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Review Article

Implant crest module: A review of biomechanical

considerations

Aparna IN, Dhanasekar B, D Lingeshwar, Lokendra Gupta

Department of Prosthodontics,
Manipal College of Dental
ABSTRACT
Sciences, Manipal University,
Manipal, Karnataka, India
Received : 10-04-11
Review completed : 25-08-11
Accepted : 10-11-11
The success of dental implants has long been established through various studies with a
particular emphasis laid on an implant design. Crest module is that portion of a two-piece metal
dental implant, designed to hold the prosthetic components in place and to create a transition
zone to the load bearing implant body. Its design, position in relation to the alveolar crest, and
an abutment implant interface makes us believe that, it has a major role in integration to both
hard and soft tissues. Unfortunately, in most clinical conditions, early tissue breakdown leading
to soft tissue and hard tissue loss begins at this region. Early crestal bone loss is usually highest
during the first year after placement ranging from 0.9 to 1.6mm and averaged 0.05-0.13mm
in the subsequent years. Various hypotheses have been stated to reason it however, none has
been proved convincingly. In light of this, various attempts have been made to overcome this
undesirable bone loss, by varying an implant design, the position, surgical protocol, and the
prosthetic options. Irrespective of an implant system and designs that are used, crestal bone
loss of up to the first thread is often observed. The purpose of this review is to look into the
various designs and treatment modalities, which have been introduced into the crest module
of an implant body to achieve the best biomechanical and esthetic result.
Key words: Crestal bone loss, crest module, implant, implant microthreads, platform switching

INTRODUCTION place and to create a transition zone to the load bearing

implant body.[2] The design of which is unique, making
Integration between implants, hard and soft tissues is highly it compatible with both, hard and soft tissues where
accountable for the success of dental implants.[1] However, the highest amount of bone stress is concentrated.
the number of failures is still relevant; and limiting these Subsequently, its design, position in relation to the
failures remains one of the goals in today’s implant research. alveolar crest, and an abutment implant interface being
The predictability of dental implant success has long been primary reasons for the tissue breakdown.[1] There are
established through various studies with a particular as many as 6 different possible hypothesis stated for
emphasis laid on the biomechanical and biological aspects marginal bone loss such as periosteal reflection, surgical
of the crest module. trauma, occlusal overload, peri-implantitis, microgap,
biological width, for which an implant crest module also
Crest module is that portion of a two-piece metal dental plays a pivotal role.[3] The crestal bone loss further leads
implant, designed to hold the prosthetic components in to an increased risk of peri-implantitis, shrinkage of
tissue and poor cosmetic results. Early crestal bone loss
Address for correspondence: is usually highest during the first year after placement
Dr. D. Lingeshwar
E-mail: drdlingesh@yahoo.com
ranging from 0.9 to 1.6mm[4] and averaged 0.05-0.13mm
in the subsequent years.[3] Crest module is said to have
Access this article online a surgical influence, biological width influence, loading
Quick Response Code: profile considerations and a prosthetic influence. Hence,
Website:
www.ijdr.in the design of this portion of an implant plays a critical
role in the overall success of an implant.[5]
PMID:
***
The purpose of this paper is to review the importance of
DOI: the crest module and its influence on the biomechanical,
10.4103/0970-9290.100437
biological and esthetic outcome of the implants.

