Platform Switching A New Concept in Implant Dentistry For Controlling Postrestorative Crestal Bone Levels PDF

The International Journal of Periodontics & Restorative Dentistry
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9
Platform Switching: A New Concept

in Implant Dentistry for Controlling
Postrestorative Crestal Bone Levels
Richard J. Lazzara, DDS, MScD* The resulting crestal bone levels

Stephan S. Porter, DDS, MSD, MS* around dental implants following
restoration has been a topic of discus-
Histologic and radiographic observations suggest that a biologic dimension of sion and used as a reference for eval-
hard and soft tissues exists around dental implants and extends apically from the uating implant success for many years.1
implant-abutment interface. Radiographic evidence of the development of the Small changes in crestal bone height
biologic dimension can be demonstrated by the vertical repositioning of crestal following implant restoration, however,
bone and the subsequent soft tissue attachment to the implant that occurs when have not negatively affected long-term
an implant is uncovered and exposed to the oral environment and matching-
implant success in most cases. The
diameter restorative components are attached. Historically, two-piece dental
implant literature contains numerous
implant systems have been restored with prosthetic components that locate the
articles describing the 1-year
interface between the implant and the attached component element at the outer
edge of the implant platform. In 1991, Implant Innovations introduced wide-diam-
postrestorative bone levels around
eter implants with matching wide-diameter platforms. When introduced, however, threaded dental implants. These arti-
matching-diameter prosthetic components were not available, and many of the cles report that crestal bone levels are
early 5.0- and 6.0-mm-wide implants received “standard”-diameter (4.1-mm) heal- typically located approximately 1.5 to
ing abutments and were restored with “standard”-diameter (4.1-mm) prosthetic 2.0 mm below the implant-abutment
components. Long-term radiographic follow-up of these “platform-switched” junction (IAJ) at 1 year following
restored wide-diameter dental implants has demonstrated a smaller than expect- implant restoration1 but are depen-
ed vertical change in the crestal bone height around these implants than is typical- dent upon the location of the IAJ rel-
ly observed around implants restored conventionally with prosthetic components ative to the bony crest.2,3
of matching diameters. This radiographic observation suggests that the resulting Several theories exist as to the rea-
postrestorative biologic process resulting in the loss of crestal bone height is
son for the observed changes in crestal
altered when the outer edge of the implant-abutment interface is horizontally
bone height following implant restora-
repositioned inwardly and away from the outer edge of the implant platform. This
tion. The radiographic observation that
article introduces the concept of platform switching and provides a foundation for
future development of the biologic understanding of the observed radiographic
postrestorative “remodeled” crestal
findings and clinical rationale for this technique. (Int J Periodontics Restorative bone generally coincides with the level
Dent 2006;26:9–17.) of the first thread on most standard
3.75- and 4.0-mm implants has led
*Private Practice, West Palm Beach, Florida.
some authors to suggest that when
Correspondence to: Stephan S. Porter, 10130 Northlake Blvd, Suite 214-344, West Palm dental implants are placed into func-
Beach, Florida 33412-1101; fax: (561) 799-1529; e-mail: info@ithinkideas.com. tion, crestal bone remodels as a result
Volume 26, Number 1, 2006

