## 4 Discussion
Studies with longer-term follow up should be undertaken in the future. It is known that the case series is not the study design that yields the most powerful scientific results; however, our large case series is representative of current practice in the treatment of peri-implant osseous lesions. Bias inherent to the treatment protocol must be disclosed: removing prosthesis was not always possible and therefore sometimes surgery was performed with the prosthesis in place. Bone-filling graft and biomaterials are not always the same for philosophical, religious, or ethical considerations related to the patient. Membranes were not systematically used to stabilize bone-filling materials according to [PERSON] et al. [47]. It is important to mention that the chemical decontamination included in the surgical protocol of this study was empirical since, so far (January, 2023), no study has been able to show the efficacy of the tested antibacterial agents in decontaminating the implant surfaces. Implantoplasty, by mechanically and macroscopically removing a layer of the implant surface, effectively removes the adhering biofilm. This method of decontamination, although imperfect and rudimentary, could only be indicated until a chemical that is non-toxic to the peri-implant tissues but sufficiently disinfectant to remove biofilm from implant surfaces is found/discovered. Comparison of different methods of implant surface decontamination versus implantoplasty in randomized trials would allow us to propose, ideally in the very near future, a therapeutic gold standard for peri-implant lesions or at least reliable evidence-based clinical recommendations. Progressive bone loss rate based on radiographic analysis criteria alone have limitations due to its two-dimensional nature which restricts analysis to mesial and distal sites and does not allow assessment of the buccal or lingual/palatal marginal bone. For future research, it would be necessary to perform a multifactorial clinical assessment of parameters that may reveal signs of inflammation, infection, or healing, such as mean PPD reduction \(\geq\) 0.5 mm, absence of a peri-implant site with PD \(\geq\) 5 mm with concomitant bleeding or suppuration on probing, recession height, percentage of bone fill, and keratinized mucosa height. Comparative statistical analysis of the three groups was not carried out because, firstly, the groups were not comparable in terms of anatomy of bone loss and, secondly, the anatomy of bone loss was an indication for the choice among the three surgical protocols used. In our study, 96.7% of treated implants showed marginal bone stability. To refine these results, it would be necessary to compare two groups of surgically treated peri-implant bone lesions with or without associated implantoplasty. In addition, other criteria such as depth of probing, clinical attachment level, BOP, recession height, keratinized mucosa height, and percentage of bone fill, should be measured in addition to the absence of progressive bone loss. Larger prospective case series with longer-term follow up on comparable populations (plaque score, compliance, age, general health status, non-smokers) should be conducted to evaluate the therapeutic efficacy of this surgical protocol on peri-implant bone lesions.