Accepted: 16 January 2018

DOI: 10.1111/jcpe.12871

C L I N I C A L I N N O VAT I O N R E P O R T

Adapting the vertical position of implants with a conical

connection in relation to soft tissue thickness prevents early
implant surface exposure: A 2-­year prospective intra-­subject
comparison

Stijn Vervaeke1  | Carine Matthys2 | Rima Nassar1 | Veronique Christiaens1 | 

Jan Cosyn1,3 | Hugo De Bruyn1

1
Department of Periodontology and Oral
Implantology, Faculty of Medicine and Health Abstract
Sciences, School of Dental Medicine, Ghent Aim: To evaluate the effect of soft tissue thickness on bone remodelling and to inves-
University, Ghent, Belgium
2
tigate whether implant surface exposure can be avoided by adapting the vertical im-
Department of Removable
Prosthodontics, Faculty of Medicine plant position in relation to the soft tissue thickness.
and Health Sciences, School of Dental
Materials and Methods: Twenty-­five patients received two non-­splinted implants
Medicine, Ghent University, Ghent, Belgium
3 supporting an overdenture in the mandible. Soft tissue thickness was measured using
Faculty of Medicine and Pharmacy, Dental
Medicine, Free University of Brussels (VUB), bone sounding and ultrasonically. One implant was installed equicrestally (control),
Brussels, Belgium
and the vertical position of the second implant was adapted to the site-­specific soft
Correspondence tissue thickness (test). Crestal bone levels were determined on digital peri-­apical radio-
Stijn Vervaeke, Department of Periodontology
graphs and compared with baseline (implant placement).
and Oral Implantology, Faculty of Medicine
and Health Sciences, School of Dental Results: Twenty-­five patients were consecutively treated. No implants failed during
Medicine, Ghent University, Ghent, Belgium.
the follow-­up. A significant correlation was observed between soft tissue thickness
Email: stijn.vervaeke@ugent.be
and bone level alterations after 6 months (ultrasound ICC = 0.610; bone sounding
Funding information
The study was supported with a grant ICC = 0.641) with inferior bone levels for equicrestal implants when thin tissues are
from Dentsply Implants. Dentsply Implants
present. Subcrestal implants showed significantly better bone levels after 6-­month
provided free materials to be used in the
study. (n = 24, 0.04 mm versus 0.72 mm; p < .001), 1-­year (n = 24, 0.03 mm versus 0.77 mm;
p < .001) and 2-­year follow-­up (n = 24, 0.04 mm versus 0.73 mm; p < .001).
Conclusion: Initial bone remodelling was affected by soft tissue thickness. Anticipating
biologic width re-­
establishment by adapting the vertical position of the implant
seemed highly successful to avoid implant surface exposure.

KEYWORDS
bone level, dental implant, implant surface, prevention, soft tissue

1 |  INTRODUCTION
The influence of peri-­implant mucosal thickness on initial crestal bone
level alterations and long-­term stability has been a topic of debate and
enhanced research.
In 1996, Berglundh and Lindhe reported in an animal study that
implants installed at sites with thin mucosal tissues, meaning 2 mm or
less, consistently presented with crestal bone loss. The authors sug-
gested a certain minimal width of peri-­implant mucosa as a prereq-
uisite to allow a stable soft tissue attachment (Berglundh & Lindhe,
1996).
An in vivo study by Linkevicius and coworkers investigated the
influence of initial soft tissue thickness on crestal bone changes
around implants in humans. The test implants were placed 2 mm

