Implant-Abutment Connections and Their Effect on Implant

Survival Rates and Changes in Marginal Bone Levels (ΔMBL):

A Systematic Review and Meta-Analysis of 45,347 Oral Implants
Todd R. Schoenbaum, DDS, MS1/E. Dwayne Karateew, DDS2/Angela Schmidt, DDS3/Chaniun Jadsadakraisorn, DDS3/
Jörg Neugebauer, Dr Med Dent4/Clark M. Stanford, DDS, PhD, MHA5

Purpose: To quantify the cumulative oral implant survival rates and changes in radiographic bone levels based on the
configuration of the implant-abutment connection type over time. Materials and Methods: An electronic literature search
was conducted in four databases (PubMed/MEDLINE, Cochrane Library, Web of Science, and Embase), and records were
refereed by two independent reviewers based on the inclusion criteria. Data from included articles were grouped by
implant-abutment connection type into four categories ([1] external hex; [2] bone level, internal, narrow cone < 45 degrees;
[3] bone level, internal wide cone ≥ 45 degrees or flat; and [4] tissue level) and duration of follow-up (short-term 1 to 2 years,
mid-term 2 to 5 years, and long-term > 5 years). Meta-analyses were performed for cumulative survival rate (CSR) and
changes in marginal bone level (ΔMBL) from baseline (loading) to last reported follow-up. Studies were split or merged
as appropriate based on the implants and follow-up duration in the study and trial design. The study was compiled under
PRISMA 2020 guidelines and registered in the PROSPERO database. Results: A total of 3,082 articles were screened. Full-
text review of 465 articles resulted in a total of 270 articles (representing 16,448 subjects with 45,347 implants) included
for quantitative synthesis and analysis. Mean ΔMBL (95% CI) was as follows: short-term external hex = 0.68 mm (0.57, 0.79);
short-term bone level, internal, narrow cone < 45 degrees = 0.34 mm (0.25, 0.43); short-term bone level, internal wide
cone ≥ 45 degrees = 0.63 mm (0.52, 0.74); short-term tissue level = 0.42 mm (0.27, 0.56); mid-term external hex = 1.03 mm
(0.72, 1.34); mid-term bone level, internal, narrow cone < 45 degrees = 0.45 mm (0.34, 0.56); mid-term bone level, internal
wide cone ≥ 45 degrees = 0.73 mm (0.58, 0.88); mid-term tissue level = 0.4 mm (0.21, 0.61); long-term external hex = 0.98 mm,
0.70, 1.25); long-term bone level, internal, narrow cone < 45 degrees = 0.44 mm (0.31, 0.57); long-term bone level, internal
wide cone ≥ 45 degrees = 0.95 mm (0.68, 1.22); and long-term tissue level = 0.43 mm (0.24, 0.61). CSRs (95% CI) were:
short-term external hex = 97% (96%, 98%); short-term bone level, internal, narrow cone < 45 degrees = 99% (99%, 99%);
short-term bone level, internal wide cone ≥ 45 degrees = 98% (98%, 99%); short-term tissue level = 99% (98%, 100%);
mid-term external hex = 97% (96%, 98%); mid-term bone level, internal, narrow cone < 45 degrees = 98% (98%, 99%); mid-
term bone level, internal wide cone ≥ 45 degrees = 99% (98%, 99%); mid-term tissue level = 98% (97%, 99%); long-term
external hex = 96% (95%, 98%); long-term bone level, internal, narrow cone < 45 degrees = 98% (98%, 99%); long-term
bone level, internal wide cone ≥ 45 degrees = 99% (98%, 100%); and long-term tissue level = 99% (98%, 100%). Conclusion:
The configuration of the implant-abutment interface has a measurable effect on the ΔMBL over time. These changes can
be observed over a period of at least 3 to 5 years. At all measured time intervals, similar ΔMBL was noted for external hex
and internal wide cone ≥ 45-degree connections, as were internal, narrow cone < 45-degree and tissue-level connections.
Int J Oral Maxillofac Implants 2023;38(suppl):37–45. doi: 10.11607/jomi.10411

Keywords: abutment, bone level, bone loss, connection, failure, implant, review, survival

1Department of Restorative Sciences, Dental College of Georgia,
Augusta University, Augusta, Georgia, USA.
2Department of Periodontics, University of Illinois Chicago, College
of Dentistry, Chicago, Ilinois, USA.
3Department of Prosthodontics, University of Illinois Chicago,
College of Dentistry, Chicago, Illinois, USA.
4Steinbeis University, Berlin, Germany.
5University of Iowa, College of Dentistry, Iowa City, Iowa, USA.
Presented before the Academy of Osseointegration Summit, Chicago,
Illinois, August 2022.
Correspondence to: Dr Todd R. Schoenbaum, The Dental College
of Georgia at Augusta University, 1120 15th Street, GC-4220,
Augusta, GA 30912, USA. Email: tschoenbaum@augusta.edu
Submitted December 19, 2022; accepted January 4, 2023.
 2023 by Quintessence Publishing Co Inc.
© prising connective tissue and epithelium, could lead
C
ontemporary implant-supported dental restora-
tions are considered to be a favorable method of
replacement for missing or hopeless dentition due to
their reported high rates of survival and predictabil-
ity, as reported in numerous clinical studies.1–5 The
current trend in thought regarding implant longevity
is no longer focused on equating success to short or
medium temporal survival, but rather equating suc-
cess to peri-implant hard and soft tissue stability and
metrics associated with marginal bone change. 3,5,6,7
Marginal bone stability is a long-term goal, as loss of
peri-implant bone and its overlying soft tissues, com-

