Accepted: 30 September 2017

DOI: 10.1111/jcpe.12829

E P I D E M I O LO GY (CO H O RT S T U DY
O R C A S E - ­C O N T R O L S T U D Y )

Restoration contour is a risk indicator for peri-­implantitis:

A cross-­sectional radiographic analysis

Michitsuna Katafuchi1 | Bradley F. Weinstein1 | Brian G. Leroux2 | Yen-Wei Chen3 |

Diane M. Daubert1

1
Department of Periodontics, University of
Washington, Seattle, WA, USA Abstract
2
Department of Oral Health Aim: The purpose of this study was to determine whether restoration emergence
Sciences, University of Washington, Seattle,
angle was associated with peri-­implantitis.
WA, USA
3 Materials and Methods: A data set consisting of 96 patients with 225 implants (mean
Department of Restorative
Dentistry, University of Washington, Seattle, follow-­up: 10.9 years) was utilized. Implants were divided into bone-­level and tissue-­
WA, USA
level groups, and radiographs were analysed to determine the restoration emergence
Correspondence angles, as well as restoration profiles (convex or concave). Peri-­implantitis was diag-
Diane M. Daubert, Department of
nosed based on probing depth and radiographic bone loss. Associations between peri-­
Periodontics, University of Washington,
Seattle, WA, USA. implantitis and emergence angles/profiles were assessed using generalized estimating
Email: ddaubert@uw.edu
equations.
Funding information
Results: Eighty-­three patients with 168 implants met inclusion criteria. The prevalence
This study was supported by the University of
Washington School of Dentistry Elam M. and of peri-­implantitis was significantly greater in the bone-­level group when the emer-
Georgina E. Hack Memorial Research Fund
gence angle was >30 degrees compared to an angle ≤30 degrees (31.3% versus 15.1%,
p = .04). In the tissue-­level group, no such correlation was found. For bone-­level im-
plants, when a convex profile was combined with an angle of >30 degrees, the preva-
lence of peri-­implantitis was 37.8% with a statistically significant interaction between
emergence angle and profile (p = .003).
Conclusions: Emergence angle of >30 degrees is a significant risk indicator for peri-­
implantitis and convex profile creates an additional risk for bone-­level implants, but
not for tissue-­level implants.

KEYWORDS
dental implant, dental prosthesis, implant-supported, peri-implantitis, prevalence, risk factors

1 | INTRODUCTION peri-­implantitis. Moderate/severe peri-­implantitis was diagnosed in

14.5%. (Derks et al., 2016). Daubert, Weinstein, Bordin, Leroux, and
Peri-­
implantitis has been a growing issue in dentistry. Although Flemmig (2015) investigated the prevalence of peri-­implantitis in a
the long-­term overall implant survival rate is reported to be 97% US population with mean follow-­up time of 10.9 years and reported
(Busenlechner et al., 2014), survival rates do not take into account a 16% implant level prevalence of peri-­implantitis. It is critical to have
the presence of peri-­implantitis among existing implants. Systematic a better understanding of the risk factors for peri-­implantitis in order
review and meta-­analysis after at least 5 years of function show that to prevent it.
18.8% of patients have peri-­implantitis (Atieh, Alsabeeha, Faggion, & Risk indicators for peri-­implant disease have been identified in pre-
Duncan, 2013). According to a recent report from a Swedish popu- vious studies. Poor oral hygiene, history of periodontitis and cigarette
lation with 9-­year follow-­up, 45% of all patients presented with smoking are important factors associated with peri-­implant disease

J Clin Periodontol. 2018;45:225–232. wileyonlinelibrary.com/journal/jcpe © 2017 John Wiley & Sons A/S. | 225
Published by John Wiley & Sons Ltd
226 | KATAFUCHI et al.

