Platform Switching: A New Era in Implant Dentistry

International Journal of Oral Implantology and Clinical Research, May-August 2010;1(2):61-65

61
Platform Switching: A New Era in
Implant Dentistry
1
Manoj Shetty,
2
D Krishna Prasad,
3
UN Sangeetha,
4
Chethan Hegde
1
Professor, AB Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka, India
2
Head, AB Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka, India
3
Postgraduate Student, AB Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka, India
4
Professor, AB Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka, India
Correspondence: Manoj Shetty, Department of Prosthodontics, AB Shetty Memorial Institute of Dental Sciences, Deralakatte
Mangalore: 575018, Karnataka, India, e-mail: drshettym@yahoo.com
Abstract
Platform switching is the use of smaller diameter abutments on wider diameter implants. It is used as a method of reducing crestal bone
loss and maintaining the gingival papillae. Platform switching appears to limit crestal resorption and seems to preserve peri-implant bone
levels. A certain amount of bone remodeling one year after final restoration occurs, but significant differences concerning the
peri-implant bone height compared with the nonplatform switched abutments are still evident one year after final restoration.
Review method: The basic search process included a systematic review of article in PubMed/Medline database dating between January
2000 and September 2009. Studies both of human beings and animals were reviewed in order to assess the influence of platform
switching both on marginal bone loss around the cervical region of the implant and on soft tissue esthetics.
Keywords: Platform switching, Implants, crestal bone loss.
REVIEW ARTICLE
IJOICR
INTRODUCTION
The development of osseointegrated implants represents one
of the most important breakthroughs in contemporary dental
practice in the oral rehabilitation of partially or fully edentulous
patients. Based on the pioneering work of Brnemark
(University of Gothenburg, Sweden) and Schroeder
(University of Berne, Switzerland), who first proposed the
concept of osseointegration or functional ankylosis,
respectively, implant dentistry has subsequently seen some
major advances, particularly in the past two decades.
1
One aspect of implant therapy that can be extremely
challenging is the placement and subsequent restoration of
implants in the esthetic zone. In order to predictably realize
patients esthetic expectations, the crestal bone changes
that commonly occur around endosseous implants and the
subsequent soft tissue reaction to the osseous changes must
be understood. The soft tissue must then be managed to
ensure its long-term stability.
2
Crestal bone loss has been documented as one of the
important factors that affect the long-term prognosis of a
dental implant. The initial breakdown of the implant-tissue
interface generally begins at the crestal region in successfully
osseointegrated endosteal implants.
3
After second stage surgery, bone resorption of
1.5 to 2 mm may occur at the implant-abutment junction.
One criterion of successful implant osseointegration is that
vertical bone loss should not exceed 2 mm in the first year
of function and should remain less than 0.2 mm annually
thereafter.
4
Understanding how crestal bone responds to implant
placement and subsequent abutment connection is critical
in achieving an acceptable esthetic outcome. The position
of crestal bone will influence the position of the soft tissue,
which in turn dictates, along with other factors, the total
esthetic outcome.
5
BIOLOGIC WIDTHA KEY DETERMINANT
OF ESTHETICS
Garguilio, Wentz and Orban in a study of the
periodontium, demonstrated an average histological
dimension of the epithelial attachment (0.97 mm) and
connective tissue attachment (1.07 mm).
5,6
Known as
biologic width, this dimension is a key determinant of
esthetics. It acts as a barrier and seals against bacterial
invasion and food debris ingress into the tooth-tissue
interface.
3
Manoj Shetty et al
62
JAYPEE
The biologic width found around teeth is also
characteristic of the peri-implant complex. The dimensions
of peri-implant biologic width are similar to that of teeth
and is stable even after loading. The position of the gingival
architecture in relation to the osseous crest. This position
in fact follows the principles of biologic width.
5, 7-9
Early implant bone loss, in part, is from the processes
of establishing the biologic width. The amount of bone loss
and location of the biologic width may be associated with
the thickness of the soft tissue around the implants.
3,11
This
situation has important consequences for the esthetics of
the interdental papilla which can suffer mesial and distal
bone loss of around 0.07 mm after a 6 month follow-up
period.
2
Use of an implant design that aids in the preservation
of crestal bone, in theory, will support soft tissue that may
impact the esthetic outcome. Greater bone volume can also
increase blood supply for the health and maintenance of
soft tissues.
9
Factors affecting crestal bone loss:
3,12
1. Surgical trauma
2. Microgap
3. Biologic width
4. Crest module
1. Surgical Trauma
Surgical trauma due to heat generated during drilling,
elevation of the periosteal flap and excessive pressure at the
crestal region during implant placement may contribute to
implant bone loss during the healing period. Wildermann
et al reported that bone loss due to periosteal elevation was
restricted to the area just adjacent to the implant, even though
a larger surface area of the bone was exposed during surgery.
