Annals of Anatomy 231 (2020) 151525

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Annals of Anatomy
journal homepage: www.elsevier.com/locate/aanat

Special Issue Review

Marginal bone loss around bone-level and tissue-level implants:

A systematic review and meta-analysis
Mina Taheri a , Solmaz Akbari a,∗ , Ahmad Reza Shamshiri b , Yadollah Soleimani Shayesteh a

a
Department of Periodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
b
Research Center for Caries Prevention, Dentistry Research Institute, Department of Community Oral Health, School of Dentistry, Tehran University of
Medical Sciences, Tehran, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To review the scientific evidence regarding the marginal bone loss around the tissue-level and
Received 29 July 2018 bone-level implants.
Received in revised form 19 March 2020 Methods: MEDLINE-PubMed and EMBASE databases were searched for the relevant English articles (up to
Accepted 7 April 2020
February 2019) assessing the marginal bone loss (MBL) as the primary outcome. To be selected, studies
were supposed to directly mention “tissue-level” and “bone-level” implants or implants with and without
Keywords:
a smooth neck. Relevant data were extracted and meta-analysis was performed to evaluate the effect of
Dental implants
implant neck design.
Marginal bone loss
Bone–implant interface
Results: A total of 19 studies (10 clinical, and 9 RCT studies) were included for qualitative analysis. There
Dental implant–abutment design was a vast heterogeneity between studies in terms of implant designs and study protocol. Out of 19
articles included, 11 studies reached to a statistically significant difference in MBL between the groups;
however, the differences were not found to be clinically relevant. Bone-level implants with platform-
switched abutments in most of the cases showed better marginal bone stability compared to tissue-level
implants or bone-level implants with matching abutments. Seven RCTs with 12 months follow-up data
were selected for meta-analysis (I2 = 93%; heterogeneous), and the results showed less MBL around bone-
level implants compared to tissue-level group (WMD = −0.21 mm; 95% CI −0.42, 0.00; P = 0.06).
Conclusion: The available data regarding comparison of MBL around bone-level and tissue-level implants
are heterogeneous. Bone-level implants with platform switching may better preserve crestal bone.
© 2020 Elsevier GmbH. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1. PICO question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.2. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.3. Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.4. Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.5. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.6. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

∗ Corresponding author at: Department of Periodontics, Tehran University of Medical Science, School of Dentistry, Post Code: 1439955991, Tehran, Iran.
E-mail addresses: mtaherim@gmail.com (M. Taheri), soolmaz.akbari@gmail.com (S. Akbari), ar shamshiri@yahoo.com (A.R. Shamshiri), drshayesteh20@yahoo.com
(Y.S. Shayesteh).

