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 39

The Influence of Implant Neck Features and

Abutment Diameter on Hard and Soft Tissues
Around Single Implants Placed in Healed Ridges:
Clinical Criteria for Selection

Stefano Gracis, DMD, MSD1 The replacement of a missing single

Arturo Llobell, DDS, MS2 tooth with a dental implant placed
Nitzan Bichacho, DMD3 in healed edentulous ridges with ad-
Leila Jahangiri, BDS, DMD, MMSC4 equate bone and soft tissue volume
Jonathan L. Ferencz, DDS4 can be challenging. The selection of
an appropriate implant system by
The clinician’s selection of an implant system is influenced by many variables. the clinician may be influenced by
Ideally, the decision should be based on scientific evidence, but often several factors. Ideally, this process
these decisions are based on economic considerations or influenced by should be based on scientific evi-
the experience of a trusted peer. The purpose of this paper is to describe
dence and not affected by econom-
the influence of implant neck features (shape and surface) and abutment
connection (diameter that matches or is smaller than the implant’s platform) ics or peer opinions.
on hard and soft tissues around single-tooth implants placed into healed It has been shown that differ-
ridges with adequate hard and soft tissue thickness. In an effort to reduce ent features of osseointegrated
the number of variables, only two-piece implants fully placed at bone level implants, such as (1) macromorphol-
or beneath were taken into consideration. The goal is to provide additional ogy including thread design, body
guidance for clinicians on the decision-making and implant-selection processes.
shape, and neck design; (2) micro–
Int J Periodontics Restorative Dent 2020;40:39–48. doi: 10.11607/prd.4151
surface morphology with the
presence of grooves; and (3) implant-
abutment connection with diameter
mismatch (commonly known as plat-
form shifting or platform switching),
may significantly influence clinical
performance and the health and re-
sponse of the surrounding hard and
soft tissues.
Limited information is available
about the influence of implant neck
design, collar surface morphology,
Private Practice, Milan, Italy.
1 and the implant-abutment inter-
Private Practice, Valencia, Spain.
2 face, specifically platform switching
3Oral Rehabilitation Department, Faculty of Dental Medicine, Hadassah School of
or diameter shift on biologic and
Dental Medicine, Hebrew University, Jerusalem; Prosthodontics Department,
clinical outcomes. Regarding these
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
4Department of Prosthodontics, College of Dentistry, New York University, features, there are several impor-
New York, New York, USA. tant questions that arise: Is there any
difference in marginal bone stabil-
Correspondence to: Dr Stefano Gracis, Via Brera, 28/a – 20121 Milan, Italy.
Email: sgracis@dentalbrera.com
ity around implants with different
neck shapes and with either a ma-
 Submitted October 14, 2018; accepted February 4, 2019.
 ©2020 by Quintessence Publishing Co Inc. chined or treated surface? If there

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40

Table 1  Summary of the Biologic Considerations Regarding Three Morphologic Features of

Two-Piece Endosseous Implants*
Feature Biologic considerations
Implant neck shape
Straight or Creates less compression on the cortical bone
convergenta and thus reduces the chance of creating a bone
dehiscence in thin buccal plates.
Divergentb May compress bone, inducing greater stress.
The thicker the cortical plate, the higher the
likelihood of bone compression.
Implant collar surface (up to 3-mm coronal portion of any two-piece bone-level implant)
Machined No clinically significant difference in marginal
bone preservation when compared to rough
surfaces.
Reduced bone-to-implant contact.
In case of peri-implantitis, it is easier to
decontaminate the surface.
Rough Increases bone-to-implant contact.
Increases speed of osseointegration in the early
healing phase.
Higher risk of peri-implantitis if exposed.
Platform switch/shift (mismatched implant-abutment diameters)
Yes Distances the implant-abutment interface from
the bone, thus keeping the contaminated area
further away.
Allows more room and circumferential sup-
port for connective tissue around the implant
platform, which may result in more-stable peri-
implant tissues.
No When an implant with a matching abutment is
placed crestally or subcrestally, it may induce the
formation of the biologic width at a more apical
position.
*When placed in healed, noncompromised sites (ridges) with adequate buccolingual bone thickness. Indications are included of the clinical
situations where endosseous implants with these features could be employed.
aDefined as having the coronal diameter equal to or narrower than the implant body.
Preferred in these clinical situations
In healed sites that have a limited thickness of the
buccal plate.
No specific situation.
Especially in patients who present a greater risk
of peri-implantitis (ie, those with poor oral hy-
giene, a reduced immune system, and who have
lost teeth due to aggressive periodontitis).
No specific situation when dealing with healed
sites.
In early/immediate loading situations.
In all situations, but especially in the following:
When two-piece bone-level implants are placed
crestally or subcrestally;
When the mesiodistal space is insufficient to
guarantee at least a 1.5-mm distance between
the implant head and neighboring teeth to
preserve the tooth’s attachment level, and the
position in the arch does not indicate the use
of a smaller-diameter implant (eg, in the
posterior region).
With some connections of narrow implant
diameters (biomechanical rationale).

