Received: 24 October 2022 Revised: 20 December 2022 Accepted: 9 January 2023

DOI: 10.1111/cid.13183

REVIEW

Implant prosthodontic design as a predisposing or precipitating

factor for peri-implant disease: A review

Adam Hamilton BDSc, DCD, FRACDS, FAANZP 1,2 |

Armand Putra BDSc, MSD, FACP 3,4 | Pranai Nakapaksin DDS, MSD, FRCD(c), FACP 5 |
Pongrapee Kamolroongwarakul DDS, MSc 6,7 | German O. Gallucci DMD, PhD 8

1
Division of Oral Restorative and
Rehabilitative Sciences, University of Western Abstract
Australia, Perth, Western Australia, Australia
Over the past decade, emerging evidence indicates a strong relationship between
2
Division of Regenerative and Implant
Sciences, Department of Restorative Dentistry prosthetic design and peri-implant tissue health. The objective of this narrative
and Biomaterials Sciences, Harvard School of review was to evaluate the evidence for the corresponding implant prosthodontic
Dental Medicine, Boston, Massachusetts, USA
3
design factors on the risk to peri-implant tissue health. One of the most important
Private Practice, Perth, Western Australia,
Australia factors to achieve an acceptable implant restorative design is the ideal implant posi-
4
Department of Graduate Prosthodontic, tion. Malpositioned implants often result in a restorative emergence profile at the
University of Washington, Seattle,
Washington, USA
implant-abutment junction that can restrict the access for patients to perform ade-
5
Department of Advanced General Dentistry, quate oral hygiene. Inadequate cleansability and poor oral hygiene has been reported
Faculty of Dentistry, Mahidol University, as a precipitating factors to induce the peri-implant mucositis and peri-implantitis
Bangkok, Thailand
6
and are influenced by restorative contours. The implant–abutment connection,
Dental Center, Private Hospital, Bangkok,
Thailand restorative material selection and restoration design are also reported in the litera-
7
Department of Graduate Prosthodontic, ture as having the potential to influence peri-implant sort tissue health.
Mahidol University, Bangkok, Thailand
8
Department of Restorative Dentistry and KEYWORDS
Biomaterials Sciences, Harvard School of
abutments, fixed implant prosthesis, implant design, peri-implantitis
Dental Medicine, Boston, Massachusetts, USA

Correspondence What is known

Adam Hamilton, BDSc, DCD, FRACDS,
Peri-implant diseases are characterized by inflammation in the peri-implant connective tissue which
Discipline Lead and Graduate Program
Convenor in Prosthodontics, Division of Oral
commences with the implant supra-crestal tissue complex. Key elements of prosthesis design, includ-
Restorative and Rehabilitative Sciences, ing implant position, implant-abutment connection, restorative material selection, restoration design,
University of Western Australia Dental School, and cleansability all play an integral role in the biology within this transition zone.
M512, 17 Monash Avenue, Nedlands,
Western Australia 6009, Australia.
Email: [email protected] What this study adds
This study summarizes the current literature on prosthesis design factors that may influence
peri-implant soft tissue health.

1 | I N T RO DU CT I O N attention in the dental literature.1,2 Healthy peri-implant tissues are a

requirement for long-term success of dental implants, with peri-
The prosthodontic design of implant prosthesis has been long con- implantitis being the most common reason for late implant failure.3 It
nected to long-term peri-implant health and has received much is commonly accepted that peri-implant diseases are mostly a chronic

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Clinical Implant Dentistry and Related Research published by Wiley Periodicals LLC.

710 wileyonlinelibrary.com/journal/cid Clin Implant Dent Relat Res. 2023;25:710–722.

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HAMILTON ET AL. 711

inflammatory condition associated with microbial challenge presented

by the peri-implant biofilm.4
Prosthesis design has been identified as one of the local predis-
posing factors for the initiation and progression of peri-implant dis-
eases.5 As plaque accumulation has been attributed as one of the
leading causes of peri-implant diseases, attention has been given to
the prosthesis features that can minimize the establishment of dental
biofilm and facilitate its removal. Implant maintenance protocols,
through both professional maintenance and adequate home care, are
critical for minimizing the risk of biological complications.6
F I G U R E 1 The relationship of implant depth to the prosthetic
Recently, Katafuchi has shown a link between the restorative free gingival margin and contour of restoration is illustrated with
contour and risk of peri-implantitis.7 His study assessed the preva- (A) being the ideal depth, (D) being shallow and the need for ridge lap
lence of bone loss with the degree of restorative emergence angle. contour
While restorative contours have been critically evaluated in the litera-
ture for single implant restorations, limited evidence is present evalu-
ating the contours of restorations replacing multiple missing teeth, and emergence of the final restoration. With this understanding, pros-
particularly when compensating for significant loss of alveolar con- thetic driven implant placement should also consider the emergence
tours with pink prosthetics.8 of the restoration from implant platform to the proposed mucosal
Access for adequate cleansability of the restoration should be margin of the final restoration (critical contour).
kept in mind during the planning stage of implant therapy. Failure to
plan the definitive restoration contours during the initial stage of ther-
apy, may compromise restorative outcome and affect the mainte- 2.1 | Apico-coronal
nance of final restoration. The creation of cleansable and biologically
favorable restoration contours needs to be balanced with the func- The depth of the implant is one of the most critical dimensional posi-
tional requirements of the prosthesis in terms of mechanical strength, tions of an implant. This should ideally be assessed in relation to the
phonetic and aesthetic requirements. This should also be based on proposed mucosal margin and zenith of the planned restoration to
the individual patient's manual dexterity and ability to perform ade- predictably provide a harmonious soft tissue contours in relation to
quate oral hygiene measures. the adjacent teeth.12 This is then modified by the alveolar crest posi-
This narrative review aims to summarize the relevant literature on tion and implant design.13,14
key prosthodontic design elements that have been linked with peri- Shallow placement will reduce the subcritical zone of the restora-
implant disease and bone loss. tion which will sharpen the angle of the contour even to the extent of
ridge lap (Figure 1).7 Furthermore, shallow placement limits the pros-
thetic option considerably and reduces the ability for the restoration
2 | IMPLANT POSITION to emerge from the implant platform to the critical contour. Con-
versely, Derks has shown implants that have been placed too deep to
As the coronal contours of the final restoration is pre-determined by have higher prevalence of peri-implantitis.15 Although it is not well
aesthetic and function, the implant position is the determining factor described in the literature, this may be due to the difficulty of restor-
for the restorative contour in the transition zone.9 With final restora- ing overly deep implants.
tion in mind, the position of the implant can be divided into four dif- There has been considerable literature that supports a range of
ferent planes: apico-coronal, bucco-lingual, mesio-distal, and axial implant depths from 2 to 4 mm.16–20 Authors who have described
inclination. Violation of each plane will affect the final contour of the placement of implant to be 2 mm deep measure the proposed implant
restoration. Furthermore, this determines if pre-prosthetic surgery depth from the cemento-enamel junction (CEJ) of the adjacent teeth,
such as grafting, or resection is required to achieve ideal restorative which may affect the predictability given the variability of CEJ posi-
contours. Understanding the relationship of both tooth position and tion in relation to the gingival margin.21 Linkevicius has also highlights
implant position is even more critical in full arch implant therapy. As that 3 mm of tissue thickness is critical to maintain tissue stability.22
the prosthesis increases in size to replace more teeth, the importance He has described 1 mm subcrestal should tissue thickness is 2 mm or
of restorative contours is further highlighted. Poor contours will pro- should tissue thickness is insufficient, soft tissue augmentation is
mote plaque retention and develop into food trap therefore increases needed. However, implants placed excessively deep also pose a risk
the chance to compromise the peri-implant health. for the development and resolution of peri-implant disease, and are
Su and colleagues was the first to describe critical and subcritical associated with increased probing depths.23
contour, and Gomez-Meda and colleagues has also described different Overall the literature supports an ideal bone level implant depth
restorative zones with the aesthetic biologic contour concept.10,11 of 3–4 mm from the proposed mucosal margin as the reference
Both concepts describe the link of the implant position and the shape position.
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712 HAMILTON ET AL.