https://doi.org/10.1016/j.aanat.2020.151525
0940-9602/© 2020 Elsevier GmbH. All rights reserved.
2 M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525
1. Introduction
Implant treatments, today, are commonly prescribed as a
result of their remarkable rates of survival and high predictability
(Moraschini et al., 2015). Although varied in terms, definitions pro-
posed for implant success usually concur to include the amount of
marginal bone loss around the implant as a criterion (Albrektsson,
1985; Albrektsson et al., 1986; Buser et al., 1997; Roos et al., 1997;
Zarb and Albrektsson, 1998). Indeed, once the implant is placed into
the bone, the remodeling will commence (Terheyden et al., 2012)
and the bone resorption will continue in the following years. Vari-
ous causes have been discussed for this process, including trauma
from surgery (Esposito et al., 1998), formation of biologic width
(Cochran et al., 1997), micromovement of the abutment (Liu and
Wang, 2017), plaque accumulation (Lang et al., 1993), inflamma-
tion in the microgap area (Ericsson et al., 1995), and occlusal trauma
particularly in conjunction with inflammation (Naert et al., 2012).
In addition, the most commonly-referred definitions of implant
success are permissive of a 1 mm marginal bone loss (MBL) for the
first year and an annual rate of 0.2 mm in next years (Albrektsson
et al., 1986; Roos et al., 1997). MBL has been reported to be affected
by different factors as timing of implant placement (Kinaia et al.,
2014), bone grafting (Yang et al., 2016), macrodesign (Vandeweghe
et al., 2012), neck design (Penarrocha-Diago et al., 2013), and sur-
face topography (De Bruyn et al., 2017) of the implants, shape and
configuration of the implant–abutment connection (Lemos et al.,
2017), prosthetic design (Derks et al., 2016), soft tissue thickness
(Vervaeke et al., 2014), oral hygiene (Ramanauskaite and Tervonen,
2016), history of periodontitis (Sgolastra et al., 2015), smoking
(Chrcanovic et al., 2015b), etc.
Some of the implant features/properties that receive huge atten-
tion are the neck designs and surface characteristics, an array
of which – such as microthreads (Niu et al., 2017), and sur-
face roughness (Teughels et al., 2006) – have been investigated
in order to maintain osseointegration, prevent plaque accumu-
lation, and reduce bone stress. Another point of interest is the
implant–abutment junction (IAJ). Studies have shown that there
is a microgap in this area, reported to range from 0 to 135 ␮m
in size (Dellow et al., 1997; Callan et al., 1998). The microgap is
prone to bacterial accumulation that may lead to the inflamma-
tion in the surrounding tissues and bone resorption (Broggini et al.,
2006). However, what merits attention is that as in teeth, the bio-
logical width is formed around implants, consisting of junctional
epithelium and connective tissue with the average dimension of
about 2 mm and 1–1.5 mm respectively (Berglundh et al., 1991).
This structure provides a protective mechanism against the sur-
rounding environment of the implants. The formation area of the
biological width and the subsequent resorption of the bone is asso-
ciated with the location of the IAJ microgap and rough–smooth
border in the two- and one-stage implants, respectively (Weber
et al., 1996).
Based on their designs, dental implants can be categorized into
either bone-level (BL) or tissue-level (TL) types. Traditionally placed
in a two-stage procedure, the former benefit from the atraumatic
healing in submerged conditions. The latter, however, are usu-
ally inserted in a one-stage surgery that leaves the smooth neck
above the crest and permits the attachment of soft tissue (Buser
et al., 1999). Various studies compared the MBL between the TL
and BL implants; however, the results are not consistent. The
meta-analysis by Vouros et al. in 2012 showed a pooled estimated
difference of 0.05 mm in MBL in favor of TL implants compared to
BL group, it was not statistically significant though (Vouros et al.,
2012). In the systematic review and meta-analysis by van Eekeren
et al., the implants placed above the crest (tissue-level implants)
had 0.29 mm more crestal bone resorption than epicrestal (bone-
level) implants (van Eekeren et al., 2016b). Therefore, the purpose
of the present review study was to address the following focused
question: Is there any significant difference in MBL around tissue-
level and bone-level implants?
2. Methods
This is a systematic review aimed at investigating the effect
of implant neck design on the amount of marginal bone resorp-
tion around it. This study follows the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) checklist.
2.1. PICO question
Do the marginal bone-level changes differ around tissue-level
and bone-level dental implants?
• Population: individuals who received dental implants.
• Intervention: placing bone-level implants.
• Comparison: placing tissue-level implants.
• Outcomes: marginal bone loss around implants.
2.2. Search strategy
In order to investigate the difference between the effect of
tissue-level and bone-level implants on the marginal bone loss,
there was a search conducted in Medline and EMBASE databases.
The last electronic search was performed on 1st of February
2019. In Medline, the “builder” icon was selected from the
“advanced search” tab in order to make and search the two
following combinations: “implant[Title/Abstract] AND (((((((bone
level[Title/Abstract]) OR subcrestal[Title/Abstract]) OR equicrestal
[Title/Abstract]) OR at the level of the crest[Title/Abstract])) AND
(((((tissue level[Title/Abstract]) OR supracrestal[Title/Abstract])
OR “mucosal level”[Title/Abstract]))”; and “implant[Title/Abstract]
AND ((insertion depth[Title/Abstract]) OR implant–abutment con-
nection[Title/Abstract]) AND ((bone level[Title/Abstract]) OR bone
loss[Title/Abstract])”. For EMBASE the key words were “implant
AND (“bone level” OR subcrestal) AND (“tissue level” OR supracre-
stal), implant AND (“bone level” OR equicrestal) AND (“tissue level”
OR “mucosal level”)”.
The results of the above searching processes were added
together and duplicates were removed. Two independent review-
ers then screened the articles and removed the irrelevant ones by
reading the title, abstract, or full text. When necessary, the review-
ers reached a consensus by discussion. Review articles on the topic
were searched as well.
2.3. Inclusion and exclusion criteria
Inclusion criteria were retrospective or prospective clinical
studies in English that used radiographic or histologic meth-
ods to measure marginal bone loss around both tissue-level and
bone-level implants (studies were supposed to directly mention
“tissue-level” and “bone-level” implants, or implants with and
without a smooth neck). Case reports, case series, animal stud-
ies, in vitro studies, finite element analyses, studies that did not
report MBL in millimeters and articles published before the year
2002 were not included in the list. The reviewers also added any
relevant articles they came across while reading the ones already
found. Then, all the selected articles were carefully read out to
screen possible eligibility and to extract the required data.
2.4. Quality assessment
The quality of all included studies was assessed by the same
reviewers. Any disagreement was resolved by discussion. In the
 M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525
case of randomized clinical studies, Cochrane Collaboration’s tool
was used to assess the risk of bias. This tool contains five separate
