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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Novel expandable short dental implants in situations with reduced vertical bone height—technical note and first results</title><author><name sortKey="Reich, Waldemar" sort="Reich, Waldemar" uniqKey="Reich W" first="Waldemar" last="Reich">Waldemar Reich</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Schweyen, Ramona" sort="Schweyen, Ramona" uniqKey="Schweyen R" first="Ramona" last="Schweyen">Ramona Schweyen</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>University School of Dental Medicine, Department of Prosthetic Dentistry,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Magdeburger Straße 16, 06112 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Heinzelmann, Christian" sort="Heinzelmann, Christian" uniqKey="Heinzelmann C" first="Christian" last="Heinzelmann">Christian Heinzelmann</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Hey, Jeremias" sort="Hey, Jeremias" uniqKey="Hey J" first="Jeremias" last="Hey">Jeremias Hey</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>University School of Dental Medicine, Department of Prosthetic Dentistry,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Magdeburger Straße 16, 06112 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Al Nawas, Bilal" sort="Al Nawas, Bilal" uniqKey="Al Nawas B" first="Bilal" last="Al-Nawas">Bilal Al-Nawas</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Eckert, Alexander Walter" sort="Eckert, Alexander Walter" uniqKey="Eckert A" first="Alexander Walter" last="Eckert">Alexander Walter Eckert</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">29086193</idno><idno type="pmc">5662521</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5662521</idno><idno type="RBID">PMC:5662521</idno><idno type="doi">10.1186/s40729-017-0107-1</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">000D08</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000D08</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Novel expandable short dental implants in situations with reduced vertical bone height—technical note and first results</title><author><name sortKey="Reich, Waldemar" sort="Reich, Waldemar" uniqKey="Reich W" first="Waldemar" last="Reich">Waldemar Reich</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Schweyen, Ramona" sort="Schweyen, Ramona" uniqKey="Schweyen R" first="Ramona" last="Schweyen">Ramona Schweyen</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>University School of Dental Medicine, Department of Prosthetic Dentistry,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Magdeburger Straße 16, 06112 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Heinzelmann, Christian" sort="Heinzelmann, Christian" uniqKey="Heinzelmann C" first="Christian" last="Heinzelmann">Christian Heinzelmann</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Hey, Jeremias" sort="Hey, Jeremias" uniqKey="Hey J" first="Jeremias" last="Hey">Jeremias Hey</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>University School of Dental Medicine, Department of Prosthetic Dentistry,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Magdeburger Straße 16, 06112 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Al Nawas, Bilal" sort="Al Nawas, Bilal" uniqKey="Al Nawas B" first="Bilal" last="Al-Nawas">Bilal Al-Nawas</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</nlm:aff></affiliation></author><author><name sortKey="Eckert, Alexander Walter" sort="Eckert, Alexander Walter" uniqKey="Eckert A" first="Alexander Walter" last="Eckert">Alexander Walter Eckert</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</nlm:aff></affiliation></author></analytic><series><title level="j">International Journal of Implant Dentistry</title><idno type="eISSN">2198-4034</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Purpose</title><p id="Par1">Short implants often have the disadvantage of reduced primary stability. The present study was conducted to evaluate the feasibility and safety of a new expandable short dental implant system intended to increase primary stability.</p></sec><sec><title>Methods</title><p id="Par2">As a “proof of concept”, a prospective clinical cohort study was designed to investigate intraoperative handling, primary and secondary implant stability (resonance frequency analysis), crestal bone changes, implant survival and implant success, of an innovative short expandable screw implant. From 2014 until 2015, 9 patients (7–9-mm vertical bone height) with 30 implants (length 5–7 mm, diameter 3.75–4.1 mm) were recruited consecutively.</p></sec><sec><title>Results</title><p id="Par3">All 30 implants in the 9 patients (age 44 to 80 years) could be inserted and expanded without intraoperative problems. Over the 3-year follow-up period, the implant success rate was 28/30 (93.3%). The mean implant stability quotients (ISQ) were as follows: primary stability, 69.7 ± 10.3 ISQ units, and secondary stability, 69.8 ± 10.2 ISQ units (<italic>p</italic> = 0.780), both without significant differences between the maxilla and mandible (<italic>p</italic> ≥ 0.780). The mean crestal bone changes after loading were (each measured from the baseline) as follows: in the first year, 1.0 ± 0.9 mm in the maxilla and 0.7 ± 0.4 mm in the mandible, and in the second year, 1.3 ± 0.8 mm and 1.0 ± 0.7 mm, respectively.