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The Notion of Platform-Switching in Implants: A Review

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 Ankit et al., The Notion of Platform-Switching in Implants

e-ISSN : 2455-5258
Research in Pharmacy and Health Sciences
Review Article
The Notion of Platform-Switching in Implants: A Review
Ankit Rawat, Rupinder Singh Dhall, Nitish Bhat, Shivika Ahluwalia, Novika Sahni, Sunny
Sharma, Narender Singh*
Department of Prosthodontics and Implantology, Himachal Institute of Dental Sciences, Paonta
Sahib-173025, HP, India
1
Department of Pharmaceutics, Himachal Institute of Pharmacy, Paonta Sahib, HP, India

ABSTRACT Received: 03-03- 2018

Platform switching implies to the mismatch in diameter of the abutment and that Revised: 28-03-2018
of the implant collar or in particular, use of the abutments with lesser diameter on Accepted: 07-05-2018
a greater diameter implant collar. Platform switching was proposed as a process *Correspondence to:
to improve long-term bone maintenance around implants. The clinical Mr. Narendra Singh,
applications of platform switching are multiple, and all indicate better long-term Email:
predictability in implant therapy by allowing preservation of the peri-implant hard [email protected]
and soft tissue with time. In this review the influence of platform switching on Funding: Nil
various other factors affecting crestal bone loss around implants has been Competing Interests: None
discussed.
Keywords: platform switching, implant abutment junction, inflammatory connective tissue zone, osseointegration

INTRODUCTION
and 4.0-mm implants has led some authors to suggest that
Osseo-integrated implants have become a productive when dental implants are placed into function, crestal
treatment option for single, partially edentulous, and bone remodeling occurs as a result of stress concentration
completely edentulous spans in suitable patients. The at the coronal region of the implant. Other authors have
rates for survival of implant-supported single- and suggested that post-restorative crestal bone remodeling is
multiple-tooth restorations are found comparable to those due to localized inflammation within the soft tissue
for implant-supported prostheses in completely located at the implant-abutment interface, and is a result
edentulous patients. However, the goal of modern implant of the soft tissue’s attempt to maintain a mucosal barrier,
therapy is focused on more than just the successful osseo- i.e, biologic width (seal) around the top of the dental
integration (survival) of the implant. A successful result implant [2]. The bone resorption mechanism has been
must also provide an esthetic and functional restoration attempted to be explained by formation of the biologic
surrounded by sound peri-implant tissues that are in width as it is in the case of the periodontal tissue around
harmony with the existing dentition. Stable level of peri- natural teeth or due to the mechanical stress on the bone–
implant bone is one set parameter of implant success. As implant interface. Bone resorption at the implant neck
a process to improve long-term bone maintenance around region, however, is evitable because some clinical
implants, a new implant-to-abutment connection referred observations have shown that less bone resorption with
to as “platform switching” was proposed [1]. The bone preservation is possible when the narrower diameter
resulting crestal bone levels around dental implants after of abutment is connected to the implant, so called
the restoration has been a topic of discussion and used as platform switching [3].
a reference for evaluation of implant success for many
years. The literature on implants contains numerous An important factor in avoiding crestal bone loss related
articles which describe the 1-year post-restorative bone to platform switching may be that of the inflammatory
levels around threaded dental implants. These articles connective tissue around the IAJ. If the ICT is responsible
report that crestal bone levels are almost always located for bone remodeling, then moving the implant-abutment
approximately 1.5 to 2.0 mm below the implant-abutment junction inward by means of platform switching can shift
junction (IAJ) at 1 year after implant restoration but are the ICT further from the alveolar crest, thereby reducing
dependent upon the location of the IAJ relative to the its deleterious effect on the crest [4]. Lazzara and Porter
bony crest. The radiographic observation that post- theorize that this occurred because shifting the IAJ
restorative “remodeled” crestal bone generally remains inward also repositioned the inflammatory cell infiltrate
with the level of the first thread on most standard 3.75- and confined it within a 90° area that was not directly

