The Effects of Subcrestal Implant Placement on

Crestal Bone Levels and Bone-to-Abutment Contact:

A Microcomputed Tomographic and
Histologic Study in Dogs
Michael Fetner, DMD, MS1/Alan Fetner, DMD2/Theofilos Koutouzis, DDS, MS3/
Emanuele Clozza, DDS4/Nick Tovar, PhD5/Alvin Sarendranath6/Paulo G. Coelho, DDS, PhD7/
Kathleen Neiva, DDS, PhD, MS8/Malvin N. Janal, PhD9/Rodrigo Neiva, DDS, MS10

Purpose: Implant design and the implant-abutment interface have been regarded as key influences on crestal
bone maintenance over time. The aim of the present study was to determine crestal bone changes around
implants placed at different depths in a dog model. Materials and Methods: Thirty-six two-piece dental
implants with a medialized implant-abutment interface and Morse taper connection (Ankylos, Dentsply) were
placed in edentulous areas bilaterally in six mongrel dogs. On each side of the mandible, three implants
were placed randomly at the bone crest, 1.5 mm subcrestally, or 3.0 mm subcrestally. After 3 months, the
final abutments were torqued into place. At 6 months, the animals were sacrificed and samples taken for
microcomputed tomographic (micro-CT) and histologic evaluations. Results: Micro-CT analysis revealed similar
crestal or marginal bone loss among groups. Both subcrestal implant groups lost significantly less crestal and
marginal bone than the equicrestal implants. Bone loss was greatest on the buccal of the implants, regardless
of implant placement depth. Histologically, implants placed subcrestally were found to have bone in contact
with the final abutment and on the implant platform. Conclusion: Implants with a centralized implant-abutment
interface and Morse taper connection can be placed subcrestally without significant loss of crestal or marginal
bone. Subcrestal placement of this implant system appears to be advantageous in maintaining bone height
coronal to the implant platform. Int J Oral Maxillofac Implants 2015;30:1068–1075. doi: 10.11607/jomi.4043

Key words: subcrestal, dental implant, bone levels, histology

 1
Clinical Instructor, Department of Periodontology, University
of Florida College of Dentistry, Gainesville, Florida; Private
Practice, Jacksonville, Florida.
 2Clinical Assistant Professor, Department of Periodontology,
D ental implants are a viable and popular form of
tooth replacement. Over the past 30 years, re-
search has validated the success of osseointegrated
University of Florida College of Dentistry, Gainesville, Florida;
Private Practice, Jacksonville, Florida. dental implants as an alternative to removable or
 3Assistant Professor, Department of Periodontology, University
tooth-supported prosthetic restorations.1 Modern
of Florida College of Dentistry, Gainesville, Florida.
 4Postgraduate Student, Department of Periodontology and engineering and research have developed even more
Implant Dentistry, New York University College of Dentistry, successful dental implants year after year, but ultimate
New York, New York. success is still dependent on the maintenance of the
 5Adjunct Professor, Department of Biomaterials, New York

University College of Dentistry, New York, New York.
 6Research Assistant, Department of Biomedical Engineering,
The City College of New York, New York, New York.
 7
Associate Professor, Department of Biomaterials, New York
University College of Dentistry, New York, New York.
 8Clinical Assistant Professor, Department of Endodontics,
University of Florida College of Dentistry, Gainesville, Florida.
 9Adjunct Associate Professor of Epidemiology and Health
peri-implant tissues by the patient and dentist.2
Several factors may contribute to the success or fail-
ure of a dental implant, including bone support and
the stability of the bone crest adjacent to the implant.
A zone of epithelium and connective tissue integration
forms a “biologic width” that surrounds and protects

Promotion, New York University College of Dentistry, New
York, New York.
10Clinical Associate Professor, Department of Periodontology,
University of Florida College of Dentistry, Gainesville, Florida.
Correspondence to: Dr Michael Fetner, Fetner and Hartigan
Periodontics, 7043-B Southpoint Pkwy, Jacksonville, FL 32216.
Email: Mfetner@dental.ufl.edu
©2015 by Quintessence Publishing Co Inc.
an abutment and implant from pathologic insults.3 It
has been observed that if the biologic width is altered
in an apical direction, a corresponding marginal bone
loss will also occur. This area of bone loss usually starts
at the implant-abutment interface.3
Early implant-abutment designs had an interface
with an external connection and abutment walls that
were the same diameter as the implant. However,

