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, Sanaa University, Sanaa, 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.)

Recent literature has demonstrated high success and

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
208
survival rates when placing short implants in partially
edentulous patients, probably due to the advancement
in implant surfaces and design.911 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.1719
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 Universitys
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-TiTM 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
209
AA Al-Hashedi et al.
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-
facturers 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 4
5 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
210
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 (ImpregumTM Polyether; 3M
ESPE, St Paul, MN, USA) and occlusion was regis-
tered with vinyl polysiloxane (VPS) bite registration
material (ExabiteTM 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 patients 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 studies10,26,27 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
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 Two adjacent short implants in posterior mandible

(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)

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 211

AA Al-Hashedi et al.

with the data obtained from the scan until the occlu- Table 2. Implant success evaluation criteria according
sal forces were evenly distributed to the implant to the Health Scale for Dental Implants as classied
crowns and the rest of the remaining natural teeth.28 by Misch et al.38
Oral hygiene instructions were reinforced to the
Implant Quality Clinical conditions Prognosis
patients. Scale Group

I. Success (a) No pain or tenderness Very good to

Implant evaluation (optimum upon function. excellent.
health) (b) 0 mobility.
Each implant was evaluated clinically and radiograph- (c) <2 mm radiographic
bone loss.
ically by one examiner (first author) after crown (d) No exudates history.
installation (baseline), 2, 6, 12 months post-loading.
II. Satisfactory (a) No pain on function. Good to very
Reproducibility was assessed prior to the commence- survival (b) 0 mobility. good, depending
ment of the study. (c) 24 mm radiographic on the stable
Intra-examiner reproducibility was performed by bone loss. condition of the
(d) No exudates history. crestal bone.
periodontal/clinical examination on:
(1) eight patients with 104 sites to test the reliability III. Compromised (a) May have sensitivity Good to guarded,
survival on function. depending on the
for Plaque Index (PI), Gingival Index (GI), Prob- (b) No mobility. ability to reduce
ing Depth (PD), modified Bleeding Index (mBI) (c) Radiographic bone and control
and clinical attachment loss (CAL); loss >4 mm (less than stress.
1/2 implant length).
(2) eight patients with 52 sites to test the reliability (d) Probing depth >7 mm.
for width of keratinized mucosa (WKM) and (e) May have exudates
recession height (RH); and history.
(3) twelve patients with 45 teeth to test the reliabil- IV. Failure Any of following: Failure in all
ity for tooth mobility (PTVs) values. (clinical or (a) Pain on function. statistical data.
absolute failure) (b) Mobility.
For radiographic measurements, the reproducibility (c) Radiographic bone
measurements were performed on the DBSWIN soft- loss >1/2 implant length.
ware window around eight implants with 24 sites (d) Uncontrolled exudates.
(e) No longer in the mouth.
to measure the marginal bone height mesially,
distally and implant length. Repeated relevant mea-
surements on a particular subject or site were lapse of 30 seconds between probing and scoring,
performed with a time interval of 12 hours after were determined on mesial, distal, buccal and
completion of the first examination to minimize lingual surfaces of each implant. Averages of the
examiner memory recollection of the previous four obtained values of each implant were calcu-
recordings. lated and considered as the index value.34
Intra-examiner reproducibility results were consis- (3) Recession height was measured as the distance
tent for all clinical and radiographic measurements, from the abutment finish line (abutment/crown
kappa (0.800.88), intra-class correlation coefficient junction) to the gingival margin. The width of
(0.800.96) and Cronbachs a (0.860.99) tests. the keratinized mucosa was measured as the
distance from the gingival margin to the mucogin-
gival junction.34 All readings were assessed in
Evaluation of implant survival
millimetres at the mid-facial and mid-lingual
The implants success was assessed with the Health aspects of each implant.
Scale for Dental Implants (Table 2; International (4) Clinical attachment level was calculated by
Congress of Oral Implantologists (ICOI), Pisa, Italy, summing the values of the recession height and
Consensus Conference, 2007).29 This scale categorized probing depth at the facial and lingual surfaces
implants into appropriate groups of successful, of each implant.
survival or failed based on the criteria derived from (5) Implant stability was assessed by means of Peri-
the following clinical and radiographic evaluations: otest (Periotest! M Instrument, Medizintechnik
(1) Presence or absence of pain or suppuration, as Gulden e.K. Modautal, Germany). It has the
reported by the patients or detected during the advantages of rapid, safe and non-invasive mea-
periodic clinical examinations. surement35 that are useful for long-term implant
(2) Plaque Index,30 Gingival Index31 and Probing follow-up. The measurements were performed by
Depth in millimetres32 measured to the nearest positioning the device perpendicular to the long
1 mm by using a calibrated periodontal probe axis of the implant within a distance of 0.6 to 2
(UNC 15; Hu-Friedy, Chicago, IL, USA) and mm from the crown facial surface. The assess-
modified Bleeding Index,32,33 with a given time ment was repeated until the Periotest recorded
212 2016 Australian Dental Association
 Two adjacent short implants in posterior mandible

