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Received: 25 February 2022 | Revised: 9 June 2022 | Accepted: 22 June 2022

DOI: 10.1111/clr.13985

ORIGINAL ARTICLE

Impact of abutment geometry on early implant marginal bone

loss. A double-­blind, randomized, 6-­month clinical trial

Mario Pérez-­Sayans1,2 | Pablo Castelo-­Baz3 | David Penarrocha-­Oltra4 |

1 5,6
Flavio Seijas-­Naya | Mercedes Conde-­Amboage | José M. Somoza-­Martín1,2

1
Oral Medicine, Oral Surgery and
Implantology Unit (MedOralRes), Faculty Abstract
of Medicine and Dentistry, University
Objectives: The objective of this study was to analyze the impact of the abutment
of Santiago de Compostela, Santiago de
Compostela, Spain width on early marginal bone loss (MBL).
Material and Methods: A balanced, randomized, double-­blind clinical trial with two
2
Health Research Institute of Santiago
de Compostela (IDIS), Santiago de
Compostela, Spain
parallel experimental arms was conducted without a control group. The arms were
3
Department of Restorative Dentistry “cylindrical” abutment and “concave” abutment. Eighty hexagonal internal connection
and Endodontics, Faculty of Medicine implants, each with a diameter of 4 × 10 mm, were placed in healed mature bone. The
and Dentistry, University of Santiago de
Compostela, Santiago de Compostela, main variable was the peri-­implant tissue stability, which was measured as MBL at
Spain 8 weeks and 6 months.
4
Department of Oral Surgery and
Results: The final sample consisted of 77 implants that were placed in 25 patients. 38
Implantology, University of Valencia,
Valencia, Spain (49.4%) were placed using the cylindrical abutment, and the other 39 (50.6%) were
5
CITMAga, Santiago de Compostela, Spain placed using the concave abutment. The early global MBL of −0.6 ± 0.7 mm in the cy-
6
Department of Statistics, Mathematical
lindrical abutment group was significantly higher than it was in the concave abutment
Analysis and Optimization, Models
of Optimization, Decision, Statistics group, in which the early global MBL was −0.4 ± 0.6 mm (p = .030). The estimated ef-
and Applications Reseach Group
fect size (ES) was negative for the cylindrical abutment (ES = −1.3730, CI −2.5919 to
(MODESTYA), Universidade de Santiago
de Compostela, Santiago de Compostela, −0.1327; t-­value = −2.4893; p = .0139), therefore implying a loss of mean bone level,
Spain
and it was positive for the concave abutment (ES = 2.8231; CI: 1.4379 to 4.2083; t-­
Correspondence value = 4.0957; p = .0002), therefore implying an increase in the average bone level.
David Penarrocha-­Oltra, Department of
Conclusions: The concave abutments presented significantly less early MBL at
Oral Surgery and Implantology, University
of Valencia, Valencia, Spain. 6 months post-­loading than classical cylindrical abutments did.
Email: [email protected]
KEYWORDS
Funding information
dental implant, early marginal bone loss, prostheses abutment width, randomized clinical trial,
Ministerio de Ciencia e Innovación, Grant/
single tooth
Award Number: PID2020-­116587GB-­I 00;
European Union; Nueva Galimplant and
the University of Santiago de Compostela,
Grant/Award Number: USC-­2019-­CE178

Clinical Trial Registration: Unique identification number: NCT03796494.

This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made.
© 2022 The Authors. Clinical Oral Implants Research published by John Wiley & Sons Ltd.

1038 | 
wileyonlinelibrary.com/journal/clr Clin Oral Impl Res. 2022;33:1038–1048.
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PÉREZ-­SAYANS et al. 1039

