Received: 30 November 2017 | Revised: 8 February 2018 | Accepted: 13 February 2018

DOI: 10.1111/cid.12608

REVIEW

Clinical outcomes of ultrashort sloping shoulder implant design:

A survival analysis

Joji Markose MDS, PhD1 | Shruthi Eshwar MDS, PhD2 | Suresh Srinivas MDS3 |
Vipin Jain MDS2

1
Cosmo French Medical Center, Sharjah,
United Arab Emirates
Abstract
2
Department of Public Health Dentistry, Background: Short implants are preferred in cases of limited bone height. Length and design of
Karnatak Lingayat Education Society Dental
implant credits to stability and implant success, shorter implants tend to survive for longer time
College & Hospital, Bangalore, Karnataka,
India duration.
3
Department of Prosthodontics, The Oxford Purpose: Retrospective cohort study was conducted with an aim to assess the clinical outcome
Dental College, Bangalore, Karnataka, India
and cumulative survival rate of sloping shoulder implants over a period of 8 years.
Correspondence Materials and Methods: Data was collected from all patients attending private clinics in Dubai,
Dr. Shruthi Eshwar, Department of Public
UAE. Subjects received ultrashort sloping shoulder (Bicon) implant. Implants of 6 mm and less than
Health Dentistry, Karnatak Lingayat
Education Society Dental College & 6 mm length were included in the study. Subject’s information like age, gender, systemic condition,
Hospital, No. 20, Yeshwanthpur, Suburb, habits, and radiographs were collected. Implant variables that is number of implants placed, loca-
IInd Stage, Tumkur Road, Bengaluru tion of placement, loading type, bone type, bone condition, and graft type were collected. Data
560022, Karnataka, India.
was analyzed using multivariate cox regression model to evaluate the correlation between implant
Email: shruthy2015@gmail.com
variables and to identify the implant variables associated with failure. Kaplan–Meier method was
adopted to assess the survival pattern of implants.

Results: Cumulative survival rate was 97% with average follow up of 28 months. Statistically sig-
nificant differences were seen with implant length, arch type, bone type, and bone condition with
P value <.001.

Conclusion: Short implants with sloping shoulder design and plateau-type roots have superior sur-
vival rates when compared with regular implants. The bone condition was also witnessed to be
statistically significantly superior

KEYWORDS
implant failure, Kaplan–Meier analysis, sloping shoulder design, survival rate, ultrashort implants

1 | INTRODUCTION effective osseointegration of dental implants. However, the adequate

requirement of bone height is compromised by the atrophy of alveolar
Osseointegrated dental implants are an effective substitute in the reha- bone.2 There are very few conservative treatment options for severe
bilitation of partial or complete tooth loss. Although dental implants are alveolar resorption; in such conditions pre-prosthetic reconstructive sur-
believed to be predictive aspect in prosthodontic treatment, failure up geries are often done to increase the alveolar ridge height and thus
to 10% is encountered. Implant failure is often associated with the improve the retention and stability. Though these procedures are widely
quality of bone and volume which are major determinants for both used, they involve increased morbidity to compensate bone loss, longer
1
early and late failure. treatment time, and higher cost. Hence implants with alternative length
The implant length is usually considered during the treatment plan- and diameter were introduced in response to clinical demands.3
ning and the length is decided based upon the existing bone. Bone height Short implants simplify the restoration in posterior sextant and
of 10 mm long in mandible and 13 mm in maxilla are preconditions for minimize the complications involved with placement of long implants.

Clin Implant Dent Relat Res. 2018;1–7. wileyonlinelibrary.com/journal/cid V

C 2018 Wiley Periodicals, Inc. | 1
2 | MARKOSE ET AL.