bDefined as having the coronal part wider than the implant body.

is a difference, what is the clinical
relevance? Is there any difference in
marginal bone stability around im-
plants with matching or mismatch-
ing implant-abutment connections?
Therefore, the purpose of this
paper is to assist the clinician’s de-
cision-making process by analyzing
the present insights of the influence
of implant neck features and abut-
ment diameter on hard and soft tis-
sues around single implants placed
into healed ridges with adequate
hard and soft tissue thickness. In
an effort to reduce the number of
variables, only two-piece implants
placed at or below bone level were
considered.
Table 1 summarizes the biologic
considerations regarding the three
highlighted morphologic features of
endosseous implants when placed
in healed, noncompromised sites
(ridges) with adequate buccolingual
bone thickness and proposes the
clinical situations where endosseous
implants could be employed.

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 41

a b c
Fig 1  Schematic representation of the implant collar designs: (a) straight, (b) convergent, and (c) divergent.

Implant Neck Shape
The implant neck is considered a
critical portion of any endosseous
implant, since it can influence both
the amount of bone remodeling
due to compressive forces1–3 and the
initial primary stability values due to
its anchorage to cortical bone. The
implant neck is also critical from a
biomechanical point of view, as it is
subject to considerable mechanical
stresses and off-axis loads.4 Further-
more, the inner-most coronal part of
the implant neck area will be in con-
tact with the gingival tissue, which is
intended to provide a barrier to bac-
terial invasion and resultant epithe-
lial downgrowth.5 For the present
article, the authors define “implant
neck” as the coronal 3 mm of any
two-piece, bone-level implant.
When analyzing the shape of
the neck region of two-piece im-
plants placed at crestal or sub-
crestal bone levels, three different
morphology profiles can be identi-
fied: straight, convergent (narrower,
coronally), and divergent (wider,
coronally). These morphologies can
be defined as having the coronal di-
ameter equal to (Fig 1a), smaller than
(Fig 1b), or larger than (Fig 1c) the
implant body. The authors decided
to group together the first two mor-
phologies (straight and convergent/
narrow) since insufficient scientific
evidence was found to indicate dif-
ferent behaviors of the surround-
ing tissues that could be attributed
to their morphologic differences.
Thus, a comparison was made only
between straight plus convergent/
narrower and divergent/wider neck
shapes. However, a logical reduc-
tion in bone stress following con-
ventional drilling sequences may be
assumed for the convergent group.
The amount of residual bone,
that is the amount on the buccal
or lingual aspects of the implant, is
considered an important factor in
bone remodeling.6,7 This character-
istic is especially important when
dealing with healed sites that have
a resorbed thin ridge, as greater
amounts of bone compression on
the cortical bone can be related
to divergent implant designs when
compared to straight or conver-
gent implant neck shapes under the
same drilling sequences, therefore
increasing the chances of creating
bone dehiscences or microcracks.
These critical microcracks can lead
to further bone remodeling,2 in-
creasing the risk of leaving part of
the implant surface uncovered by
bone. In addition, thin bone plates
lack vascularity or endosteum and
may therefore be susceptible to
avascular necrosis over time.8–10
In order to prevent this in-
creased risk of bone stress with
divergent necks, some clinicians
employ a bone mill or countersink
drill to remove part of the healthy
cortical bone at the implant site.
However, when doing so, precious
bone is removed.
Therefore, it is only logical to
conclude that divergent implant
designs, when placed at crestal or
subcrestal levels, can lead to greater
complications after bone remodel-
ing while their clinical benefits re-
main unclear.

