M. A.

Peñarrocha-Diago Influence of implant neck design and

A. J. Flichy-Fernández
R. Alonso-González
implant–abutment connection type on
D. Peñarrocha-Oltra peri-implant health. Radiological study
J. Balaguer-Martı́nez
M. Peñarrocha-Diago

Authors’ affiliations: Key words: external connection, internal connection, machined surface, microthreads, peri-
M. A. Peñarrocha-Diago, A. J. Flichy-Fernández, R. implant bone loss, platform switching, treated surface
Alonso-González, D. Peñarrocha-Oltra, J. Balaguer-
Martı́nez, M. Peñarrocha-Diago, Oral Surgery and
Implantology, Valencia University Medical and Abstract
Dental School, Valencia, Spain
Objective: To carry out a comparative study of two implants with different neck features and
Corresponding author: prostheses platform connection (machined with external connection and rough-surfaced with
Antonio J. Flichy Fernández switching platform) upon peri-implant marginal bone loss, before and after functional loading.
Cirugı́a Bucal. Clı́nicas Odontológicas
Gascó Oliag 1 Material and methods: A randomized, prospective radiological study was made. Eighteen totally
46021 Valencia, Spain edentulous patients were selected. Subjects were divided into two groups according to the type of
Tel.: +34 96 386 4144 implant neck used: (a) Osseous®, with machined surface, without microthreads, external
Fax: +34 96 386 4785
e-mail: antonio.flichy@uv.es connection, and without platform switching; and (b) Inhex®, with treated surface, microthreads,
internal connection, and platform switching. Mesial and distal marginal bone loss was measured.
Implant success was assessed according to the criteria of Buser. Control timepoints were as follows:
(a) at implant placement; (b) at prosthesis placement; (c) 6 months after loading; (d) 12 months
after loading.
Results: Fifteen patients that received 120 dental implants were included: 47% Osseous® group
and 53% Inhex® group. Global mean marginal bone loss with Osseous® was 0.27 ± 0.43 mm and
0.38 ± 0.51 mm as determined 6 and 12 months after prosthetic loading, respectively, whereas in
the case of Inhex® was 0.07 ± 0.13 and 0.12 ± 0.17 mm. These differences were statistically
significant (P = 0.047). Difference between Osseous® and Inhex® in maxilla (P = 0.272) and
mandibular (P = 0.462) bone loss were not statistically significant.
Conclusions: Bone loss after 6 and 12 months proved statistically significant between two groups,
with comparatively greater loss in the case of Osseous® implants vs. Inhex® implants. Regardless
the heterogeneity of the two groups (neck shape, microthreads, surface texture), the implant–
abutment connection appears to be a significant factor on peri-implant crestal bone levels.
Anyway, in both groups, the values obtained were within normal ranges described in the
literature.

Date:
Accepted 29 June 2012
To cite this article:
Peñarrocha-Diago MA, Flichy-Fernández AJ, Alonso-
González R, Peñarrocha-Oltra D, Balaguer-Martı́nez J,
Peñarrocha-Diago M. Influence of implant neck design and
implant–abutment connection type on peri-implant health.
Radiological study.
Clin. Oral Impl. Res. 24, 2013, 1192–1200
doi: 10.1111/j.1600-0501.2012.02562.x
Marginal bone loss occurs following dental
implant placement (Peñarrocha et al. 2004).
Such initial marginal bone loss progresses to
the first implant thread or to the first contact
of the bone with the rough surface (Lee et al.
2007). In the last decades, it has been sug-
gested that marginal bone loss is dependent
upon a series of factors, including the
implant neck surface characteristics (Peñarro-
cha et al. 2004) and the implant–abutment
connection (Hürzeler et al. 2008; Prosper
et al. 2009; Canullo et al. 2009; Farronato
et al. 2012). The possible influence of
performing surgery in one or two steps is
subjected to debate (Cecchinato et al. 2008).
Finite elements studies have demonstrated
that bone loss may be attributed to the lack
of effective mechanical stress distribution
between the machined implant neck and the
surrounding bone (Oh et al. 2002). In con-
trast, roughness and retentive elements such
as microthreads at implant neck may coun-
teract marginal bone loss (Hansson 1999;
Piao et al. 2009). A number of clinical and
radiological studies (Puchades-Roman et al.
2000; Bratu et al. 2009; Piao et al. 2009) have
evaluated marginal bone loss according to the
implant neck involved, comparing machined
necks with treated necks and microthreads.
In all cases, greater bone loss was observed