Considering the placement of implants (6 mm) in the posterior zones

of maxilla and mandible, it was reported to be only 38% and 50%
respectively.4
In the last decade, the use of short implants has been a growing
interest among clinicians due to the promising survival rates. Recent
systematic reviews reported that short implants have the same survival
rates and degree of marginal bone loss as longer implants.5
Short implants biocompatibly transfers occlusal forces from the
abutment to the surrounding bone. The entire design of short implant
optimizes the effectiveness of each of the features within the available
implant’s surface area and length.5
The Bicon short implant system is a screwless implant system. The
plateau root-formed implant body provides 30% more surface area
when compared with same-sized threaded implants. But more impor-
tantly, the plateaus provide faster bone formation (20–50 microns per
day), resulting in a unique Haversian bone with clinical capabilities dif- FIGURE 1 Bicon short implant (sloping shoulder design)
ferent from the slower forming (1–3 microns per day) appositional
bone around threaded implants. Additionally, the plateau allows appro- Before commencement of the study the approval from IRB and written
priate transfer of compressive forces to the bone throughout the entire consent from patients was taken.
implant.6
Among Bicon implants, sloping shoulder design facilitates the
appropriate transfer of occlusal load to the bone when placed subcres- 3.1 | Study variables
tal, improves esthetic implant restorations, and provides space for the
The patient data included complete recording of case history and radio-
interdental papillae with the bony support.6
graphs; data included age, gender, systemic conditions, presence of
The purpose of this study was to assess the clinical outcome of
adverse habits like smoking and alcohol. Based on age, patients were
ultrashort (5 and 6 mm) sloping shoulder implants. It was hypothesized
classified as 30–40, 40–50, and >50 years.
that the survival of ultrashort implants was similar to the survival of
short implants.

3.2 | Implant specific variables

2 | OBJECTIVES The Bicon sloping shoulder implant was used in the present study.
Implant length and width were 5 and 6 mm, respectively, with well
1. To evaluate the success of short implant survival rate in posterior diameter of 3 mm (Figure 1). The information was collected about the
maxillary and mandibular regions. number of implants placed; location of placement; type of loading
2. To assess the marginal bone gain or loss and soft tissue thickness implants (immediate loading or delayed loading). The type of restora-
around the short implants. tion for each implant was noted. The radiographic information was also
collected, whether patient had IOPA, OPG, or CBCT, to assess the
3. Identify the factors associated with implant failure.
bone growth or resorption (Figure 2).

3 | MATERIALS AND METHODS

The present study was a retrospective cohort study which aimed to

evaluate the survival rate of ultrashort implants. The data was collected
over the past 8 years that is from 2016 to 2008. Detailed information
of 375 patients who had ultrashort implants (Bicon sloping shoulder)
was collected from private clinics in Dubai, where the investigator per-
formed implant surgeries. All the cases completed by the investigator
were included in the study. All implants of 6 mm or less than 6 mm and
sloping shoulder implant design were included in the study. Patients
who were medically compromised with bone diseases, skeletal asym-
metries, congenital disorders, and pathologic disorders of the maxilla
and mandible and syndromic patients were excluded from the study. FIGURE 2 Radiograph before surgery
MARKOSE ET AL. | 3

significance between different lengths of implants. The 6 mm implants

showed more survival when compared with 5 mm (Table 1 and
Graph 1).
The results of the survival analysis for each arch type showed that
implant failure was more in maxillary which were 13, whereas mandib-
ular arch had lesser implant failure of 1. There was a statistically signifi-
cant difference in overall implant survival distributions between the
different arches (LR 5 0.250, P 5 .003) (Table 1 and Graph 2).
Implant failure versus bone type showed that, out of 36 implants 5
implants had failed in type 2; in type 3 bone, out of 199 implants none
had failed; in type 4 bone, out of 37 implants 9 implants had failed.
This results suggested that, type 4 bone had more chances of failure
when compared with other 2 types but the difference was statistically
significant between the bone type and the survival of implants (P 5
FIGURE 3 About 8 years prosthesis follow-up
.021). (Table 1)
Implant failure versus implant loading showed that out of 313, 13
3.3 | Implant survival analysis
implants had failed in immediate type of loading, whereas in delayed
Failure of the implant was the primary outcome to assess the success. type of loading out of 59 implants there was only 1 failure. The differ-
The following criteria were used: clinical stability with complete func- ence was not statistically significant between the loading and the sur-
tion, no discomfort to the patient, no presence of infection or suppura- vival of implants with P value being .896 (Table 1).
tion at the implant site (Figure 3), and also no radiolucency around the Implant failure versus graft type showed that, out of 312, 9
implants in a radiographic examination (Figure 4). implants had failed when type 1 (autograft) was used, whereas in type
2 (allograft) out of 60 implants there were 5 failure. The difference was
3.3.1 | Data analysis and statistical tests
not statistically significant between the type of graft and the survival of
The statistical software SPSS version 22.0 was used for analysis and implants with P value being .866 (Table 1).
Microsoft word and excel were used to generate graphs and tables. Cross tabulation of bone condition and outcome showed that, out
Descriptive statistics was computed for all the variables. Multivari- of 372 implants, 133 implants had bone growth over the sloping
ate cox regression model was developed to evaluate the possible co shoulder implants, 96 implants showed bone gain up to sloping
relation between variables and to identify the variables which have shoulder with good soft tissue attachment, 106 implants showed bone
been associated with implant failure. filled with good soft tissue attachment, only 26 implants had bone loss
The success of the implant was analyzed by Kaplan–Meier survival up to first thread. There was statistically significant difference with
analysis.

