DOI: 10.1111/prd.
12290
REVIEW ARTICLE
Restorative design and associated risks for peri‐implant
diseases
Douglas R. Dixon | Robert M. London
University of Washington, Seattle, Washington, USA
Correspondence
Douglas R. Dixon, Department of Periodontics, University of Washington, Seattle, WA, USA.
Email: ddixon@uw.edu
1 |  I NTRO D U C TI O N
Over the past decade, there has been a global and systematic effort
to understand the prevalence as well as identify the etiologies as‐
1,2
sociated with both peri‐mucositis and peri‐implantitis. Based on
current data, evidence indicates that peri‐mucositis may be similar
1,3,4
to gingivitis, in that it may be a reversible, inflammatory state.
Interestingly, poor oral hygiene around dental implants has been
listed as a major factor for both forms of peri‐implant disease (muco‐
5-12
sitis and peri‐implantitis), and improvement of hygiene effective‐
ness was associated with successful implant therapy.5,13 Likewise,
prosthetic design5,10,13 has also been associated with peri‐implant
disease if and when the prosthesis hinders/obstructs the patient or
dental professional in daily hygiene measures or gaining access to
the implant platform or surrounding surfaces for examination.
Therefore, the purpose of this review was to explore the fac‐
tors associated with implant restorative design and risks for peri‐im‐
plant diseases. A focus of this review was to explore the relationship
between the natural emergence profile of teeth and prosthetic
attempts to duplicate these contours, as well as other prosthetic
design features related to implant dentistry. Specific concepts re‐
garding implant materials, local factors associated with cemented
restorations (eg, retained cement) or the histologic similarities/dis‐
similarities as risk factors for peri‐implant disease are discussed in
other chapters.
2 |  PROS TH E TI C D E S I G N A N D D I AG N OS I S
O F I N FL A M M ATI O N
Current diagnosis of either peri‐mucositis or peri‐implantitis requires
an accurate assessment of probing depths around an implant.14,15
For peri‐implantitis, an incremental scale of increasing depths along
with bleeding and suppuration are the essential criteria for grading
the extent of disease around the implant.15 These measurements
Periodontology 2000. 2019;81:167–178. wileyonlinelibrary.com/journal/prd   © 2019 John Wiley & Sons A/S. |  167
are essential for diagnosis of the clinical status of implants and im‐
plant‐supported restorations and have resulted in multiple decision
options regarding treatment.16-19 A range of probing sites (from one
to six sites) for evaluation have been recommended for accurate
diagnosis, and site selection is similar to that of natural teeth.15,20-
22
Additionally, the use of light forces during probing has also been
recommended during assessment due to the suspected differ‐
ences in the histologic attachment and anatomy of the peri‐implant
mucosa.14,23
A potential factor for causing inaccurate implant assessment or
inadequate hygiene measures may come from the implant prosthesis
itself. For example, bulky or excessive restorative contours (convex
or concave) may hinder daily oral hygiene measures by the patient as
well as diagnostic and supportive care efforts by professional care
providers during scheduled maintenance appointments. With this
concept in mind, it is therefore essential for long‐term implant health
that the implant prosthetic/restorative design allows for both effec‐
tive oral hygiene efforts and accurate assessment of the peri‐implant
soft tissue interface to allow for early diagnosis and treatment if ei‐
ther mucositis or peri‐implantitis is identified (Figure 1).
Emergence profile is the contour of the natural tooth as it tran‐
sitions (or “emerges”) from the sulcus towards the formation of the
interproximal contacts or the establishment of the buccal/lingual
heights of contour. It is one of the most important concepts to un‐
derstand, as prosthetic goals are centered on achieving natural repli‐
cation of implant prosthetic emergence for biologic health. It is best
understood in the context of a single implant restoration. Therefore,
Figure 2 illustrates the relationship between natural tooth emer‐
gence and implant/prosthesis emergence from the periodontium.
Within the context of identifying the presence of peri‐implant dis‐
ease, the inset in Figure 2 reveals two distinct and interrelated zones
for consideration.
