Heimes et al.

International Journal of
International Journal of Implant Dentistry (2023) 9:20
https://doi.org/10.1186/s40729-023-00485-z Implant Dentistry

REVIEW Open Access

How does dental implant macrogeometry

affect primary implant stability? A narrative
review
Diana Heimes1*† , Philipp Becker1,2†, Andreas Pabst1,2, Ralf Smeets3,4, Annika Kraus5, Amely Hartmann1,6,
Keyvan Sagheb1 and Peer W. Kämmerer1

Abstract
Purpose The macrogeometry of a dental implant plays a decisive role in its primary stability. A larger diameter, a
conical shape, and a roughened surface increase the contact area of the implant with the surrounding bone and thus
improve primary stability. This is considered the basis for successful implant osseointegration that different factors,
such as implant design, can influence. This narrative review aims to critically review macro-geometric features affect-
ing the primary stability of dental implants.
Methods For this review, a comprehensive literature search and review of relevant studies was conducted based on
formulating a research question, searching the literature using keywords and electronic databases such as PubMed,
Embase, and Cochrane Library to search for relevant studies. These studies were screened and selected, the study
quality was assessed, data were extracted, the results were summarized, and conclusions were drawn.
Results The macrogeometry of a dental implant includes its surface characteristics, size, and shape, all of which play
a critical role in its primary stability. At the time of placement, the initial stability of an implant is determined by its
contact area with the surrounding bone. Larger diameter and a conical shape of an implant result in a larger contact
area and better primary stability. But the linear relationship between implant length and primary stability ends at
12 mm.
Conclusions Several factors must be considered when choosing the ideal implant geometry, including local factors
such as the condition of the bone and soft tissues at the implant site and systemic and patient-specific factors such
as osteoporosis, diabetes, or autoimmune diseases. These factors can affect the success of the implant procedure
and the long-term stability of an implant. By considering these factors, the surgeon can ensure the greatest possible
therapeutic success and minimize the risk of implant failure.
Keywords Implant geometry, Primary stability, Macro-design, Thread design, Implant length, Implant diameter,
Narrative review

†
Diana Heimes and Philipp Becker contributed equally to this work.
*Correspondence:
Diana Heimes
[email protected]
Full list of author information is available at the end of the article

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Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 2 of 11

Graphical Abstract

Background or bridges, which include improved function, durabil-

Implantology is a branch of dentistry that deals with ity, and esthetics. Dental implants can last for decades
dental implants to replace missing teeth. A dental or even a lifetime [3–5] with proper care and mainte-
implant is a screw-shaped post made of a biocompat- nance. One of the most important advantages of dental
ible material, such as titanium surgically inserted into implants is the high survival and success rates. Studies
the jawbone to support a replacement tooth or bridge have shown that dental implants have a success rate of
[1, 2]. Dental implants are a popular and effective treat- over 95%, meaning they are successful in most cases.
ment option for patients who have lost teeth due to [3]. This high success rate is due to the biocompatibility
trauma, decay, or other causes. They offer many advan- of the implant material, which allows it to fuse with the
tages over tooth replacement options such as dentures jawbone and form a stable foundation for restoration.
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 3 of 11

