Implant Maintenance

CLINICAL

Prosthetic design and choice of components for

maintenance of optimal peri-implant health: a
comprehensive review
Martin Janda*1 and Nikos Mattheos2,3

Key points
Certain design elements of the Avoiding convex and overcontoured The decision to use non-original The selection between original
contour of implant prostheses have prostheses near the bone level, as components involves a trade-off and non-original dental implant
been associated with mucositis, well as at the mucosal margin, can between cost savings and increased components can involve visible
peri-implantitis, early marginal help decrease the risk for long-term risks associated with performance macroscopic differences, such as
bone loss and recession. complications and inflammation. and longevity. The use of original length and engagement, as well
components is recommended for as critical microscopic variations,
optimal long-term success in dental impacting fit and precision, even
implant treatments. While non-original when not visually apparent.
components may offer cost reductions,
their use raises concerns about
compatibility issues, improper fit, and
compromised stability, potentially
leading to mechanical complications
and a higher risk of adverse outcomes
compared to original components.

Abstract
Current research has identified features of the prosthetic design with potential to significantly impact the long-term
health of peri-implant tissues, while the choice of prosthetic components is also shown to be critical in an effort to
reduce long-term complications of implant therapy. Overcontouring of the prosthesis emergence profile has been
associated with marginal bone loss, recession and peri-implantitis, while the mucosal emergence angle is shown
to have a strong association with peri-implant tissue inflammation. Further elements of interest include convexity/
concavity of the restoration, the prosthetic connection and the different geometric configurations of junctions, as well
as the peri-implant tissue dimensions. With regards to implant components, the choice between original and third-
party-manufactured components might come with implications, as differences in material and microgeometry might
impact precision of fit and overall performance, potentially leading to complications. Scrutiny of the specifications and
manufacturing is essential when third-party-manufactured components are considered.
The aim of this narrative review was to summarise the current evidence with regards to the restorative features of
the implant prosthesis and also the selection of prosthetic components which can have implications for the long-
term success of the implant therapy. Furthermore, the review aimed at interpretating current scientific evidence into
meaningful strategies and recommendations to implement in clinical practice of implant dentistry.

Introduction has contributed to the evolution of new and restorative clinical procedures, but
paradigms in implant therapy, with emphasis also competence with designing an implant
Implant dentistry has long been established as in planning of the entire treatment before prosthesis that can best serve long-term
an effective and predictable treatment modality the intervention, as well as the design of all successful clinical outcomes.
for edentulism. The introduction of digital surgical and prosthetic components. Three- The prosthetic design has, in the past, been
workflows into contemporary implantology dimensional imaging and computer-assisted linked to increased risk for peri-implantitis,3
design and manufacturing (CAD/CAM) as well as marginal bone loss,4 but early
1
Department of Prosthodontics, Faculty of Odontology, have empowered clinicians to completely research in this field was scarce and did not
Malmö University, Sweden; 2Department of Oral and
individualise the treatment plan, ‘visualise’ attempt to identify, describe or quantify the
Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn
University, Thailand; 3Department of Dental Medicine, the optimal prosthesis and consequently exact prosthetic design elements responsible
Karolinska Institute, Stockholm, Sweden. define the appropriate implant position before for this increased risk observed. The concept
*Correspondence to: Martin Janda
Email address: [email protected] any clinical intervention.1 Computer-assisted of the implant supracrestal complex has
Refereed Paper.
implant surgery can be thereafter used to been introduced to describe this essential
Submitted 29 October 2023 precisely transfer the planned treatment to interrelation of prosthetic components, human
Revised 7 January 2024 the individual patient.2 Consequently, the tissue and bacteria5 and set the framework
Accepted 11 January 2024 responsibility of the implant dentist today is to help identify the critical features that
https://doi.org/10.1038/s41415-024-7357-0
not only to ensure proficiency of the surgical can support long-term clinical success or

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 CLINICAL

Table 1 Studies assessing the contour of the emergence profile by measuring specific angles. The first generation consists of
methodologies mainly based on Periapical Radiographs (PR) and tangent contour lines (TCLs), while a second generation is emerging
introducing measurements on 3D imaging and plane/point defined angles (PPDAs)