(Ferreira, Silva, Cortelli, Costa, & Costa, 2006; Karoussis et al., 2003;
Roos-­Jansåker, Renvert, Lindahl, & Renvert, 2006). Diabetes has also Clinical Relevance
been linked with peri-­implantitis risk (Daubert et al., 2015). Derks et al. Scientific rationale for the study: No prior study has evaluated
(2016) demonstrated higher odds ratios for moderate to severe peri-­ whether emergence angle has any influence on peri-­
implantitis in patients with periodontitis and with ≥4 implants, as well implantitis risk, and how much restoration flare can be toler-
as implants of certain brands and prosthetic therapy delivered by gen- ated before the risk of peri-­implantitis increases.
eral practitioners. Higher odds ratios were also identified for implants Principal findings: This study found a correlation between
placed in the mandible and with crown restoration margins positioned restoration emergence angle and peri-­implantitis and identi-
≤1.5 mm from the crestal bone at baseline. Excess cement was identi- fied a wider emergence angle is a risk for peri-­implantitis.
fied as a possible risk indicator for peri-­implant disease and an associa- Practical implications: With knowledge of the emergence
tion has been found with a tendency to higher disease prevalence with angle, clinicians can adjust their implant selection and place-
cemented compared to screw-­retained implant restorations (Staubli, ment depth, as well as their restoration design when using
Walter, Schmidt, Weiger, & Zitzmann, 2016). bone-­level implants to reduce the risk of peri-­implantitis.
The restoration contour of fixed dental prostheses on natural teeth
has been reported to have an impact on the periodontium. Numerous
studies since the early 1970s have been conducted to understand
the effects of restoration contours on gingival inflammation. Over-­ remodelling. New radiographs were taken of the implants at the fol-
contoured restorations have been linked with gingival erythema due low-­up examination. Ninety-­six patients presented for a follow-­up ex-
to plaque retention, whereas well-­contoured restorations allowed for amination (48 males and 48 females, aged 34 to 86 years; mean ± SD
the maintenance of gingival health (Becker & Kaldahl, 1981; Yuodelis, age: 67.6 ± 10.6 years) with a total of 225 implants included.
Weaver, & Sapkos, 1973). Another study reported that restoration Peri-­implantitis was defined as the presence of BOP and/or sup-
contours more pronounced than natural tooth convexities have po- puration, with 2 mm of detectable bone loss after initial remodelling,
tential to create problematic plaque retention (Parkinson, 1976). On and PD ≥4 mm. The presence of 2 mm of bone loss alone without mu-
the other hand, the majority of studies that report on the restoration cositis symptoms did not count as a case of peri-­implantitis. Because
contour of implant-­supported prostheses have been related to the gin- of non-­standardized radiographs at prosthetic insertion and follow-­up
gival aesthetics. To our knowledge, restoration contour as a risk factor examination, the case definition of a threshold of 2 mm from the ex-
for peri-­implantitis has not been assessed in a clinical trial. pected marginal bone level after remodelling after implant placement
The glossary of prosthodontic terms (2005) describes two specific was included (Sanz & Chapple, 2012). Implant failure was defined as a
terms for restoration contours: emergence angle and emergence profile. removed, lost, mobile or fractured implant (Buser et al., 2012).
Emergence angle is defined as the angle of an implant restoration’s tran- This data set was utilized to explore the question of restoration
sitional contour as determined by the relation of the surface of the abut- contour and was utilized for the radiographic analysis. Implants with
ment to the long axis of the implant body. Emergence profile is defined any of following conditions were excluded from the radiographic
as the contour of a tooth or restoration, such as a crown on a natural analysis: (i) implants with a fixed-­detachable restoration or removable
tooth or dental implant abutment, as it relates to the adjacent tissues. overdenture; (ii) failed implants; (iii) implants that were not restored
We hypothesized that over-­
contoured restorations, defined as with definitive implant-­supported restorations; and (iv) implants that
having a wide emergence angle and/or convex profile, would increase supported an ill-­fitting restoration. All implants included radiographic
the risk for peri-­implantitis. The aim of this study was to analyse a analysis were divided into bone-­level and tissue-­level groups depend-
cross-­sectional data set comparing healthy implants to those diag- ing on the location of the implant platforms. Details on implants in-
nosed with peri-­implantitis to determine whether emergence angle cluding size, locations, brands and bone grafting are included in the
and profile were associated with the prevalence of peri-­implantitis. prior publication (Daubert et al., 2015).

