Review

Platform switching minimises crestal bone loss around

dental implants: truth or myth?
G. E. ROMANOS* & F. JAVED

*School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA and

Engineer Abdullah Bugshan Research Chair for Growth Factors and Bone Regeneration, 3D Imaging and Biomechanical Laboratory, Col-
lege of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
SUMMARY The aim was to assess the role of platform
switching (PS) in minimising crestal bone loss
around dental implants through a systematic
review of the currently available clinical evidence.
To address the focused question Does PS minimise
crestal bone loss compared with non-platform-
switched (NPS) implants?, PubMed/Medline and
Google Scholar databases were explored from 1986
up to and including December 2013 using the
following key words in different combinations:
bone loss, dental implant, diameter, mandible,
maxilla and platform switching. Letters to the
Editor, unpublished data, historical reviews, case
reports and articles published in languages other
than English were excluded. Fifteen clinical studies
were included. In seven studies, PS and NPS
implants were placed in both the maxilla and
mandible. In 13 studies, implants were placed at
crestal bone levels whereas in one study, implants
were placed supracrestally. Three studies reported
the bucco-lingual (or transversal) width of the
alveolar ridge which ranged between 78 mm.
Seven studies reported that implants placed
according to the PS concept did not minimise
crestal bone loss as compared with NPS implants.
3D-Implant positioning, width of alveolar ridge and
control of micromotion at the implant-abutment
interface are the more critical factors that inuence
crestal bone levels than PS.
KEYWORDS: bone loss, peri-implantitis, platform
switching
Accepted for publication 30 April 2014
Introduction
Nearly three decades ago, Albrektsson et al. (1) sug-
gested that a crestal bone loss of 0102 mm per
annum after implant loading is a normal phenome-
non, which occurs due to crestal bone remodelling.
Early crestal bone loss may also facilitate the stagna-
tion and proliferation of anaerobic bacteria on exposed
implant surfaces, which if left uncontrolled may
increase the possibility of further bone loss in future
(2). Thus, implants placed at crestal levels are more
likely to be associated with a higher risk of implant
exposure over period of time as compared with sub-
crestally placed implants. The occurrence of such bone
loss may compromise the long-term prognosis of the
implant and if extensive, may ultimately cause
implant failure. Various factors that have been
reported to inuence crestal bone loss include peri-
odontal biotype (3, 4), bone density and formation of
biological width (5), implant placement depth (6),
interimplant distance (7), implant micro- and macro-
design (8, 9), occlusal overloading (10) and surgical
trauma (11). Although minimising crestal bone loss is
essential for the long-term success and survival of
implants; this objective continues to challenge clini-
cians and researchers as no authoritative treatment
protocol in this regard exists in indexed literature (12).
In implant dentistry, the concept of platform
switching (PS) is based on the placement of a narrow
diameter abutment on a wider diameter implant.
Implants placed according to the PS concept have
implant-abutment junction placed closer to the centre
2014 John Wiley & Sons Ltd doi: 10.1111/joor.12189
Journal of Oral Rehabilitation 2014 41; 700--708
J o u r n a l o f
Oral Rehabilitation
of the implant (horizontal mismatch). Studies (1317)
have reported that implants placed according to this
concept undergo minimal peri-implant bone loss as
compared with non-platform-switched (NPS) implants
(that is, implants with matching abutment
and implant body diameters). In a systematic review,
Al-Nsour et al. (18) supported the effect of PS on
minimising peri-implant marginal bone. Results from
this study (18) demonstrated that PS is a useful tech-
nique in minimising peri-implant bone loss as use of
abutments with smaller diameter than their corre-