</p></sec><sec><title>Conclusions</title><p id="Par4">Compared to other prospective studies, in this indication, the success rate is acceptable. Implant stability shows high initial and secondary stability values. The system might present an extension of functional rehabilitation to the group of elderly patients with limited vertical bone height. Further long-term investigations should directly compare this compressive implant with standard short implants.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (10.1186/s40729-017-0107-1) contains supplementary material, which is available to authorized users.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Schwarz, F" uniqKey="Schwarz F">F Schwarz</name></author><author><name sortKey="Terheyden, H" uniqKey="Terheyden H">H Terheyden</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gates, Wd" uniqKey="Gates W">WD Gates</name></author><author><name sortKey="Cooper, Lf" uniqKey="Cooper L">LF Cooper</name></author><author><name sortKey="Sanders, Ae" uniqKey="Sanders A">AE Sanders</name></author><author><name sortKey="Reside, Gj" uniqKey="Reside G">GJ Reside</name></author><author><name sortKey="De Kok, Ij" uniqKey="De Kok I">IJ De 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Int J Implant Dent</journal-id><journal-id journal-id-type="iso-abbrev">Int J Implant Dent</journal-id><journal-title-group><journal-title>International Journal of Implant Dentistry</journal-title></journal-title-group><issn pub-type="epub">2198-4034</issn><publisher><publisher-name>Springer Berlin Heidelberg</publisher-name><publisher-loc>Berlin/Heidelberg</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">29086193</article-id><article-id pub-id-type="pmc">5662521</article-id><article-id pub-id-type="publisher-id">107</article-id><article-id pub-id-type="doi">10.1186/s40729-017-0107-1</article-id><article-categories><subj-group subj-group-type="heading"><subject>Technical Advance</subject></subj-group></article-categories><title-group><article-title>Novel expandable short dental implants in situations with reduced vertical bone height—technical note and first results</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Reich</surname><given-names>Waldemar</given-names></name><address><phone>+49 345 557 5359</phone><email>waldemar.reich@medizin.uni-halle.de</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Schweyen</surname><given-names>Ramona</given-names></name><address><email>ramona.schweyen@uk-halle.de</email></address><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Heinzelmann</surname><given-names>Christian</given-names></name><address><email>christian.heinzelmann@uk-halle.de</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Hey</surname><given-names>Jeremias</given-names></name><address><email>jeremias.hey@uk-halle.de</email></address><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Al-Nawas</surname><given-names>Bilal</given-names></name><address><email>bilal.al-nawas@uk-halle.de</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Eckert</surname><given-names>Alexander Walter</given-names></name><address><email>alexander.eckert@uk-halle.de</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>Department of Oral and Plastic Maxillofacial Surgery,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Ernst-Grube Str. 40, 06120 Halle (Saale), Germany</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0679 2801</institution-id><institution-id institution-id-type="GRID">grid.9018.0</institution-id><institution>University School of Dental Medicine, Department of Prosthetic Dentistry,</institution><institution>Martin Luther University Halle-Wittenberg,</institution></institution-wrap>Magdeburger Straße 16, 06112 Halle (Saale), Germany</aff></contrib-group><pub-date pub-type="epub"><day>30</day><month>10</month><year>2017</year></pub-date><pub-date pub-type="pmc-release"><day>30</day><month>10</month><year>2017</year></pub-date><pub-date pub-type="collection"><month>12</month><year>2017</year></pub-date><volume>3</volume><elocation-id>46</elocation-id><history><date date-type="received"><day>18</day><month>8</month><year>2017</year></date><date date-type="accepted"><day>12</day><month>10</month><year>2017</year></date></history><permissions><copyright-statement>© The Author(s). 2017</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold>This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.</license-p></license></permissions><abstract id="Abs1"><sec><title>Purpose</title><p id="Par1">Short implants often have the disadvantage of reduced primary stability. The present study was conducted to evaluate the feasibility and safety of a new expandable short dental implant system intended to increase primary stability.