2 | MATERIALS AND METHODS 2.2 | Radiographic analysis

Radiographs used for analysis were taken when the patients came
2.1 | Subjects and diagnosis of peri-­implantitis
in for the study examination and peri-­implant diagnosis. Digital ra-
The research protocol was approved by the Institutional Review diographs were made of the implants at the time of the follow-­up
Board at the University of Washington (No. 41380). All subjects pro- examination using film holders to ensure paralleling technique and di-
vided written informed consent. STROBE guidelines were followed. minish distortion of the image. The image processing program (Image
Subject recruitment, details on diagnosis and clinical examination, J, National Institutes of Health) was used to assess the emergence
and prevalence and risk that resulted from analysis of this subject angle and profile of restorations. While performing the radiographic
population were previously reported (Daubert et al., 2015). Briefly, analysis, the examiner was blinded to the implant status (healthy, peri-­
patients were assessed who had implants placed in a university setting implant mucositis or peri-­implantitis) in order to prevent potential bias.
between 1998 and 2003 and had radiographs taken after the initial Selected radiograph images were cropped to hide the marginal bone
KATAFUCHI et al. | 227

loss if it exists to aid with blinding. Examples of emergence angle and for multiple implants within patients. Analyses of emergence angle
profile assessments are shown (Figure 1). The method of the emer- as a dichotomous variable (less than or equal to 30 degrees versus
gence angle measurement described by Yotnuengnit, Yotnuengnit, greater than 30 degrees) used ANOVA models to assess main effects
Laohapand, and Athipanyakom (2008) was utilized to measure the of emergence angle and profile as well as their interaction for each
emergence angle of implant restorations on the radiographs. The type of implant (bone level and tissue level). We used logistic regres-
emergence angle was calculated as the angle between the implant long sion models with emergence angle as a continuous variable to plot
axis and a line tangent to the restoration. First, a line parallel to implant estimated peri-­implantitis prevalence versus emergence angle. We
long axis was drawn at the outer collar of the implant. Then, another also used logistic regression models to build a predictive model for
line tangential to the restoration from the platform was drawn. The peri-­implantitis. The following predictor variables were considered for
angle of the intersection was measured as the emergence angle. The inclusion in the model: patient age, patient periodontal disease status,
measurements were repeated twice, and the mean was calculated for patient diabetic status, implant diameter, implant type, emergence
each mesial and distal interproximal surface. Each emergence profile angle and emergence profile. A final model was selected for presenta-
was categorized as either concave, straight or convex. Both mesial and tion by minimizing the Akaike information criterion (AIC).
distal surfaces were rated three times, and the majority selection was For the emergence angle measurement, intra-­rater reliability be-
chosen as the emergence profile. For the implants in the bone-­level tween the examiner’s two measurements was very high (r = 0.95).
group, the transmucosal abutment was considered as a part of restora- Inter-­rater reliability between the examiner and the volunteer was
tion. Therefore, the emergence angle and profile were assessed from also high (r = 0.82). For the emergence profile rating, intra-­rater agree-
the platform at the marginal bone level. The implants in the tissue-­level ment was high (81.6%) and inter-­rater agreement was moderately high
group have a polished shoulder that allows for soft tissue adaptation (70%). While this is only a moderately high agreement percentage, the
around it, and the platform is located at the tissue level. The contour of six cases for which there was disagreement involved a discrepancy of
the transmucosal part is preset. The emergence angle and profile were only one rating level (e.g. convex versus straight). There were no dis-
assessed only above the platform at the tissue level. A volunteer exam- crepancies greater than one level (e.g. convex versus concave).
iner was recruited and calibrated to repeat assessment on 20 randomly
selected surfaces. For the emergence angle measurement, intra-­rater
3 | RESULTS
reliability and inter-­rater reliability were calculated. For the emergence
profile rating, intra-­rater agreement and inter-­rater agreement were
3.1 | Prevalence of peri-­implantitis within Included
calculated. Additionally, for the bone-­level group, implant depth was
patients and implants
categorized as supracrestal, crestal and subcrestal on each mesial and
distal aspect using radiographs at the implant placement. Eighty-­three patients with 168 implants were included in the radio-
graphic analysis. There were 101 implants, placed in 59 unique pa-
tients, in the bone-­level group. In the tissue-­level group, there were
2.3 | Statistical analysis and validation of
67 implants placed in 27 unique patients. Implant level prevalence of
radiographic analysis
peri-­implantitis was 22.8% in the bone-­level group and 7.5% in the
Associations between peri-­implantitis and emergence angle and pro- tissue-­level group (Table 1). Thirteen patients and 57 implants were
file were assessed using generalized estimating equations to account excluded from the radiographic analysis. The details regarding ex-
cluded implants follow: (i) thirty-­five implants with a fixed-­detachable
restoration or removable overdenture were excluded due to the dif-
ficulty of performing emergence angle and profile assessments. (ii)
Eighteen failed implants were excluded. (iii) One patient with three
implants had a long-­term implant-­supported provisional restoration
for orthodontic treatment. Those implants were excluded because the
contour of the restoration may not have been consistent over time.
(iv) One implant had an obvious ill-­fitting restoration with a significant