sponding implant platform diameter exerts favourable
effects on peri-implant marginal bone levels. Likewise,
results from a prospective RCT (16) showed that irre-
spective of the surgical technique (one-stage or two-
stage implant placement), implants placed according
to the PS concept exhibited signicantly less bone loss
within the rst 2 years of placement compared with
NPS implants. However, controversial results have
also been reported. Results by Enkling et al. (1921)
showed no signicant inuence of PS in minimising
crestal bone loss compared with NPS implants. Clini-
cal results by Romanos et al. (22) emphasised that
control of micromotion at the implant-abutment con-
nection (IAC) plays a more critical role in maintaining
crestal bone levels than PS. The study concluded that
crestal bone loss around immediately loaded platform-
switched dental implants (placed at bone level) seem
to be associated with implant platform shape and
diameter under the requirement that abutments are
not removed (22). Similar results were reported in a
long-term RCT (23).
Based on the previous controversial results (1923)
that have been reported regarding the efcacy of plat-
form-switched implants in minimising bone loss, it is
speculated that the signicance of implants, placed
according to the PS concept remains dubious. The aim
of this study was to assess the role of PS in minimis-
ing peri-implant bone loss through a systematic
review of currently available evidence.
Materials and methods
Focused question
The addressed focused question was are dental
implants placed according to the PS concept more
effective in minimising crestal bone loss as compared
with NPS implants?
Eligibility criteria
The following eligibility criteria were applied: (i) origi-
nal studies; (ii) clinical and randomized controlled
trial (RCT) studies; (iii) intervention: role of implants
placed according to the PS in minimising crestal bone
loss; (iv) inclusion of a control group; and (v) articles
published only in English language. Letters to the Edi-
tor, experimental studies, case reports, commentaries,
review articles and unpublished studies were not
sought.
Search strategy
PubMed/Medline (*) and Google Scholar databases
were searched from 1986 up to and including Decem-
ber 2013 using the following key words in different
combinations: bone loss, dental implant; diameter,
mandible, maxilla and platform switching. Titles
and abstracts of studies that fullled the eligibility cri-
teria were screened and checked for agreement. Full
texts of studies judged by title and abstract to be rele-
vant were read and independently assessed in
accordance with the eligibility criteria. In addition,
hand-searching of the reference lists of potentially rel-
evant original and review studies was also performed
and checked for agreement via discussion among the
authors.
The initial search yielded 20 studies. Five studies did
not full the eligibility criteria and were excluded (see
Appendix A). In total, 15 studies (8, 1317, 1927)
were included and processed for data extraction.
Results
Characteristics of the studies included
All studies (8, 1317, 1927) were performed at uni-
versity settings. The numbers of participants ranged
between 880 patients, and the numbers of implants
placed ranged between 50360 implants. In these
studies (8, 1317, 1927), implants with abutment
diameters and platform diameters ranging between
336 mm and 3855 mm were used, respectively.
The average post-implant insertion healing period was
~4 months. Post-implant insertion follow-up periods
ranged between 12625 months (Table 1). Canullo
*National Library of Medicine, Bethesda, MD, USA
2014 John Wiley & Sons Ltd
P L AT F OR M S WI T C HI NG AND B ONE L OS S 701
et al. (8, 24, 25, 27) assessed crestal bone loss around
maxillary platform-switched implants, and in four
studies (15, 1921), the role of PS in minimising cres-
tal bone loss was assessed around implants placed
exclusively in posterior mandible. In seven studies
(13, 14, 16, 17, 22, 23, 26), platform-switched
implants were placed in the posterior maxilla and
