REVIEWS

The Implant Supracrestal Complex and Its

Significance for Long-Term Successful
Clinical Outcomes
Nikos Mattheos, DDS, MASc, PhD
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University,
Bangkok, Thailand; Department of Dental Medicine, Karolinska Institute, Sweden.

Ioannis Vergoullis, DDS, MS

Department of Periodontics, Louisiana State University, Baton Rouge, Louisiana, USA.

Martin Janda, DDS, MSc, PhD

Department of Prosthodontics, Malmö University, Malmö, Sweden.

Alberto Miseli, DDS

Department of Prosthodontics, Universidad Central de Venezuela, Caracas, Venezuela.

Emerging evidence implies significant interrelations between the condition of the peri-implant tissues and
the implant-abutment-prosthesis complex. A new paradigm for studying the peri-implant tissues in close
interrelation with the implant-abutment-prosthesis complex in the presence of the oral biofilm is essential.
The aims of this paper are to introduce the concept of the “implant supracrestal complex” (ISC) and to
describe the critical elements that define it as a unique anatomical and functional system of human tissues,
mechanical components, and oral bacteria/biofilm. This paper reviews recent evidence to identify the impact
of design features on short-term clinical outcomes and long-term health of the peri-implant bone and soft
tissues. Prosthetic-driven implant placement is a prerequisite for proper ISC design, which in turn can indirectly
influence the structure and dimensions of the peri-implant soft tissues. Design features of the implant-
prosthesis-abutment complex, such as the emergence profile, emergence angle, and cervical margin, as well
as the design of the implant-abutment and abutment-prosthesis junctions and their locations in relation to the
tissues of the ISC, can have a significant impact on the maintenance of stable and healthy peri-implant tissues
in the long term. Int J Prosthodont 2021;34:88–100. doi: 10.11607/ijp.7201

A
multitude of terms have been used to describe the peri-implant tissue coronal
to the marginal bone. Initial terms were a direct extrapolation of periodontal
terms, from the concept of the “biologic width”1 to the recently introduced
“supracrestal tissue attachment.”2 However, the significant anatomical and structural
differences between periodontal and peri-implant tissues (with the latter displaying
“attachment” only at the level of the junctional epithelium [JE]) do not allow for a
direct extrapolation of terms from the periodontium. Consequently, the terms “peri-
Correspondence to: implant soft tissue barrier,”3 “peri-implant mucosa,”4 “implant mucosal tunnel,”5
Dr Nikos Mattheos
and, most recently, the specific “peri-implant phenotype,”6 have been suggested to
Department of Oral and
Maxillofacial Surgery describe peri-implant tissues.
Faculty of Dentistry Although such definitions appear adequate for describing the peri-implant soft tis-
Chulalongkorn University,
sues, there is an increasing body of evidence pointing toward significant interrelations
Bangkok, Thailand
34 Henri Dunant Road, between the condition of the peri-implant tissue and the implant-abutment-prosthesis
Wangmai, Patumwan (IAP) complex, all in the constant presence of oral bacteria. Emerging evidence suggests
Bangkok, Thailand 10330
that factors such as the type of implant-abutment junction (IAJ) and prosthesis design
Fax.: +66-2218-8581
Email: nikos@mattheos.net and retention can have a significant influence on the short-term clinical outcomes
and long-term health of the peri-implant bone and soft tissues.7,8
Submitted June 15, 2020;
Consequently, a new paradigm is essential by which peri-implant tissues will be
accepted August 23, 2020.
©2021 by Quintessence studied in close interrelation with the IAP complex under the presence of oral bio-
Publishing Co Inc. film as one multi-element anatomical and functional unit. In such a system of close

