Whether to remove or to treat an implant affected by peri-implantitis remains one of the most challenging and consequential decisions in contemporary implant dentistry. This lecture will critically explore this clinical dilemma through the presentation of representative cases illustrating both successful surgical management of peri-implantitis and strategic implant removal followed by three-dimensional hard- and soft-tissue reconstruction. Moving beyond anecdotal decision making, the lecture will introduce an evidence-based, clinically oriented flowchart designed to support rational and reproducible treatment decisions. This framework aims to assist clinicians in determining when implant preservation is justified and when removal represents the most predictable therapeutic option.