mandible (Table 1).
Out of the 15 studies (8, 1317, 1927) included,
seven studies (8, 1923, 26) reported that implants
placed according to the PS concept do not reduce
crestal bone loss as compared with NPS implants.
Enkling et al. (19), Romanos et al. (22) and Canullo
et al. (25) reported the bucco-lingual widths of the
alveolar ridge, which were 7 mm, at least 8 mm and
7 mm, respectively. In 13 studies, (8, 1417, 1925,
27) implants were placed at crestal bone levels
whereas in one study (26), implants were placed in
fresh extraction sockets. In the study by Fernandez-
Formoso et al., (13) depth of implant placement
remained unclear (Table 2).
Discussion
From the literature reviewed, nearly 50% studies
(8, 1923, 26) reported no signicant difference in
crestal bone levels among platform-switched and NPS
implants. Studies (28, 29) based on PS concept usu-
ally credit the geometry of platform-switched implants
in contrast to NPS implants in terms of minimising
bone loss. However, contradictory results were
reported by Canullo et al. (8). In this study (8),
implants with abutment diameter 38 mm were
placed on a platform 43 mm in diameter (Group 1).
In Group 2, implants with abutment diameter
43 mm were placed on a platform 48 mm in diame-
ter. The 18 month follow-up results showed no signif-
icant difference in mean crestal bone loss around
implants in both groups. These authors suggested that
bone resorption is most likely related to biological fac-
tors, such as biological width re-establishment, rather
than to biomechanical factors, such as implant plat-
form diameter (8).
A critical parameter that remained unaddressed in
the methodology of most studies (8, 1317, 20, 21,
23, 24, 26) included in the present review is the
transversal width of the alveolar ridge. Implants
(whether platform-switched or NPS) placed in narrow
ridges are more likely to exert pressure on the buccal
plate of the alveolus thereby constricting the buccal
blood vessels and compromising the vascular supply
to the region as compared with implants placed in
arches with wider transverse widths. This is com-
monly associated with an increased crest bone loss and
compromised soft tissue architecture around implants.
It is noteworthy that in studies by Enkling et al. (19),
Romanos et al. (22) and Crespi et al. (26) implants
with body diameters ranging between 3355 mm
were placed in ridges with widths of 79 mm. How-
ever, results from these clinical trials (19, 22, 26)
reported no signicant difference in platform-switched
and NPS implants in terms of preservation of crestal
bone levels. These results (19, 22, 26) suggest that
wide ridges facilitate implant (whether platform-
switched or NPS) placement without jeopardising the
buccal vascular supply and crestal bone height in the
region. Interestingly, Canullo et al. (25) reported sig-
nicantly more bone loss around NPS implants com-
pared with platform-switched implants placed in a
ridge with 7 mm width; however, a limitation of this
study (25) was that radiographic evaluation only
assessed the mesial and distal bone level, whereas
buccal and oral bone levels remained uninvestigated.
In an experimental study on dogs, Abrahamsson
et al. (30) investigated the effect of repeated abutment
removal and xation on peri-implant marginal con-
nective tissues (CT). In this study (30), abutments on
the test side were removed and re-connected 59
throughout the 6 month study period whereas
implant abutments on the control side remained
undisturbed. The results demonstrated that repeated
abutment removal and reconnection resulted in sig-
nicantly more soft tissue recession on the test side
(about 15 mm) as compared with the control side
(approximately 07 mm) (30). An explanation in this
regard is that repeated abutment removal and recon-
nection (for example during the implant-level impres-
sions) induces micromotion at the IAC thereby
allowing microleakage and microgap formation (31).
In a recent RCT, Romanos et al. (22) assessed crestal
bone loss around two platform-switched implant sys-
tems (ANKYLOS plus