J Clin Periodontol. 2018;45:605–612. wileyonlinelibrary.com/journal/jcpe   © 2018 John Wiley & Sons A/S. |  605
Published by John Wiley & Sons Ltd
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606       VERVAEKE et al.
supracrestally, whereas the control implants were placed equicrestally.
The major finding was that placing an implant 2 mm supracrestally and
thus moving the microgap away from the alveolar crest did not prevent
peri-­implant bone loss if thin soft tissues were present at the time of
implant placement. The authors concluded that a soft tissue thickness
of 2 mm or less resulted in crestal bone loss up to 1.45 mm, despite a
supracrestal position of the implant–abutment interface (Linkevicius,
Apse, Grybauskas, & Puisys, 2009).
More recently, Vervaeke, Dierens, Besseler and De Bruyn (2014)
suggested that the soft tissue thickness at the time of implant place-
ment may influence peri-­implant bone loss. Implants installed at sites
with thin mucosal tissues showed increased crestal bone loss because
of the biologic necessity to re-­establish the biologic width. The abut-
ments in this study were placed at time of implant placement, and the
height was adapted to the site-­specific soft tissue thickness. Hence,
the abutment height more or less reflected the initial soft tissue
thickness.
As a consequence, it was suggested to adapt the vertical position
of the implant to the initial soft tissue thickness in order to avoid un-
foreseen exposure of the implant surface after initial bone remodel-
ling. However, the shortcoming of the study was the lack of accurate
soft tissue measurements (Vervaeke et al., 2014).
The aim of this study was to investigate the influence of the soft
tissue thickness on peri-­implant bone remodelling in a prospective
split-­mouth clinical study. The research hypothesis was that bone
level alterations around equicrestal implants are influenced by the soft
tissue dimensions at the time of implant placement. The secondary
aim was to investigate whether early implant surface exposure can be
avoided by adapting the vertical implant position in relation to soft
tissue thickness.
2 |  MATERIALS AND METHODS
2.1 | Patient population and surgical/prosthetic
procedures
Fully edentulous patients visiting Ghent University Hospital and in
need of an overdenture in the mandible were included in this pro-
spective split-­mouth study. Exclusion criteria were smoking and sys-
temic diseases. Removable dentures in mandible and maxilla were
made by an experienced prosthodontist (CM) prior to implant treat-
ment. Whenever tooth extraction in the anterior mandible was re-
quired prior to implant placement, a healing period of 3 months was
respected. Thereafter, the ideal prosthetically driven implant position
was determined by the prosthodontist and indicated in the remov-
able denture using gutta-­percha markers for radiological evaluation. A
CBCT of the mandible was made to evaluate bone volume. Soft tissue
thickness was measured at the site of implant placement with an ul-
trasonic device (EPOCH 600, Olympus, Aartselaar, Belgium, Figure 1)
and bone sounding prior to implant surgery. A transducer probe with
a diameter of 4 mm was applied to the measurement site with minimal
pressure. Measurements were performed three times and averaged to
obtain one value for every single implant.
Clinical Relevance
Scientific rationale for the study: The literature is inconclusive
about the effect of soft tissue thickness on early bone re-
modelling. The aim of this study was to evaluate this effect
in a split-­mouth study.
Principal findings: Implants at sites with thin mucosal tissues
show inferior crestal bone levels. However, anticipating
early bone remodelling by adapting the vertical implant po-
sition to soft tissue thickness prevented early implant sur-
face exposure.
Practical implications: Early implant surface exposure may
increase the risk for peri-­implantitis. Hence, implant place-
ment in relation to soft tissue thickness is advised.
F I G U R E   1   Soft tissue thickness was measured at the site of
implant placement with an ultrasonic device (EPOCH 600, Olympus,
Aartselaar, Belgium)
The implant surgery was performed by the same surgeon (SV). The
existing removable prosthesis was used as a surgical guide. Access
holes were made at the position of the gutta-­percha markers allow-
ing implant placement in the ideal prosthetic position. The patients
were asked to rinse for 1 min with a 0.12% chlorhexidine solution
(Perio-­Aid, Dentaid, Barcelona, Spain) after receiving local anaesthe-
sia. A full-­thickness mucoperiosteal flap was elevated to expose the