88 The International Journal of Prosthodontics

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Mattheos et al

anatomical and functional interaction of the mechani- the zone of the CT and the JE occupying between 3 and
cal components and the human tissues, deficiencies or 4.5 mm3,15 in a vertical dimension. This zone, previously
problems in one of the parts might manifest problems called the “biologic zone” or “biologic width,”3 might be
clinically through complications in any of the other. Such genetically determined. Although individual studies have
a paradigm is well aligned with the emerging concept of suggested small differences in the JE and CT dimensions
health and chronic disease being perceived as symbiosis when different surfaces were used3,16 or when two-piece
or dysbiosis; ie, the outcome of complex interactions were compared to one-piece implants,17 at present, no in-
between human tissues and medical devices (such as tervention, surface, or implant design has been shown to
dental implants) and bacteria.9–11 predictably achieve any morphologic or structural changes
The aim of this paper is to introduce the concept of in these tissues.18,19 As with all anatomical structures, it is
the “implant supracrestal complex” (ISC) and to describe reasonable to assume that the dimensions of the CT and
the critical elements that define it as a unique anatomi- JE could present with natural, limited variations between
cal and functional system of human tissues, mechanical different individuals, different anatomical locations,20 or
components, and oral bacteria/biofilm. Furthermore, this different peri-implant tissue sites.
paper aims to review the current evidence on critical de- In contrast to the JE/CT zone, the peri-implant sulcus
sign features of the ISC that can contribute to long-term varies significantly in depth depending on the local anat-
sustainable and healthy outcomes or introduce risks. omy, the implant position, or the different sites around
the same implant, especially in the anterior maxilla.21,22
ANATOMY AND COMPONENTS OF THE IMPLANT Unlike natural teeth, where the healthy sulcus extends
TRANSMUCOSAL COMPLEX between 0.5 and 1.5 mm in depth, peri-implant sites
might present with a much deeper sulcus. The natural
The anatomical structures of the human tissues, the scalloping of the gingival tissues observed around teeth
mechanical components of the implant, abutment, and is a result of the corresponding scalloping of the underly-
prosthesis, and the oral bacteria are closely interrelated ing bone and the corresponding shape of the cemen-
toward maintaining health, as expressed through clinically toenamel junction (Fig 1). Such scalloping of the tissues
stable long-term outcomes. In this capacity, the ISC dis- has not been possible to maintain around implants,
plays elements of homeostatic regulation, and the tissues and the use of scalloped dental implants has resulted
of the ISC are in close anatomical and functional relation in increased bone loss.23 Consequently, the scalloping
with mechanical components through the interface of of peri-implant soft tissues—pronounced primarily in
osseointegration and epithelial attachment. Homeostasis the esthetic zone—is only possible with a peri-implant
can be thought of as a dynamic equilibrium rather than a sulcus depth of 3 to 5 mm at interproximal sites, while
constant, unchanging state, as tissues and cells respond the sulcus depth in the buccal sites of the implant could
to constant internal and external changes in order to be as little as 0.5 to 1.5 mm. It is therefore evident that
maintain long-term anatomical integrity and function. the concept of supracrestal attachment as described
around natural teeth cannot be applied to peri-implant
Anatomical Structures of Human Tissues in the ISC tissues. Similarly, a peri-implant sulcus deeper than 3
From apical to coronal in the vertical direction, the tis- mm is not to be confused with a periodontal pocket.
sues of the ISC are defined by the marginal bone (MB), The former is the outcome of tissue healing around a
the connective tissue (CT), the JE, and the sulcus, along clean biomaterial surface, while the latter is the result of
with the sulcular epithelium. slow apical migration of the JE due to a challenge from
In implants, CT appears with no vascular supply close biofilm-induced chronic inflammation.
to the abutment and very few fibroblasts, more resem- Taking into consideration the above information, it
bling a scar tissue. This is likely attributed to lack of becomes important to establish a minimum peri-implant
the PDL vascular complex.3 Blood vessels originating supracrestal vertical tissue height of about 3 to 4.5 mm
from the supraperiosteal complex are located in the that will adequately accommodate the biologic demands
lateral borders of the CT/JE zone. These blood vessels of sustainable health. In cases where the vertical height
are the origin of the immune response to bacteria in of the peri-implant tissue is less than 3 mm, marginal
the sulcus.12,13 In a process similar to that of teeth, peri- bone resorption has often been reported around the
implant crevicular fluid (PICF) is produced and flows into implant platform. This might be a physiologic remodel-
the sulcus through the JE. Analysis of PICF for protein ing that results in reestablishing the vertical dimensions
biomarkers such as proinflammatory cytokines, chemo- required to accommodate the soft tissues at the expense
kines, and bone turnover markers can reveal clinical and of the crestal peri-implant bone. Several researchers
subclinical inflammation.14 have correlated this pattern of early bone resorption
Although the great majority of histomorphometry stud- and preoperative supracrestal gingival tissue height.24,25
ies available are animal studies, human studies point to

Volume 34, Number 1, 2021 89

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Reviews

Fig 1  Natural scalloping of the periodon-

tal tissues corresponding to the interdental
CT
papilla is a result of the corresponding bone
JE Emergence
profile anatomy and root morphology of the natu-
ral teeth. Simulating this interproximal scal-
Cervical loping with implants, in particular in the
margin esthetic zone, is only possible with a deep
peri-implant sulcus at the interproximal sites.
The emergence profile remains the transition
from the bone crest to the cervical margin,
regardless of whether bone- or tissue-level
implants are utilized. Interproximal view of
the connective tissue (CT) and junctional
epithelium (JE) space, emergence profile
(yellow line), cervical margin (red line), and
interproximal sulcus depth (probe) for bone-
(left) and tissue-level (right) configurations
of the supracrestal complex.

Characteristics of the IAP Interface the most coronal part of the peri-implant mucosa to the
The critical design characteristics of the IAP complex implant platform for a bone-level implant, or as the most
that have been shown to impact the configuration of coronal intraosseous segment for a tissue-level implant
the peri-implant marginal bone and soft tissues will be (Fig 1). In the case of tissue-level implants, the soft tissue
discussed separately for bone-level and tissue-level im- collar of the implant constitutes the apical end of the EP.
plants. The authors consider all implants with a smooth The function of the EP is to ensure a proper transition
transmucosal collar that varies from 0.5 to 3 mm in verti- from the implant to the CM while allowing for adequate
cal height to be tissue-level implants, whereas bone-level space for the peri-implant tissues.
implants are implants without a transmucosal part that The emergence angle (EA), likewise, was defined as
are intended to be placed with bone contact for their “the angle between the average tangent of the transi-
entire length, while the transmucosal part is facilitated tional contour relative to the long axis of a tooth, dental
through a detachable abutment. Platform switching is implant, or dental implant abutment.” The EA has been
defined as a horizontal discrepancy between the diam- initially defined on natural teeth and was calculated by
eter of the implant shoulder of bone-level implants and bringing the tangent line on the crown to the point cor-
the diameter of the corresponding abutment.26 responding to the gingival margin. Thus, as defined on
Two critical design features of the IAP intended to be natural teeth, the EA represents the angle of the tooth
in close contact with the peri-implant soft tissues are or prosthesis crown at the exact “point of emergence”
the EP and the CM. The shape, position, and dimensions through the gingival tissues.27,28
of both the EP and CM could significantly influence the Two recent studies7,29 have measured the EA mesial
short- and long-term outcomes of implant treatment. and distal of implant restorations using periapical radio-
Furthermore, the IAP contains two important interfaces: graphs. The major limitation of radiographs is that they
the implant-abutment junction (IAJ) and the abutment- do not allow for estimation of the soft tissue margin;
prosthesis junction (APJ). thus, calculation of the EA was conducted without any
Understanding the influence of such design choices on relevance to the actual “point of emergence,” which was
the healing and long-term configuration of the bone and invisible in the radiographs. Instead, two points were
soft tissues is essential for successful clinical outcomes. defined, one on the shoulder of the bone-level implant
Emergence profile or the collar of the tissue-level implant and one on a
The EP is defined in the ninth edition of the Glossary selected point of the profile of the prosthesis, and the
of Prosthodontic Terms as “the contour of a tooth or tangent line was drawn. The clinical relevance of defining
restoration, such as the crown on a natural tooth, den- the EA in this manner and what it actually represents re-
tal implant, or dental implant abutment, as it relates to main to be further clarified. Such measurements include
the emergence from circumscribed soft tissues.” In this a significant risk of subjective judgment, as the convexity
definition, no differentiation is being made related to or concavity of the EP might influence the position of the
implants vs teeth; rather, the emphasis is placed on its second point and consequently the tangent line. Further-
interrelation with the “circumscribed soft tissues.” For more, the true emergence and level of the soft tissues
the purpose of this paper and based on the implant are not considered in the calculation of the EA, which
literature so far, the EP could be further defined as the might reduce the clinical relevance. Finally, when a mea-
entire transmucosal part of the IAP that extends from surement is conducted on tissue-level implants, the first

