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Technical Note
“Platform switching”: Serendipity
Kalavathy N, Sridevi J, Roshni Gehlot1, Santosh Kumar2
Departments of Prosthodontics
and 2Preventive and Community
ABSTRACT
Dentistry, DAPM RV Dental Implant dentistry is the latest developing field in terms of clinical techniques, research, material
College, Bengaluru, 1Private
practitioner, Bangalore,
science and oral rehabilitation. Extensive work is being done to improve the designing of implants
Karnataka, India in order to achieve better esthetics and function. The main drawback with respect to implant
restoration is achieving good osseointegration along with satisfactory stress distribution, which
in turn will improve the prognosis of implant prosthesis by reducing the crestal bone loss. Many
concepts have been developed with reference to surface coating of implants, surgical techniques
for implant placement, immediate and delayed loading, platform switching concept, etc. This
article has made an attempt to review the concept of platform switching was in fact revealed
accidentally due to the nonavailability of the abutment appropriate to the size of the implant
placed. A few aspect of platform switching, an upcoming idea to reduce crestal bone loss have
been covered. The various methods used for locating and preparing the data were done through
Received : 17‑11‑13 textbooks, Google search and related articles.
Review completed : 06‑01‑14
Accepted : 23-05-14 Key words: Crestal bone loss, osseointegration, platform switching
There are a range of factors involved in achieving good 1.2‑mm marginal bone loss from the first thread during
aesthetic result with implants. The correct positioning of healing and in the first year after loading with an average
the implant is one of the most important factors, along with 0.1‑mm bone loss annually thereafter.
establishing the optimum volume of hard and soft tissues.[1]
The success of dental implants is highly dependent upon Vertical bone loss (<0.2 mm) annually following the 1st year
the integration between the implant and the intraoral hard/ of implant function is the criteria for implant success as
soft tissue. The initial breakdown of the implant‑tissue given by Smith and Zarb.[4] A post restorative remodelled
interface generally begins at the crestal region in successfully crestal bone generally coincides with the level of the first
osseointegrated endosteal implants regardless of surgical thread on most standard diameter implants. The first thread
approaches used, with the potential to cause implant failure.[2] changes the shear force of the crest module to a component
of compressive force to which the bone is most resistant.
The various methods used for locating and preparing the
data was done through textbooks, Google search and related There are various factors that can lead to crestal bone loss,
articles. such as:[2]
• Surgical trauma
REVIEW OF LITERATURE • Biologic width/seal
• Microgap
The first report quantifying early crestal bone loss was a • Occlusal overload
15 year retrospective study by Adell et al.[3] He reported • Crest module.
Address for correspondence: During the first year of use, stabilization of the crestal bone
Dr. N Kalavathy
E‑mail: [email protected] at the level of the first thread of a screw‑retained Brånemark
type implant has always been observed and considered
Access this article online normal. In fact, it has been observed that resorption around
Quick Response Code: Website:
the collar begins when the implant is exposed, and as long as
www.ijdr.in the latter remains submerged, the crestal bone is stabilized
at the level of the collar. Following loading, or surgical Stage
PMID:
*** II, bone stabilization beneath the collar seems to depend on
several factors, such as, respecting the biological space, the
DOI: location of an area of inflammatory connective tissue (ICT),
10.4103/0970-9290.135938
and the state of the implant surface [Figure 1].
254 Indian Journal of Dental Research, 25(2), 2014
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Platform switching Kalavathy, et al.
In 1997, Abrahamsson et al. showed that multiple screwing Surgical trauma due to heat generated during drilling,
and unscrewing movements of the healing screw results elevation of periosteal flap and excessive pressure at the
in an apical migration of the epithelial attachment around crestal region during implant placement may contribute to
the implant collar.[5] The authors stress that this epithelial implant bone loss during the healing period. Signs of bone
migration results, in turn, in an apical relocation of the loss due to surgical trauma and periosteal reflection are
bone level, so that a biological space/biologic width not commonly seen during Stage II surgery in successfully
compatible with the health of the peri‑implant‑tissues is osseintegrated implants.[2]
restored.
Excessive stress on the immature bone implant interface is
Biologic width forms with in first 6 weeks after the likely to cause bone loss during the early stage of prosthesis
implant‑abutment junction (IAJ) is exposed to the oral in function. However, bone loss due to occlusal loading is
cavity. It is the barrier against bacterial invasion and food considered to be progressive rather than limited to first year
ingress at the implant‑tissue interface. of implant loading.[2]
The ultimate location of the epithelial attachment following The clinician’s ability to reduce or eliminate crestal
restoration in part, determines early postsurgical bone loss. bone loss can result in significant aesthetic and clinical
Thus the implant bone loss is in part, a process of establishing benefits.
the biological seal.[2] Several studies have also shown that
crestal bone loss occurs following implant placement and CONCEPT OF “PLATFORM‑SWITCHING”
its connection to the abutment.
