Straumann® ProTalk Ep. 19 “Clinical Edition” with Alberto Monje on the prevention of peri-implantitis

The foundation: what peri-implantitis is and why it grows

Peri-implantitis remains highly prevalent as implant dentistry grows, with Alberto Monje stressing that more implants almost inevitably mean more peri-implantitis cases. He explains that peri-implantitis is a site-specific, largely manmade disease, often affecting some implants in a patient but not all, which points directly to local and prosthetic factors rather than just systemic ones. He adopts the World Workshop definition and, in practical terms, considers peri-implantitis present when there is ≥3 mm of bone loss, pocket depth >6 mm, and clear clinical signs of inflammation such as profuse bleeding and frequent suppuration, not just a single bleeding point.

Once he establishes a diagnosis, Monje routinely uses CBCT to assess defect morphology, number of residual walls, and 3D implant position, because these features heavily influence whether an implant is worth saving. He emphasizes that if local confounders like poor position or non-cleansable prosthetics are not modifiable, disease tends to recur regardless of how skillful the treatment is. Non-surgical therapy serves mainly as a hygienic and risk-modification phase, especially in smokers, uncontrolled diabetics, and patients with high plaque levels, and in his experience around 80–85% of cases still require surgery afterward.
 

Treatment strategy: reconstruct, resect, or remove

In surgery, Alberto focuses on three checkpoints: defect configuration, soft tissue characteristics, and implant position, which together guide the choice between reconstructive vs. resective approaches. Narrow, contained intra-bony defects (with small defect angles) offer better prospects for true bone regeneration, while shallow, non-contained, horizontal, or “HIS-type” defects are more suitable for resective therapy and implantoplasty, with the realistic endpoint being a pocket depth of ≤5 mm and a shift to a more aerobic environment. He underlines that clinicians should not fool themselves by chasing vertical bone gain in every case; the primary goal is to stop disease progression, not to create textbook radiographs.

Monje stresses the importance of prosthetic design and the transition zone between implant and soft tissue. Evidence shows that a larger distance from the restorative margin to the bone crest increases the long-term risk of peri-implantitis, which favors tissue-level implants or bone-level implants with longer transmucosal abutments (>2 mm). Surface decontamination is another critical, often underestimated piece, where he highlights newer technologies such as GalvoSurge as promising options that outperform traditional methods like hydrogen peroxide or locally delivered antibiotics. When deciding whether to extract or keep an implant, he weighs four main elements: biomechanical relevance (can the prosthesis remain stable without it?), modifiability of local prosthetic factors, esthetic zone sensitivity, and extent of bone loss, with implants showing >50% bone loss (≈6–7 mm) responding poorly to any therapy.

Prevention and future trends: fewer implants, smarter planning, better maintenance

From a preventive standpoint, Alberto’s message is clear: “the fewer implants, the less peri-implantitis” in the future. He encourages minimally invasive concepts, careful case selection, and patient-centered planning rather than chasing maximal regeneration or “heroic” full-arch reconstructions. Digital technologies (3D planning, guided surgery, accurate restorative workflows) have the potential to dramatically reduce malposition and prosthetic problems, but he notes that currently less than 10% of clinicians truly embrace these tools. Meanwhile, a large proportion of patients with peri-implantitis present with manmade complications from undertrained or undereducated providers who do not invest in technology or updated education, even though prevention strategies are well known.

Long-term supportive periotherapy and maintenance programs are non-negotiable in Alberto’s philosophy. Patients who attend regular supportive care visits fare significantly better, while erratic or non-compliant patients are up to five times more likely to develop peri-implantitis compared to regular compliers. He insists that this must be communicated clearly and transparently before treatment begins so that patients understand implants are not a “place and forget” solution, but a lifelong commitment. Reflecting on his own learning curve, he admits he once overestimated the capacity to “rescue” implants as if they behaved like periodontally treated teeth; now he teaches younger clinicians to think longer term, accept that some implants are better removed, and always put the patient’s quality of life and maintenance capability at the center of every decision.
 

Key takeaways

• Peri-implantitis is largely site-specific and manmade, driven heavily by implant position, defect configuration, prosthetic design, and maintenance—not just systemic risk factors.
• Successful management means realistic diagnosis and planning: CBCT-based analysis, clear thresholds (≥3 mm bone loss, >6 mm pockets, profuse bleeding), and honest decisions about when to reconstruct, resect, or extract.
• Long-term success depends on minimally invasive planning, smart implant/prosthetic choices, digital accuracy, and strict supportive care.