The International Journal of Oral & Maxillofacial Implants 37

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Schoenbaum et al
to esthetic and functional compromises.6 Early obser-
vations with machined, external-hex, and platform-
matched implants anticipated marginal bone loss
of < 1.5 mm during the first year of function, and in
consecutive years, a loss of < 0.2 mm annually. 2 Re-
modeling may be considered to be physiologically
acceptable and anticipated. This postplacement mar-
ginal bone loss has been discussed by many authors,
and the amount of marginal bone loss may be con-
sidered as one of the variables defining the success
criteria. 2,8–11
Multiple factors have been suggested as potential
causative agents for biologic remodeling of the coronal
bone profile. Postulated factors for early and long-term
bony remodeling include, but are not limited to, trauma
to the bone from surgical manipulation, occlusal over-
load transferred through the restoration/abutment
to the implant-bone interface, temporal sequence of
implant placement, whether or not bone grafting has
been completed in the immediate area, horizontal and
vertical violation of the peri-implant biologic width (su-
pracrestal tissue attachment), influence of the implant
collar design, neck design, implant surface macroto-
pography and microtopography, shape and configura-
tion of the implant-abutment connection,12 prosthetic
design,13 soft tissue thickness,14 oral hygiene,15 history
of periodontitis,16 smoking,17 and the position of the
implant-abutment microgap.12,13,15,17–29
Revisions of engineered implant characteristics
have been a scientific and industry focus to reduce the
negative factors unrelated to patient history or con-
founding biologic circumstances. Smooth machined
implant surfaces compared to rough surfaces30,31 and
implants with and without cervical threads have been
examined32 to determine their influence(s) on mar-
ginal bone loss. Other designs modeled and in use for
many years are evidence for clinical acceptance. These
include “platform-matched” and “platform-switched”
implant-abutment interfaces, external and internal
connections, narrow and wide cone interfaces at the
implant-abutment junction (IAJ), and designs at sub-
crestal, equicrestal, supercrestal, or soft tissue level
positions.33–43 Current trends suggest that platform-
switched implants enjoy not only greater favor among
clinicians (vs platform-matched implants) but that
they may be superior with respect to maintenance of
healthy bone levels around the most coronal aspect of
the implants.41,44–46
The aim of this meta-analysis and systematic
review was to quantify the effect of four implant-
abutment configurations (external hex connections,
internal connections < 45 degrees, internal connec-
tions ≥ 45 degrees, and tissue-level implant designs
on marginal bone changes and implant survival),
grouped into three follow-up intervals (short-term,
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1 to 2 years; mid-term, 2 to 5 years; and long-term,
≥ 5 years).
MATERIALS AND METHODS
This systematic review followed the PRISMA 2020
(Preferred Reporting Items for Systematic Reviews)47
guidelines using Population, Intervention, Control,
and Outcome (PICO) format, to analyze clinical stud-
ies of patients treated with two-piece titanium den-
tal implants (P) with fixed prostheses (I), with various
implant-abutment configurations (C), and their ef-
fects on changes in peri-implant bone levels and sur-
vival over time (O). This protocol was registered with
PROSPERO #42022313835.
Focused Question
The focused question was as follows: Does implant-
abutment connection design influence changes in
marginal bone levels (ΔMBL) and survival in two-piece
titanium implants with fixed restorations?
Search Strategy
An electronic search was conducted in PubMed/
MEDLINE, Cochrane Library, Web of Science, and Em-
base to identify English language publications from
peer-reviewed journals (Fig 1). The search was con-
ducted using the Medical Subject Headings (MeSH)
keywords: “(dental implants [MESH] OR dental implant
OR dental implants) AND (connection OR platform)
AND (survival rate [MESH] OR dental restoration failure
[MESH] OR dental prosthesis failures OR implant fail-
ure OR survival rates OR implant survival OR complica-
tion OR marginal bone loss OR marginal bone level OR
peri-implant bone loss OR peri-implant bone level OR
crestal bone level).”
Study Selection
Abstracts and selected full texts were screened, and the
following inclusion and exclusion criteria were applied.
Inclusion criteria were as follows:
• ≥ 1 year follow-up postloading
• Patients > 18 years of age
• Human studies (no limitations on patients’ systemic
status)
• Titanium-based, two-piece implants
• Must measure MBL or implant survival
• MBL only measured with 2D radiographs (no CBCT,
panographic, or histology)
• Fixed prostheses only (single- or multi-unit or
full-arch)
• Minimum of 20 implants/study
• English language publication