257 Indian Journal of Dental Research, 23(2), 2012

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Biomechanical considerations of implant crest module Aparna, et al.
BIOMECHANICAL DELIBERATIONS
Implant neck/crest module/implant collar[6,7]
Crest module is the transosteal region of an implant body,
which is designed to accept the prosthetic component in
one piece or two piece implant system.[8] It represents the
transition zone from an implant body to the transosteal
region of an implant at the crest of the ridge.[8] The abutment
connection area often has a platform on which the abutment
is set. This platform offers physical resistance to axial
occlusal load. An anti rotational component often resides
on the platform, but may extend to lie within an implant
body.[8] They transfer stress to the crestal compact bone
during loading. It is the region, where highest amount of
bone stress is reported to be concentrated as demonstrated
in the finite element analysis of loaded implants, with or
without superstructure.[5,9-11]
Collar design
Shape
The collar of an implant is not ideally designed for the load
bearing as evidenced by the bone loss, commonly occurring
regardless of the design or technique. Based on current
literature, collar designs varying from straight /parallel
sided to flared /divergent and tapered/convergent have been
proposed[6] [Figure 1].
Misch and Bidez claimed that, a smooth, parallel sided
[12]
crest module may result in a shear stress in the crestal
region and that an angled crest module of more than 20 0
with a surface texture which increases the bone implant
contact, might impose a slight beneficial compressive and
tensile component to the contiguous bone, and decrease the
risk of bone loss. Francesco Carinci et al.[13] evaluated the
effectiveness of conventional verses reverse conical neck
implants; and observed no clinical differences in survival
and success rates between them. However, reverse conical
neck implants gave an increased residual crestal bone
volume and reduced mechanical stress around an implant
neck. This was in accordance with the concept of platform
switching, where the abutment diameter is smaller than the
fixture diameter. In a finite element analysis on the influence
of implant collar design on stress and strain distribution
in the crestal compact bone, Wan-Ling Shen et al. 2010[6]
evaluated divergent, straight and convergent collar designs
and demonstrated lowest stress and strains for the divergent
collar designs, followed by straight and convergent. The
reason being that divergent collar has the maximum surface
area of all the three designs hence transferring the least force
under similar loading conditions. This was in confirmation
with a study by Bozkaya D et al. 2004[14] who suggested
that, implants with converging collar was more favorable
for transfer and distribution of stress.
Size
The crest module diameter should be slightly larger than the
outer thread diameter of an implant body thereby providing
Indian Journal of Dental Research, 23(2), 2012
initial stability to implants, especially soft bone. [5,15] This
larger diameter will seal the osteotomy site completely acting
as a barrier for an ingress of bacteria and fibrous tissue during
the initial healing. It also increases the surface area thereby
decreasing the stress at the crestal region. A larger platform
additionally would aid in reducing the stress transferred to
the abutment screw for the abutment connection.[5]
Surface
The concept of smooth / machined collar was developed
for a reduction in plaque accumulation and to aid in an
improved hygiene.[5] However, studies have reported that
on an average, the initial sulcus depth around an implant is
about 3mm above the bone approximately and the extent
to which the brush bristles can reach is only about 0.5-
1mm.[5] Thus unless the tissue recedes, the crest module
would not be accessible for the maintenance of hygiene.
By submerging an implant, the maintenance of hygiene as
a measure to reduce an ingress of bacteria cannot be relied
upon, unless the crestal bone resorbs along with the soft
tissue recession so as to expose the collar.[5] A 0.5mm smooth
collar length would therefore, provide a desirable smooth
surface close to the peri-gingival area for the formation of
biological width.[5,16]
A significant drawback of smooth collar stems with its
questionable integration with the hard tissue. When the
smooth collar of an implant is placed under the crest of the
bone, increased shear forces are created. Bone being 65%
weaker to shear forces, resorbs; leading to marginal bone loss
with an eventual pocket formation (Hermann et al. 2001[10]
and Hanggi et al. 2005.[11] Hermann et al. 2001[10] examined
the peri-implant soft tissue dimensions at varying locations
of a rough / smooth implant border in one-piece and two-
piece implants in relation to the crest of the bone, when
submerged and non-submerged techniques were employed.
Their findings suggest a coronal location of the gingival
margin with the biologic width dimensions being more
similar to natural teeth around one-piece non-submerged
implants, compared to either two-piece non-submerged or
two-piece submerged implants. An absence of bone loss was
also observed when the implants with rough crest modules
were placed at the level of crestal bone.[10] Crestal bone