almost two similar successive measurements. The Statistical analysis

measurements were identified as implants Peri-
Data were analysed with the SPSS programme (IBM
otest values (PTVs) and classified according to
SPSS Statistics 20, Statistical Packages for Social
the manufacturers guide as follows: 0.8 to 0:
Science, New York, USA). ShapiroWilk test and mea-
good osseointegration, the implant is well inte-
sures of skewness were used to determine the normality
grated and pressure can be applied to it; +1 to
of distribution of all clinical and radiographic data. A
+9: a clinical examination is required, the appli-
p-value of <0.05 was set to represent a statistically sig-
cation of pressure on the implant is generally not
nificant difference between different groups and inter-
possible; +10 to +50: osseointegration is insuffi-
vals. Friedman, repeated measures ANOVA, Wilcoxon
cient and no pressure should be applied on the
signed-rank and paired sample t-tests with Bonferroni
implant.
correction for multiple comparisons were applied to
(6) Radiographic peri-implant bone changes were
compare different observation intervals, while Mann
measured on standardized digital intraoral peri-
Whitney and chi-square were used to evaluate differ-
apical radiographs (RVG, Trophy Radiology,
ences between the two study groups at each observa-
Inc., Marietta, GA, USA) at the mesial and distal
tion interval. A univariate model was used to evaluate
surfaces of each implant. Intraoral radiographs
the influence of some variables such as implant system,
were taken with a long cone paralleling tech-
length and C/I ratio on bone changes.
nique (70 kV, 6 mA and 0.160 seconds). The
radiographs were scanned (VistaScan scanner,
Durr Dental AG, Germany) with an effective RESULTS
resolution of 22 lp/mm (1100 dpi) and images
Twenty healthy participants (6 males and 14 females)
were digitized by using imaging software (D urr
with a mean age of 47.1 years ! 12.97 (25 to 70
Dental AG, Bietigheim-Bissingen, Germany). The
years) at baseline were enrolled in this study. The two
marginal bone level was determined by measuring
implant groups were homogenous in relation to all
the linear distance from the implantabutment
demographic variables except for gender. A higher
interface to the point of the first visible bone-to-
number of females (n = 14) was allocated to the
implant contact.36 Both the mesial and distal
Bicon! group due to the employed block randomiza-
implant sites were measured separately and an
tion. A total of 40 (20/group) short implants were
average value was calculated. Marginal bone
placed and reviewed for at least 12 months post-loading
changes were calculated as the difference
without dropout cases or implant loss (Table 3).
between the last measurement (6 or 12 months)
All implants in the present study were in the success
and the first (baseline) measurement for each
category according to the Health Scale for Dental
implant. Negative values indicated bone loss and
Implants for up to 12 months of follow-up (Table 2).
positive values indicated bone gain.
A survival rate of 100% was recorded based on clini-
(7) Crown-to-implant ratio (C/I) was determined by
cal and radiographic assessments.
dividing the crown length to the implant length
for all implants and then averaged. The crown
length was measured from the highest point of Peri-implant clinical and radiographic outcomes
the crown to the implant shoulder and the
Table 4 shows the comparison of the clinical parameters
implant length from the implant shoulder to its
at various time intervals between the two implant
apex, then ratios were calculated. For descriptive
groups. There was no significant difference for most
analysis, the C/I ratios were further categorized
clinical parameters except for PI at baseline (p < 0.01)
into two groups: C/I ratio 1 and C/I ratio >1.
and 2 months (p = 0.01), and for PTVs at all intervals.
In order to correct the dimensional distortion of
The PTV score of Ankylos! implants (2.19 ! 2.23) was
radiographic data, the accuracy of the radiograph
significantly lower (p < 0.001) than the Bicon! implants
measurements was achieved by measuring the
(1.09 ! 2.83) at 12 months post-loading, indicating
implant width or height on the image and by
better stability in the Ankylos! group. Bone levels were
using the known dimensions as a standard to cal-
significantly lower in Bicon! implants at both baseline
ibrate the software measuring tools before each
and 12 months compared to Ankylos!; however, the
measurement.
bone changes were not statistically different.
(8) Occlusal parameters included the relative
Within each implant group, there were no significant
maximum biting force and occlusion time were
changes in the clinical parameters over time except for
measured at 2, 6 and 12 months to evaluate
the PTV scores (p = 0.01 for the Bicon! group and p =
changes in occlusal force balance over the obser-
0.04 for the Ankylos! group). Ankylos! implants
vation time using T-Scan III system28 following
demonstrated a bone loss of 0.08 mm ! 0.38 at
the manufacturers protocol.
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AA Al-Hashedi et al.