Exclusion criteria were as follows:
• Animal or benchtop studies
• One-piece zirconia implant or < 2.9-
mm–diameter implants
• Scalloped implant or intermobile
element IAJs
• Solid zirconia or alumina abutments
directly interfacing the implant (ie,
those with no titanium component
interface)
• Implants splinted to teeth
• Abutments cemented onto implants
• Extensive active periodontitis patients
or active peri-implantitis patients
• Implants used as orthodontic
anchorage
• Partial extraction therapy techniques
• Studies in which the data could not
match (due to a lack of disclosure) the
standard rubrics for the extraction
format
Full texts of all selected articles were re-
trieved and screened independently by two
independent reviewers (A.S. and C.J.) ap-
plying the inclusion and exclusion criteria.
Both evaluation stages were performed in
Rayyan software (Rayyan.ai, Qatar Founda-
tion).48 In case of disagreement, the two
reviewers discussed the study or a third ref-
eree (T.S.) reconciled with a final vote.
Data Extraction
Data extraction was performed manually by
one author (T.S.) using a customized data
instrument (Excel v16.61, Microsoft) with
the following headings: authors, publica-
tion year, follow-up time, connection type,
number of patients, number of implants,
number of surviving or failed implants, MBL
(mean and SD), depth of implant place-
ment, platform switch design, and implant
manufacturer. Studies containing implants
with more than one connection design or
more than one-follow up time interval were
split, and data were extracted separately.
Studies that did not report MBL or survival
or did not separate reporting for included
and excluded implants or prosthesis de-
signs were excluded from the study.
Meta-analysis
Single-arm weighted meta-analyses were
performed for each implant connection
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Schoenbaum et al
Records identified from:
Identification
Records removed before
•Medline (n = 539)
•Cochrane Trials (n = 431)
screening:
•Duplicate records removed
•Web of Science (n = 956) (n = 1,124)
•Embase (n = 1,156)
Screening
Records screened (n = 1,958) Records excluded (n = 1,482)
Reports sought for retrieval
Reports not retrieved (n = 11)
(n = 476)
Eligibility
Reports assessed for eligibility Reports excluded:
(n = 465) •Excluded implant type (n = 4)
•Excluded abutment or prostheses
Included
Studies included in review (n = 43)
(n = 270) •Data incomplete or unextractable
(n = 70)
•Insufficient reporting follow-up or
sample size (n = 5)
•Incorrect/excluded measurement
reported (n = 49)
•Insufficient information regarding
materials and methods (n = 24)
Fig 1   PRISMA 2020 diagram.
design at three follow-up intervals using a random-effects model
in OpenMeta v. 12.11.14 (Brown University). Forest plots were used
to synthesize pooled means and 95% CIs for ΔMBL and survival for
each connection group at each follow-up time interval. Heteroge-
neity was assessed using the I2 test.
RESULTS
Study Selection
Initial database searches resulted in 3,082 total records meeting
the inclusion criteria (1,156 from Embase, 431 from Cochrane tri-
als, 956 from Web of Science, 539 from PubMed); 1,124 duplicated
records deleted; 1,958 abstracts screened; 1,482 records excluded
for failure to meet inclusion; and 476 records sought for retrieval.
Eleven full-text records could not be located. The 465 remaining
full-text records were screened for inclusion and synthesis. A total
of 270 studies were included in the quantitative analyses.
Peri-implant Bone Loss Meta-analyses
The 270 included studies represent 16,448 patients and 45,347 im-
plants. Implant counts for each group were: external hex = 14,598;
bone level, internal, narrow cone < 45 degrees = 22,613; bone level,
internal wide cone ≥ 45 degrees or flat = 4,729; and tissue level
= 3,310 (Fig 2).
Changes in marginal bone levels were summarized at three time
intervals with the mean ΔMBL (95% CI) as follows: short-term ex-
ternal hex = 0.68 mm (0.57, 0.79); short-term bone level, internal,
narrow cone < 45 degrees = 0.34 mm (0.25, 0.43); short-term bone
The International Journal of Oral & Maxillofacial Implants 39
Schoenbaum et al
n = 14,598 n = 22,613
Abutment/prosthesis IAJ IAJ IAJ
Implant
External hex Bone level, internal con-
(ie, Brånemark, 3i ext) nection < 45 degrees
(ie, Astra, Nobel CC,
Straumann BL, Bicon,
Ankylos, Conelog)
level, internal wide cone ≥ 45 degrees = 0.63 mm (0.52,
0.74); short-term tissue level = 0.42 mm (0.27, 0.56);
mid-term external hex = 1.03 mm (0.72, 1.34); mid-term
bone level, internal, narrow cone < 45 degrees = 0.45
mm (0.34, 0.56); mid-term bone level, internal wide
cone ≥ 45 degrees = 0.73 mm (0.58, 0.88); mid-term
tissue level = 0.4 mm (0.21, 0.61); long-term external
hex = 0.98 mm, 0.70, 1.25); long-term bone level, inter-
nal, narrow cone < 45 degrees = 0.44 mm (0.31, 0.57);
long-term bone level, internal wide cone ≥ 45 degrees
= 0.95 mm (0.68, 1.22); long-term tissue level = 0.43 mm
(0.24, 0.61). Cumulative survival rates (CSRs; 95% CI)
were: short-term external hex = 97% (96%, 98%); short-
term bone level, internal, narrow cone < 45 degrees
= 99% (99%, 99%); short-term bone level, internal wide
cone ≥ 45 degrees = 98% (98%, 99%); short-term tissue
level = 99% (98%, 100%); mid-term external hex = 97%
(96%, 98%); mid-term bone level, internal, narrow cone
< 45 degrees = 98% (98%, 99%); mid-term bone level,
internal wide cone ≥ 45 degrees = 99% (98%, 99%);
mid-term tissue level = 98% (97%, 99%); long-term
external hex = 96% (95%, 98%); long-term bone level,
internal, narrow cone < 45 degrees = 98% (98%, 99%);
long-term bone level, internal wide cone ≥ 45 degrees
= 99% (98%, 100%); long-term tissue level = 99% (98%,
100%). Heterogeneity was high in all groups (Table 1;
Figs 3 to 6 can be found at the end of the article, and all
24 forest plots can be seen in the online version of this
article at www.quintpub.com/journals).
DISCUSSION
This systematic review and meta-analysis was conducted
to focus on a unique PICO question: to analyze clinical
studies of patients treated with two-piece titanium den-
tal implants with fixed prostheses, with various implant-
abutment configurations, and the effect on changes in
peri-implant bone levels and survival over time. Essen-
tially, this systematic review and meta-analysis sought
to determine the effect of the implant-abutment
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Fig 2   Diagrammatic representa-
n = 4,729 n = 3,310 tion of the four classes of implant
connections included in this
IAJ analy­sis, including number of im-
IAJ plants per group.
Bone level, internal con- Tissue level
nection ≥ 45 degrees (ie, Straumann TL)
(ie, Nobel TriLobe,
3i Certain, BioHorizons,
Zimmer, Camlog)
connection on change in mean MBL between a baseline
and follow-up defined as changes in mesial and/or distal
radiographic measured osseous vertical bone height or
“ΔMBL” (change in marginal bone level) and survival over
time. Since the early studies by Albrektsson and Zarb2
and others, changes in marginal bone levels and other
clinical criteria have been noted as a direct indicator of
success or a harbinger of future biologic and mechanical
problems. Preservation of marginal bone level has been
the goal of implant therapy from implant placement,
definitive prosthetic abutment connection, and through
the functional life of the implant/prosthetic unit. Loss of
bone from the coronal aspect of the implant body has
been radiographically measured and recorded as ΔMBL,
a metric of crestal stability. Notably, this measure usu-
ally does not include the midfacial aspect of the implant
body, which can be esthetically the most important
aspect.
The quantified results from this systematic review
are notable. Over the 10-year interval of time cov-
ered by this systematic review, two implant groups,
(1) internal connection, bone level, < 45-degree con-
nection and (2) tissue-level implants, performed bet-
ter than their counterparts of either (3) external-hex
connections and (4) internal connection, bone level,
> 45-degree connection. However, one may question
whether these results are clinically significant. Certainly,
at the 10-year completion of this analysis, the difference
in ΔMBL is both statistically and clinically significant be-
tween the above groups 1 and 2 and groups 3 and 4, as
there is a demonstrable difference of 0.5 mm. However,
when earlier temporal points are noted, the difference
in ΔMBL is not as distinct. It appears from the data that
the internal-connection, bone-level, < 45-degree con-
nection, and tissue-level implants show an early ΔMBL
of approximately 0.4 mm and lose less mesial/distal
bone over the 10-year observation period. Conversely,
the group of external-hex and internal-connection,
bone-level, > 45-degree connection have a ΔMBL rep-
resenting approximately 1 mm at > 5 years. Note that
tables present results to the hundredth of a millimeter,
 Schoenbaum et al