</p></sec><sec><title>Methods</title><p id="Par2">As a “proof of concept”, a prospective clinical cohort study was designed to investigate intraoperative handling, primary and secondary implant stability (resonance frequency analysis), crestal bone changes, implant survival and implant success, of an innovative short expandable screw implant. From 2014 until 2015, 9 patients (7–9-mm vertical bone height) with 30 implants (length 5–7 mm, diameter 3.75–4.1 mm) were recruited consecutively.</p></sec><sec><title>Results</title><p id="Par3">All 30 implants in the 9 patients (age 44 to 80 years) could be inserted and expanded without intraoperative problems. Over the 3-year follow-up period, the implant success rate was 28/30 (93.3%). The mean implant stability quotients (ISQ) were as follows: primary stability, 69.7 ± 10.3 ISQ units, and secondary stability, 69.8 ± 10.2 ISQ units (<italic>p</italic> = 0.780), both without significant differences between the maxilla and mandible (<italic>p</italic> ≥ 0.780). The mean crestal bone changes after loading were (each measured from the baseline) as follows: in the first year, 1.0 ± 0.9 mm in the maxilla and 0.7 ± 0.4 mm in the mandible, and in the second year, 1.3 ± 0.8 mm and 1.0 ± 0.7 mm, respectively.</p></sec><sec><title>Conclusions</title><p id="Par4">Compared to other prospective studies, in this indication, the success rate is acceptable. Implant stability shows high initial and secondary stability values. The system might present an extension of functional rehabilitation to the group of elderly patients with limited vertical bone height. Further long-term investigations should directly compare this compressive implant with standard short implants.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (10.1186/s40729-017-0107-1) contains supplementary material, which is available to authorized users.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Bone atrophy</kwd><kwd>Expandable</kwd><kwd>Macrodesign</kwd><kwd>Short implant</kwd><kwd>Implant stability</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2017</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Introduction</title><p id="Par8">Endosseous implants have been established over several decades. The evaluation of treatment results under biomechanical, physiological, psychological, social and economic aspects has been well documented [<xref ref-type="bibr" rid="CR1">1</xref>]. Furthermore, patient-based outcomes reveal a predictable gain in oral health-related quality of life [<xref ref-type="bibr" rid="CR2">2</xref>].</p><p id="Par9">Especially in patients with limited vertical bone height, process of treatment is extensive. Prior to implantation, augmentation procedures are required [<xref ref-type="bibr" rid="CR3">3</xref>]. Depending on gender, vascularisation and bone mineralisation up to 25% of the primary volume are resorbed due to remodeling of augmented alveolar ridges [<xref ref-type="bibr" rid="CR4">4</xref>]. Recently, short dental implants have evolved into a promising and reliable treatment option in the orofacial rehabilitation of atrophic mandibles and maxillae, namely as an alternative to vertical ridge augmentation [<xref ref-type="bibr" rid="CR5">5</xref>–<xref ref-type="bibr" rid="CR8">8</xref>]. The prognosis of short implants and patient satisfaction is high [<xref ref-type="bibr" rid="CR9">9</xref>–<xref ref-type="bibr" rid="CR12">12</xref>].</p><p id="Par10">The definition of short implants in the literature is not uniform. In this present study, we considered short implants with 5–8-mm length [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR7">7</xref>, <xref ref-type="bibr" rid="CR13">13</xref>]. Other authors set the cut-off at 6 mm [<xref ref-type="bibr" rid="CR8">8</xref>, <xref ref-type="bibr" rid="CR9">9</xref>, <xref ref-type="bibr" rid="CR11">11</xref>, <xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR15">15</xref>]. According to the recent consensus paper of the 11th European Consensus Conference (EuCC), dental implants are referred to as “short” if their intrabony length measures ≤ 8 mm and considered as “ultra-short” with lengths < 6 mm [<xref ref-type="bibr" rid="CR16">16</xref>].</p><p id="Par11">Biomechanical studies show that the crestal bone is strained under axial and extra-axial loading [<xref ref-type="bibr" rid="CR17">17</xref>]. While bone quality, implant design and position, prosthetic devices and material characteristics contribute to the character of stress distribution, the role of implant length seems to be of underpart [<xref ref-type="bibr" rid="CR17">17</xref>, <xref ref-type="bibr" rid="CR18">18</xref>]. Nevertheless, implant length is crucial in D4 bone quality [<xref ref-type="bibr" rid="CR19">19</xref>], and the crown-to-implant length itself influences stress distribution under <italic>extra-axial</italic> loading in the crestal bone [<xref ref-type="bibr" rid="CR20">20</xref>] and in the abutment screw [<xref ref-type="bibr" rid="CR21">21</xref>]. According to Petrie and Williams [<xref ref-type="bibr" rid="CR22">22</xref>], the influence of increased implant diameter on stress reduction in the crestal bone is more efficient than increased implant length. Möhlhenrich and co-authors [<xref ref-type="bibr" rid="CR23">23</xref>] confirmed these findings that the diameter of an implant has greater influence on primary stability than implant length. Based on in vitro analysis, they concluded additionally that especially in patients with poor bone quality, a variation of implant dimensions is expected to lead to a significant increase of primary stability. Furthermore, stress distribution on short implants is affected by the bone-to-implant contact ratio [<xref ref-type="bibr" rid="CR24">24</xref>]. Consequently, several options to increase the implant surface of short implants are elaborated, which consecutively enhance the implant stability: thread number, thread shape, thread depth, implant diameter, implant design and surface topography [<xref ref-type="bibr" rid="CR25">25</xref>–<xref ref-type="bibr" rid="CR27">27</xref>].