio-resorbable membranes.
The second study [30] reported explantation of a single
fixture with immediate implant placement. After flap reflec-
tion, a diamond fissure bur was used to create a gap around the
coronal 2-–3-mm part of the implant. A carbide round bur was
then used to split the implant in a mesio-distal direction.
However, the authors reported difficulties in maintaining the
bur direction due to cutting vibrations at the apical third.
Elevators and forceps were then used to detach and remove
the split implant. The whole procedure required 45 min. The
presence of titanium particles in the surrounding bone and soft
tissues was noted but not considered harmful. Moreover, an
Clin Oral Invest (2020) 24:47–60
Fig. 1 Flow chart for the search
strategy
implant of a similar size and design was successfully placed
during the same surgical procedure.
Piezosurgery
Two publications reported using piezosurgery for implant
removal [32, 34]. The first [32] reported explantation of a
malpositioned implant perforating the lingual cortical
plate, which caused difficulties in breathing and
swallowing, upper airway obstruction, and subsequent
hospitalization. The fixture was scheduled for removal 3
months post-operatively due to persistent pain and
swallowing difficulty. Following flap access, a circumfer-
ential osteotomy was performed using a piezosurgical de-
vice. The implant was removed and the site reconstructed
in 20 min without further complications.
The second study [34] described a technique using
piezosurgical inserts to create small perforations around
the implant and close to its apex in depth. A cutting insert
was then used to join the cavities prior to implant remov-
al. Ten cases were successfully explanted using this tech-
nique without complications.
Laser
A single case report described removal of a failing im-
plant using an erbium, chromium: yttrium, scandium, gal-
lium, garnett (Er,Cr:YSGG) laser [56]. The implant was
damaged at the implant-abutment interface with clinical
and radiographic signs of peri-implantitis. The laser was
used for both soft and hard tissue incisions under different
settings. The entire procedure lasted 10 min, but neither
53
socket grafting nor immediate implant placement were
attempted.
Studies describing multiple explantation techniques
Three studies described a combination of different techniques.
Stajcic et al. [58] reported removal of 95 implants from 81
patients. A “bur-forceps technique” described flap reflection
and utilization of burs to remove resorbed facial bone follow-
ed by explantation by forceps. The “neo bur-elevator-forceps
technique” aimed for mesial and distal bone removal up to the
implant’s apex, followed by utilization of forceps or elevators
in case of high resistance. Thirty-eight implants (42.7%) were
successfully explanted using burs and 17 out of 19 implants
(89.5%) were removed using trephine drills after flap reflec-
tion. The “neo bur-elevator-forceps technique” was success-
fully employed whenever others failed. Reverse torque was
employed in 32 cases with 88.5% success rate. A round bur
was required for removal of the coronal bone surrounding the
implant’s neck in five cases. Immediate implant placement
was performed in 23 sites. Of these, 17 implants (73.9%) were
placed following explantation with reverse torque devices, 5
(21.7%) with the “neo bur-elevator-forceps technique” and
one implant (4.3%) was removed using trephine drills.
Dvorak et al. [16] reported explantation of four implants
supporting a maxillary bar-retained removable prosthesis. All
fixtures were fractured at the apical third following an acci-
dent. After removal of the bar and the fractured coronal parts
of the implants, a mucoperiosteal flap was elevated. Two im-
plants were removed with a piezoelectric device, one with a
trephine bur, while the forth was isolated using a rose-head bur
for circumferential osteotomy. When the explanted fixtures
were examined under a scanning electron microscope, greater
54 Clin Oral Invest (2020) 24:47–60

Table 2 Quality assessment and risk of bias for included studies

Patient selection Index test Reference standard Flow and timing

[2] ☹ ☹ ☹ ?
Anitua et al. [1] ☹ ☹ ☹ ?
[33] ☹ ☹ ☹ ☹
Cardoso [7] ☹ ☹ ☹ ☹
Deeb [15] ☹ ☹ ☹ ☹
Jin [23] ☹ ☹ ☹ ☹
Jo [24] ☹ ☹ ☹ ☹
Oguz [44] ☹ ☹ ☹ ☹
Watanabe [68] ☹ ☹ ☹ ☹
[41] ☹ ☹ ☹ ☹
Li [30] ☹ ☹ ☹ ☹
Covani [10] ☹ ☹ ☹ ☹
Marini [32] ☹ ☹ ☹ ☹
Messina [34] ☹ ☹ ☹ ☹
Smith et al. [56] ☹ ☹ ☹ ☹
Stajcic [58] ☹ ? ? ☹
Dvorak [16] ☹ ☹ ☹ ☹
[28] ☹ ☹ ☹ ☹
Low risk = ☺ High risk = ☹ Unclear = ?