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 Ankit et al., The Notion of Platform-Switching in Implants

adjacent to the crestal bone, thus reducing crestal bone submerged titanium implants in a dog model for 6
resorption [5]. Few clinical, histological, and months, and it concluded that bone remodeling is not
retrospective studies have shown that crestal bone loss effected by platform switching in non submerged cases.
around dental implants can be reduced by using platform Enkling et al did another study to evaluate the effect of
switching. In a standard protocol, implants are fitted with healing mode (open or submerged) on marginal bone
abutments of the same diameter. Mechanical and levels in platform switched implants and they found that
biological principles of platform switching have been the healing mode does not affect the marginal bone.
given to minimize the bone loss. First, with the greater
surface area created by the exposed implant seating Effect of platform switching on inter implant distance:
surface, the amount of crestal bone loss necessary to
expose a minimum area of implant surface to which the Platform switching can aid in preserving the bone around
soft tissue can attach is reduced. Second, and may be the implant [12,13,14]and retain the inter implant bone
more important, by repositioning the micro-gap inward peaks. This can be explained on the basis of the concept
and away from the outer edge of the implant and adjacent that platform switching shifts the IAJ towards the center
bone, the overall effect of the abutment inflammatory cell of the implant and therefore provide biologic width
infiltrate (ICT) on surrounding tissue may be decreased, modification so less resorption occurs. The placement of
thus decreasing the resorption of the crestal bone. As a platform switched implant in proximity of natural tooth
consequence, the reduced exposure and confinement of does not have any adverse effect on the natural tooth or
the platform-switched abutment ICT may result in a the implant itself [15].
decreased inflammation within surrounding soft tissue
and crestal bone [6]. Success in tooth replacement is In an another study done by tabata et al [16] pellizer et al
marked by the restoration of adequate function and [17] cimen et al[18], stress distribution in peri implant
esthetics without any negative effects on the adjacent bone tissue, implants, and prosthetic components of
hard and/or soft tissue structures. As there will be bone single implants in platform switching technique was
resorption at the implant platform following uncovering measured, and they found that there was better stress
and loading, younger patients receiving restorations face distribution in peri implant bone tissue.
a higher risk of future complications. That is why the
This can be explained by the fact that platform switching
selection of a better alternative to preserve healthy
decreases the stress concentration on peri implant bone
adjacent peri-implant structures seems important [7]. The
and tissues by shifting the implant abutment junction
interest created by this concept is demonstrated by the
which leads to less micro damage in the bone, resulting
fact that all major dental implant manufacturers are
in minimized crestal bone loss but higher stresses were
providing at least one implant line with platform
evident for the retention of screw and prosthesis,
switching in their catalogs [8]. Furthermore, The distance
concentration of stresses at the screw are mechanically
between two implants has been reported to effect the inter
harmful because it could clinically transfer into increased
proximal bone level and any forfeiture of interproximal
frequency of complications in implant supported
bone will adversely affect the soft tissue between
prosthesis such as screw loosening and fracture or screw
implants. It has been demonstrated that inter-implant
deformation[16] of the abutment if the stresses overcome
bone crest moves apically when the horizontal inter-
the elastic limit.
implant distance is decreased. It has been suggested that
the vertical bone loss to the first thread with conventional Khurana et al[19], studied influence of fine threads and
platform– abutment interface may be due to a decrease in platform switching on crestal bone stress around implant
inter-implant distance less than 3 mm [9], so in the areas and found that crestal bone stress is increased by the fine
where inter implant distance cannot be maintained easily threads upon loading, fine threads increase the bone
platform switching can help to maintain the mucosal resistance to load by changing shear load to tensile or
barrier. The Platform switching can help to decrease the compressive load. Ana paula et al[20] evaluated stress in
stress level at the implant-bone interface area. The peri-implant bone with straight and angulated abutments.
reduction of the stress concentration at the implant-bone They concluded that angulated abutments produce more
interface area is a favorable development to confirm the stress on peri implant bone when compared to straight
osseo-integration. Another possible explanation of the abutments.
efficacy of the platform-switching configuration is the
establishment of the implant abutment connection at the Effect of different platform width on crestal bone loss
bone level [10]. in platform switching concept:

2. Influence of Platform Switching on Various Factors Bone stability is an important factor in evaluation of
affecting crestal bone loss around implants. longievity of osseointegrated implants, as extensive bone
Effect on open and submerged healing of implants loss can cause peri-implantitis leading ultimately to
with platform switching: A study [11] evaluated the implant failure. Resorption of bone in marginal areas can
effect of platform switching on crestal bone loss at non change the surrounding soft tissue profile which can

