CLINICAL

Short Versus Longer Implants in Mandibular Alveolar Ridge

Augmented Using Osteogenic Distraction: One-Year
Follow-up of a Randomized Split-Mouth Trial
Sara Bernardi, DDS, PhD1*
Roberto Gatto, MD1
Marco Severino, DDS, PhD1

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Gianluca Botticelli, DDS2
Silvia Caruso, DDS1
Claudio Rastelli, DDS1
Ettore Lupi, MD3
Adolfo Quiroz Roias, DDS4
Enzo Iacomino, MD5
Giovanni Falisi, DDS, PhD1

The aim of this study was to evaluate the reliability of 6-mm-long implants compared with normal-length implants placed in a vertical
augmented atrophic posterior mandible, supporting cemented single crowns. Thirty-six patients with bilateral posterior edentulous
mandible and presenting a bone availability height less than 9 mm from the mandibular canal were enrolled in this study. Patient
hemiarches were randomized to receive both 6-mm-long and normal-length implants (10 mm). The technique used for the vertical bone
augmentation was the ‘‘sandwich’’ technique, using a bone substitute block as graft. The data outcomes at 1 year postloading follow-up
were the loss of implants and complications. Eighty-six 6-mm-long implants and 84 normal implants were inserted. Five short implants and
13 normal implants were lost. In 28 patients, complications occurred, and in 21 cases, the complication was present on the side of the
ridge vertical augmentation. From the statistical analysis, the association between the side of the ridge augmentation and the side of
occurrence of the complication was statistically significant (P , .05). The results from this trial suggest short implants can be preferred over
vertical bone augmentation for the placement of longer implants in the rehabilitation of edentulous posterior mandibles. These initial
results must be confirmed by larger and longer follow-ups of 5 years or more.

Key Words: atrophic posterior mandible, vertical bone augmentation, short implants, RCTs

INTRODUCTION atrophic jaws can be challenging, especially when the bone

defect is wide.3 The resorption of the available bone leads the

O
ral diseases and traumatic injuries involving the
alveolar crest close to the noble anatomical structures
periodontal and dental tissues can lead to tooth loss
(maxillary sinus and alveolar nerve) in the superior and inferior
with consequent atrophy of the alveolar bone of the
jaws. In classical implant dentistry, a minimal bone height
jaws. Although a removable prosthesis is a low-risk
between 10 and 12 mm is required to insert a 9–11 mm length
solution, the mobility of the device often represents a
implant.4 This particular length is considered one of the factors
discomfort that patients do not appreciate or tolerate. Indeed,
in achieving a long and favorable prognosis. After tooth loss,
excessive bone loss causes improper denture retention and the alveolar bone tends to collapse and undergo a resorption
consequent instability during normal daily oral functions, such process. Even with modern guided bone regeneration tech-
as masticatory and phonatory acts.1 Fixed rehabilitation on niques, implant placement in a jaw with a low bone level is not
implants can reach high success levels,2 but rehabilitating predictable.5
The therapeutic options that are available nowadays for
1
Department of Life, Health and Environmental Sciences, University of implant supported-prosthesis are the following3:
L’Aquila, L’Aquila, Italy.
2
Private practice, L’Aquila, Italy. 1. bone augmentation procedures such as osteogenic distrac-
3
Maxillofacial Division, San Salvatore Hospital, L’Aquila, Italy. tion,
4
Unversidad Autonoma Gabriel Rene Moreno, Santa Cruz, Bolivia.
5
ENT Division, San Salvatore Hospital, L’Aquila, Italy.
2. use of zygomatic implants in case of maxillary jaws, and
* Corresponding author, e-mail: sara.bernardi@univaq.it 3. use of so-called short implants, meaning fixtures with a
DOI: 10.1563/aaid-joi-D-16-00216 length from 4 to 8 mm.