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manufacturing tolerance restrictions produce mat-
ing parts that do not match perfectly, resulting in an
implant-abutment gap.4 The presence of this gap
leads to bacterial contamination at the interface and
an associated inflammatory infiltrate. This zone of
inflammatory infiltrate can lead to bone loss at the
implant-abutment interface.4
Several methods have been used to prevent bone
loss at the implant-abutment interface. One such
method is to centrally locate the margin of the abut-
ment on the platform of the implant, a technique
known as “platform switching.”5 This method moves
the zone of irritation of the interface further from the
bone and results in less bone loss than an interface
that is flush between the implant and abutment.5,6
Another technique used in implant design to limit
the irritation caused at the implant-abutment junction
is to use an internal connection in conjunction with a
centrally located abutment margin. Such a configura-
tion can result in a more mechanically stable connec-
tion that reduces contamination of the interface. These
connections have been associated with less marginal
bone loss than external, non–centrally located abut-
ment connections.7
Bacterial colonization of the peri-implant tissues
occurs within minutes of implant placement.8 These
microorganisms may establish colonies at the implant-
abutment interface (the microgap).9 These microbial
colonies may lead to inflammation of the peri-implant
tissues and, eventually, bone loss around the im-
plant.10 Prevention of the inflammatory effect of mi-
crobial contamination at the microgap is important in
the design of two-piece implant systems.11
Tissue-level implants with an implant-abutment in-
terface located more than 1 mm from the bone crest
have been found to lose minimal to no bone at the
interface.12 When two-piece implants are placed with
the implant-abutment interface at the bone level, even
in a one-stage approach, bone is lost at the crest.2 Two-
piece implants placed with the implant-abutment in-
terface 1 mm apical to the bone crest tend to lose even
more bone than those placed at the bone crest.4,13
These findings support the theory that the implant-
abutment interface influences the amount of bone
remodeling around implants over time.
Placement of the implant-abutment interface apical
to the bone crest—known as subcrestal implant place-
ment—has many proposed advantages. An implant
placed apical to the bone decreases the risk of expo-
sure of the metal top of the implant or the abutment
margin, thus preventing contamination of the surface
of the implant.14 It could allow sufficient vertical space
to create an appropriate esthetic emergence profile,
even with a large platform switch. It has been speculat-
ed that subcrestal implant placement could also allow
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Fetner et al
implants to be placed closer to each other by limiting
the cumulative effect of their microgap.15,16 Implants
placed subcrestally may also retain more bone coronal
to the implant-abutment interface, but may tend to
have a longer soft tissue attachment.17
Subcrestal implant placement can result in more
crestal bone loss than equicrestal placement as a result
of the microgap. Several studies have found that more
inflammation at the microgap leads to greater bone
loss.4 To successfully place an implant subcrestally, the
inflammation from the microgap must be minimal to
nonexistent, or more bone loss will occur.18 In vitro fi-
nite element analyses have shown that a depth of 0.5
to 2.5 mm subcrestal is ideal for stress distribution.19
Precision Morse taper connections have been avail-
able for more than a decade20 and have been previ-
ously characterized as a configuration that produces
a bacteria-resistant connection.21–23 Depending on its
design, the Morse taper allows the abutment to fit so
precisely to the implant that no microgap or micro-
movement occurs under normal forces.24 The design
features an aggressive platform switch that allows am-
ple space for connective tissue and bone homeostasis
over the implant platform.18
These characteristics of the Morse taper connection
allow for subcrestal placement without corresponding
bone loss around the implant margin caused by the
microgap that is present in most implant systems.11,25
A clinical study26 of Morse taper–connection implants
placed at the bone crest or 1 or 2 mm subcrestally re-
sulted in no statistically significant difference in bone
loss between groups. This same study reported that
significantly more bone was observed on the plat-
form of the subcrestally placed implants versus those
implants placed at the bone crest (90% versus 35%).26
