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Australian Dental Journal The official journal of the Australian Dental Association
Australian Dental Journal
The official journal of the Australian Dental Association

Australian Dental Journal 2016; 61: 208218

doi: 10.1111/adj.12337

Outcomes of placing short implants in the posterior mandible: a preliminary randomized controlled trial

AA Al-Hashedi,*TB Taiyeb-Ali,N Yunus§

*Department of Prosthodontic Dentistry, Sana’a University, Sana’a, Yemen. Department of Oral Biology and Biomedical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia. Professor, Department of Oral Biology and Biomedical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia. §Professor, Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.

ABSTRACT

Background: Short dental implants can be an alternative to bone augmentation procedures at sites of reduced alveolar bone. Most studies on short implants are retrospective or multicentre reports that lack controlled and consistent compar- ison between different systems. This study aimed to compare clinical and radiographic outcomes of short implants in two different systems in the posterior mandible. Methods: Twenty patients with two adjacent missing posterior teeth were recruited. Patients were assigned equally and ran- domly into two groups; Bicon (6 or 8 mm) and Ankylos (8 mm) implants. A two-stage surgical approach and single crowns were used for implant placement and loading. Outcomes included peri-implant clinical parameters, implant stability (Periotest values; PTVs) and peri-implant bone changes, which were assessed at baseline, 2, 6 and 12 months post-loading. Results: No implant loss was encountered up to 12 months post-loading. No significant difference in the clinical or radiographic parameters was observed except for PTVs (p < 0.05) that was lower in Ankylos implants. Conclusions: The use of short dental implants was associated with excellent 12 months clinical and radiographic outcomes. Ankylos and Bicon implants demonstrated similar peri-implant soft tissue and alveolar bone changes. However, Ankylos implants demonstrated better implant stability at all evaluation intervals.

Keywords: Ankylos , Bicon , implant stability, partial edentulism, short implants.

Abbreviations and acronyms: CAL = clinical attachment loss; CBCT = cone beam computed tomography; GI = Gingival Index; mBI = modified Bleeding Index; PD = Probing Depth; PI = Plaque Index; PTVs = Periotest values; RH = Recession Height; WKM = width of keratinized mucosa.

(Accepted for publication 2 May 2015.)

INTRODUCTION

Over the last decades, implant prostheses have been routinely used to rehabilitate partial and complete edentulous patients due to their biocompatibility and high survival rates. 1,2 However, in the posterior mand- ible with reduced alveolar bone height, implant length is further limited by the position of the inferior alveo- lar nerve. 3,4 From the biomechanical aspect, occlusal bite forces are significantly higher in the posterior region (500 N) compared to the anterior region (<100 N) of the mouth, 5 resulting in high occlusal overload that increases the risk of implant failure. Short dental implants can be used as an alternative to vertical bone augmentation procedures for conven- tional dental implants placement, 4,6 which are associ- ated with more complications and higher failure risk. 7,8 In addition, short implants may have the advantage of lower cost, morbidity and treatment time. 9

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Recent literature has demonstrated high success and survival rates when placing short implants in partially edentulous patients, probably due to the advancement in implant surfaces and design. 9 11 Gentile et al. 12 and Testori et al. 13 reported comparable survival rates of short and long implants, while Fugazzatto et al. 14 demonstrated 7-year cumulative survival rates between 98.1% and 99.7% of all implants shorter than 10 mm. However, the survival rates of placing short implants in the posterior maxilla or soft bone are somewhat lower. 15 The Bicon implant was the first short implant system introduced to the market with a favourable survival rate (92.2% 98.2%), 12,16 and the Ankylos implant system has an excellent and reliable clinical performance. 17,18 Both implant systems have rough (alumina blasted/acid etched) surfaces, platform switching and passive tapered connection designs that are associated with good long-term outcomes. 17 19

© 2016 Australian Dental Association

However, to our knowledge, to date no randomized controlled trial has compared the clinical and radio- graphic outcomes of Ankylos short implants to other short implants for rehabilitation of posterior mand- ible. Most of the reported studies were retrospective or multicentre prospective studies that lacked consis- tency and a controlled comparison environment, and the short implants were mainly splinted to longer implants. 10,11,20 Moreover, no studies have evaluated the predict- ability and success of two adjacent single implants in the posterior mandible. Therefore, the aim of this prospective randomized controlled study was to com- pare the clinical and radiographic outcomes of placing two adjacent short implants from two different sys- tems in the posterior mandibular edentulous ridge.

MATERIALS AND METHODS

This study was conducted as a randomized controlled trial to compare the clinical and radiographic outcomes of two different implant systems: Bicon (Bicon LLC, Boston, MA, USA) and Ankylos (Friadent GmbH, Mannheim, Germany). The study was approved by the Ethical Board Committee of the Faculty of Dentistry at the University of Malaya [DF PE0902/0028(P)] and conformed with the provisions of the Declaration of Helsinki.

