Clinical Assessment of Short Implants Retaining

Removable Partial Dentures: 4-year Follow-up

Elisabetta Bellia, DDS, PhD1/Guido Audenino, DDS2/Paola Ceruti, DDS, MSc3/
Francesco Bassi, MDS, DDS4

Purpose: To prospectively evaluate the survival at 1 and 4 years of short implants retaining removable
partial dentures (RPDs) in Kennedy Class I and II edentulism. Materials and Methods: Twenty patients
(Kennedy Class I and II) rehabilitated with RPDs were selected for the insertion of one short implant in
the distal edentulous ridge, connected to the RPD with a Locator attachment after osseointegration. The
following data were recorded at the 1- and 4-year follow-up: bone loss, bleeding on probing (BOP), probing
depth (PD), implant mobility, and survival. Results: Thirty-five implants were placed from September 2012
to April 2014. At the 4-year follow-up, 12 implants showed BOP, and for PD, 15 implants showed 2 mm, 16
implants showed 3 mm, and 2 implants showed 4 mm. One implant showed mobility, and two were lost
(survival rate: 94.3%; 95% CI: 80.84 to 99.30). The mean bone loss was 1.04 ± 1.88 mm. Conclusion:
Within the limitations of this study, the implant survival rate and the mean bone loss values reported are
comparable with those reported by other authors. The use of short implants for retaining RPDs may be
considered a viable treatment option for patients with distal edentulism and contraindications for more
complex implant rehabilitation. Int J Oral Maxillofac Implants 2020;35:207–213. doi: 10.11607/jomi.7239

Keywords: bone loss, implant survival rate, removable partial denture, short implants

T he number of partially edentulous patients is con-

stantly increasing,1 and the choice of treatment
plan depends on several variables, such as the patient
oral and systemic health, preference, compliance and
available budget, and the clinician’s knowledge and
therapeutic skills. The literature reveals that many pa-
tients, especially the elderly, refuse to receive an im-
plant-supported fixed prosthesis even in the absence
1Research
Assistant, Department of Surgical Sciences, C.I.R.
Dental School, Oral and Maxillofacial Rehabilitation, University
of Torino, Torino, Italy.
2 Adjunct Professor, Department of Surgical Sciences, C.I.R.
Dental School, Oral and Maxillofacial Rehabilitation, University
of Torino, Torino, Italy.
3Assistant Professor, Department of Surgical Sciences, C.I.R.
of systemic pathologies contraindicating implant re-
habilitation, citing cost, fear of surgical procedures,
or satisfaction with their current removable partial
denture (RPD),2–5 which is indeed cheaper and easier
to clean, handle, and repair. Therefore, in spite of de-
creasing costs, implant fixed rehabilitation remains
a solution for the few instead of the many. However,
in some clinical situations, particularly in Kennedy
Classes I and II, the difference in visco-elastic behavior
under load between the mucosa and the abutment
teeth leads to unfavorable rotational movements of
the RPD. The incidence of Kennedy Classes has not
changed substantially in the last 40 years.6 Never-
theless, while the incidence of Class I rehabilitation,
which is the most frequent, has remained unchanged,
the incidence of Class II has increased. A recent re-

Dental School, Oral and Maxillofacial Rehabilitation, University

of Torino, Torino, Italy.
4Full Professor, Department of Surgical Sciences, C.I.R. Dental
School, Oral and Maxillofacial Rehabilitation, University of
Torino, Torino, Italy.
Correspondence to: Dr Elisabetta Bellia, Via Tripoli 16,
13900 Biella, Italy. Fax: +390158353371.
Email: bettybellia@gmail.com
Submitted June 18, 2018; accepted September 29, 2019.
©2020 by Quintessence Publishing Co Inc.
view analyzed the prevalence of partial edentulism
and its correlation to age, sex, arch predominance,
socio-economic factors, and the incidence of various
Kennedy Classes. The results showed that there is no
sex correlation for partial edentulism, which is more
common in the mandible than the maxilla. Moreover,
Class III and IV RPDs are more common in younger
adults, while distal extension Class I and II RPDs are
more common in the elderly.7 Therefore, there is a
clear necessity to apply adequate rehabilitative solu-
tions in these clinical cases.