domains: selection bias, performance bias, detection bias, attrition
bias and reporting bias. The risk of bias within each study was cat-
egorized as follows: low risk of bias if there was a low risk of bias
for all the key domains, unclear risk of bias if there was a low or
unclear risk of bias for all key domains, and high risk of bias if
there was a high risk of bias for one or more key domains (Higgins
et al., 2011). In addition, the quality of non-randomized compara-
tive studies was assessed by the 12-item criteria of Methodological
Index for Non-Randomized Studies (MINORS) (Slim et al., 2003).
The items are scored as 0 (not reported), 1 (reported but inade-
quate), or 2 (reported and adequate) and the highest possible score
for comparative studies is 24.
2.5. Data extraction
From each study, following data were extracted: name of
first author, publication year, study design, method of bone loss
measurements, follow-up duration, brand of implants, implant
placement protocol (one-stage vs. two-stage), implant connection
type, presence of platform switching, number of samples in each
group (bone-level and tissue-level implants), mean and standard
deviation of marginal bone loss and survival rate in each group.
2.6. Data synthesis
For the meta-analysis, randomized controlled clinical trials were
selected that measured the extent of marginal bone change from
the time of prosthesis delivery to one year thereafter. Data were
entered to Review Manager (RevMan [Computer program], Ver-
sion 5.3. Copenhagen: The Nordic Cochrane Center, The Cochrane
Collaboration, 2014). Mean differences of marginal bone loss and
95% confidence interval were calculated. The results (mean differ-
ences) checked for heterogeneity by chi-square and I2 and random
effect model was selected for data synthesis. Subgrouping data
(stratification) by brand of implants reduced heterogeneity but not
resolved. Forest plot was provided to show meta-analysis sum-
mary and funnel plot to evaluate publication bias (although it is
not recommended for less than 10 studies).
3. Results
As shown in Fig. 1, from the total of 457 articles found by
electronic and hand search, 21 original articles were assessed for
eligibility. Two articles (van Eekeren et al., 2015, 2016a) reported
data from one study protocol on the same population, and only
one was chosen to be reviewed (van Eekeren et al., 2015). Two
other studies also reported 1-year and 3-year results from the same
investigation (Astrand et al., 2002, 2004); therefore, just the long-
term data were included. Finally, 19 studies including 9 RCTs and 10
non-randomized clinical studies were included in this systematic
review (Fig. 1). Detailed data from the included studies are shown
in Table 1.
The details of the risk of bias in 9 included RCTs are presented
in Fig. 2. For non-randomized studies, the scores pertaining to
MINORS ranged from 12 to 18 out of a possible score of 24 (Table 2).
As dictated by their prospective properties and the consecutive
inclusion of participants, the studies included in the review were
classed as moderate scientific evidence.
The included studies varied from numerous features such
as the sample size, the time reference and method for bone-
level measurements, the follow-up period, the implant–abutment
connection type (platform switching/butt joint; internal/external
hex or Morse Taper), the geometry of the implant neck (e.g.
microthread), the surgical protocol for implant placement, and the
3
type of prostheses. In accordance with the inclusion criteria of this
review, TL implants were supposed to have a machined neck and
BL implants were not. Height of the transmucosal part ranged from
1.5 mm to 3.3 mm. In 13 out of 19 studies, the platform switching
abutments were connected to the BL implants; the others either
had implant–matching abutments or did not mention the type of
connection. The geometry of the remained part of the fixture was
also different in most of these studies.
As a primary outcome, the amount of MBL was measured in dif-
ferent time periods: in some studies (Kumar et al., 2014; Andreasi
Bassi et al., 2016; Lopez et al., 2016; Hadzik et al., 2017; Valles
et al., 2017; Wallner et al., 2018) the measurement lasted from the
time of implant insertion to the final follow-up, and in the oth-
ers (Astrand et al., 2004; Shin et al., 2006; Ozkan et al., 2007; Bilhan
et al., 2010; Fernández-Formoso et al., 2012; Chiapasco et al., 2014;
Sanchez-Siles et al., 2015; van Eekeren et al., 2015; Rokn et al.,
2017; Sanz-Martin et al., 2017; Lago et al., 2018, 2019; Vianna
et al., 2018) it was conducted from the time of prosthesis deliv-
ery to the last follow-up. The reported marginal bone loss varied
from −0.2 mm (bone gain) to 2.63 mm for BL implants and from
−0.2 mm (bone gain) to 2.23 mm for TL implants. In 11 studies, the
difference between TL and BL implants was reported to be statis-
tically significant in favor of the former or latter group (6 for TL; 5
for BL); however, it could not be considered as an evidence for the
differences to be clinically significant as well.
One recent study (Chappuis et al., 2016), relying on the cone
beam computed tomography, determined the dimensions of the
saucer shape defect around the implants of study. The BL implants
related defect was narrower near to 40% compared to that of TL
implants.
From the 19 studies, seven RCT studies that reviewed results 12
months after implant restoration were selected for meta-analysis.
The chi-square test showed that these studies are heterogeneous
and the I2 value was 93%. In four articles, Straumann implants
were used in one or both of tissue-level and bone-level groups.
The I2 value for these four studies was 82% and for the remain-
ing three articles was 97%. Thus, as shown in Fig. 3, meta-analysis
was separately performed in two subgroups 1 and 2 and also for
all seven studies. The weighted mean difference (WMD) of MBL
between BL and TL implants in subgroup 1 was −0.23 (95% confi-
dence interval [CI] −0.44, −0.01), indicating significant less bone
resorption around bone-level implants compared to tissue-level
implants (P = 0.04). In the analysis of the other three articles, the
mean difference between BL and TL groups was not statistically
significant (WMD = −0.18; 95% CI −0.61, 0.24; P = 0.39). Similarly,
the meta-analysis of all seven studies showed that BL implants had
lower MBL in comparison with TL implants one year after load-
ing, and statistical significance was not reached (WMD = −0.21 mm;
95% CI −0.42, 0.00; P = 0.06) (Fig. 4).
4. Discussion
Bone-level and tissue-level implants have been widely and suc-
cessfully used in dental practices. However, there is no consensus
as to which one has better outcomes. This review investigated the
studies which were primarily concerned with comparing the effect
of bone-level or tissue-level design on MBL around implants.
The mean bone-level changes around TL and BL implants among
the included studies varied from 0.2 mm gain to 2.23 mm loss and
from 0.2 mm gain to 2.63 mm loss, respectively. Meta-analysis was
performed on the randomized controlled clinical studies which had
measured the mean MBL from the time of prosthesis delivery to one
year after. According to those seven studies, bone-level implants
had 0.21 mm less MBL than the tissue-level implants. However,
the articles were heterogeneous (I2 = 93%) and the difference was
 4
Table 1
Characteristics of studies comparing marginal bone loss around tissue-level and bone-level implants.

