SYSTEMATIC REVIEW

Inuence of interimplant distance on the crestal bone

height around dental implants: A systematic review and
meta-analysis
Mohammad D. Al Amri, BDS, MS, FRCDC

Maintenance of interproximal ABSTRACT

crestal bone height (ICBH) Statement of problem. Indexed publications lack a systematic review and meta-analysis of the
plays a signicant role in the inuence of interimplant distance on the interproximal crestal bone height (ICBH) around implants.
long-term success and survival
Purpose. The purpose of this systematic review and meta-analysis was to assess the inuence of
of dental implants.1 Local fac-
interimplant distance on ICBH around implants.
tors that may inuence ICBH
around dental implants include Material and methods. The question addressed was, Does interimplant distance inuence the
depth of implant placement ICBH around implants? Indexed databases from 1978 up to April 2015 were searched by using the
keywords crestal bone level, bone loss, bone height, and interimplant distance. Reference
(crestal or subcrestal implant
lists of potentially relevant original and review articles were searched manually to identify any
placement); implant abutment unidentied studies. Articles available online in electronic form ahead of print were eligible for
geometry (platform-switched inclusion. Letters to the Editor, case reports, case series, commentaries, studies involving bone
or conventional implants); im- augmentation procedures, and studies published in languages other than English were excluded. A
plant surface roughness; time meta-analysis of mean differences in ICBH among study groups was also performed.
of loading (immediate or de- Results. In total, 5 animal studies with relatively short follow-up periods (2e12 months) were
layed loading); and achieve- included. Results from 4 studies showed no signicant differences in ICBH around implants
ment of sufcient primary placed 1 to 3 mm apart. However, 1 of the 5 studies found that vertical bone loss was
stability at the time of implant signicantly lower in implants that had an interimplant distance of 5 mm than those placed at a
placement.2-9 Studies have distance of 1 mm. Platform switched and rough surface implants were used in all studies.
reported that the horizontal Conclusions. The inuence of interimplant distance on ICBH around dental implants remains
distance between 2 adjacent unclear. (J Prosthet Dent 2016;115:278-282)
implants can also inuence
ICBH.10-12 When 2 implants are placed adjacent to one according to Tarnow et al,12 an interimplant distance of
another, the distance between them inuences the degree greater than 3 mm between 2 adjacent implants helps
of lateral bone loss and interproximal bone peak resorp- preserve the interproximal bone peak and results in
tion.12 This phenomenon is independent of the time of average bone resorption of 0.45 mm for up to 3 years of
implant loading and surface characteristics.13 In a histo- follow-up. However, where the distance between the
morphometric study, Elian et al11 compared the effects of implants is less than or equal to 3 mm, the average
2 interimplant distances (2 mm and 3 mm) on bone resorption of the interproximal bone peak increases to 1.04
maintenance with bone-level implants. The results mm, which in turn compromises support for the inter-
showed that the interproximal bone loss measured from implant papilla.12 The results of the study by Tarnow
the edge of the implant platform to the bone crest did not et al12 also demonstrated that when the distance from the
differ for interimplant distances of 2 or 3 mm. Moreover, base of the contact point to the crest of bone was 3, 4, or 5

Associate Professor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia.

278 THE JOURNAL OF PROSTHETIC DENTISTRY

March 2016 279

Records identified through

Identification
Clinical Implications database searching
(n=17)
From currently available evidence, interimplant
distance does not seem to inuence the
interproximal crestal bone height (ICBH) around Records after duplicates
implants. Additional parameters that may inuence removed
ICBH include the presence of interdental papilla, (n=17)
implant geometry, and implant dimensions.