1 | I NTRO D U C TI O N 2 | M E TH O D S

Modern dental implantology has evolved in a crucial way, leaving be- 2.1 | Trial design, participants, and setting
hind any concerns regarding osseointegration and the strength and
esthetics of restorative materials. Nonetheless, the considerable This study was designed as a balanced, randomized, double-­blind
number of dental implants that are being fitted worldwide is caus- clinical trial, which was conducted with two parallel experimental
ing new problems, in particular with regards to peri-­implant diseases arms, without a control group. The participants were recruited solely
(PD) (Barootchi & Wang, 2021). In fact, long-­term preservation of from Spain. The trial was conducted from February 2020 to July
healthy peri-­implant tissues that allow for functional and aesthetic 2021. The study protocol was registered in Clini​calTr​ials.gov, under
aspects to be maintained is still one of the greatest challenges that the identifier: NCT03796494, and it was approved by the Regional
is currently affecting this profession (Schwarz et al., 2021). Marginal Committee for Research Ethics (Ref. 2019/169).
bone loss (MBL) associated to implants and prosthetic restorations Patients who met the inclusion criteria were recruited by the Unit
remains an issue that is proving difficult to control and especially of Oral Medicine, Oral Surgery and Implantology of the University of
difficult to prevent (Chambrone et al., 2018). Santiago de Compostela from February 2020 to April 2020. The pa-
Mattheos, Vergoullis, et al. (2021) recently introduced the con- tients were fully informed of the characteristics of the study and were
cept of “implant supracrestal complex” (ISC) as a way of identifying invited to participate. A complete medical history was taken for each of
the impact that design features have on both short-­term clinical out- the patients, and they also underwent a thorough oral examination and
comes and the long-­term health of the peri-­implant bone and soft a cone beam tomography (CBCT)-­based radiology study (i-­CAT-­FLX).
tissues. They suggested that implant-­prosthesis-­abutment complex The tests were carried out in accordance with the criteria recom-
design features, such as the implant-­abutment design, the junction, mended in the CONSORT Guidelines. The selection criteria for this
and their location in relation to the ISC tissues, could have a sig- study were (1) patients without any systemic pathologies that could be
nificant impact on the long-­term maintenance of stable and healthy considered as grounds for absolute contraindication; (2) adult patients
peri-­implant tissues (Mattheos, Janda, et al., 2021). who agreed to form part of the study and who signed the informed
The individual risk factors associated with MBL, such as to- consent form; (3) patients who consumed less than five cigarettes/
bacco consumption, poor plaque control, prior or current peri- day; (4) patients who were not completely edentulous; (5) patients
odontal disease, endocrine-­m etabolic factors (diabetes mellitus), or with a single/multiple tooth gap/s in the posterior maxillary or man-
certain genetic polymorphisms, have all been assessed and stud- dibular area that did not require the use of regenerative techniques;
ied, and a certain amount of evidence has already been drawn up (6) patients with an area of healed mature bone at least 6 months post-­
(Schwarz et al., 2021). Nonetheless, there are still certain incon- extraction; (7) implants with a minimum torque of 20 N to insert the
sistencies in the information provided on factors related to the abutment at one time; (8) patients with a sufficient amount of bone
implant itself, and, in particular those related to its intermediate to place implants of 4 mm in diameter and 10 mm in length; and (9)
prosthodontic components, and there is often deep gaps in the edentulous areas with prosthetic space of at least 5 mm.
specific literature. Subjects were not included in the RCT if any of the following
Alongside the different techniques that are used to minimize or exclusion criteria were met: (1) patients lacking teeth in esthetic
prevent MBL, a range of strategies have also been proposed, which zones 13–­23 and 33–­43 (second and fifth sextants); (2) patients who
include modifications to the drilling protocol (undersized drilling, smoked more than five cigarettes a day; (3) patients with a bleeding
osteocondensation [Stocchero et al., 2016]), platform switching index that was >30%; (4) patients with <2 mm of keratinized gingiva,
(Atieh et al., 2010), immediate or early loading (Chen et al., 2019), or patients who required soft tissue grafting; (5) any cases in which a
and the intraoperative application of photobiomodulation (Bozkaya safety margin of at least 1 mm from the inferior alveolar nerve could
et al., 2021). However, despite their importance in terms of the mu- not be guaranteed; (6) patients with dental caries or periodontal dis-
cointegration of peri-­implant tissues, other aspects related to pros- ease; (7) pregnant or lactating women. In the case of patients who
thetic attachments have not been as widely studied. It has been required multiple dental replacements, implants could be placed
found that by following the “one abutment-­one time” protocol, that next to each other as long as they met the randomization criteria;
is to say, by placing the definitive abutment at the time of surgery, and (8) implants with a primary stability of lower than 55 ISQ.
and by choosing abutments that are more than 2 mm in height to
facilitate fibrointegration, it is possible to improve the stability of the
peri-­implant tissues and minimize MBL. However, very few studies 2.2 | Interventions
have actually considered the effect that the shape of abutments, in
terms of their horizontal diameter, has on MBL. Patients were divided into two parallel experimental arms, and nei-
The objective of this study was to analyze the impact of the ther control nor placebo groups were established given that neither
abutment width on early MBL through a randomized clinical trial in of the groups were considered superior. The arms were cylindrical
which conventional cylindrical abutments were compared with con- abutment and concave abutment. For this specific 4 mm implant, the
cave abutments placed in the same surgical procedure. manufacturer's instructions were followed for the drilling protocol.
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1040 PÉREZ-­SAYANS et al.

This means, drilling up to a 3.6 mm drill only the most crestal 3 mm of drilling was performed according to the manufacturer's instructions.
the implant bed for type I (dense) bone, up to a 3.2 mm drill in type II The implants were placed mechanically up to a maximum of 40 Ncm,
and III (medium) bone, and up to a 2.8 mm drill for bones type IV (soft). and the implantation process was finished manually using a surgical
torque wrench. It was determined that the implant was always to be
placed 4 mm under the future gingival margin, and if possible, 1 mm
2.2.1 | Study products below the residual alveolar crest.

Eighty Hexagonal Internal Connection Implants (IPX Model, Nueva

Galimplant) each with a diameter of 4 × 10 mm were placed in healed 2.2.3 | Abutment insertion
mature bone (more than 6 months post-­extraction), and 80 screw-­
retained abutments, 40 cylindrical (Straight™) esthetic antirotational According to the applicable randomization, as long as the bone and
abutments (Nueva Galimplant), and 40 concave (Slim™) antirota- gingival availability allowed for this, 3 mm abutments were used,
tional abutments (Nueva Galimplant), each of 2 or 3 mm in height therefore allowing 4 mm for the biological width. If it was not pos-
were used (Figure 1) sible to attain this measurement, lower abutments (2 mm) were used.
This implant model was manufactured in Ti-­IV, and it boasted All of the abutments were placed in a single surgical procedure for
a macroscopic design, which favors primary stability in any situa- implant insertion following the “one-­abutment-­one-­time” philoso-
tion. The implant model had an internal 11° conical connection and phy in order to avoid any changes in hard and soft peri-­implant tis-
a single prosthetic platform. Microscopically, it has a Nanoblastplus sues (Becker et al., 2012). The abutment was placed at a minimum
surface with an average roughness (Ra) of 1.7 μm and a composition of 25 Ncm, and if the primary stability of the implant allowed it, the
of 99.9% TiO2. The implant reference was IPX 4010//Hexagonal IC abutment was placed at 35 Ncm. A healing cap was inserted to pro-
post-­extraction implant Ø4 × 10 mm. tect the abutment until the final impression.