184 Vol. XLIV / No. Three / 2018

 Bernardi et al

Augmentation surgical techniques are technically demand-  Patients with poor oral hygiene (score of 2 to 3 according to
ing, depending on the operator’s skills; are associated with the Simplified Oral Hygiene Index9)
significant postoperative morbidity and complications; can be  Patients with bone availability height greater than 9 mm
expensive; and may require longer times (up to 1 year) for  Patients on bisphosphonate therapy
prosthetics loading.6
The definition of ‘‘short’’ implants is still controversial: some Implant and graft material information
authors consider short implants to have a length ranging
between 7 and 10 mm, and others consider short those fixtures The normal long implant (10 mm, ConicalActive, Maco Dental
with an intrabony length of 8 mm or less than 9 mm.7 Care, Salerno, Italy) presented a surface of titanium pure grade
Because of the higher demands from edentulous patients 4. The locking taper connection is a connection with a screw
for a fixed prosthodontics solution that lowers the surgical risks, and internal hexagon, and the system profile is cylindrical-
the reliability of short implants as an alternative has been conical. The diameter used was 3.90 mm.
questioned through the years. Several systematic reviews and The short implant (6-mm long, IM Macon, Maco Dental
meta-analyses have examined these issues, and a need for Care) presented the same surface type as the ‘‘normal’’ ones.

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additional clinical trials on the use of short implants in fixed- The connection was Morse taper type. The diameter used was
prosthodontic rehabilitation emerged. 4.10 mm.
The aim of this randomized split-mouth trial is to compare The graft material used was the bone block graft SP Block
the implant survival rate of short implants (intrabony length of Tecnoss S.r.l. (Giaveno, Italy) of dimension 10 3 10 3 20 mm.
6 mm) with the implant survival rate of longer, ‘‘normal’’ The prostheses were single crown cemented type. The data
implant (intrabony length of 10 mm), placed in the vertical were analyzed at 1-year postloading follow-up.
mandibular alveolar ridge in posterior atrophic mandibles.
Complications and occurrence of side effects are considered. Randomizing method

The patients were randomized with a simple sequence of list

MATERIALS AND METHODS randomization. For each patient, the decision of whether to use
the left or right side of the mandible as the test site (ie, short
This trial was designed as a randomized trial of split-mouth implant used) or the site of surgical bone augmentation was
design. The justifying reason in choosing a split-mouth design selected by flipping a coin and depending on the day of the
is that it yielded a more efficient comparison of treatments than surgery, described as follows.
a parallel design, providing a consistent number of test and If the side of the coin was head, the treatment would be a
control samples.8 short implant placement, and if the day was an odd day, the
The protocol has been approved by the University of side would be the right one.
L’Aquila Ethical Committee, protocol 38534. All patients were Because of the surgical procedure, the blindness of the
informed regarding the nature of the study and their patients was not guaranteed, but the data blindness evaluation
participation, and written consent was granted by every was guaranteed, since the researcher evaluator was different
participant according to the Helsinki Declaration of 1994. from the treating physician.
Patient selection Surgical procedure: Placement of short implants and normal-
length implants
Thirty-six patients attending the dental clinic of the University
of L’Aquila were enrolled in the study. All of the patients underwent professional oral hygiene
The following inclusion criteria were adopted: sessions 3 days before any surgical interventions, whether
undergoing the implant placement or the surgical bone
 18 years or older
augmentation procedure. Antibiotic prophylaxis was pre-
 Able to understand and sign an informed consent form
scribed before any surgical procedure. For implant placement,
 No sign of facial trauma
the sequence of surgical drilling strictly complied with that
 Presenting good oral hygiene (score of 0 or 1 according to
provided by the manufacturing company. Sutures were
the Simplified Oral Hygiene Index9),
removed after 7 days.
 High compliance with oral hygiene
After the surgery, a sheet with postoperative instructions
 Presenting a posterior bilateral edentulous mandible, with
was provider to the patients. The instructions included the
bone height quantity less than 9 mm
following:
Exclusion criteria were:
 continue antibiotic prophylaxis,
 Patients who did not consent to join the experimental  consume routine painkillers if necessary,
procedure  bed rest with head elevated at about 308 and apply ice to
 Patients with a low grade of compliance avoid/decrease the swelling for the 24/48 hours after the
 Patients lacking in general good health, degrees 3 and 4 surgery, and
referring to American Society of Anesthesiologists physical  brush the teeth as usual as well as gently cleaning the
classification system surgical area.

