Bone or tissue level? Mr. Trevisan

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  Posted by: Dental Design      7th February 2018

The rehabilitation of partially and completely edentulous patients with dental implants has become a popular and routine method of treatment; however this therapy is not free from challenges.

Of the complications experienced, peri-implant infections represent one of the most common issues. Classified as peri-implant mucositis and peri-implantitis, these inflammatory reactions affect the implant surrounding tissues in the osseointegrated functional implant after normal bone remodelling. If left untreated, peri-implant mucositis could progress and lead to crestal bone resorption, which is considered the main characteristic of peri-implantitis.[1]

Identifying specific risk factors for peri-implantitis before the implant is even placed is therefore crucial to ensure a long-term successful result. Several systemic as well as behavioural and local factors have been identified as risk indicators of peri-implant diseases. Such factors may include genetic traits, diabetes mellitus, smoking, a history of periodontitis, irregular maintenance programmes, poor plaque control, inadequate widths of keratinised mucosa, and implant bioshape and surface.1

Furthermore, implants are often placed in patients with a history of poor oral hygiene and edentulism, where structures and surfaces differ from those with natural teeth. For successful treatment, an implant system that causes minimal marginal bone loss should be used. It is believed that alveolar crestal bone remodels and loses height due to the implant placement and prosthetic reconstruction. The maintenance of the crestal bone support around implants is considered one of the most important factors of long-term efficacy and success. However, the aetiology of the marginal bone loss around dental implants is poorly understood.[2] Several factors can influence the loss of surrounding bone, including the implant type (one-piece, two-piece), the type of connection between the implant and abutment (platform switch or matching platform), the location and stability of the implant-abutment junction in relation to the alveolar crest and the soft tissue.2

Many different implant systems with various surgical solutions are available that aim to improve biomechanical properties such as primary and secondary stability and to limit the extent of peri-implant bone loss. Among them are bone-level implants with the abutment junction at the level of the crestal bone and tissue-level solutions that have the implant-abutment junction above the crestal bone, at soft tissue level.2 Selection depends on the case. When treatment planning, it is important to consider the type and number of implants required to replace the missing teeth, appropriate positions for implantation, prosthesis design, cantilever length, proper diameter and length of implants, prosthetic materials and type of occlusion.[3]

Aesthetics is another important area that requires increasing consideration and treatment must address this along with optimal occlusal function. Establishing an adequate amount of gingiva that is firmly attached to the underlying periosteum and bone has been cited as one of the main goals in implant maintenance. In accordance with the phenomenon of biological width, an undercut distance of the alveolar crest to the implant-abutment connection will lead to unfavourable bone remodelling.

The traditional tissue-level implant with an implant-abutment connection at a 2–3mm distance to the alveolar bone crest does not conflict with the biologic width, and when using implants with biocompatible materials such as zirconia, a pleasing aesthetic result can be achieved. Indeed, when tissue heals around zirconia, the epithelial fibres that develop are perpendicular, unlike the more vertical fibres which tend to develop around titanium – this mimics natural gingival growth. In some specific cases, though, bone-level implants may offer a preferred solution.[4]

The concept of platform switching has been one of the most significant innovations in bone-level implant provision in recent years. It is based on the use of small-diameter abutments compared to the platform diameter of the implant, therefore creating a mismatch between both components at the level of the implant-abutment interphase. This allows the horizontal implant surface to move away the connective tissue inflammatory infiltrate from the bone crest and thus reduce the loading stress in the crestal portion of the bone.[5]

TBR implant systems from Dental Express (a trading division of Surgery Express LLP) provide a multitude of features to help optimise and simplify surgery. It’s bone-level implants offer platform switching and a real morse taper connection, which helps develop a gingival ring-shaped sleeve protecting the implant. TBR’s innovative tissue-level design has a unique zirconia collar, which helps maximise tissue healing due to being highly biocompatible, and reduces the risk of developing peri-implantitis. Practitioners who have been using the Z1 implant for more than a decade say they are placing it in 99% of clinical situations because it makes implantology more comfortable for the surgeon, for the technician and for the patient. It requires less chairtime and it leads to more aesthetic and more predictable long-term results.

Selecting the correct implant for the case depends on a number of factors that need to be taken into consideration during treatment planning. Bone- and tissue-level implants both offer different benefits and solutions. Dental professionals should ultimately choose an implant system that utilises the highest quality of materials and provides the most effective and safe solution to patients.


For more information visit Dental Express at, call 0800 707 6212 or learn more about the Z1 implant at


[1] Rokn, A., et al. (2017). Prevalence of peri-implantitis in patients not participating in well-designed supportive periodontal treatments: a cross-sectional study. Clinical Oral Implants Research, 28 (3), 314-319.

[2] Hadzik, J., et al. (2017). Comparative evaluation of the effectiveness of the implantation in the lateral part of the mandible between soft tissue level (TE) and bone level (BL) implant systems. Annals of Anatomy – Anatomischer Anzeiger, 213, 78-82.

[3] Mosavar, A., Nili, M., Hashemi, S. R., & Kadkhodaei, M. (2015). A comparative analysis on two types of oral implants, bone-level and tissue-level, with different cantilever lengths of fixed prosthesis. Journal of Prosthodontics, 00, 1-7.

[4] Rieder, D., et al. (2016). Implant therapy outcomes, peri-implant biology aspects. Clinical Oral Implants Research, 27, 469.

[5] Molina, A., et al. (2016). The effect of one-time abutment placement on interproximal bone levels and peri-implant soft tissues: a prospective randomized clinical trial. Clinical Oral Implants Research, 1-10.

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