2.2.2 | Surgical procedures 2.2.4 | Definitive prosthesis

The implants were placed following the usual surgical technique for The impressions for the definitive prosthesis and its placement were
nonsubmerged implants with a mucoperiosteal flap. The implant bed taken 8 weeks after the surgical procedure had been performed. The

F I G U R E 1 Study design
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PÉREZ-­SAYANS et al. 1041

metal-­porcelain prosthesis was screwed to the definitive abutment of the measurements performed by the two examiners was evalu-
using a burnout cap and the torque used for the definitive prosthesis ated using the k-­statistic in order to determine the probing depth
was 20 N. and MBL, with values of 0.82 and 0.93 recorded, respectively,
therefore demonstrating a high degree of reliability in terms of the
measurements.
2.3 | Measurement and primary and
secondary objectives
2.4 | Sample size calculation
The main variables were (1) peri-­implant tissue stability, measured
as MBL using digital intraoral radiology (CS 7600, Carestream) at For the “a priori” calculation of the sample size, the following statis-
8 weeks preloading and 6 months post-­loading (8 months after im- tical criteria were established based on previous studies (Galindo-­
plantation); (2) primary and post-­prosthodontic stability of implants Moreno et al., 2015): an effect size (ES) on MBL of 0.5 mm, an alpha
evaluated by means of resonance frequency analysis (RFA) quanti- error of 0.05, and a statistical power of 90%. By assuming these cri-
fied as the ISQ (Ostell); and the secondary variables were (1) de- teria and applying the Student T contrast for independent samples,
mographic variables: age and sex; (2) habits: smoking and bruxism; it was determined that a sample containing 40 implants would be re-
(3) topographic variables: tooth position, premolar/molar, maxilla/ quired for each of the two groups, therefore meaning that a total of
mandible, and type of antagonist tooth; (4) periodontal clinical vari- 80 implants would be required, with an estimated loss ratio of 15%.
ables: (1) periodontal biotype/phenotype (thin or thick at the opera- The sample size was calculated using the G Power 3.1.5 programme.
tor's discretion, following Müller and Eger-­s recommendations) (10);
(2) bleeding index (Lindhe Index [LI-­s], which measures bleeding on
four of the surfaces of all teeth present × 100); (3) O'Leary plaque 2.5 | Randomization (random number generation,
index (four surfaces per tooth, number of total plaque surfaces/ allocation concealment, and implementation)
total surfaces × 100 of all of the teeth present through disclosure
with erythrosine); (4) overall average probing depth (six surfaces per As patients were recruited prior to the surgical procedure, implants
tooth, sum of the depth on all of the measured surfaces/number of were randomized by means of simple randomization by location for
measured surfaces); (5) vestibular gingival thickness (measured using the order of implant placement and by abutment type for each of
a periodontal probe after folding the flap); and (6) abutment type said locations, using an SPSS 24.0 macro (Figure 3).
(cylindrical or concave).
All of the periodontal measurements were taken using a ster-
ile oral mirror and a calibrated millimetre by millimetre periodontal 2.6 | Blinding
probe from the University of North Carolina (UNC 15; Hu Friedy).
The tissue stability evaluations, as well as the periodontal indexes, This was a randomized, double-­blind clinical trial, in which the pa-
were performed 8 weeks after the implantation procedure, and tients and the person analyzing the data were unaware of the group
6 months (8 months after implantation) after the prosthetic loading (type of abutment) which each subject had been assigned to.
procedure had taken place.
All of the radiological images were taken using the same intra-
buccal radiology device (X-­Mind AC Satelec, Acteon). This process 2.7 | Interim analysis
was performed by the same operator using an XCP type intraoral
X-­ray positioner p/4 (Bader). An independent data monitoring board reviewed the efficacy and
The images were captured using intraoral smart plates, and these safety data periodically. A formal interim analysis of the efficacy
images were visualized using digital software (Vistascan, Dürr). In of MBL was conducted once 50% of the anticipated number of
order to calculate MBL, a calibration calculation based on the known study subjects and 50% of the overall follow-­up time had been
diameter of the implant (4 mm) and/or the abutment height (2–­3 mm) accumulated. No trial correction was performed following these
was performed first for each implant. The position of the implant interim tests.
neck in relation to the most coronal portion of the peri-­implantary
bone crest was taken as a reference point for the implants that were
placed subcrestally. MBL was calculated as the difference between 2.8 | Statistical analysis
the bone position values measured in two periods in the mesial and
distal area of each implant (Figure 2). The analysis carried out used the implant as the main unit of
The measurements were taken by two independent observers study. The categorical variables were expressed as frequency
(FSN and MPS). The calibration was completed prior to the study and percentage, and the continuous variables were expressed
in the Oral Surgery Unit using 15 patients who underwent treat- as mean ± SD. The samples were checked for normality using the
ment in this unit but who were not part of the study. The reliability Kolmogorov Smirnov Test. The independent-­s ample t test was
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1042 PÉREZ-­SAYANS et al.

F I G U R E 2 Examples of cases from the study regarding the radiological evaluation of the MBL. (a) Baseline situation of two upper
implants with cylindrical (#24) and concave (#25) abutments. (b) Radiological bone level at 8 weeks. (c) Clinical aspect of the crowns from
the previous case at 6 months. (d) Graphical representation of the MBL calculation in a case with three lower implants (#34 cylindrical, #35
concave, #36 cylindrical). The blue line represents the baseline measurement at the neck of the implant and the red lines represent the gain
or loss in the mesial and distal sites. (e) Radiological baseline situation of the implants in case D. (f) Radiological bone level at 6 months.

used to compare the means for different dichotomous variables, and 15 women (60%). 38 (49.4%) had their implants placed using the
and the paired-­s ample t test was used when comparing intragroup cylindrical abutment, and the other 39 (50.6%) had their implants
bone loss. The anova one-­way test was used to compare the means placed using the concave abutment. The average age of the patients
of the variables from more than two categories. Pearson's correla- was 56.7 ± 10.9, with a range from 36.3 to 77.5 years. A summary of
tion coefficient was used to study bivariate correlations between all the variables of the study can be seen in Tables 1–­3.
the periodontal indices at different times. The statistical analysis
was performed using IBM SPSS 24.0 software (IBM Inc.). Mixed
linear regression models were constructed in order to determine 3.2 | Periodontal indices
the role of the abutment type and height on MBL. The effect of in-
dividual variations derived from the number of implants placed in In relation to the baseline periodontal indices, the bleeding index
each patient was balanced and weighted accordingly. To estimate was 16.9 ± 11.5%, the mean plaque index was 12.3 ± 5.2%, and the
both the fixed and random effects associated with a model, ver- overall mean probing depth was 3.9 ± 2.2 mm. The bleeding index at
sion 4.1.1 of the statistical software R was used. The significance 8 weeks was 8.4 ± 8.8%, the mean plaque index was 29.5 ± 25.4%,
level was established at p < .05. and the overall mean probing depth was 3.4 ± 1.2 mm. No statisti-
cally significant differences were recorded.