T A B L E 1 Prevalence at implant and patient level of peri-­

implantitis by implant type

Bone level Tissue level Overall

F I G U R E 1 Example of the emergence angle measurement on an Implant level (N = 101) (N = 67) (N = 168)
implant in the bone-­level group (a) and in the tissue-­level group (b). Peri-­implantitis, n (%) 23 (22.8%) 5 (7.5%) 28 (16.7%)
Example of the emergence profile assessment on an implant in the Patient level (N = 59) (N = 27) (N = 83)
bone-­level group (c) and in the tissue-­level group (d). EA, Emergence
Peri-­implantitis, n (%) 17 (28.9%) 4 (14.8%) 21 (25.3%)
angle
228 | KATAFUCHI et al.

open-­margin. This patient had been given a recommendation to have

3.4 | Prevalence of peri-­implantitis by
the restoration replaced at the follow-­up examination.
emergence angle
Average mesial and distal emergence angles were the same. The mean
3.2 | Distribution of emergence angle and profile
of the emergence angle ranged from 25 to 29 degrees. Therefore, we
In the bone-­level group, the mean ± SD emergence angle was 27.8 decided to use 30 degrees as a threshold for over-­contour. This angle
degrees ± 11.6 on the mesial surface and 25.1 degrees ± 10.3 on the was used as a benchmark in a prior animal study where 30 degrees
distal surface. In the tissue-­level group, the mean ± SD emergence was described as a normal contour (Kohal, Gerds, & Strub, 2003;
angle was 28.6 degrees ± 14.4 on the mesial surface and 28.3 de- Kohal, Pelz, & Strub, 2004).
grees ± 13.3 on the distal surface. There was no statistically significant In the bone-­level group, the risk of peri-­implantitis was signifi-
difference in the distribution of emergence angle either within a group cantly greater when the emergence angle was >30 degrees compared
or between groups (Table 2). In the bone-­level group, the convex pro- to an angle of ≤30 degrees (31.3% compared to 15.1%, p = .04). In
file was found on 35.6% of the mesial surfaces and 39.6% of the distal contrast, in the tissue-­level group, the emergence angle was not as-
surfaces. In tissue-­level group, the convex profile was found on 35.8% sociated with peri-­implantitis (Table 4). We also found an association
of the mesial surfaces and 38.8% of the distal surfaces. There was between peri-­implantitis and emergence angle as a continuous vari-
no statistically significant difference in the distribution of the convex able in the bone-­level group but not in the tissue-­level group (Fig. S1).
profile either within a group or between groups (Table 2). Emergence
angles tended to be larger for convex profiles (mean 37.5, SD 11.7)
3.5 | Prevalence of peri-­implantitis by
compared with straight or concave profiles (mean 26.7, SD 8.9). This
emergence profile
pattern was similar for bone and tissue-­level implants.
In the bone-­level group, the prevalence of peri-­implantitis was 28.8%
with a convex profile when compared to 16.3% with a straight or con-
3.3 | Patient and implant characteristics
cave profile. The difference was not statistically significant.
Implants were placed into two groups: those with at least one inter- In the tissue-­level group, the emergence profile was not associated
proximal surface with >30 degrees, and those with both interproximal with peri-­implantitis (Table 4).
surfaces measuring ≤30 degrees. Implants were also grouped into two
additional groups: those having at least one interproximal surface with
3.6 | Prevalence of peri-­implantitis by a combined
a convex profile, and those with both interproximal surfaces either
effect of emergence angle and profile
concave or straight. For both bone-­and tissue-­level groups, patient
characteristics consisting of gender, age, smoking, diabetes and pres- The combined effect of the emergence angle and emergence pro-
ence of periodontal disease, and implant characteristics consisting of file on the presence of peri-­implantitis was analysed. An interaction
cemented restoration and posterior implant were distributed evenly plot for the bone-­level group showed that the highest rate of peri-­
between the two groups of emergence angles as well as between the implantitis (37.8%) occurred when a convex profile was combined
two groups of emergence profiles. We found no indication of differ- with a restoration emergence angle of >30 degrees. Regression analy-
ences in angle or profile by brand for bone-­level implants (Table 3). sis found a statistically significant interaction between the restoration
emergence angle and emergence profile (p = .003; Figure 2a). For the
tissue-­level group, there was no evidence for a combined effect of
restoration emergence angle and emergence profile on the rate of
peri-­implantitis (Figure 2b).
T A B L E 2 Distribution of emergence angle and profile by surface
and implant type

