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Platform Switching for Marginal Bone

Preservation Around Dental Implants: A
Systematic Review and Meta-Analysis

ARTICLE in JOURNAL OF PERIODONTOLOGY OCTOBER 2010

Impact Factor: 2.71 DOI: 10.1902/jop.2010.100232 Source: PubMed

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 Volume 81 Number 10

Review
Platform Switching for Marginal Bone Preservation Around
Dental Implants: A Systematic Review and Meta-Analysis
Momen A. Atieh,* Hadeel M. Ibrahim, and Ahmad H. Atieh

Background: Platform switching for maintaining peri-implant bone

levels has gained popularity among implant manufacturers over the last
few years. However, the assumption that the inward shifting of the im-
plant-abutment junction may preserve crestal bone was primarily based
on serendipitous finding rather than scientific evidence. The objectives of
the present study were to systematically review radiographic marginal
bone-level changes and the survival of platform-switched implants com-

T
pared to conventional platform-matched implants. he peri-implant bone
Methods: A literature search of electronic databases (MEDLINE, level has been used as
EMBASE, The Cochrane Oral Health Groups Trials Register, The one of the criteria to
Cochrane Central Register of Controlled Trials, the U.K. National Research assess the success of dental
Register, the Australian New Zealand Clinical Trials Registry, the Database implants.1-6 It is an important
of Abstracts of Reviews of Effectiveness, and Conference Proceedings Cita- prerequisite for preserving the
tion Index) was performed up to March 15, 2010. Hand searches included integrity of gingival margins
several dental journals, and authors were contacted for missing informa- and interdental papillae.7,8
tion. Controlled trials that compared marginal bone-level changes around Traditionally, a radiographic
platform-switched dental implants with those restored with platform- marginal bone loss of 1.5 mm
matched prostheses were selected. The review and meta-analysis were during the first year followed
done according to the guidelines of the Preferred Reporting Items for Sys- by a radiographic marginal
tematic Reviews and Meta-Analyses statement. Data were analyzed using bone loss of 0.2 mm during
two meta-analytic statistical packages. Mean differences (MDs) were cal- each succeeding year is an
culated for analyzing continuous data, and risk ratios (RRs) were used for important parameter for the
dichotomous data with 95% confidence intervals (CIs). assessment of implant suc-
Results: Ten studies with 1,239 implants were included. The marginal cess.2 The peri-implant bone
bone loss around platform-switched implants was significantly less than remodeling occurs once the
around platform-matched implants (MD: -0.37; 95% CI: -0.55 to -0.20; implant is exposed to the oral
P <0.0001). No statistically significant difference was detected for implant environment in a second sur-
failures between the two groups (RR: 0.93; 95% CI: 0.34 to 2.95; P = 0.89). gical procedure or when the
Subgroup analyses showed that an implant-abutment diameter differ- abutment is placed immedi-
ence 0.4 was associated with a more favorable bone response. ately after implant placement.
Conclusions: The review and meta-analysis show that platform switch- The remodeling process in-
ing may preserve interimplant bone height and soft tissue levels. The de- volves marginal bone resorp-
gree of marginal bone resorption is inversely related to the extent of the tion that is affected by one or
implant-abutment mismatch. Further long-term, well-conducted, random- more of the following factors:
ized controlled studies are needed to confirm the validity of this concept. 1) a traumatic surgical tech-
J Periodontol 2010;81:1350-1366. nique;9 2) excessive loading
conditions;10 3) the location,
KEY WORDS shape, and size of the implant-
Alveolar bone loss; dental implants; meta-analysis; review. abutment microgap and its
microbial contamination;11-13
4) the biologic width and soft
* Sir John Walsh Research Institute, School of Dentistry, University of Otago, Dunedin, New Zealand. tissue considerations;14,15 5)
Department of Oral Rehabilitation, School of Dentistry, University of Otago.
Private practice, Amman, Jordan. a peri-implant inflammatory