Early implant bone loss is in the form of horizontal
saucerization. However, bone loss after osseous surgery in
natural teeth is more vertical. Signs of bone loss from
surgical trauma and periosteal reflection are not commonly
observed at the implant stage two surgery in successfully
osseointegrated implants. Thus, surgical trauma is unlikely
to cause early crestal bone loss.
11
2. Microgap
In most of the two-stage implant systems (submerged
implants), after abutment is connected, a microgap exists
between the implant and the abutment at or below the
alveolar crest. For all two-stage implants, the crestal bone
levels are dependent upon the location of the microgap and
are approximately 2 mm below it.
13
The micro-gapcrestal bone level relationship was studied
radiographically by Hermann et al, who for the first time,
demonstrated that the microgap between the implant/
abutment has a direct effect on crestal bone loss, independent
of surgical approaches (submerged or nonsubmerged).
This study also demonstrated that epithelial proliferation to
establish biological width could be responsible for crestal
bone loss found about 2 mm below the microgap.
13
Microgap may not be considered as the only cause of
early implant bone loss, it might cause implant crestal bone
loss during the healing phase, if it is placed at or below the
bony crest.
3
3. Biologic Width
As discussed earlier, the biologic width term essentially
pertains to the physiologic attachment apparatus made up
of the connective tissue and epithelium, and is approximately
2.04 mm. Early implant bone loss, in part, is from the
processes of establishing the biologic width.
2,3,5,9,11
4. Crest Module
The crest module of an implant body is defined as the
transosteal region of the implant and serves as the region
which receives the crestal stresses to the implant after loading.
A smooth crest module may actually contribute to the
crestal bone loss. Cortical bone is strongest to compressive
loads, 30% weaker to tensile forces, and 65% weaker to
shear forces compared to compressive forces. A smooth,
parallel-sided crest module may result in shear stresses in
this region, and an angled crest module of more than 20
degrees with a surface texture that increases bone contact
might impose a slight beneficial compressive and tensile
component to the contiguous bone and decreases the risk
of bone loss.
3,14
It can be hypothesized that the bone loss may slow down
at the first thread because the first thread changes the shear
force of the crest module to a component of compressive
force to which bone is the most resistant.
3
IMPLANT-ABUTMENT CONNECTION AND
MICRO-PUMPING EFFECT
15
Implant abutment connections are based on the design model
allowing for a clearance fit, which permits the two parts
Platform Switching: A New Era in Implant Dentistry
International Journal of Oral Implantology and Clinical Research, May-August 2010;1(2):61-65
63
(abutment and implant) to fit together. The very nature of
this clearance fit creates a microgap, both microscopically
and macroscopically (Fig. 4). This microgap not only allows
for movement of bacteria and their toxins to and from the
abutment-implant external interface, but also allows for
micromovement of the abutment within the implant.
15
Micromovement can create movements and stresses
on the abutment screw which causes loosening and a
micropumping effect that expels additional bacterial by-
products and toxins at implant-soft tissue interface and
eventually at the osseous crest. With a concentration of
toxins, the bodys defenses come into play, including
increased inflammatory cells at the osseous crest, causing
soft tissue detachment and crestal bone loss. The implant
design that displays the smallest microgap consists of dental
abutment connections called the press fit, conus, or
conical connections.
13
insure bone stability at or above the shoulder of the implant,
thereby producing a lasting papilla and soft tissue contours
around the implant crown.
15,16
CONTROLLING CRESTAL BONE LOSS
Crestal bone loss around implants has both horizontal
and vertical components. Following abutment connection,
crestal bone will move away from the microgap 1.3 mm to
1.4 mm in a horizontal direction.
This can influence the interproximal height of bone if
implants are not placed correctly adjacent to teeth (1.5 mm)
or other implants (3 mm).
14
The loss of interproximal bone
will increase the distance to the contact point, influencing
esthetics.
5,17
Clinicians, researchers and implant companies have
dedicated time to finding ways to control crestal bone loss
after abutment connection. Use of nonsubmerged implants
to control or eliminate bone loss is a proven way to
accomplish this.
18
A scalloped implant platform has been
developed to follow osseous architecture and eliminate
crestal bone loss.
5
Another method is altering the horizontal position of
the microgap. As stated previously, crestal bone loss
following abutment connection has both horizontal and
vertical components. The horizontal component consists
of the 1.3 mm to 1.4 mm of bone loss from the microgap
to the crest of bone. If the horizontal component can be
controlled or decreased, then crestal bone loss can also be
decreased.
5
This can be done by means of what is now
called as the platform switching concept.
ACCIDENTAL DISCOVERY OF PLATFORM
SWITCHING
19, 20
Platform switching (the concept was introduced in the
literature by Lazzara and Porter and Gardner), limits the
circumferential bone loss around dental implants by using
prosthetic components having a platform diameter
undersized when compared to the diameter of the implant
platform. In this way, the implant abutment junction is
displaced horizontally inwards from the perimeter of the
implant platform, and further away from the bone. This
creates an angle, or step, between the abutment and the
implant. Because it essentially is resting on the outer
circumference of the implant platform, the inflamed
connective tissue does not extend laterally to the same extent
as it does with a traditional matched implant-abutment
junction.