Table 1 Data Summarized from Individual Meta-analyses of Each Implant Connection Group at Each
Follow-up Interval for DMBL and Survival
Survival rate (%) DMBL (mm)
Connection
category <2y 2–5 y >5y <2y 2–5 y >5y
External hex
Mean (95% CI) 96.8 (95.8, 97.7) 97 (96, 98) 96.4% (95.2, 97.6) 0.68 (0.57, 0.79) 1.03 (0.72, 1.34) 0.98 (0.70, 1.25)
Patients, n 1,039 1,860 1,818 1,039 1,860 1,818
Implants, n 3,034 5,184 6,380 3,034 5,184 6,380
Internal, bone level <
45-degree cone
Mean (95% CI) 99.2 (99.1, 99.4) 98.4 (97.9, 98.8) 98.1 (97.6, 98.6) 0.34 (0.25, 0.43) 0.45 (0.34, 0.56) 0.44 (0.31, 0.57)
Patients, n 2,738 2,800 2,808 2,738 2,800 2,808
Implants, n 7,769 7,758 7,086 7,769 7,758 7,086
Internal, bone level ≥
45-degree cone
Mean (95% CI) 98.3 (97.7, 98.8) 98.6 (97.9, 99.2) 98.5 (97.5, 99.5) 0.63 (0.52, 0.74) 0.73 (0.58, 0.88) 0.95 (0.68, 1.22)
Patients, n 977 385 801 977 385 801
Implants, n 1,991 1,225 1,513 1,991 1,225 1,513
Tissue level
Mean (95% CI) 98.9 (98.1, 99.6) 98.0 (96.8, 99.1) 99.0 (98.0, 99.9) 0.42 (0.27, 0.56) 0.41 (0.21, 0.61) 0.43 (0.24, 0.61)
Patients, n 352 221 491 352 221 491
Implants, n 826 1,393 975 826 1,393 975