doi: 10.1902/jop.2010.100232

1350
J Periodontol October 2010
infiltrate;16 6) micromovements of the implant and
prosthetic components; 11,17 7) repeated screwing
and unscrewing;18 8) the implant-neck geometry;19
and 9) the infectious process.20
In the late 1980s, wide-diameter implants were
commercially introduced. Initially, the implants were
restored with standard-diameter abutments because
of the lack of matching prosthetic components. Con-
trary to what was expected, post-loading radiographic
evaluations showed no changes in the crestal bone
levels around those implants. This serendipitous find-
ing led to the introduction of the concept of platform
switching, in which a smaller-diameter prosthetic com-
ponent was connected to a larger-diameter implant
platform to create an ;90 step between the implant
and abutment.21-23 Several clinical reports24-27 demon-
strated more favorable soft and hard tissue responses
using implants placed with platform switching com-
pared to standard platform-matched implants. Con-
sequently, an increasing number of implant systems
incorporated platform switching into their designs
as an innovative feature for preserving the peri-
implant bone.
Although the concept of platform switching is a rel-
atively new one in the implant market, implants were
restored with mismatched prosthetic components for
more than a decade. In fact, a long-term prospective
study28 with a follow-up period of 11 to 14 years was
recently published. The article28 did not include a con-
trol group but confirmed the advantageous features of
platform-switched implants in preserving crestal bone
levels. In addition, the use of platform-switched im-
plants was suggested in anatomic sites where the
recommended minimum distances between implants
and adjacent units cannot be achieved.29 In a prospec-
tive study,30 41 pairs of platform-switched implants
were placed at <3 mm of interimplant distance. The ra-
diographic evaluation showed that a platform-switched
implant design can reduce the vertical and horizontal
components of bone loss and may be used in atrophic
sites.30
However, the concept of platform switching was
not fully understood, and several theories were sug-
gested to explain this phenomenon. The biomechani-
cal theory proposed that connecting the implant to
a smaller-diameter abutment may limit bone resorption
by shifting the stress-concentration zone away from the
crestal boneimplant interface and directing the forces
of occlusal loading along the axis of the implant.31 One
theory23 assumed that shifting the implant-abutment
connection may medialize the location of the biologic
width and minimize the marginal bone resorption. This
theory was based on previous studies32,33 that showed
that placing the implant-abutment junction (IAJ) at or
below the crestal bone level may cause vertical bone re-
sorption to reestablish the biologic width. Another the-
Atieh, Ibrahim, Atieh
ory concerned the role of the inflammatory cell infiltrate
at the IAJ. Ericsson et al.13 showed that the bone re-
sorption at the IAJ was caused by an inflammatory
cell infiltrate that formed a 1.5-mm semispherical
zone around the IAJ. The presence of the peri-implant
microbiota was suggested to influence the crestal
bone resorption by maintaining the inflammatory cell
infiltrate within the IAJ.16,34 However, the relationship
between the composition of microorganisms at the
IAJ and marginal bone resorption was recently ques-
tioned.35 Regardless of the nature of the peri-implant
inflammatory infiltrate, the physical repositioning of
the IAJ away from the external outer edge of the im-
plant and neighboring bone may limit bone resorption
by containing the inflammatory cell infiltrate within
the angle formed at the interface away from the adja-
cent crestal bone.23
In addition to the clinical studies,24-28,34 the con-
cept of platform switching was extensively studied
histologically and biomechanically. In histomorpho-
metric studies in dogs,36,37 there was no significant
difference in the marginal bone level around plat-
form-switched and -matched implants after 28 days
of healing. In contrast, other studies38-40 reported a sig-
nificantly less bone loss around platform-switched
implants after a loading period of 2 to 6 months. More-
over, the biomechanical advantages of internally
connected, platform-switched implants were pro-
posed because of the inward shifting of the stress
concentration.31,41 Conversely, Canay and Akcxa42
and Schrotenboer et al.43 showed that the horizontal
shifting of the implant-abutment connection did not
significantly alter the stress generated at the mar-
ginal bone around the implants.
The choice to use a platform-switched or -matched
implant design is currently not guided by evidence-
based protocols and is mainly influenced by manu-
facturers recommendations. Hence, the aims of
this systematic review and meta-analysis examine
whether there is a difference in the marginal bone
level changes around dental implants restored with
either narrower or matched prostheses (platform-
switched versus platform-matched prostheses) and
evaluates the effect of platform-switching on implant
survival.
MATERIALS AND METHODS
The current systematic review and meta-analysis was
conducted according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA)
statement44 and the Cochrane Collaboration recom-
mendations.45 The four Population, Intervention,
Comparison, and Outcome (PICO) elements46 were
used to summarize the objectives and inclusion crite-
ria into a well-defined formulated question: In patients
1351
Platform Switching of Dental Implants
who receive implant treatment, does the use of platform-
switched implants compared to platform-matched im-
plants result in more favorable marginal bone level
changes (primary outcome) and lower implant failure
rate (secondary outcome)?
Selection Criteria
Eligible studies were included in the meta-analysis if
they met the following criteria: 1) published in En-
glish; 2) human study population; 3) were randomized
controlled trials (RCTs) or controlled clinical trials
(CCTs) with two treatment groups, with one related
to the use of platform-switched implants and the other
related to the use of conventional platform-matched
implants; 4) had 10 implants in the platform-
switched group; and 5) had a mean follow-up period
12 months.
In the presence of duplicate publications, only the
study with the most inclusive data was selected.
Search Sources and Strategy
A systematic electronic searching was performed in
the following databases:
1. MEDLINE (1969 to March 15, 2010).
2. EMBASE (1980 to March 15, 2010).
3. The Cochrane Oral Health Groups Trials Register
(up to March 15, 2010).
4. The Cochrane Central Register of Controlled Trials
(up to March 15, 2010).
5. U.K. National Research Register (up to March
15, 2010).
6. Australian New Zealand Clinical Trials Registry
(up to March 15, 2010).
7. Database of Abstracts of Reviews of Effectiveness
(up to March 15, 2010).
8. Conference Proceedings Citation Index (up to
March 15, 2010).
The following search format was performed using
Boolean operators: (platform-switching OR plat-
form-switched implant) AND (platform-matched
implant OR non-platform switched implant)
AND (immediate placement OR delayed place-
ment) AND (immediate loading OR immediate
restoration) AND (dental implant OR oral im-
plant) AND (marginal bone level OR crestal bone
level) AND (success rate OR survival rate).
In addition, the previous 7 years of the following
journals were manually searched: Clinical Implant
Dentistry & Related Research, Clinical Oral Implants
Research, Implant Dentistry, International Journal of
Oral and Maxillofacial Implants, International Journal
of Oral and Maxillofacial Surgery, International Jour-
nal of Periodontics & Restorative Dentistry, Interna-
tional Journal of Prosthodontics, Journal of Clinical
Periodontology, Journal of Dental Research, Journal
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Volume 81 Number 10
of Oral and Maxillofacial Surgery, Journal of Oral Im-
plantology, Journal of Oral Rehabilitation, Journal of
Periodontology, and Journal of Prosthetic Dentistry.
The bibliographies of all selected articles were fur-
ther scanned for potentially relevant articles. In cases
of missing or insufficient data, clarification was sought
from corresponding authors.
Data Collection
A data-extraction form was developed and used by
each author (MAA, HMI, and AHA) to collect the fol-
lowing study information: 1) title; 2) year of publica-
tion; 3) site and number of implants; 4) implant
design and system; 5) implant length and diameter;
6) implant-placement protocol; 7) use of regenerative
procedures; 8) time of placement of definitive crown;
9) difference between implant and abutment diame-
ters in the platform-switched implant group; 10) mar-