2.2 | Bucco-lingual 2.4 | Bucco-lingual Inclination

The bucco-lingual position of the implant should fit within the con- The bucco-lingual inclination of an implant not only has a direct impact on
fines of the planned prosthetic tooth replacement and material the prosthetic options for restoring the implant, but also affects the peri-
thickness requirements, whilst providing sufficient circumferential implant soft tissue health and stability. As illustrated in Figure 3, the angu-
bone and soft tissue to maintain peri-implant tissue health. Ideally, lation of the implant will affect the position of the screw channel and abil-
the bucco-lingual position of the implant shoulder should be located ity to provide retrievable screw retained restorations.32 The viability of
1.5–2 mm palatally to the point of emergence on the buccal aspect screw retained solution has increased with the availability of angulated
of the future implant crown.12 Implants which are positioned more screw channel solutions.33 However, should screw retained restoration
buccally leads to an increased risk of thin buccal bone, soft tissue not be possible, cement retained restoration is the second restorative
recession and implant exposure which will compromise aesthetic option.28,34–36 Excessive buccal inclination of an implant is often associ-
24–26
outcomes and peri-implant tissue health. Buccal placement of ated with buccal malpositioning and can lead to buccal tissue defects as
an implant also leads to compromised prosthetic thickness in the shown in Figure 4, where the only viable treatment option is explantation.
area and may impede the development of an ideal emergence profile Implant placement taking into account of these positions will
(Figure 2). Implants placed too far palatally will result in an exagger- allow ideal restorative contours which will facilitate long-term soft tis-
ated palatal contour of the prosthesis with potential for functional sue stability and peri-implant health.
and phonetic impairment. Where an ideal three-dimensional implant
placement is compromised due to a deficiency in buccal bone thick-
ness, hard and soft tissue augmentation should be considered. 3 | IMPLANT DESIGN

3.1 | Implant–abutment connection

2.3 | Mesio-distal
A significant aspect of the prosthesis design is related to the implant–
Mesio-distal placement mostly related to the adjacent teeth or abutment connection which has an important role in the mechanical
implants. Esposito was the first to describe a strong correlation stability of the prosthesis and transfer of occlusal forces. The implant–
between bone loss at adjacent teeth and the horizontal fixture-tooth abutment connection design and related prosthetic fit has also been
27
distance. It is recommended by authors to stay 1.5 mm away from identified as a risk factor for peri-implant diseases.37,38
28
adjacent teeth and at least 3 mm from adjacent implants in order Early implant platform designs, such as the external hex implant
to prevent bone loss and also allow for complete inter-implant (Figure 5A), had a platform matched flat–flat implant–abutment connec-
mucosa fill.29,30 However, should the implants prescribed incorpo- tion. These types of connections have demonstrated bone remodeling
rate platform switching, a smaller inter-implant distance of 2 mm after integration, which can be described as a crater of bone loss around
may be possible.31 the implant platform.39 While initial bone loss around implant may not
lead to peri-implantitis, it is generally regarded that early crestal bone
loss is an undesirable finding around dental implants. This will lead to
exposure of the rough surface of the implant into the peri-implant sul-
cus which presents a risk factor for long term peri-implant health.40
Most contemporary implant designs incorporate a degree of plat-
form shift which can assist in minimizing early crestal bone loss. The
rationale of platform shifting is to move the micro-gap of implant–
abutment connection away from bone crest. This can be achieved by
providing an abutment diameter that is narrower than the implant
diameter creating a horizontal offset of the abutment away from the
bone crest which is widely reported to reduce early crestal bone
loss.41,42 This can also be achieved through a vertical platform shift
which is the basis of tissue level implants.2,14,38
The geometry of the implant–abutment connection can also play
a role in the biomechanical stability of the connection and propensity
F I G U R E 2 As illustrated in these diagrams, palatal placement for bone loss. Implants with steep internal conical connections
(A) will create buccal contour that may be more difficult to clean and (Figures 3E and 5D) provide superior resistance to lateral loading. This
maintain. Palatal placement further than 3 mm will create an
feature in an implant design perspective increases the stability of the
exaggeration of the contour further and impinge of the palatal
abutment during loading and reduced pumping effect which can cause
thickness of the material. Buccal placement (D) will create contour
that is extremely under contoured and may compromise restorative pumping of bacteria and endotoxins from within the implant–
strength and long-term tissue stability abutment connection into the per-implant sulcus.43 Whilst no
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HAMILTON ET AL. 713

F I G U R E 3 The relationship between the prosthesis

emergence profile and facio-lingual implant angulation is
illustrated with (A) providing ideal screw access of the
restoration and ideal contour, (B) slight buccal angulation
requiring either angulated screw channel or cemented
restoration, (C) increased buccal angulation requiring a
customized cement retained restoration, (D) compromised
placement with excessive buccal angulation where
explanatation may need to be considered, and (E) slight
lingual angulation may be suitable for direct screw
retained restorations, however note the resulting increase
in lingual thickness of the restoration