Patient selection

Of the 60 patients screened at the Department of Restorative Dentistry from 2009 to 2011, 20 fulfilled the selection criteria and were recruited to the study (Table 1). Participants attended prosthodontic and surgical consultations and were asked to sign an informed consent form prior to the start of treatment. A sample size (20 subjects; 40 implants in total) was calculated before starting the study to give a power of 80% (alpha, two-tailed, was set at 0.05) using power and sample size calculations software (Version 3.0, January 2009; Vanderbilt University’s Clinical and Translational Science Award [CTSA] programme). Calculations were made based on the clinical and radiographic results of other studies, 21,22 assuming that the first-year crestal bone loss was less than 1 mm. The study power was calculated again after analysing the study data, based on the difference in bone level between two consecutive measurements and was found to be 76% with the same software.

Preoperative preparation and assessments

Dental and periodontal examinations included evalua- tion of plaque deposits, gingivitis and probing level depths, and radiographic bone levels of all remaining

© 2016 Australian Dental Association

Two adjacent short implants in posterior mandible

Table 1. Details of inclusion and exclusion criteria of patients who participated in the study

Inclusion criteria

  • 1. Adequate bone dimensions to place an implant of at least 3.5 mm in diameter and 8 mm in length.

  • 2. The presence of unilateral two adjacent missing mandibular posterior teeth.

  • 3. The opposing arch is fully dentate or completely restored with fixed prostheses.

  • 4. Aged 25 years or older.

  • 5. Absence or elimination of periodontal diseases with controlled oral hygiene.

  • 6. Good general health status.

Exclusion criteria

  • 1. Insufficient alveolar bone dimensions that restrict the placement of at least 6 mm (in length) implants and/or require ridge augmentation procedure.

  • 2. Severe intermaxillary skeletal discrepancy.

  • 3. Bruxism or TMJ dysfunction.

  • 4. Smoking, drug or alcohol abuse.

  • 5. Radiotherapy to the head and neck region for malignancy.

  • 6. Systemic uncontrolled disease or patients under the medication of intravenous bisphosphonate.

  • 7. Immunocompromised state, including HIV.

  • 8. Pregnancy.

teeth were measured. If any dental or periodontal treatment was indicated, it was performed at this stage. A panoramic radiograph (OPG) was taken for each patient and served as reference for the primary investigation of the general status of dentition and periodontium. Periapical radiographs (PA) were also taken for the implant sites to show any abnormalities. The implant length and width for each patient were evaluated through the use of cone beam computed tomography (CBCT) scans and I-CAT 3 dimensional dental imaging system (Imaging Sciences International, Hatfield, PA, USA). Simplant software (Simplant R; Materialise, Leuven, Belgium) was used to assess the ridge angulation and to measure the thickness and density of the alveolar bone following the classifica- tion of Misch. 23 Block randomization was used to generate a random sequence of allocation for the study parallel groups. Patients were allocated to each group based on the random sequence list and the enrolment time. Operator and patient blinding was not employed in this study. The allocated implant system was disclosed to patients for ethical reasons and to the surgeon/ operator in order to follow the specific surgical and restorative protocols of each system. Twenty participants were assigned randomly into two equal groups. Bicon short implants with Inte- gra-Ti TM surface were used in the first group (n = 10 patients; 20 implants) while the second group (n = 10 patients; 20 implants) received Ankylos short implants with Friadent plus surface. All implants were of the same dimensions (8 mm length 9 3.5 mm diameter) except two Bicon implants that were of

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6 mm length 9 4.5 mm diameter due to the limited alveolar bone height at the recipient sites.

Surgical procedures

Implant surgery was performed following the manu- facturer’s surgical protocol for each implant system. The original Br anemark et al. 24 two-stage surgical technique with unloaded healing time of 23 months was implemented in all implantations to ensure the success of osseointegration. The first-implant surgery was performed at least 45 months after extraction or in a healed socket with local anaesthesia (an infiltration of 2% Ligno- caine hydrochloride monohydrate with 1:100 000 epi- nephrine acid tartrate; Duopharma Biotech, Selangor, Malaysia). A horizontal mid-crestal incision and two releasing incisions were made at the sites of implant placement. The design of the incision was mostly trapezoidal, resulting in a flap which was wider at the base in an attempt to provide optimal vascular circu- lation. Full-thickness flaps were then reflected expos- ing the alveolar ridge. Implant sites for the Ankylos and Bicon implants were prepared with preparation drills while keeping a distance of 3 mm between the two adjacent implants. Implants were placed in a position so that the shoul- der of the implant was about 11.5 mm below the crestal bone level in accordance with the manufactur- ers’ protocols. After implant insertion, the flap edges were approximated and secured with simple inter- rupted sutures (4.0 silk suture, SupramidR; Novaxa Spa, Milan, Italy).