ginal bone level changes; 11) implant survival rate of
each treatment group; and 12) follow-up period.
Quality Assessment
The methodologic quality assessment was based on
the Jadad quality scale (Appendix 1); the scale as-
signs a score ranging from 0 to 5 points, with a score
of 3 indicating a higher study quality.47 In addition,
the Cochrane scale for assessment of allocation was
also used to evaluate the validity of the included stud-
ies (Appendix 2).48
Data Synthesis
Meta-analyses were carried out using two statistical
software programs.i The first program was used to
pool the data and produce the forest plots, whereas
the second programi was used to assess the publica-
tion bias. We planned to test the significance of treat-
ment effects by using a fixed-effects model in the
absence of a statistically significant heterogeneity
and a random-effects model in the case of substantial
heterogeneity among the trials. Heterogeneity was as-
sessed using the x2-based Q-statistic method and I2
measurement. A significant heterogeneity was indi-
cated by P <0.1 because of the moderate insensitivity
of the Q statistic.49 The value of I2 ranged from 0 to
100, with larger values (75%) suggesting high het-
erogeneity.50
For continuous-data elements such as marginal
bone changes, the mean difference (MD) and 95% con-
fidence interval (CI) were calculated. For dichotomous
data, such as the implant-failure rate, a risk ratio (RR)
with the 95% CI was used to pool the results of each
treatment group. The pooled effect was considered sig-
nificant if P was <0.05. The possibility of publication
RevMan software, version 5.0, The Nordic Cochrane Center, The
Cochrane Collaboration, Copenhagen, Denmark.
i Comprehensive Meta-Analysis software, version 2.2, Biostat, Englewood, NJ.
J Periodontol October 2010
bias was visually detected using a funnel plot51 and
quantitatively using the regression asymmetry test52
and the trim-and-fill method.53 In addition, the sensitiv-
ity and subgroup analyses were planned to identify any
potential causes of heterogeneity.
RESULTS
The initial electronic literature search identified 146
titles (Fig. 1). The hand search did not provide any
additional studies. The review of the abstracts and
key words resulted in 43 studies. After full-text eval-
uation, 26 studies were excluded because they failed
to meet the inclusion criteria. The remaining 17 stud-
ies and one conference paper were further analyzed
in depth for potential inclusion in the review. Eight
studies were excluded from the review for the follow-
ing reasons: four studies did not include a control
group,26,54-56 two studies used a finite element
model,31,42 one study had an observation period of
6 months,24 and one study was a duplicate57 of an-
other published report.58 Thus, a total of 10 stud-
ies25,27,34,58-64 that contained 1,239 implants in
total were included in the systematic review and
meta-analysis (Table 1).
Description of Studies
The selected 10 studies25,27,34,58-64 were published
between 2007 to 2010 and reported similar inclusion
criteria, including the presence of sufficient alveolar
bone height and width, the absence of signs of local in-
fection, and adequate plaque control. The selected
studies excluded patients with chronic systemic dis-
eases, untreated periodontitis, or bruxism and heavy
smokers (>10 cigarettes/day). Seven of the studies
were randomized,25,34,58,59,61-63 and the remaining
three studies27,60,64 were CCTs. The observation pe-
riod ranged from 12 months25,27,34,63 to 60 months.64
Only two studies58,60 reported implant placement into
fresh extraction sockets followed by immediate resto-
ration/loading, where the other studies25,27,34,59,61-64
followed the conventional placement protocol.
With regard to the surgical protocol, five stud-
ies58-61,63 described the use of a pre- and postopera-
tive antibiotic regimen, and all implants were placed in
type II and III bone.65 Bone regenerative procedures
were used in three studies: one study58 filled the
socket voids with bovine bone matrix during implant
placement into fresh extraction sockets, another
study59 used sinus-lift augmentation,# and the third
study63 performed minor bone augmentation. The
assessment of bone-level changes around test and
control implants was based on digital radiographic
measurements in all of the selected studies25,27,34,58-63
but one.64 Measurements were usually limited to the
vertical extent of marginal bone resorption in the stud-
Atieh, Ibrahim, Atieh
ies,25,27,58-64 except for one study34 in which both the
vertical and horizontal changes in marginal bone level
were measured.
Canullo et al.58 performed an RCT to measure the
amount of marginal bone loss and periodontal indices
at 22 implants placed in maxillary fresh-extraction
sites and restored with either platform-switched or
matched prostheses. A significant radiographic differ-
ence in marginal bone levels was observed between
the test and control groups after a mean follow-up pe-
riod of 25 months. On the other hand, periodontal pa-
rameters (i.e., bleeding on probing, probing depth,
and the modified plaque index) did not show any
statistically significant difference between the two
groups. In addition, no correlation was detected be-
tween the gingival biotype (thick or thin) and amount
of marginal bone loss.
Canullo et al.59 assessed the marginal bone level
around 80 implants. The implants were randomly as-
signed into four groups (three test and one control)
based on the discrepancy between the diameters of
the abutment and the implant platform. The use of
3.8-, 4.3-, 4.8-, and 5.5-mm diameter implants with
3.8-mm abutments resulted in a 0.25-mm (test
group 1), 0.50-mm (test group 2), and 0.85-mm
(test group 3) implant-abutment diameter difference,
and a matched-implant-abutment diameter in the
control group. After a follow-up period of 33 months,
the mean marginal bone losses of 0.99 0.42 mm for
test group 1, 0.87 0.43 mm for test group 2, 0.64
0.32 mm for test group 3, and 1.48 0.42 mm for the
control group were reported. The findings suggested
that the extent of the inward shifting was inversely pro-
portional to the amount of marginal bone loss.
Cappiello et al.27 evaluated the marginal bone-
level alterations of 73 implants with an extended
platform of 4.8 mm and 55 implants with a matched
platform of 4.0 mm. One implant failed in the control
group. After 1 year of function, the radiographic ex-
amination showed that the marginal bone loss around
the platform-switched implants ranged between 0.6
and 1.2 mm (mean: 0.95 0.32 mm), whereas the
marginal bone loss around the control implants ranged
between 1.3 and 2.1 mm (mean: 1.67 0.37 mm). The
difference between the two groups was considered to
be statistically significant.
Crespi et al.60 placed 30 platform-switched im-
plants and 34 platform-matched implants. All im-
plants were placed into fresh extraction sockets of
incisors, canines, and premolars. Provisional crowns
were immediately placed after surgery, and implants
were followed up for a period of 2 years. A radio-
graphic marginal bone resorption of 0.73 0.52 mm
Bio-Oss Collagen, Osteohealth, Shirley, NY.
# Nanobone Artoss, Rostock, Germany.
1353
Platform Switching of Dental Implants
Figure 1.
Flow chart for search strategy.
and 0.78 0.49 mm were reported in the platform-
switched and platform-matched groups, respectively.
No statistically significant difference was shown be-
tween the two groups. In the authors view, the use
of an atraumatic surgical protocol might have pre-
served the peri-implant bone levels and minimized
the difference between the two groups.
Enkling et al.34 performed a split-mouth trial of 50
platform-switched and matched implants placed in
the posterior mandible and followed up for 12 months.
The radiographic examination included the measure-
ment of the vertical and horizontal extents of marginal
bone loss. The differences in both dimensions were
not statistically significant. Microbiologic samples
were collected at different time points after implant
1354
Volume 81 Number 10
insertion. The authors suggested that the extent of
microbial colonization had a greater impact on the
amount of peri-implant bone loss than the platform
design.
Hu rzeler et al.25 evaluated the marginal bone-level
changes of 22 wide-diameter implants, which were
randomly connected to either platform-switched or
nonplatform-switched abutments. Baseline stan-
dardized digital radiography was taken at the time
of placement of the definitive prosthesis and at 1-year
after placement. The mean bone loss for the platform-
switched implants was significantly less than those
placed with traditional abutments (P 0.013). The au-
thors concluded that platform switching may reduce
peri-implant bone loss but warned of the limitation
 Table 1. Characteristics of Included Studies