First generation Second generation

Authors Study Methods Results Authors Study Methods Results

• Cone beam
computed Increase MEA
Katafuchi et al. • PR >30o CA associated with Rungtanakiat
Cross-sectional Cross-sectional tomography (CBCT) associated with
2018 • TCL increased peri-implantitis et al. 2023
• Optical scan higher inflammation
• PPDA
>30o CA + convex
• PR • Optical Scan
Yi et al. 2020 Retrospective associated with increased Mancini et al. In vitro N/A
• TCL • PPDA
peri-implantitis

Mahzoud et al. • PR >30o CA associated with

2020 • TCL increased peri-implantitis

• Optical
No influence of CA on
Lopps et al. Cross-sectional • Scan
peri-implantitis
• TCL

No influence of CA on
Prospective – peri-implantitis
• PR
Strauss et al. randomised
• TCL
clinical trial CA <40° may limit the initial
marginal bone loss
• PR
• CBCT
No influence of CA on
Inoue et al. 2020* Cross-sectional • Optical
peri-implantitis
scan
• TCL
• CBCT
Pelekos et al. • Optical Increase MEA associated with
Cross-sectional
2023* Scan higher prevalence of mucositis
• TCL
• PR >28–34 o DA associated with
Han et al. 2023** Retrospective
• PPDA increased marginal bone loss
Key:
* = Study used 3D imaging for measurements but assessed angles by means of TCLs.
** = Study used PRs for measurements but assessed angles by means of PPDAs.

predispose to complications. This multifaceted will include key considerations such as the reproducibly defined or associated with
interrelation has been illustrated in recent role of the prosthesis contour and emergence specific design features. Although such studies
clinical research6 where design features of profile, as well as the different parameters offered significant insight in the influence of
the prosthesis emergence profile have been that have been used in research to describe prosthetic choices to the long-term condition
linked with mucositis,7 peri-implantitis,8,9,10 it. Furthermore, this review will summarise of the peri-implant tissue, the prosthetic
recession11 or increased marginal bone loss.12,13 the current evidence on the influence of design features were vaguely defined and
Furthermore, the choice of the components using non-original components and potential clinical interpretation of the results was limited
which constitute critical parts of the implant- implications for long-term clinical outcomes. by several confounding factors. The first
abutment-prosthesis complex can add to structured attempt to ‘quantify’ design features
the complexity of the design features and Design elements connected with and relate them to risk for peri-implantitis
potentially influence long-term clinical peri-implant tissue health and was the study by Katafuchi et al. 2018,8
outcomes 14 through both biological and disease which assessed the contour angle (CA) of the
technical complications, events which are often prosthesis on peri-apical radiographs (PRs)
interrelated.15 Several prosthetic elements have, in the and found an association with prevalence of
The aim of this review is to summarise past, been associated with increased risk for peri-implantitis.
the evidence on the importance of the mucositis or peri-implantitis.16 Rather than
prosthetic design features for the long-term actual design features, however, early studies Contour of the prosthesis and the
health of the peri-implant tissue, review how mainly assessed prosthetic choices, such as respective characteristic angles of the
these features can be clinically assessed, and screw versus cement retention,17,18,19,20,21,22,23,24 restoration
discuss respective clinical recommendations tissue versus bone level implants,25 use or no The association of the prosthesis contour
to support decision-making and appropriate use of prosthetic abutment26 or ‘accessibility with risk for periodontal inflammation is
design of the implant therapy. This exploration for oral hygiene’,3 which, however, was not something well-documented on natural teeth.