Postoperative protocol and follow-up

All patients received: (1) oral antibiotics for one week (Doxycycline 100 mg; Pharmaniaga Manufacturing Berhad, Selangor, Malaysia) twice a day; (2) non- steroidal analgesics for 12 days (Arcoxia 90 mg; Merck Sharp & Dohme Sdn Bhd, Petaling Jaya, Malaysia) once a day; (3) detailed instructions for dental plaque control with chlorhexidine gluconate mouthrinse (Chlorhexidine 0.12%; Oral B, Boston, MA, USA) twice daily for 710 days; and (4) Gen- gigel gel 20 ml (Ricerfarma Srl, Milano, Italy) over the wound, 34 times daily for 7 days. Postopera- tive home care instructions included a soft diet and discontinuing toothbrushing for 12 weeks to avoid trauma or pressure at the surgical site. Sutures were removed 814 days after surgery. Patients were recalled after 23 months to check the implants and bone healing using standardized digi- tal periapical radiographs. A customized film holder was fabricated for each patient using a self-cured acrylic template to ensure reproducibility of

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radiographic positioning. The second-stage implant surgery was conducted under local anaesthesia to open the gum tissue and gain access to the underlying implants. The healing abutments (3.55.0 mm in diameter) were then attached to the implants.

Prosthetic procedures

Three weeks following the second-stage surgery, implants were restored using the prosthetic protocol recommended by the manufacturer of each system. For Bicon implants, a closed-tray technique with transfer posts was used while an open-tray technique with transfer posts and pins was employed for Anky- los implants. Impressions were taken with polyether impression material (Impregum TM Polyether; 3M ESPE, St Paul, MN, USA) and occlusion was regis- tered with vinyl polysiloxane (VPS) bite registration material (Exabite TM II NDS; GC America Inc.). Ankylos abutments were connected to the implants with internal screws to a final torque of 15 N/cm and the metal ceramic crowns were cemen- ted using temporary non-eugenol zinc oxide cement (Temp-Bond; Kerr Corporation, Romulus, MI, USA). For Bicon implants, the crowns were cemented to the abutments extraorally using zinc polycarboxylate cement (Poly-F Plus; Dentsply) and the crown/abut- ment assembly was then inserted into their specified place to engage the locking taper of the implant, before gently tapping the custom-made seating jig and underlying crown (Figs. 1 and 2). For both implant systems, post-loading standardized digital periapical radiographs were then taken for baseline record, and to ensure the crown seating and excess cement removal. The concept of crown non-splinting was applied in this study to: (1) avoid risking the entire prosthesis if one implant or crown is compromised; (2) minimize component loosening and/or fracture when the mand- ible undergoes flexure and torsion during function; 25 (3) optimize aesthetics, especially for patient’s with missing premolars; (4) overcome the problem of floss- ing and maintaining good oral hygiene difficulties that are usually experienced with splinted restorations. To accommodate the high occlusal load in the poste- rior mandible, loading recommendations proposed in previous short implant studies 10,26,27 such as narrow occlusal table, anterior incisal guidance, no lateral forces and cantilevers avoidance were considered. In addition, a computerized occlusal analysis system (T-Scan III , Tekscan Inc., Boston, MA, USA) was used to evaluate and adjust the occlusal interference. This system provides information about the distribu- tion of forces between the two halves of the arch, the pattern of the contacts and the corresponding forces over time. Therefore, occlusal adjustment was made

© 2016 Australian Dental Association

Two adjacent short implants in posterior mandible

(a) (b) (c) (d)
(a)
(b)
(c)
(d)

Fig. 1 Representative case of a patient treated with two adjacent individual short Ankylos implants. (a) Abutments after nal tightening of implants in place. (b) Occlusal view of the crowns after cementation. (c) Periapical standardized radiograph shows implant/crown assemblies at baseline. (d) Periapical standardized radiograph shows implant/crown assemblies at 12 months post-loading.

(a) (b) (c) (d)
(a)
(b)
(c)
(d)

Fig. 2 Representative case of a patient treated with two adjacent individual short Bicon implants. (a) Try-in of abutment/implant assemblies for accuracy of t. (b) Occlusal view of the crowns after cementation. (c) Periapical standardized radiograph shows implants/crowns assemblies at baseline. (d) Periapical standardized radiograph shows implant/crown assemblies at 12 months post-loading.

© 2016 Australian Dental Association

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with the data obtained from the scan until the occlu- sal forces were evenly distributed to the implant crowns and the rest of the remaining natural teeth. 28 Oral hygiene instructions were reinforced to the patients.

