# A Novel, Minimally Invasive Method to Retrieve Failed Dental Implants in Elderly Patients
## 4 Discussion
\begin{table}
\begin{tabular}{c c c c c c c} \hline \hline
**Connection** & **100–199 N (n)** & **200–299 N (n)** & **300–399 N (n)** & **400–499 N (n)** & **Total (n)** & **Mean Torque (N)** \\ \hline  
Whereas the most common reasons for the removal of orthopedic implants and osteosynthesis screws are iatrogenic and biomechanical [5], the most common cause of dental implant failure was observed to be biological. This finding is concurrent with previous research [11; 16; 21], given the constant exposure of dental implants to the oral microbiota. Iatrogenic factors were the second cause of implant failure, i.e., non-restorable positions [8], concurring with the rate (12-14%) of other studies [16; 17]. This shows that the sample is representative since the most frequent causes of implant failure are consistent with what was previously reported. Different from the study of [PERSON] et al. [17], which compared the surface of removed implants, this study was unable to identify specific surface treatments. Studied patients had their implants placed by other dentists. Different treatments may influence surface energy, improve the osteoblast proliferation and the bone-implant contact [29; 30; 31], and consequently, the osseointegration, which can be related or not with the torque values during the removal procedure. However, authors understand that present findings reflect a pragmatic sample, and thus can be applied to elderly patients needing implant removal. Among the limitations of the study, one can mention the elderly population, which precludes extrapolation to young adults. However, answering questions specifically for this population is paramount, since they need minimally invasive procedures the most. In addition, other limitations were that the level of satisfaction between groups (trephine vs. removal kit) was not compared, as well as potential selection bias since it was a convenience sample. However, our practice-based study provides realistic results of our daily clinical routine, as stated by [PERSON] et al. [32]. Furthermore, a systematic review [20] reported that most of the studies regarding implant removal have considerable issues, including small sample sizes, no disclosure of complications and misuse of statistical methods. We tackled those issues by reaching a considerable sample size, careful statistical analysis and reporting adversities. However, randomized clinical trials considering patient-reported outcomes studies are still needed to determine the best implant removal method for elderly patients. In conclusion, the use of a counter-torque ratchet system is a minimally invasive technique with a high success rate, which reduces the postoperative morbidity and the time of healing/treatment in elderly individuals. The data presented in this study are available on request from the corresponding author. The data are not publicly available due to data include some names of the clinicians that placed previously the implants (including iatrogenic) as well as the brands of retrieved implants. The authors declare no conflict of interest.