1192 © 2012 John Wiley & Sons A/S


with machined implant necks – rough necks
with microthreads being seen to help main-
tain the marginal bone of the implant.
Studies have analyzed strain distribution
and concentration in the implant neck
caused by varying the fixture-abutment
design (Nishioka et al. 2011) and its influ-
ence on marginal bone resorption after load-
ing. High strains (Hoshaw et al. 1994) and
marginal bone loss have been found around
the neck of implants with an external hexa-
gon design (Hoshaw et al. 1994; Lee et al.
2011), maybe due to the abutment screw
being responsible on its own for maintaining
the fixture-abutment joint in this type of
connection. The internal hexagon and the
Morse taper connections have greater
mechanical friction, stability, and form lock
than the external hexagon joint (Nishioka
et al. 2011).
Factors such as the transmission of stress
at the implant–abutment interface, micro-
movements (Canullo et al. 2010), and bacte-
rial infiltration (Broggini et al. 2006; Canullo
et al. 2010) give rise to apical migration of
the biological width to isolate and protect
the bone from irritation when using a con-
ventional platform (Lazzara & Porter 2006).
With the platform switching concept, the
implant–abutment interface (IAI) is displaced
horizontally toward the center of the plat-
form and separated from the marginal bone.
Thus, stress, micro-movements, and bacterial
infiltration occurs at a distance from the
marginal bone, giving rise to lesser apical
migration of the biological width (Canullo
et al. 2010) and therefore to less marginal
bone reabsorption (Hürzeler et al. 2008). A
number of studies (Hürzeler et al. 2008;
Bilhan et al. 2010; Canullo et al. 2010)
involving two-step surgical treatment using
implants with platform switching have
reported bone losses of between 0.12 and
0.91 mm.
Marginal bone loss is evaluated radiograph-
ically, and the timing of the X-ray controls is
important: in most studies, the first X-ray is
obtained at prosthesis placement and the
marginal bone loss is measured after prosthe-
sis loading (Hartman & Cochran 2004),
whereas in others, it is obtained at the time
of implant placement (Cochran et al. 2009).
Taking initial X-rays at the time of implant
placement is interesting when using the one-
stage non-submerged protocol to observe
marginal bone remodeling. Some longitudinal
studies have reported significant bone loss
before the insertion of the definitive restora-
tion when one-stage protocol was used
(Cochran et al. 2009), or after the reopening
© 2012 John Wiley & Sons A/S
Peñarrocha-Diago et al
Implant neck design on peri-implant health. Radiological study
operation with the two-stage protocol (Brog-
gini et al. 2003).
This study was designed to compare the
influence of the implant neck design and
implant–abutment connection upon peri-
implant marginal bone loss before prosthetic
restoration and 6 and 12 months after pros-
thetic loading.
Material and methods
Study population
A randomized, clinical trial was carried out
in the Oral Surgery and Implantology Unit of
a University Clinic, between January 2008
and October 2009. Patients were included
according to the following criteria: 1) com-
pletely edentulous arch requiring implant
placement for: a) fixed prostheses (6–8
implants); b) bar overdentures (4 implants); or
c) Locator® overdentures (2–4 implants);
2) patients were classified according to the
treated maxilla (upper or lower); and 3) bone
availability: a) minimum width 7 mm; and b)
minimum height 6 mm. Available bone was
determined in the computed axial tomogra-
phy, prior to the surgery. The exclusion crite-
ria were: 1) systemic diseases contrain-
dicating surgery; 2) a history of bisphospho-
nates use; 3) active infection at the implant
site; 4) bone atrophy requiring regeneration;
5) systemic disorders (e.g., immune altera-
tions) or drug treatments capable of affecting
gingival health; 6) pregnant or nursing
women; and 7) incomplete protocols.
All patients were required to sign an
informed consent form to participate in the
study. The study was approved by the local
ethics committee, and was performed follow-
ing the principles of the Declaration of
Helsinki.
Patients were randomized into two groups
using the SPSS statistical package (SPSS, Chi-
cago, IL, USA):
Group A – Osseous®: nine patients treated
with implants presenting a neck design with-
out microthreads, with machined surface,
external connection, and without platform
switching (Osseous®, Mozo-Grau, S.L., Valla-
dolid, Spain).
Group B – Inhex®: nine patients treated
with implants presenting a neck design with
microthreads, treated surface, internal con-
nection, and platform switching (Inhex®,
Mozo-Grau, S.L. Valladolid, Spain).
Surgical technique
All implants were placed using the same sur-
gical protocol under local anesthesia with 4%
1193 |
articaine with epinephrine 1 : 100,000. A
crestal incision was made, and a full-thick-
ness mucoperiosteal flap was raised. The
surgical zone was subjected to curettage
before the drilling sequence, which was car-
ried out according to the instructions of the
manufacturer. Drilling speed was reduced as
the drill diameter increased, to lessen heating
of the implant bone bed. Drilling was carried
out under cold saline irrigation. Implants
were placed with a torque of 35 N and posi-
tioned at crestal level in both groups (Fig. 1).
Suturing was carried out with 3/0 silk
sutures. All patients were treated following a
two-step procedure.
Postoperative control
A 3-month osteointegration period was
observed in both maxilla and mandible. Fol-
low-up controls were made during this period
of time, after which the prosthetic restora-
tions were carried out.
Study data
The following patient data were collected:
age, gender, smoking habit (<10 cigarettes/
day, 10–20 cigarettes/day, >20 cigarettes/day),
and frequency of tooth brushing (classified as
follows: 1) no brushing, 2) 1–2 times/day, 3)
three or more times/day).
Follow-up visits
Control visits were made by trained and cali-
brated clinicians, at the following timepoints:
(0) at implant placement; (1) at prosthesis
placement; (2) 6 months after prosthe-
sis placement; and (3) 12 months after pros-
thesis placement.
Success criteria and data analyzed
Implant success was assessed according to
the clinical and radiographic criteria of Buser
et al. (1999): 1) absence of clinical implant
mobility; 2) absence of pain or subjective sen-
sation; 3) absence of recurrent peri-implant
infection; and 4) absence of a continuous
radiolucency around the implant as deter-
mined 6 and 12 months after loading.
Radiographic assessment
Intraoral X-rays were used to measure mar-
ginal bone loss. Radiographic exploration was
carried out using the intraoral XMind system
(Groupe Satelec-Pierre Rolland, Bordeaux,
France) and the RVG intraoral digital sensor
(Kodak Dental System, Atlanta, GA, USA).
To reproduce the X-ray angles in posterior
reviews, XCP positioners were used (Dents-
ply, Des Plaines, IL, USA), placing the guide
bar parallel to the direction of the X-ray
Clin. Oral. Implants. Res. 24, 2013 / 1192–1200
Peñarrocha-Diago et al
Implant neck design on peri-implant health. Radiological study