Implant evaluation

Each implant was evaluated clinically and radiograph- ically by one examiner (first author) after crown installation (baseline), 2, 6, 12 months post-loading. Reproducibility was assessed prior to the commence- ment of the study. Intra-examiner reproducibility was performed by periodontal/clinical examination on:

(1) eight patients with 104 sites to test the reliability for Plaque Index (PI), Gingival Index (GI), Prob- ing Depth (PD), modified Bleeding Index (mBI) and clinical attachment loss (CAL); (2) eight patients with 52 sites to test the reliability for width of keratinized mucosa (WKM) and recession height (RH); and (3) twelve patients with 45 teeth to test the reliabil- ity for tooth mobility (PTVs) values. For radiographic measurements, the reproducibility measurements were performed on the DBSWIN soft- ware window around eight implants with 24 sites to measure the marginal bone height mesially, distally and implant length. Repeated relevant mea- surements on a particular subject or site were performed with a time interval of 12 hours after completion of the first examination to minimize examiner memory recollection of the previous recordings. Intra-examiner reproducibility results were consis- tent for all clinical and radiographic measurements, kappa (0.800.88), intra-class correlation coefficient (0.800.96) and Cronbach’s a (0.860.99) tests.

Evaluation of implant survival

The implants success was assessed with the Health Scale for Dental Implants (Table 2; International Congress of Oral Implantologists (ICOI), Pisa, Italy, Consensus Conference, 2007). 29 This scale categorized implants into appropriate groups of successful, survival or failed based on the criteria derived from the following clinical and radiographic evaluations:

(1) Presence or absence of pain or suppuration, as reported by the patients or detected during the periodic clinical examinations. (2) Plaque Index, 30 Gingival Index 31 and Probing Depth in millimetres 32 measured to the nearest 1 mm by using a calibrated periodontal probe (UNC 15; Hu-Friedy, Chicago, IL, USA) and modified Bleeding Index, 32,33 with a given time

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Table 2. Implant success evaluation criteria according to the Health Scale for Dental Implants as classied by Misch et al. 38

Implant Quality

Clinical conditions

Prognosis

Scale Group

I. Success

(a)

No pain or tenderness

Very good to

(optimum

upon function.

excellent.

health)

(b)

0 mobility.

(c)

<2 mm radiographic bone loss.

(d)

No exudates history.

II. Satisfactory

(a)

No pain on function.

Good to very

survival

(b)

0 mobility.

good, depending

(c)

24 mm radiographic bone loss.

on the stable condition of the

(d)

No exudates history.

crestal bone.

III. Compromised

(a)

May have sensitivity

Good to guarded,

survival

on function.

depending on the

(b)

No mobility.

ability to reduce

(c)

Radiographic bone

and control

loss >4 mm (less than

stress.

1/2 implant length).

(d)

Probing depth >7 mm.

(e)

May have exudates history.

IV. Failure

Any of following:

Failure in all

(clinical or

(a)

Pain on function.

statistical data.

absolute failure)

(b)

Mobility.

(c)

Radiographic bone

loss >1/2 implant length.

(d)

Uncontrolled exudates.

(e)

No longer in the mouth.

lapse of 30 seconds between probing and scoring, were determined on mesial, distal, buccal and lingual surfaces of each implant. Averages of the four obtained values of each implant were calcu- lated and considered as the index value. 34 (3) Recession height was measured as the distance from the abutment finish line (abutment/crown junction) to the gingival margin. The width of the keratinized mucosa was measured as the distance from the gingival margin to the mucogin- gival junction. 34 All readings were assessed in millimetres at the mid-facial and mid-lingual aspects of each implant. (4) Clinical attachment level was calculated by summing the values of the recession height and probing depth at the facial and lingual surfaces of each implant. (5) Implant stability was assessed by means of Peri- otest (Periotest M Instrument, Medizintechnik Gulden e.K. Modautal, Germany). It has the advantages of rapid, safe and non-invasive mea- surement 35 that are useful for long-term implant follow-up. The measurements were performed by positioning the device perpendicular to the long

axis of the implant within a distance

of 0.6 to 2

mm from the crown facial surface. The assess- ment was repeated until the Periotest recorded

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almost two similar successive measurements. The measurements were identified as implants Peri- otest values (PTVs) and classified according to the manufacturer’s guide as follows: 0.8 to 0:

good osseointegration, the implant is well inte- grated and pressure can be applied to it; +1 to +9: a clinical examination is required, the appli- cation of pressure on the implant is generally not possible; +10 to +50: osseointegration is insuffi- cient and no pressure should be applied on the implant. (6) Radiographic peri-implant bone changes were measured on standardized digital intraoral peri- apical radiographs (RVG, Trophy Radiology, Inc., Marietta, GA, USA) at the mesial and distal surfaces of each implant. Intraoral radiographs were taken with a long cone paralleling tech- nique (70 kV, 6 mA and 0.160 seconds). The radiographs were scanned (VistaScan scanner,