90 The International Journal of Prosthodontics

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Mattheos et al

Mucosal
margin

Sulcus

JE
CT
Sulcus CM

JE
CT

Fig 2   Tissues surrounding the emergence profile in a typical implant-abutment-prosthesis complex in the esthetic zone. Subcrestal place-
ment of this bone-level implant (in relation to the mesial and distal bone levels of neighboring teeth) has allowed for maintaining the desired
scalloping of the soft tissues, but resulted in an increased sulcus depth in the mesial and distal areas. Observe that implant position and the
design of the emergence profile allow for the cervical margin (CM) to coincide with the most coronal part of the sulcus, as in natural teeth.
JE = junctional epithelium; CT = connective tissue.

point is placed in a different location of the supracrestal prefabricated microgeometry, together with the lack of
complex than when in bone-level implants, which could platform switching, could limit the options when design-
also seriously affect the calculation of the EA. ing the EP in such implants. Two studies7,29 investigat-
Bone-level implants allow for the design of the EP ing the impact of the EP in peri-implantitis prevalence
in its entirety, and the angle of the emergence can be have, however, excluded the transmucosal collar when
determined by the prosthetic abutment. Although “pre- calculating the EA in tissue-level implant restorations.
fabricated” or “catalogue” abutments offer very little This might lead to inconsistencies when attempting to
variation in EP, current CAD/CAM custom-made abut- assess the impact of the EP between bone- and tissue-
ments allow for individual design of critical elements level implants.
such as the EA and convexity/concavity. Even prefabri- Cervical margin
cated abutments in many implant systems today come The CM of a prosthesis refers to the circumferential
with different cuff heights, thus allowing the selection margin, where the most coronal border of the peri-
of different angles for the EP. The additional ability of implant mucosa receives the most apical visible portion
platform switching in bone-level implants facilitates fur- of the prosthesis or “cervix.” Terms such as “restoration
ther customization of the EP. contour” or “soft tissue contour” have been used inter-
The EP of tissue-level implants starts with the smooth changeably in the past to describe this margin. The pres-
implant collar, which corresponds to the apical part of ent authors, however, would like to emphasize that the
the abutment in bone-level implants. This smooth col- CM is a feature of the implant prosthesis that is subject
lar provides the surface for CT adhesion and, depend- to the planning and design of the clinician, while the
ing on the height of the collar, possibly the whole or peri-implant soft tissue margin is the respective feature
part of the JE attachment. Both the angle and height of the peri-implant mucosa formed in response to the
of the soft tissue collar vary significantly between dif- CM. Around natural teeth, the CM will coincide with the
ferent implant systems and even in implants of differ- most coronal part of the periodontal sulcus. In implant-
ent types within the same system. Consequently, the supported prostheses, the CM is a prosthetic concept
design of the EP is predetermined for the most apical that is defined by the visible portion of the implant crown
couple of millimeters, as height and angle are defined by (Fig 2). Again, the CM ideally coincides with the most
the design and dimension of the soft tissue collar. This coronal part of the peri-implant sulcus.

Volume 34, Number 1, 2021 91

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Reviews

a b

remodeling.32 Bacterial and fluid mi-

croleakage has been related to oral
malodor, inflammation, and marginal
bone loss, apart from the potential
technical implications it could have
for the long-term tight fit of the
connection.33,34 On the other hand,
implants with an internal tapered
connection and platform switching
have been shown to increase con-
nection fit and stability30,35 and ef-
fectively prevent microleakage,36
while interface gaps are found to be
no more than 1 to 2 μm (Fig 3).37
c d Although implants with such con-
figurations have demonstrated clini-
Fig 3   Implant-abutment junction under scanning electron microscopy of bone-level implants.
(a and b) Astra Tech Morse Taper internal connection at ×32 and ×120 magnification, respec-
cally less marginal bone remodeling
tively. (c and d) Straumann Bone Level CrossFit connection at ×20 and ×55 magnification, re- during the first and consecutive years
spectively. The tight fit at the implant shoulder in both cases allows for a gap of less than 2 μm. postsurgery,38,39 microbiologic inves-
tigations have shown bacterial con-
tamination of the IAJ in both external
and internal connection types after 5
Implant-abutment junction years in function.40 Seen collectively,
The interface between the implant and the abutment is probably the most such results suggest that although
studied and best documented junction, and knowledge in this area has the connection design might influ-
evolved significantly as a result. The original configuration of an external hex, ence bacterial activity levels qualita-
flat-to-flat connection of Brånemark implants has been followed by a wide tively and quantitatively, no design
array of designs, with the most notable changes being the internal tapered has been shown to be completely
connections and the concept of platform switching. The original flat-to-flat immune clinically to effects of micro-
external connection was reported to allow wider micromovement30 and leakage in the long term. At the same
also potential microleakage.31 The fact that in this configuration the IAJ time, it should be noted that not all
was placed at bone level might have been the reason for the marginal bone implant configurations might achieve
resorption or remodeling observed during the first months postsurgery, very tight fit of the IAJ, in particular
which might have led to the wide acceptance of 1.5 mm of marginal bone when third-party prosthetic compo-
loss during the first year postsurgery as a biologic consequence of bone nents are used (Fig 4).