However, it is not currently known whether there is an
ideal subcrestal depth of placement for this implant
system. The objective of the present study was to eval-
uate the effect of subcrestal implant placement depth
in a canine preclinical model.
MATERIALS AND METHODS
Experimental Subjects
Six female hound-type dogs, approximately 25 to
30 kg each and greater than 2 years of age, were se-
lected for the experiment. The protocol was mod-
eled after a previous study27 and had a timeline of 9
months. Regular feeding, activities, and veterinary care
were provided by the University of Florida Department
of Animal Care Services. Tramadol and buprenorphine
were used for postoperative pain management. The
dogs were fed a soft diet after the first surgery that
consisted of canned or moistened dog food.
The International Journal of Oral & Maxillofacial Implants 1069
Fetner et al
Fig 1  Implants at placement. (Left to Fig 2   Implants at 3 months postplace-
right) 3 mm, 0 mm, 1.5 mm subcrestal. ment, with abutments in place.
First, all eight mandibular premolars were surgically
extracted from each dog under general anesthesia.
Antibiotics and anti-inflammatory medications were
given before and after all surgical procedures.
Implant Placement
Following a healing period of 3 months, implants were
placed. Antibiotics and anti-inflammatory medications
were given before and after surgical procedures. A
crestal incision was made, and buccal and lingual flaps
were elevated on the edentulous ridge. The ridge was
flattened using a high-speed handpiece with a flat dia-
mond bur under copious irrigation. Six 3.5- × 9.5-mm
implants with a Morse taper connection were placed in
each dog (total n = 36 implants; Ankylos, Dentsply). On
each side of the mandible, three implants were placed
0 mm, 1.5 mm, or 3 mm subcrestally in a randomized
order (Fig 1). Sulcus-forming abutments were placed
at the time of surgery in the two test implants at equal
crestal heights. The equicrestal implant received the
cover screw provided with the implant packaging. The
flaps were then sutured to provide primary closure. All
implant procedures were completed according to the
manufacturer’s guidelines.
Abutment Placement
Three months after implant placement, implants were
accessed by full-thickness flaps. Each implant received
a straight stock abutment with a height of 4.0 mm
from the margin. Implants placed at the crest received
an abutment with a margin 1.5 mm coronal to the im-
plant. Implants placed 1.5 mm subcrestally received
an abutment with a margin 3.0 mm coronal to the im-
plant. Implants placed 3.0 mm subcrestally received
an abutment with a margin 4.5 mm from the implant.
These abutment heights ensured that the coronal
height of all abutments was the same (Fig 2). The sites
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Fig 3  Flaps sutured at abutment
placement.
were then sutured to obtain primary closure (Fig 3).
The abutments were never removed from the implants
after they were placed.
Sample Collection and Processing
The animals were sacrificed 6 months after implant
placement and 3 months after abutment placement.
Samples were immediately preserved in 10% neutral
buffered formalin for histologic examination. Prior to
processing for histologic examination, all samples were
scanned using microcomputed tomography (micro-CT).
Three-dimensional bone formation around the im-
plant was examined using micro-CT (µCT40, Scanco
Medical) with a slice resolution of 20 µm. Five hundred
micro-CT slices were imaged at an x-ray energy level
of 55 kVp and a current of 145 µA. Integration time
was 200 ms, with a total scanning time of 45.4 minutes
(160 mA). All data were imported into Amira software
(FEI Visualization Sciences) for evaluation. The data
were cropped along the implant axis to where the cor-
tical bone started to exclude unnecessary information
above the cortical bone. Before segmentation, thresh-
old levels for bone and implant were determined based
on the complete slices. This was done by determining
the upper and lower threshold levels for bone and im-
plant. Threshold determination was repeated to evalu-
ate intraexaminer and interexaminer repeatability.
Measurements and analyses of the micro-CT data
were completed with Amira software (FEI Visualization
Sciences). Crestal bone height (CBH) was defined as the
most coronal extent of bone in relation to the implant
platform. Marginal bone height (MBH) was defined as
the bone height coronal to the outside diameter of
the implant on the mesial and distal of each implant
(Fig 4). Marginal bone level (MBL) was measured as the
bone height coronal to the diameter of the implant on
the buccal and lingual of each implant (Fig 4).