inter-­foraminal bone. Dental implants (Astra Tech OsseoSpeed TX™,
Dentsply implants, USA) measuring 3.5 or 4 mm in width and 8, 9 or
11 mm in length were installed.
One implant was installed according to the manufacturer’s guide-
lines (equicrestal placement=control implant). The vertical position of
the second implant was adapted to the soft tissue thickness (subcr-
estal placement=test implant), allowing at least 3 mm space for bio-
logic width establishment (Vervaeke et al., 2014). This means that
an implant installed at a site with a mucosal thickness of 2 mm was
placed 1 mm supracrestally. A systematic non-­random assignment was
VERVAEKE et al.
applied to determine the position of test and control implants. Hence,
the experimental site was altered for every consecutive patient based
on the chronological order of patient inclusion. Implants were imme-
diately restored with Locator abutments (Zest). The crestal bone was
slightly adapted around the subcrestal implants to install the Locator
abutments. There was no direct contact between the bone and the
abutments. All patients were intentionally treated using a one-­stage
surgical procedure. However, after implant installation, primary sta-
bility was evaluated using a torque wrench, and in case of insufficient
primary stability (<20 Ncm), a two-­stage approach was preferred and
implants were submerged for 3 months. In those cases where a two-­
stage approach was required, the implant–bone relationship for test
and control implants was the same as for the one-­stage surgical proce-
dure. Only, the installation of the final abutment was postponed, and
tissues were closed to allow an undisturbed integration of the implant.
The mucoperiosteal flap was closed using single interrupted, monofil-
ament sutures (Seralon® 5.0, Serag Wiessner, Naila, Germany).
A peri-­apical radiograph was taken immediately after the im-
plant surgery to determine baseline bone levels. Antibiotics were
(a) (b)
(d) (e)
(g) (h)
(j) (k)
F I G U R E   2   (a) Edentulous mandible. (b) Markers for pre-­surgical planning. (c) Access holes. (d) Determination of Implant position. (e) Bone
sounding using periodontal probe. (f) Ultrasonic soft tissue measurement. (g) Equicrestal (control) and subcrestal (test) implant placement. (h)
Locator abutments. (i) Suturing. (j) Baseline radiograph, reference point = lower border of the smooth implant collar. (k) Radiograph at 6 months.
(l) Radiograph at 2-­year follow-­up
|
      607
administered from the day of surgery (amoxicillin 1 g, 2 times daily,
during 4 days), and a plaque control regimen was instructed by
means of a 0.12% chlorhexidine mouth rinse twice a day during
1 week (Perio-­Aid, Dentaid, Barcelona, Spain). The sutures were
removed 7 days after implant surgery. If necessary, oral hygiene re-
inforcement was given. All implants were connected with the pros-
thesis and functionally loaded 3-­4 months after implant placement
using the Locator System. The clinical procedure is illustrated in
Figure 2.
This clinical trial has been conducted in full accordance with the
Helsinki Declaration (1975) as revised in 2000. All patients were
thoroughly informed and signed a written informed consent. The
study protocol was approved by the ethics committee of the Ghent
University Hospital.
2.2 | Clinical and radiographic examination
Clinical examination followed after 1 week, 1, 3, 6 months, 1 year
and 2 years. During the follow-­up visits, plaque and bleeding scores
(c)
(f)
(i)
(l)
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608       VERVAEKE et al.
were evaluated using the modified plaque and bleeding index
(Mombelli, van Oosten, Schurch, & Land, 1987). Probing pocket
depths were measured 3 months after implant surgery and at every
visit thereafter on four implant sites (midmesial, mid-­distal, midbuc-
cal and midlingual).
Digital peri-­apical radiographs were taken at baseline (implant
placement), at 3, 6 months, 1 year and 2 years using a guiding sys-
tem in order to obtain the X-­rays perpendicular to the film. The
radiographs were calibrated using the length of the implant or the
microthreads and analysed using AxioVision Rel. 4.8. Bone levels
were determined as the distance from a reference point, which cor-
responds with the lower edge of the smooth implant bevel at the
implant–abutment interface, to the most crestal bone-­to-­implant
contact point (Figure 2).
2.3 | Statistical analysis
Bone level was considered the primary outcome measure (depend-
ent variable), whereas soft tissue thickness and surgical procedure
were the explanatory variables. The sample size was calculated using