92 The International Journal of Prosthodontics

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Mattheos et al

Tissue-level implants are not de-

signed to have an IAJ at bone level,
but rather more coronally in the ISC,
depending on the height of the im-
plant soft tissue collar. In the time of
flat-to-flat external hex connections,
the absence of an IAJ on tissue-level
implants was considered by many a
“safer” configuration, as it eliminated
the risks associated with the junction
being close to the marginal bone.
Nevertheless, the height of the soft
tissue collar is an important parame-
ter, seen under the light of the current
understanding of essential vertical di-
mensions of soft tissues. A soft tissue
collar of less than 2 mm might be a b
too short to properly accommodate
the adequate soft tissue vertical di-
mensions. Furthermore, the IAJ on
tissue-level implants is less precise,
even if it is tight. As the abutment sits
externally on the implant collar, minor
vertical discrepancies are shown to
result in a significant “undercut” of
50 to 100 μm (Fig 5),41 which might
turn into a plaque-retentive point if
populated with biofilm. As this junc-
tion is almost always located in the
apical section of the sulcus, continu-
ous apical migration of the biofilm
reaching this point could exacerbate
the vicious circle of peri-implant tissue
inflammation. This might reduce the
c d
ability to disinfect the implant after
being affected by mucositis if this Fig 4   Scanning electron microscopy of Straumann Bone Level implant restored with (a and
junction is placed deep in the ISC.5 b) Straumann CARES abutment and (c and d) third-party abutment at (a, c) ×20, (b) ×40, and
(d) ×27 magnification. Deficient fit of the abutment in the coronal part of the internal con-
Abutment-prosthesis junction
nection is evident in (c) and (d).
The APJ can be present in both
bone- and tissue-level implants, but
varies significantly between implant
systems and types of restoration. In
certain one-piece APJ configurations
(eg, precious alloy abutments where Prosthesis cemented on an extraorally cementable screw-retained abut-
the prosthesis is being cast on the ment, such as a titanium base. In this configuration, the often milled or
abutment), this junction might not CAD/CAM prosthesis will be cemented outside the mouth. The prosthesis-
be detectable clinically, as the abut- abutment complex is then polished and placed in the mouth as a one-piece,
ment and the prosthesis are fused. screw-retained restoration.42 The extraoral cementation eliminates the risk
When present, the APJ is intended of cement rests, but a thin layer of cement is very likely to be exposed in
to be within the sulcus and is thus the APJ, even in ideal conditions (Fig 10).43 Even when tight, the interface
of high clinical significance. between the abutment and prosthesis in such cases can result in some
The interface between the implant discrepancies that can act as plaque retention points. An alternative con-
and prosthesis is commonly struc- figuration is a prosthesis cast on top of a base abutment, which will result in
tured in one of four different ways a one-piece restoration without any clinically detectable interface between
(Figs 6 to 9): the abutment and prosthesis.

Volume 34, Number 1, 2021 93

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Reviews

a b

c d

Fig 5   Implant-abutment junction under scanning electron microscopy of tissue-level implants. (a and b) Straumann Tissue Level synOcta
connection with gold abutment at ×30 and ×100 magnification, respectively. (c and d) Straumann Tissue Level synOcta connection with
third-party titanium abutment at ×13 and ×100 magnification, respectively. Observe the tight fit between the implant and abutment at the
shoulder, which in both cases allows for a gap of less than 2 μm. However, the horizontal discrepancy in both cases creates an “undercut”
exceeding 50 μm.

Prosthesis cemented on an intraorally cementable with one or two screws for every implant. Tight fit of
screw-retained abutment. In this configuration, the both the IAJ and APJ is paramount for preventing mi-
prosthesis will be cemented in the mouth typically due croleakage and plaque retention.
to esthetic requirements when the implant angle is not Prosthesis attached directly to the implant (without
optimal. In such cases, the APJ coincides with the ce- an intermediate abutment). A typical example of this
mentation level, so it is important to place it as close configuration would be a milled partial denture at the
to the sulcus opening as possible. The risk of cement implant level. This will result in one screw retaining
rests increases significantly when this junction is placed the prosthesis on each implant. Studies have shown
deeper in the sulcus.44 Cement rests can constitute a prostheses of this type on bone-level implants to pres-
major long-term risk by being pushed under the JE, ent with increased risk of bone resorption,46 possibly
jeopardizing the integrity of the ISC, and/or acting as related to increased risk of misfit. The tight fit of this
plaque retention points.45 junction, as well as the absence of misfit, discrepancies,
Prosthesis retained by a screw on an intermediate and gaps, is of paramount importance, since otherwise
abutment. This configuration will result in a restoration bacterial products will directly affect the sulcus through

94 The International Journal of Prosthodontics

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Mattheos et al

Fig 6  Schematic representation

of common types of implant-abut-
ment-prosthesis configurations for
bone-level implants. (a) Prosthesis
cemented on an extraorally ce-
mentable abutment, such as a tita-
nium base. (b) Prosthesis cemented
on an intraorally cementable abut-
ment. (c) Prosthesis retained by
a screw on an intermediate abut-
ment. (d) Prosthesis attached di-
rectly to the implant (without an
intermediate abutment).

a b c d

a b

c d

Fig 7  Details of the implant-abutment-prosthesis interfaces of (a) a prosthesis cemented extraorally on the abutment; (b) a prosthesis
cemented on an intraorally cementable abutment; (c) a prosthesis retained by a screw on an intermediate abutment; and (d) a prosthesis at-
tached directly to the implant (without an intermediate abutment) in bone-level implants. Red line = peri-implant soft tissues and emergence
profile; blue line = prosthesis-abutment junction; yellow line = implant-abutment junction.