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Bellia et al
As suggested by the scientific literature, the anchor-
age of an RPD to one or two implants in partial eden-
tulism with distal edentulous ridges can definitely
improve retention, support, stability and function, and
the psychologic comfort of the patient while main-
taining the residual structures.8–15 One finite element
method (FEM) simulation showed how two implants
placed in the edentulous ridges can improve the sta-
bility of the occlusal support, thus reducing ridge
bone resorption.16 Another FEM study,17 evaluating
the effects of implant length and inclination on pos-
terior abutment teeth and the implants themselves in
mandibular Class I RPDs, showed that vertical implant
placement produces lower stress on implants; stress
gradually increases with increasing angle of place-
ment. Ohkubo et al18,19 demonstrated that this rehabil-
itative choice makes the distal extension more stable,
increasing both force and masticatory area while keep-
ing mandibular movements unvaried.
Thus, implant-retained RPDs are presented as a via-
ble treatment option to rehabilitate edentulous ridges
by maintaining the benefits of implant therapy while
providing the ease of management of an RPD, with
a success rate for implants up to 93.75% and a 100%
success rate for prostheses.20,21 However, partial distal
edentulism very often shows a low quantity of residual
bone, thus making the use of conventional-length im-
plants impossible. In these cases, it becomes necessary
to resort to short implants (ie, less than 7 mm). Al-
though the use of short implants in fixed prosthodon-
tics is well documented in the literature,22 studies on
their application in RPDs are still missing.
Aim of the Study
The purpose of this study was to evaluate the survival
at 1 and 4 years for short implants retaining RPDs in
Kennedy Class I and II edentulism.
MATERIALS AND METHODS
All patients rehabilitated with RPDs at the Department
of Prosthodontics of CIR Dental School, Oral and Maxil-
lofacial rehabilitation, University of Torino, from 2004
to 2011 and fulfilling the following eligibility criteria
were prospectively included in the study. The inclusion
criteria were as follows: presence of a Kennedy Class I or
II rehabilitated with an RPD (either mandibular or max-
illary); absence of systemic pathologies contraindicat-
ing implant rehabilitation, that is, diabetes not under
medical control, patients undergoing chemotherapy
or radiotherapy, or patients treated with intravenous
bisphosphonates; absence of temporo-mandibular
disorders; absence of smoking; presence of low bone
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quantity in the posterior ridges, but enough for plac-
ing 6-mm-long implants; and a willingness to undergo
surgery for improvement of RPD stability, retention
and support, and no further costs.
The prosthetic state was checked and reestablished
as necessary in terms of occlusal contacts, extension
and precision of the denture base, and the retentive
efficacy of the clasps. Every patient underwent or-
thopanoramic radiograph and cone beam computed
tomography scans. The clinical protocol called for the
insertion of one short implant in the distal edentulous
ridge to be connected to the RPD with an attachment
after osseointegration (Figs 1a to 1d). Implants were
placed juxta crestally; the Super Short 3i implants with
NanoTite surface and external hex chosen for this pur-
pose were available in four different combinations of
diameter and length: 5 × 5 mm (NXFOS550), 5 × 6 mm
(NXFOS560), 6 × 5 mm (NXFOS650), and 6 × 6 mm (NX-
FOS660) (Biomet 3i). Two distinct expert operators (G.A.,
F.B.) performed surgical interventions. After performing
anesthesia with Optocain 20 mg/mL and epinephrine
1:100,000, a full-thickness flap was elevated, and the
implant was placed with dedicated drills in accordance
with the manufacturer’s instructions. After 3 months of
healing for mandibular implants and 4 months for max-
illary implants, the stage-two surgery was performed.
A platform-matching protocol was carried out for all
implants. Locator (Biomet 3i) attachments were used
for the connection, ranging from 1 to 4 mm in height
and 4 mm in diameter. Laboratory matrices were first
applied to each prosthesis during the connection pro-
cedure and then changed to soft-retention pink Teflon
matrices.
Implant survival and mobility, peri-implant bone
loss evaluated with periapical radiographs from the
implant margin level/implant-prosthetic junction,
bleeding on probing (BOP), and probing depth (PD)
were assessed and recorded at the time of prosthetic
connection (T0), at 1-year follow-up (T1), and at 4-year
follow-up (T2) (Figs 2a to 2e).
Radiographic evaluations were carried out by three
previously calibrated operators (E.B., F.B., G.A.) by mea-
suring the bone loss levels directly on the periapical
radiographs, which were edited and standardized us-
ing ImageJ software23–26 (Figs 3a to 3c).
Statistical Analysis
Demographic and clinical characteristics of patients
and implants were summarized using frequency and
percentage for qualitative variables and median and
range for continuous variables.
Clinical assessments during the follow-up were re-
ported as frequency. Confidence intervals for bone
loss and PD were calculated.
 Bellia et al

Fig 1   Radiographs before (a, b) and after

(c, d) super short implant placement.

a b

c d

Fig 2  4-year follow-up case of a

mandibular Kennedy Class I: (a)
frontal view, (b) occlusal view, (c)
right lateral view, (d) left lateral
view, (e) prosthetic view.

a b

c d e

a b c
Fig 3   Radiographs at (a) implant anchorage, (b) at the 1-year follow-up, and (c) at the 4-year follow-up in a mandibular Kennedy
Class II.