Canullo et al., Canullo et al., Cappiello et al., Crespi et al., Enkling et al., Hurzeler et al., Kielbassa et al., Prosper et al., Trammell et al., Vigolo and Givani,
200958 201059 200827 200960 200934 200725 200963 200961 200962 200964

Study design RCT RCT CCT CCT RCT RCT RCT (multicenter) RCT (multicenter) RCT CCT

Implants (n) 22 61 128 64 50 22 325 360 25 182

PS 11 17 (test group 1);13 (test 73 30 25 14 199 180 13 97
group 2);14 (test group 3)
J Periodontol October 2010

PM 11 17 55 34 25 8 126 180 12 85
i # i
Implant system * * Not clear **

Implant 5.5 PS: 4.3, 4.8, 5.5; PS: 4.0; PM: 4.1 PS: 4.5, 5.5; 4.0 5.0 3.5, 4.3 PS: body/neck 3.3/3.8, 3.8/4.5, 4.0, 5.0, 6.0 5.0
diameter (mm) PM: 3.8 PM: 3.8, 5.0 4.5/5.2; PM: 3.3, 3.8, 4.5

Implant 13.0 13.0 10.0, 11.5, 13.0 PS: 14.0; Not clear Not clear PS: 10.0, 11.5, 13.0, 15.0; 13.0 8.5, 10.0, 11.5, 13.0 Not clear
length (mm) PM: 13.0 PM: 8.0, 10.0, 13.0, 16.0

Implant-abutment 0.85 0.25, 0.5, 0.85 0.4 0.25, 0.35 0.35 0.45 0.25 0.5, 0.7 0.45 0.45
diameter difference
on each side (mm)

Implant location Maxilla Maxilla Maxilla, mandible Maxilla, mandible Mandible Maxilla, mandible Maxilla, mandible Maxilla, mandible Mandible Maxilla, mandible

Placement protocol Immediate Delayed Delayed Immediate Delayed Delayed Delayed Delayed Delayed Delayed

Implant insertion 32 to 45 Not clear Not clear 35 Not clear Not clear 40 to 50 Not clear Not clear 32
torque (Ncm)

Loading/restoration Immediate Delayed Provisional crowns Immediate Delayed Delayed loading Immediate Delayed loading Provisional Delayed loading
protocol provisional placed at loading provisional crowns placed
restoration 2 months restoration at 2 months

Time to definitive 2 3 4 6 Not clear Not clear 12 6 (maxilla); 6 4

restoration (months) 3 (mandible)