Research on crestal bone loss around dental implants has
Other studies indicate that such remodeling is the result of largely focused on implant systems with matching diameter
localized inflammation of soft tissue at the IAJ (microgap), implant seating surfaces and restorative components.[2]
as a biological seal becomes established. [1] Once the
biologic width has been established, the soft tissue takes In most two piece implant systems, after the abutment
on a protective function toward the crestal bone. This is connected, a microgap exists between the implant
situation has important consequences for the esthetics of and the abutment. The microgap – crestal bone level
the interdental papilla, which can suffer mesial and distal relationship studied radiographically by Hermann et al.,
bone loss of around 0.07‑mm after a 6 month follow‑up demonstrated that the microgap between the implant
period.[6] and the abutment has a direct effect on crestal bone loss,
independent of surgical approaches. Epithelial migration
Finally, unlike the parameter mentioned, the condition of to establish biologic width could be responsible for
the implant surface plays a positive role with regard to the crestal bone loss.
resorption phenomenon. When the implant surface is rough
and when significant stresses are applied the bone’s capacity The histology of peri‑implant‑tissue was studied
to adhere to the titanium is increased, particularly during by Ericsson et al., who observed that the peri‑implant bone
immediate loading. crest was consistently located 1.0-1.5‑mm apical to the
IAJ [Figure 2]. The apical border of the implant associated
inflammatory cell infiltrate (ICT) was always separated
from the bone crest by approximately 1.0‑mm of healthy
Figure 1: Crestal bone level around a nonrestored, covered, two staged
implant placed subcrestally (left) and the postoperative crestal bone
level located at the first dental implant approximately 1.5-mm apical to
the implant-abutment junction (right), CT = connective tissue Figure 2: Histologic picture of peri-implant-tissue
Indian Journal of Dental Research, 25(2), 2014 255
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Platform switching Kalavathy, et al.
connective tissue. Thus, he concluded that the presence restorative platform) with the 4.1‑mm prosthetic
of ICT is an etiological factor in crestal bone loss.[6] component medializes the IAJ.[2]
Hence, the platform switching concept implies the use
In 1991, Implant Innovations, Inc. (3i, Palm Beach of prosthetic components having a platform diameter
Gardens, FL) introduced 5‑mm and 6‑mm diameter undersized when compared with the diameter of the implant
implants with seating surfaces (i.e. restorative platforms) platform. In this way, the prosthetic connection is displaced
of the same dimensions [Figure 3]. These large‑diameter horizontally inwards from the perimeter of the implant
implants, with a larger surface area, were intended to platform, creating an angle, or step between the implant
increase the amount of bone‑to‑implant contact when and abutment.
placing shorter implants in areas of limited bone height,
such as under the maxillary sinus or above the inferior Application
alveolar canal.[7] • In situations where larger implant is desirable but
prosthetic space is limited
The ability to increase the bone‑to‑implant contact • In the esthetic zone
by the use of wide‑diameter implants also enhanced • Where preservation of crestal bone can lead to improved
the likelihood of achieving primary stability in areas esthetics
of poor‑quality bone. At the time of introduction of • Where shorter implants must be utilized.
the wide‑diameter implants’ no matching, similarly
dimensioned prosthetic components were available. Advantages
Hence, clinicians restored them with standard 4.1‑mm • The inflammatory cell infiltrate, which surrounds the
abutments. After a 5‑year period, the typical pattern of IAJ in a collar like fashion, is contained within the
crestal bone resorption was not observed radiographically angle formed at the interface and thus prevented from
in cases where platform switching was utilized. Lazzara spreading further apically along the implant where it
and Porter theorize that this occurred because shifting would otherwise result in inflammatory changes to the
the IAJ inward also repositioned the inflammatory cell bone crest[5,6,9] [Figures 5 and 6]
infiltrate and confined it within a 90° area that was not • The horizontal dimension of the step allows for an
directly adjacent to the crestal bone, thus reducing crestal additional area where biologic attachment may take place,
bone resorption.[8] thus limiting the extent of physiologic remodeling of the
bone crest needed to accommodate the biological zone[8]
THUS THE DISCOVERY OF PLATFORM • Optimal management of restorative space. With the
SWITCHING WAS SERENDIPITY! crestal bone preserved both horizontally and vertically,
support is thus retained for the interdental papillae.