</p><p id="Par12">It is known that achievement of primary stability is one precondition for osseointegration and treatment success. There are few reports of immediate [<xref ref-type="bibr" rid="CR14">14</xref>] and early (6 weeks) functional loading of short implants [<xref ref-type="bibr" rid="CR28">28</xref>]. This is related to good bone quality, implant design or implant site preparation (e.g. under-drilling). However, under-drilling of the crestal aspect may lead to decreased bone-to-implant contact [<xref ref-type="bibr" rid="CR29">29</xref>]. It is desirable to reduce the periimplant stress on the crestal bone while providing sufficient primary stability for all bone densities.</p><p id="Par13">Therefore, optimisation of the macro- and microdesign of short dental implants to improve the success rate and long-term stability is preferable. In fact, elderly patients with general comorbidity should benefit from the overall short treatment time [<xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR30">30</xref>]. As previously shown, the oral health-related quality of life is compromised during the healing period after implant insertion [<xref ref-type="bibr" rid="CR31">31</xref>], especially when augmentation procedures are required [<xref ref-type="bibr" rid="CR11">11</xref>]. For several reasons, the overall treatment time should be reduced in patients with atrophic alveolar ridges.</p><p id="Par14">The purpose of the present study was to clinically analyse the feasibility and safety of a new short dental implant system with an expandable compressive design in the apical region. We hypothesised that the innovative expandable macrodesign of this implant provides a reliable implant success rate and ensures high implant stability in vivo.</p></sec><sec id="Sec2"><title>Material and methods</title><sec id="Sec3"><title>Study population and measures</title><p id="Par15">The study was designed as a prospective monocentric longitudinal cohort study according to the STROBE criteria. The participants of this study were recruited at the university hospital of Martin Luther University Halle-Wittenberg, Department of Oral and Plastic Maxillofacial Surgery, implantological consultation from 2014 (June) until 2015 (June). Inclusion and exclusion criteria of adult patients interested in implantological treatment are summarised in Table <xref rid="Tab1" ref-type="table">1</xref>. Written informed consent was obtained from all individual participants included in this study.<table-wrap id="Tab1"><label>Table 1</label><caption><p>Patient recruitment</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Inclusion criteria</th><th>Exclusion criteria</th></tr></thead><tbody><tr><td>1. Adult patients, male and female</td><td>1. Comorbidity ASA category ≥ III</td></tr><tr><td>2. Partially/totally edentulous patients</td><td>2. Pregnancy, bruxism</td></tr><tr><td>3. Alveolar process atrophy Cawood et Howell category ≥ IV</td><td>3. Smoking ≥ 10 cigarettes/day</td></tr><tr><td>4. Minimum vertical bone height of 7–9 mm for placement of short implants (5–7-mm length)</td><td>4. Radiotherapy ≥ 50 Gy [<xref ref-type="bibr" rid="CR72">72</xref>] or<break></break>5. Intravenous bisphosphonate therapy [<xref ref-type="bibr" rid="CR73">73</xref>] with a significant risk of developing osteo(radio)necrosis of the jaw</td></tr><tr><td>5. Patients without willingness to accept vertical bone augmentation</td><td>6. Psychiatric comorbidity that could influence course of treatment</td></tr><tr><td></td><td>7. Untreated or poorly controlled diabetes mellitus</td></tr><tr><td></td><td>8. Highly atrophic jaws that require vertical augmentation</td></tr></tbody></table></table-wrap></p><p id="Par16">As a “proof of concept”, the pilot study was designed to investigate the intraoperative handling and to evaluate the feasibility and safety of a new short implant system. Therefore, sample size calculation was not performed. The primary outcome variable was implant success rate, which was calculated considering known success criteria (implant in function, no sign of infection or pain, no mobility, no radiolucent area around the implant) [<xref ref-type="bibr" rid="CR32">32</xref>, <xref ref-type="bibr" rid="CR33">33</xref>]. The implant survival was calculated according to the Kaplan-Meyer method. Secondary measures were implant stability (initial and secondary) and periimplant crestal bone changes. Implant stability was measured by resonance frequency analysis (RFA; Osstell AB, Göteborg, Sweden).