The first zone represents the portion of the prosthesis that
emerges from the gingival sulcus from the free gingival margin to the
contact point interproximally or to establish the facial and lingual/
Published by John Wiley & Sons Ltd
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168       DIXON and LONDON

F I G U R E 1   A,B, Implant position,

diameter selection, and emergence angles
have significant impact on prosthetic
A design and post‐treatment oral hygiene
and maintenance. C, Clinical view of
mandibular restorations (B) with minimal
embrasure space for patient hygiene
and proper access for maintenance and
B
evaluation

F I G U R E 2   Inset: A, Supragingival restorative zone. Area of potential deflection of probe measurement or inaccuracies. Restoration
overcontour or ridge‐lap approaches may deflect  or obstruct both probing and oral hygiene attempts. B, Subgingival restorative‐biologic
zone. Another area of potential probing inaccuracies due to convex profiles or abrupt changes in emergence profile through the implant‐
prosthesis biologic complex. C, Illustration example of altered prosthesis contour affecting probing pathway and potential accuracy
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palatal restorative contours and can be classified as the supragin‐
gival restorative zone. Overcontour of the restoration (excessive
heights of contour, extreme convex/concave profiles) or restorative
material covering or obstructing the gingival sulcus (ie, ridge lap/par‐
tial ridge lap) will deflect/obstruct a periodontal probe entering into
the gingival sulcus. This results in either the inability to probe or,
at least, inaccuracies in probing measurements. Depending on the
relative depth of the implant, the second zone (subgingival, restor‐
ative zone) contains the gingival sulcus, tissue‐abutment‐restoration
interface, and the abutment‐implant interface, and this subgingival
component could potentially be referred to as the restorative “bio‐
logic” zone. Probe deflection or extreme concave or convex restor‐
ative profiles within these zones will also affect the accuracy of a
straight periodontal probe in measurement procedures reducing the
value of this clinical assessment and disease detection. Differences
in restorative material biocompatibility or the effects of tissue‐abut‐
ment interface disturbance (eg, provisionalization, impression pro‐
cedures, final restorative insertion effects or misfit) are assumed to
have a potential effect in the preservation of tissue health and/or
potentiation of inflammation.
Another concept that requires examination is the proposed po‐
sition of the interproximal contact. Figure 3 represents three gen‐
eral positions of the interproximal contact that may affect either the
implant clinical assessment or hygiene measures for the patient. To
evaluate the position of the contact, one must remember that the
F I G U R E 3   Implant restoration contact position is dependent
on implant mesial and distal position, prosthetic tooth size, shape,
and orientation of adjacent teeth and will affect the overall
establishment of the interproximal emergence profile. A‐C, Incisal,
middle, and gingival contact levels. Establishment of interproximal
contact points close to the gingiva may hinder both hygiene efforts
and probing assessment
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implant position, if relatively off‐center (mesial or distal) within the
edentulous area, will have a major impact on restorative contours to
achieve interproximal contact. In this example, for illustration pur‐
poses, the implant position will be centered within the edentulous
space; therefore, three relatively vertical positions for the restor‐
ative contact emerge (incisal, middle, gingival). One can imagine that,
as the contact position shifts towards the middle or gingival posi‐
tions, difficulties in both assessments of the gingival sulcus and oral
hygiene measures increase. Unfortunately, the literature is replete
regarding the association of peri‐implant disease relative to inter‐
proximal contact positions for implant restorations.
Implant width selection is another important consideration
regarding the establishment of proper emergence profile and po‐
tential consequences towards inflammation. It is well understood
that the circular shape of current endosseous implants struggles
to replicate the various tooth dimensions they were created to re‐
place. Invariably, they are undersized in a 360° dimensional aspect.