Durr

Dental AG, Germany) with an effective

resolution of 22 lp/mm (1100 dpi) and images were digitized by using imaging software (Durr Dental AG, Bietigheim-Bissingen, Germany). The marginal bone level was determined by measuring the linear distance from the implantabutment interface to the point of the first visible bone-to- implant contact. 36 Both the mesial and distal implant sites were measured separately and an average value was calculated. Marginal bone changes were calculated as the difference between the last measurement (6 or 12 months) and the first (baseline) measurement for each implant. Negative values indicated bone loss and positive values indicated bone gain. (7) Crown-to-implant ratio (C/I) was determined by dividing the crown length to the implant length for all implants and then averaged. The crown length was measured from the highest point of the crown to the implant shoulder and the implant length from the implant shoulder to its apex, then ratios were calculated. For descriptive analysis, the C/I ratios were further categorized into two groups: C/I ratio 1 and C/I ratio >1. In order to correct the dimensional distortion of radiographic data, the accuracy of the radiograph measurements was achieved by measuring the implant width or height on the image and by using the known dimensions as a standard to cal- ibrate the software measuring tools before each measurement. (8) Occlusal parameters included the relative maximum biting force and occlusion time were measured at 2, 6 and 12 months to evaluate changes in occlusal force balance over the obser- vation time using T-Scan III system 28 following

the manufacturer’s protocol.

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Two adjacent short implants in posterior mandible

Statistical analysis

Data were analysed with the SPSS programme (IBM SPSS Statistics 20, Statistical Packages for Social Science, New York, USA). ShapiroWilk test and mea- sures of skewness were used to determine the normality of distribution of all clinical and radiographic data. A p-value of <0.05 was set to represent a statistically sig- nificant difference between different groups and inter- vals. Friedman, repeated measures ANOVA, Wilcoxon signed-rank and paired sample t-tests with Bonferroni correction for multiple comparisons were applied to compare different observation intervals, while MannWhitney and chi-square were used to evaluate differ- ences between the two study groups at each observa- tion interval. A univariate model was used to evaluate the influence of some variables such as implant system, length and C/I ratio on bone changes.

RESULTS

Twenty healthy participants (6 males and 14 females) with a mean age of 47.1 years 12.97 (25 to 70 years) at baseline were enrolled in this study. The two implant groups were homogenous in relation to all demographic variables except for gender. A higher number of females (n = 14) was allocated to the Bicon group due to the employed block randomiza- tion. A total of 40 (20/group) short implants were placed and reviewed for at least 12 months post-loading without dropout cases or implant loss (Table 3). All implants in the present study were in the success category according to the Health Scale for Dental Implants for up to 12 months of follow-up (Table 2). A survival rate of 100% was recorded based on clini- cal and radiographic assessments.

Peri-implant clinical and radiographic outcomes

Table 4 shows the comparison of the clinical parameters at various time intervals between the two implant groups. There was no significant difference for most clinical parameters except for PI at baseline (p < 0.01) and 2 months (p = 0.01), and for PTVs at all intervals. The PTV score of Ankylos implants (2.19 2.23) was significantly lower (p < 0.001) than the Bicon implants (1.09 2.83) at 12 months post-loading, indicating better stability in the Ankylos group. Bone levels were significantly lower in Bicon implants at both baseline and 12 months compared to Ankylos ; however, the bone changes were not statistically different. Within each implant group, there were no significant changes in the clinical parameters over time except for the PTV scores (p = 0.01 for the Bicon group and p = 0.04 for the Ankylos group). Ankylos implants demonstrated a bone loss of –0.08 mm 0.38 at

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Table 3. Demographic data of Ankylos and Bicon patients/implant at baseline

Variable

Group

Bicon Patients/implants n (%)

Ankylos Patients/implants n (%)

Total

P value*

Gender

Male

1 (10%)

5 (50%)

6

0.01

Female

9 (90%)

5 (50%)

14

Age group (Years)

2544

5 (50%)

6 (60%)

11

0.7

4570

5 (50%)

4 (40%)

9

Bone quality (Hounsfield units)

D1

0 (0%)

2 (10%)

2

0.04 Min Exp

D2

8 (40%)

3 (15%)

11

count = 1

D3

12 (60%)

11 (55%)

23

D4

0 (0%)

4 (20%)

4

Implant location

Premolar

2 (10%)

0 (0%)

2

0.07

Molar

18 (90%)

20 (100%)

38

Arch side

Right

6 (31.6%)

10 (50%)

16

0.3

Left

14 (68.4%)

10 (50%)

24

Abutment diameter (mm)

3.54.9

6 (30%)

7 (35%)

13

0.9

56.5

14 (70%)

13 (65%)

27

Abutment angulation (˚)

0

17 (85%)

15 (75%)

32

0.043 Min Exp

7.5

0 (0%)

1 (5%)

1

count = 0.50

10

3 (15%)

0 (0%)

3

15

0 (0%)

4 (20%)

4

Crown/Implant ratio

1

4 (20%)

1 (5%)

5

0.1

>1

16 (80%)

19 (95%)

35

* Indicates between implant groups significant difference (p 0.05) based on chi-square test.

6-month intervals. However, at 12 months post-

loading a significant bone gain of

0.04 mm

0.33

was reported (p = 0.03). Bicon implants demon-

strated a bone gain of 0.07 mm 0.37 at 6 months

and

0.12

mm

0.40 at 12 months post-

loading but this bone change was not significant (p =

0.3). The crown-to-implant ratio was comparable in

both implant groups (1.4:1 0.21).