but caution should be exercised in interpretation at this
level due to the inability of the individual interpreting
the dental radiograph to measure and accquire data to
this level.
The tissue-level implant-abutment connection in-
terface is positioned to minimize the influence of the
implant-abutment microgap on peri-implant bone
levels. The data suggest that the most stable long-
term bone-level connection is the internal, bone-level,
< 45-degree connection, which may minimize the mi-
crogap and increase long-term stability at the implant-
abutment interface, thereby minimizing microleakage.
This microgap movement and associated microleak-
age has been suspected to be a causative agent of
ΔMBL, resulting in significant complications in the
peri-implant tissues, specifically peri-implant mucocitis,
peri-implantitis, and implant loss.49
Due to the nature of a systematic review involving
hundreds of investigators, implant designs, surfaces,
patient populations, etc, there are several factors that
may have an influential role that cannot be accounted
for. Patient population variability, including age, ge-
netics, epigenetic influences, and oral hygiene norms
cannot be accounted/adjusted for. This is also true for
variations in implant macrodesign and microdesign,
surface preparation and collar finishing, and for varia-
tions in abutment design, including macrofeatures and
microfeatures as well as composition of the abutment
(CP Ti vs TiN treated). Lastly, there is likely heterogene-
ity in depth of the placement of the shoulder of the
implant and arch location. All these factors may influ-
ence the results in the individual studies reviewed and
thus have biased the final results here, though most are
unlikely to disproportionately affect one implant con-
nection design group more than another. On the other
hand, from a provider perspective, the heterogeneity
adds to the validity of the effectiveness of specific im-
plant configurations in daily practice. The typical stan-
dard clinical trial design is to homogenize the inclusion
and exclusion criteria so much that the outcomes of the
study are very limited (a measure of efficacy). The value
of the heterogeneity described with the “guardrails”
on inclusion and exclusion criteria in this study allows
for a comprehensive understanding of the influence
of implant/abutment designs on a specific but narrow
outcome assessment (a common one that the literature
allows). As such, a measure of common everyday out-
comes in practice (ie, effectiveness) is suggested.
As with any systematic review and data synthesis
from multiple investigations (in this case, 465), it is im-
plausible to control for all confounding variables. Also,
while a confounding variable (ie, patients with higher
HbA1c levels) may reduce CSRs or ΔMBL in one study
and not another, there is no compelling reason for any
one of the connection classification groups to have a
higher prevalence of that variable than another con-
nection class.
Confounding variables unaccounted for in this analy­
sis but unlikely to disproportionately affect any one
group, though not exhaustive, include: publication and
observer bias (efficacy, not effectiveness); reliability in
skill, training, and experience of surgeons, prosthodon-
tists, restorative clinicians, and technicians; variations
in prosthesis designs, materials, and configuration;
variation in follow-up and maintenance practices; in-
consistencies in radiographic measurements between

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Schoenbaum et al
studies; inconsistencies in radiograph capture within a
study; variations in amount of native/grafted bone, soft
tissue thickness, width of keratinized peri-implant tis-
sue, flap vs flapless surgical approaches, and occlusion;
and variations in surgical techniques, tooth arch posi-
tion, immediate vs early vs delayed placement, original
equipment manufacturer (OEM) vs non-OEM prosthetic
components, “one-abutment, one-time” vs abutment
removal, and cement- vs screw-retained restorations.
This study used the measurement ΔMBL, which was
not always consistently used in the included reports.
Some investigators simply measured the total distance
from the IAJ to the bone attachment on the implant
without accounting for the bone position at T0 (load-
ing). Failure to account for initial bone position follow-
ing integration confounds the changes in bone levels
based on initial placement depth. The use of ΔMBL miti-
gates this concern. Included data were adjusted to take
this into account and standardize the measurements.
The use of ΔMBL gives a better understanding of bone
changes over time compared to the use of simply mar-
ginal bone loss or level.
The secondary outcome variable of implant survival
was selected over implant “success” due to inherent
difficulties in synthesizing the latter across multiple in-
vestigations. Survival is a binary outcome measure with
no ambiguity. Implant “success” is certainly more useful
clinically, but there exist a myriad of definitions of what
is or is not “success,” and reporting is inconsistent. What
merits a successful outcome for one group of investiga-
tors would be deemed a failure by others.
The results of this report indicate that the general
design classification of dental implant connections
does result in differential bone loss over time. The pres-
ent systematic review and meta-analysis found that
bone-level connections with a narrow cone fit at the IAJ
and tissue-level implants maintained more bone over
time compared to the alternatives. However, individual
clinicians must consider dozens of individual factors
when selecting an implant, and the ΔMBL difference
between groups is just one of these factors. Differences
in survival between groups were not clear, except that
external-hex implants averaged a few percent lower
long-term. Caution should be exercised in interpret-
ing this difference, however, as the investigations on
external-connection implants were on average older,
this difference may be due to improvements in implant
surfaces, prosthetic designs/materials, and surgical
protocols/techniques. Most investigations reported
CSRs and not proper survival modeling, which would
account for subject attrition. It is also worth noting that
there are likely strong observer and publication biases
at play. As such, it should be well noted that the data
reported here are likely optimistic.
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CONCLUSIONS
The results of this systematic review and meta-analysis
suggest that there are significant differences in ΔMBL
between various implant-abutment configuration de-
signs at short-term, mid-term, and long-term periods
of observation (up through 10 years). The data present-
ed suggest that at each of the temporal observations,
the external-hex and internal wide cone ≥ 45-degree
configurations behaved similarly with respect to
ΔMBL, as did the tissue-level and internal narrow cone
< 45-degree configurations. The respective CSRs for
all implant-abutment configurations at all times were
≥ 96%.
The results of this systematic review and meta-
analysis should be interpreted with caution due to the
presence of uncontrolled confounding factors in the
included studies. However, it is interesting to note the
implant-abutment geometries that performed similarly
at each juncture.
ACKNOWLEDGMENTS
No authors have any conflicts of interest relevant to this investiga-
tion. The authors would like to thank the Academy of Osseointegra-
tion for the opportunity to contribute on this topic.
REFERENCES
1. Moraschini V, Poubel LA, Ferreira VF, Barboza Edos S. Evaluation of
survival and success rates of dental implants reported in longitudinal
studies with a follow-up period of at least 10 years: A systematic
review. Int J Oral Maxillofac Surg 2015;44:377–388.
2. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term
efficacy of currently used dental implants: A review and proposed
criteria of success. Int J Oral Maxillofac Implants 1986;1:11–25.
3. Geraets W, Zhang L, Liu Y, Wismeijer D. Annual bone loss and success
rates of dental implants based on radiographic measurements.
Dentomaxillofac Radiol 2014;43:20140007.
4. Hadzik J, Botzenhart U, Krawiec M, et al. Comparative evaluation
of the effectiveness of the implantation in the lateral part of the
mandible between short tissue level (TE) and bone level (BL) implant
systems. Ann Anat 2017;213:78–82.
5. Albrektsson T, Zarb GA. Current interpretations of the osseointegrat-
ed response: Clinical significance. Int J Prosthodont 1993;6:95–105.
6. Sanz M, Ivanoff CJ, Weingart D, et al. Clinical and radiologic out-
comes after submerged and transmucosal implant placement with
two-piece implants in the anterior maxilla and mandible: 3-year
results of a randomized controlled clinical trial. Clin Implant Dent
Relat Res 2015;17:234-246
7. Hermann F, Lerner H, Palti A. Factors in influencing the preservation
of the periimplant marginal bone. Implant Dent 2007;16:165–175.
8. Albrektsson T, Isidor F, Consensus Report of Session IV. In: Lang NP, Kar-
ring T (eds). Proceedings of the First European Workshop on Periodon-
tology, London: Quintessence, 1994: 365–369.
9. Buser D, Mericske-Stern R, Pierre Bernard JP, et al. Long-term evalua-
tion of non-submerged ITI implants. Part 1: 8-year life table analysis
of a prospective multi-center study with 2359 implants. Clin Oral
Implants Res 1997;8:161–172.