Authors Study design Implant system and No. of Platform Implant Follow up Method of Survival rate Results (mean marginal bone loss)
number surgeries switching connection measurement
type

Astrand et al. Split-mouth Branemarka BL (N: 73) Two No Mirus cone or 3 years after Periapical X-ray 97.3% BL: −0.1 ± 0.09 mm (gain)
(2004) RCT angulated prosthesis
abutments
Straumannb TL (N: 77) One No Octa-type 97.3% TL: −0.2 ± 0.25 mm (gain) (N.Sig.c )
abutments

Shin et al. Stage-1d TL (N: 34) One No 100% TL: 0.76 ± 0.21 mm
RCT
(2006) Oneplante BL (N: 38) One Yes N.mf 3, 6, and 12 months Periapical X-ray 100% BL1: 0.18 ± 0.16 mm
after prosthesis

Ozkan Camlogg BL (N: 53) Two 100% MBL at 3 years:

Clinical
et al. BL1: 0.25 ± 0.11 mm

M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525
study
(2007) Frialith BL (N: 45) Two N.m N.m 6, 12, 24, 36 Periapical X-ray 100% BL2: 0.28 ± 0.16 mm
months after
prosthesis
Straumann TL (N: 105) One 98.1% TL: 0.26 ± 0.13 mm (N.Sig.)

Bilhan Astra Techi BL (N: 42) Two Yes Internal cone 100% BL1: 0.66 ± 0.1 mm
Clinical
et al. connection
study
(2010) Brånemark BL (N: 36) Two No Flat-to-flat 6 months, 1 and 2 Periapical X-ray 100% BL2: 1.1 ± 0.1 mm (Sig.)
years after
prosthesis
Straumann TL (N: 29) One No Internal-cone TL: 0.8 ± 0.1 mm
(Morse taper)

Fernández- Straumann BL (N: 58) Yes 1 year after Periapical X-ray 100% BL: −0.04 ± 0.50 mm (gain)
Formoso et al. RCT
prosthesis
(2012) Straumann TL (N: 56) N.m No N.m 100% TL: 0.42 ± 0.11 mm (Sig.)

