This retrospective study compared the 5-year clinical and radiographic outcomes of short implants (6 mm) (short group), and standard-length implants (≥9 mm) placed after a vertical augmentation with autologous bone blocks (augmentation group), supporting partial fixed prostheses in the posterior mandible. Forty-five partially edentulous patients were enrolled in the study and evaluated after 5 years: 22 (51 implants) in the augmentation group and 23 (46 implants) in the short group. Eight surgical complications occurred in the augmentation group versus none in the short group ( P = 0.003). One short implant failed before loading and one standard-length implant failed after 4 years because of peri-implantitis ( P = 1.0). Eight biological and two prosthetic complications occurred in the augmentation group vs. three biological and three prosthetic complications in the short group ( P = 0.09 and P = 1.0, respectively). A mean marginal bone loss of 1.61 ± 1.12 mm in the augmentation group and 0.68 ± 0.68 mm in the short group was found ( P = 0.002). Within the limitations of this study, both techniques resulted in successful clinical results after 5 years, but short implants exhibited less surgical complications and marginal bone loss than standard-length implants placed in augmented bone.
The atrophic posterior mandible often poses a challenge to treatment with dental implants because the vertical and horizontal ridge resorption after tooth loss may preclude the placement of standard-length implants in the correct position and with ideal inclination. Various procedures to augment the native bone volume have been clinically tested, including onlay and inlay autologous bone grafts, alveolar nerve transposition, distraction osteogenesis and guided bone regeneration . Unfortunately, these techniques are associated with increased postoperative morbidity, higher costs, and higher risks of complications during the healing period that often deter patients from seeking implant therapy . Thus, short implants with an intra-bony length of 8 mm or less could be a simpler, cheaper, and faster alternative to augmentation procedures, if they demonstrate to result in similar survival rates . Some authors have reported that short implants did not have a good long-term prognosis when compared with standard-length implants in posterior jaws , although the implant surface may have played a confounding role in the survival rates . Other recent comparative clinical trials have documented that even short implants with a length of 5–6 mm may have a similar short-term survival rate compared with longer implants placed in augmented bone . Nevertheless, very few data have been published comparing these two treatment approaches with an observation period longer than 3 years .
The aim of this retrospective study is to compare the clinical and radiographic outcomes of 6 mm short implants with those of 9 mm or longer implants placed following vertical ridge augmentation with autologous block bone grafts, for the partial fixed restoration of atrophic posterior mandibles after a follow-up period of 5 years. This study is reported following the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) guidelines for reporting observational studies ( www.strobe-statement.org/ ).
Materials and Methods
A retrospective chart review was performed for all patients who had implants placed in the atrophic posterior mandible between January 1, 2009, and February 1, 2012, in one private dental practice. Five years after implant placement, patients were contacted and invited for a comprehensive clinical and radiographic examination (including periapical radiographs of the implants and their restorations). Each patient gave informed consent to participate in the study. The study protocol was approved by the Ethics Committee of Area Vasta Romagna and IRST, and was conducted according to principles stated in the Helsinki Declaration.
The following patient inclusion criteria were applied: (1) vertical bone atrophy in the posterior edentulous mandible (a residual bone height between 7 and 9 mm above the inferior alveolar nerve measured on a preoperative cone beam computed tomography (CBCT)); (2) treatment involving the placement of at least two short implants (6 mm) in the native bone or standard-length implants (≥9 mm) in ridges augmented with mandibular block bone grafts supporting a fixed partial denture; (3) delayed implant loading; (4) patients enrolled in a regular maintenance care programme; (5) a minimum follow-up period of 5 years from implant placement; (6) availability of a baseline peri-apical radiograph taken on the day of implant surgery.
The patients were excluded if were diagnosed with systemic conditions known to alter bone metabolism, such as cancer requiring chemotherapy or facial radiotherapy, intravenous amino-bisphosphonates for metastatic bone diseases, uncontrolled diabetes mellitus, immunosuppression or immunodepression and smoking habit of more than 20 cigarettes per day (all pipe or cigar smokers were also excluded).
All surgeries were performed by a single surgeon under local anaesthesia only or local anaesthesia with oral sedation (triazolam, 0.125 mg or 0.25 mg). All patients received prophylactic antibiotic therapy: 1 g of amoxicillin–clavulanic acid (or clindamycin 500 mg if allergic to penicillin) starting the night before the intervention, and twice per day for a total of 7 days, and pain medication (ibuprofen, 600 mg as needed every 6–8 hours). They were also asked to rinse with 0.2% chlorhexidine digluconate (every 12 hours starting 1 day preoperatively for 2 weeks).