10
Tissue levels Biologic width

at placement established
≈ 1-mm sulcus
≈ 1-mm epithelial attachment
≈ 1-mm supracrestal CT
Fig 1 Eleven-year follow-up demonstrates crestal bone remodel- Fig 2 Crestal bone level around a nonrestored, covered, two-
ing to approximately the first thread on the restored and functioning stage implant placed subcrestally (left); and the postrestorative
implant, with no radiographic crestal bone change observed around crestal bone level located at the first thread on a threaded dental
the mesial implant, which is still covered with soft tissue. implant approximately 1.5 mm apical to the implant-abutment junc-
tion (right). CT = connective tissue.
of stress concentration at the coronal closed (sealed) during healing, crestal The same biologic bone remod-
region of the implant.4 Other authors bone remodeling does not typically eling process that occurs around a two-
have suggested that postrestorative occur around the top of the submerged stage dental implant beginning when
crestal bone remodeling is a result of implant, and the height of the sur- the implant is uncovered can also be
localized inflammation within the soft rounding crestal bone remains at observed radiographically when a one-
tissue located at the implant-abutment presurgical levels. However, when sec- stage surgical procedure is used with
interface5,6 and is a consequence of ond-stage surgery is performed or if the a two-stage implant system, ie, when
the soft tissue’s attempt to establish a implant becomes prematurely exposed a healing abutment or prosthetic com-
mucosal barrier, ie, biologic width (seal) to the oral environment and bacteria, ponent is attached to the implant
around the top of the dental implant. crestal bone changes occur at the coro- immediately after implant placement.
Historically, the standard surgical nal aspect of the implant. To create However, unlike the delayed forma-
protocol that is recommended for plac- adequate space for the biologic soft tis- tion of the biologic width that is
ing two-stage, threaded, straight- sue seal and attachment of the soft tis- observed following exposure of an
walled, external-hex implants requires sue to the stable implant top, crestal implant in a two-stage surgical
positioning the implant platform bone remodeling occurs to approxi- approach (Fig 2), the one-stage surgi-
approximately 1.0 mm below the bony mately the first thread, 1.5 to 2.0 mm cal technique exposes the IAJ to the
crest to allow for the top of the cover apical to the IAJ. The image in Fig 1 oral environment immediately follow-
screw to be level with the bone crest illustrates the radiographic appearance ing implant placement and abutment
during the healing period. With this of crestal bone remodeling to approx- connection. As a result, crestal bone
protocol, it can be observed radio- imately the first thread following remodeling begins immediately.
graphically that as long as the soft tis- implant uncovering and restoration.
sue covering the implant remains

11
In a series of studies using a dog to create adequate space for soft tis-
model, Hermann et al2,3,7,8 described sue attachment to the implant.
the biologic response of crestal bone Berglundh and Lindhe,11 after
around the top of a two-piece dental investigating the dimension of the peri-
implant following abutment connec- implant mucosa in a beagle dog
tion and demonstrated that crestal model, concluded that a certain mini-
bone remodels to a level approxi- mum width (approximately 3 mm) of
mately 2.0 mm apical to the IAJ. The peri-implant mucosa was required to
authors reported that following create a mucosal barrier around a den-
implant exposure and abutment con- tal implant and that crestal bone
nection, the distance between the IAJ resorption occurred to allow for the
and the resulting remodeled crestal formation of a minimum dimension of
bone position along the surface of the soft tissue attachment to the implant.
implant remained relatively constant, Abrahamsson et al12 reported that, fol-
regardless of the original vertical posi- lowing repeated removal and recon-
tion of the IAJ in relation to the origi- nection of an abutment, the most coro-
nal level of the bony crest. Hermann et nal portion of the peri-implant soft
al,8 Todescan et al,9 and Piattelli et al10 tissue attachment was located slightly
have demonstrated that when the IAJ apical to the IAJ. The authors
is positioned deeper within bone, the explained that the repeated removal
resulting loss of vertical crestal bone and reconnection of the abutment may
height increases; however, the newly have created a wound within the soft
formed crestal bone position remains tissue and that the crestal bone resorp-
approximately 2.0 mm apical to the tion that they observed may have been
IAJ. Of particular significance is that a consequence of the soft tissue’s
Hermann et al8 demonstrated that the attempt to establish a proper biologic
formation of the approximate 2.0-mm dimension of mucosal barrier attach-
distance between the IAJ and the ment to a stable implant surface. In
newly formed crestal bone location addition, Berglundh and Lindhe11
remained constant even when a bone- reported that when the soft tissue sur-
loading surface that had been sand- rounding an implant is intentionally
blasted and acid etched extended made thin (ie, 2 mm or less), more
coronally to within 0.5 mm of the IAJ. crestal bone loss is observed. This
This observation provides direct evi- observation supports the theory that
dence that the biologic process result- peri-implant mucosa has a minimum
ing in the formation of the biologic thickness (approximately 3 mm) and
dimension and position of hard and that the body attempts to re-establish
soft tissues around a dental implant this minimum soft tissue dimension.
has a greater capacity to influence and The loss of crestal bone height follow-
direct the bone remodeling process ing tissue thinning and crown-length-
than does the ability of a bone-loading ening procedures around teeth has
implant surface to resist the resorptive also been reported and suggests that
process of crestal bone remodeling the crestal bone remodeling process is
that results from the biologic attempt a biologic response to create space