When a dental implant is placed it stimulates the sur- Methods

rounding bone tissue, helps maintain bone density, and The first step was to define the research question or goal
prevents bone loss [4]. of the review clearly. For example, “What is the impact
Dental implant placement can be categorized into of the macrogeometry of the implant on primary stabil-
immediate, delayed, and late. Each category refers to the ity?”. Electronic databases, such as PubMed, Embase, and
time frame between the extraction of a tooth and the the Cochrane Library, were then used to search for rele-
placement of a dental implant [5]. Immediate placement vant studies. Search terms also included "dental implant",
of dental implants involves placing an implant immedi- "macrogeometry", "primary stability", "implant shape",
ately after tooth extraction. This procedure is usually "implant size" and "implant surface properties". Reference
performed when the extraction site has sufficient bone lists of retrieved articles were reviewed to find other rel-
volume and the implant can be stabilized. The established evant studies. A list of relevant studies was created, titles
and well-documented benefits of immediate implants, and abstracts were screened for inclusion criteria, and
like reduced treatment time, high patient satisfaction, the methodological quality of the included studies was
comfort, and high survival rates, implicate that it is a reli- assessed using appropriate tools such as the Cochrane
able treatment method [1, 3, 6]. Of course, the position Risk of Bias Tool or the Newcastle–Ottawa Scale for
of the immediate implant is crucial. Bone formation and observational studies. The next step was to extract rel-
bone preservation of the buccal wall were shown to be evant data from the included studies in a standardized
influenced by the initial labio-palatal socket dimension form. This data included information on study design,
[7]. New protocols like task-autonomous robotic systems sample size, intervention, outcome measures, and out-
in immediate implant placement seem to be beneficial comes. After analyzing the extracted data, patterns and
[8]. But studies have shown no evidence for any effect of trends in the results were identified. Finally, based on
the implant’s macrogeometry on the accuracy of guided the summarized results, conclusions were drawn on the
implant insertion [9]. With growing scientific evidence influence of the implant macrogeometry on the primary
and experience in the field, according to the authors, stability.
the indications for immediate implant placement will
increase in the future. Results and discussion
Delayed implant placement is performed several weeks Literature review on the effect of dental implant
to months after tooth extraction. This procedure is usu- macrogeometry on primary implant stability
ally performed when the extraction site needs healing As a limitation, the terms "short", "long", "standard”, "nar-
time to ensure the bone is dense enough to support the row", "wide”, and "regular” dental implants are not defined
implant. Delayed implant placement allows adequate consistently [16]. Several studies have investigated the
healing time and reduces the risk of implant failure [10]. effects of dental implant macrogeometry on primary
Late implant placement refers to the placement of an implant stability. A literature review of these studies
implant after a long period has passed since tooth loss. suggests that implant macrogeometry may be essential
This can be due to various factors, including patient in achieving primary implant stability. One study com-
preferences, systemic or local diseases, or other factors pared the primary stability of dental implants with differ-
that may have prevented earlier implant placement. Late ent macrogeometries, including cylindrical, conical, and
implant placement may require additional augmenta- hybrid designs. The study found that the hybrid design
tion procedures such as bone grafting or sinus lift to had the greatest primary stability, followed by the coni-
ensure adequate bone volume for the implant [11]. The cal design and then the cylindrical design [17]. Another
choice of implant placement type depends on several fac- study compared the primary stability of dental implants
tors including the indication for tooth replacement, the with different thread designs including V-shaped and
quality and quantity of remaining bone, and the patient’s square threads. The study found that implants with
overall health. Implant design is critical in achieving the V-shaped threads had higher primary stability than those
primary and secondary stability essential for successful with square threads [18]. The literature suggests that
osseointegration and long-term implant success. Sev- implant macrogeometry can significantly influence pri-
eral important design factors can affect implant stabil- mary implant stability. Hybrid and conical designs pro-
ity including implant diameter, implant length, implant vide the greatest primary stability, while thread design
thread design, implant surface roughness, and implant may also play a role. However, further studies are needed
shape [12–15]. This narrative review aimed to find an to investigate the effect of macrogeometry on primary
adequate answer to the question: What influence does implant stability and to determine the optimal macroge-
the macro-design have on the primary stability of dental ometry design for different clinical situations.
implants?
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 4 of 11

What is the impact of implant body shape on primary 27]. Apically conical implants show increased primary
stability? stability among the hybrid forms due to more substantial
An essential distinction is made between cylindrical and crestal compression. In contrast, crestal parallel implants
conical implants; there are now numerous mixed forms or back taper designs better relieve the bone [19]. Self-
(see Fig. 1) [19]. Tapered implants are primarily anchored tapping threads can also contribute to increasing primary
by lateral and vertical bone compression, while cylindri- stability.
cal implants transmit static friction to the implant base Immediate implant placement requires high primary
along the implant axis [20]. Tapered implants are becom- stability, so conical implant systems with double threads
ing increasingly popular given the ease of clinical use, and a low thread helix angle should be selected [19].
reduced drilling sequences, potentially shorter healing The influence of the shape of the implant body on pri-
times, and decreased surgical trauma [21]. The interplay mary stability is an essential aspect of implantology [28].
of loading magnitude, loading direction, frequency, bone As mentioned earlier, tapered or conical implants pro-
quality, and quantity, and the ability of cells to respond vide greater primary stability than cylindrical implants
to loading affect the bone’s response. Tapered and because they can distribute forces more evenly and
threaded implants distribute the load better than cylin- incorporate more bone [29]. However, there are some
drical implants [22]. In addition, buccal/facial bone per- challenges associated with the use of tapered or coni-
foration is less likely with conical-shaped implants due cal implants. One challenge is that these implants may
to their anatomical design [21, 23]. In a human ex vivo require a more invasive surgical approach to prepare
study, O-Sullivan et al. [23] demonstrated that coni- the implant site and to ensure proper placement [30].
cal implants have a significantly higher primary stability According to the Group 1 ITI Consensus Report: The
than the standard Brånemark design. These results were influence of implant length and design and medications
also confirmed by Merideth et al. in a clinical setting [3, on clinical and patient-reported outcomes of 2018, evi-
24]. Tapered implants exert lateral compressive forces on dence shows that both tapered and non-tapered implants
the cortical bone, which may be a significant reason for demonstrate satisfactory performance with respect to
their increased primary stability [12, 25]. In addition to marginal bone levels at 3 years. Based on the consen-
the high primary stability, conical implants are thought sus statements, tapered and non-tapered implants can
to have improved osseointegration properties [12, 26, be used according to the operator’s preference. Tapered
implants might be beneficial in clinical situations to avoid
injuring anatomical structures or causing apical fen-
estrations. Furthermore, in situations where increased
insertion torque is needed, tapered implants may be con-
sidered; however, the clinical significance of the implant
shape on long-term success is still unclear [31].

How does implant length affect primary stability?