changes around two types of implants with varying smooth
collar lengths (2.8mm and 1.8mm was evaluated by Hanggi
et al.(2005).[11] It was observed that, there is no
additional crestal bone loss when placing implants with
their rough / smooth implant border at the bone crest level
exhibiting a shorter, (1.8 mm) as opposed to a slightly larger
(2.8 mm) machined collar portion. This finding may help to
reduce the risk of an exposed implant margin in the areas
of esthetic concerns.
Van Zyl 1995[17] and Clift et al 1993[18] reiterated that, peri-
implant bone stress might reach a magnitude that might be
258
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Biomechanical considerations of implant crest module Aparna, et al.
detrimental to an implant. Many authors favor the concept
of local overload, which might lead to microfractue thereby
resulting in bone loss.[3,17,18]
Lack of effective mechanical loading, which might also be
a causative factor for the crestal bone loss, cannot be ruled
out. This was demonstrated by Vaillancourt et al.1995.[19]
In a finite element analysis by Vaillancourt et al.1996,[20]
who investigated the crestal bone loss by varying the
design of the prosthesis, length of the uncoated region of
an implant,and friction at the non coated portion of implant
and an adjacent host bone. It was concluded that, the design
of the prosthesis to achieve transfer of forces to the implants
without producing significant mesial and distal bending
moments, would result in low stress regions next to the
coronal implant zones that could lead to disuse atrophy.
Even though surface modifications benefit certain aspects
of an implant such as increasing the surface area of implant,
increasing bone implant interaction and helping in better
stress distribution, its effectiveness is not adequate enough
to prevent the crestal bone loss.[19,20]
Stress shielding is one other explanation, where in the
difference in the modulus of elasticity between the bone
and an implant might be a reason for the inadequate stress
distribution leading to bone loss.[21] The modulus of elasticity
of the Titanium being 5-10 times more rigid than the cortical
bone, when loaded with no intervening material, a stress
contour increase would be observed where the two materials
first comes into the contact.[22] These stress contours form a
’ V’ or ‘ U’ shaped pattern with greater magnitude near the
point of first contact.[23]
To overcome this undesirable event, surface roughening of
the collar was introduced.[24] Roughening could be carried
out by sand blasting, acid etching or by incorporation of
microthreads on an implant collar. Textured surface is said to
provide a mechanical link between bone and an implant that
is required for adequate stimulation of an osseous tissue. [21]
The magnitude of force generated should match the strain
level required to trigger specific lineages of bone cells to
commence bone production. Strains that range outside the
physiologic limit and mild overload, serve no useful purpose
in terms of bone homeostasis or augmentation.[16,21,25,26]
Valderrama P et al. 2010[24] evaluated the radiographic bone
level of early loaded chemically modified sandblasted and
acid etched implants with and without machined collar in
canine mandibles. They observed that, the radiographic
bone change around the non machined collar was
significantly less than that for the modified machined collars.
Non machined collar implants established bone gain was
described as ‘creeping osseointegration’ and this increase in
bone, was not affected by the loading. Histomorphometric
evaluation by Schwarz F et al 2008[27] also proved that, crestal
bone level changes for rough surface implant necks was less
259
than that for the smooth collars. Welander M et al. 2009[28]
evaluated implants with surface modification extending up
to an implant margin that included the shoulder part of an
implant and abutment. They observed that, osseointegration
occurred coronal to an implant-abutment interface. Such
a result, however, appears to be dependent on the surface
characteristics of an implant components. Abrahamsson I
et al. 2009[29] in a review concluded that, there was no
particular improvement in the marginal bone preservation
for any particular surface modification. No implant system
was found to be superior in marginal bone preservation.
Microthreads
The concept ofan incorporation of microthreads on to
the crestal portion has been introduced in recent times
to preserve the marginal bone and soft tissues around the
implants. The presence of retentive elements at an implant
neck would help dissipate some forces leading to the
maintenance of crestal bone height as per the Wolff’s law
(Hansson 1999) which states that, an increased stress tends
to elicit the bone stimulation while reduced stress tends to
elicit the bone loss.[25] Finite element analysis was carried
out on dental implants with microthreads way up to the
crest by Hansson S in 1999.[25] It was concluded that, the
amount of axial load, the dental implant could bear with the
retention element up to the crest, would be considerably
higher compared to an implant with a smooth collar.
Comparison of alveolar bone reduction after immediate
implantation using the microgrooved and smooth collar
implants was researched by Shin SY et al. 2010.[30] It was
recognized that, the microgrooved implants provided a more