4 | RESULTS

In this study, out of 372 subjects, 136 subjects were in the age group
of 30–40 years, among them 4(2.9%) implants failed; whereas among
40–50 years 8(5.1%) implants failed and in subjects above 50 years 2
(2.5%) implants failed. The estimated mean survival time was 3.503 in
30–40 years age group, 3.455 in 40–50 years, and 3.873 in above 50
years. Log rank value was 2.489 with P 5 .288, hence log rank showed
no overall survival difference between age groups (Table 1).
Out of 372 subjects, 225 were males among them 215 (95.6%)
cases showed implant survival and out of 147 females in 143 (97.3%)
cases the implants survived. The failure was 10 (4.4%) in males and 4
(2.7) in females. The estimated mean survival time was 3.572 in males
and 3.548 in females. Log rank test was considered for early failures.
Log rank value was 0.007 with P value of .934, hence log rank tests
shows no overall survival difference between genders (Table 1).
In this study short implant of 5 mm length and 6 mm width was
used. When 5 mm length was used, there was failure of 12 (6.3%)
whereas with 6 mm implant length 2 (1.1%) were failure. Log rank
value was 1.579 with P value being .000. There was statistical FIGURE 4 Radiograph after 8 years
4 | MARKOSE ET AL.

TA BL E 1 Distribution and survival analysis of short implants in terms of demographics and implant variables

Total number No. of events Censored events Estimate Std. error P value

Age
30–40 136 132 4 3.503 0.162 .288
40–50 156 148 8 3.455 0.138
>50 80 78 2 3.873 0.198
Overall 372 358 14 3.564 0.094

Gender
Male 225 215 10 3.572 0.119 .934
Female 147 143 4 3.548 0.152
Overall 372 358 14 3.562 0.094

Length
5 mm 122 110 12 2.722 0.125 .001
6 mm 250 248 2 3.934 0.116
Overall 372 358 14 3.564 0.094

Width
5 mm 210 199 11 3.738 0.126 .091
6 mm 162 159 3 3.345 0.138
Overall 372 358 14 3.562 0.094

Arch
Maxillary 98 85 13 3.105 0.175 .003
Mandibular 274 273 1 3.704 0.109
Overall 372 358 14 3.562 0.094

Bone type
D2 136 131 5 3.290 0.316 .021
D3 199 199 0 3.746 0.133
D4 37 28 9 3.334 0.140
Overall 372 358 14 3.562 0.094

Loading
Immediate 313 300 13 3.601 0.099 .896
Delayed 59 58 1 3.361 0.265
Overall 372 358 14 3.562 0.094

Graft type
Type 1 312 303 9 3.566 0.102 .866
Type 2 60 55 5 3.545 0.243
Overall 372 358 14 3.562 0.094

GRAPH 1 Survival curve for implant length (5 and 6 mm) GRAPH 2 Survival curve for arch type (maxilla and mandibular)
MARKOSE ET AL. | 5

TA BL E 2 Cross tabulation of bone condition and outcome

Bone condition
Bone resorption
Bone gain up Bone gain Bone filled, up to first thread,
to sloping shoulder, over sloping shoulder, good soft tissue food lodgment, Chi-square
Outcome Bone loss no bleeding, STA no bleeding, STA attachment gingival bleeding value P value