amounts of residual bone were found around implants re-
moved with burs than those explanted using piezosurgery.
Finally, two cases have been reported by Lee [28]. The first
was diagnosed with a fractured implant body and a damaged
prosthetic screw, which was successfully removed using a
trephine drill following flap elevation. Bone augmentation
was simultaneously performed and a new implant was placed
4 months later. The second patient presented with three failing
implants due to peri-implantitis. Following flap reflection, the
authors reported successful explantation of two implants using
the reverse torque technique (Neo FR Kit; NeoBiotech, Seoul,
Korea). The third fixture was removed using a trephine bur,
which resulted in perforation of the inferior alveolar bone of
the sinus without concomitant damage to the Schneiderian
membrane. Neither bone augmentation nor immediate im-
plant placement were attempted in this case.
Immediate implant placement
Following explantation, implant placement was not planned in
a number of publications [7, 16, 23, 24, 28, 32, 34, 44, 56].
Immediate implant installation was described in 9 articles for
83 implants [1, 2, 10, 15, 30, 33, 41, 58, 68]. Socket grafting
was performed in 8 studies whether delayed implant place-
ment was considered or not [2, 7, 23, 24, 28, 32, 34, 44].
Various biomaterials were used: autogenous bone blocs,
PRGF (plasma rich in growth factors), xenogenic, allogenic,
or alloplastic materials. Only one study [44] reported the site
unsuitable for implant placement 6 months post-operatively
despite socket grafting at the time of implant removal using
trephine drills.
Discussion
This systematic review focused on the different available tech-
niques for explanting osseointegrated oral implants. The tech-
niques described in the 18 selected studies allowed the explan-
tation of all 372 implants in 241 patients. The reverse torque
technique was the most commonly utilized method of explan-
tation (284 implants). However, it was only successful in re-
moval of 249 out of 284 implants (87.7%). The use of trephine
burs was indicated in cases with fractured implants or when
the torque values exceed 200 Ncm [1, 2]. Yet in spite of its
inferior success rate when compared with other resective
methods, reverse torque remains the most conservative ap-
proach requiring removal of little to no bone. Furthermore,
mucoperiosteal flap elevation was not always required.
Nevertheless, explantation kits could be expensive owing to
the disposable nature of the extraction inserts. Another factor
to consider when utilizing this technique is the implant’s de-
sign, length, and surface modification, which was shown to
significantly affect its removal torque. Implants with acid-
etched, particle-blasted, and oxidized surfaces have a higher
removal torque than those with titanium plasma–sprayed sur-
faces [2]. Moreover, using counter torque techniques may
Clin Oral Invest (2020) 24:47–60 55

Table 3 Excluded studies and reasons for exclusion osteotomies, and the frequent need for flap elevation, their use
Study Reason for exclusion remains comparatively simple. Certain implant manufacturers
even provide guiding cylinders and sleeves to ensure correct
[3] Full-text not available angulation of the drills. However, when explanting tissue-
[4] Explantation technique not described level fixtures, where the implant’s neck is usually wider than
[11] Blade implant its body, implantoplasty is required to reduce the neck’s diam-
[12] Non-osseointegrated implant eter. The subsequent release of metal particles has raised dis-
[17] Review cussions of pro-inflammatory reactions, as well as cytotoxic
[20] Review and genotoxic effects on peri-implant tissues. The amount and
[29] Histologic analysis physiochemical properties of the debris determine the extent
[31] Review of the adverse effects on both surrounding tissues and distant
[45] Full-text not available organs. Also, despite their rarity, titanium allergies and hyper-
[67] Review sensitivity reactions should be taken into consideration [39,
[62] Full-text not available 43, 54]. Furthermore, using trephine drills may complicate
[63] Full-text not available immediate implant placement. The new implants often need
[65] Apicoectomy to be larger in diameter and/or longer than the explanted ones
[61] Expert opinion in order to ensure primary stability. However, anatomical con-
[57] Explantation of the implant with surrounding bone block and siderations and surrounding vital structures should be evalu-
re-implantation ated. Whether implant placement is immediately planned or
not, care should be taken when utilizing resective techniques.
Fortunately, only one study [28] reported perforation of the
result in implant fracture and deformation or detachment of sinus floor without concomitant damage to the Schneiderian
bone fragments between the implant threads [1]. However, membrane. Finally, trephine drills should be utilized at a low
such complications have been reported when reverse torque speed with copious irrigation in order to avoid overheating
was applied without an appropriate extractor [22, 55]. Another and the consequent risk of necrosis and impaired bone regen-
limitation faced with such systems is that extraction inserts eration [37, 53].
cannot always be screwed into fractured implants or those F e w s t u d i e s ut i l i z e d b u r s f o r e x pl a n t a t i o n o f
with damaged prosthetic components. osseointegrated fixtures with variable protocols. Yet flap re-
Trephine burs were used for explantation of 35 implants flection was performed in all cases [10, 30, 58]. Despite the
with a 94.3% success rate. Trephines are hollow burs with a successful implant removal reported in all cases, these tech-
slightly larger internal diameter than the implant, and therefore niques remain more invasive and highly dependent on the
naturally more aggressive than the reverse torque approach. operator’s skill. One study [30] described a two-part separa-
Flap elevation is often required when using trephines. tion of the implant in order to minimize bone damage. This
However, the use of an explantation guide, as suggested by technique was described as difficult, especially when separat-
Deeb et al. [15], may eliminate the need for flap reflection and ing the apical portion of the implant. Nevertheless, successful
minimize bone removal. Still, the required CBCT’s radiation explantation and simultaneous implant placement could be
dose and the additional financial burden should be taken into performed using a similar implant in both length and diameter.
account. Despite the slightly more invasive nature of trephine Moreover, the significant amount of titanium debris generated