However, to minimize this offset, the clinician can choose from a vari‐
ety of implant platform dimensions, with the idea to place as large an
implant (platform dimension) as possible to minimize any restorative
challenges while creating proper emergence profiles. Relative to the
natural tooth, Figure 4 details potential emergence profile effects
with narrow implant platform dimensions and platform switching
(depicted in cross‐section). In Figure 4, example 1 shows the relative
effects on emergence profiles when a reduced implant platform is
selected; example 2 depicts the potential emergence profile when
implant platform diameter is close to the natural tooth dimension;
and example 3 shows the potential effects of reducing platform size
via the platform switching concept (assuming that example implants
were placed in identical vertical positions).
Matching implant restorative platform dimensions to tooth di‐
mensions has emerged as a valuable tenet in case design. Utilizing a
wider implant platform under a wider tooth results in a more verti‐
cally directed emergence profile, easier and more direct probing, and
easier hygiene procedures to maintain the implant health. Implant
platform switching has emerged as a method to help reduce initial
bone remodeling after implant placement. By utilizing an implant
abutment narrower in dimension than the implant platform, a re‐
sulting inward horizontal offset is achieved. The implant abutment
interface is moved inward, and thus farther away from bone. This
increase in distance allows for biologic width, with less bone remod‐
eling needed, at least theoretically. We will look at the actual ex‐
perimental results of this phenomenon. We must also consider that
this switch results in a narrower start to restorative emergence. An
implant with a 4.8 mm top but an emergence diameter of <3 mm
may result in an overcontoured profile, thus negating any benefit of
preserving a small amount of bone initially.
Two‐piece implants generally are designed for the implant to end
approximately at the bone crest, with the abutment continuing cor‐
onally through the soft tissue. Though designs vary, the microgap
space at the implant abutment interface is approximately 10 μm;
the mean diameter of bacteria, however, is of smaller dimension,
<2.0  μm. 24,25 The implant‐abutment interface can favor bacterial
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170       DIXON and LONDON
colonization and result in inflammation of peri‐implant mucosa and
24-27
peri‐implantitis. Occlusal loading of the abutment may result in
additional flexing or opening of this interface, increasing the level
of bacterial access. 24,27-34 On the other hand, the implant‐abutment
interface contamination alone may not necessarily result in inflam‐
24,34
mation of the mucosa or peri‐implantitis.
The effect of platform switching has been studied in cohort and
randomized controlled trials. Results of these studies have been in‐
consistent in their conclusions. Platform switching tends to result
in a clinically small but statistically significant gain in bone height
at 1 year, compared with implants restored with platform match‐
ing abutments. The gain is between 0.25 and 0.37 mm.35,36 Some
showed no difference at 1 year.37 A systematic review concluded that
there is about 0.5 mm of bone preservation with platform‐switched
implants; however, heterogeneity of data and publication bias noted
suggest resisting strong conclusions.38 No difference in implant sur‐
vival rates between the two types of restorative design was seen in
36,38
systematic reviews. In a randomized clinical trial with a 3‐year
follow‐up, there was no significant difference in bone height, with
a mean intraindividual difference of 0.05 mm between the platform
switching and the traditional implant‐abutment approaches.39 A 5‐
year trial showed a 1 year difference of 0.3 mm favoring bone levels
on platform‐switched abutments. No changes were noted from that
point out to 5 years.40
Available research indicates that platform switching results in
about 0.4 mm mean improvement in maintaining bone height ad‐
jacent to the implant in early remodeling. This does not seem to re‐
sult in an improvement in patient outcomes. Platform‐switching
F I G U R E 4   Implant platform dimension
may have a significant impact on implant
restoration emergence profiles
or platform‐matching designs should probably be selected based
on other criteria, such as matching the contour of the restoration.
Matching a wide restoration with a wide implant platform may result in
a more maintainable contour and implant assessment via probe mea‐
surements. Selecting a platform‐switched design resulting in a narrow
start to emergence may result in a large overhanging contour and lead
to greater peri‐implantitis (Figure 1A,B). This would negate the small
gain in initial bone height. However, in cases where the implant diam‐
eter is close to the natural tooth (diameter) being replaced, platform
switching maybe beneficial if provisional and final restorative contours
remain maintainable to both patient and dental care provider.