Brunner and Langer, providing an ANOVA-

a b
type statistic. The statistical analysis was per-
formed using the SPSS version 15.0 statistical
package for Microsoft Windows (SPSS Inc.,
Chicago, IL, USA) and software R 2.15.0 (R
Foundation for Statistical Computing). The
level of statistical significance was established
as 5% (a = 0.05). The post hoc statistical
power for comparisons between both groups of
implants was estimated as 86.9% (effect size
0.25 and correlation among repeated measures
0.7), for an ANOVA-type test.

Fig 1. Surgical procedure, implant insertion level: (a) Group A – OsseousÒ (b) Group B – InhexÒ. Results

beam, perpendicular to the digital sensor. normal and dependence of observations, the Patient data
The examiner of the radiographs was differ- corresponding nonparametric tests were Eighteen totally edentulous patients were
ent from the surgeon who placed the applied: method for longitudinal data of treated with a total of 141 dental implants:
implants.
Marginal bone loss was measured based on a1 b1
the radiographic criteria of Buser (Buser et al.
1999). Two reference points were marked on
the surface of the implant platform and joined
with a line representing height zero. Two verti-
cal lines were traced perpendicular to the zero
line up to the first implant bone mesial and dis-
tal contact points. Differences between these
perpendicular lines in x-rays taken at the differ-
ent timepoints were used to calculate bone
loss. Bone loss was measured between implant
placement and prosthesis placement, and
between prothesis placement and 6 and
a2 b2
12 months after loading (Fig. 1; Fig. 2).

Peri-implantitis
Peri-implant disease is a collective term for
pathological changes of inflammatory type of
tissue surrounding an implant under load
(Zarb & Smitt 1990). Peri-implant mucositis
describe the presence of inflammation in the
mucosa, with no signs of loss of supporting
bone. Peri-implantitis, in addition to inflam-
mation of the mucosa, with no signs of loss of
supporting bone (Lindhe & Meyle 2008).
Then, an implant was considered to have peri- a3 b3
implantitis when peri-implant bone loss up to
1.8 mm existed, following Ross-Jansaker crite-
ria et al. (2006, 2007, 2011), sometimes
accompanied by bleeding on probing (0.25°N),
with or without an increase in probing depth
and sometimes pus. Bone loss was evaluated
with respect to a periapical radiograph at the
time of prosthesis placement, which was con-
sidered baseline (Lang et al. 2011).

Statistical analysis
A descriptive analysis of the parameters was
made. Sample distribution of bone loss was
assessed and due to lack of adjustment to
Fig 2. Measurement of peri-implant marginal bone loss. (A) OsseousÒ implant: (A1) at prosthesis placement; (A2)
after 6 months; and (A3) after 12 months of follow-up. (B) InhexÒ implant: (B1) at prosthesis placement; (B2) after 6
months; and (B3) after 12 months of follow-up.