Fig 4   Micro-CT images. (top) Crestally placed implant and abut-
ment; (bottom) implant and abutment placed subcrestally. CBH
was measured as the most coronal extent of bone in relation to
the implant platform. MBH was measured as the bone height
coronal to the outside diameter of the implant on the mesial
and distal. MBL was measured as the bone height coronal to
the outside diameter of the implant on the buccal and lingual.
Following micro-CT data acquisition, the blocks
were gradually dehydrated in a series of alcohol solu-
tions (70% to 100% ethanol). Then the samples were
embedded in a methacrylate-based resin (Technovit,
Heraeus Kulzer) according to the manufacturer’s in-
structions. The blocks were then cut into slices (~300 µm
thickness) at the center of the implant along its long
axis with a precision diamond saw (Isomet, Buehler);
glued to acrylic plates with an acrylate-based cement;
and allowed to set for 24 hours prior to grinding and
polishing. The sections were then reduced to a final
thickness of ~30 µm by means of a series of silicon
carbide abrasive papers (400, 600, 800, 1,200, and
2,400 grit) (Buehler) in a grinding/polishing machine
(Metaserv 3000, Buehler) under water irrigation.28
The sections were stained with Stevenel blue and van
Gieson fuchsin and examined under an optical micro-
scope for histomorphologic evaluation. For the 1-week
histology samples, a second thin section was also pro-
duced and stained with Stevenel blue and van Gieson
fuchsin in an attempt to evaluate the interaction of
osteogenic cells with the implant surface.
Bone-to-implant contact (BIC) was determined at
×50 to ×200 magnification (Leica DM2500M, Leica
Microsystems) by means of computer software (Leica
Application Suite, Leica Microsystems). All regions of
bone-to-implant contact along the implant perimeter
were subtracted from the total implant perimeter, and
calculations were performed to determine the BIC. The
bone area fraction occupied (BAFO) between threads
in trabecular bone regions was determined at ×100
magnification (Leica DM2500M) by means of computer
software (Leica Application Suite). The areas occupied
by bone were subtracted from the total area between
threads to determine the BAFO (reported in percent-
age values).29
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Fetner et al
Buccal
Lingual
Mesial Distal
CBH
CBH
MBL MBH MBH Distal
Mesial
MBL
Buccal Lingual
Statistical Analysis
Preliminary analysis of the data showed that one out-
lier greatly skewed the distribution of outcome data;
this one outlier was therefore ignored to maintain a
symmetric distribution. Linear regression was used
to calculate correlation of subcrestal implant depth
(SID) and change in CBH (∆CBH), MBH, MBL, BIC, and
BAFO. A linear mixed-model analysis of variance with
fixed factors of depth and site was used to determine
statistical differences between groups for ∆CBH, MBH,
MBL, BIC, and BAFO. One-way analysis of variance and
the Tukey multiple comparison test (P < .05) were used
to determine significance in regard to BIC and BAFO
in the histologic samples. The Kruskal-Wallis and Dunn
multiple-comparison tests (P < .05) were used to deter-
mine the significance of differences between individu-
al groups regarding whether the bone approximated
the abutment surface.
RESULTS
A total of three implants failed, one in each group. One
of the failed implants had severe bone loss and was
excluded from statistical measurements as an outlier.
Thus, the total number of implants used for analysis
was 33, resulting in a survival rate of 91.7%.
Micro-CT Analysis of Bone Levels
Figure 5 illustrates the mean MBLs as a function of im-
plantation depth and site. Thus, implants at the crest
of bone exhibited, on average, lower MBLs than the
subcrestally placed implants, regardless of buccal/
lingual site (P < .05). While MBLs were higher for im-
plants placed 3 mm subcrestal than for those placed
1.5 mm subcrestal, this difference failed to reach sta-
tistical significance (.05 < P < .10). Similarly, the buccal
The International Journal of Oral & Maxillofacial Implants 1071
Fetner et al