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Bellia et al

Patient recruitment

Search through the department database of patients rehabilitated with a RPD between 2004 and 2011

140 patients found in the database and called on the phone for preliminary visit

100 patients reachable 40 patients not reachable

(deceased or changed phone
number) and excluded
50 patients not interested in the 50 patients interested from the study
protocol and excluded from the in the protocol and
study willing to be visited

20 patients (13 females, 30 patients not fulfilling

7 males) fulfilling inclusion inclusion criteria and
criteria and joining the study excluded from the study

Fig 4   Flowchart of patient recruitment process.

Table 1   Patient Characteristics Table 2   Implant Characteristics

No. % No. %
Age, median (range) 61.5 (39–76) Rehabilitation site   
Sex      Mandible 28 80.0
 Female 12 60.0  Maxilla 7 20.0
 Male 8 40.0 Sitea    
Kennedy Class      14 1 2.9
 I 12 60.0  16 25.7
 II 8 40.0  17 1 2.9
 24 1 2.9
No. of implants      26 2 5.7
 1 7 35.0  36 15 42.9
 2 12 60.0  45 1 2.9
 4 1 5.0  46 12 34.3
Total 20 100.0 Implant    
 5 x 5 1 2.9
 5 x 6 19 54.3
Because of the limited number of failures (n = 2)  6 x 5 15 42.9
and the absence of censored observations, the sur- Mucosa type    
vival probability of the implants was estimated using   Alveolar mucosa 11 31.4
 Keratinized 24 68.6
the cumulative proportion with its 95% confidence
Total 35
interval.
Opposing arch
 FPDi 2 10.0
 RPD 7 35.0
RESULTS  RPDi 1 5.0
Complete denture 4 20.0
The selection process of patients is described in Fig 4: Natural dentition 6 30.0
Total 20
20 patients fulfilled the eligibility criteria, and overall,
aFDI tooth-numbering system.
35 implants were placed from September 2012 to April FDPi = implant-supported fixed partial denture; RPD = removable
2014. Patient and implant characteristics are reported partial denture; RPDi = implant-supported removable partial denture.
in Tables 1 and 2.
Only two implants were lost during the follow-
up; the implant survival rate was 94.3% at 4 years
(95% CI: 80.84 to 99.30), and the mean bone loss was
1.04 ± 1.88 mm. one implant of 5 mm. Considering that two implants
The peri-implant bone loss at each year, BOP, mobil- were lost at the 4-year follow-up, the remaining two
ity, and PD rates are reported in Tables 3 and 4. At the implants showing a PD of 4 mm were those rehabili-
1-year follow-up, three implants had a PD of 4 mm and tated with a 4-mm-high Locator attachment.

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 Bellia et al

DISCUSSION Table 3   Clinical Assessment at T1 and T2

The use of short implants applies especially to patients %
n % cumulative
with low vertical bone height, when complementary
Bone loss 1 y (n = 35)
surgeries are not favorable, for saving time and mini-  < 1 30 85.71 85.71
mizing patient discomfort while simultaneously maxi-  1–2 4 11.43 97.14
mizing implant insertion in a strategic position.  2–3 1 2.86 100
The indication of implant-supported RPDs presents Bone loss 2 y (n = 35)
critical aspects in prosthodontic practice, as the best  < 1 26 74.29 74.29
implant location in mandibular distal extension and  1–2 2 5.71 80
the most appropriated retention system to minimize  2–3 6 17.14 97.14
 3–4 1 2.86 100
masticatory stress, preventing marginal bone loss
Bone loss 3 y (n = 35)
around the implant and tooth. A finite element anal-
 < 1 22 62.86 62.86
ysis provided some directions to clinical approach in  1–2 3 8.57 71.43
mandibular free-end arches; Memari et al27 concluded  2–3 6 17.14 88.57
that on the residual ridge soft tissue, at the mesial and  3–4 3 8.57 97.14
distal areas of each implant, the lowest stress was seen  ≥ 4 1 2.86 100
when the implant was placed in the first molar region, Bone loss 4 y (n = 33)
due to the better stress distribution in the supporting  < 1 16 48.48 48.48
 1–2 8 24.24 72.73
tooth and bone gingival tissues. On the other hand,
 2–3 4 12.12 84.85
Cunha et al28 found that approximating the implant  3–4 3 9.09 93.94
to the terminal abutment improved the RPD stability  ≥ 4 2 6.06 100
on the vertical plane, positively affected the distribu- PD at 1 y (n = 35)
tion of stresses on the supporting structures, and di-  2 23 65.71 65.71
minished the demand to the abutment tooth. In the  3 8 22.86 88.57
present study, implant location was planned in the  4 3 8.57 97.14
 5 1 2.86 100
first molar region, due to the anatomical limitations, in
order to avoid damaging the mental foramen during PD at 4 y (n = 33)
 2 15 45.45 45.45
the surgical procedures and enable a possible future  3 16 48.48 93.94
rehabilitation with an implant-fixed restoration after  4 2 6.06 100
the loss of anterior teeth.29 BOP rate 1 y (n = 35) 7 20
In the present study, Locator attachments were ad-
BOP rate at 4 y (n = 33) 12 36.36
opted as the retention system. Cakarer et al observed
Mobility rate 1 y (n = 35) 0 0.00
fewer prosthodontic complications and less mainte-
Mobility rate at 4 y (n = 33) 1 3.03
nance of the oral function for the Locator system than
for ball and bar attachments30–33; moreover, signifi- BOP = bleeding on probing.