1194 | Clin. Oral. Implants. Res. 24, 2013 / 1192–1200 © 2012 John Wiley & Sons A/S

69 Osseous® implants (group A) and 72
Inhex® implants (Group B) (Mozo-Grau S.L.,
Valladolid, Spain). Three patients did not
fulfill the inclusion criteria and were
excluded: two due to failure to report to the
control visits, and the other did not come up
for prosthesis placement. Thus, 15 subjects
(11 women and 4 men) were finally included
in the study, aged between 44 and 77 years
(mean 56.9 ± 7.8 years). There were 12 non-
smokers, while three smoked fewer than 10
cigarettes/day. Eleven patients brushed their
teeth 1–2 times/day, and four patients – three
or more times/day.
Eight patients received Osseous® implants
and the remaining seven received Inhex®
implants. Five patients underwent rehabilita-
tion of the upper maxilla, one patient of the
mandible, and the remaining nine underwent
rehabilitation of both dental arches. Forty-
seven percent of the total 120 implants corre-
sponded to Group A (Osseous®) and 53% to
Group B (Inhex®).
Success and survival criteria
Two implants failed, one in Group A and
another one in Group B. Globally, 98.6%
implants survived and 97.2% were success-
ful. Four implants did not meet the success
criteria of Buser; two because of mobility and
two for continuous radiolucency. On sepa-
rately evaluating the two groups, 98.6%
implants survived and 97.1% were successful
in the Osseous® group, and 98.6% implants
survived and 97.2% were successful in the
Inhex® group. In each group, one implant
was not successful because of mobility and
another one for continuous radiolucency.
A total of 24 arches were studied. Prosthe-
sis type was distributed as follows: a) Loca-
tor® overdentures – Osseous® (LOO) in five
cases, b) Locator® overdentures – Inhex®
(LOI) in four cases; c) bar overdentures –
Osseous® (BOO) in four cases; d) bar overden-
tures – Inhex® (BOI) in three cases; e) fixed
prostheses – Osseous® (FPO) in four cases;
and f) fixed prostheses – Inhex® (FPI) in
remaining four cases.
Bone loss
Marginal bone loss with the Osseous®
implants was 0.27 ± 0.43 mm and 0.38 ±
0.51 mm as determined 6 and 12 months
after prosthetic loading, respectively, whereas
in the case of the Inhex® implants, the mar-
ginal bone loss was 0.07 ± 0.13 and
0.12 ± 0.17 mm. These differences were sta-
tistically significant (P = 0.047) (Table 2).
No significant differences were observed on
evaluating bone loss in terms of patient’s age
© 2012 John Wiley & Sons A/S
Peñarrocha-Diago et al
Implant neck design on peri-implant health. Radiological study
and gender, considered either globally or
according to dental implant group (Osseous®
or Inhex® implants).
Maxillary marginal bone loss with the
Osseous® implants was 0.32 ± 0.48 mm and
0.44 ± 0.56 mm as determined 6 and 12
months after prosthetic loading, respectively,
whereas in the case of the Inhex® implants,
maxillary marginal bone loss was 0.08 ±
0.14 mm and 0.13 ± 0.16 mm. Mandibular
marginal bone loss with the Osseous®
implants was 0.13 ± 0.23 mm and 0.17 ±
0.25 mm as determined 6 and 12 months
after prosthetic loading, respectively, whereas
in the case of the Inhex® implants, mandibu-
lar marginal bone loss was 0.06 ± 0.12 mm
and 0.11 ± 0.18 mm. The differences were
not statistically significant in maxilla (P =
0.272) and neither in the mandible (P =
0.462) (Fig. 3, Table 2).
The implant diameter was 3.75 mm in
34% of the Osseous® implants and in 56% of
the Inhex® implants, whereas the implant
diameter was 4.25 mm in 66% of the Osse-
ous® implants and in 44% of the Inhex®
implants. An increased implant diameter was
associated with greater marginal bone loss in
both groups (Tables 1 and 2), involving statis-
tical differences (P = 0.034). No significant
differences between groups were observed on
assessing bone loss according to implant
diameter and dental arch (maxilla or mandi-
ble) (Tables 1 and 2, Figs 4 and 5).
The implant length was 10 mm in 20% of
the Osseous® implants and in 42% of the
Inhex® implants, while the length was
11.5 mm in 55% and 27%, respectively, and
13 mm in 25% and 31%, respectively. Bone
loss was greater with length 10 and 11.5 mm
compared with length 13 mm, and signifi-
cant differences were reached (P = 0.012).
Bone loss in Osseous® group was greater than
in Inhex®, but statistical significance was not
reached (P = 0.081) (Table 2). There was no
statistical significance in maxilla; but in
Fig 3. Marginal bone loss according to dental arch and implant type.
1195 |
mandibular, length 10 mm with Osseous®
was associated with maximum greater bone
loss (P = 0.015) (Tables 1 and 2, Figs 6and 7).
On dividing the patients into smokers and
non-smokers, no significant differences
(P = 0.332) were observed in marginal bone
loss on considering both the type of implant
and the rehabilitated dental arch.
In both implant groups, bone resorption
proved fastest between timepoints 0 and 1,
immediately before placement of the prosthe-
sis, except in the Inhex® group at mandibular
level. Taking into account the bone loss after
12 months of follow-up, reabsorption in the
Osseous® group between timepoints 0 and 1
represented 40.9% and 52.9% of the annual
total in the maxilla and mandible, respec-
tively, whereas in the Inhex® group, the reab-
sorption represented 61.5% and 18.1% of the
annual total (Tables 1 and 2, Fig. 3).
Significant differences were observed
between the different prosthesis subgroups –
the greatest marginal bone loss corresponding
to the Osseous® implants mainly in combi-
nation with BOO (bar overdentures – Osse-
ous®) (P = 0.034) – from the moment of
prosthesis placement to the end of follow-up
(Table 3).
Peri-implantitis
According to the peri-implantitis criteria
(Roos-Jansåker et al. 2011), no peri-implanti-
tis was seen in any implant, for any time-
point or prosthetic rehabilitation type.
Discussion
A number of authors (Puchades-Roman et al.
2000; Bratu et al. 2009; Piao et al. 2009) have
observed differences in relation to the preser-
vation of marginal bone in comparing the
behavior of implants with a machined neck
vs. treated neck with microthreads, 1 year
after prosthetic loading. Piao et al. (2009);
Puchades-Roman et al. (2000); and Bratu
Clin. Oral. Implants. Res. 24, 2013 / 1192–1200
Peñarrocha-Diago et al
Implant neck design on peri-implant health. Radiological study