In addition to the implant shape, the macro-design is
determined by the length and thickness of the implant.
Long and thick dental implants are intended for use with
significant bone loss or to support a more extensive pros-
thetic restoration. These implants are typically used in
areas where conventional implants are not suitable due
to insufficient bone volume or density. Long implants are
usually defined as those 15 mm or more in length. These
implants offer a larger surface area for osseointegration
and can attach to more bone, resulting in greater primary
stability. Long implants are often used in the posterior
maxilla or mandible where bone density and height are
typically lower [21].
Thick implants, on the other hand, are designed for
greater mechanical stability and can withstand higher
Fig. 1 Different implant designs commercially available. Created with loads. These implants are larger in diameter and can
BioRender.com be used where larger prosthetic restorations need to be
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 5 of 11

supported or where there is high occlusal loading. Thick beneficial stress values in tissue-level compared to bone-
implants are often used in the posterior maxilla or man- level designs [39].
dible, where there is usually greater bone density and
height. A potential challenge with using long and wide How does implant diameter affect primary stability?
implants is that they require a more invasive surgical Narrow-diameter implants are defined as dental implants
approach and may be more difficult to place accurately with a diameter of ≤ 3.5 mm. They can be further divided
due to their size. Bruggenkate et al. reported a 10-year into category 1, narrow-diameter implants with a diame-
survival rate of 94% based on a total of 253 short (6 mm) ter < 2.5 mm (mini-implants; mostly one-piece implants),
implants placed. They recommended the placement category 2, with a diameter of 2.5 mm to < 3.3 mm and
of short and long implants in combination, especially category 3, with a diameter of 3.3 mm to 3.5 mm [40].
when implant restoration in less dense bone is planned Implants with a diameter ≥ 5 mm are referred to as
[1]. Barikanie et al. concluded from an in vitro study that wide-diameter implants [40]. Animal studies suggest a
primary stability increased significantly with implant larger diameter is associated with greater primary sta-
length. However, it should be noted that implant lengths bility [41–43]. Since stress is applied to the implant
between 10 and 16 mm were examined in this study [32]. shoulder, the implant diameter is considered the most
In contrast, Staedt et al. showed that different implant critical parameter for stress and load distribution [44,
lengths and diameters do not achieve significantly dif- 45]. Increasing the implant diameter increases both pri-
ferent primary stability parameters in dense bone [33]. mary stability, and functional surface area, contributing
Dense bone refers to bone tissue with a higher density to better load distribution. However, a considerable num-
and mineral content than other types of bone tissue. This ber of studies have shown that implants with reduced
type of bone is stronger and more resistant to fractures diameters can also develop sufficient primary stability
and different types of damage [34]. This article adopts the in reduced-quality bone. Rossa et al. reported similar
ITI Consensus definition of a short implant of ≤ 6 mm. results in their retrospective evaluation of failure rates
The ITI Consensus Report on the influence of implant in dental implants [46]. Accordingly, an increased prob-
length on clinical and patient-reported outcomes con- ability of early dental implant failure has been observed
cluded that short implants (≤ 6 mm) exhibit similar sur- with implants in the mandible—especially in the poste-
vival rates compared to longer implants after 1 to 5 years. rior part of the jaw. Contrary to this, a higher patient age,
Based on ten randomized-controlled studies, a mean a localization within the maxilla, and a greater implant
survival rate of 96% for short compared to 98% for longer length was associated with late dental implant failure.
implants over 1 to 5 years was calculated. Furthermore, Javed et al. assumed implant diameter to play a second-
prosthodontic restorations’ survival was comparable in ary role in implant survival and suspected the surface
both groups after 1 to 5 years of function. A meta-anal- quality to be much more relevant [11]. Among these are
ysis showed that, after a 1-, 5- and 10-year follow-up, retention sites or micro-threads at the implant shoulder,
short implants (≤ 6 mm) and longer implants (≥ 8.5 mm) which have led to better load distribution in the alveolar
showed no significant differences in survival rates even ridge [47]. Furthermore, Kämmerer et al. showed that
in the non-atrophic jaw without the need for bone aug- mini-implants could also achieve satisfactory results. The
mentation. However, the data regarding implant geom- strict reduction of insertion torque and the best possible
etry (length and diameter) are very heterogeneous [31, preparation of the bone were described as particularly
35]. The ITI Consensus Group recommends using short relevant [48]. Some studies attribute a lower survival rate
implants where bone grafting procedures are contraindi- to wide-diameter implants. In a meta-analysis, Lee et al.
cated/where the morbidity of such procedures should be confirm a promising 5-year survival rate for wide-diam-
avoided or to reduce treatment time. Furthermore, they eter implants. But to make a statement with strong evi-
may be indicated where the possibility of damaging adja- dence on this question, further high-quality studies are
cent structures, like the maxillary sinus, nerves, or other needed [41]. The data regarding the effect of the implant’s
implants, can be reduced. Implants longer than 6 mm diameter on the survival and success rate are heteroge-
should be preferred when placed without increased sur- nous [31, 49]. But the ITI Consensus Conference in 2018
gical risk [31]. In this context, not only the length of the reported similar survival rates of narrow implants with
implant itself should be considered. The ratio of crown a diameter of 2.5 mm and larger than standard diameter
length to implant length should also not be ignored. The implants [31]. Since the stress is concentrated around the
stress on the peri-implant must be considered, as this can implant neck, where bone loss occurs at an early stage, it
increase as the crown-to-implant ratio increases, espe- is now assumed that diameter becomes a more decisive
cially in the case of immediate loading concepts [36– factor as soon as implant length is sufficient. Particularly
38]. Three-dimensional finite-element analyses indicate in the posterior region, two complementary, unfavorable
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 6 of 11