SAS Power and Sample size calculator for related samples based on
an effect size of 1 mm and a standard deviation of 0.60, with the
level of significance set at 0.05 and β = .80. The effect estimation
was based on the findings of Vervaeke et al., 2014. Statistical analy-
sis was performed using SPSS® 22 for Windows (SPSS Inc., Chicago,
IL, USA). Correlations between soft tissue thickness initial bone level
changes were analysed using the intra-­class correlation coefficient.
Longitudinal bone level changes as well as differences in bone levels
between test and control implants at 6, 12 and 24 months were ana-
lysed using the Wilcoxon signed ranks test. Inter-­subject differences
between submerged and non-­submerged implants for test and control
implants were analysed using the Mann–Whitney U test.
3 |  RESULTS
A sample size of 14 patients was calculated. Hence, 25 patients (=50 im-
plants) were consequently included to anticipate future dropouts. The
sample consisted of 12 men and 13 women with a mean age of 65 years
(SD = 9.09, range=43-­
82) who were consecutively treated between
January 2013 and September 2014. In one patient with a knife edge,
2 test implants were mandatory to test, implants were mandatory to have
the implants completely surrounded by the crestal bone. This patient was
excluded from the study based on the absence of a control condition.
T A B L E   1   Initial soft tissue thickness at test (subcrestal placement) and control (equicrestal placement) sites using ultrasound and bone
sounding
Test
Sites Mean (mm) SD
Bone sounding n = 24 1.92 0.56
Ultrasound n = 24 1.97 0.64
No implants failed during the follow-­up, resulting in a survival rate
of 100%. Implants were placed in a one-­stage procedure. However,
in five patients, implants were submerged as a consequence of a lack
of primary stability (<20 Ncm). If only one implant, either test or con-
trol, had insufficient primary stability, a submerged procedure was ad-
opted for both implants to avoid the inclusion of confounding surgical
factors.
A mean initial soft tissue thickness of 1.93 mm (N = 24, SD = 0.60,
range=1.00-­3.00) and 1.98 mm (N = 24, SD =  0.65, range=0.67-­3.40)
was measured before implant placement, using bone sounding and
ultrasonic measurements, respectively. A strong correlation was ob-
served between both techniques (ICC = 0.925). Data on initial soft tis-
sue thickness for test and control sites are presented in Table 1. Mean
plaque scores, bleeding scores and probing pocket depths after 1 year
and 2 years are given in Table 2.
Statistical analysis did not reveal a significant difference between
mesial and distal bone levels (p = .120). Hence, one bone level value
was calculated for each individual implant. Based on 24 control im-
plants in 24 patients, a significant correlation was observed between
initial soft tissue thickness and bone level alterations after 6 months
using ultrasound (ICC = 0.610) and bone sounding (ICC = 0.641), with
inferior bone levels for equicrestal implants when thin tissues are
present (Figure 3). After 6, 12 and 24 months, control implants (equi-
crestal implants) showed a mean bone level of 0.72 mm (n = 24, SD
0.75, range 0.00 -­2.45), 0.78 mm (n = 24, SD 0.81, range 0.00 – 2.92)
and 0.73 mm (n = 24, SD 0.72, range 0.00 – 2.61), respectively, com-
pared with a mean bone level of 0.04 mm (n = 24, SD 0.11, range 0.00
– 0.45), 0.03 mm (n = 24, SD 0.10, range 0.00 – 0.36) and 0.04 mm
(n = 24, SD 0.10, range 0.00 – 0.30) for the test implants (subcrestal
implants). Submerged control implants demonstrated no bone level
changes after 3 months, compared with 0.83 mm for non-­submerged
control implants (p < .001). However, 6 months after implant place-
ment (=3 months after second-­stage surgery), this difference was no
longer observed (p = .526) (Table 3, Figure 4). Hence, the only differ-
ence between submerged and non-­submerged conditions is the mo-
ment when biologic width formation takes place, being after implant
placement for non-­submerged implants and after the second-­stage
surgery for submerged implants (Table 3, Figure 4).
After initial bone remodelling, bone levels remained stable up to
2-­year follow-­up. Bone level values at 3, 6, 12 and 24 months for
submerged and non-­submerged implants are given in Table 3. When
taking 1 mm of bone level changes as a threshold, 100% of the test
implants and 83.3% of the control implants were considered a success.
The corresponding values for 0.5 mm were 100% and 54.2%.
Control
Range Sites Mean SD Range
1.00 -­3.00 n = 24 1.94 0.65 1.00–3.00
0.67 -­3.40 n = 24 1.99 0.67 0.94–3.30
VERVAEKE et al. |
      609