3 | R E S U LT S
3.3 | Primary stability
3.1 | Sample description
With regard to the RFA of the implants, the average was
Of the 80 initial implants, three were excluded from the study, two 69.1 ± 10.9 ISQ, with a range of 23–­82.3 ISQ and no differences were
because they suffered osseointegration failure and one due to a observed when taking the abutment type into account. The abut-
fracture of the concave abutment. The final sample consisted of 77 ments were bolted at an average of 71.3 ± 7 ISQ, with a range from
implants that were placed in 25 patients (after applying the exclusion 46–­85 ISQ. No differences were found in terms of the main clinical
criteria only two patients only had one single implant), 10 men (40%) variables, neither at the baseline nor at 8 weeks.
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PÉREZ-­SAYANS et al. 1043

F I G U R E 3 CONSORT 2010 flow diagram

3.4 | Baseline bone level when taking the abutment type into account, with this being
−0.5 ± 0.5 for the cylindrical abutment, and −0.2 ± 0.4 mm for the
Following the surgical protocol, the implants were placed subcre- concave abutment (p = .010). The MBL from loading at 6 months was
stally in order to ensure that there was sufficient room for the peri-­ statistically higher in the distal area, recorded as −0.1 ± 0.5 mm for
implant tissues, with an average of 0.9 ± 0.8 mm and a range from the cylindrical abutment and 0 ± 0.3 mm for the concave abutment
0.3 to 4.5 mm. In the mesial area, the implants were placed in a more (p = .028). No differences were found in the average measurements
subcrestal position, at 1 ± 0.8 mm, compared to their positioning in (p = .109).
the distal area, at 0.7 ± 0.9 mm (p = .002).

3.6 | Global MBL at 6 months (after loading)

3.5 | Mesial bone loss (MBL) at 8 weeks
(preloading) and at 6 months (after-­loading) The early global mesial bone loss at 6 months in relation to the base-
line location was −0.4 ± 0.7 mm, with no differences regarding the
Mesial bone loss at 8 weeks was 0.4 ± 0.5 mm and distal bone loss distal bone loss of −0.3 ± 0.6 mm. The average bone loss in this pe-
was −0.3 ± 0.5 mm, and no statistically significant differences were riod was −0.4 ± 0.6 mm. In this case, it was observed that the early
recorded (p = .946). The average MBL for the preloading period was global MBL of −0.6 ± 0.7 mm in the cylindrical abutment group was
−0.3 ± 0.5 mm. Statistically significant differences were recorded significantly higher than in the group in which the concave abutment
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1044 PÉREZ-­SAYANS et al.

TA B L E 1 Descriptive data of categorical variables by the type of was used, in which it was −0.4 ± 0.6 mm (p = .030). The mesial
abutment
(p = .029) and distal (p = .004) MBLs were also higher in the cylindri-
Cylindrical, Concave, cal abutment group.
Variable n (%) n (%) p value

Sex
Male 13 (48.1) 14 (51.9) .533 3.7 | Adverse events
Female 25 (50) 25 (50)
Implant failure occurred in two cases (2.6%) and abutment fracture
Tooth
occurred in one case (0.8%). No other adverse events were recorded
Premolar 10 (35.7) 18 (64.3) .058
during the follow-­up period, that is, to say that no evidence of mu-
Molar 28 (57.1) 21 (42.9)
cositis, loosening/mobility of the crown, or chipping of the ceramic
Arch
restorations was recorded.
Maxilla 9 (47.4) 10 (52.6) .526
Mandible 29 (50) 29 (50)
Smoking 3.8 | Regression analysis
>5 cig/day 1 (50) 1 (50) .998
<5 cig/day 8 (50) 8 (50) In the coefficients that were associated with the temporal evolu-
No 29 (49.2) 30 (50.8) tion (at 8 weeks and at 6 months), it was observed that time had a
Periodontal biotype negative impact resulting in a decrease in the average bone level,

Thin 5 (50) 5 (50) .615 although this effect was much more pronounced at 8 weeks than
at 6 months. Fixed at the initial instant, the estimated intercept
Thick 33 (49.3) 34 (50.7)
ES was negative for the cylindrical abutment (ES = −1.3730, CI:
Abutment height
−2.5919 to −0.1327; t-­value = −2.4893; p = .0139), implying a loss
2 mm 33 (50.8) 32 (49.2) .396
of mean bone level, while for the concave abutment it was positive
3 mm 5 (41.7) 7 (58.3)
(ES = 2.8231; CI: 1.4379 to 4.2083; t-­value = 4.0957; p = .0002),
Occlusion
which implied an increase in the average bone level. For the cy-
No occlusion 6 (60) 4 (40) .746 lindrical abutment, it was observed that the coefficient associated
Natural 21 (46.7) 24 (53.3) with the abutment height was positive (ES = 1.0633; CI: 0.5494
Ceramic 11 (50) 11 (50) to 1.5772; t-­value = 4.1579; p = .0001), therefore implying that
Parafunctional habits increasing the height of the abutment produced a higher average
Yes 7 (50) 7 (50) .595 bone level. To the contrary, a negative coefficient was obtained
No 31 (49.2) 32 (50.8) for the concave abutment, which implied that by increasing the
Bone type height of the abutment there was a reduction in the mean bone