Surface Bone level Tissue level 3.7 | Prediction of peri-­implantitis

Emergence angle The predictive model selected using AIC included patient age, peri-
Mesial, mean (SD) 27.8 (11.6) 28.6 (14.4) odontal disease status, implant type and emergence angle as predic-
Distal, mean (SD) 25.1 (10.3) 28.3 (13.3) tors (Table S1). The area under the receiver operating curve is 0.78
Emergence profile (Fig. S2).

Mesial (N = 101) (N = 67)

Convex, n (%) 36 (35.6%) 24 (35.8%) 3.8 | Effect of implant depth in the bone-­level group
Concave or Straight, n (%) 65 (64.4%) 43 (64.2%)
We found emergence angle was affected by implant depth. The mean
Distal (N = 101) (N = 67)
emergence angle was 28.9, 29.0 and 22.3 degrees for implant depths
Convex, n (%) 40 (39.6%) 26 (38.8%)
for supracrestal, crestal and subcrestal, respectively. However, we
Concave or Straight, n (%) 61 (60.4%) 41 (61.2%)
found no association between implant depth and peri-­implantitis for
KATAFUCHI et al. | 229

TABLE 3 Distribution of patient characteristics by emergence angle and profile

Mesial and/or distal EA >30 Both EA 30 degrees or Mesial and/or distal Both concave
degrees less convex or straight

Bone-­level implants
N 48 53 52 49
Male, n (%) 28 (58.3%) 29 (54.7%) 26 (50.0%) 31 (67.6%)
Age, mean (SD) 66.4 (9.8) 65.2 (11.9) 67.3 (10.1) 64.1 (11.5)
Smoking, n (%) 4 (8.3%) 6 (11.3%) 7 (13.5%) 3 (6.1%)
Diabetes, n (%) 3 (6.3%) 8 (15.1%) 5 (9.6%) 6 (12.2%)
Periodontal Disease*, n (%) 9 (18.8%) 17 (32.1%) 12 (23.1%) 14 (28.6%)
Periodontal Disease* at Baseline, 15 (31.3%) 18 (34.0%) 15 (28.9%) 18 (36.7%)
n (%)
Cemented restoration, n (%) 41 (85.4%) 42 (79.2%) 45 (86.5%) 38 (77.6%)
Posterior implants, n (%) 46 (96%) 40 (75%) 44 (85%) 42 (86%)
Brand
Nobel Biocare 11 (23%) 9 (17%) 11 (21%) 9 (18%)
Branemark system 1 (2%) 4 (8%) 2 (4%) 3 (6%)
Biomet 3i 29 (60%) 30 (57%) 33 (63%) 26 (53%)
Centerpulse 3 (6%) 6 (11%) 4 (8%) 5 (10%)
Astra 2 (4%) 0 (0%) 1 (2%) 1 (2%)
Sulzer dental 2 (4%) 3 (6%) 1 (2%) 4 (8%)
Steri-­oss 0 (0%) 1 (2%) 0 (0%) 1 (2%)
Tissue-­level implants
N 39 28 34 33
Male, n (%) 27 (69.2%) 12 (42.9%) 23 (63.3%) 16 (48.5%)
Age, mean (SD) 69.1 (9.9) 67.7 (12.5) 69.4 (10.8) 67.5 (11.2)
Smoking, n (%) 1 (2.6%) 0 (0%) 1 (2.9%) 0 (0%)
Diabetes, n (%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Periodontal Disease*, n (%) 6 (15.4%) 12 (42.9%) 6 (17.6%) 12 (36.4%)
Periodontal Disease* at Baseline, 16 (42.1%) 16 (59.3%) 19 (55.9%) 13 (41.9%)
n (%)
Cemented restoration, n (%) 35 (89.7%) 25 (89.3%) 32 (94.1%) 28 (84.8%)
Posterior implants, n (%) 38 (97%) 27 (96%) 33 (97%) 32 (97%)
Brand
Straumann 39 (100%) 28 (100%) 34 (100%) 33 (100%)