T A B L E   2   Mean plaque scores, bleeding scores and probing pockets depths measured at four implant sites (mesial, distal, buccal and lingual)
and averaged to obtain one single value for test and control implants after 1 year (n = 24) and 2 years (n = 24)

1 year 2 years

Test Control Test Control

Plaque 0.95 (SD = 0.86; range 0.75 (SD = 0.79; range 0.72 (SD = 0.78; range 0.56 (SD = 0.72;
0.00–3.00) 0.00–3.00) 0.00–3.00) range 0.00–3.00)
Bleeding 0.26 (SD = 0.58; range 0.20 (SD = 0.19; range 0.20 (SD = 0.28; range 0.25 (SD = 0.32;
0.00–2,75) 0.00–0.50) 0.00–1.00) range 0.00–1.00)
PPD (mm) 1.83 (SD = 0.53; range 1.70 (SD = 0.44; range 2.56 (SD = 0.84; range 2.30 (SD = 0.66;
1.00–2.75) 1.00–2.50) 1.25–4.50) range 1.50–4.50)

F I G U R E   3   Scatter plot illustrating the

correlation between soft tissue thickness
(ultrasound) and crestal bone levels around
control implants after 6-­month follow-­up
(Trendline = Loess curve fitted at 50% of
the data)

T A B L E   3   (a) Bone Levels (mm) after 3, 6, 12 and 24 months for non-­submerged test (subcrestal) and control equicrestal) implants. (b) Bone
Levels (mm) after 3, 6, 12 and 24 months for submerged test (subcrestal) and control (equicrestal) implants

Control Test

(a) Implant number Bone Level (mm) SD Min Max Implant Number Bone level (mm) SD Min Max

3 Months 19 0.83 0.78 0.00 2.33 19 0.05 0.13 0.00 0.48

6 Months 19 0.73 0.68 0.00 2.11 19 0.05 0.13 0.00 0.45
12 Months 19 0.70 0.70 0.00 2.57 19 0.04 0.11 0.00 0.36
24 Months 19 0.61 0.6 0.00 2.61 19 0.05 0.11 0.00 0.3

Control Test

(b) Implant number Bone Level (mm) SD Min Max Implant Number Bone Level (mm) SD Min Max