Volume 34, Number 1, 2021 95

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Reviews

Fig 8  Schematic representation

of common types of implant-abut-
ment-prosthesis configurations for
tissue-level implants. (a) Prosthesis
cemented on an extraorally ce-
mentable abutment such as a tita-
nium base. (b) Prosthesis cemented
on an intraorally cementable abut-
ment. (c) Prosthesis retained by a
screw on an intermediate abut-
ment. (d) One-piece prosthesis cast
on abutment.

a b c d

a b

c d

Fig 9   Details of the implant-abutment-prosthesis interfaces of (a) a prosthesis cemented extraorally on the abutment; (b) a prosthesis ce-
mented on an intraorally cementable abutment; (c) a prosthesis retained by a screw on an intermediate abutment; and (d) a prosthesis cast
on the abutment in tissue-level implants. Red line = peri-implant soft tissues and emergence profile; blue line = prosthesis-abutment junction;
yellow line = implant-abutment junction.

96 The International Journal of Prosthodontics

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Mattheos et al

microleakage and/or plaque retention. In vitro studies

have also documented that even small misfit in partial
dentures with this configuration can have detrimental
effects on the veneer as well.46,47 Certain laboratory
manufacturing processes resulting in an oxidation layer
on the surface of the prosthesis might affect the tight
fit, as the oxidation layer has to be removed often with
airborne-particle abrasion, thus altering the surface of
the prosthesis that connects to the implant.41

Bacteria: Oral Biofilm

Plaque accumulation is detrimental for the health of
peri-implant tissues. Studies of experimental peri-im-
plant mucositis in humans have shown that undisturbed
plaque accumulation will lead to inflammation of the
peri-implant tissues within 3 weeks without any excep-
tions.5,48–50 At this point it is important to emphasize
that detrimental peri-implant inflammation is not caused
by the presence of bacteria in the sulcus in planktonic
status, but is rather the result of accumulation of mature
pathogenic biofilm. Biofilm formation requires a solid
hard surface and a liquid environment infected with bac-
teria. As both conditions are met on the prosthesis sur-
face, the biofilm forms first on the part of the prosthesis
that is exposed in the oral cavity and first interacts with Fig 10   Portion of prosthesis under scanning electron microscopy
the soft tissues at the CM. Establishment of a mature, (×40 magnification) after extraoral cementation on a titanium abut-
ment and polishing. A thin layer of cement is present in the interface
pathogenic biofilm at the CM will require at least 7 to 14
between the prosthesis and the abutment. The undercut between
days, after which it will provoke the immune response the implant and abutment is also visible.
and lead to inflammation of the oral mucosa.5,48–50 In
the case of oral mucosa not in proximity to implants, the
inflammation remains limited superficially in the mucosa;
as, for example, under an uncleanable prosthesis pontic
or a denture. However, biofilm accumulation in close
proximity to the peri-implant sulcus leads to an inflam-
matory response from the peri-implant soft tissue mar- response to plaque accumulation than at teeth,51 sug-
gins and the sulcular epithelium, leading to peri-implant gesting that plaque control around implants may be of
mucositis and kickstarting a vicious circle that eventually critical importance in averting the cascade of destruc-
results in apical migration of the JE, peri-implantitis, and tive inflammatory peri-implant disease. There are two
formation of a peri-implant pocket. There is at present main factors that can expose the peri-implant sulcus to
no evidence that sulcus depth influences the initiation the detriments of biofilm accumulation: deficient oral
of peri-implant mucositis. On the contrary, a study of hygiene and improper design of the CM. The former
experimental mucositis5 showed that peri-implant tissues requires proper training and motivation from the pa-
around shallow and deep sulci remained equally healthy tient, while the latter is an iatrogenic condition. When
with the application of professional maintenance care the CM coincides with the coronal margin of the peri-
and self-performed oral hygiene, thus maintaining a implant sulcus, oral hygiene can efficiently remove the
biofilm-free CM. The same study, however, also sug- biofilm from the proximity of the sulcus (Fig 2). On the
gested a less favorable pattern of resolution when peri- contrary, a nonanatomical cervical margin, as created
implant mucositis was initiated in tissue-level implants by the commonly used stock abutments that are cylin-
with a deeper sulcus. drical in shape, can be located away from the sulcus,
resulting in a horizontal discrepancy between the CM
Clinical Implications for Design of the ISC and sulcus (or a “ridge lap”). Plaque accumulation in
The ISC and plaque-induced peri-implant proximity of the sulcus can then proceed with little or
inflammation no inhibition from oral hygiene, posing a significant risk
Recent evidence has demonstrated that peri-implant and increasing the prevalence of peri-implantitis.52 The
tissues in particular mount a greater host-inflammatory wider the prosthesis, the bigger this ridge lap becomes;