Type I 5 (50) 5 (50) .615

level (ES = −1.3340; CI: −1.9685 to −0.6994; t-­value = −4.2246;
p = .0001). All of these results were verified separately for mesial
Type II, III or IV 33 (49.3) 4 (50.7)
and distal bone level.
Implant insertion torque
<15 N 3 (75) 1 (25) .573
15–­4 0 N 15 (48.4) 16 (51.6)
4 | DISCUSSION
>40 N 20 (47.6) 22 (52.4)
Abutment insertion torque Early bone loss has been associated with longer term MBL (Galindo-­
<15 N 4 (66.7) 2 (33.3) .673 Moreno et al., 2015). For this reason, minimizing early MBL should
15–­4 0 N 27 (48.2) 29 (51.8) be one of the objectives of all professionals who perform dental im-
>40 N 7 (46.7) 8 (53.3) plant treatments given that this facilitates peri-­implant health main-
Mesial contact tenance. For a large part of dental implant history, the mechanisms
No contact 3 (50) 3 (50) .827 behind early MBL have been barely understood. However, recent re-

Tooth 25 (47.2) 28 (52.8) search has thrown light upon this topic, and clinicians are now aware
of several local conditions among patients, implant system design
Implant 10 (55.6) 8 (44.4)
characteristics, and technical (surgical/prosthetic) aspects that have
Distal contact
an impact on early MBL (Oh et al., 2002) loss.
No contact 11 (45.8) 13 (54.2) .569
A conical implant connection with platform switching seems to
Tooth 20 (55.6) 16 (44.4)
significantly reduce peri-­implant MBL loss (Caricasulo et al., 2018).
Implant 7 (41.2) 10 (58.8)
To the contrary, thin soft tissues have been associated with increased
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PÉREZ-­SAYANS et al. 1045

TA B L E 2 Descriptive data of quantitative variables by type of it is no longer disconnected are other factors that seem to have
abutment an influence on MBL. Borges et al. (2021) compared this factor

Cylindrical Concave in a randomized prospective clinical trial with a sample size of 59

Variable mean (±SD) mean (±SD) p value implants in 29 patients. A significantly lower MBL was detected

Age 56.12 (10.77) 57.26 (1.09) .649 when the abutment was installed immediately after implant place-
ment (1 stage) than when the abutment was installed 2 months
Baseline bone level
after the implant had been placed (2 stages). One of the common
Mesial 1.18 (0.99) 0.92 (0.65) .186
elements among the factors that significantly influence MBL is
Distal 0.88 (1.04) 0.55 (0.60) .096
that the more the peri-­implant soft tissues are respected (by al-
Average 1.03 (0.97) 0.74 (0.55) .111
lowing them adequate space and reducing disturbances), the more
Bone level at 8 weeks preloading
the MBL is reduced. This coincides with the hypothesis of the belt-­
Mesial 0.68 (0.77) 0.71 (0.59) .841
like seal that peri-­implant connective tissues should ideally form
Distal 0.36 (0.73) 0.40 (0.53) .814 around the implant (Rodríguez et al., 2016).
Average 0.52 (0.68) 0.55 (0.49) .808 With this in mind, it makes sense that in the present study con-
Bone level at 6 months post-­loading cave implant abutments resulted in a significantly lower early MBL
Mesial 0.49 (0.51) 0.71 (0.61) .083 than conventional cylindrical abutments. As far as we know, only
Distal 0.31 (0.61) 0.40 (0.55) .526 three randomized clinical trials have studied the effect of the macro
Average 0.40 (0.46) 0.56 (0.51) .166 design of the prosthetic abutment on MBL. The first two studies
MBL at 8 weeks preloading (Patil et al., 2014; Weinländer et al., 2011) compared a commer-
Mesial −0.50 (0.60) −0.21 (0.41) .017 cially available abutment to a cylindrical abutment (only cylindrical

Distal −0.51 (0.56) −0.15 (0.36) .001 in the apical portion of the abutment). Despite the fact that this

Average −0.5 (0.51) −0.18 (0.35) .02

modification allowed more space for the soft tissues, it did not have
a statistically significant effect on MBL. In the other clinical trial,
MBL 6 months post-­loading
two prosthetic abutments were designed specifically using CAD-­
Mesial −0.18 (0.55) 0.007 (0.43) .89
CAM, one of which was concave and the other convex (Koutouzis
Distal −0.52 (0.47) −0.002 (0.3) .02
et al., 2019). Although the main aim of the study was to determine
Average −0.11 (0.46) 0.002 (0.32) .1
any changes in the peri-­implant marginal mucosa, MBL was also de-
Global MBL
termined around those customized abutments. From the moment
Mesial −0.68 (0.81) −0.2 (0.44) .002
the abutments were placed to the first year, a loss of −0.66 ± 0.46 mm
Distal −0.56 (0.76) −0.15 (0.31) .003 was registered for the convex abutment and −0.24 ± 0.25 mm for the
Average −0.62 (0.72) −0.17 (0.32) .001 concave abutment (p = .007), respectively. These results were sim-
The significance for bold valus is 〈 .05. ilar to those of the present study in which significant differences
were observed between the two designs. This might be explained
early MBL loss (Canullo et al., 2017). Linkevicius et al. (2009) demon- by the narrowing along the entire prosthetic abutment, which leaves
strated that 2 mm of soft tissue thickness was the minimum thickness more space for soft tissues than other previously studied modified
required to avoid peri-­implant MBL; however, subcrestal implant abutments.
placement seems to reduce early bone loss especially around im- There are some indirectly related studies that address the shape
plants with thin mucosa (Linkevicius et al., 2020). of the transmucosal component and support the findings of this
In a retrospective study comprised of 308 dental implants, present study. Souza et al. (2018) evaluated the effect of the shape
Galindo-­Moreno et al. (2014) found that abutment height could of the healing abutment in a preclinical study in which sixty-­t wo-­
influence peri-­implant MBL. MBL was significantly superior for <2 piece dental implants were placed in four beagle dogs. Two differ-
than for ≥2 mm prosthetic abutment heights. Due to the retrospec- ent abutment designs were analyzed; one with a wide emergence
tive nature of their study, these results might have been confounded profile of 45°, and the other with a narrow emergence profile of 15°.
by the thickness of the soft tissue. However, several randomized In the micro-­C T analysis, MBL was higher in the case of the wide
clinical trials have since confirmed that abutment height has a sig- abutments (1.1 ± 0.66 mm) than in the case of the narrow abutments
nificant influence on early bone loss, irrespective of the thickness (0.12 ± 0.21 mm). In the histologic analysis, the peri-­implant histologic
of the soft tissue, therefore meaning that abutments with a height width was comparable, but there were statistically significant differ-
of 1 mm should be avoided (Blanco et al., 2018; Borges et al., 2021; ences in terms of MBL. Similarly, Yi et al. (2020) observed that there
Pico et al., 2019). was a significant correlation between the prosthetic emergence pro-
It has been demonstrated that preventing abutment discon- file and MBL in a clinical study. A total of 349 implants were retro-
nections and reconnections (one abutment—­o ne time concept) spectively analyzed, and the results showed that if the emergence
benefits peri-­implant bone changes (Degidi et al., 2011, 2014). profile was ≥30°, the prevalence of peri-­implantitis was greater.
Moreover, the timing of the abutment insertion and the fact that Majzoub et al. (2021) also analyzed this aspect retrospectively, and
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1046 PÉREZ-­SAYANS et al.