efficiently transfers occlusal loading forces to the crestal module of

the implant, and may present as a risk factor for implant fracture when
combined with the thin walls of reduced diameter implants made from
commercially pure titanium.47,48 Crown to Implant ratio has been
reviewed and was found to have no effect on the survival of the
implant.49,50 However loss of crestal bone around an implant has been
shown to change the force distribution of the implant.47 This change
also shows increase of the levering effect to the implant which may
increase the risk of implant fracture.
Catastrophic horizontal implant fractures are relatively uncom-
mon.51 However, it is often difficult to clinically diagnose vertical frac-
F I G U R E 4 Excessive implant angulation has led to over-
tures within the implant abutment connection, and they may be
contoured buccal emergence profile and thin soft tissue with resulting
aesthetic compromises and peri-implant disease concomitantly diagnosed as peri-implantitis (Figures 6 and 7). The two
main signs of vertical fracture are screw loosening and crestal bone
implant–abutment connection has been found to be impermeable to loss. Removal of the prosthesis will show signs of inflammation and
bacteria, in vitro studies have found that the implant–abutment con- bleeding which can make diagnosing fractures challenging. Careful
nection design characteristics do have an impact.37 inspection of the connection with a microscope may identify a frac-
The influence of the implant–abutment connection on crestal bone ture line (Figure 6).
levels is further complicated by the presence of clinical misfit due to
manufacturing processes, handling of components by laboratory techni-
cians, debris, proximal contacts, and splinted implants. All the in vitro lit- 4 | PROSTHETIC DESIGN
erature on internal conical implant–abutment connection designs are
performed with optimal fit and seating of a single abutment. Achieving 4.1 | Cement versus screw-retained restoration
passive fit of an implant prosthesis on multiple dental implants with a fit
at the implant–abutment connection comparable to single unit restora- Intra-oral cementation of implant restorations presents as a risk fac-
tions is not realistic.44 Although a biological tolerance for multiunit res- tor for peri-implant diseases.36,52 There are two main restorative
toration misfit has been reported, this has only been assessed at the options for implant prosthesis; cement retained, and screw retained
multi-unit abutment level.45 As such, much of the benefits reported on restorations. The selection between the two modalities should take
internal conical connections may not be applicable for multi-unit resto- into consideration the advantages and disadvantages of each, how-
rations provided at the implant level and the use of multi-unit abut- ever there are conflicting reports in the literature in terms of suc-
46
ments may provide superior biological results. cess with cement retained restorations. The presence of increased
inflammatory cells and more significant bone loss around implants
restored with cement retained restorations compared to screw
3.2 | Implant fracture retained restorations has been reported in the literature.53,54 This is
however conflicting to the report by Nissan and colleagues which
One of the main advantages of internal connection design is the sta- supported cement retained restoration over screw-retained
bility of implant–abutment connection. However, this design restoration.55
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714 HAMILTON ET AL.

(A) (B) (C)

(D) (E)

F I G U R E 5 Several different implant connections (A) external hex connection (B) flat-top internal tri-channel that allows 120 prosthetic
indexing (C) Synocta connection-8 of morse taper (D) crossfit connection with four internal grooves and an internal cone of 15 (E) Astra TX
internal 11 conical connection with a 12-point double hex

(A) (B) F I G U R E 6 Implant with history of

screw loosening. After replacement of the
crown with healing abutment, a
photograph was taken to capture a crack
on the mesial of the fixture. The peri-
apical showed bone-loss signs similar to
that of peri-implantitis

The most common complication of cement retained restoration compared with cement-retained crowns.59,60 It has also been sug-
that has been reported is cement extrusion to the peri-implant tissue. gested that residual cement is likely to be a cause of peri-implantitis
Cement remnants may develop into acute or chronic inflammation of and bone loss around implants.61
56
the peri-implant tissue. It has been shown that excess cement can- As detection of cement remnant is challenging,62 many avoid
not be predictably removed around cemented restorations with mar- cement-retained restoration and elect for screw-retained restora-
gins placed more than 1–1.5 mm submucosally, with damage of the tion. However, it is a misconception to attribute peri-implantitis
abutment surface during cement removal.57,58 This excess cement with the retention mechanism of restoration and not the cementa-
around implant restorations has been shown clinically to equate to tion technique and risk of excess cement remnants. Appropriate
signs of peri-implant disease, with studies finding peri-implant soft tis- abutment design with the cement margin located close to that of
sues responded more favorably to screw-retained crowns when the mucosal crest, as well as techniques to reduce the volume of
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HAMILTON ET AL. 715

F I G U R E 7 Implant with history of (A) (B)

mobility and loss of integration due to a
crack. The peri-apical radiographs show
sign of bone-loss similar to the peri-
implantitis

(C) (D)

cement excess have been proposed to minimize the risk of cement prosthesis remains ambiguous due to the unclear methodology of the
63–65
extrusion. measurement.68 Both Katafuchi and Yi's studies measured EA accord-
ing to the periapical radiograph without mentioning the soft tissue
relationship.7,67
4.2 | Emergence angle and emergence profile One systematic review and meta-analysis suggested that con-
cave/convergence implant transmucosal design has significantly less
According to the Glossary of Prosthodontic Terms 9, Emergence angle MBL than that of parallel/divergent design in platform switching
(EA) is defined as the angulation between the average tangent of the implant. However, the effect of transmucosal design was not signifi-
transitional contour relative to the long axis of the implant body.66 cantly different in platform matching implant.56
More than 30 degrees of the restorative EA was defined as an over- Improper prosthesis contours prevent the adequate access for
contour restoration.7 Emergence Profile (EP) is defined as the contour oral hygiene practices which increase the risk for peri-implantitis.69
of the restoration or tooth, such as the crown on a natural tooth, den- There is evidence that modifying the contour of the prosthesis to
tal implant, or dental implant abutment, which classified into convex, improve oral hygiene access has benefits in reducing the mucosal per-
concave, and straight profile. implant inflammation.70 Chu has described the importance of sub-
Two cross-sectional studies analyzed the relationship between critical emergence profile to help maintain tissue stability. He has
EA, EP and the occurrence of peri-implantitis disease, and concluded recommended concave sub-critical emergence profiles may be utilized
that more than 30 degrees of the EA associated with convex EP to help maximize soft tissue thickness, height, and stability.71
increases the risk (37.8%) for peri-implantitis in the bone-level Preclinical studies have identified that the configuration of the
implant.7 Yi and collegues67 showed the highest prevalence (46.7%) of transmucosal component have directly influenced the orientation of
the marginal bone loss (MBL) and peri-implantitis was observed if peri-implant biological width and the amount of marginal bone remo-
EA > = 30 degrees, when EP is convex and splinted-middle implant deling. The flat and wide emergence profiles were found to induce an
67
prosthesis. apical displacement of the peri-implant biologic width and more bone
The EA were defined in the same manner for both natural teeth loss, which further supports the benefits of concave subcritical con-
and implant prosthesis. However, the application of the EA to implant tours72,73 (Figure 8). This introduces the notion of biologic width
 17088208, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cid.13183 by Readcube (Labtiva Inc.), Wiley Online Library on [21/03/2025]. 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
716 HAMILTON ET AL.