12
for new attachment of supracrestal around extracted teeth, as reported

fibers to the tooth.13,14 Thus the bone by Waerhaug,15 is of a similar dimen-
remodeling process around the coro- sion to the overall 0.5- to 0.75-mm
nal aspect of a two-stage dental coronal and 0.5- to 0.75-mm apical
implant and the subsequent develop- extension of the abutment ICT, as
ment of a biologic width and soft tis- reported by Ericsson et al.5
sue attachment to the implant appear Historically, the resulting 1-year
to have a similar barrier function as the postrestorative repositioned crestal
soft tissue attachment around teeth, bone level (approximately 1.5 mm
as described by Waerhaug,15 who apical to the IAJ or at the first thread)
reported similar dimensions. has been used as one of the criteria for
Ericsson et al5 described histolog- success of a dental implant. 1,16
ically the peri-implant tissues around a Importantly, the literature describing
two-piece dental implant system in the postrestorative crestal bone positions
dog model. The authors quantified the is based on a vertically coordinated
dimension and location of the gingival implant-abutment relationship (ie, the
Fig 3 Platform switching is demonstrated. sulcus, the epithelial attachment, and abutment component and implant
A 0.95-mm circumferential horizontal mis- the connective tissue above the bone- seating surface have matching diame-
match in dimension is created when a 4.1-
implant connection. Two types of ters). This matching implant-abutment
mm-diameter prosthetic UCLA abutment is
placed on a 6.0-mm-diameter implant with inflammatory lesions were observed in diameter positions the abutment ICT,
matching 6.0-mm-diameter platform. the peri-implant soft tissues. One was as described by Ericsson et al5 and
associated with the gingival sulcus, Abrahamsson et al,6,12 at the outer
which they termed the “plaque-asso- edge of the IAJ and in direct approxi-
ciated” inflammatory cell infiltrate mation to the crestal bone at the time
(P/ICT), and the second lesion was a of abutment connection surgery. The
1.0- to 1.5-mm (apicocoronal) zone of close proximity of the abutment ICT to
inflammatory cell infiltrate associated bone may explain in part the biologic
with the IAJ, which they termed the and radiographic observation of crestal
“abutment” inflammatory cell infiltrate bone loss around exposed and
(abutment ICT). The authors report that restored two-piece dental implants.
the peri-implant bone crest was con- The following is a description of
sistently located 1.0 to 1.5 mm apical radiographic observations made over
to the IAJ and that the apical border of a 13-year period resulting from the
the abutment ICT was always sepa- placement of smaller-diameter heal-
rated from the bone crest by approxi- ing and prosthetic components on
mately 1.0 mm of healthy connective wider-diameter implants. The authors
tissue. This indicates that once the bio- have termed the inward horizontal
logic dimension is established, the soft repositioning of the IAJ “platform
tissue seal and attachment to the den- switching” (Fig 3). A description and
tal implant provides a protective func- hypothesis supporting the radi-
tion to isolate crestal bone from the oral ographic observation that little or no
environment. Of interest is that the crestal bone loss occurs with platform
0.94-mm dimension of P/ICT at the switching is presented.
base of the subgingival plaque front

13
Fig 4a (left) A 4.0-mm-diameter implant

and two 6.0-mm-diameter implants with 4.1-
mm-diameter healing abutments attached.
Fig 4b (right) Ten-year follow-up illustrat-

ing platform switching on the two 6.0-mm-
diameter implants with the use of 4.1-mm-
diameter prosthetic components. Note that
the level of crestal bone around the 6.0-
mm-diameter implants approximates the
level of the implant platform; compare to
the anterior implant, where the bone level is
at the expected first thread.
Fig 5 (left) Ten-year follow-up of two 6.0-

mm-diameter implants that were platform
switched with 4.1-mm-diameter prosthetic
components. Note that the level of crestal
bone around both implants approximates
the level of the implant platform.
Fig 6 (right) Five-year follow-up of a 5.0-