Table 1. Peri-implant marginal bone loss according to dental arch and dental implant type, diameter and length at timepoints 0 and 1. Mean ± SD
(median).
Timepoint 0 Timepoint 1

Group A -Osseous® Group B -Inhex® Group A -Osseous® Group B -Inhex®

Global
Global 0.00 ± 0.01 (0.00) 0.00 ± 0.00 (0.00) 0.16 ± 0.31 (0.00) 0.05 ± 0.11 (0.00)
Ø 3.75 0.01 ± 0.02 (0.00) 0.00 ± 0.00 (0.00) 0.02 ± 0.04 (0.00) 0.03 ± 0.06 (0.00)
Ø 4.25 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.23 ± 0.37 (0.00) 0.07 ± 0.14 (0.00)
L 10 0.01 ± 0.03 (0.00) 0.00 ± 0.00 (0.00) 0.17 ± 0.30 (0.10) 0.05 ± 0.13 (0.00)
L 11.5 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.20 ± 0.35 (0.00) 0.06 ± 0.12 (0.00)
L 13 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.06 ± 0.21 (0.00) 0.02 ± 0.05 (0.00)
Maxilla
Global 0.00 ± 0.02 (0.00) 0.00 ± 0.00 (0.00) 0.18 ± 0.34 (0.00) 0.08 ± 0.13 (0.00)
Ø 3.75 0.01 ± 0.03 (0.00) 0.00 ± 0.00 (0.00) 0.02 ± 0.04 (0.00) 0.05 ± 0.08 (0.00)
Ø 4.25 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.27 ± 0.40 (0.00) 0.10 ± 0.18 (0.00)
L 10 0.01 ± 0.03 (0.00) 0.00 ± 0.00 (0.00) 0.19 ± 0.33 (0.00) 0.08 ± 0.15 (0.00)
L 11.5 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.24 ± 0.39 (0.00) 0.08 ± 0.15 (0.00)
L 13 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.07 ± 0.23 (0.00) 0.06 ± 0.08 (0.00)
Mandible
Global 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.09 ± 0.22 (0.00) 0.02 ± 0.05 (0.00)
Ø 3.75 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.01 ± 0.02 (0.00)
Ø 4.25 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.13 ± 0.25 (0.00) 0.03 ± 0.08 (0.00)
L 10 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.10 ± 0.00 (0.10) 0.00 ± 0.00 (0.00)
L 11.5 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.11 ± 0.26 (0.00) 0.06 ± 0.09 (0.00)
L 13 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00) 0.00 ± 0.00 (0.00)

Ø = Diameter; L = Length.