TA B L E 3 Linear mixed regression model for the marginal bone loss (MBL)

Value Std. error t-­value p-­value 95% CI

Fixed effects: distal MBL

Intercept straight group −1.3623 0.6224 −2.1888 0.0301 (−2.5919, −0.1327)
Time 8 weeks −0.3312 0.0586 −5.6552 0.0000 (−2.5919, −0.1327)
Time 6 months −0.3584 0.0586 −6.1209 0.0000 (−0.4741, −0.2427)
Slim group 2.7993 0.8111 3.4513 0.0012 (1.1694, 4.4292)
Abutment height 0.9872 0.2882 3.4248 0.0013 (0.4079, 1.5665)
Slim group interaction × abutment height −1.3369 0.3716 −3.5973 0.0007 (−2.0838, −0.5901)
Fixed effects: mesial MBL
Intercept −1.4896 0.6062 −2.4574 0.0151 (−2.6873, −0.2920)
Time 8 weeks −0.3519 0.0665 −5.2952 0.0000 (−0.4833, −0.2206)
Time 6 months −0.4402 0.0665 −6.6239 0.0000 (−0.5716, −0.3089)
Slim group 2.8566 0.7127 4.0083 0.0002 (1.4244, 4.2888)
Abutment height 1.1943 0.2812 4.2474 0.0001 (0.6292, 1.7593)
Slim group interaction × abutment height −1.3384 0.3263 −4.1013 0.0002 (−1.9942, −0.6826)
Fixed effects: average MBL
Intercept −1.3730 0.5515 −2.4893 0.0139 (−2.4627, −0.2833)
Time 8 weeks −0.3415 0.0567 −6.0272 0.0000 (−0.4535, −0.2296)
Time 6 months −0.3993 0.0567 −7.0470 0.0000 (−0.5113, −0.2874)
Slim group 2.8231 0.6893 4.0957 0.0002 (1.4379, 4.2083)
Abutment height 1.0633 0.2557 4.1579 0.0001 (0.5494, 1.5772)
Slim group interaction × abutment height −1.3340 0.3158 −4.2246 0.0001 (−1.9685, −0.6994)

Abbreviations: CI, confidence interval; NS, not significant; Std, standard.

their results showed higher MBL in prosthetic emergence profiles 5 | CO N C LU S I O N

that were >30° than in those that were ≤30° (2.33 ± 1.20 mm and
0.59 ± 0.71 mm, respectively). In a retrospective study, Katafuchi The concave abutments present significantly less early MBL at
et al. (2018) divided a sample of 168 implants into tissue-­level and 6 months post-­loading than classical cylindrical abutments. In rela-
bone-­level groups. The prevalence of peri-­implantitis was signifi- tion to the height of the abutment, specific studies must be devel-
cantly greater in the bone-­level group when the emergence profile oped in order to evaluate its possible protective effects on MBL.
was more than 30° than when the angle was ≤30° (31.3% versus These results must be taken into consideration when looking at early
15.1%, p = .04). MBL and, likewise, they must be confirmed by a study with a longer
Bernabeu-­Mira et al. (2021) analyzed the influence of the abut- follow-­up period.
ment characteristics on MBL changes in immediate loading implant-­
supported full-­arch fixed dental prostheses in a retrospective study AU T H O R C O N T R I B U T I O N S
with a 1-­year follow-­up. Considering only 3-­mm high abutments, sig- Mario Pérez Sayáns: Conceptualization (equal); data curation
nificantly higher MBL was detected at 12 months in angulated abut- (equal); formal analysis (equal); funding acquisition (equal); investi-
ments than in axial ones. Moreover, within angulated abutments, gation (equal); methodology (equal); project administration (equal);
higher MBL was recorded in mesial than in distal sites. Both of these software (equal); supervision (equal); validation (equal); visualization
findings suggest that it is not height but shape (and thus the space (equal); writing –­ original draft (equal); writing –­ review and editing
allowed for peri-­implant soft tissues) that influence MBL. (equal). Pablo Castelo-­Baz: Conceptualization (equal); data curation
The main limitation of this study was the assessment time for the (equal); investigation (equal); writing –­ original draft (equal); writ-
bone levels and the associated MBL, which was limited to 6 months. ing –­ review and editing (equal). David Peñarrocha Oltra: Formal
Therefore, it is worth noting that these results only make reference analysis (equal); methodology (equal); writing –­ original draft
to early MBL. Another limitation was caused by the exclusion crite- (equal); writing –­ review and editing (equal). Flavio Seijas Naya:
ria, since the results for the anterior teeth in the esthetic sector were Data curation (equal); formal analysis (equal); investigation (equal);
not verified in this study. Likewise, there are other possible factors methodology (equal); writing –­ original draft (equal); writing –­ re-
related to MBL that may not have been determined in this study, view and editing (equal). Mercedes Conde Amboage: Investigation
such as the shape of the prosthesis and its emergence profile. (equal); methodology (equal); software (equal); writing –­ original
 |