* and Certain

PREVAILTM

)
over a follow-up period of 24 months. At the follow-
up, both implant systems demonstrated at least 2 mm
*Dentsply Implants, Waltham, MA, USA

Biomet 3i, Palm Beach Gardens, FL, USA

2014 John Wiley & Sons Ltd
G. E . R OMANOS & F . J AV E D 702
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2014 John Wiley & Sons Ltd
P L AT F OR M S WI T C HI NG AND B ONE L OS S 703
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2014 John Wiley & Sons Ltd
G. E . R OMANOS & F . J AV E D 704
of crestal bone loss (11% and 70% of ANKYLOS
plus

and Certain

PREVAILTM systems, respectively)

with no signicant difference in mid-facial gingival
recession between the two implant designs (22).
Although these clinical results (22) support the exper-
imental outcomes reported by Abrahamsson et al.
(30), it is pertinent to mention that in the study by
Romanos et al. (22) crestal bone loss could not have
been associated with the IAC microgap because the
abutments were never removed and all implants were
splinted together (22). Moreover, both the implant
designs used in the study by Romanos et al. (22) had
Morse-tapered (conical) and internal polygonal abut-
ment connections. However, according to a previous
study (32), the superior mechanics of the conical
abutment connections help to explain the signicantly
better long-term stability in the clinical application.
Among the studies included in the present review
(8, 1317, 1927), implants were crestally placed in
12 studies (8, 1417, 1922, 24, 25, 27). Out of these,
50% studies (8, 1922, 26) reported PS to be ineffec-
tive in preserving crestal bone levels. According to
Albrektsson et al. (1), a 0102 mm of crestal bone
loss per annum after loading is a normal phenomenon
due to the crestal bone remodelling. Therefore,
implants placed at crestal levels are more likely to be
associated with a higher risk of implant exposure over
period of time as compared with subcrestally placed
implants. Results by Veis et al. (33) showed that cres-
tal placement of the IAC resulted in higher marginal
bone loss in straight and platform-switched abut-
ments. The study concluded that PS does not benece
bone levels and subcrestal placement of the abut-
ment connection is a vital factor that helps minimise
crestal bone loss (33). This suggests that subcrestal
placement of implants minimises the risk of implant
exposure and subcrestal placement of platform-
switched implants allows bone stability or growth
over the implant shoulder. However, in a recent clini-
cal study providing long-term results, Romanos et al.
(6) reported values for minimal marginal bone loss
around implants placed at crestal or subcrestal posi-
tion to be comparable with Morse-tapered connec-
tions without abutment removal. Further long-term
RCTs are needed in this regard.
A maximum follow-up duration period of 3 years
was observed in studies (1317, 24, 25, 27), which
reported PS to be effective in maintaining crestal bone
levels. However, in a long-term (at least 625 month
follow-up) longitudinal clinical trial, Romanos et al.
(23) showed that minimal crestal bone loss occurred
around PS implants placed in heavy smokers and
Table 2. Implant placement (crestal/subcrestal), alveolar ridge width, biological width and inuence of platform switching on bone
levels
Authors et al.
Implant
placement
Width of alveolar
ridge Biological width
Did platform switching
minimise BL?
Canullo et al. (8) Crestal NA NA No
Vandeweghe and De Bruyn (13) NA NA There was no signicant effect
of PS on BL when the BW was <6 mm
Yes
Fernandez-Formoso et al. (14) Crestal NA NA Yes
Trammell et al. (15) Crestal NA There was no signicant difference
in BW among PS and NPS implants
Yes
Prosper et al. (16) Crestal NA NA Yes
Telleman et al. (17) Crestal NA NA Yes
Enkling et al. (19) Crestal At least 7 mm NA No
Enkling et al. (20) Crestal NA NA No
Enkling et al. (21) Crestal NA NA No
Romanos et al. (22) Crestal At least 9 mm NA No
Romanos et al. (23) Crestal NA NA No
Canullo et al. (24) Crestal NA NA Yes
Canullo et al. (25) Crestal At least 7 mm NA Yes
Crespi et al. (26) Subcrestal NA NA No
Canullo et al. (27) Crestal Wide* NA Yes
BL, Bone loss; BW, biological width; NPS, non-platform-switched; PS, platform-switched.
*The precise width of the alveolar ridge was not reported.
2014 John Wiley & Sons Ltd
P L AT F OR M S WI T C HI NG AND B ONE L OS S 705
non-smokers (~05 mm mesially and ~04 mm in