Chiapasco Retrospective Straumann BL (N: 95) Two Yes N.m 12–68 m after Periapical X-ray 100% Ramus grafts
et al. clin- prosthesis BL: 0.48 mm, TL: 0.23 mm (Sig.)
(2014) i- Straumann TL (N: 97) Two No 100% Iliac grafts
cal BL: 1.34 mm, TL: 0.36 mm (Sig.)
study Calvarial grafts
BL: 0.35 mm, TL: 0.21 mm (Sig.)
Retrospective Straumann BL (N: 179) Two Yes Mechanically 1, 2, 3 and 4 years Panoramic X-ray 99% 1-year follow up:
Kumar
clin- locking friction after implantation BL: 0.3 ± 0.431 mm,
et al.
i- fit with a 15◦ TL: 0.61 ± 1.13 mm
(2014)
cal taper (N.Sig.)
study Straumann TL (N: 158) Two No 2-year follow up:
BL: 0.38 ± 0.233 mm,
TL: 0.54 ± 0.462 mm
(N.Sig.)
98% 3-year follow up:
BL: 0.48 ± 0.269 mm,
TL: 0.93 ± 0.420 mm
(Sig.)
4-year follow up:
BL: 0.33 ± 0.098 mm,
TL: 1.11 ± 0.748 mm
(Sig.)
Sanchez- Retrospective BIS Conic Biotechj BL (N: <5-year follow-up:
Siles clin- 729) BL: 2.63 ± 1.61 mm,
et al. i- TL: 1.08 ± 1.27 mm
(2015) cal (Sig.)
study
Table 1 (Continued)

Authors Study design Implant system and No. of Platform Implant Follow up Method of Survival rate Results (mean marginal bone loss)
number surgeries switching connection measurement
type

BIS Biotech TL (N: 515) N.m N.m N.m 5–10 years Periapical X-ray N.m 5–10-year follow-up:
BL: 2.39 ± 1.59 mm,
TL: 1.12 ± 1.21 mm
(Sig.)
>10-year follow-up:
BL: 2.41 ± 1.35 mm,
TL: 1.18 ± 1.39 mm
(Sig.)

Andreasi Bassi Prospective TISk BL (N: 37) One or two Yes An 64 ± 38 m after Periapical and 100% BL: 0.12 ± 1.47 mm

M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525
et al. (2016) clinical study anti-rotational implantation panoramic X-ray
octagon inside
the conical
connection
TIS TL (N: 96) No TL: 0.04 ± 1.3 mm (Sig.)

Lopez et al. Retrospective l

CIS BL (N: 49) N.m N.m An 84 ± 47 m after Periapical and Together: BL: 0.12 ± 1.47 mm
(2016) clinical study anti-rotational implantation panoramic X-ray 98.7%
octagon inside
the conical
connection.
CIS TL (N: 99) TL: 0.04 ± 1.3 mm (N.m)

Chappuis Prospective Straumann BL (N: 20) Yes 5-to-9 years Periapical X-ray, CBCT m
Proximal implant shoulder to fBIC:
et al. clin- BL: −0.44 mm,
(2016) i- TL: −2.18 mm (Sig.)
cal Straumann TL (N: 41) N.m No N.m N.m Facial implant shoulder to fBIC:
trial BL: −0.5 mm,
TL: −2.3 mm (Sig.)
Facial implant shoulder to first crest
contact:
BL: +0.2 mm,
TL: −1.6 mm (Sig.)

van Eekeren SPIn BL (N: 39) One No N.m 1 year after Periapical X-ray 97.4% BL: 0.4 ± 0.4 mm
RCT
et al. (2015) prosthesis
SPI TL (N: 39) 100% TL: 0.2 ± 0.5 mm (Sig.)

Hadzik et al. Astra Tech BL (N: 16) Two Yes N.m 9 m after Periapical X-ray and 100% BL: 0.29 ± 0.2 mm
RCT
(2017) implantation CBCT
Straumann TL (N: 16) One No TL: 0.57 ± 0.3 mm (Sig.)

Sanz-Martin Sweden and Martina BLo

One Yes Internal 12 months after Periapical X-ray N.m BL: 0.56 ± 0.51 mm
RCT
et al. (2017) (N: 22) hexagon prosthesis
Sweden and Martina TL (N: No Internal TL: 0.39 ± 0.53 mm (N.Sig.)
25) hexagon with
20o conical
cone

Rokn et al. Retrospective Straumann, Noble One and N.m N.m 1–11 years after Periapical X-ray N.m BL: 1.37 ± 1.5 mm
(2017) clinical study Biocarep , Branemark, Astra two prosthesis
Tech, Xiveq , Biomet 3ir , and
Implantiums BL (N: 272)

5
 6
Table 1 (Continued)

Authors Study design Implant system and No. of Platform Implant Follow up Method of Survival rate Results (mean marginal bone loss)
number surgeries switching connection measurement
type

Straumann, and Dr. Ihdet TL: 0.28 ± 0.53 mm (Sig.)