The univariate model analysis based on bone

changes at 6 and 12 months showed no detectable

effect on bone with different implant systems (p =

0.44 and 0.17), implant length (p = 0.63 and 0.59) or

C/I ratio (p = 0.76 and 0.66), respectively.

Digital occlusal analysis showed no significant

changes in relative maximum biting force and

occlusion time between initial baseline and 12 months

records for both implant groups (Fig. 3).

Surgical and prosthetic complications

Satisfactory clinical and radiographic outcomes were

recorded over time with no noticeable signs or

symptoms of biologic complications or unusual

radiographic findings. In relation to technical compli-

cations, one case of abutment loosening in each

implant group (two in total), and two cases of crown

loosening were recorded in the Ankylos group. These

complications were easily managed in the same visit

without recurrence, indicating minimal postoperative

complications in both implant groups.

DISCUSSION

The present preliminary randomized controlled trial

evaluated and compared the success outcomes of

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placing two adjacent short implants (8 mm length) of

two different systems, loaded with single crowns in

the posterior mandible. The clinical and radiographic

implant outcomes of the two study groups were

comparable and consistent with those reported in pre-

vious clinical studies on short implants, 11 with no

recorded implant failure up to 12 months post-loading.

First-year outcomes have been reported to be crucial

for the success of short implants. 16,37 Indeed, the

reported 100% one-year success rate in the present

study provided evidence on the short-term high

predictability of using short implants for partial reha-

bilitation of the posterior mandible. This finding is

consistent with the results of previous short implant

studies that reported survival/success rates ranging

from 99% to 100%, 11,16,38 and is higher than that

reported in other studies. 12,21 This high success rate

may be attributed to implementing strict surgical and

restorative protocols, appropriate patient selection,

careful evaluation of the subject’s clinical history and

accompanied radiologic evaluation. Careful treatment

planning including periodontal and restorative treat-

ments before implant placement to ensure periodontal

health, careful adjustment and monitoring of the occlu-

sion using the T-Scan system may also be contributing

factors.

The results showed healthy tissue and good oral

hygiene that could be attributed to proper patient

compliance with oral hygiene instructions and the

reinforcement of oral hygiene in each follow-up visit.

Our results are in agreement with that reported in

single-tooth implants studies. 39,40

Periotest values indicated satisfactory osseointegra-

tion and the overall decrease in PTVs over time

indicated positive development of implant stability in

© 2016 Australian Dental Association

Two adjacent short implants in posterior mandible

Table 4. Mean ( standard deviation) and median (Quartiles) values of the clinical and radiographic parameters

of Ankylos (n = 20) and Bicon (n = 20) short implants at different observation intervals

Parameter

Implant system

Baseline n = 40 Mean (SD) Median (IQR)

2 months n = 40 Mean (SD) Median (IQR)

6 months n = 40 Mean (SD) Median (IQR)

12 months n = 40 Mean (SD) Median (IQR)

p** value

PI

GI

CAL (mm)

PD (mm)

mBI

RH (mm)

WKM (mm)

PTVs

Bone level (mm)

Bone change (mm)

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

Ankylos

Bicon

p* value

0.60 (0.29)

0.50

(0.0,0.50)

0.29 (0.27)

0.25

0.00

(0.0,0.5)

0.28 (0.44)

0.0

(0.0,0.0)

0.25 (0.08)

0.0

(0.0,0.0)

0.08

1.98 (0.45)

2.0

(1.75,2.25)

1.98 (0.56)

1.88

0.65

(1.66,2.19)

1.89 (0.37)

2.0

(1.56,2.00)

1.98 (0.51)

2.0

(1.66,2.19)

0.82

0.30 (0.37)

0.25

(0.0,0.50)

0.41 (0.48)

0.25

0.63

(0.0,0.94)

0.18 (0.37)

0.0

(0.0,0.0)

0.03 (0.11)

0.0

(0.0,0.0)

0.14

3.15 (1.06)

3.0

(2.5,3.88)

2.48 (0.95)

2.5

(2.0,3.0)

0.07

-1.61 (2.02)

-1.95 (-3.,-1)

2.15 (2.52)

2.1

(0.23,3.5)

<0.001

2.038 0.62

2.727 1.14

0.02

-

-

-

0.48 (0.42)

0.50 (0.0,0.25)

0.15 (0.31)

0.0 (0.0,0.25)

0.01

0.0 (0.0)

0.0 (0.0,0.0)

0.04 (0.12)

0.0 (0.0,0.0)

0.15

1.95 (0.36)

1.83 (1.75,2.00)

2.16 (0.52)

2.19 (1.75,2.5)

0.12

1.92 (0.29)

1.83 (1.75,2.00)

2.11 (0.50)

2.19 (1.75,2.5)

0.13

0.26 (0.34)