favorable condition for attachment of hard and soft tissues,
reduced bone resorption and soft tissue recession. Park YS
et al.2010[31] evaluated the effect of microthread geometry
of a scalloped implant design on marginal bone resorption.
Type1 having a machined collar, Type2 sandblasted and acid
etched, Type3 with horizontal microthreads, and Type4
with parabolic microthreads corresponding to the scalloped
collar were evaluated. They concluded that, the amount of
bone loss for Type3 and 4 were minimal and bone around
the Type4 implant seemed to follow the scalloped margin.
In a two dimensional finite element analysis by Schrotenboer J
et al.,[32] it was concluded that microthreaded implants
increased bone stress at the crestal portion when compared
with the smooth neck implants. This was in accordance with
the study by Palmer et al 2000. Abrahamsson I et al.[29] also
found an increase in bone implant contact in implants with
the microthreads in the coronal portion, compared to non-
microthreaded implants in a dog model. This was further
reiterated by Lee et al,[33] who concluded on similar grounds
in a human study.
Schrotenboer J et al.[32] studied the effect of microthreads and
platform switching on crestal bone stress levels and found
Indian Journal of Dental Research, 23(2), 2012
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Biomechanical considerations of implant crest module Aparna, et al.
(a) (b)
Figure 1: Implant collar designs. (a) Parallel collar, (b) Divergent collar,
(c) Convergent collar
Figure 2: Schematic representation of submerged and non-submerged
two-piece implants. A- Submerged implant collar. B- Non-submerged
implant collar. L- Bone level. D- Crestal bone loss
Figure 3: Schematic representation of biologic width around non-
submerged implant. S - Sulcus depth. JE - Junctional epithelium.
CA - Connective tissue attachment. BW - Biologic width
that, platform switching reduced stress in both the groups,
but to a greater degree in the microthread model compared
to the smooth-neck model.
In general, the addition of threads or microthreads up to
the crestal module of an implant might provide a potential
positive contribution on bone implant contact, as well as,
on the preservation of the marginal bone. However, in cases
Indian Journal of Dental Research, 23(2), 2012
of bone deficiency or poor bone quality, rough surfaces get
exposed to the oral cavity and tend to accumulate plaque
intensely.[34] The reason being that implant surfaces with a
higher surface roughness or surface free energy facilitate
biofilm formation. [35] These observations suggest that
the roughened implants are more prone to develop the
peri-implant mucositis and peri-implantitis,.[36] Since the
impact of microtextured implant collars on the initiation
and progression of peri-implant pathology has not yet
been documented, the clinician should be cautious when
using these modified implants, especially patients in high
risk category such as those with a history of aggressive
periodontitis.[37]
(c)
Implant – abutment interface
Microgap
There ar e currently two types of root form implants, the
two-piece implants, which consists of an implant body and
a separate abutment and a one-piece implant.[38] Microgap
is a connection line between an implant and an abutment
in a two-piece implant and has long been a topic of intense
research.[39] A smooth collar provides a better implant
abutment connection as compared to a rough surface
connection. Various studies have shown that, a bone to
implant contact settles at a vertical radiologic distance of
2mm from the microgap, irrespective of its location. The
actual size of the microgap does not have an influence on
the amount of peri-implant bone resorption as long as micro
movement does not become an additional factor. [10,39,40]
Wang D et al,[39] evaluated the microgap location and
configuration of peri-implant bone morphology in non-
submerged implants and concluded that, the amount and
shape of peri-implant bone defect depends on an implant
– abutment connection, especially for implants placed
subcrestally [Figure 2].
Alomrani AN  et al. [41] suggested that, the least amount of
bone loss occurred when the microgap was at the rough-
smooth border, 1mm or more above the bone crest. The
distance between the microgap and the bone crest was
the smallest when the top of an implant was in level with
the bone crest. These findings suggest that, the effect of
microgap and rough-smooth border was not cumulative
but one effect may obscure or dominate, and thus cancel
or overcome the effect of the other. Studies by Gargiul AW
et al.[42] confirmed that, the biological width around the
single piece non-submerged implants was similar to that
of the natural teeth. The marginal bone loss was directly
influenced by the presence or absence of microgap and its
location. This bone loss was generally not observed with
one-piece dental implant.[42]
Anti-rotational component
The platform of the crest module incorporates an anti-
rotational feature to retain the prosthetic component.
The anti-rotational component can be incorporated over
260
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Biomechanical considerations of implant crest module Aparna, et al.
the platform as an external hex or included within an
implant body as an internal hex, morse taper, octagon,