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42

Although early performance

a b
Fig 2  Examples of implant collar surfaces: (a) machined and (b) rough.
Implant Collar Surface
Over the last two decades, many im-
plant systems have been introduced
to the market. Most of these display
surfaces characterized by roughness
with or without a polished collar and
the presence of specific microgeo-
metric features (Fig 2). Different
degrees of roughness have been
applied to the implant surface by
various manufacturers. These treat-
ed surfaces and features, when they
are applied along the total implant
surface, claim faster osseointegra-
tion, followed by an increased bone-
to-implant contact with increased
survival rates in compromised situ-
ations. Furthermore, these surfaces
can improve marginal bone mainte-
nance provided there is adequate
vertical soft tissue thickness or im-
plant depth. Microtextured surfaces,
such as laser-etching, have been
shown histologically to inhibit down-
growth of epithelial cells, thereby
allowing connective tissue fibers to
adhere to the implant collar.11,12 Con-
versely, some may dispute these
statements and claimed advantag-
es, as they have not been proven
clinically.13
Faster bone apposition and
greater bone-to-implant contact
have been shown with rough surfac-
es.14 Also, a stronger biomechanical
bond during initial healing has been
reported in animal and human stud-
ies14,15 that has been correlated with
significantly higher mean torque val-
ues in the removal of these implants.16
These advantages have made rough-
surfaced implants preferable in im-
mediate/early loading protocols and
placement in compromised sites,
such as postextraction sockets.
of machined implants is frequently
considered to have a statistically
significant difference in published
data, the direct influence on bone
preservation by the implant surface
has to be evaluated carefully, since
the data compares implants with
different macrogeometric and/or
connection designs. When clinical
studies are well controlled for im-
plants with the same macrogeom-
etry, connection, and similar clinical
scenarios,17–19 minimal differences
are observed and the marginal bone
preservation is similar with no clini-
cally significant differences.
Caution should also be taken
when evaluating marginal bone
level changes in implants over time
with a noninvasive radiographic ap-
proach. The accuracy of the mea-
surements can largely be influenced
by the orientation and precision
of the radiographic and measure-
ment techniques used. Small differ-
ences in angulation can frequently
cause measurement errors of up to
0.4 mm20 as well as intraobserver
variations of up to 0.14 mm,21 thus
making it difficult to evaluate minute
changes over the follow-up period.
For this reason, radiographic follow-
ups should be taken with customized
intraoral radiograph holders as stan-
dardized measurements. Any article
that evaluates measurements on a
panoramic radiograph should not
be considered when assessing and
comparing marginal bone levels.
Major concerns have been
voiced about a higher risk of peri-
implantitis progression when em-
ploying rough-surface implants.22
Implants with machined or turned

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 43

a b

Fig 3  (a) A 28-year-old female was treated orthodontically to

recreate space and replace the congenitally missing maxillary
lateral incisors. (b) A 3.0-mm–diameter rough-surface implant
was placed in each of the lateral incisor sites at the bone crest.
(c, d) Radiographic control of the implants immediately after
surgical insertion. (e) Five-year clinical follow-up of the restored
implants. (f, g) Radiographic control at the 5-year follow-up.
The abutments are titanium and the crowns are alumina.
The external root resorptions visible in the radiographs are
asymptomatic.

c d

e f g

surfaces have been reported to be
associated with less bone loss23 and
reduced progression of peri-im-
plantitis. Machined surfaces, when
exposed to the oral environment,
accumulate up to 25-times less sub-
gingival plaque, as well as being
easier to clean.24
Through clinical experience
and following the available scien-
tific evidence, the present authors
believe that, under the same clinical
scenarios, differences in marginal
bone preservation between the two
surfaces are not clinically significant
and, therefore, will not be clinically
relevant (Fig 3). Implants with ma-
chined necks are preferred in pa-
tients presenting a greater risk of
peri-implantitis, such as those with
poor oral hygiene, a reduced im-
mune system, or loss of teeth due
to aggressive periodontitis. The
machined-neck implants should be