0.25 (0.0,0.25)

0.64 (0.66)

0.38 (0.0,1.25)

0.10

0.10 (0.31)

0.0 (0.0,0.0)

0.08 (0.18)

0.0 (0.0,0.0)

0.74

3.10 (1.10)

3.0 (2.5,3.88)

2.43 (0.89)

2.5 (2.0,3.0)

0.06

-1.80 (1.96) a -2.1 (-3.17,-0.9) 2.23 (2.33) a

2.35 (0.80,3.35)

<0.001

-

-

-

-

-

0.43 (0.36)

0.38 (0.0,0.25)

0.15 (0.31)

0.13 (0.0,0.25)

0.07

0.0 (0.0)

0.0 (0.0,0.0)

0.04 (0.06)

0.0 (0.0,0.0)

0.32

2.06 (0.24)

2.0 (2.00,2.25)

2.16 (0.49)

2.25 (1.75,2.5)

0.30

1.98 (0.16)

2.0 (2.00,2.00)

2.11 (0.41)

2.0 (1.75,2.5)

0.28

0.22 (0.29)

0.0 (0.0,0.50)

0.64 (0.39)

0.25 (0.0,0.5)

0.45

0.15 (0.33)

0.0 (0.0,0.0)

0.13 (0.32)

0.0 (0.0,0.0)

0.71

3.0 (1.20)

3.0 (2.13,3.88)

2.45 (0.99)

2.5 (2.0,3.0)

0.17

-2.0 (2.03)

-2.1 (-3.7,-0.7)

2.01 (2.55)

b

2.1 (0.30,3.33)

<0.001

2.117 0.47 2.655 1.14

0.06

-0.08 0.38 0.073 0.37

0.209

0.50 (0.32)

0.50 (0.0,0.69)

0.44 (0.61)

0.25 (0.0,0.69)

0.12

0.10 (0.31)

0.0 (0.0,0.0)

0.04 (0.12)

0.0 (0.0,0.0)

0.91

2.03 (0.22)

2.0 (2.00,2.19)

2.1 (0.52)

2.0 (1.81,2.0)

0.45

2.0 (0.21)

2.0 (2.00,2.00)

2.02 (0.46)

2.0 (1.81,2.25)

0.58

0.15 (0.24)

0.0 (0.0,0.25)

0.25 (0.34)

0.0 (0.0.0,0.5)

0.41

0.13 (0.26)

0.0 (0.0,0.19)

0.15 (0.33)

0.0 (0.0,0.0)

0.85

3.0 (1.18)

3.0 (2.0,3.88)

2.45 (0.99)

2.5 (2.0,3.0)

0.19

-2.19 (2.23) a -2.45 (-4,-0.8)

1.09 (2.83)

ab

0.85 (0.1,2.15)

<0.001

2.00 0.42 2.607 1.18

0.04

0.035 0.33 0.120 0.40

0.467

0.59

0.07

0.007

0.91

0.23

0.20

0.31

0.27

0.48

0.13

0.64

0.51

0.009

0.73

0.04

0.01

0.27

0.28

0.03

0.30

PI = Plaque Index; GI = Gingival Index; CAL = clinical attachment loss; PD = Probing Depth; mBI = modified Bleeding Index; RH = recession height; WKM = width of keratinized mucosa; PTVs = Periotest values; Bone change from baseline. *Between groups significant difference based on Mann-Whitney and Independent samples t-tests(p < 0.05); **Within group significant difference over time based on Friedman, repeated measures ANOVA and paired sample t-tests(p < 0.05); same superscripts indicate significant difference based on Wilcoxon signed-rank (p 0.01).

all implants. This could be explained by maturation

and remodelling of the surrounding bone through the

process of osseointegration during the first year of fol-

low-up. 41 A significant difference in PTVs between the

two implant groups was noted, although there was no

significant difference in bone quality at the time of

implant surgery. The difference in the implant design

and surface condition, especially thread geometry,

might explain this finding. 42 The Ankylos implant

has a special thread design in which the thread depth

© 2016 Australian Dental Association

increases gradually towards the apex, which helps to

distribute occlusal forces towards the flexible spongy

bone and provides simultaneous load relief at the cre-

stal bone region. 43 In contrast, the Bicon implant

has a fin or plateau root form design that offers at

least 30% more surface area than a screw implant of

the same dimensions and allows for faster cortical-like

bone formation among the fins of the implant. 44,45

Radiographic assessment showed that the average

bone level was significantly different between the two

215

AA Al-Hashedi et al.

(a) (b)
(a)
(b)

Fig. 3 Occlusal parameters comparison between Ankylos and Bicon implants at different observation intervals. (a) Line chart shows the percentage of maximum biting force. (b) Line chart shows the occlusion time (in seconds) as recorded by the T-Scan III system. *Indicates the signicant difference between the two groups at p < 0.05.

implant systems at both baseline and 12 months. This

could be explained by the fact that Bicon implants

were placed subcrestally at lower levels (1.5 mm) than

Ankylos implants (0.51 mm) in accordance with the

manufacturers’ instructions. Consequently, Ankylos

implants demonstrated a marginal bone loss at 6

months post-loading in comparison to its level at

baseline, and a significant marginal bone gain at 12

months of follow-up. However, in Bicon implants there

was a bone gain at both 6 and 12 months of follow-up.