Screening
Records excluded
Records screened (n=12)
(n=17) See Supplemental
mm, the papilla was present almost 100% of the time;
References S1-S12
however, when the distance was 7, 8, 9, or 10 mm, the
papilla was mostly missing.
Results from the aforementioned studies show that Full-text articles assessed Full-text articles excluded,

Eligibility
for eligibility with reasons
interimplant distance plays a role in maintaining ICBH (n=5) (n=0)
around implants. However, to date, a systematic review
of this concept is missing in indexed publications. The
purpose of this systematic review and meta-analysis was Studies included in
to assess the inuence of interimplant distance on ICBH qualitative synthesis
(n=5)
around implants.
Included

MATERIAL AND METHODS Studies included in

quantitative synthesis
The Preferred Reporting Items for Systematic Reviews and
(meta-analysis)
Meta-Analyses (PRISMA) guidelines require participants (n=5)
to have undergone implant treatment (www.prisma-
statement.org). The intervention of interest was the Figure 1. Protocol for publication search.
effect on ICBH of implants placed at varying distances. The
and reasons for exclusion is shown in the Supplemental
outcome measure was ICBH around implants with varying
References S1-S12.
interimplant distances. In accordance with the PRISMA
A meta-analysis of mean differences was performed for
guidelines, the question was, Does interimplant distance
ICBH between the control and test groups on an animal
(2e5 mm) inuence ICBH around dental implants? To
level. By denition, a mean difference of <0 indicated a
identify studies pertinent to the focused question, the
greater effect size in the control group. In the case of
following databases were electronically searched for
missing data for the meta-analysis, the corresponding
available data: PubMed/MEDLINE (OVID), EMBASE,
author was contacted for additional data. Heterogeneity
Cochrane Central Register of Controlled Trials (CEN-
among the included studies for each outcome was
TRAL), Scopus, Web of Knowledge, Cumulative Index to
assessed using the Q statistic and I2 statistic.14 Outcome
Nursing and Allied Health Literature, and Google-
measures were combined with a xed-effects model, un-
Scholar. Studies conducted from 1978 up to and
less signicant heterogeneity among studies was found.
including April 2015 were searched in these databases
In the case of heterogeneity, a random-effects model using
using different combinations of the following keywords:
the DerSimonian-Laird method was preferred.15 Forest
crestal bone level, bone loss, bone height, and
plots were produced reporting weighted mean differences
interimplant distance. Titles and abstracts of studies
and 95% condence intervals (CI). Sensitivity analysis was
identied using the above-described protocol were
performed by removing outlier studies in terms of sample
screened. Full texts of the studies judged by title and
size (smallest) and effect size (largest) to assess the
abstract to be relevant were read and evaluated in accor-
robustness of the results (a=.05). All statistical analyses
dance with the following eligibility criteria: clinical and
were carried out with computer R metafor software
experimental studies and assessment of ICBH around
(R Development Core Team).
dental implants. Reference lists of potentially relevant
original and review articles were searched manually to
RESULTS
identify any additional studies. Articles available online
in electronic form ahead of print were considered eligible In total, 5 studies performed with animal models11,16-19
for inclusion. Letters to the Editor, case reports, com- were included. Four studies11,16-18 assessed ICBH around
mentaries, and studies published in languages other than implants placed 2 and 3 mm apart. In the study by Choi
English were not sought (Fig. 1). A list of excluded studies et al,19 ICBH around implants placed 2 and 5 mm apart