cantly higher retention and stability are shown with

Locator connectors,34 which are easy to use with fewer Table 4 Bone Loss and PD Confidence Intervals
complications reported.35 Obs Mean SE 95% CI
Implant survival rate at the 4-year follow-up was
Bone loss 1 y 35 0.23 0.09 0.05 0.41
94.3%. Other studies12,20,29,36–40 regarding patients
Bone loss 2 y 35 0.59 0.16 0.26 0.91
rehabilitated with RPDs show implant survival rates
ranging from 93.75% to 100% with follow-up times Bone loss 3 y 35 0.90 0.20 0.50 1.30
comprised between 9 months and 8 years. Lemos et Bone loss 4 y 33 1.11 0.21 0.68 1.53
al22 underlined lower survival rates in short implants PD 1 y 35 2.49 0.13 2.22 2.75
than standard implants, suggesting caution in the use PD 4 y 33 2.61 0.11 2.39 2.82
of short implants in the posterior arch. PD = probing depth; SE = standard error; obs = observed implants/
Clinical and radiographic investigations carried out number of implants.
in the trial showed bone loss associated with PD and
BOP in some cases. The literature shows that up to 1 mm Kaufmann et al21 reported 0.94 ± 1.93 mm in the maxilla
of bone loss can occur during the first year after implant and 0.52 ± 0.9 mm in the mandible with a follow-up be-
placement, and it can be considered within physiologic tween 1 and 8 years. Esposito et al43 reported a higher
limits.41 Mean bone loss reported at the 4-year follow-up bone loss for short implants in fixed prosthodontics at
was 1.04 ± 1.88 mm. Krennmair et al42 showed a higher the 3-year follow-up (1.79 ± 0.51 mm in the mandible
bone loss at the 3-year follow-up, 2.2 ± 1 mm, while and 1.36 ± 0.57 mm in the maxilla). Similarly, higher

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Bellia et al
values at the 5-year follow-up were reported by Rossi et
al44 (2.30 ± 0.52 mm), Felice et al45 (2.24 ± 0.47 mm), and
Romeo et al46 (2.97 ± 0.47 mm).
In the present protocol, wide-platform implants were
adopted. It has been suggested that the implant diam-
eter has a positive influence on the survival rates of im-
plants,47,48 so the use of wide diameter in short implants
could be favorable. Conversely, some studies that used
short implants with a wide diameter in the posterior
atrophic maxilla did not show a significant influence on
long-term implant survival.49–51 Verri et al52 confirmed by
means of an FEM that length and diameter of implants
can positively influence RPDs with distal extension.
However, even implants with small dimensions (such as
3.75 × 7.00 mm length) improved stress distribution and
did not induce any risk for the longevity of the prosthe-
ses when the implants were used as RPD supports.
The present study called for the use of external-hex
implants. Recent systematic reviews53,54 aimed to es-
tablish if implant connection configuration influences
peri-implant bone loss after functional loading, con-
cluding that crestal bone levels are better maintained
in the short to medium term when internal kinds of in-
terfaces are adopted, but further studies are necessary
to reach definitive conclusions.
On the other hand, another review55 stated that
both internal and external connections show high sur-
vival rates and that the external connection is reliable
on a long-term basis. Moreover, Esposito et al’s system-
atic review56 did not show any statistical difference be-
tween the two connection types 5 years postloading.
The present protocol, by using implants, healing abut-
ments, and attachments provided by the same com-
pany, with the same diameter for all the components,
followed the platform-matching concept.
CONCLUSIONS
Considering the results and limitations of this pre-
liminary study, short implant-retained RPDs may be
considered a viable treatment option for partially
edentulous patients presenting reduced mandibu-
lar bone vertical height to avoid complementary and
sometimes not predictable surgeries. Further investi-
gations are needed to demonstrate long-term survival
and success of short implants through periodic radio-
graphic and clinical examination to assess the occur-
rence, severity, and progression of bone resorption.
ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this
study.
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