16000501, 2022, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/clr.13985 by Universitat Internacional De Catalunya, Wiley Online Library on [16/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PÉREZ-­SAYANS et al. 1047

draft (equal); writing –­ review and editing (equal). Manuel Somoza-­ Blanco, J., Pico, A., Caneiro, L., Nóvoa, L., Batalla, P., & Martín-­L ancharro,
Martin: Conceptualization (equal); project administration (equal); P. (2018). Effect of abutment height on interproximal implant bone
level in the early healing: A randomized clinical trial. Clinical Oral
supervision (equal); validation (equal); writing –­original draft (equal);
Implants Research, 29, 108–­117.
writing –­review and editing (equal). Borges, T., Montero, J., Leitão, B., Pereira, M., & Galindo-­Moreno, P.
(2021). Periimplant bone changes in different abutment heights and
AC K N OW L E D G M E N T S insertion timing in posterior mandibular areas: Three-­year results
from a randomized prospective clinical trial. Clinical Oral Implants
We would like to thank to Doctors: Gisela Camolesi, José Martín
Research, 32, 203–­211.
Cruces, Benjamín Martín Biedma, Pilar Gándara Vila, Dolores Bozkaya, S., Uraz, A., Guler, B., Kahraman, S. A., & Turhan Bal, B. (2021).
Reboiras López, Cintia M Chamorro Petronacci, Catalina Barba The stability of implants and microbiological effects following pho-
Montero, Samuel Rodríguez Zorrilla, Eva Otero Rey, Andrés Blanco tobiomodulation therapy with one-­stage placement: A randomized,
controlled, single-­blinded, and split-­mouth clinical study. Clinical
Carrión, and Abel García García for their valuable participation in
Implant Dentistry and Related Research, 23, 329–­3 40.
this clinical trial. Canullo, L., Camacho-­Alonso, F., Tallarico, M., Meloni, S. M., Xhanari, E.,
& Penarrocha-­Oltra, D. (2017). Mucosa thickness and peri-­implant
F U N D I N G I N FO R M AT I O N crestal bone stability: A clinical and histologic prospective cohort
trial. The International Journal of Oral & Maxillofacial Implants, 32,
The study was supported by Nueva Galimplant and the University
675–­681.
of Santiago de Compostela (Ref. USC-­2019-­CE178). The funding Caricasulo, R., Malchiodi, L., Ghensi, P., Fantozzi, G., & Cucchi, A. (2018).
source played no role in the design of this study, the data collec- The influence of implant-­abutment connection to peri-­implant
tion and analyzes, the decision to publish, and the preparation of the bone loss: A systematic review and meta-­analysis. Clinical Implant
Dentistry and Related Research, 20, 653–­664.
manuscript. M. Conde-­Amboage acknowledge the financial support
Chambrone, L., Wang, H.-­L ., & Romanos, G. E. (2018). Antimicrobial
received through grant PID2020-­116587GB-­I 00 funded by MCIN/
photodynamic therapy for the treatment of periodontitis and peri-­
AEI 10.13039/501100011033 and the European Union. implantitis: An American Academy of Periodontology best evi-
dence review. Journal of Periodontology, 89, 783–­8 03.
C O N FL I C T O F I N T E R E S T Chen, J., Cai, M., Yang, J., Aldhohrah, T., & Wang, Y. (2019). Immediate ver-
sus early or conventional loading dental implants with fixed prosthe-
Nothing to declare.
ses: A systematic review and meta-­analysis of randomized controlled
clinical trials. The Journal of Prosthetic Dentistry, 122, 516–­536.
DATA AVA I L A B I L I T Y S TAT E M E N T Degidi, M., Nardi, D., Daprile, G., & Piattelli, A. (2014). Nonremoval of im-
Data available on request from the authors mediate abutments in cases involving subcrestally placed postex-
tractive tapered single implants: A randomized controlled clinical
study. Clinical Implant Dentistry and Related Research, 16, 794–­8 05.
ORCID Degidi, M., Nardi, D., & Piattelli, A. (2011). One abutment at one time:
Mario Pérez-­Sayans https://orcid.org/0000-0003-2196-9868 Non-­removal of an immediate abutment and its effect on bone
Pablo Castelo-­Baz https://orcid.org/0000-0003-3031-5532 healing around subcrestal tapered implants. Clinical Oral Implants
Research, 22, 1303–­1307.
David Penarrocha-­Oltra https://orcid.
Galindo-­Moreno, P., León-­C ano, A., Ortega-­Oller, I., Monje, A., OValle,
org/0000-0002-6670-9886 F., & Catena, A. (2015). Marginal bone loss as success criterion in
Flavio Seijas-­Naya https://orcid.org/0000-0003-4094-0411 implant dentistry: Beyond 2 mm. Clinical Oral Implants Research, 26,
Mercedes Conde-­Amboage https://orcid. e28–­e34.
Galindo-­Moreno, P., León-­C ano, A., Ortega-­Oller, I., Monje, A., Suárez,
org/0000-0003-0306-8142
F., ÓValle, F., Spinato, S., & Catena, A. (2014). Prosthetic abutment
José M. Somoza-­Martín https://orcid.org/0000-0001-9386-784X height is a key factor in peri-­implant marginal bone loss. Journal of
Dental Research, 93, 80S–­85S.
REFERENCES Katafuchi, M., Weinstein, B. F., Leroux, B. G., Chen, Y.-­W., & Daubert,
D. M. (2018). Restoration contour is a risk indicator for peri-­
Atieh, M. A., Ibrahim, H. M., & Atieh, A. H. (2010). Platform switching for
implantitis: A cross-­sectional radiographic analysis. Journal of
marginal bone preservation around dental implants: A systematic
Clinical Periodontology, 45, 225–­232.
review and meta-­analysis. Journal of Periodontology, 81, 1350–­1366.
Koutouzis, T., Adeinat, B., & Ali, A. (2019). The influence of abutment
Barootchi, S., & Wang, H.-­L . (2021). Peri-­implant diseases: Current under-
macro-­design on clinical and radiographic peri-­implant tissue
standing and management. International Journal of Oral Implantology
changes for guided, placed, and restored implants: A 1-­year ran-
(Berlin, Germany), 14, 263–­282.
domized controlled trial. Clinical Oral Implants Research, 30,
Becker, K., Mihatovic, I., Golubovic, V., & Schwarz, F. (2012). Impact of
882–­891.
abutment material and dis−/re-­connection on soft and hard tissue
Linkevicius, T., Apse, P., Grybauskas, S., & Puisys, A. (2009). Reaction of
changes at implants with platform-­switching. Journal of Clinical
crestal bone around implants depending on mucosal tissue thick-
Periodontology, 39, 774–­780.
ness. A 1-­year prospective clinical study. Stomatologija, 11, 83–­91.
Bernabeu-­Mira, J. C., Soto-­Peñaloza, D., Peñarrocha-­Diago, M., &
Linkevicius, T., Puisys, A., Linkevicius, R., Alkimavicius, J., Gineviciute,
Peñarrocha-­Oltra, D. (2021). Influence of abutment characteristics
E., & Linkeviciene, L. (2020). The influence of submerged healing
on marginal bone level changes in immediate loading implant-sup-
abutment or subcrestal implant placement on soft tissue thickness
ported full-­arch fixed dental prostheses: A retrospective case se-
and crestal bone stability. A 2-­year randomized clinical trial. Clinical
ries study with 1-­year follow-­up. Frontiers of Oral and Maxillofacial
Implant Dentistry and Related Research, 22, 497–­506.
Medicine, 3, 34. https://doi.org/10.21037/​fomm-­21-­6 4
 |