Table 4 Reasons for explantation as reported in 16 studies*

Reason for explantation No. of implants %

Peri-implantitis 172 59.9%

Crestal bone loss 48 16.7%
Fracture of the implant and/or prosthetic component 31 10.8%
Malposition 24 8.4%
Chronic periodontitis of neighboring teeth affecting implants 5 1.7%
Malposition causing neurosensory deficit 4 1.4%
BRONJ/osteomyelitis 3 1.0%
Total 287 100.0%

BRONJ bisphosphonate-related osteonecrosis of the jaws

*Data of Anitua et al. [1] and [34] were not available for inclusion in this table
56
Table 5 Success rate for the different explantation techniques
Technique
Reverse torque
Trephine burs
Burs with or without utilization of forceps and/or elevators
Piezosurgery
Er.Cr:YSGG laser
*In the study by Messina, it was assumed that at least 10 implants were explanted from the reported 10 patients
Er.Cr:YSGG erbium, chromium:yttrium, scandium, gallium, garnett laser
by the implant separation represents a major limitation [39].
The additional risk of injury to adjacent bone and anatomical
structures should also be considered when utilizing this tech-
nique [37, 53].
Piezoelectric devices seem to provide an excellent alterna-
tive to conventional osseous surgery. They provide highly
precise and safe osteotomies without the risk of injury to ad-
jacent soft tissues and vital structures [64]. Still, an animal
study [51] conducted in 2008 had shown that direct exposure
of peripheral nerves to piezosurgery did induce some func-
tional and structural damage despite the apparent lack of nerve
damage. However, the correct utilization of piezoelectric de-
vices, without application of heavy pressure, significantly im-
proves the safety margins compared with burs. Osteotomies
using piezosurgery are also more conservative compared with
traditional surgical instruments. Histological examination had
demonstrated lesser amounts of residual bone around implants
removed using piezosurgery compared to those explanted
with traditional burs [16]. The cavitation phenomenon in ul-
trasonic osteotomies provides several additional advantages. It
ensures local hemostasis, good visibility, and antibacterial
properties, while maintaining a constantly cooling stream.
Superior osseous repair and remodeling were associated with
piezosurgery compared with burs [26, 66]. Notwithstanding,
such devices can be costly and time consuming with rapidly
worn inserts. An additional aspect to consider when using
piezosurgery is the working pressure. Care should be taken
not to apply heavy pressure which could impede insert vibra-
tion, thus transforming energy into heat [27]. Finally,
piezosurgical appliances may cause interferences in patients
with pacemakers [19, 47, 64]. A detailed medical history is
mandatory prior to any kind of dental treatment.
The Er.Cr:YSGG laser was utilized for the successful ex-
plantation of a single implant [56]. This technique is thought
to be conservative and efficient, causing limited thermal injury
to the surrounding bone. However, the relative fragility of the
optical tip was considered a limiting factor. The Er.Cr:YSGG
laser can be utilized for both hard and soft tissues as the energy
is absorbed by collagen, hydroxyapatite, and water [25, 46].
However, when an ex vivo study [14] on bovine bone blocks
evaluated osteotomies using Er:YAG and Er,Cr:YSGG lasers
Clin Oral Invest (2020) 24:47–60
No. of implants successfully removed Success rate
284 87.7%
35 94.3%
49 100%
11* 100%
1 100%
in comparison with conventional burs, Er,Cr:YSGG produced
more thermal damage with irregular hard and soft tissue mar-
gins. The time required for bone ablation was also significant-
ly higher [14]. Nevertheless, the lack of additional clinical
studies on laser explantation prevents further analysis of this
technique.
None of the included studies reported major drawbacks.
Unfortunately, complications were not disclosed in 7 studies,
while 7 others reported absence of both intra-operative and
post-operative complications. Only Anitua et al. [2] reported
fracture of three implants after reverse torque application,
while Lee et al. [28] described perforation of the sinus floor
using a trephine drill without damaging the Schneiderian
membrane.
This review was remarkably limited by the quality of the
available studies and the high degree of bias inherent in case
series and single case reports. Fifteen out of the 18 included
articles were single case reports or case series with small sam-
ple sizes describing the surgeon’s experience as opposed to
objective analysis of a certain technique. Only three studies [1,
2, 58] reported on larger samples with comparatively suffi-
cient details. However, Anitua E. is the scientific director of
the BTI Biotechnology institute while another author
(Alkhraisat M.H.) was a scientist there [2]. The authors de-
clared no conflict of interest, but it is reasonable to assume that