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 Ankit et al., The Notion of Platform-Switching in Implants

cause loss of inter-dental papilla leading to aesthetic, a biological seal. Thus a close proximity of the
phonetic changes and food impaction. There are many IAJ to the bone, which is always established
factors responsible for influencing the marginal bone loss when implants are placed epicrestally, is
including the dental implant connection type. eliminated by bone resorption and the seal is
established. An internal repositioning of the IAJ
According to Rodrigo et al [21] osseo integrated implants by platform switching may decrease the effect of
with internal connections showed less marginal bone loss ICT and as a result may decrease bone loss.
as compared to external connection implants. This is
mainly due to presence of platform switching present in The effect of platform switching on marginal bone level
internal connection implants. This is because in platform seemed to be dose dependent, i.e the greatest platform
switching the implant abutment connection is far away abutment mismatch resulted in the least marginal bone
from the margin, which causes decreased load loss. There is a strong tendency that around two or more
concentration, decreased micromovements, and also the adjacent platform switched implants peri implant bone is
bacterial colonization takes place at a farther region of better preserved. The influence on inter implant distance
bone. on crestal bone loss in the platform switching designed
internal connections was found to be -0.26mm with a
In a systematic review done by Maram et al[22] there can mean error of 0.14mm even in the cases where inter
be presence of some confounding factors which can mask implant distance is less than 3 mm[24].
the real effect of platform switching which are:-
Effect of platform switching on soft tissue:
1. Apico coronal position of implants in relation
to crestal bone. This review concluded that the The presence of the soft tissue above the bone is
more deeper the implant is placed the more bone explained as a defense mechanism – a sort of barrier or
loss will occur. protective seal capable of protecting the alveolar crest
2. Presence of various implant microtextures. The from the bacterial invasion of oral cavity.
closer the micro threads were to the top of the
implant the less is the marginal bone loss. This seal is merely the biologic width that is present on
3. The degree of platform switch. The effect of the natural tooth surface and in a similar way on implants
degree of platform switching on marginal bone exposed to oral cavity. The thickness of this mucosal seal
loss is inversely related i.e the greater the degree is approx 3 mm. it has been hypothesized that the
of platform switch the least is the maginal bone mismatching of implant/abutment is consequent to the
loss. reduction in inflammation within the soft tissue.
4. Reliability of examination methods. A three
dimensional examination method is more Inflammatory cells were detected in clinically healthy
reliable as compared to a two dimensional peri gingival and perimplant mucosa as well as peri implant
apical radiograph. mucositis and peri implantitis. In clinically healthy
Effect of platform switching on hard and soft tissues: gingiva and peri implant tissues, mostly T lymphocytes
were found in a narrow area of connective tissue lateral
Platform switching demonstrates less vertical change in to JE. In the inflamed peri implant tissues B cells
the crestal bone heights around implants than expected. gradually increases. At the histological evaluation
There is a good soft tissue healing and maintenance of platform switching, it reduces the inflammatory infiltrate
papillae and buccal margin levels were consistently at the IAJ.
observed [17,23]. PS implants behave better than NPS
implants, regarding soft and hard tissue maintenance. In healthy peri implant connective tissue, collagen fibers
were well organized and generally are homogeneous.
Two main reasons for the reduced bone loss around However in inflamed peri implant tissue the collagen
platform switched implants: fibers are loosely packed, thin fibrils, disorganized and
not well arranged, impairing the structural resistance of
1. Shifting of the stress concentration area away soft tissue to bacterial penetration. Mismatching seems to
from the cervical bone- implant surface to lead to the establishment of a wider and more resistant
ensure less micro movement in the adjacent zone of connective tissue at level of implant abutment
bone structure. connection [11].
2. It shifts the inevitable microgap of the IAJ away
from the outer edge of the implant and The fibers that are perpendicular to the implant change
neighboring bone. The IAJ is always encircled their direction and arrange themselves in a circular way
by an inflammatory cell infiltrate (ICT) when they meet the implant surface. In PS implants this
(0.75mm above and below IAJ, to protect the circular fiber formation takes place at IAJ while in NPS
bone from this inflammatory infiltrate 1 mm of implants takes place at first thread, so in PS implants it
healthy connective tissue is needed to establish