Marginal bone At 25 months: At 21 months: PS test group 1 At 12 months: At 12 months: At 12 months: At 12 months: At 12 months: At 12 months: At 24 months: At 12 months:
level changes PS = 0.30 = 0.99 0.42; PS test group 2 PS = 0.95 0.32; PS = 0.78 PS = 0.56 PS = 0.12 PS = 0.80 1.17; PS = 0.021 0.110; PS = 0.99 0.53; PS = 0.90 0.30;
(mm; mean SD) 0.16 and PM = = 0.82 0.36; PS test group 3 PM = 1.67 0.37 0.49; PM = 0.44; PM = 0.40; PM = 0.63 1.18 PM = 0.101 0.274 PM = 1.19 0.58 PM = 0.60 0.20
1.19 0.35 = 0.56 0.31; PM = 1.49 0.54 0.82 0.40 0.61 0.57 PM = 0.29
0.34
At 33 months: PS test group 1 = At 24 months: At 24 months: At 60 months:
0.99 0.42; PS test group 2 = PS = 0.73 PS: 0.055 0.234 PS: 1.10 0.30
0.87 0.43; PS test group 3 = 0.52; PM = PM: 0.193 0.474 PM: 0.60 0.20
0.64 0.32; PM = 1.48 0.42 0.78 0.49 (non-submerged)

Allocation concealment Grade A Grade A Grade D Grade D Grade B Grade B Grade A Grade B Grade B Grade D

Jadad score 4 4 1 0 1 1 3 3 2 0

Follow-up period (months) 24 to 27 33 12 24 12 12 12 24 24 60

Survival rate (%)

PS 100 100 98.3 100 100 100 97.7 100 100 100
PM 100 100 100 100 100 100 97.6 98.3 100 100

PS = platform-switching; PM = platform-matched. * Global, Sweden-Marina, Padova, Italy. Osseotite, 3i Implant Innovations, Palm Beach Gardens, FL.
Seven, Sweden-Marina. Ankylos Plus, Dentsply Friadent, Mannheim, Germany. i 3i Implant Innovations.
NobelReplace, Nobel Biocare, Gothenburg, Sweden. # NobelActive, Nobel Biocare. ** WINSIX, Winsix, London, U.K.
Atieh, Ibrahim, Atieh