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44

a b c

d e
Fig 4  (a) A machined-surface implant with a polished collar and external connection was used to replace the maxillary left central incisor,
which was lost due to root resorption in a patient with generalized incipient bone loss. (b) The implant platform was placed at the crestal
level. (c) Over a period of 3 months, the mucosal tunnel was modified by a screw-retained provisional crown whose cervical morphology
was progressively increased. (d) Clinical appearance of the screw-retained crown 22 years after implant placement. (e) Radiographic follow-
up 22 years after the implant was uncovered and loaded.

placed with the implant head level
with the bone crest or slightly above
it, and care should be applied dur-
ing the surgical phase to maximize
primary stability, especially when
placing entirely machined-surface
implants (Fig 4).
When using implants with a
rough-surfaced collar, the head or
implant-abutment interface should
not be placed supracrestally. Rather,
it is recommended to place these
implants equicrestally or subcrest-
ally, depending on abutment con-
nection and design, to avoid a risk
of surface contamination on long-
term follow-ups. Regardless of the
selection of implants with either a
machined- or rough-surfaced col-
lar, a stable abutment connection
with a tight seal that minimizes mi-
cromotion is recommended due
to the inherent risk of bacterial
contamination, which may lead to
bone resorption.25
Platform Switch/Shift
Platform shift or switch describes an
implant system with an abutment
whose diameter at the connection
level is smaller than that of the im-
plant platform,26,27 thus creating an
inward horizontal step between the
implant’s outer surface and that of
the abutment (Fig 5). The implant
head design, connection type,
abutment wall thickness, and mate-
rial have an influence on the amount
of platform switch/shift that can be
incorporated in the design, which
can range from 0.1 mm to more
than 1.0 mm. With internal conical
connection implants, a platform
switch/shift is inherent in most sys-
tems. In vitro studies have shown
that in platform-switch systems, me-

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 45

chanical stress is shifted from the Fig 5  (a) A platform-switch implant system
has an abutment whose diameter is smaller
periphery of the implant internally than the diameter of the implant’s platform;
towards the long axis, thus reducing allegedly, this inward step of the abutment
allows the surrounding bone to maintain a
the potential gap during functional more coronal position than in the case of
micromovements.28,29 (b) a non–platform-switch implant system.
This mismatch of the implant
and abutment diameters was in-
dicated in many studies as the
reason for the improved preserva-
tion of interproximal crestal bone
when compared to loaded implants a b
with matching abutment diam-
eters.30–32 It has been suggested
that the larger the mismatch, the
less bone resorption will occur31,33
(Fig 6). However, this behavior was
not always observed and therefore
these studies34,35 could not sup-
port a direct correlation between
platform switch/shift and reduced
a
physiologic crestal bone resorp-
tion. The apparently conflicting
reports and outcomes could be
explained by the large heterogene-
ity and variety of study designs in
regards to: randomized clinical tri-
als vs retrospective studies; animal
and clinical models; surgical tech-
niques; corono-apical positions of
the implant head at insertion; buc-
colingual thickness of the alveolar b c
ridge; crestal soft tissue thickness;
control groups; implant systems;
abutment connections and diam-
eters; follow-up time; and many
other variables.36 The advantage of
platform switching may be that it al-
lows the enhancement of the hori-
zontal thickness of the peri-implant
d e
soft tissues. This, in turn, creates a
Fig 6  (a) A rough-surface implant with a noncircular, parallel-sided neck was selected to
“biologic seal” at the platform level,
replace a missing mandibular first molar. (b) The implant was placed subcrestally in the
where gingival fibers reside, which existing bone. (c) The soft tissue healing at 2 months after implant placement. Note that
favors tissue stability, both hard and the soft tissue might mature onto the peripheral platform, thereby creating a biologic seal,
even with multiple abutment disconnections. (d) The completed screw-retained zirconia
soft, despite multiple abutment dis- crown. (e) The radiographic control 55 months after loading. Note the mismatch between
connections.37,38 implant and abutment diameters.