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

Variable Group Bicon! Ankylos! Total P value*
Patients/implants n (%) Patients/implants n (%)

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
214
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 subjects 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 2 months n = 40 6 months n = 40 12 months n = 40 p** value
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Median (IQR) Median (IQR) Median (IQR) Median (IQR)

PI Ankylos 0.60 (0.29) 0.48 (0.42) 0.43 (0.36) 0.50 (0.32) 0.59
0.50 (0.0,0.50) 0.50 (0.0,0.25) 0.38 (0.0,0.25) 0.50 (0.0,0.69)
Bicon 0.29 (0.27) 0.15 (0.31) 0.15 (0.31) 0.44 (0.61) 0.07
0.25 (0.0,0.5) 0.0 (0.0,0.25) 0.13 (0.0,0.25) 0.25 (0.0,0.69)
p* value 0.00 0.01 0.07 0.12
GI Ankylos 0.28 (0.44) 0.0 (0.0) 0.0 (0.0) 0.10 (0.31) 0.007
0.0 (0.0,0.0) 0.0 (0.0,0.0) 0.0 (0.0,0.0) 0.0 (0.0,0.0)
Bicon 0.25 (0.08) 0.04 (0.12) 0.04 (0.06) 0.04 (0.12) 0.91
0.0 (0.0,0.0) 0.0 (0.0,0.0) 0.0 (0.0,0.0) 0.0 (0.0,0.0)
p* value 0.08 0.15 0.32 0.91
CAL (mm) Ankylos 1.98 (0.45) 1.95 (0.36) 2.06 (0.24) 2.03 (0.22) 0.23
2.0 (1.75,2.25) 1.83 (1.75,2.00) 2.0 (2.00,2.25) 2.0 (2.00,2.19)
Bicon 1.98 (0.56) 2.16 (0.52) 2.16 (0.49) 2.1 (0.52) 0.20
1.88 (1.66,2.19) 2.19 (1.75,2.5) 2.25 (1.75,2.5) 2.0 (1.81,2.0)
p* value 0.65 0.12 0.30 0.45
PD (mm) Ankylos 1.89 (0.37) 1.92 (0.29) 1.98 (0.16) 2.0 (0.21) 0.31
2.0 (1.56,2.00) 1.83 (1.75,2.00) 2.0 (2.00,2.00) 2.0 (2.00,2.00)
Bicon 1.98 (0.51) 2.11 (0.50) 2.11 (0.41) 2.02 (0.46) 0.27
2.0 (1.66,2.19) 2.19 (1.75,2.5) 2.0 (1.75,2.5) 2.0 (1.81,2.25)
p* value 0.82 0.13 0.28 0.58
mBI Ankylos 0.30 (0.37) 0.26 (0.34) 0.22 (0.29) 0.15 (0.24) 0.48
0.25 (0.0,0.50) 0.25 (0.0,0.25) 0.0 (0.0,0.50) 0.0 (0.0,0.25)
Bicon 0.41 (0.48) 0.64 (0.66) 0.64 (0.39) 0.25 (0.34) 0.13
0.25 (0.0,0.94) 0.38 (0.0,1.25) 0.25 (0.0,0.5) 0.0 (0.0.0,0.5)
p* value 0.63 0.10 0.45 0.41
RH (mm) Ankylos 0.18 (0.37) 0.10 (0.31) 0.15 (0.33) 0.13 (0.26) 0.64
0.0 (0.0,0.0) 0.0 (0.0,0.0) 0.0 (0.0,0.0) 0.0 (0.0,0.19)
Bicon 0.03 (0.11) 0.08 (0.18) 0.13 (0.32) 0.15 (0.33) 0.51
0.0 (0.0,0.0) 0.0 (0.0,0.0) 0.0 (0.0,0.0) 0.0 (0.0,0.0)
p* value 0.14 0.74 0.71 0.85
WKM (mm) Ankylos 3.15 (1.06) 3.10 (1.10) 3.0 (1.20) 3.0 (1.18) 0.009
3.0 (2.5,3.88) 3.0 (2.5,3.88) 3.0 (2.13,3.88) 3.0 (2.0,3.88)
Bicon 2.48 (0.95) 2.43 (0.89) 2.45 (0.99) 2.45 (0.99) 0.73
2.5 (2.0,3.0) 2.5 (2.0,3.0) 2.5 (2.0,3.0) 2.5 (2.0,3.0)
p* value 0.07 0.06 0.17 0.19
PTVs Ankylos -1.61 (2.02) -1.80 (1.96)a -2.0 (2.03) -2.19 (2.23)a 0.04
-1.95 (-3.,-1) -2.1 (-3.17,-0.9) -2.1 (-3.7,-0.7) -2.45 (-4,-0.8)
Bicon 2.15 (2.52) 2.23 (2.33)a 2.01 (2.55)b 1.09 (2.83)ab 0.01
2.1 (0.23,3.5) 2.35 (0.80,3.35) 2.1 (0.30,3.33) 0.85 (0.1,2.15)
p* value <0.001 <0.001 <0.001 <0.001
Bone level (mm) Ankylos 2.038 ! 0.62 - 2.117 ! 0.47 2.00 ! 0.42 0.27
Bicon 2.727 ! 1.14 - 2.655 ! 1.14 2.607 ! 1.18 0.28
p* value 0.02 0.06 0.04
Bone change (mm) Ankylos - - -0.08 ! 0.38 0.035 ! 0.33 0.03
Bicon - - 0.073 ! 0.37 0.120 ! 0.40 0.30
p* value - - 0.209 0.467

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.41A 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)
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 implants16,46 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 manufacturers 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-
ies15,26,27 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
2016 Australian Dental Association