F I G U R E 8 Histological
representations of the biological
compartment surrounding wide (left) and
narrow (right) emergence profiles with
wider profiles exhibiting more bone loss73

which is a two-dimensional histological measurement needing to be Marginal bone loss in six studies showed no significant difference,
redefined as a three-dimensional biologic volume of soft tissue sur- varying from 0.4 ± 0.2 mm to 1.48 ± 1.05 mm and 0.5 ± 0.3 mm to
rounding the transmucosal portion of the implant-abutment complex. 1.43 ± 0.67 mm with Zirconia and titanium abutment prospec-
tively.76,77,80–83 For soft tissue recession, Zembic and colleagues
reported no significant difference after 5 years in service between zir-
4.3 | Material selection conia and titanium abutments.77
Roughness of ceramic from different surface treatment could
Prescription of customized prosthetic design has been a critical part of potentially affect soft tissue adhesion. In vitro study comparing raw,
implant treatment. Such abutments have an individual shape providing hand polished, and glazed lithium disilicate surface showed better cell
advantages of soft tissue support, and favorable location of the cementa- adhesion and proliferation on polished surface than glazed ceramic.84
63
tion margin. Currently, when fabricating customized prosthetic abut- A similar finding was reported on polished zirconia surface. Adhesion
ments, various materials can be utilized, such as, titanium, cast metal alloy, for epithelial cells was favorable to polished zirconia when comparing
ceramics, and resin composite. Cast gold abutment was widely accepted to titanium.85
to be state of the art for customized abutments, however due to increase
cost of precious metals, other alternatives have been considered as the
standard of care. Gold abutments were found to have no mucosal attach- 4.4 | Cleansability
ment, with soft tissue recession and crestal bone loss being reported in
preclinical studies using a beagle dog model.74 The least favorable mate- The presence of a pathogenic biofilm has been associated with peri-
rial was reported to be feldspathic porcelain, with tissue recession and implant disease,86 and much of the literature on management of
74
bone loss were reported to be the highest. these conditions focuses on biofilm removal.3,4,87,88 It would seem a
Composite resin abutments are suggested to have comparable logical assumption that cleansability of an implant prosthesis which
75
strength as zirconia. However, the use of composite resin abut- would lend itself to adequate home care and maintenance would
ments is limited due to concern with mucosal inflammation associated play a key role in prevention of peri-implant diseases. Unfortunately,
with plaque accumulation on composite resin surfaces. there has not been much scientific evidence which has assessed the
With utilization of CAD/CAM technology, current state of the art prosthetic design parameters in relation to cleansability and impact
material for customized abutments are zirconium and titanium. The on peri-implant disease, with most recommendations based on
selection of an appropriate material should be based on its physical empirical observations. However, it is generally regarded that pros-
properties and biologic integration for ideal soft tissue outcomes thetic reconstructions need to allow access for proper personal
whilst minimizing technical and mechanical complications. The influ- cleaning, diagnosis by probing and professional plaque removal.69,89
ence of different materials on peri-implant soft tissue is still unclear. A provisional prosthesis can provide a means for patient specific
Pocket probing depth showed no statistical difference between assessment regarding their level of dexterity and home care, as well
zirconia and titanium abutments with two 5-year studies.76,77 Both as the specific prosthesis contours (Figure 9). This can be used to
titanium and zirconia have increased probing depths from the baseline guide the design of an optimally cleansable definitive prosthesis
0.5 and 0.4 mm prospectively. Bleeding on probing around zirconia (Figure 10).
and titanium abutments have shown to be insignificant at 1-year fol- Poor restorative design will be a predisposing factor to biofilm
low up,78 3-years follow up,79 and 5-years follow up.77 attachment and development of calculus which in-turn causes further
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HAMILTON ET AL. 717

F I G U R E 9 Provisional prosthesis is a (A) (B)

good indicator of the prosthetic design
and the patient's ability to clean the
prosthesis. In this case, implant was
placed too far lingual creating a shelf that
prevent proper hygiene by the patient

(A) (A)

(B) (B)

(C) F I G U R E 1 1 Excessive buccal-lingual contour due to implant

placement in relation to the teeth position. This excessive contour
may be more challenging for the patient to clean. However no
prosthetic change can be done without changing the implant position

biofilm build up. The creation of a cleansable restorative contour is

further challenged in restoration of multiple teeth where more often
there is a larger degree of alveolar bone resorption, and the prosthesis
may include significant pink tissue replacement. Compensation of
skeletal discrepancies in fixed implant rehabilitations may also lead to
large bucco-lingual prosthesis widths with extensive horizontal tissue
contours (Figure 11) Ideal implant restorative design should be cleans-
F I G U R E 1 0 A cleansable prosthetic design. Note implant access
able, therefore a convex shape is the preferred shape. However, shal-
and teeth position relationship. Minimal bucco-lingual prosthetic
contour minimizing area for possible food packing and easier access low implant placement and excessive lingual placement will force a
for cleaning concave design which is known as ridge lap (Figure 12).
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718 HAMILTON ET AL.

(A) (B) F I G U R E 1 2 Ridge lap prosthetic design will create an

embrasure that will trap plaque and will be difficult to
maintain and keep clean

F I G U R E 1 3 Adequately designed embrasures are required to

facilitate hygiene measures with interdental brushes (Image courtesy
of Dr. Luiz Gonzaga)

Splinting of adjacent implants has been postulated to have biome-

chanical advantages through distribution of occlusal load across multi-
ple implants. It is suggested that this may decrease stress
concentration in the crestal bone around any one particular implant
and assists in minimizing mechanical/technical implant complica-
tions.90 Clinical studies, however, have found similar degrees of mar-
ginal bone loss and prosthetic complication rates between splinted
F I G U R E 1 4 Plaque accumulation beneath a poorly contoured
and non-splinted implant restorations.90–93 Achieving a passive fit of
prosthesis which is most evident on the palatal and intaglio aspects
splinted adjacent restorations can be challenging, particularly where
implants with conical connections are involved. Any resulting misfit at inserted effectively without causing mechanical trauma to the muco-
the implant-abutment connection may contribute to biological and sal tissues with limited evidence showing that this may be more effec-
mechanical complications.45,94 tive than flossing (Figure 13).97,99,100
Un-splinted individual restorations provide the opportunity for In planning for full arch implant rehabilitation, there has been
floss to be passed through the contact point and can encourage oral many debates on whether fixed prosthesis is superior to removable
hygiene practices more similar to natural teeth. The role of flossing prosthesis. It is a common outcome of studies that patient feels more
however around implants has been questioned due to the potential comfortable with fixed solution but finding removable prosthesis to
risk of floss remnants being caught in between components and any be easier to clean.101–103 Although, there is no different when com-
95,96
exposed rough implant surfaces. The use of alternative oral paring mean marginal bone loss between two types of prosthesis.103
hygiene adjuncts in conjunction with regular tooth brushing, such as However, implants in both type of prosthesis are not immune to peri-
interproximal brushes and oral irrigators may be considered and have implantitis. In fact, Grischke and collegues104 found higher rate of
been found to be effective on natural teeth in the prevention and mucositis and peri-implantitis on overdenture cases.104 He found rate
97,98
management of periodontitis. Embrasure spaces in implant resto- of peri-implantitis on overdenture cases can go up to 25% while fixed
rations should be designed such that interproximal brushes can be prosthesis will have a rate of 12.68%.
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HAMILTON ET AL. 719