Volume 34, Number 1, 2021 97

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Reviews

a b

Fig 11   Placement of this bone-level implant in a shallow and palatal position has resulted in the need for a ridge lap in order to fulfill the
esthetic requirements of the prosthesis. A = the vertical height. B = the ridge lap of the cervical margin of the prosthesis, inhibiting the success
of plaque control for the opening of the sulcus buccally.

in particular as the restoration location moves anterior to The ISC and implant-abutment/prosthesis
posterior, since the lateral size of the prosthesis increases. junctions
An improper CM could further inhibit monitoring of Attention must be paid to the risks presented by any
the health of peri-implant tissues, preventing efficient gaps within the supracrestal complex, such as those that
probing or resulting in a false negative probing depth might be created in the IAJ or IPJ. If not tight enough,
and thus underestimating the extent of bone loss.53 As such interfaces might facilitate microleakage and circula-
the design of the CM is key for access to oral hygiene tion of bacterial products into the ISC, while micromobil-
and sustainability, calculation of the EA in an implant ity of the components might also contribute to problems.
prosthesis for exactly this location might be a much more Furthermore, gaps within the ISC might act as retention
clinically relevant measurement, as if it was conducted points when infected with biofilm, possibly inhibiting
on natural teeth.27 A tangent line to the CM of the im- disinfection efforts with professional means and oral
plant prosthesis might reflect the ability to maintain oral hygiene and complicating the resolution of inflamma-
hygiene much more precisely than a line drawn for the tion. Modern bone-level implant systems with internal
whole EP. A wide EA there would approximate a ridge connection can achieve a very tight fit in the IAJ, which
lap and inhibit oral hygiene, while a narrow one would can be at the level of 1 to 2 μm. In addition, in the case
resemble the EA reported for natural teeth.27,28 To do of bone-level implants with platform switching, the IAJ
such a calculation on implants, however, would require remains well apical of the JE, and is thus potentially
a precise location of the mucosal margin, which cannot protected by direct plaque contamination in the early
be done through radiographs. stages of mucositis. Nevertheless, screw loosening of
Avoiding the need for a ridge lap design necessitates the healing, temporary, or prosthetic abutment at the
placement of the implant in the optimal restorative posi- bone-level implant could potentially be more detrimental
tion, angle, and depth (Fig 11). Katafuchi et al showed to the bone margins and tissue health than in the case
a correlation between the depth of placement of bone- of a tissue-level implant.
level implants and the EA, with the latter being more The IAJ of tissue-level implants presents with a differ-
favorable when implants were placed subcrestally.29 ent configuration; however, the fit of the components
This indicates that although subcrestal placement of can be equally tight in the range of 1 to 2 μm (Fig 5).
bone-level implants should not be seen as the norm, it Depending on the height of the smooth collar, this junc-
might be essential if directed by the need to create the tion is in most cases exposed in the sulcus coronal of the
desired prosthesis contour, CM, and EP. JE or close to the sulcus opening and is thus more easily