3 Months 5 0.00 0.00 0.00 0.00 5 0.00 0.00 0.00 0.00

6 Months 5 0.66 1.03 0.00 2.45 5 0.00 0.00 0.00 0.00
12 Months 5 1.08 1.21 0.00 2.92 5 0.00 0.00 0.00 0.00
24 Months 5 0.96 1.05 0.00 2.59 5 0.00 0.00 0.00 0.00
 |
610       VERVAEKE et al.
4 |  DISCUSSION
The present study shows that initial bone remodelling is affected by soft
tissue thickness (Vervaeke et al., 2016). Consequently, implants installed
at sites with thin soft tissues, meaning 2 mm or less, presented inferior
bone levels. However, anticipating biologic width re-­establishment by
adapting the vertical position of the implant (subcrestal implant place-
ment) seemed highly successful to avoid exposure of the implant surface.
At the Estepona Consensus meeting in 2012, it was concluded that
a limited amount of crestal bone loss can occur as an adaptive, biologic
response immediately after implant placement or implant restoration
(Albrektsson et al., 2012). A recent retrospective analysis described
a correlation between abutment height and initial bone remodelling
with more crestal bone loss around implants with short abutments.
The abutment height was adapted to the site-­
specific soft tissue
thickness at the time of implant placement (Vervaeke et al., 2014). The
same findings were observed by Galindo-­Moreno and coworkers. A
shortcoming of the aforementioned studies was the absence of accu-
rate soft tissue measurements (Vervaeke et al., 2014; Galindo-­Moreno
et al. 2015).
In the present study, soft tissue dimensions were measured using
an ultrasonic device. This is a non-­invasive alternative for histologic
measurements (Anderegg, Metzler, & Nicoll, 1995; Tomasi et al., 2014)
or bone sounding (Eger, Müller, & Heinecke, 1996; Olsson, Lindhe, &
Marinello, 1993; Studer, Allen, Rees, & Kouba, 1997; Wara-­aswapati,
Pitiphat, Chandrapho, Rattanayatikul, & Karimbux, 2001). The ultra-
sonic device was validated by Eghbali and coworkers. They described
a strong correlation between ultrasonic and micro-­CT measurements.
Also, repeated ultrasonic measurements demonstrated very consis-
tent results. Hence, they concluded that ultrasonic soft tissue mea-
surements are reliable, accurate and non-­invasive (Eghbali, De Bruyn,
Cosyn, Kerckaert, & Van Hoof, 2014).
A recent systematic review scrutinizing the effect of gingival bio-
type on crestal bone loss concluded that, at present, there is insuf-
ficient evidence to determine a causal effect of thin soft tissues on
crestal bone loss around dental implants (Akcalı et al., 2016). On the
contrary, another recent systematic review, including meta-­analysis,
favoured thick tissues in terms of initial crestal bone maintenance
(Suárez-­López Del Amo, Lin, Monje, Galindo-­Moreno, & Wang, 2016).
Hence, one can conclude that the literature is inconclusive, and it was
suggested that more well-­designed, controlled studies are needed to
elucidate this important issue. Therefore, a controlled split-­mouth de-
sign was chosen for the present study to further investigate whether
soft tissue dimensions affect initial bone remodelling.
In the present study, patients with thin soft tissues consistently
showed bone loss around the control implant. Bone loss, as a result
of initial bone remodelling, was not avoided around test implants.
However, subcrestal implant placement avoided early implant surface
exposure. Consequently, bacterial colonization of the implant surface
can be avoided. It is well known that this bacterial colonization may
induce peri-­implantitis (Quirynen, Abarca, Van Assche, Nevins, & van
Steenberghe, 2007). Long-­term follow-­up of the present study popula-
tion is not yet available. However, there is evidence that patients with
initial bone loss are at risk to develop long-­term biologic complica-
tions. In a long-­term follow-­up study of 39 patients with fixed full-­arch
implant-­supported rehabilitations, a mean bone loss of 1.63 mm was
described after 9 years. Initial soft tissue thickness was the only pre-
dictor for early bone loss after 1-­year follow-­up. However, bone levels
deteriorated afterwards, especially in high-­risk patients. Smokers with
a history of periodontitis lost on average 2.37 mm more bone around
their implants compared with periodontally healthy, non-­smoking pa-
tients (Vervaeke et al., 2016).
Subcrestal implant placement may not be feasible for all implant
designs. Broggini and coworkers described persistent acute inflam-
mation at the microgap of the implant–abutment interface around
implants with a flat-­to-­flat connection resulting in increased crestal
bone loss. They showed the presence of an inflammatory cell infil-
trate with predominantly neutrophils as a reaction to the presence of
bacteria in the microgap of the implant–abutment interface (Broggini
et al., 2003). Moreover, Hermann and coworkers showed that deeper