Buccal Buccal Buccal

Lingual Lingual Lingual
1.5  3  1.5 
1.00 
2  1.0 
0.5 
MBL

CBH

MBH
0.00  1  0.5 
–0.5 
0  0.0 
–1.00 

–1.5  –1  –0.5 

0.0 1.5 3.0 0.0 1.5 3.0 0.0 1.5 3.0
Placement depth (mm) Placement depth (mm) Placement depth (mm)

Fig 5   Mean MBL as measured on micro- Fig 6   Mean CBH as measured on micro- Fig 7   Mean MBH as measured on micro-
CT scans on the buccal and lingual of im- CT scans on the buccal and lingual of im- CT scans on the mesial and distal of im-
plants placed per group. plants placed per group. plants placed per group.

Fig 8  Histologic images of implants

placed with evidence of bone-to-abutment
L B L B L B contact. (a) 0-mm group implant with no
0 mm 1.5 mm 3.0 mm
bone-to-abutment contact on the buccal
or lingual, (b) a 1.5-mm group implant with
bone-to-abutment contact on the lingual
but not the buccal, (c) a 3-mm group im-
plant with bone-to-abutment contact on
the buccal and the lingual.

a b c

sites showed lower MBLs than the lingual sites, regard-
less of implantation depth (P < .001). There was no in-
dication of an interaction between depth and buccal/
lingual site (P = .74). Thus, as measured by MBL, im-
plantation at the crest resulted in lower MBLs than im-
plantation at 1.5 or 3 mm subcrestal, and buccal sites
showed lower MBLs than lingual sites.
Figure 6 shows CBH as a function of implantation
depth and buccal/lingual site. Analysis showed an in-
teraction between these factors (P = .03). Thus, while
CBH was lower at buccal than lingual sites for the
1.5- and 3-mm implantation depths, there was no dif-
ference between sites for implants placed at the crest.
In addition, there was a main effect of depth (P < .001),
such that each implantation depth resulted in signifi-
cantly different levels of CBH.
Figure 7 depicts MBH as a function of implanta-
tion depth and site. Analysis showed an interaction
between these factors (P = .03). Thus, while CBH was
lower at buccal than lingual sites for the 1.5- and 3-mm
implantation depths, there was no difference between
sites for implants placed at the crest. In addition, there
was a main effect of depth (P < .001), such that each
implantation depth resulted in significantly different
CBH values.
Histologic Analyses
Figure 8 shows histologic specimens from each group
of implants placed. BIC and BAFO were very similar
between all groups. The average percent perimeter of
bone in contact with the implant surface was around
60% for all groups (Fig 9). There was no significant

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 Fetner et al

Fig 9 (left)  Histologic mean percent of

implant perimeter, with BIC by group. No 100 
significant differences were seen between 80 
groups. 80 

Percent perimeter
60 

Percent area
60 
Fig 10 (right)  Histologic mean percent 40 
area with bone within the threads. 40 
20 20
0  0 
0.0 1.5 3.0 0.0 1.5 3.0
Placement depth (mm) Placement depth (mm)

Table 1  Histologic Data of Sites with Bone-to-Abutment Contact

Implant depth (mm) Buccal Lingual Percent of sites buccal Percent of sites lingual Percent of sites
0 0 0 0 0 0
1.5 1 5 8% 42% 25%
3.0 6 7 67% 78% 74%