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 Ankit et al., The Notion of Platform-Switching in Implants

prevents bone loss as the switched Platform seems to implants is better as it changes the stress distribution from
stabilize the circular fibers. the abutment to the implant and from the implant to the
bone when occlusal loading occurs. The von mises
The use of PS implants may help to minimize the stresses in the abutment of platform switched models
perimplnat bone loss and consequently alterations on were lower [28] than the abutment of conventional
adjacent soft tissues, associated to the correct surgical and models. The reduction of stresses in in the abutment with
prosthetic planning ensuring excellent esthetics and platform switching versus the conventional abutment was
function [25]. 36.91% at 15 degrees, 39.69% at 30 degrees and 40.07%
at 45 degrees [29].
Specifically by coupling platform switching to abutment
emergence profile modification, clinicians will create Stress Analysis by Photoelastic Method [6]:
more space around implant abutment interface to allow
for the development of additional soft tissue volume, Photoelasticity allows prediction of the mechanical
better control of gingival margin and good oral hygiene response of photoelastic model when load is applied. The
maintenance . analysis resulted in a conclusion that in platform switched
implants there is more centralization of stresses at the
Influence of Individual bone patterns on platform implant apex. This can be explained by the load
switching: concentration at IAJ, which transfers the stress to a more
centralized position and the stress concentrations at
Canullo et al [26] conducted a study to determine whether cervical region are decreased.
individual bone markers might be associated with peri
implant resorption around implants restored with Stress Analysis by Finite Element Method [13,28,30]
platform switching concept. The clinical evidence has
shown that post restorative peri implant bone resorption FE analysis revealed higher compressive and tensile
is not static but subject to interindividual variations from stresses in conventional models than in platform
implant to implant and from patient to patient. This switching models at the compact bone vicinity of the
assumption was corroborated by data from the study of implant neck. However the value decreases by 41.7% for
canullo et al. they found that bone resorption trends the first principal stress in compression. Apparent stress
differed between patients. Individual local bone structure distribution in compact bone is reduced and stress
and quality seemed to be correlated to peri implant bone concentration in cancellous bone was shifted along the
resorption. entire surface of the thread in platform switched models.
On comparing the stress distribution in different areas i.e.
Influence of Platform Switching on Stress distribution peri implant bone tissue, implant, prosthetic screw and
on Bone-Implant Biomechanical System: prosthesis it was conclude that cortical bone exhibits
higher stresses than trabecular bone. stress values are
Stress and strain fields around osseointegrated dental higher in the retention screws than in bone tissue, implant,
implants are effected by a number of biomechanical and prosthesis. Platform switching decreases the stresses
factors and platform switching is one of them. The concentration in all the areas except for the retention
stress/strain distribution in the bone also includes the screw. The influence of platform switching was more
length of bone implant interface. For a given implant, evident for cortical bone than for trabecular bone[31], but
placement in maxillary and mandibular posterior region there is an improvement in peri implant bone preservation
induces stress distributions that were dissimilar at bone and better stress distribution and less stress transfer to the
implant interface as a consequence of different geometry bone[32].
and bone mechanical properties, resulting in higher
compressive overloading risk in the maxillary segment. Effect of Immediate placement and Immediate
For a given implant, the compressive peaks and average loading:
stress at maxillary cortical bone were about 140% of the
values for mandibular bone. Stress analysis of implants According to canullo et al[17,24,27,33] the marginal
with similar diameters highlights that the risk of bone bone around single, PLS implant placed immediately and
overloading in compact bone strongly increases when restored immediately showed average bone resorption of
significant crestal bone loss occurs. When crestal bone 0.14 to 0.46 mm in a short span of 25 months, whereas
geometry is modeled by platform switching the non PLS implants showed bone resorption of 0.84mm
configurations and subcrestal positioning, the best stress to 1.54 mm.
based performance for compact bone was obtained,
together with acceptable stress values at cancellous In an another study[12] the average bone loss in the PLS
interface [13]. group was 0.45mm to 0.61mm in one year follow up
period. They also examined hard and soft tissue changes
Recent studies [27] have also shown that the in response to single PLS implants placed in anterior and
biomechanical performance in platform switched posterior region following the immediate placement and