internal grooves, pin slots etc.[8] An intimate and accurate
fit between the components is paramount to the stability of
an implant body. Conical implant–to-abutment connections
are preferred over flat-to-flat connections, because they are
superior when subjected to bending tests.[37] In addition;
load is also more evenly distributed in conical connections
as demonstrated by Wang D.[39]
Esthetics
If observed from a perspective of an implant function, the
amount of peri-implant bone loss during early healing
phases might not be a significant factor in the success of an
implant. [39] But from an esthetic point of view, any loss of
hard tissue would lead to collapse of the peri-implant soft
tissue and compromise esthetics. The interface of a one-
piece implant is often placed sufficiently above the crest
of the bone and apical to gingival margin, thus producing
excellent esthetic results. Whereas, for two-piece implants
which are often placed subcrestally to achieve a better
emergence profile, a hard tissue loss of 2mm and soft tissue
loss of 1mm is often perceived in order to establish biologic
width of 3mm, and this should be taken into account so as
to achieve the esthetics[38,43,44] [Figure 3].
Scalloped collar
In view of natural, scalloped, bone and soft tissue
topography, and to improve the biologic and esthetic
outcome, a scalloped implant collar was introduced .This
design intends for the shoulder of an implant to be placed
above the bone on the proximal area to minimize bone
loss and lower in the buccal and lingual aspects, so there
is minimal esthetic compromise due to an implant collar
exposure in situations with differential gingival height
between the facial and proximal aspect of an implant site.[45]
Kan JY et al.[46] in a multi-center study assessed the success
rates, changes in marginal bone level, the papilla index
of scalloped implants undergoing immediate provisional
restoration and observed favorable implant success rates
and peri-implant tissue response with immediate provisional
restoration in an esthetic zone, although bone was not
regularly maintained at the original levels around the
scalloped area of the implants.[46]
Platform switching
This concept was introduced by Lazzara and Porter in
2006[47] and is accomplished by resting the dental fixture
with an abutment of a smaller diameter. Platform switching
facilitates an increase in residual crestal alveolar bone
volume around the neck of an implant, repositions the
papilla to a more esthetic and an apposite level, reduces
the mechanical stress in the crestal alveolar bone area and
assists in enhancing the vascular supply to hard and soft
tissue in case of reduced interdental space. This concept
261
however, does not increase the distance between an implant
abutment junction and an alveolar crestal bone, thereby
having no protective effect on the microgap, which may
encase microflora.[48]
Fickl S et al.[49] observed that, in platform switched implants,
an implant-abutment junction is made to move inward
from an implant shoulder and further away from the bone;
shifting the inflammatory cell infiltrate to the central axis of
an implant and away from the adjacent crestal bone, thereby
limiting crestal bone remodelling. This was also confirmed
in studies by Cappiello et al,[50] and Hürzeler et al.[51]
Maeda et al,[52] in a finite element analysis revealed that,
platform switching configuration reduced the shear stress
at the bone-implant interface, but increased the stress in
abutment or the abutment screw. Thereby, from a biologic
standpoint, it was observed to be efficacious to shift an
inevitable microgap of an implant-abutment junction, which
is always encircled by an inflammatory cell, infiltrate away
from the outer edge of an implant and adjoining bone by
formation of a healthy connective tissue.[53] Nonetheless,
limited scientific evidence supports the concept of platform
switching with further research being obligatory.
CONCLUSION
Irrespective of an implant system and designs that are used,
crestal bone loss of up to the first thread is often observed.
This may be due to the transformation of stress patterns
from being shear in nature to compressive. The magnitude of
the crestal bone loss is often directly related to the distance
between the crest module and the first thread distance.
Though various designs of the crest modules have been
proposed to overcome this, sufficient clinical studies are
needed to determine the actual mechanism of the crestal
bone loss. However, implants with surface treated and micro
threaded implant collar have proven to be of an advantage
from a mechanical and biological point of view. Similarly,
one-piece implants have shown to preserve both, hard and
soft tissue at a better level than that of regular two-piece
implants. New concepts of scalloped collars and platform
switching have revolutionized the field of implant esthetics,
however their validity needs further research for implants
to eventually mimic the natural teeth.
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How to cite this article: Aparna IN, Dhanasekar B, Lingeshwar D, Gupta
L. Implant crest module: A review of biomechanical considerations. Indian J
Dent Res 2012;23:257-63.
Source of Support: Nil, Conflict of Interest: None declared.

263 Indian Journal of Dental Research, 23(2), 2012