EA, emergence angle.

*Moderate or severe periodontal disease.

bone-­level implants (Table S2). Furthermore, in sensitivity analyses, 4 | DISCUSSION

adjustment for depth did not substantially change the results for ef-
fects of emergence angle and profile on prevalence of peri-­implantitis 4.1 | Brief summary
(Table S3).
In this present study, restoration emergence angle and emergence
profile (convex, straight, concave) were assessed to determine
whether they are associated with peri-­implantitis. For bone-­level im-
3.9 | Effect of number of implants per patients in the
plants, a restoration emergence angle >30 degrees on at least one
bone-­level group
proximal surface was associated with a higher rate of peri-­implantitis.
Adjustment for number of implants did not substantially change the The highest rate of peri-­implantitis was found when a convex profile
results for effects of emergence angle and profile on prevalence of was combined with a restoration emergence angle of >30 degrees.
peri-­implantitis. (Table S3). These results suggest that an over-­contoured restoration on a dental
230 | KATAFUCHI et al.

TABLE 4 Prevalence of peri-­implantitis by emergence angle and

profile
4.2 | Strengths and limitations of the study

Implant Mesial and/or Both EA 30 Difference (95% Are restoration contours related to peri-­implantitis? This is a valu-
type distal EA >30 degrees or less CI), p-­value able question to ask. Not enough literature is available to support
the superiority of implant-­
supported restoration design, such as
Bone-level, 15/48 (31.3%) 8/53 (15.1%) 16.2% (0.5%,
n (%) 31.8%), 0.04 shape and emergence profile in relation to implant health, although
Tissue-level, 3/39 (7.7%) 2/28 (7.1%) 0.5% (−14.5%, certain design might be related to peri-­implantitis due to limited ac-
n (%) 15.6%), 0.94 cessibility/capability of proper oral hygiene (Serino & Ström, 2009).

Mesial and/or Both straight

Canullo et al. (2016) classified peri-­implantitis into three categories,
distal convex or concave surgically triggered, prosthetically triggered and plaque-­induced peri-­
implantitis, based on the specific predictive profile. Excess cement
Bone-level, 15/52 (28.8%) 8/49 (16.3%) 12.5% (−3.4%,
n (%) 28.5%), 0.12 was reported as a prosthetic risk factor (Canullo, Schlee, Wagner, &
Tissue-level, 2/34 (5.9%) 3/33 (9.1%) −3.2% (−13.0%, Covani, 2015; Linkevicius, Puisys, Vindasiute, Linkeviciene, & Apse,
n (%) 6.6%), 0.52 2013; Wilson, 2009). Derks et al. (2016) reported that prosthetic

EA, emergence angle.