• The design details of a platform switched implant are Maintenance of midfacial bone height helps to maintain
mentioned below and Figure 4 depicts the same facial gingival tissues[2]
• The collar bevels medially into a smaller‑diameter • Improved bone support for shorter implants[2]
prosthetic platform • The possible influence of the microgap on bone
• Restoring the 4.8‑mm diameter collar (implant resorption may be diminished by moving the junction
inwards from the bone crest.[9]
Figure 3: The use of prosthetic abutments with reduced width in relation
to the implant diameter (platform switching) Figure 4: Design details of platform switched implant restoration
256 Indian Journal of Dental Research, 25(2), 2014
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Platform switching Kalavathy, et al.
Figure 5: Apical view from long axis of implant Figure 6: Apical view from long axis of implant. Note: Inflammatory
connective tissue does not infiltrate beyond platform dimensions
Disadvantages
• Need for the components that have similar design Gardner discusses the literature dealing with the changes
• Need for sufficient space to develop proper emergence that occurred when an implant is placed in bone and he
profile. presented a case study using platform switching implants.
He stated that the main advantage is that it is an effective
DISCUSSION way to control circumferential bone loss around dental
implants but he concluded that platform switching needs
Hermann et al . reviewed biologic width, platform further investigation. Furthermore, he noted several
switching, and implant design in the cervical region, nano potential disadvantages of this procedure such as the need
roughness, fine threads, insertion depths, abutment design for components that have similar designs (the screw access
and avoidance of microlesions in the periimplant soft hole must be uniform) and the need for enough space to
tissue as factors that determine the preservation of crestal develop a proper emergence profile.[12]
bone levels. According to them, these factors along with
several others, determine the aesthetic outcomes of implant In his article “Platform switching with a new implant
restorations.[10] design,” 2007, Calvo Guirado et al. noted the success of
the placed implants after 8 months with minimal marginal
Vela‑Nebot et al . concluded that platform switching resorption (<0.8 mm) and highly satisfactory esthetic
improves aesthetic results and that when invasion of the results.[7]
biologic width is reduced, bone loss is reduced (P < 0.0005).
However, he says that further microbiological, pathological In their prospective study, Hürzeler et al. revealed that
and clinical studies are necessary to confirm both these although bone remodeling is encountered during the first year
results as well as the study’s working hypothesis.[11] after the final restoration with platform switching implants,
there are significant differences compared with non‑platform
Lazzara and Porter discovered that during a 13 year switching implants. In his opinion, a larger number of patients
radiographic observation period of the periapical region of should be studied to confirm these results.[13]
wider implants with reduced diameter abutments, improved
crestal bone preservation was seen, but it was thought Degidi et al. evaluated the histology and histomorphology of
that further investigation was needed to prove the real three Morse cone connection implants in a real case report
advantages of this technique.[9] and explained that when there is zero microgap and no
micromovement, platform switching shows no resorption.
Baumgarten et al . described the platform switching He also observed that this method provided better aesthetic
technique and its usefulness in situations where shorter results.[14]
implants must be used, where implants are placed in
esthetic zones, and where a larger implant is desirable, but Canullo et al. is in favor of platform switching and he
prosthetic space is limited. He believed that a sufficient evaluates the relation between immediate loading with these
tissue depth (approximately 3‑mm or more) is necessary to implants and its effects on soft and hard tissues.[15]
accommodate an adequate biologic width. He stated that
platform switching helps prevent the anticipated bone loss Esposito et al. tested different flap designs in order to
and also preserves crestal bone; he has cited a particular case determine the best techniques for soft tissue handling but
report as the basis of his theory.[8] he does not specify the implant system utilized.[16]
Indian Journal of Dental Research, 25(2), 2014 257
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Platform switching Kalavathy, et al.
Becker et al. in a histomorphometric study conducted altering the starting point from which the crestal bone
on dogs concluded that 28 days after implant placement, resorption occurs. It provides the clinician with additional
both computer‑aided manufacturing (sand blasted and surgical and prosthetic treatment options with the use of
acid etched screw type implants with either matching) wide diameter implants.
and Complete Prosthetic Set (smaller diameter healing
abutments) revealed crestal bone level changes, but he The clinical benefits of platform switching needs further
found no significant differences between them. He thinks investigations. The techniques of platform switching as
that further studies with a higher number of animals and illustrated by the authors require additional studies to
implant sites are needed in order to clarify the influence of establish the biologic process responsible for positive
platform switching on crestal bone changes.[17] radiographic findings.
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Implants Res 2008;19:271‑5.
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Source of Support: Nil, Conflict of Interest: None declared.
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Indian Journal of Dental Research, 25(2), 2014 259