conditions appear: on the one hand, masticatory forces Dental implants with a small pitch automatically have
are more than 300% higher than in other tooth regions, more threads per implant length and thus a greater
and on the other hand, the posterior region often pre- implant surface, which could result in a better load distri-
sents a comparably low bone quality in the maxilla. Con- bution [55–57]. These macro-design parameters are inter-
sidering this, conventional protocols based on increasing dependent, and all increase primary stability. A current
the surface area merely by changing the implant diameter systematic review states that the study situation on thread
are insufficient. While such a concept can only contrib- design is very heterogeneous. In summary, however, it was
ute to a 30% increase in surface area, up to a 300-fold found that higher bone–implant contact was found with
increase in surface area is possible by modifying the the mere presence of threads, with implants with a smaller
diameter and thread type [1]. pitch, with V-threads with implants with smaller thread
pitches (0.6 to 0.8 mm on average), and with a larger thread
How does the thread design affect primary stability? depth [12]. Especially aggressive self-tapping threads have
Threads increase bone–implant contact area, primary been reported to increase primary stability [58, 59].
stability, implant surface area, and better load distri-
bution [50]. Here, the thread design is a decisive factor Thread depth
for the initial mechanical primary stability and the sub- Threaded implants were initially developed to allow
sequent biological secondary stability of the implant greater compression of the cortical bone in sites of poor
[51–53]. Thread depth, width, pitch, face angle, and helix bone quality [61]. The thread depth is defined by the ratio
angle variations are possible (see Fig. 2). Thread shapes of the outer contour to the main body of the implant. It
include V-shaped, square, buttress, and helical designs. indicates the distance by which the coils protrude from
The insertion of fewer threaded implants was reported the main body of the implant. The longer this distance,
to be smoother, which could be an advantage in denser the more the surface and the load distribution increase
bone [54]. [20, 47]. Greater thread depths could be advantageous
due to the increased functional surface, especially with
softer bone and high occlusal forces, and increase primary
stability in these situations. Still, greater thread depths
may also reduce insertion accuracy [62–64]. The implant
design also comes up against biological limits here since,
with very deep threads, it is impossible to guarantee
adequate vascular supply to the bone that extends to the
thread’s root. With a considerable thread depth, it is,
therefore, advisable to pre-tap threads to avoid excessive
compressive stress on the surrounding bone [20, 47]. The
more threads an implant has and the deeper they are, the
greater the functional surface of the implant [1, 65]. Stud-
ies have shown implants with a progressive thread to have
a higher bone–implant contact area histomorphological
and radiologically compared to cylindrical designs and to
provide a higher primary stability [66].

Thread helix angle

The thread helix angle is defined as the angle between the
thread grind and the plane perpendicular to the longitu-
Fig. 2 Characteristics of the implant macro design. Thread helix dinal axis of the implant [60]. It defines the propulsion
angle: angle between the thread helix and the horizontal to the of the implant when it is inserted. The higher the thread
longitudinal axis of the implant. Apical face angle: angle between the helix angle, the fewer rotations the implant requires to
thread face and the horizontal to the longitudinal axis of the implant. insert it to its entire length. A a high thread helix angle
Pitch: distance between the center of a thread to the next thread
in the longitudinal axis of the implant or implant length divided by
can also lead to longitudinal rotation of the implant under
the number of threads. Thread depth: distance between the outer axial loading [20]. Finite element analysis has shown that
contour of the thread and the implant base body. Thread width: faster placement of multi-threaded implants is associated
distance between the most coronal and the most apical portion of with a higher implant failure rate [60]. There are systems
the same thread (Mod. according to [60]). Created with BioRender. without a thread helix angle and multiple threads availa-
com
ble, which differ primarily in the insertion technique [20].
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 7 of 11