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 CLINICAL

per the Glossary of prosthodontic terms: www.

academyofprosthodontics.org/lib_ap_articles_
download/GPT9.pdf). A further confounder
was that the EA in these studies was calculated
based on different landmarks for bone-
level as opposed to tissue-level implants,
introducing some source of bias in the
calculations. Nevertheless, these first studies
collectively conveyed an important message
that overcontouring the prosthesis close to the
bone margin is associated with higher risk of
marginal bone loss in the short- to medium-
term, something that has been suggested
in animal and clinical studies as well.12,29,30
Whether there is a true increased risk for
peri-implantitis, or the observed association
is due to the marginal bone loss being anyway
the major diagnostic determinant for the
definition of peri-implantitis in cross-sectional
and retrospective studies, remains to be
clarified in future research.
A second generation of studies has been
recently introduced, where 3D optical and
radiographic imaging is used together
with specific planes and points in order to
reproducibly calculate precise dimensions and
angles of the prosthesis and further associate
Fig. 1 Cross-sectional studies based on PRs have associated the CA (right) with increased them with clinical outcomes (Table 1). In a
prevalence of peri-implantitis. A next generation of studies, however, by means of 3D imaging, cross-sectional study, Rungtanakiat et al.7
have identified and studied separately the MEA (top left) and the DA (bottom left). The first
analysed the emergence profile using eight
has been associated with increased risk for inflammation (mucositis) of the peri-implant tissue
and the latter with early bone remodelling and marginal bone loss vertical planes for each crown. Not surprisingly,
the key for the prevention of inflammation was
the angle of the implant prosthesis at the point of
The concept of the ‘emergence angle’ (EA) study of this type concluded that the CA of emergence through the oral mucosa, which was
was actually introduced to study the contour implant-supported crowns may limit the defined as ‘mucosal EA’ (MEA). Although no
of fixed dental prostheses on natural teeth initial marginal bone loss when <40° but cut-off value was suggested, it was evident that
at the critical point of emergence through without resulting in a significant difference the risk for inflammation of the peri-implant
the gums.27 The same concept for dental in the long-term and without association to tissue rose steeply when this angle exceeded
implants, however, took much longer to peri-implanitis.11 40–45o, reaching an odds ratio of 33 when the
materialise. As implant dentistry was initially This ‘first generation’ of studies represented angle was 70o. Furthermore, a MEA of 60–70o
focused on osseointegration, it required a first attempt to describe the elements of the was more likely to inhibit correct probing, thus
several decades to awaken to the importance prosthetic design and quantify the respective limiting the ability to clinically diagnose peri-
of the prosthesis-tissue interface and how associated risks, albeit under certain limitations. implantitis. The same study assessed separately
the design of the transmucosal complex can Defining the prosthesis ‘overcontour’, solely by the angle of the abutment as it ascends from
influence both aesthetics and long-term tissue means of two-dimensional PRs, implied that the bone platform, which the authors described
health. The discussion of the ‘emergence the complex three-dimensional (3D) structure as ‘deep angle’ (DA), as well as the ‘total CA’,
profile’ was present in several publications. It of the implant supracrestal complex was which represented the same angle which was
remained, however, in the realm of empirical approached only by the limited information previously assessed in PRs (Fig. 1). Neither
investigations or expert opinion.28 Katafuchi provided in the interproximal projection. of the two was found to be associated with
et al. 20188 showed that ‘overcontouring’ of Furthermore, as the calculation of the CA peri-implant tissue inflammation. A similar
the prosthesis more than 30o, as this contour was based on tangent lines without specific 3D model for the analysis of the emergence
appears in PRs, was correlated with increased and reproducible landmarks, a high degree profile was proposed recently by Mancini et al.
risk for peri-implantitis in bone-level implants. of subjectivity was inevitable. Finally, the 2023,31 albeit assessed only in vitro at present.
His study was followed by four more where PRs did not account for the position of the Collectively seen, these results suggest the
measurements were conducted with a similar soft tissue, thus the estimation of a true ‘EA’ presence of multiple areas of interest within the
approach on PRs, albeit not always confirming was not possible, as this can only be done in emergence profile: the circumferential area of
these results (Table 1). The only prospective relation to the ‘circumscribed soft tissues’ (as the prosthesis at the mucosal margin and the

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area at the base of the implant supracrestal

complex, where the abutment is ascending
from the implant platform. The first is described
by the MEA and has been shown to associate
with mucositis,7,32 while the latter is described
by the DA and is shown to associate with early
marginal bone loss.11,12

Concavity – convexity of the emergence

profile
Convexity of the prosthesis emergence profile
is a feature which has been correlated with
increased recession,33 marginal bone loss13
and, when combined with overcontouring,
peri-implantitis.9 At the same time, there
appears no standard method for definition and
assessment of convexity or concavity, which in
most studies is conducted in a dichotomous
way by means of PRs with a rather high risk
of subjectivity.