When providing fixed implant supported bridges, consideration DATA AVAILABILITY STAT EMEN T
needs to be given to the degree of tissue contact or hygiene space Data sharing is not applicable to this article as no new data were cre-
underneath the prosthesis and in between the implants. Early studies ated or analyzed in this study.
published on fixed implant rehabilitations used tall abutments, and a
prosthesis completely free of tissue contact with 1–2 mm of hygiene OR CID
space underneath.105,106 The “high-dry” design is commonly pre- German O. Gallucci https://orcid.org/0000-0001-6386-594X
scribed to facilitate access for patients to perform oral hygiene mea-
sures. However, there are no publications comparing hygiene RE FE RE NCE S
measures or peri-implant health in relation the degree of hygiene 1. Mattheos N, Vergoullis I, Janda M, Miseli A. The implant supracrestal
space or tissue contact in fixed implant supported bridges. In situa- complex and its significance for long-term successful clinical out-
comes. Int J Prosthodont. 2021;34(1):88-100.
tions where tissue contact is necessary, a concave intaglio surface of
2. Saleh MHA, Ravidà A, Suárez-Lo  pez Del Amo F, Lin GH, Asa'ad F,
a fixed prosthesis must be avoided, with a minimum of 3 mm dis- Wang HL. The effect of implant-abutment junction position on
tance between implants, which will help patient's ability to reduce crestal bone loss: a systematic review and meta-analysis. Clin Implant
plaque accumulation (Figure 14),107 also described the plaque accu- Dent Relat Res. 2018;20(4):617-633.
3. Schwarz F, Ramanauskaite A. It is all about peri-implant tissue
mulations beneath fixed prosthesis to be three times more on palatal
health. Periodontol 2000. 2022;88(1):9-12.
side, where access for cleaning is more challenging.107 Therefore, 4. Schwarz F, Derks J, Monje A, Wang HL. Peri-implantitis.
should the patients' anatomical characteristics and placement of J Periodontol. 2018;89(Suppl 1):S267-s290.
implants provide an unfavorable situation for a hygienic fixed pros- 5. Monje A, Insua A, Wang HL. Understanding peri-Implantitis as a
plaque-associated and site-specific entity: on the local predisposing
thesis design, a removable solution may be a better option to main-
factors. J Clin Med. 2019;8(2):279. doi:10.3390/jcm8020279
tain tissue health. 6. Monje A, Aranda L, Diaz KT, et al. Impact of maintenance therapy
for the prevention of peri-implant diseases: a systematic review and
meta-analysis. J Dent Res. 2016;95(4):372-379.
5 | C O N CL U S I O N S 7. Katafuchi M, Weinstein BF, Leroux BG, Chen YW, Daubert DM. Res-
toration contour is a risk indicator for peri-implantitis: a cross-sectional
radiographic analysis. J Clin Periodontol. 2018;45(2):225-232.
In conclusion, the prosthetic design of an implant restoration has a 8. Coachman C, Salama M, Garber D, Calamita M, Salama H, Cabral G.
close relationship to the future of peri-implant health. It is impor- Prosthetic gingival reconstruction in fixed partial restorations. Part 3:
tant to understand these concepts and to respect the restorative laboratory procedures and maintenance. Int J Periodontics Restorative
Dent. 2010;30(1):19-29.
outcome when planning an implant treatment. Restorative contour
9. Esquivel J, Meda RG, Blatz MB. The impact of 3D implant position
and cleansability of the prosthesis need to be part of the planning. on emergence profile design. Int J Periodontics Restorative Dent.
Should the planned implant compromise the future restoration, 2021;41(1):79-86.
adjunctive surgical therapy such as bone and soft tissue augmenta- 10. Gomez-Meda R, Esquivel J, Blatz MB. The esthetic biological con-
tour concept for implant restoration emergence profile design.
tion may be required, or an alternative prosthesis should be
J Esthet Restor Dent. 2021;33(1):173-184.
planned. Both the implant placement and the final prosthesis will 11. Su H, Gonzalez-Martin O, Weisgold A, Lee E. Considerations of
need to be respected to achieve stable and healthy peri-implant implant abutment and crown contour: critical contour and subcritical
tissue. contour. Int J Periodontics Restorative Dent. 2010;30(4):335-343.
12. Buser D, Martin W, Belser UC. Optimizing esthetics for implant res-
torations in the anterior maxilla: anatomic and surgical consider-
AUTHOR CONTRIBUTIONS ations. Int J Oral Maxillofac Implants. 2004;19(Supplement):43-61.
Adam Hamilton and German O. Gallucci conceived the ideas; Armand 13. Cruz RS, Lemos CAA, de Luna Gomes JM, Fernandes EOHF,
Putra, Pranai Nakapaksin, and Pongrapee Kamolroongwarakul Pellizzer EP, Verri FR. Clinical comparison between crestal and sub-
crestal dental implants: a systematic review and meta-analysis.
reviewed the literature content, Armand Putra led the writing in con-
J Prosthet Dent. 2022;127(3):408-417.
junction with Adam Hamilton, Pranai Nakapaksin, Pongrapee Kamol-
14. Hermann JS, Buser D, Schenk RK, Schoolfield JD, Cochran DL. Bio-
roongwarakul, and German O. Gallucci; Adam Hamilton and German logic width around one and two-piece titanium implants. A histo-
O. Gallucci revised the manuscript critically for important intellectual metric evaluation of unloaded nonsubmerged and submerged
content; and Adam Hamilton gave the final approval of the version to implants in the canine mandible. Clin Oral Implants Res. 2001;12(6):
559-571.
be submitted.
15. Derks J, Schaller D, Håkansson J, Wennström JL, Tomasi C,
Berglundh T. Effectiveness of implant therapy analyzed in a Swedish
ACKNOWLEDGMENT population: prevalence of peri-implantitis. J Dent Res. 2016;95(1):
Open access publishing facilitated by The University of Western Aus- 43-49.
16. Chiche FA, Leriche MA. Multidisciplinary implant dentistry for
tralia, as part of the Wiley - The University of Western Australia
improved aesthetics and function. Pract Periodontics Aesthet Dent.
agreement via the Council of Australian University Librarians. 1998;10(2):177-186. quiz 188.
17. Kois JC, Kan JY. Predictable peri-implant gingival aesthetics: surgical
CONF LICT S OF INTE R ES T and prosthodontic rationales. Pract Proced Aesthet Dent. 2001;13(9):
691-698. quiz 700, 721–692.
The authors report no conflicts of interest related to this research.
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720 HAMILTON ET AL.