Table 2. Peri-implant marginal bone loss according to dental arch and dental implant type, diameter and length at timepoints 2 and 3. Mean ± SD
(median).
Timepoint 2 Timepoint 3
Effect: p ANOVA-type test
® ®
Group A -Osseous Group B -Inhex Group A -Osseous® Group B -Inhex®
Global
Global 0.27 ± 0.43 (0.00) 0.07 ± 0.13 (0.00) 0.38 ± 0.51 (0.10) 0.12 ± 0.17 (0.10) Implant type P = 0.047
Ø 3.75 0.16 ± 0.32 (0.00) 0.05 ± 0.07 (0.00) 0.18 ± 0.33 (0.00) 0.10 ± 0.13 (0.10) Ø P = 0.034
Ø 4.25 0.32 ± 0.48 (0.10) 0.10 ± 0.17 (0.00) 0.47 ± 0.56 (0.20) 0.15 ± 0.21 (0.10)
L 10 0.30 ± 0.44 (0.20) 0.10 ± 0.17 (0.00) 0.40 ± 0.57 (0.30) 0.13 ± 0.19 (0.00) L P = 0.012
L 11.5 0.30 ± 0.43 (0.00) 0.08 ± 0.11 (0.00) 0.45 ± 0.51 (0.20) 0.13 ± 0.16 (0.10)
L 13 0.19 ± 0.46 (0.00) 0.03 ± 0.06 (0.00) 0.19 ± 0.46 (0.00) 0.11 ± 0.15 (0.05)
Maxilla
Global 0.32 ± 0.48 (0.05) 0.08 ± 0.14 (0.00) 0.44 ± 0.56 (0.15) 0.13 ± 0.16 (0.00) Implant type P = 0.272
Ø 3.75 0.20 ± 0.35 (0.00) 0.06 ± 0.08 (0.00) 0.23 ± 0.37 (0.00) 0.09 ± 0.09 (0.10) Ø P = 0.105
Ø 4.25 0.38 ± 0.53 (0.10) 0.11 ± 0.18 (0.00) 0.56 ± 0.62 (0.20) 0.17 ± 0.21 (0.10)
L 10 0.30 ± 0.49 (0.10) 0.09 ± 0.16 (0.00) 0.42 ± 0.63 (0.20) 0.11 ± 0.15 (0.10) L P = 0.256
L 11.5 0.39 ± 0.47 (0.10) 0.09 ± 0.15 (0.00) 0.58 ± 0.54 (0.40) 0.19 ± 0.21 (0.10)
L 13 0.21 ± 0.49 (0.00) 0.06 ± 0.08 (0.00) 0.22 ± 0.49 (0.00) 0.11 ± 0.09 (0.10)
Mandible
Global 0.13 ± 0.23 (0.00) 0.06 ± 0.12 (0.00) 0.17 ± 0.25 (0.00) 0.11 ± 0.18 (0.00) Implant type P = 0.462
Ø 3.75 0.03 ± 0.05 (0.00) 0.04 ± 0.07 (0.00) 0.03 ± 0.05 (0.00) 0.11 ± 0.15 (0.00) Ø P = 0.135
Ø 4.25 0.17 ± 0.26 (0.00) 0.09 ± 0.17 (0.00) 0.23 ± 0.28 (0.15) 0.12 ± 0.22 (0.00)
L 10 0.30 ± 0.00 (0.30) 0.11 ± 0.19 (0.00) 0.30 ± 0.00 (0.30) 0.15 ± 0.25 (0.00) L P = 0.022
L 11.5 0.11 ± 0.26 (0.00) 0.08 ± 0.08 (0.10) 0.17 ± 0.29 (0.00) 0.08 ± 0.08 (0.10)
L 13 0.05 ± 0.07 (0.05) 0.01 ± 0.03 (0.00) 0.05 ± 0.07 (0.05) 0.10 ± 0.17 (0.00)

Ø = Diameter; L = Length.

et al. (2009) compared implants with a
machined neck vs. treated neck with mic-
rothreads – the bone loss being
0.89 ± 0.27 mm, 1.6 mm, 1.47 ± 0.4 mm for
the machined neck implants, respectively;
and 0.42 ± 0.27 mm, 0.6 mm, and
0.69 ± 0.25 mm for treated neck with mic-
rothreads, respectively. According to these
authors, microthreads in the implant neck
could contribute to preserve marginal bone.
These data coincide with our own observa-
tions, where lesser bone loss was recorded
with the implants presenting a treated neck
surface and microthreads.
Implant characteristics such as shape, sur-
face roughness and microthreads (Lee et al.
2007), and the position of a microgap
between implant and abutment relative to
crestal bone levels implants (Hürzeler et al.
2008; Rodrı́guez-Ciurana et al. 2009; Bilhan
et al. 2010; Canullo et al. 2010) have been
compared with different variables. Although
studies have attempted to reason the etio-
logic factors of crestal bone loss, one aspect
has received limited attention: the influence
of the implant/abutment connection mode
(internal vs. external). A recent study (Lee
et al. 2011) investigates the influence of the
abutment connection on peri-implant crestal
bone levels, comparing external vs. internal
connections using radiographs. They observed
40 single implants with the same macro-
design and surface texture and positioned at

1196 | Clin. Oral. Implants. Res. 24, 2013 / 1192–1200 © 2012 John Wiley & Sons A/S