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280 Volume 115 Issue 3

Table 1. Interimplant distances that were assessed in the studies bone loss around implants.21 In a clinical and radio-
included graphic study, Tarnow et al12 assessed the inuence of
Interimplant Distances Investigated (mm) different interimplant distances on the loss of crestal
Study (Ref) Group 1 Group 2 Group 3 Group 4 bone. Results showed a clear trend of increased bone loss
Elian et al11 2 3 d d
as the interimplant distances decreased.12 However, to
de Oliveira et al16 1 2 3 d
this authors knowledge, no systematic review of studies
Novaes et al17 2 3 d d
assessing crestal bone remodeling around implants at
Scarano et al18 2 3 4 5
varying interimplant distances exists in the body of
Choi et al19 2 5 d d
indexed publications. The present study was performed
to systematically review the effect of increasing interim-
plant distance on crestal bone levels around implants.
was investigated. de Oliveira et al16 investigated the ef-
A limitation of the present systematic review and
fect of placing implants at interimplant distances of 1, 2,
meta-analysis is that the outcomes were based entirely on
and 3 mm on ICBH; whereas Scarano et al18 assessed the
the results from 5 animal model studies.11,16-19 Although
effect of placing implants at interimplant distances of 2, 3,
during the initial search the author identied 4 clinical
4, and 5 mm on ICBH (Table 1).
studies22-25 that assessed crestal bone levels in relation to
The numbers of implants placed ranged from 48 to 72
interimplant distances, those studies22-25 could not be
implants. In all studies, rough surfaced, platform-
used for meta-analysis for technical reasons such as
switched implants were used with diameters ranging
missing odds ratios for the test and control groups and the
between 3.75 mm and 4.5 mm and lengths between 8
absence of a control group. In the present systematic re-
mm and 10 mm. In 3 studies,11,17,19 implants were placed
view and meta-analysis, results from 80% of the studies
at bone level (crestal), while in the study by Scarano
showed no signicant inuence of interimplant distance
et al,18 all implants were submerged in bone (Table 2).
on ICBH around implants. In those studies, the interim-
In one study,18 both horizontal and vertical bone
plant distances ranged from 1 to 3 mm. This suggests that
losses were measured. The follow-up period ranged
if the horizontal component of crestal bone loss is reduced,
between 2 and 12 months. Results from 4 studies showed
it minimizes the potential bone loss from overlapping
no signicant relationship between changes in ICBH
between adjacent implants, thereby allowing maintenance
around implants and interimplant distance.11,16,17,19 In
of the interimplant vertical bone height.
the study by Scarano et al,18 60 implants were placed in
A number of factors may have biased the outcomes of
the mandibles of dogs at interimplant distances of 2 mm
the studies included in the present systematic review.
(group-1), 3 mm (group-2), 4 mm (group-3) and 5 mm
Studies26-28 have shown that the implanteabutment
(group-4). There was a statistically signicant difference
interface designs with a reduced abutment diameter
between the groups with reference to vertical bone loss
relative to the implant platform diameter (platform
(VBL) except for group-1 versus group-2. Furthermore,
switching) can decrease the amount of crestal bone loss
there was a signicant difference in horizontal bone loss
around the implants. In a clinical and radiographic study,
(HBL) in all group comparisons except for group-1 versus
Wennstrom et al29 showed a marginal vertical bone loss
group-4.18 The study18 concluded that, although inter-
of 0.06 mm after 12 months of follow-up. Likewise, in a
implant distance does not inuence VBL, it does affect
radiographic study in dogs, Jung et al30 demonstrated
HBL (Table 3).
limited bone loss around platform-switched implants
after 6 months of loading, regardless of whether the
Meta-analysis
implant platform was placed at the crestal or subcrestal
Tests demonstrated no signicant heterogeneity among
level. All implants placed in the included studies were
the included studies (P>.05). Results of the random ef-
platform-switched. Therefore, platform-switching may
fects meta-analyses showed that the mean differences in
have contributed to reduction in crestal bone loss around
ICBH among the groups in the included studies
implants.
were 0.36 mm (95% CI= 0.79 to 0.06) with the dif-
Another important parameter that remained unad-
ference being nonsignicantly larger in the control group
dressed in the methodology of the included studies was
(P>.05) (Fig. 2).
the transversal width of the alveolar ridge. When im-
plants (whether platform switched or nonplatform
DISCUSSION
switched) are placed in narrow ridges, they may exert
The precise mechanism responsible for crestal bone more pressure on the buccal process of the alveolus than
remodeling in 2-piece implants has yet to be deter- implants placed in wider ridges, thereby constricting the
mined.20 However, periimplantitis, surgical trauma, buccal blood vessels and compromising the vascular
occlusal overload, presence of a microgap, and crestal supply to the region. This factor may also contribute to
module considerations have been associated with crestal alveolar bone loss, regardless of how far apart the

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March 2016 281

Table 2. Implant-related characteristics

Total No. of Implant Implant
Study (ref) Implants Placed Threaded? Geometry Implant (DL) Surface Implant Placement
Elian et al11 72 Yes PS 4.18 Rough Crestal
de Oliveira et al16 56 Yes PS 4.59.5 Rough Crestal and subcrestal
Novaes et al17 48 Yes PS 4.510 Rough Crestal
Scarano et al18 60 Yes PS NA Rough Subcrestal
Choi et al19 70 Yes PS 3.75-3.8 8-8.5 Rough Crestal
DL, diameter length; NA, not available; PS, platform switched.