Journal of Oral Implantology 185

Short Implants vs Vertical Augmentation

Surgical bone augmentation procedure These variables were inserted in contingency tables and
analyzed with association measures. The statistics measure-
The procedure used for the surgical bone augmentation ments were performed using SAS University Edition software.15
followed the ‘‘sandwich technique.’’10 The surgical protocol
illustrated in this study included the expansion of the posterior
mandibular alveolar crest of severe vertical atrophy conditions, RESULTS
characterized by a remaining height of 6 mm (Figure 1).
The preparation of the patients was the same as previously At 1-year final follow-up, the collected data were inserted in a
mentioned. Excel spreadsheet to be statistically processed.
The osteotomies were performed by means the piezoelec- As stated in the ‘‘Materials and Methods’’ section, the
tric handpiece, which enables a more precise osteotomy line statistical analysis of the data followed a preestablished plan.
selective for the bone than traditional rotating instruments, Each implant was considered as a statistical unit. The level of
resulting in maximum savings of bone tissue. The piezoelectric significance was set at the .05 level. The statistical results were
osteotomy is also characterized by reduced exposure of the reviewed by an independent statistician.

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operating field with minimal dissection and the selective
Demographic data
cutting protects any type of soft tissue11 increasing postoper-
ative comfort in terms of edema and maintaining the The 36 enrolled patients ranged in age from 43 to 77 years.
vascularization of the cranial fragment, thus limiting the Eighteen were female, and 18 were male (Table 1).
reabsorption. The first phase of surgery was represented by
an incision horizontal of the vestibular mucosa in the free Short implants outcomes
gingiva, compatible with the emergence of the inferior alveolar
Eighty-six short implants were placed, and 5 were lost for lack
nerve. The second phase consisted with the detachment of the
of primary stability (n ¼ 1) and infections (n ¼ 4). Forty-three
mucoperiosteal plans limited to the vestibular side, paying
implants were placed on the right side and 43 on the left side
particular attention to saving the alveolar ridge in the area of
of the mandibles. Three patients experienced complications
surgical interest. Subsequently, using the piezo-handpiece, the
(paresthesia) on the side of the short implants placement
surgical site was submitted to a partial osteotomy performing
(Figure 2).
incisions in the vertical and horizontal direction, giving it a
‘‘drawer’’ shape. The osteotomy included the crest region to Normal implant with surgical augmentation procedure
expand, preserving the cortical region of the tongue. The outcomes
fragment previously osteotomized was then fractured to ‘‘green
wood’’ type, and the alveolar ridge was expanded to ‘‘hinge’’ of Thirty-six augmentation procedures were performed. Eighty-
about 5 mm. After the grafting stage, the stabilization of the four normal implants were placed, and 13 were lost due to lack
fragments into the surgical site was reached through the use of of primary stability (n ¼ 3) and site infection (n ¼ 10). Forty-five
a microplate fixed through microscrews titanium. The last step implants were inserted on the right side and 39 on the left side.
of the surgical procedure involved the surgical site closure with Twenty-two patients experienced complications on the side of
absorbable suture. After a reasonable period of healing (6 the ridge vertical augmentation. Nevertheless, with the use of a
months), implants were placed. piezoelectric handpiece, the main complication experienced by
the patients was paresthesia, a sign of a little touch of the
Radiologic assessment alveolar inferior canal (Figure 2).
The representative orthopantomograms of an enrolled
Following the last guidelines released from the European patient from the initial situation (Figure 3) to the implant
Association for Osseointegration, the radiologic assessment placement (Figure 4) and to the 1-year follow-up (Figure 5)
included the tridimensional evaluation of the anatomical showed the good results obtained using both short and normal
condition to plan the surgery12,13 and the use of the implants.
ortopantomograph technique for the follows-up.14 Thus, each The intraoral radiographs at 1-year follow-up (Figure 6)
patient underwent a computerized tomography study prior to confirm the good marginal level of the alveolar bone.
the first surgery, whether undergoing short implant placement
or the augmentation. After each surgical operation, success was Statistical analysis
verified by means of orthopantomographs. A final orthopanto-
Statistical analysis was performed using SAS University Edition
mogram at 1-year follow-up was made to verify the status of
software.15 The Pearson chi-squared test on the contingency table
the implants.
comparing the side where the complication was raised and the
Statistical analysis side of the surgical augmentation procedure resulted in statistical
significance, with a P value ,.05, showing an association between
The variables considered from a statistical point of view were: the 2 variables (Table 2). Since the chi-squared test was not
completely trustable, because 67% of the cells had expected
 The loss of normal implants counts less than 5, Fisher exact test was performed, confirming
 The loss of short implants the significance of the association (Table 3).
 The side of the vertical augmentation The same statistical procedures had to be applied on the
 The side where the complication raised contingency tables comparing the loss of the normal-length