Continuing the discussion of emergence profile should include an
evaluation of the vertical position of the implant platform itself and its
associate effects on restorative contour. In a three‐dimensional con‐
text, the vertical position (Figure 5) of the implant platform may be the
most essential component that the restorative dentist has to deal with
while designing the restoration and creating an esthetic and hygienic
emergence profile angle. One could argue that alterations in any im‐
plant position (buccal, lingual, mesial, or distal) will have a direct effect
on related restorative contours, but only vertical position has an effect
on all positions. During surgery, intentional changes in vertical posi‐
tioning may help correct, or at least help mitigate, some deficiencies of
the other dimensional proportions or implant position. In other words,
an implant placed too shallow will result in dimensional alterations in
all directions with a resulting acute angle of restorative material (hori‐
zontal contours) emanating from the implant abutment (Figure 5A). In
contrast, an implant placed slightly deeper (vertically) the more obtuse
the restorative angle is, by comparison, potentially allowing for less
DIXON and LONDON
F I G U R E 5   Vertical placement relative
to implant platform dimension may require
consideration for implant emergence
profile and restorative contours
obstructed hygiene access as well as potential correction of inadequa‐
cies or deficiencies in dimensional proportions due to implant position.
In contrast, the same implant placed slightly deeper will result in a more
obtuse restorative angle, creating easier hygiene access (due to a more
gradual emergence profile) and potentially correcting inadequacies or
deficiencies in dimensional proportions due to improper implant posi‐
tion. One interesting observation is that if the natural length of a single
rooted tooth is considered relative to its contact points, a simple ver‐
tical angle is established. It also becomes relatively apparent that, in
this scenario, to maintain a vertically sloping emergence profile, implant
platform diameters fall on different vertical positions along this dimen‐
sion. Figure 5A,B illustrates that implant platforms of 4 mm may need
to be placed vertically deeper relative to a 6 mm platform implant if
one is to achieve the same profile dimensions, and the 3 mm down rule
may be too generalized to achieve proper vertical positioning. A simple
concept to remember may be that the narrower the implant platform is,
the deeper one may need to place the implant. Obviously, when placing
an implant deeper to obtain a vertical emergence, that additional depth
must be maintained in a healthy manner. If deeper vertical placement
is not advisable due to anatomic limitation or prosthetic factors, one
can look at selecting a wider diameter implant as a method to allow
shallower placement and maintain the same favorable emergence.
Furthermore, the exact position of the platform, relative to the exist‐
ing bone crest, appears not to influence future crestal bone loss. A re‐
cent retrospective study reported that vertical position of the implant
platform (ie, crestal vs subcrestal) was not a risk factor for increased
crestal bone loss if specific parameters were followed (delayed loading,
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minimal disturbance of implant‐abutment interface, platform shift con‐
cepts).41 If correct, then other factors, such as prosthetic contour, may
hinder patient hygiene and maintenance, thereby initiating or propagat‐
ing inflammation. Therefore, final prosthetic contours should allow for
adequate access and “cleansability,” especially in those cases where the
location of the implant‐abutment interface is subgingival.