18. London RM. The esthetic effects of implant platform selection. Com- 38. Sasada Y, Cochran DL. Implant-abutment connections: a review of
pend Contin Educ Dent. 2001;22(8):675-682. quiz 683. biologic consequences and peri-implantitis implications. Int J Oral
19. Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional Maxillofac Implants. 2017;32(6):1296-1307.
implant position for soft tissue aesthetics. Pract Periodontics Aesthet 39. Abrahamsson I, Berglundh T, Lindhe J. The mucosal barrier following
Dent. 1999;11(9):1063-1072. quiz 1074. abutment dis/reconnection. An experimental study in dogs. J Clin
20. Weisgold AS, Arnoux JP, Lu J. Single-tooth anterior implant: a world Periodontol. 1997;24(8):568-572.
of caution. Part I. J Esthet Dent. 1997;9(5):225-233. 40. Windael S, Collaert B, De Buyser S, De Bruyn H, Vervaeke S. Early
21. Gluckman H, Pontes CC, Du Toit J, Coachman C, Salama M. Dimensions peri-implant bone loss as a predictor for peri-implantitis: a 10-year
of the dentogingival tissue in the anterior maxilla. A CBCT descriptive prospective cohort study. Clin Implant Dent Relat Res. 2021;23(3):
cross-sectional study. Int J Esthet Dent. 2021;16(4):580-592. 298-308.
22. Linkevicius T, Puisys A, Linkeviciene L, Peciuliene V, Schlee M. 41. Canullo L, Menini M, Santori G, Rakic M, Sculean A, Pesce P. Tita-
Crestal bone stability around implants with horizontally matching nium abutment surface modifications and peri-implant tissue behav-
connection after soft tissue thickening: a prospective clinical trial. ior: a systematic review and meta-analysis. Clin Oral Investig. 2020;
Clin Implant Dent Relat Res 201;17(3):497-508. 24(3):1113-1124.
23. Chan D, Pelekos G, Ho D, Cortellini P, Tonetti MS. The depth of the 42. Meijndert CM, Raghoebar GM, Vissink A, Delli K, Meijer HJA. The
implant mucosal tunnel modifies the development and resolution of effect of implant-abutment connections on peri-implant bone levels
experimental peri-implant mucositis: a case-control study. J Clin Peri- around single implants in the aesthetic zone: a systematic review
odontol. 2019;46(2):248-255. and a meta-analysis. Clin Exp Dent Res. 2021;7(6):1025-1036.
24. Monje A, Galindo-Moreno P, Tözüm TF, Suárez-Lo  pez del Amo F, 43. Zipprich H, Weigl P, Lange B, Laurer H-C. Micromovements at the
Wang HL. Into the paradigm of local factors as contributors for peri- implant-abutment Interface: measurement, causes, and conse-
implant disease: short communication. Int J Oral Maxillofac Implants. quences. Implant Dent. 2007;15(1):31-46.
2016;31(2):288-292. 44. Kan JY, Rungcharassaeng K, Bohsali K, Goodacre CJ, Lang BR. Clini-
25. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thick- cal methods for evaluating implant framework fit. J Prosthet Dent.
ness on facial marginal bone response: stage 1 placement through 1999;81(1):7-13.
stage 2 uncovering. Ann Periodontol. 2000;5(1):119-128. 45. Jemt T, Book K. Prosthesis misfit and marginal bone loss in edentu-
26. Testori T, Weinstein T, Scutella F, Wang HL, Zucchelli G. Implant lous implant patients. Int J Oral Maxillofac Implants. 1996;11(5):
placement in the esthetic area: criteria for positioning single and 620-625.
multiple implants. Periodontol 2000. 2018;77(1):176-196. 46. Toia M, Stocchero M, Becktor JP, Chrcanovic B, Wennerberg A.
27. Esposito M, Ekestubbe A, Gröndahl K. Radiological evaluation of Implant vs abutment level connection in implant supported screw-
marginal bone loss at tooth surfaces facing single Brånemark retained fixed partial dentures with cobalt-chrome framework:
implants. Clin Oral Implants Res. 1993;4(3):151-157. 1-year interim results of a randomized clinical study. Clin Implant
28. Shadid R, Sadaqa N. A comparison between screw- and cement- Dent Relat Res. 2019;21(2):238-246.
retained implant prostheses. A literature review. J Oral Implantol. 47. Bing L, Mito T, Yoda N, et al. Effect of peri-implant bone resorption
2012;38(3):298-307. on mechanical stress in the implant body: in vivo measured load-
29. Ramanauskaite A, Roccuzzo A, Schwarz F. A systematic review on based finite element analysis. J Oral Rehabil. 2020;47(12):1566-
the influence of the horizontal distance between two adjacent 1573.
implants inserted in the anterior maxilla on the inter-implant mucosa 48. Steinebrunner L, Wolfart S, Ludwig K, Kern M. Implant-abutment
fill. Clin Oral Implants Res. 2018;29(Suppl 15):62-70. interface design affects fatigue and fracture strength of implants.
30. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant dis- Clin Oral Implants Res. 2008;19(12):1276-1284.
tance on the height of inter-implant bone crest. J Periodontol. 49. Fathi A, Rismanchian M, Khodadadi R, Dezaki SN. Does the crown-
2000;71(4):546-549. implant ratio affect the survival and complications of implant-
31. Rivara F, Macaluso GM, Toffoli A, Calciolari E, Goldoni M, Lumetti S. supported prostheses? A systematic review. J Prosthet Dent. 2022;
The effect of a 2-mm inter-implant distance on esthetic outcomes in 22:S0022-3913(22)00175-5. doi:10.1016/j.prosdent.2022.03.007.
immediately non-occlusally loaded platform shifted implants in 50. Pellizzer EP, de Luna Gomes JM, Lemos CAA, Minatel L, de Oliveira
healed ridges: 12-month results of a randomized clinical trial. Clin Limírio JPJ, de Moraes SLD. The influence of crown-to-implant ratio
Implant Dent Relat Res. 2020;22(4):486-496. in single crowns on clinical outcomes: a systematic review and meta-
32. Edmondson EK, Trejo PM, Soldatos N, Weltman RL. The ability analysis. J Prosthet Dent. 2021;126(4):497-502.
to screw-retain single implant-supported restorations in the 51. Salvi GE, Brägger U. Mechanical and technical risks in implant ther-
anterior maxilla: a CBCT analysis. J Prosthet Dent. 2022;128(3): apy. Int J Oral Maxillofac Implants. 2009;24(Suppl):69-85.
443-449. 52. Wittneben JG, Millen C, Brägger U. Clinical performance of screw-
33. Rasaie V, Abduo J, Falahchai M. Clinical and laboratory outcomes of versus cement-retained fixed implant-supported reconstructions--a
angled Screw Channel implant prostheses: a systematic review. Eur J systematic review. Int J Oral Maxillofac Implants. 2014;29(Suppl):
Dent. 2022;16(3):488-499. 84-98.
34. Hebel KS, Gajjar RC. Cement-retained versus screw-retained implant 53. Sailer I, Mühlemann S, Zwahlen M, Hämmerle CH, Schneider D.
restorations: achieving optimal occlusion and esthetics in implant Cemented and screw-retained implant reconstructions: a systematic
dentistry. J Prosthet Dent. 1997;77(1):28-35. review of the survival and complication rates. Clin Oral Implants Res.
35. Millen C, Brägger U, Wittneben JG. Influence of prosthesis type and 2012;23(Suppl 6):163-201.
retention mechanism on complications with fixed implant-supported 54. Thoma DS, Wolleb K, Bienz SP, Wiedemeier D, Hämmerle CHF,
prostheses: a systematic review applying multivariate analyses. Int J Sailer I. Early histological, microbiological, radiological, and clinical
Oral Maxillofac Implants. 2015;30(1):110-124. response to cemented and screw-retained all-ceramic single crowns.
36. Wittneben JG, Joda T, Weber HP, Brägger U. Screw retained Clin Oral Implants Res. 2018;29(10):996-1006.
vs. cement retained implant-supported fixed dental prosthesis. Peri- 55. Nissan J, Narobai D, Gross O, Ghelfan O, Chaushu G. Long-term
odontol 2000. 2017;73(1):141-151. outcome of cemented versus screw-retained implant-supported par-
37. Koutouzis T. Implant-abutment connection as contributing factor to tial restorations. Int J Oral Maxillofac Implants. 2011;26(5):1102-
peri-implant diseases. Periodontol 2000. 2019;81(1):152-166. 1107.
 17088208, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cid.13183 by Readcube (Labtiva Inc.), Wiley Online Library on [21/03/2025]. 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
HAMILTON ET AL. 721