mm-diameter implant (right) that was plat-
form switched with a 4.1-mm prosthetic
abutment. Note that the level of crestal
bone on the distal aspect of the implant is
at approximately the level of the implant
seating surface, while the mesial crestal
bone level has remodeled to slightly above
the first implant thread as a result of
reduced (< 3 mm) soft tissue height.
Summary of radiographic ment implants when standard-diame- between the implant seating surface
observations ter (3.75-mm) implants failed to inte- and the attached component. The
grate or in areas of poor quality bone radiographs in Figs 4a, 4b, 5, and 6
Altering the horizontal relationship in an attempt to achieve improved pri- show implant-supported prostheses
between the outer edge of the implant mary stability. However, when intro- restored with reduced-diameter pros-
and the attached, smaller-diameter duced, there were no matching wide- thetic components, resulting in cir-
component seems to reduce or elim- diameter prosthetic components cumferential horizontal dimensional
inate the expected postrestoration available, and as a result, most of the variances of 0.45 mm and 0.95 mm.
crestal bone remodeling that is typi- initially placed wide-diameter implants Upon reviewing radiographs of
cally observed around a two-piece were restored with standard 4.1-mm- patients in whom platform switching
implant. The reduced vertical crestal diameter components. The dimen- has been used, after an initial 5-year
loss of bone was first noticed, coinci- sional mismatch between the implant period, it is observed that the crestal
dently, on the Implant Innovations (3i) seating surface diameter and the diam- bone lateral to implants with the cir-
wide-diameter implants. Introduced in eter of the prosthetic component cre- cumferential dimensional difference
1991, the 3i wide-diameter 5.0- and ates either a 0.45-mm (4.1-mm pros- appears to respond differently than
6.0-mm implants were designed with thetics/5.0-mm implant platform) or a what is typically observed when
a matching 5.0- and 6.0-mm-diameter 0.95-mm (4.1-mm prosthetics/6.0-mm implants are restored with matching-
seating surface. These wide-diameter implant platform) circumferential hor- diameter components. What is typi-
implants were used mainly as replace- izontal difference in dimension cally observed, but with some vari-

14
Fig 7 Composite approximation of soft tissue interface dimen-

sions according to Ericsson et al5 and Abrahamsson et al.6,12 IAJ =
implant-abutment interface; aICT = 1.5-mm abutment inflammato-
ry cell infiltrate (0.75 mm above IAJ to 0.75 mm below IAJ); CT =
zone (approximately 1.0 mm) of healthy connective tissue between
the base of aICT and bone.
0.75 mm˛ aICT

IAJ
≈ 0.75 mm 0.75 mm aICT
+ ≈ 1.00 mm CT
≈ 1.75 mm
ance, is that when matching-diameter Biologic rationale for

implant and restorative components platform-switching observation
are used in the fabrication of the defin-
itive restoration, the crestal bone con- A partial explanation as to why there
tacting the implant normally remodels appears to be little or no crestal bone
1.5 to 2.0 mm apically, to approxi- remodeling following platform switch-
mately the first implant thread. The ing is as follows.
same result is observed radiographi- Studies have demonstrated that a
cally when an implant is uncovered minimum thickness of approximately 3
and a matching-diameter healing mm of soft tissue is necessary to allow
abutment is attached and remains in for the formation of a biologic seal
place for several months. This obser- around the top of a two-stage dental
vation indicates that the crestal bone implant and that crestal bone will
remodeling process is not dependent resorb in an attempt to create the
upon an implant being placed into space necessary for soft tissue attach-
function, but rather its exposure to the ment. Additionally, Berglundh and
oral environment. In contrast, when Linde11 and Ericsson et al5 observed in
smaller-diameter components are histologic sections of crestal bone and
placed on wider-diameter implant plat- soft tissue that crestal bone is always
forms, the amount of crestal bone separated from the base of the abut-
remodeling is noticeably reduced, ment ICT by an approximate 1-mm-
with many platform-switched wide zone of healthy connective
restored implants exhibiting no tissue, as depicted in Fig 7.
vertical loss in crestal bone height.