10. Roos J, Sennerby L, Lekholm UL, Jemt T, Gröndahl K, Albrektsson T. A
qualitative and quantitative method for evaluating implant success:
A 5-year retrospective analysis of the Brånemark implant. Int J Oral
Maxillofac Implants 1997;12:504–514.
11. Zarb GA, Albrektsson T. Consensus report: Towards optimized
treatment outcomes for dental implants. J Prosthet Dent
1998;80:641.
12. Lemos CAA, Verri FR, Bonfante EA, Santiago Júnior JF, Pellizzer EP.
Comparison of external and internal implant-abutment connections
for implant supported prostheses. A systematic review and meta-
analysis. J Dent 2018;70:14–22.
13. Derks J, Schaller D, Håkansson J, Wennström JL, Tomasi C, Berglundh
T. Effectiveness of implant therapy analyzed in a Swedish population:
prevalence of peri-implantitis. J Dent Res 2016;95:43–49.
14. Suárez-López del Amo F, Lin GH, Monje A, Galindo-Moreno P, Wang
HL. Influence of soft tissue thickness on peri-implant marginal
bone loss: A systematic review and meta-analysis. J Periodontol
2016;87:690–699.
15. Ramanauskaite A, Tervonen T. The efficacy of supportive peri-
implant therapies in preventing peri-implantitis and implant loss: a
systematic review of the literature. J Oral Maxillofac Res 2016;7:e12.
16. Roccuzzo M, Bonino F, Aglietta M, Dalmasso P. Ten-year results of a
three arms prospective cohort study on implants in periodontally
compromised patients. Part 2: clinical results. Clin Oral Implants Res
2012;23:389–395.
17. Chrcanovic BR, Albrektsson T, Wennerberg A. Smoking and
dental implants: A systematic review and meta-analysis. J Dent
2015;43:487–498.
18. Quirynen M, Naert I, van Steenberghe D. Fixture design and overload
influence marginal bone loss and fixture success in the Brånemark
system. Clin Oral Implants Res 1992;3:104–111.
19. Oh TJ, Yoon J, Misch CE, Wang HL. The causes of early implant bone
loss: Myth or science? J Periodontol 2002;73:322–333.
20. Kinaia BM, Shah M, Neely AL, Goodis HE. Crestal bone level changes
around immediately placed implants: A systematic review and meta-
analyses with at least 12 months’ follow-up after functional loading. J
Periodontol 2014;85:1537–1548.
21. Yang J, Cheng Z, Shi B. Augmentation of the alveolar ridge compared
with shorter implants in atrophic jaws: A meta-analysis based on
randomised controlled trials. Br J Oral Maxillofac Surg 2016;54:68–73.
22. Canullo L, Tallarico M, Radovanovic S, Delibasic B, Covani U,
Rakic M. Distinguishing predictive profiles for patient-based risk
assessment and diagnostics of plaque induced, surgically and
prosthetically triggered peri-implantitis. Clin Oral Implants Res
2016;27:1243–1250.
23. Vandeweghe S, Cosyn J, Thevissen E, Teerlinck J, De Bruyn H. The in-
fluence of implant design on bone remodeling around surface-mod-
ified Southern Implants. Clin Implant Dent Rel Res 2012;14:655–662.
24. Peñarrocha-Diago M, Flichy-Fernandez AJ, Alonso-Gonzalez R,
Peñarrocha-Oltra D, Balaguer-Martinez J, Penarrocha-Diago M. Influ-
ence of implant neck design and implant–abutment connection type
on peri-implant health. Radiological study. Clin Oral Implants Res
2013;24:1192–1200.
25. De Bruyn H, Christiaens V, Doornewaard R, et al. Implant surface
roughness and patient factors on long-term peri-implant bone loss.
Periodontol 2000 2017;73:218–227.
26. Sgolastra F, Petrucci A, Severino M, Gatto R, Monaco A. Periodontitis,
implant loss and peri-implantitis. A meta-analysis. Clin Oral Implants
Res 2015;26:e8–e16.
27. Scarano A, Assenza B, Piattelli M, et al. Interimplant distance and
crestal bone resorption: A histologic study in the canine mandible.
Clin Implant Dent Relat Res 2004;6:150–156.
28. Sasada, Y., Cochran DL. Implant-abutment connections: A review of
biologic consequences and peri-implantitis implications. Int J Oral
Maxillofac Implants 2017;32:1296–1307.
29. van Eekeren PJ, Tahmaseb A, Wismeijer D. Crestal bone changes
around implants with implant-abutment connections at epicrestal
level or above: Systematic review and meta-analysis. Int J Oral Maxil-
lofac Implants 2016;31:119–124.
© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Schoenbaum et al