3 | PROS TH E TI C D E S I G N ( A S A R I S K
FAC TO R FO R PE R I ‐ I M PL A NT D I S E A S E S)
Peri‐mucositis has been defined as the presence of inflammation within
gingival tissue surrounding implants without the presence of bone loss,
whereas peri‐implantitis is diagnosed when chronic inflammatory fac‐
tors result in destruction of the supporting bone and tissue ultimately
leading to the loss of the dental implant.42,43 A recent systematic review
and meta‐analysis of 1497 individuals with over 6000 implants placed
reported that the prevalence of peri‐implant mucositis was 30.7% of
implants in over 60% of patients, and peri‐implantitis affected 9.6%
of implants placed in 18.8% of individuals.44 A recent meta‐regression
analysis indicates that the prevalence of peri‐implant mucositis and
peri‐implantitis could be as high as 65% and 47%, respectively.45 The
pathogenesis of peri‐implant disease is similar to that of periodontal
disease, which, according to national health surveys, affects approxi‐
mately 50% of American adults aged 30 years or older.46-48
Oral hygiene and access for hygiene and implant maintenance
is essential for the overall long‐term success of dental implants. In
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172       DIXON and LONDON
2009, Serino and Ström reported that, of 109 implants placed in 23
patients, 74% of the implants evaluated had limited to no access
for appropriate oral hygiene procedures. In a direct comparison
of implants with and without proper accessibility for oral hygiene,
the authors rendered a diagnosis of peri‐implantitis in 48% of im‐
plants deemed inaccessible or lacking the capability for oral hygiene
procedures, compared with only 4% of implants with appropriate
accessibility.10
Compliance with a scheduled maintenance procedure has also
49
been identified as essential. In 2011, Rinke et al reported a reduc‐
tion in risk for peri‐implantitis with patients with good compliance
and an elevated risk for those with inadequate oral hygiene and non‐
compliant with implant maintenance. In individuals with a history
50
of periodontal disease, Pjetursson et al reported that patients in
active supportive care after implant placement with residual deeper
probing depths (≥5  mm) had a significant risk for developing peri‐
implantitis and had higher implant loss. However, the prevalence of
peri‐implantitis in those patients in well‐controlled and organized
supportive care was lower. Taken together, the vast majority of
research indicates a link between adequate oral hygiene, and the
ability for access for daily hygiene measures and professional main‐
3,5,10,13
tenance, with implant inflammatory states.
Implant‐retained overdentures have proven to be a versatile and
valuable solution for many edentulous patients. A recently reported
subanalysis of two prospective studies evaluating the health of im‐
plants used as support for an overdenture identified the incidence
of peri‐mucositis to be approximately 52% and 57% at 5 years and
10 years, respectively. Likewise, comparison of fully edentulous pa‐
tients compared with partially edentulous patients, restored with
dental implants, revealed that implants of fully edentulous patients
A B
F I G U R E 6   Occlusal overload. A, Post‐loading of implant restoration with initiation of excessive occlusal forces. B, This resulted in  fracture
of the implant fixture and loss of prosthesis without the loss of osseointegration of retained implant body. C, Abutment screw loosening with
separation and fracture of implant crown with no impact on implant integration [Colour figure can be viewed at wileyonlinelibrary.com]
had higher plaque scores and modified bleeding index scores, sug‐
gesting that prosthetic design(s) hinders hygiene access and that
maintenance procedures may propagate plaque accumulation, and
therefore inflammation.51 Interestingly, the authors also reported
that the 5‐ to 10‐year survival rates were similar between groups,
suggesting that inflammation, although it may exist, may not have
long‐term survival effects, understanding the limitations of the stud‐
ies reviewed.51
Studies on splinting together implant restorations and compar‐
ing the effect of clinical implant complications between splinted and
nonsplinted implant restorations are sparse. Early studies suggested
that when implants were splinted together for bar fabrication to re‐
tain mandibular overdentures, more mucositis and gingival hyper‐
plasia were noted around these splinted implants compared with
individual implants with either magnet or ball attachments. 52 In both
a prospective study and randomized control trial, Vigolo and cowork‐
ers evaluated marginal bone loss around splinted, cement‐retained
vs non‐splinted, cement‐retained implant restorations and found
that marginal bone loss levels were nearly clinically identical be‐
tween the groups at 5‐year and 10‐year observational periods.53,54
Likewise, a recent systematic review of six studies concluded that
there were no discernable differences in loss of crestal bone around
either splinted or nonsplinted fixed implant restorations.55
Occlusal overload can occur on natural teeth, natural teeth with
restorations, and the restoration‐abutment‐implant complex.56 Early
implant studies suggested that occlusal load, when excessive, may re‐
sult in bone loss around dental implants.57,58 Likewise, studies evalu‐
ating off‐axis loading or lateral forces/function due to occlusal design
or angled abutments suggested that increased implant bone stress
and loss, due to these factors, could occur.56,57,59-61 However, several
C
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subsequent studies have challenged this initial concept, suggesting
that neither magnitude nor force vector affected implant bone sta‐
bility or support, leading to a general consensus that occlusal force  finite‐element analysis, Sotto‐Maior et al76 determined that higher
(functional load) was not a risk factor for significant bone resorp‐
tion.62-69 Clinically, however, occlusal overload may result in increased
prosthetic complications such as abutment screw fatigue, with loos‐
ening resulting in separation of the implant‐supported restoration and
predisposing the peri‐implant complex to inflammatory changes or
catastrophic fracture. Figure 6A‐C illustrates cases of occlusal over‐
load resulting in loss of implant prosthesis but not implant integration.