15
Fig 8 Amount of exposure the abutment ICT will have with the
surrounding bone and soft tissue when positioned at the outer
edge of the implant (left). In contrast, the inward, horizontal reposi-
tioning of the abutment ICT (right) will move the abutment ICT
away from the crestal bone and into a more confined area.
There appear to be two results of degree confined area of exposure process of biologic width formation
the horizontal inward repositioning of instead of a ≤ 180-degree area of direct begins immediately following expo-
the implant-abutment interface. First, exposure to the surrounding hard and sure to the oral environment. Thus,
with the increased surface area soft tissues, as depicted in Fig 8. As a whether an implant is placed using a
created by the exposed implant seat- consequence, the reduced exposure one- or two-stage surgical procedure,
ing surface, there is a reduction in the and confinement of the platform- the first component placed on the
amount of crestal bone resorption nec- switched abutment ICT may result in a implant must be of a smaller diameter
essary to expose a minimum amount reduced inflammatory effect within the if a horizontally repositioned biologic
of implant surface to which the soft tis- surrounding soft tissue and crestal width is to be accomplished. This is
sue can attach. Second, and perhaps bone. important because after crestal bone
more important, by repositioning the It is theorized by the authors that has remodeled to a postrestorative
IAJ inward and away from the outer these related mechanical and biologic resting position around the top of an
edge of the implant and adjacent concepts may explain in part the 13- implant, it will not return to its presur-
bone, the overall effect of the abut- year radiographic observation of gical level if platform-switching princi-
ment ICT on the surrounding tissue as reduced or no bone loss around ples are implemented at a later time.
described by Ericsson et al 5 implants that have used the platform-
and Abrahamsson et al6,12 may be switching technique. However, it is
reduced, thus decreasing the resorp- important to note that to benefit from
tive effect of the abutment ICT on the platform-switching bone preser-
crestal bone. It is further suggested vation technique, reduced-diameter
that platform switching repositions the components, beginning with the heal-
abutment ICT further away from crestal ing abutment, must be used from the
bone and locates the inflammatory moment that the implant is exposed to
infiltrate within an approximate ≤ 90- the oral environment, because the

16
Discussion 1. A minimum of 3 mm of soft tissue,

which is necessary for the forma-
Much discussion has occurred regard- tion of a biologic seal without an
ing postrestorative radiographic crestal increased loss of crestal bone
bone levels and the reasons for the height
observed changes. After an implant is 2. The position of the abutment ICT
exposed to the oral environment, and its proximity to crestal bone
bone remodels downward along the 3. The implant surface topography
implant body and then stops at some
predefined position. Such changes in
crestal bone height have been attrib-
uted to implant loading and concen- Conclusions
tration of forces, the countersinking
procedure during implant placement Platform switching is a method for pre-
procedures, and localized soft tissue serving crestal bone around the top of
inflammation, among other reasons. wide-diameter implants and seemingly
The distance between the IAJ and the alters the starting point from which
remodeled crestal bone following sec- crestal bone remodeling occurs.
ond-stage surgery has been shown to Platform switching provides the clini-
be consistent in several animal and cian with additional surgical and pros-
human clinical studies, regardless of thetic treatment options for use with
the original position of the IAJ in rela- wide-diameter implants. During a 13-
tion to the bone crest. This observation year observation period, greater
is so consistent, in fact, that it became crestal bone loss has never been
a part of the accepted implant suc- observed with platform-switched
cess criteria, reported by Albrektsson restorations than would be expected
et al1 and Smith and Zarb.16 There is with two-piece dental implants
evidence that the IAJ is one of the pri- restored conventionally with match-
mary controllers of postrestoration ing-diameter components. The clinical
crestal bone position; however, soft benefits of platform switching will be
tissue thickness (minimum of 3 mm), discussed in a subsequent article. The
the position of the abutment ICT, and technique of platform switching as
the implant surface itself also seem to illustrated by the authors requires
play roles in determining the final additional studies to establish the bio-
postrestorative crestal bone position. logic process(es) responsible for the
It is suggested, therefore, that the fac- observed positive radiographic findings.
tors controlling crestal bone levels
around dental implants, in order of
importance, are as follows:

17
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Albrektsson T, Gioso M. Influence of the
1. Albrektsson T, Zarb G, Worthington P, microgap in the peri-implant hard and soft
Eriksson AR. The long-term efficacy of cur- tissues: A histomorphometric study in
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2. Hermann JS, Cochran DL, Nummikoski PV, Annibali S, Scarano A. Role of the micro-
Buser D. Crestal bone changes around gap between implant and abutment: A
titanium implants. A radiographic evalua- retrospective histologic evaluation in mon-
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6. Abrahamsson I, Berglundh T, Linde J. Soft 15. Waerhaug J. Subgingival plaque and loss
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16. Smith DE, Zarb GA. Criteria for success of
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8. Hermann JS, Schoolfield JD, Nummikoski
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The International Journal of Periodontics & Restorative Dentistry

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