</p><p id="Par17">Primary stability was measured immediately after implant insertion and completed expansion (see below), and secondary stability after the submerged healing period (3 months in the mandible, 6 months in the maxilla; Table <xref rid="Tab2" ref-type="table">2</xref>) during the re-entry operation just before the healing abutments were inserted. Implant stability quotient (ISQ) values were obtained using the Smartpegs (type 17 and 35). According to each measurement, implant stability was classified as low with ISQ values < 60, medium with ISQ values 60–70, and high with ISQ values > 70 [<xref ref-type="bibr" rid="CR34">34</xref>].<table-wrap id="Tab2"><label>Table 2</label><caption><p>Surgical treatment protocol</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Surgical protocol</th><th colspan="4">Bone quality</th></tr><tr><th></th><th>D1</th><th>D2</th><th>D3</th><th>D4</th></tr></thead><tbody><tr><td>1. Drilling sequence (splint)</td><td>Last drill</td><td>Last drill</td><td>Second to last drill</td><td>Second to last drill</td></tr><tr><td>2. Condensing preparation</td><td>–</td><td>–</td><td>(Analogue to last drill)</td><td>Analogue to last drill</td></tr><tr><td colspan="5">3. Implant insertion (maximum torque ≤ 40 N cm)</td></tr><tr><td colspan="5">4. Expansion (maximum torque ≤ 40 N cm)</td></tr><tr><td colspan="5">5. Evaluation of primary stability by resonance frequency analysis, primary wound closure</td></tr><tr><td colspan="5">6. Postoperative digital radiogram</td></tr><tr><td colspan="5">7. Re-entry after a conventional period of submerged healing (mandible 3 months, maxilla 6 months), evaluation of secondary stability by resonance frequency analysis and insertion of healing abutments</td></tr><tr><td colspan="5">8. Postoperative digital radiogram</td></tr></tbody></table></table-wrap></p><p id="Par18">Digital radiograms (orthopantomogram, standard periapical radiograms) were taken prior to surgery, after implant insertion and re-entry, and at yearly follow-up examinations for crestal and periapical bone evaluation (see below).</p></sec><sec id="Sec4"><title>Implants</title><p id="Par19">In this study, a short expandable titanium screw implant (PYRAMIDION dental implant, DenTack Implants Ltd., Kfar-Saba, Israel) was used, which leads to dynamic condensing of the apical bone. The implants had the following dimensions and special characteristics: 5, 6 and 7 mm in length, 3.75 and 4.1 mm in diameter and an internal (7-mm length) or external (5- and 6-mm length) hexagon platform. The apical expansion is performed after implant insertion using a special expansion tool and a ratchet torque, resulting in a pyramid shape (Fig. <xref rid="Fig1" ref-type="fig">1a–f</xref>). The implant expansion process using the expansion tool is visualised in the movie clip (Additional file <xref rid="MOESM1" ref-type="media">1</xref>).<media xlink:href="40729_2017_107_MOESM1_ESM.mp4" id="MOESM1"><label>Additional file 1:</label><caption><p>Simulation of the expansion process. At the end of the expansion process, a minimal snap back is realised. (MP4 9407 kb)</p></caption></media><fig id="Fig1"><label>Fig. 1</label><caption><p><bold>a</bold> Closed short expandable dental implant (4.1 × 7 mm). The implant-abutment connection is characterised by an internal hexagon for rotation stability, combining the advantages of conical and parallel surfaces to reduce microgaps and micromovement [<xref ref-type="bibr" rid="CR68">68</xref>]. The microthread concept and platform switching concept are implemented in the implant shoulder to reduce periimplant bone strain [<xref ref-type="bibr" rid="CR53">53</xref>]. <bold>b</bold> Manual fixation of the expansion tool. Take note of the distance between both <italic>yellow rings</italic>. <bold>c</bold> Completion of the expansion process using the ratchet. Take note of the contact between both <italic>yellow rings</italic>. <bold>d</bold> Opened short expandable dental implant (4.1 × 7 mm). The expanded implant provides an increased bone-to-implant interface (<italic>pyramid shape</italic>) in the apical portion [<xref ref-type="bibr" rid="CR54">54</xref>]. <bold>e</bold> Cross-section view of the implant apex. The apical expansion process is characterised by the unfolding of four wings, which are connected by four foils. D1: diameter of the closed implant. D2: diameter of the opened implant. <bold>f</bold><italic>Top view</italic> of the expanded implant. The expanded implant (4.1-mm diameter) displays an apical diameter of 4.7 mm and length of the edge (base) of 4.4 mm</p></caption><graphic xlink:href="40729_2017_107_Fig1_HTML" id="MO1"></graphic></fig></p></sec><sec id="Sec5"><title>Surgical and prosthetic protocol</title><p id="Par20">Planning of the implantological treatment followed usual clinical and radiological examination and, concerning the position and number of implants, the recommended categories from the German consensus conference [<xref ref-type="bibr" rid="CR35">35</xref>]. The drilling sequence, condensing preparation (where necessary) and manual implant insertion as well as expansion are described in detail in Table <xref rid="Tab2" ref-type="table">2</xref>. Participants were instructed not to wear their denture 1 week after surgery. Afterwards, the conventional dentures were relined with soft material (Visco-gel, Dentsply, Salzburg, Austria). In this study, conventional periods of submerged healing were chosen: 3 months in the mandible and 6 months in the maxilla. During the re-entry surgery, a minimum of 2-mm keratinised periimplant soft tissue mucosa was considered.