Bone loss
Count 11 0 0 0 0 372.00 .001*
% of total 3.0% 0.0% 0.0% 0.0% 0.0%

Bone gain
Count 0 96 133 106 26
% of total 0.0% 25.8% 35.8% 28.5% 7.0%

between bone condition and implant survival with P value being .001 Short implants have become very popular in recent years because of
(Table 2). increased success rates and survival rates which are mainly attributed to
The hazard ratio of implant length (6 vs 5 mm) is 1.44, the chances implant design and structural features. One of the short dental implant
of failure of 5 mm implants is about 0.44 times when compared with systems is Bicon short implant which has a sloping shoulder screwless
6 mm with P value <.05. Hence length of the implant is considered as design which facilitates the appropriate transfer of occlusal load to the
a major predictor variable for failure of the implants. Implant failure bone when placed subcrestally, improves esthetics of implant restorations
was 0.25 times more among subjects aged more than 50 years when and provides space for the interdental papillae with bony support. It also
compared with 30–40 years old. Implants placed in the maxillary arch provides sensible biological width and impressive bone maintenance.6
has 0.08 times more failure when compared with those placed in man- All the short implants placed in the study were functional with no
dibular arch, proving that age and arch type are biological and potential complications. As noted in the previous literatures in this study also all
confounders in implant failure. Similarly when bone gain was consid- the implant failures were seen in early phases of treatment and follow
ered, the failure rate of implants was significant with bone resorption up.6-8 The cumulative survival rate was 97% with an average of 28
up to first thread of the implant, food lodgment, and gingival bleeding months of follow up. The survival rates in this study was higher than
were 1.677 times more when compared with no bone loss (Table 3). those in the studies on bicon implants conducted by Vehemente et al
which reported 1 and 5 year survival rate of locking taper implants as
95.2% and 90.2%, respectively.7 Gentile and colleagues showed that
5 | DISCUSSION
when implants of 6 3 5.7 mm and more than 6 3 5.7 mm were used,
the survival rates were 92.2% and 95.2%, respectively.8 Similar studies
Majority of longitudinal studies showed that the failure due to loss of
by Testori and colleagues and Degidi and colleagues have shown sur-
follow up was 18%. The studies on implant survival failed to character-
vival rates at par with our study.9,10
ize the cause of loss. The purpose of this study was to assess the clini-
The higher survival rates achieved in this study may be due to dif-
cal outcome of ultrashort (5 and 6 mm) sloping shoulder implants.
ferences in the micro and macro geometric design of implants, as well
as physics and distribution of forces. All implants in the present study
TA BL E 3 Factors associated with implant failure had an HA coating and were placed using two stage surgical protocol.
A study conducted by Lee and colleagues reported 97% survival rate
Variable Hazard ratio 95% CI P value
for HA coated locking taper subcrestal implants. The presence of coat-
Major predictor variable
ing has been shown as a predictor for crestal bone gain. Gentile and
Implant length 1.44 1.33-1.65 .032* colleagues reported that there were 80% reduced failure rates when
Biologically relevant factors delayed loading was done.11
Age The connection between the endosseous root form implants and
30–40 years (R) surrounding bone involves the process of osseointegration where the
41–50 years 1.191 0.893-1.589 .234
>50 years 1.250 0.944-1.654 .119 bone grows and adheres to the implant surface. The bone implant con-
nection is direct and no periodontal ligament is present. When osseoin-
Potential confounders
tegration is complete, the implant will be stable and will support the
Arch 1.086 0.826-1.429 .554
Type of loading 0.983 0.731-1.322 .912 occlusal load.6
Bone type In this study there was a statistically significant difference seen
D3 (R)
with length, arch and bone gain and survival analysis. The hazard ratio
D2 0.948 0.608-1.477 .312
D4 0.845 0.658-1.085 .186 shows that length of the implant is a major predictor variable; age and
Bone gain gender are biologically relevant factors whereas arch type and bone
0 and 1 0.000 0.000–1.006E1098 .90
type are potential confounders for implant failure.
6 | MARKOSE ET AL.