TL (N: 206)

Lago et al. Straumann BL (N: 102) One Yes Internal 1 year and 5 years Periapical X-ray In 5years: Baseline to 1 year:
RCT
(2018) connection after loading 96.1% BL: −0.03 ± 0.74 mm (gain),
TL: 0.26 ± 0.55 mm (loss) (Sig.)
Straumann SP TL (N: 100) One No 98% Baseline to 5 years:
BL: −0.20 ± 0.75 mm,
TL: 0.61 ± 0.73 mm (Sig.)

Lago et al. Split-mouth Straumann BL (N: 50) One Yes N.m 1 year and 3 years Periapical X-ray In 3 years: Baseline to 1 year:
(2019) RCT after loading 100% BL: 0.08 ± 0.26 mm,
TL: 0.15 ± 0.49 mm (N.Sig.)

M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525
Straumann SP TL (N: 50) One No 100% Baseline to 3 years:
BL: 0.14 ± 0.35 mm,
TL: 0.18 ± 0.46 mm (N.Sig.)

Vianna Split- Straumann BL (N: 20) One Yes Syn Octa Morse 6 and 24 m after Periapical X-ray 100% Baseline to rest delivery:
et al. mouth taper prosthesis delivery BL: 0.59 ± 0.86 mm,
(2018) RCT connection TL: 0.83 ± 0.96 (N.Sig.)
with an
octagon;
Straumann SP TL (N: 20) One No 100% Baseline to 6 m after loading:
BL: 0.54 ± 0.75 mm,
TL: 0.91 ± 0.92 mm (N.Sig.)
Baseline to 24 m after loading:
BL: 0.70 ± 0.72 mm,
TL: 0.75 ± 1.12 mm (N.Sig.)

Wallner et al. Straumann BL (N: 22) N.m Yes N.m Mean time after Periapical X-ray 100% BL: −0.02 ± 0.35 mm (gain)
Clinical study
(2018) implantation:
BL: 1.9 years TL:
4.9 years
Straumann SP TL (N: 20) No TL: 0.15 ± 1.53 mm
a
Branemark System@, Nobel Biocare AB, Gothenburg, Sweden.
b
Straumann AG, Waldenburg, Switzerland.
c
Not significant.
d
Lifecore, Chaska, MN.
e
Warantec, Seoul, Korea.
f
Not mentioned.
g
Camlog Biotechnologies AG, Basel, Switzerland (CAM).
h
Friatec AG,Mannheim, Germany (FRI).
i
Astra Tech AB Dental Implant system, Molndal, Sweden.
j
Biotech International, Marseille, France.
k
Tapered Implant System (FMD, Rome, Italy).
l
Cylindrical Implant System (FMD, Rome, Italy).
m
Cone beam computed tomography.
n
SPI ELEMENT INICELL; Thommen Medical AG, Grenchen, Switzerland.
o
Due Carrare, Padova, Italy.
p
Nobel Biocare, Gothenburg, Sweden.
q
DENSTPLY, Friadent, GmbH, Germany.
r
Biomet 3i, Palm Beach Gardens, FL.
s
Dentium, Seoul, South Korea.
t
S-system, Dr. Ihde Dental AG, Gommiswald, Switzerland.
 M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525
Table 2
Summary of quality assessment for included non-randomized clinical trials, based on methodological index for non-randomized studies (MINORS).

Ozkan et al. Bilhan et al. Chiapasco et al. Kumar et al. Sanchez-Siles Andreasi Bassi Lopez et al. Chappuis et al. Rokn et al. Wallner et al.
(2007) (2010) (2014) (2014) et al. (2015) et al. (2016) (2016) (2016) (2017) (2018)

1- Clearly stated aim 2 2 2 2 2 2 2 2 2 2

2- Inclusion of consecutive patients 1 1 1 2 0 1 1 1 2 1
3- Prospective collection data 2 2 1 0 0 2 2 2 0 2
4- End point appropriate to the aim of 2 2 2 2 2 1 1 2 2 2
study
5- Unbiased assessment of study 1 0 1 1 0 0 0 1 1 1
endpoints
6- Follow-up period appropriate to the 2 2 2 2 2 2 2 2 2 2
aim of study
7- Loss to follow up less than 5% 0 0 0 0 0 0 0 0 0 0
8- Prospective collection of the study 0 0 0 0 0 0 0 0 0 2
sample
9- An adequate control group 2 2 2 2 2 2 2 2 2 2
10- Contemporary group 2 2 1 0 0 1 1 0 0 1
11- Baseline equivalence of 2 2 2 2 2 1 1 1 1 1
12- Adequate statistical analysis 2 2 2 2 2 1 1 2 2 2
Overall score 18 17 16 15 12 12 13 15 14 18

The items are scored 0 (not reported), 1 (reported but inadequate) or 2 (reported and adequate).