</p><p id="Par21">All prosthetic treatments were provided at the University School of Dental Medicine, Department of Prosthetic Dentistry. At the earliest, 2 weeks after surgical re-entry, prosthetic treatment was started. All treatment steps were performed as described in detail in Table <xref rid="Tab3" ref-type="table">3</xref>. The abutment screws were fixed with a torque of 15 N cm. Wherever possible, adjacent implants were primarily splinted (crowns, bar) and <italic>extra-axial</italic> loading during dynamic occlusion was avoided. In other cases, eccentric group guidance was achieved. To reduce overloading in the periimplant bone and implant-abutment connection, the occlusal surface was designed smaller [<xref ref-type="bibr" rid="CR20">20</xref>, <xref ref-type="bibr" rid="CR21">21</xref>, <xref ref-type="bibr" rid="CR30">30</xref>, <xref ref-type="bibr" rid="CR36">36</xref>]. Patients were instructed about optimal oral hygiene, and the use of a dental water jet was recommended.<table-wrap id="Tab3"><label>Table 3</label><caption><p>Prosthetic treatment protocol</p></caption><table frame="hsides" rules="groups"><thead><tr><th colspan="2">Type of prosthetic treatment</th><th>Session</th><th>Procedure</th></tr></thead><tbody><tr><td rowspan="3" colspan="2">Fixed denture (bridge)</td><td>1</td><td>Open impression</td></tr><tr><td>2</td><td>Abutment check, set-up<break></break> • Titanium abutments<break></break> • Non-precious metal framework, completely lined<break></break> • Neighbouring crowns interlocked</td></tr><tr><td>3</td><td>Check and insertion of the suprastructure<break></break> • Cementation (ImProv™, Dentegris, Duisburg, Germany)</td></tr><tr><td rowspan="6">Combined fixed-removable denture</td><td rowspan="6">Telescope</td><td>1</td><td>Open impression (implants and stumps)</td></tr><tr><td>2</td><td>Jaw relation (wax splint)</td></tr><tr><td>3</td><td>Aesthetic check</td></tr><tr><td>4</td><td>Check of the primary telescope, fixation impression</td></tr><tr><td>5</td><td>Complete check</td></tr><tr><td>6</td><td>Insertion of the definitive denture<break></break> • Cementation of the primary telescope (Ketac™ Cem, 3M ESPE, Neuss, Germany)</td></tr><tr><td rowspan="11">Removable denture</td><td rowspan="7">Jaw bar</td><td>1</td><td>Open impression</td></tr><tr><td>2</td><td>Abutment check</td></tr><tr><td>3</td><td>Jaw relation (wax splint)</td></tr><tr><td>4</td><td>Aesthetic check</td></tr><tr><td>5</td><td>Jaw bar check</td></tr><tr><td>6</td><td>Complete check</td></tr><tr><td>7</td><td>Finishing</td></tr><tr><td rowspan="4">Ball attachment</td><td>1</td><td>Impression of the edentulous alveolar ridge</td></tr><tr><td>2</td><td>Jaw relation (wax splint)</td></tr><tr><td>3</td><td>Aesthetic check</td></tr><tr><td>4</td><td>Chairside insertion of the matrices</td></tr></tbody></table></table-wrap></p><p id="Par22">All treatments were provided by two experienced maxillofacial surgeons (WR, CH) and two experienced prosthodontists (RS, JH) to minimise bias.</p></sec><sec id="Sec6"><title>Follow-up investigation</title><p id="Par23">The first clinical follow-up was arranged at the latest 4 weeks after prosthetic treatment was completed. Further follow-ups were scheduled quarterly in the first year and later every 6 months. Patients were screened clinically and radiologically (yearly) for biological and technical complications. The authors applied the abovementioned success criteria according to Buser et al. [<xref ref-type="bibr" rid="CR32">32</xref>]. Crestal bone changes were evaluated on digital radiograms (SIDEXIS imaging software, Sirona, Bensheim, Germany). The distance between the implant shoulder and first bone-implant contact at the mesial and distal aspect of each implant was measured (implant length as reference) by the first author (WR), and the mean values per implant were calculated [<xref ref-type="bibr" rid="CR37">37</xref>] 1 and 2 years after loading.</p></sec><sec id="Sec7"><title>Data gathering and statistics</title><p id="Par24">All patients were pseudonymised, parameters were attached to a databank and analysed statistically (Additional file <xref rid="MOESM2" ref-type="media">2</xref>). Statistical analyses were performed using statistics software (IBM SPSS statistics, version 20, Chicago, IL, USA). The descriptive statistics presented the frequency and distribution of several occurrences as well as combinations of certain features. Analytical statistics were performed depending on the scale: paired and independent <italic>t</italic> tests for differences of mean values. The implant survival was calculated according to the Kaplan-Meyer method. The level of significance was set at 5%.