For 5 mm length implants there were 12 failures whereas for implant’s bone/soft tissue stability; it provides space for the interdental
6 mm length implants there were only 2 failures. Similarly when arch papillae with bony support even when an implant is contiguous to
type was considered there were 13 implant failures in maxilla and 1 in another implant or tooth.
mandible. The comparable survival estimates of ultrashort implants sug- The magnitude of stress produced by masticatory forces in the pos-
gest that 5 and 6 mm long implants integrate and bear a functional terior mandible are distributed around the implant in a manner that
load after placement. Results of this study are at par with studies done causes adjacent bone to be loaded at levels equal to, or higher than, the
by Deporter and colleagues which reported 2 failures out of 26 ultra- minimum effective strain necessary for bone modeling and remodeling.
short implants of 5 mm length which were used. The results of this This resulted in positive gains in both bone density and crestal height.
study are similar to those of studies conducted by Deporter and col- The Plateau root form implants have a series of separate circumfer-
leagues where failures were more in maxillary (87%) when compared ential threads (fins). This design feature creates large space available
with mandible.12 Another study by Ten Bruggenkate and colleagues between the fins (pitch) of the implant called healing chambers. After
reported 7 failures in maxilla.4 A study by Rossi and colleagues showed implant insertion, healing chambers become filled with blood clot, which
95% survival rate; 6 mm implants showed 47% survival and 5 mm is eventually replaced with new bone, leading to biomechanical fixation.
implants showed 52% survival. A study by Gentile and colleagues It has been suggested that the vascularization and filling sequence in
reported 94% survival rate of ultrashort implants which were restored this is relatively fast compared with the regular screw from implants.17
with single crowns and were observed for 2 years.8 Himmlova and colleagues showed that more than an increase in
Despite being shorter in length, Plateau designs have greater func- the implant length, an increase in the implant diameter decreases the
tional surface areas maximizing osseous contact compared with same stress around the implant neck as a result of a more favorable distribu-
size threaded implants. Bicon implants used in this study have 30%
tion of the simulated masticatory forces. The short implant maximizes
more functional surface area than the same size threaded implants. The
the functional surface area which is the main contributing factor to the
plateau effectively transfers compressive forces in to the bone
high success rate. The plateau or fin design offers at least 30% more
throughout the entire length of the implant body.13
surface area than a screw implant of the same dimensions and allows
An FEM study by Chou and colleagues reported localized remodel-
for callus formation of mature Haversian bone between the fins of the
ing that was restricted to the perimeter of the implant and reported
implant.18
bone density distributions similar to that of the natural tooth, author
Plateau root form implants initially demonstrate a less bone
concluded that short implants were better suited to prevent bone loss
implant contact within the osteotomy site than regular threaded
at high occlusal loads and conserve the natural mechano-transductive
root form dental implants but shows very significant role in the peri-
signaling environment.14
implant bone healing process. Its inherent bone healing pathway
The literature shows that bone loss around long implants have
results in unique opportunities to accelerate the osseointegration
been caused by stress shielding effects on crestal bone and resultant
phenomenon at the short-term and its maintenance on the long-
disuse atrophy. In this study, 133 (36.8%) implants had bone over-
term through a Haversian-like bone morphology and mechanical
growth which is not seen in case of regular implants which is more sig-
properties.19
nificant in terms of esthetics. Two hundred and twelve (58.7%)
This study’s limitations were that it was retrospective in nature,
implants showed steady bone level with good soft tissue attachment,
the use of single center for implant placement and that there was no
whereas with regular implants within 1 year bone loss is evident. Only
comparison group to assess the outcome. Hence prospective studies
26 (7.2%) implants had bone loss up to first thread which is again con-
with larger sample and longer follow up are needed to validate the
sidered as normal when compared with regular implants. There was
findings of short implants.
statistically significant difference between bone condition and implant
survival with P value being .001. The results were similar to the studies
conducted by Yoo and colleagues, reported that 32.2% showed bone
6 | CONCLUSION
gain, with five implants showing bone gain greater than 2.0 mm.15 In a
similar study, Urdaneta and colleagues showed that 24.8% of implants
As per the findings of this study it was possible to conclude that:
demonstrated crestal bone gain 5 years after crown insertion, with sig-
nificant bone gains around 5.0 3 8.0 mm implants in the mandible.16  Short implants with sloping shoulder design and plateau-type roots
This bone gain is explained on the basis of the implant design used have good survival rates. The bone condition was also witnessed to
in this study; the Bicon implant system has an implant-abutment con- be statistically significantly superior.
nection with a 38 locking taper which creates high-friction force. The
 Ultrashort implants have a cumulative survival rate of 97% with
locking taper breaks down the oxide layer and the metals become
average follow up of 28 months.
fused together which is called cold welding. This cold weld connection
develops a microbial seal. The bicon implant sloping shoulder facilitates  There was a statistically significant difference seen in the study with

the appropriate transfer of occlusal loads to the bone when positioned implant length, arch type and bone type.

below the bony crest. But more practically, the sloping shoulder facili-  There was a statistically significant difference between bone condi-
tates aesthetic implant restorations. 6
Short implants maintain the tion and implant survival with P value being <.001.
MARKOSE ET AL. | 7

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