In multi-threaded implants, more than one thread runs is the angle between the thread face and the horizontal to the
parallel to another thread. This configuration results in longitudinal axis of the implant. Each thread has an apical
faster implant placement. For example, double-threaded and coronal surface. Thread face angle is also directly related
implants cover twice as much insertion distance per rota- to thread form, with V-shaped threads having a face angle of
tion as single-threaded implants, with parameters of the 30 degrees, while reverse buttress threads have a face angle of
macro-design being otherwise equal. However, this seems just 15 degrees. This is why implants with a V-shaped thread
to come at the expense of primary stability [60, 67]. develop significantly more shear forces than implants with
a smaller face angle, which predisposes to defect formation
Thread width, thread shape and face angle
[60]. This thread face angle directly determines the direction
The thread width determines how the implant is guided of loading from the implant towards the surrounding bone
when inserted and largely depends on the thread’s shape [70] (see Fig. 3). A more than 0.8 mm pitch is considered
(see Fig. 2). V-shaped and wide square implants can cause ideal, and greater thread-to-thread spacing is associated with
significantly less stress on the cancellous bone than thin greater resistance to vertical loads [60].
square shapes. In cortical bone, no difference could be
detected. Under dynamic loading, bone density is highest Additional threads
directly under the whorl. This confirms the implicit cor- The use of smooth implant shoulders was originally used
relation between compressive load and bone density [60]. to reduce plaque accumulation when the crestal portion
With square and buttress threads, axial forces are mainly of the implant was placed above bone level (tissue-level
distributed as compressive forces. On the other hand, with implants). However, the problem with a smooth implant
V-shaped reverse buttress threads, axial forces will be con- shoulder is that putting it below bone level under shear
verted into shear and compressive forces. Using an ample stress can result in marginal bone loss with pocketing.
thread width often requires thread pre-cutting of the bone For this reason, implants with retentive elements and
cavity and also ensures easy implant guidance. The advan- threads around the implant shoulder were developed,
tage of thread cutting is a significant reduction in insertion leading to better integration in the cortical bone and,
torque. On the other hand, self-tapping implants often lead thus, a reduction in bone resorption [71]. In finite-ele-
to increased primary stability, especially in softer bone or ment analyses, this theory was confirmed by Abuhus-
fresh extraction sockets [20, 51]. Multiple cutting threads sein et al. [59], whereas ex vivo and in vivo studies show
could also provide higher primary stability in bone with low ambiguous data. It is still uncertain whether crestal-
density [68]. In addition, square threads seem advantageous located threads contribute better load distribution and
for the implant’s immediate loading [69]. A thread width thus to the desired preservation of crestal bone or its deg-
of 0.18–0.3 mm and a thread depth of 0.34–0.5 mm were radation [3]. In a systematic review, Lovatto et al. found
proven advantageous. The thread depth is more susceptible that such micro-threads protect hard and soft tissue
to stress maxima than the thread width [60]. The face angle [72]. However, a recent prospective, randomized, clini-
cally controlled, multicenter study found no differences
between machined tissue-level and roughened neck
bone-level implants regarding peri-implant bone loss,
peri-implantitis rate, implant survival rate, and hard and
soft tissue situation [73]. The original 1965 Branemark
implant had a V-shaped thread designed for better place-
ment within the pre-drilled osteotomy cavity. Threads
have come a long way since then. Implants are currently
being produced with double or triple threads, which slide
more quickly into the osteotomy cavity and are intended
to offer increased initial primary stability. Although their
advantage of faster insertion, double-threaded implants
with a higher lead angle may also cause bone tissue dam-
age because they need to be inserted with increased
torque [74]. Therefore, they are particularly indicated in
very soft bone. In addition, an extension of the thread
area up to the implant tip can lead to an increase in pri-
Fig. 3 Forces generated by axial loading of the implant at the
mary stability [75]. So far, despite many studies on the
bone–implant contact surface (Mod. according to [60]). Created with
BioRender.com different properties of the various thread types, there are
no meaningful comparative studies [1].
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 8 of 11

Conclusion suitable for immediate implant placement protocols

The shapes associated with high primary stability are and in the anterior region, as they show better load
conical, apical conical, and hybrid implants. With distribution and less bone perforation with thin buc-
increasing length, the contact surface to the surround- cal bone thickness. In the atrophic jaw, implants with a
ing bone and, thus, the primary stability rises linearly. reduced length and diameter are an alternative to aug-
This linear relationship between implant length and mentation procedures. With strict torque control and
primary stability ends at 12 mm. Conical implants are ideal bone preparation, good results can be expected
even under challenging situations. Combining short
implants with longer implants is recommended for
cases with low bone density and reduced alveolar ridge
height due to similar survival rates to increase implants’
success rates. Macrostructures associated with a high
effect on the bone-to-implant contact area and, thus,
on primary stability are diameter and thread. A high
thread depth seems advantageous when inserting with
expected high occlusal forces and low bone density.
V-shaped and square threads can reduce stress on the
bone, while square and crossed threads may reduce
compression. In addition, self-tapping threads can be
Fig. 4 Factors influencing primary implant stability. See the text for recommended to increase primary stability, especially
an explanation. [11, 46, 60]. Created with BioRender.com
in low-density bone (Fig. 4).

Fig. 5 Suggestion for the selection of implant macrogeometry according to the patient’s bone density. Created with BioRender.com
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 9 of 11