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FIGURE 1. Surgical intervention. (a) Preoperatory situation. (b) Horizontal osteotomy. (c) ‘‘Green wood’’ type fracture. (d) Grafting procedure.
(e) Stabilization of the fragments into the surgical site by means of a microplate fixed through microscrews titanium. (f) Suture.
TABLE 2
Contingency table comparing the frequency of the side
where the vertical ridge augmentation procedures was
performed and the side where the complications arose and
results of the Pearson chi-squared test*
TABLE 1
Side Where
Side of Vertical
Data regarding the recruited patients’ typology Complication Arose
Ridge Augmentation Pearson
n Procedure Dx Sx Chi-Squared Test
Male 18 Dx 13 1 P ¼ 8.84 3 105
Female 18 Sx 1 8
Mean age (range) at implant insertion, y 62 (43–77)
*Dx indicates right side; Sx, left side.

Journal of Oral Implantology 187

Short Implants vs Vertical Augmentation

implants and the side where the complication arose (Tables 4

and 5) and on the contingency table comparing the loss of the
normal and the short implants (Tables 6 and 7). The association
measures showed a P value ..05 and therefore were not
statistically significant.

DISCUSSION

If the total loss of the normal long implant was low, the
morbidity and complication rate was higher compared with the
short implant outcomes. The causes of implant lost were similar
in both groups. All these considerations are in perfect
agreement with the data reported so far in the literature
supporting the theory that the mandibular vertical bone

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FIGURE 2. Informal representations of the short and normal implants augmentation procedures are demanding, highly susceptible
outcomes. to infection and postoperative complications because of their

FIGURES 3–6. FIGURE 3. Representative postoperative orthopantomography. FIGURE 4. Postoperative orthopantomography. FIGURE 5. One-
year follow-up orthopantomography. FIGURE 6. Intraoral radiographs. (a) The short implants and (b) the normal-length implants. Both
groups show good bone level on the margin of the implant.

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 Bernardi et al

TABLE 3
Contingency table comparing the frequency of the side where the vertical ridge augmentation procedures was performed and the
side where the complications arose and the results of Fisher exact tests, including the 95% confidence interval and the odd ratio
values*
Side Where Complication Arose
Side of Vertical Ridge
Augmentation Procedure Dx Sx Fisher Exact Test 95% CI OR
4
Dx 13 1 P ¼ 1.55 3 10 4.25–4694.29 65.55
Sx 1 8

*Dx indicates right side; Sx, left side.

intrinsic nature5 and high microbial load present in the oral vertical bone augmentation and is thus susceptible to the
cavity,16–18 as well as extremely uncomfortable for the patients. related complications that vertical bone augmentation proce-