1355
Platform Switching of Dental Implants
in interpreting the results because of the small number
of implants included in their analyses.
Kielbassa et al.63 reported on the marginal bone
loss around immediately restored implants using an
implant with a built-in platform-switch and a standard
control one. A total of 325 implants were placed in 12
centers following a similar protocol. At 12 months,
three implants failed in the control group versus seven
implants that failed in the test group. No significant
difference in crestal bone levels was observed be-
tween the two implant designs (P = 0.729). Addition-
ally, all implants showed a favorable soft tissue
response with a significantly higher papilla score after
the first year of function.
Prosper et al.61 reported a multicenter RCT of 360
platform-switched and control implants that were
placed using three different placement methods: sub-
merged, non-submerged, and submerged with re-
duced abutment. Patients were followed up for 24
months. Two of the platform-matched implants failed
as a result of overloading. A masked radiographic
evaluation was carried out by one calibrated exam-
iner, and a statistically significant difference in the
crestal bone changes were found between the two
groups. In addition, there was no significant difference
in the modified sulcus bleeding index, plaque index,
and implant-stability quotient between platform-
switched and matched implants during the period of
the study.
Trammell et al.62 conducted an RCT in which 25
dental implants were placed in the mandible to eval-
uate the marginal bone loss around platform-switched
and platform-matched implants. Each patient acted
as his or her own control. The randomization was
achieved by scratching a randomization card, and
the intraexaminer reliability was tested. None of the
implants failed after a follow-up period of 2 years.
The platform-switched implants showed significantly
less crestal bone loss compared to conventional im-
plants (0.99 0.53 mm versus 1.19 0.58 mm). In
contrast, there was no difference in the radiographic
surrogate measure of biologic width in both groups.
Vigolo and Givani64 evaluated 182 single wide-di-
ameter implants placed in posterior sites. Of these,
97 implants were restored with prosthetic compo-
nents that were 0.8 mm narrower in diameter than
the implant platform, and 85 implants were restored
with prosthetic components of the same diameter.
The implants were evaluated for 5 years after the
placement of abutments, and radiographic changes
were measured using a 6 magnifying lens. There
was a statistically significant difference in the mar-
ginal bone loss between the test and control groups
at 1 year. However, the marginal bone levels did not
show any significant changes at 2, 3, 4, and 5 years
of function.
1356
Volume 81 Number 10
Methodologic Quality
The overall quality of the included studies was con-
sidered satisfactory. The Jadad score ranged from
0 to 4 because seven studies25,34,58,59,61-63 were
RCTs. The randomization was performed by the use
of sealed opaque envelopes,61 a randomization card,62
and a predefined randomization table.58,59,63 Although
it may not always be possible to mask the examiner to
the design of the implantabutment connection, one
study58 was described as a double-masked RCT. In
addition, the allocation concealment was not properly
described or was not used in all studies25,27,34,60-64 but
two.58,59
Meta-Analyses
Primary outcome. The range of the marginal bone
loss in test and control groups was 0.055 to 0.99 mm
and 0.19 to 1.67 mm, respectively. A statistically sig-
nificant reduction in peri-implant bone loss was re-
ported around the platform-switched implants in
seven studies,25,27,58,59,61,62,64 whereas three stud-
ies34,60,63 failed to show any significant difference be-
tween the two groups. In one study,59 the differences
among the three test groups and the control group
were regarded as three separate comparisons, and
each one was included in the meta-analysis as a study
unit. Thus, the 10 selected studies25,27,34,58-64 were
treated as 12 study units throughout the analyses.
When the marginal bone-level changes were mea-
sured at different follow-up intervals in one study,
the data recorded at the longest follow-up interval
was included in the overall analysis. The random-
effects model was applied as the heterogeneity
among studies was significant. The meta-analysis
of all included studies25,27,34,58-64 showed a signifi-
cant bone loss in the platform-matched implant
group with an MD of -0.37 mm (95% CI: -0.55 to
-0.20; P <0.0001; Fig. 2). The x2 of heterogeneity
was 126.79 (P <0.0001; I2 = 91%).
Secondary outcome. All included studies25,27,34,58-64
showed no significant difference in the implant-failure
rate between the two platform designs. The only re-
ported failed implants were eight platform-switched
implants27,63 and six control implants,61,63 whereas
the remaining implants in either group were well inte-
grated. Based on a fixed-effects model, there was no
significant difference in implant failure (RR: 0.93; 95%
CI: 0.34 to 2.59; P = 0.89; Fig. 3). No within-study
(x2 = 2.30; P = 0.32) or between-study heterogeneity
(I2 = 13%) was observed.
Subgroup analyses. The possible sources of het-
erogeneity were assessed by subgroup analyses on
the primary outcome (Table 2). The multiple compar-
isons included: the study design (RCT versus CCT),
sample size (60 implants versus <60 implants), time
of implant placement (immediate versus delayed),
J Periodontol October 2010
difference between the implant platform-abutment
diameter (0.4 mm versus <0.4 mm), and follow-up
period (12 months versus >12 months).
In general, the subgroup analyses showed that the
platform-switched implants offered more bone pres-
ervation than the traditional implants. However, the
difference was not always significant. The subgroup
analyses of the RCTs25,34,58,59,61-63 showed a signifi-
cant difference with less bone-level changes in the
platform-switched implant group (MD: -0.38; 95%
CI: -0.63 to -0.13; P = 0.003; Fig. 4). Likewise, the
three CCTs27,60,64 in this review demonstrated a sim-
ilar estimate of the treatment effect with a significant
difference between the two platform designs in favor
of the platform-switching implant design (MD:
-0.37; 95% CI: -0.71 to -0.03; P = 0.03; Fig. 5).
The subgroup analyses of the five studies27,60,61,63,64
that had sample sizes of 60 implants showed a bor-
derline significant difference (MD: -0.23; 95% CI:
-0.47 to 0.00; P = 0.05; Fig. 6). On the other hand,
the difference was statistically significant when only
studies25,34,58,59,62 with a smaller sample size (<60
implants) were included in the analysis (MD: -0.50;
95% CI -0.78 to -0.22; P = 0.0005; Fig. 7). Limiting
the analysis to the studies25,27,34,59,61-64 that placed
the implants in healed sites revealed a significant dif-
ference in favor of platform switching (MD: -0.35;
95% CI: -0.54 to -0.17; P = 0.0001; Fig. 8).
With regard to the degree of implant-abutment
diameter mismatch, the subgroup analyses demon-
strated a significant difference when a diameter
difference 0.4 mm was used25,27,58,59,61,62,64 (MD:
-0.50; 95% CI: -0.72 to -0.29; P <0.0001; Fig. 9).
However, the difference was not significant among
the studies34,59,60,63 that used an implant/abutment
Figure 2.
Comparison: platform switching versus platform matching. Outcome: marginal bone level changes. TG = test group; df = degrees of freedom; IV = inverse variance.
Atieh, Ibrahim, Atieh
diameter mismatch <0.4 mm (MD: -0.10; 95% CI:
-0.35 to 0.15; P = 0.43; Fig. 10). The subgroup anal-
yses of the studies58-64 with a >12-month follow-up
period showed significantly less peri-implant bone re-
sorption around platform-switched implants (MD:
-0.48; 95% CI: -0.70 to -0.26; P <0.0001; Fig. 11).
However, the difference was marginally significant
among the 12-month follow-up studies25,27,34,60,61,63,64
(MD: -0.19; 95% CI: -0.39 to 0.01; P = 0.06; Fig. 12).
Publication bias. The funnel plot showed a slight
asymmetry (Fig. 13A). However, the regression
asymmetry test did not suggest a publication bias
(P = 0.54). The trim-and-fill method53 indicated one
missing study, and the adjusted overall effect size
was not substantially different from the original esti-
mate. A slight publication bias may have been pres-
ent, suggesting that the missing study was more
likely to favor the standard platform-matching system
(Fig. 13B). Moreover, a series of analyses for publica-
tion bias was also conducted for the selected sub-
groups. The Egger regression method52 did not
suggest any possible publication bias, and the differ-
ence between the original estimate and the adjusted
effect size according to the trim-and-effect procedure
remained non-significant for all subgroups of studies
(Appendix 3).
DISCUSSION
This systematic review and meta-analysis used the re-
cent guidelines of PRISMA44 and the Cochrane Col-
laboration methods45 to evaluate the best available
evidence for the use of platform switching as a design
feature to limit peri-implant bone loss around implants.
A meta-analysis of 1,239 implants was conducted
to examine the radiographic marginal bone-level
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Platform Switching of Dental Implants Volume 81 Number 10

Figure 3.
Comparison: platform switching versus platform matching. Outcome: implant failure. df = degrees of freedom; M-H = Mantel-Haenszel.