implant placement of implants with a flat-­to-­flat connection resulted
in more bone loss. Crestal bone loss was minimized by moving the
implant–abutment interface away from the bone, suggesting a spatial
relationship between the inflammatory reaction around the implant–
abutment interface and crestal bone loss for flat-­to-­flat connections.
(Hermann, Cochran, Nummikoski, & Buser, 1997).
More recently, Cochran and coworkers (Cochran et al., 2013) showed
that subcrestal placement of platform-­switched implants with a coni-
cal connection does not result in additional bone loss. On the contrary,
the bone was maintained and remained stable over time. In the present
study, no additional bone loss was observed in the test group after initial
bone remodelling, suggesting that subcrestal implant placement.
Subcrestal implant placement may not be feasible for all implant
surfaces as well. Hammerle and coworkers demonstrated that subcr-
estal placement of a smooth implant collar resulted in bone loss on the
smooth surface up to the level of the rough implant surface (Hämmerle,
Brägger, Brügin, & Lang, 1996). In the present study, implants with a
moderately rough surface were used and restored with machined ti-
tanium Locator abutments. The aim was to maintain the bone around
the moderately rough implant surface after initial bone remodelling.
One could argue that subcrestal placement of a titanium abutment
may result in bone loss. However, it was clearly demonstrated in the
control group of the present study that equicrestal implant placement
with machined titanium abutments resulted in inferior bone levels in
patients with inadequate soft tissue dimensions (Figure 2). On the
contrary, subcrestal implant placement, driven by biology, providing
space for biologic width formation, resulted in nearly perfect bone
levels after healing. Nevertheless, it did not prevent initial bone loss,
and in most test implants, the bone even had to be reduced slightly
in order to install abutment. The radiograph in Figure 2 may suggest
direct contact between the crestal bone and the machined abutment
surface (Figure 2j). However, this was never the case.
In six patients, implants were submerged as a consequence of in-
sufficient primary stability. Submerged control implants showed no
bone alterations during the submerged healing time. However, bone
remodelling occurred during the first 3 months after the second-­stage
VERVAEKE et al.
F I G U R E   4   Bone level changes around
test and control implants in submerged
(S) and non-­submerged (NS) healing. The
control group demonstrates that biologic
width formation takes place after implant
placement for non-­submerged implants
and after the second-­stage surgery
for submerged implants. Test implants
demonstrated nearly perfect bone levels
irrespective of the submerged or non-­
submerged healing
surgery. These findings are in accordance with Hermann and cowork-
ers, comparing crestal bone changes around submerged and non-­
submerged implants (Hermann et al., 1997). On the contrary, Astrand
and coworkers described that bone loss can occur during submerged
healing (Astrand et al., 2004). Also, in cases with unintentional cover
screw perforation during submerged healing, a significant bone de-
struction (2 mm) has been described, probably as a consequence of
biologic width formation (Van Assche, Collaert, Coucke, & Quirynen,
2008). However, these findings are based on a limited sample size.
Hence, care has to be taken with the interpretation of the data. Future
studies with larger sample sizes are needed to elucidate this topic.
Within the limitations of this study, it can be concluded that ini-
tial bone remodelling is affected by the soft tissue thickness. Implants
placed at sites with thin mucosal tissues show inferior crestal bone lev-
els. However, anticipating biologic width re-­establishment by adapting
the vertical position of the implant to the soft tissue thickness may
avoid unforeseen peri-­implant bone loss. The latter may lead to expo-
sure of the implant neck and may hamper aesthetics as well as increase
the risk for peri-­implant pathology. Whether the findings of this study
are valid for all implant systems needs to be further investigated.
CO NFLI CT OF I NTE RE ST
Prof. De Bruyn has a collaboration agreement with Dentsply Implants
(York, Pennsylvania, USA).
O RCI D
Stijn Vervaeke  http://orcid.org/0000-0002-1416-6787
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How to cite this article: Vervaeke S, Matthys C, Nassar R,
Christiaens V, Cosyn J, De Bruyn H. Adapting the vertical
position of implants with a conical connection in relation to soft
tissue thickness prevents early implant surface exposure: A
2-­year prospective intra-­subject comparison. J Clin Periodontol.
2018;45:605–612. https://doi.org/10.1111/jcpe.12871