therapy delivered by general practitioners exhibited higher odds ratios
for peri-­implantitis as well as implants with crown restoration margins
positioned 1.5 mm from the crestal bone. Our study provides novel
implant (wide emergence angle and convex profile) may have a nega- information regarding prosthesis design characteristics for bone-­level
tive impact on the peri-­implant health, and increase the risk of de- implants. The position of an implant, its direction and its diameter
veloping peri-­implantitis, supporting our primary hypothesis. A wider affect the emergence angle and emergence profile. Therefore, the
restoration emergence angle represents a significant risk indicator for resulting restoration contours are determined not only by the restora-
peri-­implantitis in bone-­level implants, and a convex profile is an addi- tive dentists and laboratory technicians, but are also influenced by the
tional risk when combined with it. Our results suggest that a shallower implant position. The results of this study may aid in decision-­making
emergence angle with a straight or concave profile at the interproxi- when selecting the size of implant and deciding implant position at
mal sites should be considered to minimize peri-­implantitis risk for surgery as well as restoring implant.
bone-­level implants. For the tissue-­level implants, neither emergence In contrast to the bone-­
level group, the prevalence of peri-­
angle nor emergence profile is associated with an increased preva- implantitis in the tissue-­level group was not affected by either the
lence of peri-­implantitis, and therefore, no emergence angle or profile emergence angle or profile. The platform of the implant in this group
recommendation can be ascertained. To our best knowledge, this is is typically at the tissue level so that a wider emergence angle and a
the first cross-­sectional study to assess restoration contours related convex profile may not affect the peri-­implant tissue. The data, how-
to the prevalence of peri-­implantitis. ever, need to be interpreted with caution. Only 27 patients with 67

F I G U R E 2 Interaction plot of a
combined effect of emergence angle
and profile on the prevalence of peri-­
implantitis for the bone-­level group (a) and
the tissue-­level group (b). The bone-­level
group showed that the highest prevalence
(37.8%) occurred when a convex profile
was combined with an angle of greater
than 30 degrees. Statistically significant
interaction was found between the
emergence angle and profile in the bone-­
level group (p = .003)
KATAFUCHI et al. | 231

implants were included in the tissue-­level group, and the prevalence platform switching implants may become larger than the emergence
of peri-­implantitis in this group was 7.5%. angle on non-­
platform-­
switched implants, implying the platform
In this study, the outcome parameter was the status of the implant, switching implants may increase the risk for peri-­implantitis accord-
not the marginal bone loss on each interproximal site. Therefore, the ing to the present study. A larger scale long-­term study assessing the
direct association between the restoration contour and the marginal prevalence of peri-­implantitis in platform switching implants and its
bone loss were unknown. A question may also arise regarding the fa- relation to restoration contours is warranted.
cial and lingual aspects of the restoration contour. Computed tomog-
raphy is applicable to assess those aspects at follow-­up examination.
AC KNOW L ED G EM ENTS
It was avoided due to ethical reasons related to additional radiation.
Alternatively, the implant restorations can be removed to assess those The authors thank Dr. Russell Johnson, Graduate resident in the
aspects but it also raises ethical questions, especially for a cemented Department of Periodontics in the University of Washington, for his
restoration. Those contours should be examined on the model that contribution as a volunteer examiner. The authors also thank Dr. Robert
the restoration is fabricated on before it is inserted in a prospective London and Dr. Douglas Dixon in the Department of Periodontics in
study. Although how the facial and lingual contours affect implant the University of Washington for informative suggestions.
health is unknown in the present study, the correlation we found on
interproximal contours to peri-­implantitis is novel and valuable data
CO NFL I C T O F I NT ER ES T
for clinicians.
The authors have stated explicitly that there are no conflict of inter-
ests in connection with this article.
4.3 | Interpretation of the study supported by
existing evidence and possible mechanism
O RC I D
Peri-­implantitis is thought to be infectious in nature and caused by
bacteria from dental biofilms followed by a local host inflammatory Michitsuna Katafuchi http://orcid.org/0000-0001-9147-8605
response (Figuero, Graziani, Sanz, Herrera, & Sanz, 2014; Lang &
Berglundh, 2011). Ferreira et al. (2006) reported that very poor oral
hygiene is associated with peri-­implantitis with an odds ratio of 14.3. REFERENCES

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