Table 1: Implant abutment connection
15
Clearance Fit Press Fit
Index/parallel sides Morse taper
Micromovement No micromovement or rotation
Micropumping effect Microgap eliminated
due to microgap increase
inflammatory cells
Replace Select
TM
, Certain
TM
Ankylos
TM
, Biocon
TM
In a recent article in Implantologic, Zipprich and
coworkers observed micromovements at the implant
abutment interface when average occlusal forces were
placed on them. All but a few conical designs showed broad
evidence of a developing microgap on loading, micro-
movement and creation of the micropumping effect
mentioned previously. The implant design that displayed
the smallest microgap function fell into a second group of
dental abutment connections called the press fit, conus,
or conical connections.
13
Press fit designs employ the
Morse taper connection. This conical connection is used
in several implant designs of various lengths and angles.
This allows for a bacterial seal unlike the clearance fit
connection and nearly eliminates micro-movement. Retention
of the abutment, elimination of the microgap and
micromovement are all achieved by the press fit conical
connection. This allows this unique two-piece implant design
with a conus connection to behave like a one-piece
implant. A tight microgap and lack of micro-movement will
Manoj Shetty et al
64
JAYPEE
In 1991, the 3i Implant Innovations Inc. (Palm Beach
Gardens, FL) introduced wide diameter 5.0 and 6.0 mm
implants that had identically dimensioned platforms. These
were designed to be used mainly for poor quality bones to
achieve improved primary stability. However, when
introduced, there were no matching wide-diameter
prosthetic components available, and as a result, most of
the initially placed implants were restored with standard
4.1 mm diameter components, which created a 0.45 mm
or 0.95 mm circumferential horizontal difference in
dimension. Many platform switched restored implants
exhibited no vertical loss in crestal bone height.
19
Thus, the discovery of the concept was a coincidence.
The crestal bone clinically and radiographically appears
to maintain its position, while the soft tissue appears not to
recede as much as it does with traditional matched
configurations. In a sense, this implant configuration appears
to limit biologic width reformation because the ledge of the
implant platform, to a significant extent, may isolate the
underlying bone.
19
It is important to note that for platform switching to be
effective, the under sizing of the components must be carried
out during all phases of the implant treatment, i.e. from
placement of the implant through to final restoration.
19
CLINICAL RELEVANCE OF PLATFORM
SWITCHING
1. Increased biomechanical support: Where anatomic
structures such as the sinus cavity or the alveolar nerve
limit the residual bone height, the platform switching
approach minimizes the bone resorption and increases
the biomechanical support available to the implant.
11
2. Effect on soft tissue esthetics around dental implants:
Tarnow et al. showed how the presence of the dental
papilla is influenced by the distance between the implants.
When two implants are placed close to one another (inter-
implant distance 3 mm or less
21
) the inter-implant bone
height can resorb below the implant-abutment
connection, reducing the presence of an inter-implant
papilla. This may affect the clinical result in the esthetic
zone. Platform switching reduces this physiologic
resorption, moving the microgap away from the
inter-implant bone that supports the papilla. Maintenance
of midfacial bone height helps to maintain facial gingival
tissues. This helps to avoid cosmetic deformities,
phonetic problems, and lateral food impaction.
11
3. Effect on crestal bone stress levels in implants with
microthreads: A finite element analysis was done to study
the effect of microthreads and platform switching on
crestal bone stress levels. I t was reported that
microthreads increase crestal stress upon loading. When
the concept of platform switching was applied by
decreasing the abutment diameter, less stress was
translated to the crestal bone in the microthread and
smooth-neck groups. The study concluded that platform
switching reduced stress to a greater degree in the
microthread model compared to the smooth-neck
model.
24
CONCLUSIONS
Platform switching is a simple and effective way to control
circumferential bone loss around dental implants. By altering
the horizontal position of the microgap, the horizontal
component of bone loss after abutment connection can be
reduced. This technique, however, has its faults. Switching
can only be used with components that have similar designs,
that is, the screw access hole must be uniform. In addition,
sufficient space is needed to develop a proper emergence
profile.
5
Although the biological basis for platform switching
has been proposed, the biomechanical aspect still needs to
be investigated. In a study done to analyze the bio-
mechanical rationale for platform switching, Maeda et al.
suggested that platform switching has the biomechanical
advantage of shifting the stress concentration away from
the cervical bone implant interface. It also may have the
disadvantage of increasing stress in abutment or abutment
screw.
25
Despite the rapid growth of body of evidence with
regard to platform switching, further substantiation with
experimental and clinical outcomes with larger sample size
and longer follow-up periods is still needed to determine the
viability of this technique. More accurate long-term studies
with a more relevant number of patients are required to
allow proper conclusions related to soft and hard tissue
reaction to this alternative restorative protocol.
26,27
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