Table 2. sult may not be reliable to identify heterogeneity.66

The subgroup analyses examined the influence of the
Subgroup Meta-Analysis
study design, sample size, implant-placement method,
Category Studies (n)* MD (95% CI) P degree of discrepancy between implant and abutment
diameters, and the length of the observation period on
Study design the overall effect size. A substantially more stable peri-
RCT 9 -0.38 (-0.63 to -0.13) 0.003 implant bone level around platform-switched implants
CCT 3 -0.37 (-0.71 to -0.03) 0.03 was observed in studies25,27,34,59,61-64 that followed the
Sample size conventional placement protocol and had a smaller
N 60 5 -0.23 (-0.47 to 0.00) 0.05 number of implants (<60 implants)25,34,58,59,62 with
N <60 7 -0.50 (-0.78 to -0.22) 0.0005 a >0.4-mm difference between implant and abutment
diameters on one side.25,27,58,59,61,62,64 This indi-
Implant-placement protocol
IP 2 -0.47 (-1.29 to 0.35) 0.26
cated that the changes in marginal bone levels were
DP 10 -0.35 (-0.54 to -0.17) 0.0001 more favorable with increasing the extent of mis-
match between implants and abutments. Indeed,
Implantabutment diameter difference (mm) the positive effect of increasing the degree of mis-
0.4 8 -0.50 (-0.72 to -0.29) <0.0001 matching between the implant platform and abut-
<0.4 4 -0.10 (-0.35 to 0.15) 0.43 ment diameter was previously demonstrated.56,59
Follow-up period (months) Increasing the physical distance between the IAJ
>12 8 -0.48 (-0.70 to -0.26) <0.0001 and the marginal alveolar bone may further place
=12 7 -0.19 (-0.39 to 0.01) 0.06 the inflammatory infiltrate and its resorptive effects
IP = immediate placement; DP = delayed placement. away from the marginal bone. However, long-term
* In one report, 59 each of the three test groups was considered a separate studies with larger sample sizes may still be needed
study unit.
Three studies60,61,64 reported data at two different time points (12 and to validate such a conclusion.
>12 months) and, hence, were included in both analyses. The principle of platform-switching was previously
reviewed.67,68 Both reviews67,68 provided a summary
changes and implant-failure rate. The results of the of the current human, animal, and biomechanical
analysis showed that platform-switched implants studies on the advantages and potential applications
experienced less marginal bone loss than implants of platform switching. The authors67,68 concluded that
restored with matching prostheses. However, the platform-switching may preserve the crestal bone
implant-failure rate did not seem to be affected by level and maintain the soft tissue level in the esthetic
platform switching. zone. However, the radiographic marginal bone level
The subgroup analyses was conducted to explore is a surrogate measurement for the esthetic outcome.
the sources of heterogeneity because the test of het- Hence, the enhanced preservation of peri-implant
erogeneity had a low power, and a non-significant re- bone around a platform-switched implant may not

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J Periodontol October 2010 Atieh, Ibrahim, Atieh

Figure 4.
Comparison: platform switching versus platform matching. Outcome: marginal bone level changes (RCTs). TG = test group; df = degrees of
freedom; IV = inverse variance.

Figure 5.
Comparison: platform switching versus platform matching. Outcome: marginal bone level changes (CCTs). df = degrees of freedom; IV = inverse variance.

Figure 6.
Comparison: platform switching versus platform matching. Outcome: marginal bone level changes (sample size 60). df = degrees of freedom; IV =
inverse variance.

necessarily improve esthetics. Further research that
clearly evaluates esthetic outcomes with larger sam-
ple sizes and longer follow-up periods are recommen-
ded to validate the esthetic advantages of platform
switching. The present systematic review was differ-
ent from the previous reviews67,68 in several aspects.
First, the present review was carried out systemati-
cally following PRISMA guidelines44 and using a
well-focused PICO question. Second, only human
studies with a control group were selected. Third,
the existing literature was quantitatively assessed
by performing a meta-analysis and subgroup analy-
ses to provide a better understanding of the role of
platform-switching in the maintenance of crestal
bone levels compared to the role of standard plat-
form-matched implants.
This systematic and meta-analytic review had
several limitations. First, the search was limited to

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Platform Switching of Dental Implants Volume 81 Number 10

Figure 7.
Comparison: platform switching versus platform matching. Outcome: marginal bone level changes (sample size <60). TG = test group; df = degrees of
freedom; IV = inverse variance.

Figure 8.
Comparison: Platform switching versus platform matching. Outcome: marginal bone level changes (delayed implant placement). TG = test group;
df = degrees of freedom; IV = inverse variance.

Figure 9.
Comparison: Platform switching versus platform matching. Outcome: marginal bone level changes (implant-abutment diameter difference 0.4). TG =
test group; df = degrees of freedom; IV = inverse variance.

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J Periodontol October 2010 Atieh, Ibrahim, Atieh

Figure 10.
Comparison: Platform switching versus platform matching. Outcome: marginal bone level changes (implant-abutment diameter difference <0.4).
TG = test group; df = degrees of freedom; IV = inverse variance.

Figure 11.
Comparison: Platform switching versus platform matching. Outcome: marginal bone level changes (>12 months follow-up). TG = test group;
df = degrees of freedom; IV = inverse variance.

Figure 12.
Comparison: Platform switching versus platform matching. Outcome: marginal bone level changes (12 months follow-up). df = degrees of freedom;
IV = inverse variance.