A midcrestal incision on the edentulous ridge was made. The incision was extended via the gingival sulcus of the adjacent tooth. Mesial and distal releasing incisions were performed, and full-thickness flaps were reflected to completely expose the atrophic ridge and identify the mental foramen. The exposed alveolar bone was cleaned of all soft tissue and several decortications holes were made using a small round bur. Bone harvesting was performed from the same side of the ramus with a piezoelectric surgical device (Piezosurgery, Mectron, Carasco, Italy). The block grafts were shaped according to the morphology of the defects and rigidly fixated to the residual bone with titanium miniscrews (Cizeta Surgicals, Bologna, Italy). Anorganic bovine bone particles (Bio-Oss, Geistlich Pharma AG, Wolhusen, Switzerland) were added at the periphery and over the bone grafts. The reconstructed sites were then covered with a resorbable collagen membrane (Bio-Gide, Geistlich Pharmaceuticals). After careful periosteal releasing incisions in order to obtain absolute tension-free closure, the flaps were sutured in two layers with a combination of horizontal mattress and interrupted sutures. The sutures were removed after 3 weeks, and the patients were then checked at 2 months after surgery. Provisional removable prostheses were not allowed during the healing period. Four to five months after augmentation, a CBCT scan was retaken to plan implant placement. The flap outline was similar to the first surgery without vestibular releasing incisions. Following mucoperiosteal flap elevation and debridement, the bone block fixation screws were removed, and standard-length implants (Astra Tech OsseoSpeed, DENTSPLY Implants, Mannheim, Germany) were placed with the top of the platform flush with the facial alveolar crest ( Fig. 1 ).
Short implant group
After a crestal incision and flap reflection, implant osteotomy sites were prepared according to a standard drilling sequence. To minimize the risk of inferior alveolar nerve injury, the drills were used with adjustable stop devices that were always set at least 1 mm shorter than the radiographic working length above the canal. Two to three short implants (6 mm) (OsseoSpeed, DENTSPLY Implants) were placed in each patient ( Fig. 2 ).
All implants in both groups were left submerged for 2–3 months. Definitive titanium–composite, or zirconia–ceramic FPDs were delivered 8–10 weeks after healing abutment connection; they were either screw-retained or cemented on customized computer-aided design/computer-aided manufacturing titanium abutments. All patients were kept under regular maintenance care and received full-mouth scaling every 6 months.
The 5-year follow-up examination was conducted by two investigators (C.F. and E.C.), and included an update of the medical and dental history, a prosthodontic examination, and a peri-apical radiograph of all implants that fulfilled the inclusion criteria.
The following outcome measures were assessed.
Implant failure: defined as presence of any mobility of the individual implant and/or any situation dictating implant removal.
FPD failure: defined as planned FPD that could not be placed as planned due to implant failure(s), loss of the FPD secondary to implant failure(s), and replacement of the FPD for any reasons.
Surgical complications: including haemorrhaging during and after surgery, soft-tissue dehiscence, infections, fistulae, sensory loss, and partial or total bone graft resorption.
Biological complications: including peri-implant mucositis, and peri-implantitis. Peri-implant mucositis was defined as a heavily inflamed soft tissue without bone loss, and peri-implantitis was defined as a bone loss of more than 3 mm with suppuration, heavily inflamed tissues, or fistulas .
Prosthetic complications: including FPD detachment, screw loosening, and fracture of the screw, framework, or occlusal material.
Peri-implant marginal bone levels (MBLs) were evaluated on digital periapical radiographs (Digora Optime; Soredex/Orion Corporation, Helsinki, Finland) taken at implant placement, implant loading, and 5 years after implant placement. For standardization, a film holder-beam aiming device (Dentsply Rinn, Elgin, IL, USA) was applied according to the long cone paralleling technique. The radiographs were taken with the film placed parallel to the implant axis and the radiographic beam directed perpendicular to the implant . Customized positioners could not be used because of the retrospective character of the study. An image-analysis software (Digora for Windows, ver. 2.1; Soredex/Orion Corporation) was used to measure the linear distance between the implant platform and the most coronal level of the bone deemed to be in contact with the implant surface with an on‐screen cursor at 5× magnification. In cases where the implant platform was below the margin of the crestal bone, that is subcrestal, the value was considered as zero. To make calibrated measurements, an object of known size, the known diameter of the implant, was used. To adjust the measurements for any magnification error, the following equation was used to determine the correct MBLs: measured MBL × (actual implant diameter/measured implant diameter) . Relative mesial and distal bone height measurements were made to the nearest 0.01 mm and were averaged at a patient level. The change in MBL was calculated by subtracting the follow-up level from the baseline level at implant placement. Furthermore, at FPD placement, the crown/implant ratio was assessed for each implant, dividing the length of the restoration and the length of the implant. Radiographic measurements were performed by one experienced examiner (G.C.), who was calibrated and subjected to an intra-rater agreement test.
All data analyses were performed using a statistical software package (GraphPad InStat, GraphPad Software Inc., San Diego, CA, USA). Descriptive statistics were expressed as a frequency and percentage, and means and standard deviations, as appropriate. The patient was the statistical unit of the analyses. Differences in the proportion of patients with failures and complications were compared between the groups using Fisher’s exact test. The Friedman test was used to detect intra-group differences, and Mann-Whitney test was used to detect between-group differences in MBL values. The level of significance was set at 0.05 for all comparisons.