7
8 M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525
Figure 1. Flowchart presenting the search strategy to select eligible studies according to PRISMA guidelines.
not statistically significant (P = 0.06). The vast heterogenicity in the
results might be due to various study conditions, or truly because of
various mechanisms by which either TL or BL implants could take
benefit of enhanced bone preservation. The smooth transmucosal
neck in TL implants may affect the MBL in several ways. First, it is
assumed as an area for the formation of biological width and conse-
quently the bone resorption may be reduced (Hermann et al., 2001).
Second, the neck minimizes the inflammatory effect of bacterial
micro-leakage on crestal bone by shifting the implant–abutment
microgap away from bony crest and could subsequently decrease
the bone resorption (Buser et al., 1997; Hermann et al., 2000).
It is confirmed by the studies in which subcrestal implants dis-
played greater bone resorption than supracrestal or equicrestal
implants (Alomrani et al., 2005; Becker et al., 2016; Valles et al.,
2017). Furthermore, the smooth surfaces are less plaque reten-
tive compared to rougher surfaces (Teughels et al., 2006), which in
turn makes such implants less prone to progressive bone resorp-
tion after being exposed to the oral environment (De Bruyn et al.,
2017). The transmucosal neck could reduce the deteriorative effects
of dis/reconnection of the prosthetic components on peri-implant
bone (Atieh et al., 2017). Abrahamsson et al. in an animal study
observed that disconnection and subsequent reconnection of abut-
ment to the implant disrupted the mucosal barrier and soft tissue
attachment to the implant surface reestablished more apically
(Abrahamsson et al., 1997). On the other hand, the smooth surfaces
have shown lower osteoconductive properties (Wennerberg and
Albrektsson, 2009), and can induce shear stress onto the bone under
functional forces (Misch, 2008). As a result, if the rough/smooth
interface is placed below the crest, it will result in more apical loca-
tion of bony crest (Hermann et al., 2000). Nevertheless, there are
some studies which reporting the osseointegration coronal to the
rough-smooth border (Romanos et al., 2015; Valles et al., 2017).
It should be considered that the bone resorption subsequent to
the formation of biologic width is correlated with the soft tissue
thickness around the implant. According to the study by Berglundh
and Lindhe (1996) when the thickness of the mucosa around the
implant is inadequate for formation of the biologic width, the bone
will be resorbed to provide enough space (Berglundh and Lindhe,
1996). In a recent study (van Eekeren et al., 2016a), it was shown
that the bone-level and tissue-level implants have similar bone
resorption when the soft tissue is thicker than 2 mm. Comparing
bone loss around implants with the mucosal thickness ≤2 mm and
>2 mm, BL implants presented significantly greater MBL when the
tissue was thin, but TL implants had similar amount of MBL in
both situations. In contrary to these data, the study by Wallner in
late 2018 (Wallner et al., 2018) showed that the amount of bone
loss around either BL or TL implants with thick biotype was more
than implants with thin biotype, although the numbers were on
a hundredth-millimeter scale, and the difference between the two
groups was not statistically significant. The authors also stated that
 M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525 9

Figure 2. Summary of risk of bias for randomized clinical trials, based on Cochrane Collaboration’s risk of bias tool.

Figure 3. Forest plot of comparison.