Fig 4. Bone loss in the maxilla according to implant diameter and type.
Fig 5. Bone loss in the mandible according to implant diameter and type.
Fig 6. Bone loss in the maxilla according to implant length and type.
crestal level, being the implant connection
the only difference. One year post-loading,
bone loss was 0.90 ± 0.53 mm and
0.00 ± 0.28 mm for the external and internal
implant connection, respectively. Moreover,
linear bone level changes from prosthesis
delivery to 1 year post-loading was 0.29 ±
0.35 mm for the external connection, and
0.07 ± 0.21 mm for the internal connection.
We agree with these results: although in both
© 2012 John Wiley & Sons A/S
Peñarrocha-Diago et al
Implant neck design on peri-implant health. Radiological study
groups, the values obtained were within nor-
mal ranges described in the literature, Osse-
ous® implants (external connection)
presented comparatively greater bone loss
than Inhex® implants (internal connection).
This suggests that crestal remodeling/bone
loss is greater when using an external con-
nection than an internal one. According to
Lee et al. (2011), switching platform concept
could explain these differences between
1197 |
external and internal connections and its
bone loss pattern.
Unlike in implants with external connec-
tion (where the abutment diameter is usually
identical to the platform diameter-conven-
tional platform), in implants with internal
connection, the platform switching concept
is usually used nowadays: the implant–abut-
ment interface (IAI) is displaced horizontally
toward the center of the platform and sepa-
rated from the marginal bone. Thus, stress,
micro-movements, and bacterial infiltration
occur at a distance from the marginal bone,
giving rise to lesser apical migration of the
biological width (Canullo et al. 2010), and
therefore to less marginal bone resorption
than with a matching implant-abutment con-
figuration (Hermann et al. 2000). On examin-
ing the effect of implants with platform
switching, a number of authors have reported
low marginal bone loss with this connection
type (Hürzeler et al. 2008; Rodrı́guez-Ciurana
et al. 2009; Bilhan et al. 2010; Canullo et al.
2010; Farronato et al. 2012). Canullo et al.
(2010), in a case (implants with platform
switching) – control study (implants without
platform switching) involving a follow-up
period of 33 months – recorded less peri-
implant bone loss among the case implants
than in the controls. These results coincide
with our own findings.
Timing of the X-ray controls is important:
in most studies were two-stage protocol
is used, the first X-ray is taken at prosthesis
placement and the marginal bone loss is
measured after prosthesis loading (Hartman
& Cochran 2004). In others studies (Cochran
et al. 2009; Lee et al. 2011), the first X-ray is
obtained at the time of implant placement.
Taking initial X-rays at the time of implant
placement is interesting when using the one-
stage non-submerged protocol to observe
marginal bone changes prior to prosthesis
loading. Cochran et al. (2009) found that
most significant peri-implant marginal bone
remodeling (86% of the total bone loss)
occurred during the first 6 months after
implant placement when using a one-stage
protocol. After that, bone loss observed
around implants from prosthesis loading to
5 years post-loading was minimal. These data
indicate that the temporal pattern of bone
resorption differed between healing modes
(open or submerged); the open-healing proce-
dure provoked immediate bone resorption,
whereas under submerged-healing conditions,
bone resorption is limited before the reopen-
ing operation and accelerates after re-entry
(Broggini et al. 2003). In this study, in
both implant groups, bone resorption proved
Clin. Oral. Implants. Res. 24, 2013 / 1192–1200
Peñarrocha-Diago et al
Implant neck design on peri-implant health. Radiological study