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46

Fig 7  (a) A non–platform-shift implant with a 2-mm polished straight collar and apical bone
remodeling, 3 years after uncovering. (b) Clinical appearance of the zirconia-supported
screw-retained crown for the maxillary left central incisor.

a b

In order to address this topic in a
rational and systematic manner, the
present authors first attempted to
identify clinical behaviors on which
there is agreement. It is a common
observation that traditional systems
with matching implant-abutment
diameters, after uncovering, dis-
play an average physiologic peri-
implant bone loss of 1.5 to 2 mm
when placed at the crestal level39
(Fig 4e). This resorption has been
attributed to the establishment
of the peri-implant dentogingival
complex (biologic width plus sulcus
depth) that typically develops apical
to the exposed implant-abutment
interface (Fig 7) if the implant is not
placed deep enough (relative to the
soft tissue crest). The microgap at
the implant-abutment interface is in-
filtrated by bacteria originating from
either an internal route (the screw
chimney of the abutment) or an
external one (through the sulcus).40
The functional micromovement
(micromotion)41 of the abutment in
some implant systems can percolate
these contaminants in the surround-
ing tissues, thus triggering an im-
mune response42 that results in the
apical migration of the biologic seal.
Decreasing the abutment diam-
eter, thus distancing the contaminat-
ed zone from the implant periphery
inwards, has been presented as a
strategy that may produce two ad-
vantages: (1) It may enable a physi-
ologic reorganization of the biologic
width at a more coronal level,43,44
and (2) it provides more room and a
positive seat support for a connec-
tive tissue cuff, which may stabilize
the underlying hard tissues.5
The inherent design of the
platform switch/shift allows more
room for connective tissue forma-
tion around the implant platform,
which may result in more-stable
peri-implant tissues. Another indi-
cation for platform switch/shift is
whenever there is insufficient space
mesiodistally; ideally, a minimum
distance of 1.5 mm between the
implant and natural tooth is indicat-
ed.45 Where the space is limited, ei-
ther the implant has to be narrower
or the platform switch concept can
be utilized.30 Selecting a narrow
implant for a site subject to high
occlusal forces, however, may be
biomechanically unfavorable due to
higher risk of implant or prosthetic
component fracture.
It is the authors’ opinion that
choosing an implant system that
incorporates platform shifting may
be indicated only when implants
are placed crestally or subcrestally,
since it is likely to minimize periph-
eral crestal bone resorption during
the remodeling process.46 In healed
sites, it is unlikely to have a benefi-
cial effect if placed supracrestally if
the vertical soft tissue thickness is
less than 3 mm47 or whenever there
is bacterial contamination. In maxil-
lary anterior postextraction sockets,

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implants are frequently placed rela-
tive to the midfacial crest of bone
and are invariably subcrestal, inter-
proximally and palatally, due to the
change in elevation of the osseous
topography of the extraction socket.
This depth therefore allows the soft
tissues to sit on the peripheral plat-
form, thereby creating a “biologic
seal” that may help maintain tissue
stability with multiple abutment dis-
connections. It is believed that stable
connections with a tight seal might
have a positive impact on marginal
bone preservation, regardless of the
implant-abutment diameter discrep-
ancy. Further clinical research is nec-
essary to support this belief.
Conclusions
On the basis of the considerations
expressed in this paper and regard-
ing the features that a two-piece im-
plant needs to be placed in healed,
noncompromised sites with ade-
quate buccolingual and mesiodistal
bone thickness, the authors con-
clude the following:
The neck shape should either
be straight or convergent/narrower
because these profiles seem to
cause the least cortical bone stress
at insertion; a divergent or wider
neck shape could be considered
only if a countersinking bur is used,
but this would remove precious
crestal bone.
There are no clinically relevant
differences to date in the preserva-
tion of marginal bone level between
rough and machined-collar im-
plants. However, in the occurrence
of peri-implantitis, having an implant
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with a machined or polished collar
provides an advantage because it is
easier to decontaminate and may al-
low for a slower disease progression.
Implant-abutment diameter mis-
match may help preserve marginal
bone. Still, many other factors may
also influence the stability of the
hard and soft tissues complex, such
as the height and thickness of verti-
cal soft tissue or implant depth from
the peri-implant mucosal margin.
Although the authors tried to
isolate three different features of the
implants, the sum of all the param-
eters may present a different con-
clusion than the conclusions drawn
based on the single feature.
Acknowledgments
No authors have any direct financial inter-
ests in the products or information listed in
the paper except Dr Bichacho, who declares
to have a commercial relationship with No-
bel Biocare and MIS Implants. The authors
would like to thank Luca Vailati, CDT, for his
dedicated laboratory work displayed in this
article (clinical case Figures 3, 4, and 7).
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