being involved in the development of a device provides a
certain knowledge and experience in its utilization.
Unfortunately, most of the included publications did not
perform a statistical analysis. Anitua et al. presented descrip-
tive statistics in both articles [1, 2] with details on the im-
plants’ type, diameter, and length. However, the authors did
not attempt to analyze the relation between these parameters
and the removal torque. Some publications [7, 10, 15, 16, 23,
24, 28, 32, 34] did not describe the implants’ type, brand, or
dimensions. Moreover, none of the included studies analyzed
the explantation technique in relation to the reason for explan-
tation, ease of implant removal, time efficiency, or the possi-
bility of immediate implant placement. Therefore, a meta-
analysis could not be performed due to lack of data, and fac-
tors influencing successful implant removal could not be
extrapolated.
Clin Oral Invest (2020) 24:47–60
Fig. 2 Proposed explantation guide for removal of osseointegrated oral implants
This systematic review could not statistically establish the
superiority of one technique over another due to the scarcity of
data in the literature. However, it clearly evaluated the advan-
tages and limitations of all available methods. Randomized
controlled clinical trials examining different techniques with
larger sample sizes are required. Studies should also system-
atically report the reasons for explantation, details on the ex-
plantation technique including the time required, implant
characteristics, pre-operative, and post-operative residual
bone-level complications, and the possibility of immediate
implant placement.
After careful evaluation of the available literature, the au-
thors propose the following protocol as a guide for explanta-
tion of osseointegrated oral implants (Fig. 2):
& The explantation technique should be chosen depending
on the thickness of the cortical bone and the proximity of
the implant to adjacent structures, as well as the timing of
future implant placement. The presence of peri-implant
inflammation and concomitant bone defects should also
play a role in treatment planning.
& With the exception of reverse torque techniques,
mucoperiosteal flap elevation is recommended for suffi-
cient access and visibility.
& The reverse torque technique seems the most conserva-
tive, and in the authors’ opinion, should be the first choice
57
for explantation of an osseointegrated implant despite its
inferior success rate. However, this technique can only be
utilized when extraction inserts can be screwed into the
implant.
& When the reverse torque reaches 200 Ncm without
success, a piezoelectric device can be utilized to re-
move the coronal third of the bone. If not available,
trephine drills or burs can be utilized at low speeds
and under copious saline irrigation. Reverse torque
can then be reapplied.
& If the counter torque technique fails at this point, or in case
of fractured implants, the osteotomy can be completed up
to the implant’s apex using piezosurgery or, if not avail-
able, burs can be utilized.
– In the presence of thin cortical plates but without any
critically adjacent structures, the mesial and distal bone
can be removed to allow insertion of elevators and extrac-
tion forceps.
– In cases with thick cortical plates, or in the presence of
buccal bone defects, the osteotomy can be performed on
the vestibular aspect of the implant and up to the apex.
Extraction forceps can then be employed for implant
removal.
– In cases with lingual bone defects, the same technique can
be used on the lingual aspect; thus preserving the
58
remaining buccal tissue. This technique can also be
employed in close proximity to adjacent teeth or implants.
& Trephine drills can be used for removal of bone-level im-
plants with abundant surrounding bone and an adequate
distance from adjacent structures. Guiding cylinders or
abutments should be utilized.
Conclusion
Within the limitations of this review, the authors highly rec-
ommend reverse torque for implant removal. In case of failure,
resective techniques can be employed in a conservative and
cautious manner. Fixture’s design and proximity to vital struc-
tures, as well as feasibility and timing of future implant place-
ment, should be considered when explanting an
osseointegrated oral implant.
Authors’ contributions M.R. was the first reviewer and she collected and
analyzed the data as well as helped the writing of the manuscript. L.L. was
the second reviewer and she contributed the materials and methods part of
the writing. G.G. conceived the idea. D.H. supervised the review and led
the writing as well as the formulation of the explantation guide.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval Ethical approval was not required.
Informed consent Formal consent is not required for this type of study.
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