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 Ankit et al., The Notion of Platform-Switching in Implants

immediate restoration protocol and found that bone 1. Implants with an enlarged platform that
resorption around the implants was significantly lower incorporates platform switching in their
than the expected reference value. They also concluded shape exhibited no little or no bone loss
that PLS implants placed and loaded immediately can within first two years following the
help in preservation of papilla by providing peri implant placement irrespective of surgical
hard tissue stability. In a five year study by romanos et placement protocol (one stage or two
al[34] suggests that immediately functionally loaded PLS stage).
implants showed improved primary bone stability. 2. 2 years after placement of implants with
an enlarged platform and were placed
Delayed placement in healed sites: with submerged procedure performed
slightly better than the non submerged
The average bone loss in PL switched implants placed in ones.
healed sites is very less as compared to non pl switched Vigolo et al [3] found that the mean marginal
implants [12]. The mean peri implant bone level bone loss was 0.9mm for NPS implants while for
alterations from base line to the 12 months follow up PS implants it was 0.6mm. Platform switching
period were 0.12±0.40mm in platform switched implants has also shown less bone resorption
and radiographically in both vertical and horizontal
0.29±0.34 mm in non platform switched implants. direction when two implants are placed with an
The PLS reduces the crestal bone loss and increases the inter implant distance of less than 3 mm.
longievity of the implant therapy. In over all Platform According to crespi et al[4] the platform
switching is useful in decreasing the bone loss[35]. switched implants showed lesser mean bone loss
as compared to the external hexagon implants
Prevalence of peri implant disease on platform although it was not significant.
switching implants [36]:
Wagenberg et al [38]in their prospective study
A longitudinal study was done in which 64 implants were evaluated implant survival and crestal bone
placed in 25 patients was done. The prevalence of peri levels around platform switched implants for
implantitis (i.e pockets ≥5mm with bleeding and bone minimum of 11 years and found that 84% of
loss≥ 2mm was compared in between platform switched mesial surfaces and 88 % of distal surfaces had
and conventional implants. The conclusion of the study 0.8mm or less bone loss. This was the longest
was that there is lower prevalence of peri implantitis with follow up till that time and confirmed the conept
platform switched implants. of crestal bone preservation.
Clinical and radiographic Assessment Of Bone Level Radiological and micro CT analysis of peri
Around Platform Switched Implants: implant bone around platform switched implants
suggests that implants can be placed 2mm apart
The effects of platform switching can be relevant both
instead of 3 mm apart and 3 mm apart instead of
clinically and radiographically. Clinical relevance of
4 mm apart when platform switching is utilized
platform switching is more important in situations where
[9]. Platform switched implants remained stable
anatomic structures such as the sinus floor or alveolar
for 10 years as they showed minimal marginal
nerve limit the residual bone height, the platform
bone loss radiographically i.e. 0.78mm to
switching approach minimizes bone resorption and
1.24mm over a period of 10 year follow up and
increases biomechanical support available to the implant.
0.21 mm to 0.77mm upto 1 year.
The radiographic evaluation revealed that the peri implant
bone loss in platform switched implants after 1 year of Conclusion:
function was 0.63mm to 1.27 mm while for non platform
switched implants it was 1.30 mm to 2.24mm [24,36]. Based on the obtained data and statistics the
following conclusions can be drawn:
Loris et al [37] in their randomized prospective • Maximum and minimum principal stresses were
multicenter trial evaluated platform switching technique reduced in the peri-implant bone tissue and
for prevention of post restorative crestal bone loss implants when the platform switching concept
discussed that the platform switching technique, in was used. However stress distribution was
comparison to conventional surgical protocols that influenced more by implant diameter than by the
restore non platform switched implants , resulted in platform switching concept.
significantly less crestal bone loss(p less than 0.001).
• There is a biomechanical advantage to platform
switching in conditions of marginal bone
They further concluded two major points :
resorption. However this advantage may
decrease when bone resorption is dramatically
increased.

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 Ankit et al., The Notion of Platform-Switching in Implants

• The combination of platform switching/straight Series,Int J Oral Maxillofac Implants.

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Bone At Dental Implants Inserted 2, 3 And 4
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www.rphsonline.com Research in Pharmacy and Health Sciences | Vol 4| Issue 2 | Apr-Jun, 2018;454-460.

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