smokers and non-smokers, respectively) using imme-
diate loading concept (23). It is noteworthy that in
the study groups, the implant abutments were never
removed and all implants were splinted together
immediately after surgery. This seems to have pre-
vented micromotion thereby maintaining crestal bone
levels. We hypothesise that earlier studies (1317, 24,
25, 27) (which reported PS to be effective in main-
taining crestal bone levels compared with NPS
implants) been continued, they probably would have
observed bone loss around PS implants to the same
extent as in NPS implants.
A critical factor that may inuence the overall ef-
cacy of the implant system under investigation is the
choice of radiographs used for assessing bone loss.
Gedik et al. (34) reported that bitewing (BW) radio-
graphs show the highest accuracy in the assessment of
crestal bone levels as compared with panoramic and
periapical (PA) radiographs; whereas, according to
Akesson et al. (35), PA radiographs (using the parallel-
ing technique) are more accurate in assessing marginal
bone levels in contrast to BW and panoramic radio-
graphs. In this study (35), the underestimation of the
bone loss in panoramic, BW and PA radiographs ranged
from 13%32%, 11%23% and 9%20%, respec-
tively. Results by Pepelassi and Diamanti-Kipioti (36)
also suggested that PA radiography is more reliable in
assessing periodontal bone levels as compared with
panoramic radiography. It is therefore pertinent to
mention that in the study by Enkling et al. (1921)
crestal bone levels around platform-switched and NPS
implants were measured on panoramic radiographs.
Although these results (1921) showed no difference in
bone loss around platform-switched and NPS implants;
there is a possibility that crestal bone levels were
imprecisely assessed in these studies (1921).
Additionally to long-term follow-up studies, more
RCTs are needed to control for the other (cofounding)
factors discussed in this paper, such as the implant
diameter in relation to the bucco-lingual width of the
alveolar ridge and the corono-apical implant position-
ing. Bone changes at the buccal aspect should also be
assessed.
Conclusion
Role of PS in minimising crestal bone loss remains
debatable. Bone loss around implants seems to be
governed by several factors, such as the cervical fea-
tures of the implant design, 3D-implant positioning,
prosthetic concept and the IAC, width of alveolar
ridge and prevention of micromotion at the implant-
abutment interface and not merely placing implants
according to the PS concept.
Conicts of interest
The authors declare that they have no conicts of
interest and there was no external source of funding
for the present study.
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2014 John Wiley & Sons Ltd
P L AT F OR M S WI T C HI NG AND B ONE L OS S 707
of periodontal osseous destruction. J Clin Periodontol.
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Appendix A. List of excluded studies.
Reason for exclusion is shown in
parenthesis
a Al-Nsour MM, Chan HL, Wang HL. Effect of the
platform-switching technique on preservation of
peri-implant marginal bone: a systematic review.
Int J Oral Maxillofac Implants. 2012;27:138145.
(Review article)
b Canullo L, Iannello G, Netuschil L, Jepsen S. Plat-
form switching and matrix metalloproteinase-8
levels in peri-implant sulcular uid. Clin Oral
Implants Res. 2012;23:556559. (Focused question
not answered)
c Canullo L, Pellegrini G, Allievi C, Trombelli L, An-
nibali S, Dellavia C. Soft tissues around long-term
platform switching implant restorations: a histolog-
ical human evaluation. Preliminary results. J Clin
Periodontol. 2011;38:8694. (Focused question not
answered)
d Canullo L, Quaranta A, Teles RP. The microbiota
associated with implants restored with platform
switching: a preliminary report. J Periodontol.
2010;81:403411. (Focused question not
answered)
e Canullo L, Iurlaro G, Iannello G. Double-blind
randomized controlled trial study on post-extrac-
tion immediately restored implants using the
switching platform concept: soft tissue response.
Preliminary report. Clin Oral Implants Res.
2009;20:414420.
Correspondence: Georgios E. Romanos, School of Dental Medicine,
Stony Brook University, 106 Rockland Hall, Stony Brook, NY 11794,
USA. E-mail: georgios.romanos@stonybrook.edu
2014 John Wiley & Sons Ltd
G. E . R OMANOS & F . J AV E D 708