Limitations of the narrative review are the inconsist- University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Ham-
burg, Germany. 4 Department of Oral and Maxillofacial Surgery, Division
ency regarding the technical terms and the great hetero- of “Regenerative Orofacial Medicine”, University Medical Center Hamburg-
geneity of the included studies. Many studies assessing Eppendorf, Hamburg, Germany. 5 Department of Prosthetic Dentistry, Univer-
the effect of implant geometry on primary stability are sity Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany. 6 Private
Practice for Oral Surgery, Echterdinger Straße 7, 70794 Filderstadt, Germany.
ex vivo and finite-element analyses or retrospective clini-
cal studies. There is a lack of prospective clinical studies Received: 3 May 2023 Accepted: 21 June 2023
analyzing differences in implant macrogeometry regard-
ing primary stability and long-term success; therefore, no
conclusions can be drawn in this regard.
Figure 5 gives suggestions on the selection of the References
implant’s macrogeometry according to the patient’s bone 1. Steigenga JT, et al. Dental implant design and its relationship to long-
term implant success. Implant Dent. 2003;12(4):306–17.
density. Overall, implants should be chosen individually 2. Schiegnitz E, et al. Clinical long-term and patient-reported outcomes of
for each case. With many different implant designs, it dental implants in oral cancer patients. Int J Implant Dent. 2021;7(1):93.
is not always easy to decide. The experience of the sur- 3. Wilson TG Jr, et al. Tapered implants in dentistry: revitalizing concepts
with technology: a review. Adv Dent Res. 2016;28(1):4–9.
geon and how proficient he is with the respective implant 4. Gallucci GO, et al. Implant placement and loading protocols in partially
design are also important. An implant design that is ideal edentulous patients: a systematic review. Clin Oral Implants Res.
for the individual case does not bring any benefit if the 2018;29(Suppl 16):106–34.
5. Sakka S, Baroudi K, Nassani MZ. Factors associated with early and late
practitioner cannot deal with it in everyday life. There- failure of dental implants. J Investig Clin Dent. 2012;3(4):258–61.
fore, the patient’s local and systemic factors, the surgeon’s 6. Mustakim KR, et al. Guidance and rationale for the immediate implant
skill, and the technical possibilities must be considered. placement in the maxillary molar. J Korean Assoc Oral Maxillofac Surg.
2023;49(1):30–42.
In addition, the evidence for many parameters that define 7. Fettouh AIA, et al. Bone dimensional changes after flapless immediate
the dental implant macrodesign is often still very limited, implant placement with and without bone grafting: randomized clinical
as there is currently a lack of high-quality studies. trial. Clin Implant Dent Relat Res. 2023;25(2):271–83.
8. Chen J, et al. Accuracy of immediate dental implant placement with task-
Acknowledgements autonomous robotic system and navigation system: an in vitro study. Clin
Not applicable. Oral Implants Res. 2023. https://​doi.​org/​10.​1111/​clr.​14104.
9. Schnutenhaus S, Edelmann C, Rudolph H. Does the macro design of an
Author contributions implant affect the accuracy of template-guided implantation? A prospec-
Conceptualization: PWK, AP; RS, KS, and DH; methodology: PWK, DH, AP, KS, tive clinical study. Int J Implant Dent. 2021;7(1):42.
and RS; validation: PWK, AP, KS, and DH; formal analysis: DH and PB; resources: 10. Misch CE. Divisions of available bone in implant dentistry. Int J Oral
PWK, DH, PB, AP, AK, AH, KS, and RS; data curation: DH, PB, and PWK; writ- Implantol. 1990;7(1):9–17.
ing—original draft preparation: DH, PB, AP; writing—review and editing: DH, 11. Javed F, et al. Role of primary stability for successful osseointegration of
PB, AP, AH, AK, RS, KS, and PWK; visualization: DH; supervision: PWK, RS, and dental implants: factors of influence and evaluation. Interv Med Appl Sci.
AP; project administration: PWK, RS, DH, KS, and AP. All authors have read and 2013;5(4):162–7.
agreed to the published version of the manuscript. 12. Kreve S, et al. Relationship between dental implant macro-design and
osseointegration: a systematic review. Oral Maxillofac Surg. 2022. https://​
Funding doi.​org/​10.​1007/​s10006-​022-​01116-4.
Open Access funding enabled and organized by Projekt DEAL. 13. Lozano-Carrascal N, et al. Effect of implant macro-design on primary
stability: a prospective clinical study. Med Oral Patol Oral Cir Bucal.
Availability of data and materials 2016;21(2):e214–21.
The datasets generated and analyzed during the current study are available 14. Luke Yeo IS. Dental implants: enhancing biological response through
online and upon reasonable request from the relevant author. surface modifications. Dent Clin North Am. 2022;66(4):627–42.
15. Pabst A, et al. Osseointegration of a new, ultrahydrophilic and nanostruc-
tured dental implant surface: a comparative in vivo study. Biomedicines.
Declarations 2022;10(5):943.
16. Al-Johany SS, et al. Dental implant length and diameter: a proposed clas-
Ethics approval and consent to participate sification scheme. J Prosthodont. 2017;26(3):252–60.
Not applicable. 17. Al-Nawas B, et al. Comparative histomorphometry and resonance fre-
quency analysis of implants with moderately rough surfaces in a loaded
Consent for publication animal model. Clin Oral Implants Res. 2008;19(1):1–8.
Not applicable. 18. Kim JM, et al. A comparison of the implant stability among various
implant systems: clinical study. J Adv Prosthodont. 2009;1(1):31–6.
Competing interests 19. Righeso LAR, et al. Primärstabilität dentaler Implantate - Eine Übersi-
Andreas Pabst, Ralf Smeets, Diana Heimes, Keyvan Sagheb, Amely Hartmann chtsarbeit. Implantologie—Quintessence Publishing Deutschland, 2016:
and Peer W. Kämmerer received speaker fees and research support from Strau- p. 261–268.
mann AG, Camlog, and botiss biomaterials GmbH for different studies. This did 20. von See C. Bionische Anforderungen an das Implantatdesign moderner
not influence this study. Systeme. zwp online. 2015.
21. Wildenhof JIR. Retrospektive Analyse des Einflusses klinischer Parameter
Author details auf die Primärstabilität konischer Dentalimplantate. 2020.
1 22. Cehreli M, Sahin S, Akça K. Role of mechanical environment and implant
Department of Oral and Maxillofacial Surgery, University Medical Center
Mainz, Augustusplatz 2, 55131 Mainz, Germany. 2 Department of Oral design on bone tissue differentiation: current knowledge and future
and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacherstraße contexts. J Dent. 2004;32(2):123–32.
170, 56072 Koblenz, Germany. 3 Department of Oral and Maxillofacial Surgery, 23. Silva GAF, et al. Effect of macrogeometry and bone type on insertion
torque, primary stability, surface topography damage and titanium
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 10 of 11