the distinct results might be due to their different definition for
thick or thin biotype.
Type of implant–abutment connection (platform
switch/matching abutment) is another consideration with poten-
tial impact on peri-implant bone level. In most, but not all, of the
reviewed articles, BL implants with platform switching (PS) abut-
ments showed better results than TL implants. Although, reduced
bone resorption around implants with PS was firstly observed and
reported by accident (Lazzara and Porter, 2006), it was afterwards
confirmed by numerous studies (Chrcanovic et al., 2015a). Several
mechanisms have been proposed for crestal bone preservation
around platform-switched implants. The horizontal offset of
implant–abutment interface reduces the effect of micro-leakage
and the subsequent inflammatory cell infiltrate on the marginal
bone (Broggini et al., 2006). The relocation of biological width to
the horizontal area (Lazzara and Porter, 2006) and the reduction
of mechanical stress toward the crestal bone (Maeda et al., 2007)
are also supposed to be responsible for less MBL around implants
with PS. The magnitude of discrepancy between the abutment and
the implant impacts on the amount of reduction in MBL; wider
platforms lead to less bone resorption (Canullo et al., 2010). From
the papers reviewed here, only one study (Chappuis et al., 2016)
10 M. Taheri, S. Akbari, A.R. Shamshiri et al. / Annals of Anatomy 231 (2020) 151525
Figure 4. Funnel plot of comparison.
reported the amount of mismatch between the diameters of the
abutment and the implant platform. Thus, its effect cannot be
addressed here.
The geometric design of implant–abutment connection can also
affect MBL. When the impact of two various implant neck design
on bone resorption is examined, the connection type can act as a
confounding factor if it differs between the two groups. In a sys-
tematic review (Schmitt et al., 2014), it was found that conical
implant–abutment connections show better abutment fit and sta-
bility, smaller microgap, and less MBL compared to non-conical
connections. As shown in the table, the studies by Astrand et al.
(2004), Bilhan et al. (2010), Kumar et al. (2014), Andreasi Bassi
et al. (2016), Lopez et al. (2016), Sanz-Martin et al. (2017), Lago
et al. (2018), and Vianna et al. (2018) have referred to the type
of implant–abutment connection. Only in the studies by Andreasi
et al. and Lopez et al. the connection type was exactly the same in
both TL and BL groups and thus the results could be correlated with
the collar design merely, among the implant related features. In the
study of Astrand et al. in 2004, there was no significant difference
between the Branemark BL implants with Mirus cone or angulated
abutments and Straumann TL implants with Octa-type abutments
(Astrand et al., 2004). In the study by Sanz-Martin et al. (2017), the
implants of the TL group, in addition to the internal hexagon con-
nection used in BL implants, also had a conical portion and better
results were obtained with these implants. However, the difference
was not statistically significant. Bilhan et al. (2010) compared Astra
Tech bone-level, Straumann tissue-level and Branemark bone-level
implants, in which the two former groups had abutments with
internal cone structure. These implants showed no significant dif-
ference in MBL, while Astra Tech group had revealed significantly
less bone resorption compared to Branemark system with flat-to-
flat connection design. Eight researches, including those of Kumar
et al. (2014), Lago et al. (2018), and Vianna et al. (2018), were per-
formed on the Straumann bone-level and tissue-level implants.
Straumann bone-level implants are equipped with crossfit con-
nection which also has a conical part coronal to it. Regarding the
tissue-level implants, the prosthetic system comprises the crossfit
connection for narrow neck implants and synocta abutments for
regular neck and wide neck implants, which is also combined with
the Morse taper design. As both systems utilized sort of conical fit
between implant and abutment, the difference between the BL and
TL groups might be related to the implant collar design only, and
not the implant–abutment connection type.
In the reviewed studies, the timeframe for MBL measurement
was different not only in duration, but also in terms of the start
point; some evaluated the resorption from the time of implant
placement, and some since restoration delivery. In fact, the lat-
ter group did not include the pre-loading resorption, which, as
discussed earlier, could be affected by the implant neck design.
Only in one article (Vianna et al., 2018), the amount of MBL in this
period was measured individually, and the BL implants, although
nonsignificant, showed better results relative to TL group. In the
same study, however, during 24 months after loading the average
bone-level improved around TL implants while resorption contin-
ued around BL implants. Nevertheless, by classifying studies based
on the time reference, the results were still inconsistent and there-
fore not conclusive to the superiority of each of the implants TL or
BL.
Although most studies measured the bone level as the distance
between the implant shoulder to the first bone-to-implant contact,
one study (Chappuis et al., 2016) utilized the CBCT to evaluate the
bony crest as well. Chappuis et al. found that the BL implants with
platform switching had significantly better facial bone crest stabil-
ity compared to the TL implants (Chappuis et al., 2016). This was in
line with the results of a recent animal study where in the proximal
sites the changes in the level of bone crest and the bone in contact
with the implant were reported to be significantly less around BL
implants with PS than the TL implants with PS (Valles et al., 2017).
Bone crest level may be crucial to maintain the soft tissue height
around the dental implants and thus it may contribute to the esthet-
ics. Similar to the mentioned results, the study by Siebert et al. in
2018 found that BL implants in comparison with TL implants tend
to reveal higher results in each individual parameter and total mark
of pink esthetic score; although the difference was not statistically
significant (Siebert et al., 2018).
5. Conclusion
Among the success criteria for implants, only marginal bone loss
was assessed in this review. The present descriptive analysis of MBL
does not suggest the superiority of TL or BL implants. Nevertheless,
clinical factors such as probing depth, bleeding on probing, and
esthetic criteria are also of decisive value and were measured in
some of the included studies.
Conflict of interest
The authors declare that they have no conflict of interest.
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