30. Bassetti R, Kaufmann R, Ebinger A, et al. Is a grooved collar implant
design superior to a machined design regarding bone level altera-
tion? An observational pilot study. Quintessence Int 2014;45:
221–229.
31. den Hartog L, Meijer HJA, Vissink A, Raghoebar GM. Anterior single
implants with different neck designs: 5 year results of a randomized
clinical trial. Clin Implant Dent Relat Res 2017;19:717–724.
32. Hudieb MI, Wakabayashi N, Kasugai S. Magnitude and direction of
mechanical stress at the osseointegrated interface of the micro-
thread implant. J Periodontol 2011;82:1061–1070.
33. Bratu EA, Tandlich M, Shapira L. A rough surface implant neck with
microthreads reduces the amount of marginal bone loss: A prospec-
tive clinical study. Clin Oral Implants Res 2009;20:827–832.
34. Nickenig HJ, Wichmann M, Happe A, Zöller JE, Eitner S. A 5-year pro-
spective radiographic evaluation of marginal bone levels adjacent to
parallel-screw cylinder machined-neck implants and rough-surfaced
microthreaded implants using digitized panoramic radiographs. J
Craniomaxillofac Surg 2013;41:564–568.
35. Koodaryan R, Hafezeqoran A. Evaluation of implant collar surfaces
for marginal bone loss: a systematic review and meta-analysis.
Biomed Res Int 2016;2016:4987526
36. Shin YK, Han CH, Heo SJ, Kim S, Chun HJ. Radiographic evaluation
of marginal bone level around implants with different neck designs
after 1 year. Int J Oral Maxillofac Implants 2006;21:789–794.
37. Teughels W, Van Assche N, Sliepen I, Quirynen M. Effect of material
characteristics and/or surface topography on biofilm development.
Clin Oral Implants Res 2006;17(suppl 2):68–81.
38. Buser D, Mericske-Stern R, Dula K, Lang NP. Clinical experience
with one-stage, non-submerged dental implants. Adv Dent Res
1999;13:153–161.
39. Sánchez-Siles M, Muñoz-Cámara D, Salazar-Sanchez N, Ballester-Fer-
randis JF, Camacho-Alonso F. Incidence of peri-implantitis and oral
quality of life in patients rehabilitated with implants with different
neck designs: a 10-year retrospective study. J Craniomaxillofac Surg
2015;43:2168–2174 .
40. Cochran DL, Bosshardt DD, Grize L, et al. Bone response to loaded im-
plants with non-matching implant-abutment diameters in the canine
mandible. J Periodontol 2009;80:609–617.
41. Guerra F, Wagner W, Wiltfang J, et al. Platform switch versus platform
match in the posterior mandible—1-year results of a multicentre
randomized clinical trial. J Clin Periodontol 2014;41:521–529.
42. Degidi M, Perrotti V, Shibli JA, Novaes AB, Piattelli A, Iezzi G.
Equicrestal and subcrestal dental implants: A histologic and
histomorphometric evaluation of nine retrieved human implants. J
Periodontol 2011;82:708–715.
43. Lago L, da Silva L, Martinez-Silva I, Rilo B. Crestal bone level
around tissue-level implants restored with platform matching
and bone- level implants restored with platform switching: A
5-year randomized controlled trial. Int J Oral Maxillofac Implants
2018;33:448–456.
44. Trammell K, Geurs NC, O’Neal SJ, et al. A prospective, randomized,
controlled comparison of platform-switched and matched-abutment
implants in short-span partial denture situations. Int J Periodontics
Restorative Dent 2009;29:599–605.
45. Enkling N, Jöhren P, Klimberg V, Bayer S, Mericske-Stern R, Jepsen S.
Effect of platform switching on peri-implant bone levels: A random-
ized clinical trial. Clin Oral Implants Res 2011;22:1185–1192.
46. Pan YH, Lin HK, Lin JC, et al. Evaluation of the peri-implant bone
level around platform-switched dental implants: A retrospec-
tive 3-year radiographic study. Int J Environ Res Public Health
2019;16:2570.
47. Page MJ, McKenzie JE, Bossuyt PM, et al.. The PRISMA 2020 state-
ment: An updated guideline for reporting systematic reviews. Br
Med J 2021;372:n71.
48. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—A
web and mobile app for systematic reviews. Syst Rev 2016;5:210.
49. Alves DC, Carvalho PS, Martinez EF. In vitro microbiological analysis
of bacterial seal at the implant-abutment interface using two Morse
taper implant models. Braz Dent J 2014;25:48–53.
The International Journal of Oral & Maxillofacial Implants 43
Schoenbaum et al