difference between groups in BIC. BAFO also showed
no significant differences between groups in average
percent area. Figure 10 shows an average percent area
for all groups of approximately 40%. The amount of
surfaces with bone-to-abutment contact in the differ-
ent groups is shown in Table 1. The 3-mm subcrestal
group showed the most sites with bone-to-abutment
contact. Lingual sites presented a higher percentage
of sites with bone-to-abutment sites than mesial sites.
Significance of differences between each of the groups
with regard to surfaces with bone-to-abutment con-
tact is shown in Table 2. A comparison of the 0-mm
and 1.5-mm groups showed no significant differences
regardless of site location; the 0-mm and 3-mm groups
always showed a significant difference regardless of site
location; and the 1.5-mm and 3-mm groups showed a
significant difference only on buccal sites.
DISCUSSION
Subcrestal placement of most bone-level implants has
been shown to lead to greater bone loss than crestal or
supracrestal implant placement.3,29 The present study
has shown that an implant with a connection that
minimizes the implant-abutment microgap and micro-
movement, as well as presents with a large platform
switch, can have the same amount of crestal bone loss
when placed at the crest of the bone or up to 3 mm
subcrestally. The bone loss seen around the equicrestal
implant is consistent with similar studies in which two-
piece implants were placed at the bone crest.4
The implants placed subcrestally were able to main-
tain higher initial CBH and MBL at placement, even
at 6 months after placement. This showed that the
Table 2  Comparison of Groups Based on
Bone-to-Abutment Contact
Significant?
Depth of placement Buccal Lingual
0 vs 1.5 mm No No
0 vs 3 mm Yes Yes
1.5 vs 3 mm Yes No
marginal bone did not extensively remodel apical to
the implant-abutment interface, with some bone even
remaining on the platform, in contrast to previous
studies when implants were placed subcrestally.4,12
This difference is probably a result of factors that allow
this implant to reduce the effects of the microgap. It
is speculated that the Morse taper connection reduces
the bacterial inflow into a microgap, which will cause
less inflammation in the area and thus limit bone loss.
It is also speculated that the large platform switch re-
duces the effects felt from any irritation at the micro-
gap by distancing it from the surrounding bone. These
factors probably allow the tested implant system to
be placed subcrestally with minimal effect on the sur-
rounding bone.
Bone loss around implants occurs less than 3
months after they are placed.4,10,12,30 The implants in
this study also showed bone loss and remodeling dur-
ing the 6 months after placement. The implants placed
at the crest of bone in this study had significantly
greater loss of MBL, MBH, and CBH than implants
placed subcrestally. This bone loss may be seen as nor-
mal physiologic bone loss following full-thickness flap
elevation.31 Because crestal implants are placed with
no bone coronal to the platform, this bone loss would

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Fetner et al
then expose the rough surface of the implant to pos-
sible microbial colonization. The bone loss present in
all groups could also be a result of the microgap and
the irritation caused by it, although this was less pro-
nounced than similar studies.4
A previous study has shown that there may be his-
tologically intimate contact between bone and abut-
ment.18 The present study shows intimate contact
histologically between bone and abutment in sev-
eral of the subcrestally placed implants. Moreover, the
implants placed further subcrestally have a greater
chance of bone approximating the abutment, espe-
cially on the buccal plate. The 3-mm group showed
significantly more bone-to-abutment contact on the
buccal than the 0-mm and 1.5-mm groups. Clinically,
an implant placed 3 mm subcrestally may produce
more esthetic results because of the amount of bone
remaining at the buccal coronal implant margin. The
unpredictability of the bone approximating the abut-
ment may be attributed to the fact that all the abut-
ments in this study were polished titanium and thus
may have been less likely to osseointegrate. More stud-
ies are warranted to investigate the potential of osseo-
integrated final abutments with a roughened surface.
To the authors’ knowledge, no clinical trials have
yet investigated implants placed 3 mm subcrestal.
This study has shown that implants can be placed up
to 3 mm subcrestal without any more bone loss than
implants placed at the bone crest. The bone coronal
to the platform at placement was maintained around
these implants and may even osseointegrate with the
final abutment. The implant used in this study showed
more favorable results when placed subcrestally rather
than at the crest of bone. This was not a result of less
bone loss in the subcrestal group but was the result of
more bone remaining coronal to the implant platform.
The bone that heals coronal to the implant platform
can be used to create esthetic results by masking the
titanium color of the implant/abutment, supporting
adjacent soft tissue papillae, and allowing room for the
emergence profile.20
The effects of subcrestal placement of the implant
used in the current study have been evaluated in both
retrospective22,25 and prospective clinical studies26,32
with conventional radiography and cone beam com-
puted tomography. It has been demonstrated that
subcrestal implant placement resulted in a greater
amount of bone remodeling above the implant plat-
form in all implant surfaces but resulted in less margin-
al bone loss below the implant platform and a higher
percentage of implant surfaces with bone on the im-
plant platform. The results of the present study are in
agreement with these previous findings.
The present study has some limitations, including
the fact that the implants were not directly loaded in
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occlusion with the opposing arch. Although the find-
ings of this study represent 6 months of healing, the
final abutment was in place for only 3 months. Clini-
cal studies are necessary to investigate the effects of
subcrestally placed implants with a conical connection
and a medialized implant-abutment interface.
ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this study.
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