release of dental implants during surgical insertion into artificial bone. J 50. Chien S-K, et al. Influence of thread design on dental implant osseoin-
Mech Behav Biomed Mater. 2021;119: 104515. tegration assayed using the Lan-Yu Mini-Pig model. J Med Biol Eng.
24. O’Sullivan D, Sennerby L, Meredith N. Influence of implant taper on the 2017;37(5):627–38.
primary and secondary stability of osseointegrated titanium implants. 51. Valente M, et al. Influence of an alternative implant design and surgical
Clin Oral Implants Res. 2004;15(4):474–80. protocol on primary stability. Braz Dent J. 2019;30(1):47–51.
25. Yamaguchi Y, et al. Effect of implant design on primary stability using 52. Soto-Peñaloza D, et al. Effect on osseointegration of two implant macro-
torque-time curves in artificial bone. Int J Implant Dent. 2015;1(1):21. designs: a histomorphometric analysis of bicortically installed implants in
26. Jimbo R, et al. The combined effects of undersized drilling and implant different topographic sites of rabbit’s tibiae. Med Oral Patol Oral Cir Bucal.
macrogeometry on bone healing around dental implants: an experimen- 2019;24(4):e502–10.
tal study. Int J Oral Maxillofac Surg. 2014;43(10):1269–75. 53. Vandamme K, et al. Influence of controlled immediate loading and
27. Jimbo R, et al. The impact of a modified cutting flute implant design on implant design on peri-implant bone formation. J Clin Periodontol.
osseointegration. Int J Oral Maxillofac Surg. 2014;43(7):883–8. 2007;34(2):172–81.
28. Elias CN, et al. Influence of implant shape, surface morphology, surgical 54. Misch CE, Degidi M. Five-year prospective study of immediate/early load-
technique and bone quality on the primary stability of dental implants. J ing of fixed prostheses in completely edentulous jaws with a bone qual-
Mech Behav Biomed Mater. 2012;16:169–80. ity-based implant system. Clin Implant Dent Relat Res. 2003;5(1):17–28.
29. Dard M, et al. Integrative performance analysis of a novel bone level 55. Ormianer Z, et al. Dental implant thread design and the consequences
tapered implant. Adv Dent Res. 2016;28(1):28–33. on long-term marginal bone loss. Implant Dent. 2016;25(4):471–7.
30. Valente M, et al. Comparative analysis of stress in a new proposal of 56. Chun HJ, et al. Evaluation of design parameters of osseointegrated dental
dental implants. Mater Sci Eng C Mater Biol Appl. 2017;77:360–5. implants using finite element analysis. J Oral Rehabil. 2002;29(6):565–74.
31. Jung RE, et al. Group 1 ITI Consensus Report: the influence of implant 57. Fuh LJ, et al. Biomechanical investigation of thread designs and inter-
length and design and medications on clinical and patient-reported face conditions of zirconia and titanium dental implants with bone:
outcomes. Clin Oral Implants Res. 2018;29(Suppl 16):69–77. three-dimensional numeric analysis. Int J Oral Maxillofac Implants.
32. Barikani H, et al. The effect of shape, length and diameter of implants 2013;28(2):e64-71.
on primary stability based on resonance frequency analysis. Dent Res J 58. Kan JY, Roe P, Rungcharassaeng K. Effects of implant morphology on
(Isfahan). 2014;11(1):87–91. rotational stability during immediate implant placement in the esthetic
33. Staedt H, et al. Implant primary stability depending on protocol and zone. Int J Oral Maxillofac Implants. 2015;30(3):667–70.
insertion mode—an ex vivo study. Int J Implant Dent. 2020;6(1):49. 59. Hsieh MC, Huang CH, Hsu ML. Effect of cutting flute design features on
34. Syed Z, Khan A. Bone densitometry: applications and limitations. J Obstet primary stability of immediate implant placement and restoration: a
Gynaecol Can. 2002;24(6):476–84. dynamic experimental analysis. Med Biol Eng Comput. 2022. https://​doi.​
35. Vazouras K, et al. Effect of time in function on the predictability org/​10.​1007/​s11517-​022-​02722-w.
of short dental implants (≤6 mm): a meta-analysis. J Oral Rehabil. 60. Abuhussein H, et al. The effect of thread pattern upon implant osseointe-
2020;47(3):403–15. gration. Clin Oral Implants Res. 2010;21(2):129–36.
36. Maminskas J, et al. The prosthetic influence and biomechanics on peri- 61. Al-Sabbagh M, Eldomiaty W, Khabbaz Y. Can osseointegra-
implant strain: a systematic literature review of finite element studies. J tion be achieved without primary stability? Dent Clin North Am.
Oral Maxillofac Res. 2016;7(3): e4. 2019;63(3):461–73.
37. Sotto-Maior BS, et al. Influence of crown-to-implant ratio, retention sys- 62. Lee SY, et al. The effect of the thread depth on the mechanical properties
tem, restorative material, and occlusal loading on stress concentrations in of the dental implant. J Adv Prosthodont. 2015;7(2):115–21.