APPENDIX FOREST PLOTS

Fig 3   Forest plot summary of long-term (> 5-year follow-up) ΔMBL for external-hex implants (group 1).

Fig 4   Forest plot summary of long-term (> 5-year follow-up) ΔMBL for bone-level, internal-connection < 45-degree implants (group 2).

44 Volume 38, Supplement, 2023

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 Schoenbaum et al

Fig 5   Forest plot summary of long-term (> 5-year follow-up) ΔMBL for bone-level, internal-connection ≥ 45-degree implants (group 3).

Fig 6   Forest plot summary of long-term (> 5-year follow-up) ΔMBL for tissue-level implants (group 4).

The International Journal of Oral & Maxillofacial Implants 45

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Schoenbaum et al

ONLINE-ONLY APPENDIX FOREST PLOTS

Appendix Fig 1   Forest plot summary of short-term (1 to 2 years) ΔMBL for external-hex implants (group 1).

45a Volume 38, Supplement, 2023

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Appendix Fig 2   Forest plot summary of short-term (1 to 2 years) ΔMBL for bone-level, internal-connection < 45-degree implants (group 2).

The International Journal of Oral & Maxillofacial Implants 45b

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Schoenbaum et al

Appendix Fig 3   Forest plot summary of short-term (1 to 2 years) ΔMBL for bone-level, internal-connection ≥ 45-degree implants (group 3).

45c Volume 38, Supplement, 2023

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Appendix Fig 4   Forest plot summary of short-term (1 to 2 years) ΔMBL for tissue-level implants (group 4).

Appendix Fig 5   Forest plot summary of mid-term (2 to 5 years) ΔMBL for external-hex implants (group 1).

The International Journal of Oral & Maxillofacial Implants 45d

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Schoenbaum et al

Appendix Fig 6   Forest plot summary of mid-term (2 to 5 years) ΔMBL for bone-level, internal-connection < 45-degree implants (group 2).

45e Volume 38, Supplement, 2023

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Appendix Fig 7   Forest plot summary of mid-term (2 to 5 years) ΔMBL for bone-level, internal-connection ≥ 45-degree implants (group 3).

Appendix Fig 8   Forest plot summary of mid-term (2 to 5 years) ΔMBL for tissue-level implants (group 4).

The International Journal of Oral & Maxillofacial Implants 45f

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Schoenbaum et al

Appendix Fig 9   Forest plot summary of short-term (1 to 2 years) cumulative survival rate for external-hex implants (group 1).

45g Volume 38, Supplement, 2023

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Appendix Fig 10   Forest plot summary of short-term (1 to 2 years) cumulative survival rate for bone-level, internal-connection < 45-degree
implants (group 2).

The International Journal of Oral & Maxillofacial Implants 45h

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Appendix Fig 11   Forest plot summary of short-term (1 to 2 years) cumulative survival rate for bone-level, internal-connection ≥ 45-degree
implants (group 3).

45i Volume 38, Supplement, 2023

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 Schoenbaum et al

Appendix Fig 12   Forest plot summary of short-term (1 to 2 years) cumulative survival rate for tissue-level implants (group 4).

Appendix Fig 13   Forest plot summary of mid-term (2 to 5 years) cumulative survival rate for external-hex implants (group 1).

The International Journal of Oral & Maxillofacial Implants 45j

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Schoenbaum et al

Appendix Fig 14   Forest plot summary of mid-term (2 to 5 years) cumulative survival rate for bone-level, internal-connection < 45-degree
implants (group 2).

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 Schoenbaum et al

Appendix Fig 15   Forest plot summary of mid-term (2 to 5 years) cumulative survival rate for bone-level, internal-connection ≥ 45-degree
implants (group 3).

Appendix Fig 16   Forest plot summary of mid-term (2 to 5 years) cumulative survival rate for tissue-level implants (group 4).

The International Journal of Oral & Maxillofacial Implants 45l

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Appendix Fig 17   Forest plot summary of long-term (> 5 year) cumulative survival rate for external-hex implants (group 1).

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Appendix Fig 18   Forest plot summary of long-term (> 5 year) cumulative survival rate for bone-level, internal-connection < 45-degree im-
plants (group 2).

The International Journal of Oral & Maxillofacial Implants 45n

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Schoenbaum et al

Appendix Fig 19   Forest plot summary of long-term (> 5 year) cumulative survival rate for bone-level, internal-connection ≥ 45-degree im-
plants (group 3).

Appendix Fig 20   Forest plot summary of long-term (> 5 year) cumulative survival rate for tissue-level implants (group 4).

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