16000501, 2022, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/clr.13985 by Universitat Internacional De Catalunya, Wiley Online Library on [16/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1048 PÉREZ-­SAYANS et al.

Majzoub, J., Chen, Z., Saleh, I., Askar, H., & Wang, H.-­L . (2021). Influence Peri-­implantitis: Summary and consensus statements of group 3.
of restorative design on the progression of peri-­implant bone loss: The 6th EAO consensus conference. Clinical Oral Implants Research,
A retrospective study. Journal of Periodontology, 92, 536–­546. 32(Suppl 21), 245–­253.
Mattheos, N., Janda, M., Acharya, A., Pekarski, S., & Larsson, C. (2021). Souza, A. B., Alshihri, A., Kämmerer, P. W., Araújo, M. G., & Gallucci, G. O.
Impact of design elements of the implant supracrestal complex (ISC) (2018). Histological and micro-­C T analysis of peri-­implant soft and
on the risk of peri-­implant mucositis and peri-­implantitis: A critical hard tissue healing on implants with different healing abutments
review. Clinical Oral Implants Research, 32(Suppl 21), 181–­202. configurations. Clinical Oral Implants Research, 29, 1007–­1015.
Mattheos, N., Vergoullis, I., Janda, M., & Miseli, A. (2021). The implant Stocchero, M., Toia, M., Cecchinato, D., Becktor, J. P., Coelho, P. G., &
Supracrestal complex and its significance for long-­term successful Jimbo, R. (2016). Biomechanical, biologic, and clinical outcomes of
clinical outcomes. The International Journal of Prosthodontics, 34, undersized implant surgical preparation: A systematic review. The
88–­100. International Journal of Oral & Maxillofacial Implants, 31, 1247–­1263.
Oh, T.-­J., Yoon, J., Misch, C. E., & Wang, H.-­L . (2002). The causes of early Weinländer, M., Lekovic, V., Spadijer-­Gostovic, S., Milicic, B.,
implant bone loss: Myth or science? Journal of Periodontology, 73, Wegscheider, W. A., & Piehslinger, E. (2011). Soft tissue develop-
322–­333. ment around abutments with a circular macro-­groove in healed
Patil, R. C., den Hartog, L., van Heereveld, C., Jagdale, A., Dilbaghi, A., sites of partially edentulous posterior maxillae and mandibles: A
& Cune, M. S. (2014). Comparison of two different abutment de- clinical pilot study. Clinical Oral Implants Research, 22, 743–­752.
signs on marginal bone loss and soft tissue development. The Yi, Y., Koo, K.-­T., Schwarz, F., Ben Amara, H., & Heo, S.-­J. (2020).
International Journal of Oral & Maxillofacial Implants, 29, 675–­681. Association of prosthetic features and peri-­implantitis: A cross-­
Pico, A., Martín-­Lancharro, P., Caneiro, L., Nóvoa, L., Batalla, P., & Blanco, sectional study. Journal of Clinical Periodontology, 47, 392–­4 03.
J. (2019). Influence of abutment height and implant depth position on
interproximal peri-­implant bone in sites with thin mucosa: A 1-­year
randomized clinical trial. Clinical Oral Implants Research, 30, 595–­602.
How to cite this article: Pérez-­Sayans, M., Castelo-­Baz, P.,
Rodríguez, X., Navajas, A., Vela, X., Fortuño, A., Jimenez, J., & Nevins,
M. (2016). Arrangement of peri-­implant connective tissue fibers
Penarrocha-­Oltra, D., Seijas-­Naya, F., Conde-­Amboage, M., &
around platform-­switching implants with conical abutments and Somoza Martín, J. M. (2022). Impact of abutment geometry
its relationship to the underlying bone: A human histologic study. on early implant marginal bone loss. A double-blind,
The International Journal of Periodontics & Restorative Dentistry, 36, randomized, 6-month clinical trial. Clinical Oral Implants
533–­540.
Research, 33, 1038–­1048. https://doi.org/10.1111/clr.13985
Schwarz, F., Alcoforado, G., Guerrero, A., Jönsson, D., Klinge, B., Lang, N.,
Mattheos, N., Mertens, B., Pitta, J., Ramanauskaite, A., Sayardoust,
S., Sanz-­Martin, I., Stavropoulos, A., & Heitz-­Mayfield, L. (2021).