98 The International Journal of Prosthodontics

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Mattheos et al

accessible through oral hygiene. Abutment loosening physiologic variation between individuals or different
in this case might be less detrimental than in the case anatomical sites in the same person.20 Histologic studies
of bone-level implants. Nevertheless, if this interface is in humans are scarce and typically based on very few
deep in the sulcus, as in the case of increased vertical samples. Even so, the means describing the dimensions
dimension of the soft tissues or in subcrestal placement, are accompanied by high standard deviations, which is
this area could act as a difiicult-to-disinfect retention suggestive of significant variation.
point if colonized with biofilm. It is therefore advisable
to avoid the placement of tissue-level implants in sites ACKNOWLEDGMENTS
with increased vertical soft tissue height, which would
result in placing the IAJ several millimeters under the The authors would like to thank Professor Lisa Heitz-Mayfield for her
CM. Subcrestal implant placement is well documented critical review and important feedback to the writing of this paper.
The authors report no conflicts of interest.
in the case of platform-switching bone-level implants,
but should be avoided with tissue-level implants, as it
would result in less precise placement of the IAP junc- REFERENCES
tion (Fig 5) deep under the supracrestal complex tissues.
1. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the
dentogingival junction in humans. J Periodontol 1961;32:261–267.
Limitations 2. Caton JG, Armitage G, Berglundh T, et al. A new classification scheme
The present authors accept that the use of these terms for periodontal and peri-implant diseases and conditions – introduction
and the definitions of the respective anatomical and and key changes from the 1999 classification. J Periodontol 2018;45(sup-
pl 20):s1–s8.
morphologic structures correspond to a configuration in 3. Glauser R, Schüpbach P, Gottlow J, Hämmerle CH. Periimplant soft tissue
ideal conditions. For example, in the case of subcrestal barrier at experimental one-piece mini-implants with different surface
placement of a bone-level implant, the supracrestal topography in humans: A light-microscopic overview and histometric
analysis. Clin Implant Dent Relat Res 2005;7(suppl 1):s44–s51.
complex will be established from below the implant 4. Araujo MG, Lindhe J. Peri-implant health. J Periodontol 2018;89(suppl
crest, thus seemingly contradicting the term. The term 1):s249–s256.
“supraplatform implant complex” was thus proposed 5. Chan D, Pelekos G, Ho D, Cortellini P, Tonetti MS. The depth of the im-
plant mucosal tunnel modifies the development and resolution of experi-
to address such a configuration, but the authors ac- mental peri-implant mucositis: A case-control study. J Clin Periodontol
knowledge that such a term would be confusing in 2019;46:248–255.
the case of tissue-level implants, where the “platform” 6. Avila-Ortiz G, Gonzalez-Martin O, Couso-Queiruga E, Wang HL. The
peri-implant phenotype. J Periodontol 2020;91:283–288.
is already some millimeters coronal of the bone crest. 7. Yi Y, Koo KT, Schwarz F, Ben Amara H, Heo SJ. Association of prosthetic
Consequently, the authors have decided to describe the features and peri-implantitis: A cross-sectional study. J Clin Periodontol
anatomical and morphologic landmarks of importance 2020;47:392–403.
8. Chappuis V, Bornstein MM, Buser D, Belser U. Influence of implant neck
that will be present in most common IAP configurations design on facial bone crest dimensions in the esthetic zone analyzed by
while acknowledging that some very specific implant cone beam CT: A comparative study with a 5-to-9-year follow-up. Clin
systems or configurations might not fall exactly within Oral Implants Res 2016;27:1055–1064.
9. Ruby J, Barbeau J. The buccale puzzle: The symbiotic nature of endog-
this term. The terms have thus been described for bone- enous infections of the oral cavity. Can J Infect Dis 2002;13:34–41.
and tissue-level two-piece implants being placed for axial 10. Lasserre JF, Brecx MC, Toma S. Oral microbes, biofilms and their role in
loading. Even within this category of implants, significant periodontal and peri-implant diseases. Materials (Basel) 2018;11:1802.
11. Acharya A, Mattheos N. Gene expression signatures of experimental
diversity of design persists; for example, in the height foreign body reaction in normal peri-implant soft tissue. J Dent Res
and angle of the transmucosal collar of tissue-level im- 2019;99(Spec Issue A):1381.
plants, or the presence and extent of platform switching 12. Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the
vascular systems in the periodontal and peri-implant tissues in the dog. J
in bone-level implants. The authors also acknowledge Clin Periodontol 1994;21:189–193.
that there is a significant diversity of implant systems, 13. Kawahara H, Kawahara D, Mimura Y, Takashima Y, Ong JL. Morphologic
connections, and combinations with potentially different studies on the biologic seal of titanium dental implants. Report II. In vivo
study on the defending mechanism of epithelial adhesions/attachment
levels of precision and fit of components. The samples against invasive factors. Int J Oral Maxillofac Implants 1998;13:465–473.
that have been used for discussion in this paper originate 14. Güncü GN, Akman AC, Günday S, Yamalık N, Berker E. Effect of inflam-
from specific published research in peer-reviewed jour- mation on cytokine levels and bone remodelling markers in peri-implant
sulcus fluid: A preliminary report. Cytokine 2012;59:313–316.
nals and only address the conditions and results of these 15. Tomasi C, Tessarolo F, Caola I, Wennström J, Nollo G, Berglundh T.
investigations. The use of different materials for the Morphogenesis of peri-implant mucosa revisited: An experimental study
submucosal components, such as titanium, gold alloys, in humans. Clin Oral Implants Res 2014;25:997–1003.
16. Buser D, Weber HP, Donath K, Fiorellini JP, Paquette DW, Williams RC.
and ceramics, and also the use of nonoriginal prosthetic Soft tissue reactions to non-submerged unloaded titanium implants in
components and screws, might also impact the tissues beagle dogs. J Periodontol 1992;63:225–235.
and configuration of the supracrestal complex. 17. Judgar R, Giro G, Zenobio E, et al. Biological width around one- and
two-piece implants retrieved from human jaws. Biomed Res Int
Furthermore, the authors believe that, as with any 2014;2014:850120.
anatomical feature, the dimensions and structure of
the peri-implant tissues can present with significant