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The success of mandibular vertical ridge augmentation often dures have. They are more susceptible to the dislocation of the
relies on the clinical skills and experience of the operator as well graft, infection, neurologic and vascular complications, and
as the anatomical difficulties of an atrophic alveolar site. problems at the donor sites,24 as reported in our results.
Consequently, the vertical ridge augmentation is technically Over the years, the survival rate and success rate of short
difficult to perform. Instead, following a specific protocol and implants have been studied in order to reach a compromise for
the improvement of the bone-implant contact surface can lead the supported fixed prosthetic implant. Indeed, at the
to a more predictable result. beginning, the ratio of the length of the crown to implant
From a recent systematic review and meta-analysis by was considered unfavorable, pushing the studies of the ratio
Nisand et al,19 it can be concluded that there is a similar trend crow-root in natural teeth for a computer-aided design/
in terms of survival rate of short implants and longer implants computer-aided manufacturing implant design.25,26 The im-
placed in vertical augmented mandibles, but the number of provement of the total surface bone contact, the study of the
longer implants lost was slightly higher than the number of lost forces distribution on the fixture, and the successes in the
short implants. clinical trials strongly suggest the use of short implants when
In addition, it was pointed out that a significant increase in bone is not available or when bone augmentation cannot be
complications was experienced in patients who underwent the performed.7,27–30
grafting procedure despite the experience of the involved In particular, in a 2006 systematic review, das Neves et al20
surgeon. This concept, confirmed by our results, raised the started to assess the success rate of short implants in
question of the feasibility and the generalizability of this longitudinal studies and found that the use of a 3.75- 3 7-
approach in daily clinical practice.19 mm implant was successful. In our study, the diameter in the
Beyond these considerations, the biological basis of the short implants was chosen according the principle in the das
vertical ridge augmentation in the mandible does not favor the Neves et al systematic review,20 reaching a compromise with
results.20,21 The nature of the cortical bone and the blood the available bone horizontal width. The numerous randomized
supply seem to play fundamental roles in determining whether controlled trials (RCTs) by Esposito et al31–33 with the related
such a graft can be maintained in situ. Thus, the future updates and follow-up supported the therapeutic efficacy in
resorption is unpredictable.22 terms of survival rate and marginal bone loss of the short
From this point of view, the sandwich technique seems implants vs the longer implants placed in the vertical
quite adequate since the bone distraction provides a quite augmented atrophic mandible, recommending use of a wide
good blood supply to the graft integration.23 The technique, diameter (up to 6 mm) with short implant length of 5 mm.
used in the present study, has a quite low risk of total loss of One limitation of our study is the trial design: the crossover
the normal implants. Nevertheless, the sandwich technique is a design is indeed not widely accepted, but since there are no

TABLE 4 TABLE 5
Contingency table comparing the frequency of the side Contingency table comparing the frequency of the side
where the complications raised and the frequency of where the complications arose and the frequency of normal
normal implant loss and results of the Pearson-chi squared implant loss and results of the Fisher exact test, including
test* the 95% confidence interval and odd ratio values*
Side Where Side Where
Normal Normal
Complication Arose Complication Arose
Implant Pearson Implant Fisher
Loss Dx Sx Chi-Squared Test Loss Dx Sx Exact Test 95% CI OR
No loss 10 4 P ¼ .07207 No loss 10 4 P ¼ .1023 0.466–31.14 3.39
Loss 3 6 Loss 3 6

*Dx indicates right side; Sx, left side. *Dx indicates right side; Sx, left side.

Journal of Oral Implantology 189

Short Implants vs Vertical Augmentation

Maurizo Maravalle for statistical support and for help in

TABLE 6
improving the presentation of results.
Contingency table comparing the presence/absence of
short and normal implants at the 1-year follow-up using
Pearson chi-squared test*
NOTE
Normal Implants
Pearson
Maco Dental Care (Salerno, Italy) partially supported this trial
Short Implants Presence Lost Chi-Squared Test
and donated the implants; however, the data belong to the
Presence 23 9 P ¼ .3706 authors and by no means did Maco Dental Care interfere with
Lost 2 2
the conduct of the trial or the publication of the results.
*The variables were transformed in dichotomic variables for statistical
purpose. Dx indicates right side; Sx, left side.
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