Implant cantilever designs may increase nonaxial loading
through bending forces during mastication that are potentially
transmitted to the crestal bone associated with the cantilevered
implant. 56 It had been shown previously, in natural teeth with can‐
tilevers on terminal abutments, that overall prosthesis survival was
lower.70-72 In a study that followed 126 implants in 36 patients,
the authors reported that marginal bone loss was associated with
73
implants with cantilever‐type restorations. In contrast, however,
others determined that implants serving as the distal cantilever
in full‐arch prostheses did not show clinically significant implant
marginal bone loss (Figure 7) or other adverse biologic effects.72,74
One important implant prosthesis consequence, garnering author
agreement, is that cantilever extension may result in more re‐
storative technical complications.72,75 Therefore, to mitigate the
effects of nonaxial loading, some have suggested to increase the
number of implants when designing cantilever‐type prostheses, or
to select narrow or short implants to avoid cantilever prosthetic
design risks when possible. 56,73
F I G U R E 7   Radiographic evaluation of loaded implant‐supported
prosthesis with cantilever pontic design revealing minimal impact
on implant integration or crestal (alveolar) resorption
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Likewise, crown‐to‐implant ratios may also affect bending
stresses on the implant, thereby affecting marginal bone. Utilizing
crown‐to‐implant ratios increased stress concentrations, resulting
in approximately 12% of the total stresses subjected to the cortical
bone. In tandem, as the crown‐to‐implant ratio increased towards
a 2:1 ratio, higher stresses were observed mostly during oblique
forces.77 In a prospective, 3‐year study, Malchiodi et al78 determined
that higher bone loss and implant failures were associated with in‐
creased crown‐to‐implant ratios, suggesting that a clinical threshold
may exist at a 3:1 ratio.
It is without question that prosthetic design can be complex and
multifaceted and contain patient and case‐related variables coupled
with parallel complexities in biomechanical considerations. Although
definitive conclusions may be difficult and/or controversial, due to
variances in study variables, outcome assessments, or design, an ap‐
preciation for potential mechanical overload or excessive stresses
may be prudent in any prosthetic design to minimize potential bend‐
ing or off‐axis stresses as well as prosthetic complications.
4 | A B U TM E NT I NTE R FAC E A N D
R E S TO R ATI V E M ATE R I A L S A S A R I S K
FAC TO R
Implant surfaces are designed to be biocompatible with a variety of
host tissues, such as bone, connective tissue, and epithelium, as well
as be noncorrosive within the oral environment. Once surfaces are
exposed, they are susceptible to bacterial colonization through elec‐
trostatic, hydrophobic, lectin‐like, van der Waals–type interactions
as well as the free energy and roughness of the material surface.79-82
Studies have validated the assumption that rougher surfaces will be
more plaque and biofilm retentive, and therefore harder to clean and
maintain, and result in higher incidence of peri‐implant disease.81-83
Interestingly, microbial complexity and formation may be related
more to the individual themselves rather than the material being
used; however, some studies suggest that certain materials (eg,
gold alloys, titanium, and zirconium) may be more resistant to bac‐
terial colonization than others.79,84,85 Therefore, material selection
should consider both biologic (low biofilm formation potential) and
biofunctional goals (ie, tissue integration, material strength, etc) for
improved maintenance and hygiene performance.