Peri-implant tissue dimensions

Peri-implant soft tissue dimensions, and
in particular, the vertical ‘height’ of the
mucosa, has been also assessed as a parameter
important for health and stability. The initial
concepts of the peri-impant mucosa height
were influenced by concepts first described in
the periodontium, from the ‘biologic width’34
to the recently introduced ‘supracrestal tissue
Fig. 2 a, b) Original (a) and non-original (b) components used to support screw retained
attachment’.35 Terms such as ‘peri-implant
implant crowns. c) Crowns (c) and scanning electron microscopy images (a,b) where the
soft tissue barrier’,36 ‘peri-implant mucosa’37 macroscopic and microscopic differences are clearly visible45
and ‘peri-implant phenotype’38 have been
proposed to describe the peri-implant
tissues. These concepts have advocated the 22 o for implants placed subcrestally. The attachment loss. Consequently, whenever
importance of an essential minimum height impact of such design elements underscores feasible, the margins of implant-supported
of the mucosa in order to ensure stability of the importance of design-driven and precise prostheses should be positioned at or above
the soft and hard tissue in the long-term, implant placement for the long-term success the level of the mucosal margin surrounding
which has been approximated between of implant therapy.43 the implant. This placement facilitates access
2.5–4 mm in human histology studies.36,39,40 for effective biofilm control. If implant-
Failure to secure this soft tissue height has Re storative junctions and gaps supported reconstructions hinder access for
been associated with marginal bone loss,41 The recently introduced concept of the biofilm removal, adjustments should be made
recession and other soft tissue complications. implant supracrestal complex6 suggested that or the prostheses should be replaced with
Even more, as the implant position today is the dimensions and morphology of the peri- designs that are easier to clean.
determined by the position and margins of implant mucosa is closely reflecting the design
the prosthesis, allowing for a proper height of the respective prosthesis, from which it Original versus non-original
of soft tissue might be an imperative in cannot be studied in isolation. components
order to allow for a favourable emergence Research has shown that implants with
profile. As Puysis et al.42 have shown, the restoration margins located close to or above The selection of suboptimal implant
height of the implant supracrestal complex the mucosal line (supramucosal) result in components may exert detrimental effects on
and the emergence contour of the prosthesis significant reductions in probing depths after peri-implant health, manifesting as mucositis,
are closely interrelated, with the ‘shallow’ treating peri-implant mucositis compared to peri-implantitis and consequential bone
implant positioning the most likely to result those with margins located deeper below the loss. Given the potential repercussions on
in a wide CA of the prosthesis. This has been mucosal line (submucosal). This observation peri-implant tissue health, it is imperative to
also verified clinically, as Katafuchi et al.2 aligns with previous studies that have linked comprehend the implications associated when
found the average CA to be 29o for implants subgingival restoration margins in natural choosing implant components. Selection of
placed at crestal bone level but reduced to teeth to periodontal inflammation and implant components, either pre-fabricated

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of reputable manufacturers are necessary