single short implants. Int J Oral Maxillofac Implants. 2012;27(3):e13–8. 63. Song YW, et al. Does the fixture thread depth affect the accuracy of
38. Malchiodi L, et al. Influence of crown-implant ratio on implant success implant placement during fully guided immediate implant placement?:
rates and crestal bone levels: a 36-month follow-up prospective study. A human cadaver study. Clin Oral Implants Res. 2022. https://​doi.​org/​10.​
Clin Oral Implants Res. 2014;25(2):240–51. 1111/​clr.​14023.
39. Araki H, et al. Three-dimensional finite element analysis of extra short 64. Menini M, et al. Influence of implant thread morphology on primary
implants focusing on implant designs and materials. Int J Implant Dent. stability: a prospective clinical study. Biomed Res Int. 2020;2020:6974050.
2020;6(1):5. 65. Ibrahim A, et al. Relationship between Implant Geometry and Primary
40. Schiegnitz E, Al-Nawas B. Narrow-diameter implants: a systematic review Stability in Different Bony Defects and Variant Bone Densities: An In Vitro
and meta-analysis. Clin Oral Implants Res. 2018;29(Suppl 16):21–40. Study. Materials (Basel). 2020;13(19):4349.
41. Lee CT, et al. Survival analysis of wide dental implant: systematic review 66. Romanos G, et al. Comparison of histomorphometry and microradiogra-
and meta-analysis. Clin Oral Implants Res. 2016;27(10):1251–64. phy of different implant designs to assess primary implant stability. Clin
42. Ivanoff CJ, et al. Influence of implant diameters on the integration of Implant Dent Relat Res. 2020;22(3):373–9.
screw implants. An experimental study in rabbits. Int J Oral Maxillofac 67. Ma P, et al. Influence of helix angle and density on primary stability of
Surg. 1997;26(2):141–8. immediately loaded dental implants: three-dimensional finite element
43. Kido H, et al. Implant diameter and bone density: effect on initial stability analysis. Zhonghua Kou Qiang Yi Xue Za Zhi. 2007;42(10):618–21.
and pull-out resistance. J Oral Implantol. 1997;23(4):163–9. 68. Al-Tarawneh SK, Thalji G, Cooper LF. Macrogeometric differentiation of
44. Himmlova L, et al. Influence of implant length and diameter on stress dental implant primary stability: an in vitro study. Int J Oral Maxillofac
distribution: a finite element analysis. J Prosthet Dent. 2004;91(1):20–5. Implants. 2022;37(6):1110–8.
45. Anitua E, et al. Influence of implant length, diameter, and geometry on 69. Chang PK, et al. Distribution of micromotion in implants and alveolar
stress distribution: a finite element analysis. Int J Periodontics Restorative bone with different thread profiles in immediate loading: a finite element
Dent. 2010;30(1):89–95. study. Int J Oral Maxillofac Implants. 2012;27(6):e96-101.
46. Staedt H, et al. Potential risk factors for early and late dental implant 70. Tumedei M, et al. The influence of the implant macrogeometry on
failure: a retrospective clinical study on 9080 implants. Int J Implant Dent. insertion torque, removal torque, and periotest implant primary stabil-
2020;6(1):81. ity: a mechanical simulation on high-density artificial bone. Symmetry.
47. Jain N, et al. Short Implants: New Horizon in Implant Dentistry. J Clin 2021;13(5):776.
Diagn Res. 2016;10(9):ZE14-17. 71. Heinemann F, et al. Bone stability around dental implants: treatment
48. Kammerer PW, et al. Prospective clinical implementation of optional related factors. Ann Anat. 2015;199:3–8.
implant treatment into pregraduate dental education-mini implants for 72. Lovatto ST, et al. Influence of different implant geometry in clinical
retention and support of mandibular overdentures. Int J Implant Dent. longevity and maintenance of marginal bone: a systematic review. J
2021;7(1):87. Prosthodont. 2019;28(2):e713–21.
49. Renouard F, Nisand D. Impact of implant length and diameter on survival 73. Rothamel D, et al. Impact of machined versus structured implant shoul-
rates. Clin Oral Implants Res. 2006;17(Suppl 2):35–51. der designs on crestal bone level changes: a randomized, controlled,
multicenter study. Int J Implant Dent. 2022;8(1):31.
Heimes et al. International Journal of Implant Dentistry (2023) 9:20 Page 11 of 11

74. Yamaguchi Y, et al. Effects of implant thread design on primary stability-a

comparison between single- and double-threaded implants in an artifi-
cial bone model. Int J Implant Dent. 2020;6(1):42.
75. Staedt H, et al. Does the modification of the apical geometry of a dental
implant affect its primary stability? A comparative ex vivo study. Materials
(Basel). 2021;14(7):1728.

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