56. Valente NA, Wu M, Toti P, Derchi G, Barone A. Impact of 75. Magne P, Oderich E, Boff LL, Cardoso AC, Belser UC. Fatigue resis-
concave/convergent vs parallel/ divergent implant transmucosal tance and failure mode of CAD/CAM composite resin implant abut-
profiles on hard and soft peri-implant tissues: a systematic review ments restored with type III composite resin and porcelain veneers.
with meta-analyses. Int J Prosthodont. 2020;33(5):553-564. Clin Oral Implants Res. 2011;22(11):1275-1281.
57. Agar JR, Cameron SM, Hughbanks JC, Parker MH. Cement removal 76. Lops D, Bressan E, Chiapasco M, Rossi A, Romeo E. Zirconia and
from restorations luted to titanium abutments with simulated sub- titanium implant abutments for single-tooth implant prostheses after
gingival margins. J Prosthet Dent. 1997;78(1):43-47. 5 years of function in posterior regions. Int J Oral Maxillofac Implants.
58. Linkevicius T, Vindasiute E, Puisys A, Linkeviciene L, Maslova N, 2013;28(1):281-287.
Puriene A. The influence of the cementation margin position on the 77. Zembic A, Bösch A, Jung RE, Hämmerle CH, Sailer I. Five-year
amount of undetected cement. A prospective clinical study. Clin Oral results of a randomized controlled clinical trial comparing zirconia
Implants Res. 2013;24(1):71-76. and titanium abutments supporting single-implant crowns in canine
59. Weber HP, Kim DM, Ng MW, Hwang JW, Fiorellini JP. Peri-implant and posterior regions. Clin Oral Implants Res. 2013;24(4):384-390.
soft-tissue health surrounding cement- and screw-retained implant 78. Sailer I, Zembic A, Jung RE, Siegenthaler D, Holderegger C,
restorations: a multicenter, 3-year prospective study. Clin Oral Hammerle CHF. Randomized controlled clinical trial of customized
Implants Res. 2006;17(4):375-379. zirconia and titanium implant abutments for canine and posterior
60. Wilson TG Jr. The positive relationship between excess cement and single-tooth implant reconstructions: preliminary results at 1 year of
peri-implant disease: a prospective clinical endoscopic study. function. Clin Oral Implants Res. 2009;20(3):219-225.
J Periodontol. 2009;80(9):1388-1392. 79. Zembic A, Sailer I, Jung RE, Hammerle CH. Randomized-controlled
61. Pauletto N, Lahiffe BJ, Walton JN. Complications associated with clinical trial of customized zirconia and titanium implant abutments
excess cement around crowns on osseointegrated implants: a clinical for single-tooth implants in canine and posterior regions: 3-year
report. Int J Oral Maxillofac Implants. 1999;14(6):865-868. results. Clin Oral Implants Res. 2009;20(8):802-808.
62. Wadhwani C, Rapoport D, La Rosa S, Hess T, Kretschmar S. Radio- 80. Carrillo de Albornoz A, Vignoletti F, Ferrantino L, Cárdenas E, De
graphic detection and characteristic patterns of residual excess Sanctis M, Sanz M. A randomized trial on the aesthetic outcomes of
cement associated with cement-retained implant restorations: a clin- implant-supported restorations with zirconia or titanium abutments.
ical report. J Prosthet Dent. 2012b;107(3):151-157. J Clin Periodontol. 2014;41(12):1161-1169.
63. Dumbrigue HB, Abanomi AA, Cheng LL. Techniques to minimize 81. Hosseini M, Worsaae N, Schiodt M, Gotfredsen K. A 1-year random-
excess luting agent in cement-retained implant restorations. ised controlled trial comparing zirconia versus metal-ceramic implant
J Prosthet Dent. 2002;87(1):112-114. supported single-tooth restorations. Eur J Oral Implantol. 2011;4(4):
64. Wadhwani C, Hess T, Piñeyro A, Opler R, Chung KH. Cement appli- 347-361.
cation techniques in luting implant-supported crowns: a quantitative 82. Hosseini M, Worsaae N, Schiødt M, Gotfredsen K. A 3-year prospec-
and qualitative survey. Int J Oral Maxillofac Implants. 2012a;27(4): tive study of implant-supported, single-tooth restorations of all-
859-864. ceramic and metal-ceramic materials in patients with tooth agenesis.
65. Wadhwani C, Piñeyro A. Technique for controlling the cement for Clin Oral Implants Res. 2013;24(10):1078-1087.
an implant crown. J Prosthet Dent. 2009;102(1):57-58. 83. Payer M, Heschl A, Koller M, Arnetzl G, Lorenzoni M, Jakse N. All-
66. GPT. The glossary of prosthodontic terms: ninth edition. J Prosthet ceramic restoration of zirconia two-piece implants--a randomized
Dent. 2017;117(5 s):e1-e105. controlled clinical trial. Clin Oral Implants Res. 2015;26(4):371-376.
67. Yi Y, Koo KT, Schwarz F, Ben Amara H, Heo SJ. Association of pros- 84. Brunot-Gohin C, Duval JL, Azogui EE, et al. Soft tissue adhesion of
thetic features and peri-implantitis: a cross-sectional study. J Clin polished versus glazed lithium disilicate ceramic for dental applica-
Periodontol. 2020;47(3):392-403. tions. Dent Mater. 2013;29(9):e205-e212.
68. Mattheos N, Janda M, Acharya A, Pekarski S, Larsson C. Impact of 85. Nothdurft FP, Fontana D, Ruppenthal S, et al. Differential behavior
design elements of the implant supracrestal complex (ISC) on the risk of fibroblasts and epithelial cells on structured implant abutment
of peri-implant mucositis and peri-implantitis: a critical review. Clin materials: a comparison of materials and surface topographies. Clin
Oral Implants Res. 2021;32(Suppl 21):181-202. Implant Dent Relat Res. 2015;17(6):1237-1249.
69. Serino G, Ström C. Peri-implantitis in partially edentulous patients: 86. Mombelli A, Décaillet F. The characteristics of biofilms in peri-
association with inadequate plaque control. Clin Oral Implants Res. implant disease. J Clin Periodontol. 2011;38(Suppl 11):203-213.
2009;20(2):169-174. 87. Renvert S, Polyzois I. Treatment of pathologic peri-implant pockets.
70. de Tapia B, Mozas C, Valles C, Nart J, Sanz M, Herrera D. Adjunctive Periodontol 2000. 2018;76(1):180-190.
effect of modifying the implant-supported prosthesis in the treatment 88. Renvert S, Polyzois IN. Clinical approaches to treat peri-implant
of peri-implant mucositis. J Clin Periodontol. 2019;46(10):1050-1060. mucositis and peri-implantitis. Periodontol 2000. 2015;68(1):
71. Chu SJ, Kan JY, Lee EA, et al. Restorative emergence profile for 369-404.
single-tooth implants in healthy periodontal patients: clinical guide- 89. Jepsen S, Berglundh T, Genco R, et al. Primary prevention of peri-
lines and decision-making strategies. Int J Periodontics Restorative implantitis: managing peri-implant mucositis. J Clin Periodontol.
Dent. 2019;40(1):19-29. 2015;42(Suppl 16):S152-S157.
72. Finelle G, Papadimitriou DEV, Souza AB, Katebi N, Gallucci GO, 90. de Souza Batista VE, Verri FR, Lemos CAA, et al. Should the restora-
Araújo MG. Peri-implant soft tissue and marginal bone adaptation tion of adjacent implants be splinted or nonsplinted? A systematic
on implant with non-matching healing abutments: micro-CT analysis. review and meta-analysis. J Prosthet Dent. 2019;121(1):41-51.
Clin Oral Implants Res. 2015;26(4):e42-e46. 91. Al-Aali KA, ArRejaie AS, Alrahlah A, AlFawaz YF, Abduljabbar T,
73. Souza AB, Alshihri A, Kämmerer PW, Araújo MG, Gallucci GO. His- Vohra F. Clinical and radiographic peri-implant health status around
tological and micro-CT analysis of peri-implant soft and hard tissue narrow diameter implant-supported single and splinted crowns. Clin
healing on implants with different healing abutments configurations. Implant Dent Relat Res. 2019;21(2):386-390.
Clin Oral Implants Res. 2018;29(10):1007-1015. 92. Li QL, Yao MF, Cao RY, Zhao K, Wang XD. Survival rates of splinted
74. Abrahamsson I, Berglundh T, Glantz PO, Lindhe J. The mucosal and nonsplinted prostheses supported by short dental implants
attachment at different abutments. An experimental study in dogs. (≤8.5 mm): a systematic review and meta-analysis. J Prosthodont.
J Clin Periodontol. 1998;25(9):721-727. 2022;31(1):9-21.
 17088208, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cid.13183 by Readcube (Labtiva Inc.), Wiley Online Library on [21/03/2025]. 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
722 HAMILTON ET AL.