The bone changes in the present study concurred

with other reports on short implants 16,46 and could be

ascribed to several factors: (1) the surface characteris-

tics of the investigated implants; 47 (2) the platform

switching design of the abutments of both implant

systems; 48 (3) meticulous occlusal analysis and adjust-

ment conducted at baseline and subsequent reviews;

and (4) the shape of the implant neck the Bicon

implant has the optimal neck design in favour of

crestal bone preservation (rocket-shape design) while

the Ankylos implant has the satisfactory cylindrical

neck design. 49,50

216

The crown-to-implant ratio (C/I) in the present

study was comparable in the two implant groups and

within the acceptable ratio (up to 4.95) that has no

effect on crestal bone loss or failure rate. 51,52 How-

ever, most recent studies reported no significant asso-

ciation between C/I ratio and marginal bone loss,

regardless of the type of prosthetic rehabilitation. 53

The present study results support this finding by indi-

cating that C/I ratio did not influence the marginal

bone change.

A constant occlusal force and normal occlusion

time (0.2 seconds) were ensured and maintained for

all patients, up to 12 months of follow-up. These

results suggested that the implants in our study shared

the load equally with natural teeth and the bite was

balanced in all cases. 54,55

The maximum biting force and occlusion time were

also comparable between the two implant groups,

which might be explained by employing similar pros-

thesis design and occlusal adjustment protocols to all

implant-crowns. It could also suggest that the type of

implant has no significant influence on the magnitude

of the occlusal forces.

Postoperative complications were mainly prosthetic

in nature, abutment and crown loosening. One

recorded event of abutment loosening in each implant

group (two events in total) was encountered at the

baseline visit. It could have resulted from improper

implant/abutment connection due to inadequate tor-

que in case of Ankylos abutments or contamination

of the inner surface of the implant well with blood or

saliva before tapping of Bicon abutments. All abut-

ments were carefully reinserted and no further loosen-

ing occurred. On the other hand, crown loosening

was observed only within the Ankylos group (two

events), which might have occurred due to using tem-

porary cement to retain all the Ankylos crowns, in

accordance with the manufacturer’s recommendations.

These events were expected to occur during the first

year of function, of which patients were forewarned.

Permanent cement was used to fix the crowns after

checking the abutment status and ensuring good

crown fit.

The present findings should be interpreted with

caution, taking into account the study limitations that

include small sample size and short follow-up time

(12 months).

Care was taken to apply similar study conditions

for all patients and to exclude any case with a condi-

tion that might affect the short implant success based

on previous reports. For example, patients with miss-

ing teeth in the posterior maxillary region were

excluded because of the reported 25% failure rate,

especially during the first 18 months of loading when

short implants were placed in the posterior maxilla. 56

It was also reported that short implants should only be

© 2016 Australian Dental Association

used if bone quality is favourable. 4,27 Smokers and

patients with medically compromised conditions or any

parafunctional habits were excluded from the study in

line with recommendations from previous stud-

ies 15,26,27 to ensure the successful outcomes of the short

implants. In addition, the surgical and prosthetic proce-

dures were all carried out by an experienced team.

These conditions limited the number of patients

recruited, the treatment and overall observation period.

However, this randomized controlled clinical trial pro-

vided valuable information on the applicability of using

short implants to rehabilitate partially edentulous pos-

terior mandible with an excellent short-term success.

Moreover, this is the first study that evaluated and lon-

gitudinally compared the outcomes of two different

short implant systems. The findings of this study could

help clinicians to choose the best option for patients

with similar clinical situations.

CONCLUSIONS

The provision of short implants to rehabilitate the

partially edentulous mandibular ridge appears to be

highly predictable and demonstrates an overall success

rate of 100% at 12 months post-loading. Favourable

clinical and radiographic peri-implant tissue responses

with a mean peri-implant marginal bone gain of

0.1 mm were observed. No clinical relevant differ-

ences were observed between the two implant systems

evaluated in the present study.

DISCLOSURE

This study was funded by PPP PV002/2011 and

UMRG RG089/09HTM research grants provided by

the University of Malaya. The authors would like to

gratefully acknowledge Ola M Maria for her assis-

tance and language editing. The authors have no

financial interest, either directly or indirectly, in the

products or information listed in this paper.

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Address for correspondence:

Dr Ashwaq A Al-Hashedi

3640 University Street

Room M-65, Faculty of Dentistry

McGill University

Montreal, Quebec H3A 0C7

Canada

Email: ashwaq.al-hashedi@mcgill.ca

218

© 2016 Australian Dental Association