Likewise, studies have shown that procedural errors, such as
abutment seating errors/misfit or nonpassive fit or suprastucture/
framework connection discrepancies can also induce local factors
(ie, microbial contamination/colonization of the abutment/supra‐
structure interface with the implant platform), and initiate inflamma‐
tion or peri‐implant bone stress.56,86-91
Therefore, early identification, correction, or minimization of
these factors may be prudent to reduce potential biologic or pros‐
thetic complications, even if there may be cases in which these
factors are potentially compensated by other variables. The prepon‐
derance of current information indicates the need for meticulous
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174       DIXON and LONDON

care in implant and implant component selection and handling to
reduce microbial contamination and associated errors. Further eval‐
uation by the reader regarding surface roughness/material com‐
parisons, plaque accumulation, and biofilm formation in relation to
material properties, microgap effects, or contamination of various
internal and external implant components can be found via multiple
recent reviews.92-96
5 |  B O N E LOS S A S S O C I ATE D W ITH
I N ITI A L I M PL A NT PL AC E M E NT A N D
PROS TH E TI C PRO C E D U R E S
Interestingly, perhaps one risk factor involved with initial bone
remodeling around implants was related to the implant and ini‐
tial prosthetic procedures themselves. In a multicenter, prospec‐
tive study, Cochran et al97 evaluated the radiographic changes in
crestal bone levels adjacent to >500 implants (mandibular eden‐
tulous and maxillary partially edentulous cases) over a 5‐year
period. Following implant placement, abutment placement and
impressions were performed before final prosthesis placement.
Radiographic analysis revealed that, regardless of restoration type
(single, multiple) or implant length, approximately 86% of the total
mean bone loss occurred before the final prosthesis placement.
These results suggest that implant placement procedures (e.g. , os‐
teotomy preparation, implant placement) and abutment connec‐
tion procedures, coupled with the avascular nature of the implant
and component systems, play a major role in crestal bone remod‐
eling occurring around endosseous dental implants. However, one
cannot ignore the fact that bone loss continues after prosthesis
placement, and further studies that evaluate posterior implants in
maxillary and mandibular sites are needed.
6 | CO N C LU S I O N S
There are a number of known dental implant risk factors with
supporting literature, such as smoking, diabetes, and a history of
periodontitis. However, in regard to prosthetic design and peri‐
mucositis/implantitis, many remain putative. Therefore, it may be
tempting to hold to previous design concepts or dogma related
to esthetic principles or perceived patient demands for esthetic
results vs concerns for health. It must be remembered that the
epithelial mucosa adjacent to implant‐supported prostheses
(both restoration and abutment) is different, compared with the
natural dentition, in vascularization, adhesion, and structural sup‐
port.98-100 Alteration in natural resistance or defense to bacterial
infiltration and colonization may predispose implant sites towards
inflammatory‐based disease and loss of periodontal support,
simply due to these histologic differences. Therefore, prosthetic
design must allow for both daily hygiene and professional main‐
tenance if predictable, long‐term success is valued. To accomplish
this, a consideration of emergence profile for the implant prosthe‐
sis is essential. As stated, emergence profile is the term describing
the contours of the abutment and crown as they transition from
the round shape of the implant to the anatomic shape of the res‐
toration. The final shape of this subgingival contour varies based
on the dimension of the restorative platform at the implant level,
the dimension of the tooth to be restored, and the vertical dimen‐
sion available within which to accomplish this transition. Within

A B C

D E F

F I G U R E 8   A‐C, Initial patient presentation and implant prosthesis removed and resulting peri‐implant inflammation and gingival irritation
under pontic (due to closed embrasure spaces and inadequate access for daily homecare and maintenance). D‐F, Prosthesis recontoured (E)
to open embrasures and emergence profile and reduce/eliminate modified ridge‐lap pontic profile to allow for adequate clinical access for
both provider and patient. Tissue response (F) 2‐4 wk after prosthesis recontouring resulting in improved access for daily home care
DIXON and LONDON
the dental laboratory, it is well understood that the intent of any
dental prosthesis is to mimic the natural esthetic features and
clinical functions of the human dentition. Treatment planning, sur‐
gical placement, laboratory design, and restorative procedures all
play a critical role in the final outcome and long‐term survival of
implant‐supported prostheses. Oversights or complications during
any of these phases can have long‐term effects for both patient
and provider (Figure 1).