short and narrow implants. In contrast, other

Fig 7. Bone loss in the mandible according to implant length and type.
fastest between timepoints 0 (two-stage pro-
tocol) and 1, immediately before placement
of the prosthesis, except in the Inhex® group
in the mandible. This may be due to the
direct contact between implant and oral bac-
terial flora starting from the reopening opera-
tion or due to frequent handling of the peri-
implant mucosa until the permanent prosthe-
sis is placed(Enkling et al. 2011).
Cochran et al. (2009) registered a mean
bone loss of 2.44 ± 1.20 mm after 6 months.
According to the main success criteria
reported (Albretkson et al. 1986), more than
2 mm of marginal bone loss after the first
year is defined as failure or survival. Authors
justify the early bone remodeling naming a
number of possibly involved factors: prepara-
tion of the implant osteotomy, interruption
of the vascular supply, bacterial contamina-
tion of the butt–joint interface, among others.
Another study (Hartman & Cochran (2004))
with 42 patients and 5 years of follow-up,
likewise considers most bone loss to occur in
the first 6 months after implant surgery
when using the one-stage procedure; these
authors obtained an average bone loss of
1.10 mm, much lower than the average
obtained by Cochran et al. (2009), and found
that the early bone loss is directly related to
the position of the implant in an apico-coronal
direction. In this study, bone loss was also
greater between the surgical phase and
prosthetic rehabilitation (except in the In-
hex® group in the mandible) – after which
marginal bone loss gradually decreased over
the subsequent 12 months of follow-up.
These results support the conclusions of
Cochran et al. (2009): factors that influence
early healing around implants are signifi-
cantly different from those that affect later
marginal bone remodeling.
In most studies (Behneke et al. 1997; Bry-
ant & Zarb 1998; Boronat et al. 2008),
patient’s age and gender do not appear to
influence peri-implant bone loss, in coinci-
dence with our own data. Regarding the loca-
tion of the implants, Kemppainen et al.
(1997) and Danza et al. (2010) found marginal
bone loss during the first year to be greater
in implants located in the maxilla than in
implants placed in the mandible. This
increased maxillary bone loss could be due to
possible differences in bone remodeling
capacity between the mandibular and maxil-
lary bone – the latter being more vascularized
and with a greater remodeling potential dur-
ing the healing phase after implant place-
ment (Kemppainen et al. 1997). These data
coincide with our own observations of greater
marginal bone loss in maxillary implants,
but these differences were not significant.
Peri-implant bone loss has been related to
implant length and diameter. In 1997, Ivanoff
et al. (1997) suggested that a greater diameter
could reduce such loss. In turn, Grunder
et al. (1999) reported greater bone loss with
investigators have recorded no relationship
between implant dimensions and peri-
implant bone loss (Peñarrocha-Diago et al.
2008). In our own study, bone loss is greater
with wider diameter. Bone loss showed a
strong correlation with implant length, indi-
cating greater bone loss with length shorter
than 13 mm.
Smoking is also known to affect the out-
come of implant treatment (Vervaeke et al.
2012). Several studies reported lower survival
rates for implants installed in smokers
(Peñarrocha et al. 2004; Koldsland et al.
2009; Anner et al. 2010), especially in the
maxilla and before prosthesis loading (De
Bruyn & Collaert 1994; Vervaeke et al. 2012).
Respect to peri-implant bone loss, only a lim-
ited number of studies have compared it in
smokers and non-smokers. Lindquist et al.
(1997), and Bain & Moy (1993) found bone
loss to be more than twice as great among
smokers. However, Aalam & Nowzari (2005)
conducted a radiographic comparison of den-
tal implants with different surfaces, and no
statistically significant differences in bone
loss were found among surface implant treat-
ment or smoking habits. Minsk et al. (1996)
also observed no significant differences
between smokers and non-smokers in a study
of 1263 implants subjected to 6 years of fol-
low-up, in coincidence with our own observa-
tions. However, these results must be viewed
with caution and studies involving larger
samples are needed to draw reliable conclu-
sions.
Conclusions
Bone loss after 6 and 12 months proved sta-
tistically significant between the two
groups, with comparatively greater loss in
the case of the Osseous® implants vs. the
Inhex® implants. Regardless the heterogene-
ity of the two groups (neck shape, microth-
reads, surface texture), the implant–abutment
connection appears to be a significant factor
on peri-implant crestal bone levels. In both
groups, the values obtained were within the
normal ranges described in the literature.

Table 3. Peri-implant marginal bone loss according to the type of prosthetic rehabilitation. Mean ± SD (median).
Timepoint 0 Timepoint 1 Timepoint 2 Timepoint 3 Effect: p ANOVA-type test
LOO 0.00 ± 0.00 (0.00) 0.19 ± 0.30 (0.00) 0.31 ± 0.44 (0.05) 0.42 ± 0.47 (0.10) Prosthetic rehabilitation type P = 0.034
LOI 0.00 ± 0.00 (0.00) 0.09 ± 0.10 (0.00) 0.12 ± 0.11 (0.05) 0.15 ± 0.13 (0.05)
BOO 0.00 ± 0.00 (0.00) 0.44 ± 0.45 (0.05) 0.73 ± 0.52 (0.10) 0.99 ± 0.54 (0.45)
BOI 0.00 ± 0.00 (0.00) 0.12 ± 0.12 (0.10) 0.13 ± 0.12 (0.15) 0.15 ± 0.12 (0.20)
FMPI 0.00 ± 0.00 (0.00) 0.05 ± 0.13 (0.00) 0.10 ± 0.16 (0.00) 0.20 ± 0.21 (0.05)

LOO: Locator® overdentures - Osseous®; LOI: Locator® Overdentures – Inhex®; BOO: bar overdentures - Osseous®; BOI: bar overdentures - Inhex®; FMPI: fixed
metal-porcelain prostheses - Inhex®.

1198 | Clin. Oral. Implants. Res. 24, 2013 / 1192–1200 © 2012 John Wiley & Sons A/S

However, studies with a longer duration of
follow-up are needed to confirm the results
obtained.
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