</p></sec></sec><sec id="Sec8"><title>Results</title><p id="Par25">The first results of this longitudinal study include data from 9 patients with an average age of 57 years (range from 44 to 80) in whom 30 implants were inserted (maxilla <italic>n</italic> = 15, mandible <italic>n</italic> = 15). All 30 implants in the 9 patients could be inserted without intraoperative problems. Based on intraoperative and radiological findings, the bone quality was assessed as follows: D1 in <italic>n</italic> = 2, D2 in <italic>n</italic> = 3, D3 in <italic>n</italic> = 2 and D4 in <italic>n</italic> = 2 cases. The employed implant dimensions were as follows: 4.1 × 5 mm (<italic>n</italic> = 2), 4.1 × 6 mm (<italic>n</italic> = 1), 4.1 × 7 mm (<italic>n</italic> = 10) and 3.75 × 7 mm (<italic>n</italic> = 17). The expansion process could successfully be performed in every case. The healing period was uneventful. Patients were rehabilitated with fixed dentures in 5 cases and with removable dentures in 4 cases. Basic clinical characteristics are summarised in detail in Table <xref rid="Tab4" ref-type="table">4</xref>.<table-wrap id="Tab4"><label>Table 4</label><caption><p>Clinical characteristics of the study cohort</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Patient</th><th>Sex</th><th>Age (years)</th><th>Implant position (<italic>FDI</italic>)</th><th>Indication category<sup>a</sup></th><th>Bone quality</th><th>Prosthetic treatment</th><th>Follow-up (months)</th><th>Implant failure</th></tr></thead><tbody><tr><td>1. T. I.</td><td>F</td><td>80</td><td>Maxilla 15, 13, 11, 21, 25 (Σ = 5)</td><td>IIa</td><td>D4</td><td>Telescope</td><td>37</td><td><italic>n</italic> = 1<sup>c</sup></td></tr><tr><td>2. G. S.</td><td>F</td><td>65</td><td>Mandible 34, 32, 42, 44 (Σ = 4)</td><td>IIIb</td><td>D1</td><td>Ball attachment</td><td>34</td><td>None</td></tr><tr><td>3. S. Sa.</td><td>F</td><td>64</td><td>Maxilla 14, 12, 22, 24 (Σ = 4)</td><td>IIIa<sup>b</sup></td><td>D4</td><td>Jaw bar</td><td>34</td><td>None</td></tr><tr><td>4. Th. F.</td><td>M</td><td>76</td><td>Mandible 35, 36, 37 (Σ = 3)</td><td>IIb</td><td>D1</td><td>Bridge</td><td>33</td><td>None</td></tr><tr><td>5. A. M.</td><td>F</td><td>44</td><td>Maxilla 16, 15, 14 (Σ = 3)</td><td>IIa</td><td>D3</td><td>Bridge</td><td>32</td><td>None</td></tr><tr><td>6. S. M.</td><td>M</td><td>53</td><td>Maxilla 16, 14, 12 (Σ = 3)</td><td>IIa</td><td>D3</td><td>Ball attachment</td><td>32</td><td><italic>n</italic> = 1<sup>d</sup></td></tr><tr><td>7. K. S.</td><td>F</td><td>52</td><td>Mandible 35, 36, 37 (Σ = 3)</td><td>IIb</td><td>D2</td><td>Bridge</td><td>29</td><td>None</td></tr><tr><td>8. R. C.</td><td>F</td><td>59</td><td>Mandible 35, 36 (Σ = 2)</td><td>IIb</td><td>D2</td><td>Bridge</td><td>24</td><td>None</td></tr><tr><td>9. W. K.</td><td>F</td><td>72</td><td>Mandible 47, 45, 43 (Σ = 3)</td><td>IIb</td><td>D2</td><td>Bridge</td><td>23</td><td>None</td></tr></tbody></table><table-wrap-foot><p><italic>FDI</italic> implant position according to the World Dental Federation</p><p><sup>a</sup>Indication categories (IIa, IIb, IIIa, IIIb) with regard to the amount of implants [<xref ref-type="bibr" rid="CR35">35</xref>]</p><p><sup>b</sup>Modified due to local conditions</p><p><sup>c</sup>Implant loss before loading</p><p><sup>d</sup>Implant loss after loading</p></table-wrap-foot></table-wrap></p><p id="Par26">Over the 3-year follow-up period, the overall cumulative implant success rate in these patients was 28/30 (93.3%). Two implants were lost in the posterior maxilla. The two affected patients had highly atrophic posterior maxillae (Cawood et Howell IV–V) [<xref ref-type="bibr" rid="CR38">38</xref>] and a bone quality of D3–D4 (Table <xref rid="Tab4" ref-type="table">4</xref>). The male patient was a smoker and suffered from a squamous cell carcinoma of mouth floor. In both cases, the manufactured removable denture was successfully relined and no technical complications were observed to date.</p><p id="Par27">The Kaplan-Meyer analysis of implant survival for both jaws is visualised in Fig. <xref rid="Fig2" ref-type="fig">2</xref> (log rank test, <italic>p</italic> = 0.173): 1-year survival 96.7% and 2-year survival 93.3%. The 3-year follow-up has not yet been completed by all patients (Table <xref rid="Tab4" ref-type="table">4</xref>).<fig id="Fig2"><label>Fig. 2</label><caption><p>Cumulative implant survival over the follow-up period. The Kaplan-Meyer diagram visualises the analysis of implant survival in the maxilla and in the mandible (log rank test, <italic>p</italic> = 0.173) over the follow-up period up to 37 months (Table <xref rid="Tab4" ref-type="table">4</xref>)</p></caption><graphic xlink:href="40729_2017_107_Fig2_HTML" id="MO2"></graphic></fig></p><p id="Par28">Measurements of implant stability by resonance frequency analysis (RFA) displayed the following ISQ values: primary stability 69.7 ± 10.3 95% CI (65.9; 73.6) ISQ units and secondary stability 69.8 ± 10.2 95% CI (65.8; 73.5) ISQ units (Fig. <xref rid="Fig3" ref-type="fig">3a, b</xref>). The differences were not statistically significant (<italic>p</italic> = 0.780; paired <italic>t</italic> test). In detail, the ISQ values for primary stability displayed in the maxilla 66.9 ± 8.9 95% CI (61.9; 71.8), and in the mandible 72.5 ± 11.1 95% CI (66.4; 78.7). The differences were not statistically significant (<italic>p</italic> = 0.134; independent <italic>t</italic> test). According to the measurement of secondary implant stability, we observed comparable ISQ values in the maxilla 66.4 ± 10.0 95% CI (60.9; 71.9) and higher ISQ values in the mandible 73.0 ± 9.7 95% CI (67.6; 78.4). The differences were as well not statistically significant (<italic>p</italic> = 0.780; independent <italic>t</italic> test).