English-language publications, which may have
introduced a publication bias and excluded other
relevant articles. However, such an exclusion may
not considerably change the overall estimate of
treatment effects.69 Second, an inherent limitation
in each selected study was the use of conventional ra-
diographs, which allowed for the detection of bone
loss at the mesial and distal peri-implant sides but
did not evaluate the buccal and lingual bone levels.
Third, the bone levels were generally assessed in
one dimension, which is the vertical distance from
the most coronal aspect of the implant shoulder to

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Platform Switching of Dental Implants
Figure 13.
Funnel plot for assessment of publication bias: A) without imputed
studies; B) with imputed studies. Imputation was done according to the
trim-and-fill procedure of Duval and Tweedie.53
the first boneimplant contact. It is important to
measure the horizontal and vertical marginal bone
changes around implants because the distance be-
tween the IAJ with its associated inflammatory cell
infiltrate (0.75 mm above and below the IAJ) and
the crestal bone level can influence both the horizon-
tal and vertical extension of bone resorption.16,70-72
Only one study34 measured the marginal bone level
changes in both the vertical and horizontal dimen-
sions and concluded that platform switching may
not have a significant influence on maintaining verti-
cal and horizontal marginal bone levels. Fourth, the
implants included in the review may not have been
placed at a standardized distance from the alveolar
crest, which may have added to the heterogeneity
of the studies. The placement of the IAJ above
the crest may result in less bone loss than placing it
below the crest because bone resorption increases
to establish the biologic width.73,74 Fifth, the inclu-
sion of non-randomized CCTs in the analysis may
have introduced a bias. However, it was postulated
that CCTs can complement the evidence provided
by RCTs, particularly when RCTs are not of a high
quality.75,76 In addition, the subgroup analyses pre-
sented RCTs and CCTs separately and showed that
CCTs did not overestimate or underestimate the
treatment effect.
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Volume 81 Number 10
Nonetheless, the quality of the included studies ap-
peared to be moderately acceptable as assessed by
Jadad quality scoring and the Cochrane scale for
the assessment of allocation concealment. The obvi-
ous heterogeneity between studies was accounted for
by using a more conservative random-effects model
and performing subgroup analyses to detect the fac-
tors that may affect the outcome. Furthermore, the
possibility of a publication bias was thoroughly inves-
tigated, and an overestimation of the overall mean
effect size was excluded. A publication bias is one
of the drawbacks of a meta-analysis and its absence
substantially validated the conclusions of this review.
Nonetheless, the limitations of the publication-bias
analyses need to be considered.77,78
CONCLUSIONS
In this systematic review and meta-analysis, the con-
troversial evidence on the use of platform switching to
maintain bone levels around implants is summarized.
Within the limitation of the available data, the results
reveal that the inward shift of IAJ platform switching
can be considered a desirable morphologic feature
that may prevent the horizontal saucerization and
preserve the vertical crestal bone levels. An additional
improvement in the marginal bone levels around
dental implants may also be obtained with a greater
degree of shifting.
Additional properly designed, large RCTs are
needed before establishing the long-term predictabil-
ity of platform switching in preserving the horizontal
and vertical marginal bone levels or modifying the
minimum distances between platform-switched im-
plants and adjacent teeth or implants.
ACKNOWLEDGMENT
The authors report no conflicts of interest related to
this review.
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Submitted April 20, 2010; accepted for publication May
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Platform Switching of Dental Implants Volume 81 Number 10

Appendix 1. Appendix 2.
Jadad-Score Calculation47 Cochrane Assessment of Allocation
Concealment48
Item Jadad Score Grade Description

The study was described as randomized +1 A Adequate: the randomization sequence was
hidden from the examiners (e.g., the use of
The method for random allocation was +1 central randomization by a third party,
appropriate sequentially numbered opaque envelopes,
The study was described as double masked +1 computer generated with allocations kept in
a locked unreadable file)
The method for double masking was +1
appropriate B Unclear: the method of allocation concealment
was not described
The method used to generate the sequence -1
of randomization was inappropriate C Inadequate: allocation was not adequately
concealed (e.g., the use of the day of
The method of masking was inappropriate -1 admission, date of birth, and hospital
record number)
The number and reasons for withdrawals/ +1
dropouts were reported D Not used

Appendix 3.
Tests for Publication Bias
Original Meta-Analysis Trim-and-Fill Analysis

Studies Trimmed/ Egger Regression

MBLC MD (95% CI) P MD (95% CI) Total Studies* P (two-tailed)

Overall sample -0.37 (-0.55 to -0.20) <0.0001 -0.32 (-0.15 to -0.50) 1/12 0.54
Study design
RCT -0.38 (-0.63 to -0.13) 0.003 -0.14 (-0.41 to 0.13) 3/9 0.25
CCT -0.37 (-0.71 to -0.03) 0.03 -0.37 (-0.71 to -0.03) 0/3 0.98
Sample size
N 60 -0.23 (-0.47 to 0.00) 0.08 -0.23 (-0.47 to 0.00) 0/5 0.87
N <60 -0.50 (-0.78 to -0.22) 0.0005 -0.50 (-0.78 to -0.22) 0/7 0.34
Implant-placement protocol
DP -0.35 (-0.54 to -0.17) 0.0001 -0.29 (-0.47 to -0.11) 1/10 0.63
Implantabutment diameter difference (mm)
0.4 -0.50 (-0.72 to -0.29) <0.0001 -0.35 (-0.56 to -0.13) 2/8 0.21
<0.4 -0.10 (-0.35 to 0.15) 0.43 -0.10 (-0.35 to 0.15) 0/4 0.65

Follow-up period (months)

>12 -0.48 (-0.70 to -0.26) <0.0001 -0.33 (-0.55 to -0.12) 2/8 0.45
= 12 -0.19 (-0.39 to 0.01) 0.06 -0.19 (-0.39 to 0.01) 0/7 0.68
MBLC = marginal bonelevel change; DP = delayed placement.
59
* In one report, each of the three test groups was considered a separate study unit.
Three studies60,61,64 reported data at two different time points (12 and >12 months) and, hence, were included in both analyses.

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