Table 3. Vertical and horizontal crestal bone loss, statistical signicance, and follow-up duration of studies
Vertical Crestal Bone Loss Horizontal Crestal Bone Loss
(mm) (mm)
Differences in CBL
Study (ref) Group 1 Group 2 Group 3 Group 4 Group 1 Group 2 Group 3 Group 4 Among Groups Follow-up
Elian et al11 d d d d 0.31 0.57 d d NS 2 mo

de Oliveira et al16 6.46 5.62 6.92 d d d d d NS 3 mo

Novaes et al17 5.64 6.45 d d d d d d NS 3 mo

Scarano et al18 1.98 1.78 1.01 0.23 1.97 3 4 1.91 VBL: no signicant difference between 12 mo
groups 1 and 2
HBL: no signicant difference between
groups 1 and 4
Choi et al19 0.77 0.87 d d d d d d NS 4 mo

CBL, crestal bone loss; HBL, horizontal bone loss; NS, nonsignicant; VBL, vertical bone loss.

implants are placed. Therefore, additional split-mouth

studies using platform switched and nonplatform de Oliveira et al16 0.00 (1.04, 1.04)
switched implants placed at varying distances in wide Elian et al11 0.27 ( 0.08, 0.46)
and narrow ridges are warranted to elucidate the asso- Novaes et al17 0.30 (0.45, 0.15)
ciation between interimplant distance and crestal bone Sarano et al18 0.77 (0.88, 0.66)
loss. Another factor that may have played a role in Choi et al19 0.80 (0.98, 0.62)
minimizing crestal bone loss is implant surface topog-
raphy. As implant surface roughness has a signicant RE Model 0.36 (0.79, 0.06)
effect on bone loss,31 the contribution of implant surface
1.50 0.50 0.50 1.50
morphology, in terms of minimizing crestal bone loss,
cannot be disregarded. Furthermore, the depth of Mean Difference
implant placement also varied among studies. In 3 Figure 2. Forest plot for studies that reported percentage of bone to
studies,11,17,19 implants were placed at bone level, and in implant contact in test implant surfaces versus conventional implant
1 study,16 implants were placed at both crestal and surfaces in medically compromised animals. Plot shows weighted mean
subcrestal levels. The follow-up duration varied widely differences and 95% condence intervals. A mean difference of <0 in-
among the studies included (2 to 12 months). Therefore, dicates greater effect size in control group. Weighted mean differences
were estimated by random effects (RE) model.
hypothesizing that long-term follow-up of platform
switched, rough surface implants (regardless of interim-
plant distances) demonstrates stable crestal bone levels
are tempting. Further studies are required to test this same concept may be applicable around implants. In the
hypothesis. study by Scarano et al,18 results regarding the presence or
Interestingly, in the study by Scarano et al,18 the absence of the interdental papilla around implants placed
vertical crestal bone loss decreased from 1.91 mm to 0.23 2 to 5 mm apart was not addressed; however, based on
mm around implants placed at an interimplant distance the clinical results of the study by Tarnow et al,32 the
of 2 mm and 5 mm, respectively. This could be associated presence or absence of interdental papilla could have
with the presence and/or absence of the interdental contributed to the signicant differences in the vertical
papilla. In a study of natural teeth, Tarnow et al32 re- bone loss around the implants placed in groups 1 and 4
ported that when the distance from the base of the in the study by Scarano et al.18 Further studies are
contact point of the implant to the crest of the bone was needed to assess the signicance of the interdental
3, 4, or 5 mm, the papilla was present almost 100% of the papilla with reference to crestal bone loss around im-
time compared with distances of 7, 8, 9, or 10 mm. The plants placed at varying distances.

Al Amri THE JOURNAL OF PROSTHETIC DENTISTRY

282
CONCLUSIONS
Within the limitations of this systematic review and
meta-analysis, it was concluded that the inuence of
interimplant distance on ICBH around dental implants
remains unclear.
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Corresponding author:
Dr Mohammad D. Al Amri
Department of Prosthetic Dental Sciences
College of Dentistry, King Saud University
PO Box 60169, Riyadh 11545
SAUDI ARABIA
Email: dramri@yahoo.com
Acknowledgments
The author thanks Dr Georgios Kotsakis, Seattle, Washington, for his kind
assistance with the statistical analysis and meta-analysis.
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
Al Amri
March 2016
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THE JOURNAL OF PROSTHETIC DENTISTRY