Volume 34, Number 1, 2021 99

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Reviews

18. Sanz-Martín I, Sanz-Sánchez I, Carrillo de Albornoz A, Figuero E, Sanz 37. Fokas G, Ma L, Chronopoulos V, Janda M, Mattheos N. Differences in
M. Effects of modified abutment characteristics on peri-implant soft micromorphology of the implant-abutment junction for original and
tissue health: A systematic review and meta-analysis. Clin Oral Implants third-party abutments on a representative dental implant. J Prosthet
Res 2018;29:118–129. Dent 2019;121:143–150.
19. Schwarz F, Messias A, Sanz-Sánchez I, et al. Influence of implant neck 38. Buser D, Chappuis V, Kuchler U, et al. Long-term stability of early
and abutment characteristics on peri-implant tissue health and stability. implant placement with contour augmentation. J Dent Res 2013;92(12
Oral reconstruction foundation consensus report. Clin Oral Implants Res suppl):176s–182s.
2019;30:588–593. 39. Noelken R, Donati M, Fiorellini J, et al. Soft and hard tissue alterations
20. Romanos GE, Traini T, Johansson CB, Piattelli A. Biologic width and around implants placed in an alveolar ridge with a sloped configuration.
morphologic characteristics of soft tissues around immediately loaded Clin Oral Implants Res 2014;25:3–9.
implants: Studies performed on human autopsy specimens. J Periodontol 40. Canullo L, Penarrocha-Oltra D, Soldini C, Mazzocco F, Penarrocha M,
2010;81:70–78. Covani U. Microbiological assessment of the implant-abutment interface
21. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri- in different connections: Cross-sectional study after 5 years of functional
implant mucosa: An evaluation of maxillary anterior single implants in loading. Clin Oral Implants Res 2015;26:426–434.
humans. J Periodontol 2003;74:557–562. 41. Mattheos N, Li X, Zampelis A, Ma L, Janda M. Investigating the
22. Ivanovski S, Lee R. Comparison of peri‐implant and periodontal micromorphological differences of the implant-abutment junction
marginal soft tissues in health and disease. Periodontology 2000 and their clinical implications: A pilot study. Clin Oral Implants Res
2018;76:116–130. 2016;27:e134–e143.
23. Tymstra N, Raghoebar GM, Vissink A, Den Hartog L, Stellingsma K, Mei- 42. Helvey GA. A simple technique for fabricating a screw-retained/cement-
jer HJ. Treatment outcome of two adjacent implant crowns with differ- ed implant-supported crown. Compend Contin Educ Dent 2017;38:153–
ent implant platform designs in the aesthetic zone: A 1-year randomized 159; quiz 160.
clinical trial. J Clin Periodontol 2011;38:74–85. 43. Mattheos N, Larsson C, Ma L, Fokas G, Chronopoulos V, Janda M.
24. Linkevicius T, Linkevicius R, Alkimavicius J, Linkeviciene L, Andrijauskas Micromorphological differences of the implant-abutment junction and in
P, Puisys A. Influence of titanium base, lithium disilicate restoration vitro load testing for three different titanium abutments on Straumann
and vertical soft tissue thickness on bone stability around triangular- tissue level implants. Clin Oral Implants Res 2017;28:1523–1531.
shaped implants: A prospective clinical trial. Clin Oral Implants Res 44. Linkevicius T, Vindasiute E, Puisys A, Linkeviciene L, Maslova N, Puriene
2018;29:716–724. A. The influence of the cementation margin position on the amount of
25. Vervaeke S, Dierens M, Besseler J, De Bruyn H. The influence of initial undetected cement. A prospective clinical study. Clin Oral Implants Res
soft tissue thickness on peri-implant bone remodeling. Clin Implant Dent 2013;24:71–76.
Relat Res 2014;16:238–247. 45. Staubli N, Walter C, Schmidt JC, Weiger R, Zitzmann NU. Excess cement
26. Canullo L, Fedele GR, Iannello G, Jepsen S. Platform switching and and the risk of peri-implant disease - a systematic review. Clin Oral
marginal bone-level alterations: The results of a randomized-controlled Implants Res 2017;28:1278–1290.
trial. Clin Oral Implants Res 2010;21:115–121. 46. Göthberg C, André U, Gröndahl K, Thomsen P, Slotte C. Bone response
27. Yotnuengnit B, Yotnuengnit P, Laohapand P, Athipanyakom S. Emer- and soft tissue changes around implants with/without abutments
gence angles in natural anterior teeth: Influence on periodontal status. supporting fixed partial dentures: Results from a 3-year, prospec-
Quintessence Int 2008;39:e126–e133. tive, randomized, controlled study. Clin Implant Dent Relat Res
28. Du JK, Li HY, Wu JH, Lee HE, Wang CH. Emergence angles of the cemen- 2016;18:309–322.
toenamel junction in natural maxillary anterior teeth. J Esthet Restor 47. Löfgren N, Larsson C, Mattheos N, Janda M. Influence of misfit on the
Dent 2011;23:362–369. occurrence of veneering porcelain fractures (chipping) in implant-sup-
29. Katafuchi M, Weinstein BF, Leroux BG, Chen YW, Daubert DM. Restora- ported metal-ceramic fixed dental prostheses: An in vitro pilot trial. Clin
tion contour is a risk indicator for peri-implantitis: A cross-sectional Oral Implants Res 2017;28:1381–1387.
radiographic analysis. J Clin Periodontol 2018;45:225–232. 48. Salvi GE, Aglietta M, Eick S, Sculean A, Lang NP, Ramseier CA. Reversibil-
30. Zipprich H, Weigl P, Ratka C, Lange B, Lauer HC. The micromechanical ity of experimental peri-implant mucositis compared with experimental
behavior of implant-abutment connections under a dynamic load proto- gingivitis in humans. Clin Oral Implants Res 2012;23:182–190.
col. Clin Implant Dent Relat Res 2018;20:814–823. 49. Zitzmann NU, Berglundh T, Marinello CP, Lindhe J. Experimental peri-
31. Rizzo R, Tripodi D, Iaculli F, et al. Bacterial leakage in external hexagon implant mucositis in man. J Clin Periodontol 2001;28:517–523.
implants with and without the interposition of a sealing-connector. Am J 50. Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman SR, Lang
Dent 2018;31:234–238. NP. Experimentally induced peri-implant mucositis. A clinical study in
32. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseoin- humans. Clin Oral Implants Res 1994;5:254–259.
tegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 51. Meyer S, Giannopoulou C, Courvoisier D, Schimmel M, Müller F, Mom-
1981;10:387–416. belli A. Experimental mucositis and experimental gingivitis in persons
33. Broggini N, McManus LM, Hermann JS, et al. Persistent acute inflamma- aged 70 or over. Clinical and biological responses. Clin Oral Implants Res
tion at the implant-abutment interface. J Dent Res 2003;82:232–237. 2017;28:1005–1012.
34. Broggini N, McManus LM, Hermann JS, et al. Peri-implant inflam- 52. Serino G, Ström C. Peri-implantitis in partially edentulous patients:
mation defined by the implant-abutment interface. J Dent Res Association with inadequate plaque control. Clin Oral Implants Res
2006;85:473–478. 2009;20:169–174.
35. Piermatti J, Yousef H, Luke A, Mahevich R, Weiner S. An in vitro analysis 53. Serino G, Turri A, Lang NP. Probing at implants with peri-implantitis
of implant screw torque loss with external hex and internal connection and its relation to clinical peri-implant bone loss. Clin Oral Implants Res
implant systems. Implant Dent 2006;15:427–435. 2013;24:91–95.
36. Discepoli N, Ferrari Cagidiaco E, Landini G, Pallecchi L, Garcia-Godoy F,
Ferrari M. Sealing effectiveness against Staphylococcus aureus of five
different implant-abutment connections. Am J Dent 2018;31:141–143.

100 The International Journal of Prosthodontics

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Copyright of International Journal of Prosthodontics is the property of Quintessence
Publishing Company Inc. and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.