to minimise the risks associated with non-
original components. Some studies suggest
the superiority of original abutments over
compatible CAD/CAM abutments,57 while
others indicate comparable performance
between the two.58 This observation is likely
indicative of the diverse standards in quality
of non-original component manufacturers
and specifications/precision of CAD/CAM
machines. The importance of calibrating,
testing and certifying such machines should
be emphasised for ensuring their optimal
functioning within dental laboratories.
Fig. 3 a, b) Original (a) and none original (b). Scanning electron microscope images where
Studies have shown that the component fit,
the fit of the abutment screw threads is clearly visible.44 This will lead to different friction and
causing different preload with the same torque applied especially in systems with conical connections,
is important to ensure a high success rate in
the long term.59,60 Fundamental engineering
or customised, can include components Does this difference matter? science identifies the fit and contact surfaces
manufactured by the same company which The use of non-original dental implant as critical factors for long-term stability
produces the implant system, or components components (such as abutments, titanium in any bolted joint, such as the implant
produced by third-party manufacturers. The bases, abutment screws and prosthetic abutment connection. Studies have shown
first are habitually referred to as ‘originals’, screws) can, at times, allow cost reduction, that non-original components often do not
while the latter as ‘compatible’, ‘non-originals’ but also increase risks associated with have as good a fit and contact surface as the
or ‘copycat’, and can be branded or generic. performance and longevity of the respective originals. 46,61 Under function,
Compatible components can also mimic the prosthesis.47 The dimensions and geometry such morphological differences can lead to
geometry and dimensions of the originals of such components may not be specifically manifestations of problems, such as screw
or follow other designs. The popularity of designed to match the specifications of loosening,49,62,63 screw fractures,62 implant
non-original dental implant components, the original implant system. This can lead fractures62,64 and, by extension, veneer cracks
in particularly prosthetic abutments, can be to compatibility issues, such as improper and ‘chip-off ’ fractures. 65 Furthermore,
primarily attributed to cost related reasons, fit,48,49,50,51,52 inadequate sealing,53 rotational deficient fit can create microgaps, which
as their use can often help reduce overall misfit, 54 leakage 53 and/or compromised could then serve as channels and reservoirs
treatment expenses. stability. Poor compatibility can, in of bacteria affecting the surrounding tissues.66
the longer-term, result in mechanical Some studies suggest the superiority of
Is there a difference? complications, including component original abutments over compatible CAD/
Macroscopic differences might be visible failure, screw loosening,55 or even implant CAM abutments, 57 while other indicate
between original and non-original fracture and loss. Original dental implant comparable performance between the two.58
components44 but this can vary depending components often benefit from extensive This observation is likely indicative of the
on the specific manufacturer, design and the research, clinical trials and long-term studies diverse standards in quality of non-original
precision of replication. For example, in the to ensure their safety and effectiveness. In component manufacturers and specifications/
case of prosthetic abutments, there can be contrast, non-original components may not precision of CAD/CAM machines. The
differences of length/height or insertion in have the same level of scientific validation importance of calibrating, testing and
the implant connection, and in the design and or long-term data available. This lack of certifying such machines should be emphasised
engagement of the anti-rotation (Fig. 2). documentation and evidence, as well as wide for ensuring their optimal functioning within
Even when no macroscopic differences diversity and lower standardisation, can dental laboratories.
are visible, there can be important diversity make it difficult to accurately predict their
observable at the microscopic level,44,45,46 long-term performance and assess potential Is it worth it?
which can impact the fit and precision of the complications. While complications Management of mechanical and hardware
dental components. Original components are associated with non-original dental implant complications, even if not frequent, can be
specifically designed to match the respective components are possible, it is also important demanding and time-consuming, can place
implant connection and geometry, ensuring to note that not all non-original components severe burdens on the clinician and the
precise fit. The same is not always true for are of poor quality or have high risk to lead patient,67,68 with risks for irreversible damages.
compatible components, which can vary in to adverse outcomes,54,56 especially as some For example, while retrieving fractured
microscopic dimensions, standardisation and/ branded third-party components come screws, there might be a risk of damaging the
or material, with potential implications in the with high-quality standards and warranty internal threads of an implant. Addressing
fit and further clinical performance of the that may offer satisfactory results. However, mechanical complications can be particularly
implant prosthesis (Fig. 3).44,45,46 careful evaluation, research and selection challenging when non-original components

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are used, as standard rescue protocols and Author contributions A cross-sectional study with 916 implants. Clin Oral
Implants Res 2017; 28: 144–150.
repair guidelines may not be applicable to Martin Janda: conceptualisation, writing – review 18. Ferreiroa A, Peñarrocha-Diago M, Pradies G, Sola-Ruiz
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retained implant-supported single-tooth restorations
morphology and geometry might inhibit Mattheos: writing – review and editing.
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