93. Vigolo P, Zaccaria M. Clinical evaluation of marginal bone level 102. ELsyad MA, Elgamal M, Askar OM, Al-Tonbary GY. Patient satisfac-
change of multiple adjacent implants restored with splinted and non- tion and oral health-related quality of life (OHRQoL) of conventional
splinted restorations: a 5-year prospective study. Int J Oral Maxillofac denture, fixed prosthesis and milled bar overdenture for all-on-4
Implants. 2010;25(6):1189-1194. implant rehabilitation. A crossover study. Clin Oral Implants Res.
94. Abduo J, Judge RB. Implications of implant framework misfit: a sys- 2019;30(11):1107-1117.
tematic review of biomechanical sequelae. Int J Oral Maxillofac 103. Mumcu E, Dayan SC, Genceli E, Geckili O. Comparison of four-
Implants. 2014;29(3):608-621. implant-retained overdentures and implant-supported fixed prosthe-
95. Montevecchi M, Valeriani L, Franchi L, Sforza NM, Piana G. Evalua- ses using the all-on-4 concept in the maxilla in terms of patient satis-
tion of floss remnants after implant flossing in three different faction, quality of life, and marginal bone loss: a 2-year retrospective
implant conditions: a preclinical study. Int J Oral Maxillofac Implants. study. Quintessence Int. 2020;51(5):388-396.
2021;36(3):569-573. 104. Grischke J, Szafran ski SP, Muthukumarasamy U, Haeussler S,
96. van Velzen FJ, Lang NP, Schulten EA, Ten Bruggenkate CM. Dental Stiesch M. Removable denture is a risk indicator for peri-implantitis
floss as a possible risk for the development of peri-implant disease: and facilitates expansion of specific periodontopathogens: a cross-
an observational study of 10 cases. Clin Oral Implants Res. 2016; sectional study. BMC Oral Health. 2021;21(1):173.
27(5):618-621. 105. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of
97. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Comparison of water flos- osseointegrated implants in the treatment of the edentulous jaw. Int
ser and interdental brush on reduction of gingival bleeding and pla- J Oral Surg. 1981;10(6):387-416.
que: a randomized controlled pilot study. J Clin Dent. 2016;27(2): 106. Schnitman PA, Wohrle PS, Rubenstein JE. Immediate fixed interim
61-65. prostheses supported by two-stage threaded implants: methodology
98. Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I-III and results. J Oral Implantol. 1990;16(2):96-105.
periodontitis-the EFP S3 level clinical practice guideline. J Clin Peri- 107. Abi Nader S, Eimar H, Momani M, Shang K, Daniel NG, Tamimi F.
odontol. 2020;47(Suppl 22):4-60. Plaque accumulation beneath maxillary all-on-4™ implant-supported
99. Luz M, Klingbeil MFG, Henriques P, Lewgoy HR. Comparison prostheses. Clin Implant Dent Relat Res. 2015;17(5):932-937.
between interdental brush and dental floss controlling interprox-
imal biofilm in teeth and implants. Dent Health Curr Res. 2016;
2:3.
How to cite this article: Hamilton A, Putra A, Nakapaksin P,
100. Sälzer S, Slot DE, Van der Weijden FA, Dörfer CE. Efficacy of inter-
dental mechanical plaque control in managing gingivitis: a meta- Kamolroongwarakul P, Gallucci GO. Implant prosthodontic
review. J Clin Periodontol. 2015;42(Suppl 16):S92-S105. design as a predisposing or precipitating factor for peri-
101. Heydecke G, Pierre Boudrias MAA, de Albuquerque Jr RF, implant disease: A review. Clin Implant Dent Relat Res. 2023;
Lund JP, Feine JS. Within-subject comparisons of maxillary fixed
25(4):710‐722. doi:10.1111/cid.13183
and removable implant prostheses. Clin Oral Implants Res. 2003;
14(1):125-130.