Generally speaking and when applicable, the authors prefer
a subtle, vertical emergence pattern that is amenable to probing
and hygiene instrumentation that most closely resembles the nat‐
ural tooth emergence contours (Figure 8). To accomplish this, some
suggested guidelines for individual implants may include: (a) careful
consideration of the three‐dimensional positioning of the implant
fixtures relative to the anatomic and adjacent natural dentition;
(b) proper implant dimensional selection to coincide with natural
emergence profiles for teeth being replaced; (c) understanding and
consideration of emergence profiles and emergence angles for pros‐
thetic restorations (provisional through definitive) to balance esthet‐
ics with daily hygiene and professional supportive care. Additional
steps to minimize inflammatory states within the peri‐implant tissue
could include placing the abutment‐implant platform interface (con‐
nection) as far as possible above the bony crest for hygiene facili‐
tation and maintenance procedures but vertically deep enough for
emergence profile and esthetics. Prosthetic complications may be
reduced by avoidance of excessive crown‐to‐implant ratios (≥ 3:1 ) 
and reducing excessive occlusal load and heavy contacts. Suggested
guidelines for multiunit and splinted implant prostheses may also in‐
clude: (a) special emphasis on designs incorporating adequate access
for the use of interproximal devices designed to clean both implant
peri‐mucosal surfaces and prosthesis superstructure; (b) proper se‐
lection of materials containing high biocompatibility and mechanical
strength values; and (c) minimizing the effects of misfit/nonpassiv‐
ity of the framework and multiple abutment changes during implant
or restorative treatment. The authors also believe that overdenture
implant‐abutment designs may benefit from more attached gingiva
surrounding the transmucosal components to reduce the gingival
complications associated with physical compression, contact with
restorative material, and plaque accumulation.
One may also consider that in patients with a history of periodon‐
tal disease or oral hygiene limitations due to physical disabilities,
limitations in dental IQ, or who are simply noncompliant, an im‐
plant‐supported prosthesis purposely designed with implant smooth
surface collar and supragingival abutment/platform interface may
be helpful for long‐term health and maintenance in these at‐risk pa‐
tients. Likewise, removable restorations like implant‐retained, tissue‐
supported overdentures may serve some patient populations well by
allowing for adequate function and esthetics while providing appro‐
priate access for oral hygiene and implant component maintenance.
In conclusion, the biologic mechanisms responsible for the shift
from clinical health to inflammatory states, like peri‐mucositis or
peri‐implantitis, have yet to be determined. Many factors still wait to
be identified or validated. Therefore, to create an environment that
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may be “predisposed” for health, one should consider all of the vari‐
ous implant and restorative factors related to hygiene, maintenance,
and “retrievability,” as well as esthetics. Along these lines, in consid‐
ering patients that have a history of periodontal disease, have oral
hygiene limitations due to physical disabilities, or who suffer from
low dental IQ or who are simply noncompliant, an implant‐prosthesis
purposely designed to incorporate a smooth surface collar and/or
supragingival abutment/platform interface may prove beneficial for
long‐term health and successful maintenance/supportive periodon‐
tal therapy procedures in these at‐risk patients.
AC K N OW L E D G M E N T S
We thank the Graduate Department of Periodontics, University of
Washington, and departmental case files for representative example
radiographs and photographs with special appreciation to Dr Alaa 
Yassin and Dr Russell Johnson. We also would like to thank Ms Kate
Sweeney, medical illustrator, University of Washington, for her help
and assistance in figure creation and illustration; Note: Created fig‐
ures are Illustrator's representations and may not reflect accuracy in
implant osseointegration, bone or tissue biology.
C O N FL I C T O F I N T E R E S T
The authors report no conflicts of interest.
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How to cite this article: Dixon DR, London RM. Restorative
design and associated risks for peri‐implant diseases.
Periodontol 2000. 2019;81:167–178. https​://doi.org/10.1111/
prd.12290​