<fig id="Fig3"><label>Fig. 3</label><caption><p><bold>a</bold> Primary implant stability. The histogram visualises the distribution of the implant stability quotients (ISQ) for both jaws measured by resonance frequency analysis (Osstell AB, Göteborg, Sweden). <bold>b</bold> Secondary implant stability. The histogram shows the distribution of the implant stability quotients (ISQ) of osseointegrated implants. According to the measurement implant stability was classified as <italic>low</italic> with ISQ values < 60, <italic>medium</italic> with ISQ values 60–70, and <italic>high</italic> with values ISQ > 70 [<xref ref-type="bibr" rid="CR34">34</xref>]</p></caption><graphic xlink:href="40729_2017_107_Fig3_HTML" id="MO3"></graphic></fig></p><p id="Par29">Over the follow-up period, the mean crestal bone changes after loading were as follows (each compared to the baseline): in the first year, 1.0 ± 0.9 mm 95% CI (0.5; 1.5) in the maxilla and 0.7 ± 0.4 mm 95% CI (0.5; 1.0) in the mandible (<italic>p</italic> = 0.011; independent <italic>t</italic> test), and in the second year, 1.3 ± 0.8 mm 95% CI (0.8; 1.7) in the maxilla and 1.0 ± 0.7 mm 95% CI (0.6; 1.4) in the mandible (<italic>p</italic> = 0.644; independent <italic>t</italic> test). Clinical and radiological investigations did not reveal any inflammatory signs or radiolucency in the periapical region for all inserted implants.</p><p id="Par30">A representative case of a rehabilitated female patient is visualised in Fig. <xref rid="Fig4" ref-type="fig">4a–h</xref> and Fig. <xref rid="Fig5" ref-type="fig">5a–d</xref> (radiograms).<fig id="Fig4"><label>Fig. 4</label><caption><p><bold>a–h</bold> Prosthetic restauration—follow-up examination. Intraoral and perioral views of a rehabilitated female patient. (She asked explicitly only for implantological treatment in the mandible.)</p></caption><graphic xlink:href="40729_2017_107_Fig4_HTML" id="MO4"></graphic></fig><fig id="Fig5"><label>Fig. 5</label><caption><p><bold>a</bold> Postoperative orthopantomogram. <bold>b</bold> Follow-up orthopantomogram. <bold>c</bold> Follow-up standard periapical radiogram (implants i42 and i44). <bold>d</bold> Follow-up standard periapical radiogram (implants i32 and i34)</p></caption><graphic xlink:href="40729_2017_107_Fig5_HTML" id="MO5"></graphic></fig></p></sec><sec id="Sec9"><title>Discussion</title><p id="Par31">Recent literature has shown that short implants have achieved growing acceptance in the field of oral implantology [<xref ref-type="bibr" rid="CR9">9</xref>, <xref ref-type="bibr" rid="CR10">10</xref>, <xref ref-type="bibr" rid="CR39">39</xref>, <xref ref-type="bibr" rid="CR40">40</xref>]. Since the last years, concern has decreased about the length of endosseous implants; it should be noted that all extraoral screw implants are short implants [<xref ref-type="bibr" rid="CR41">41</xref>, <xref ref-type="bibr" rid="CR42">42</xref>]. Nevertheless, there are local physiological and biomechanical differences regarding long-term stability.</p><p id="Par32">The survival rate of short dental implants was found to increase from 80 to > 90% over time [<xref ref-type="bibr" rid="CR39">39</xref>]. This is also confirmed in recent studies. For short dental implants supporting single crowns and fixed bridges especially in the mandible, a 2-year success rate of 97% [<xref ref-type="bibr" rid="CR43">43</xref>] and a 5-year outcome of 92.2% [<xref ref-type="bibr" rid="CR10">10</xref>] are reported. Otherwise, the success rate of 100% in the maxilla (3-year outcome) [<xref ref-type="bibr" rid="CR15">15</xref>] must be critically questioned in view of our findings.</p><p id="Par33">Only a few reports in the literature have addressed <italic>expandable dental implants</italic> [<xref ref-type="bibr" rid="CR44">44</xref>–<xref ref-type="bibr" rid="CR47">47</xref>]. In 2001, Jo and co-authors reported about a 40-month prospective survival of an expandable standard-length implant (10–16 mm) for immediate loading. They found a 3-year survival rate of 96.1% in the maxilla and of 94.8% in the mandible [<xref ref-type="bibr" rid="CR46">46</xref>]. Huré and co-authors [<xref ref-type="bibr" rid="CR47">47</xref>] performed a biomechanical and histologic canine study on early loaded expandable implants of 10- and 11.5-mm lengths. Six years later (2010), in orthopaedic surgery, an expandable implant was introduced [<xref ref-type="bibr" rid="CR48">48</xref>]. Similar with the present study, these authors addressed implants under difficult regional bony conditions.</p><p id="Par34">The purpose of our study was to evaluate the intraoperative handling, safety and feasibility of a new <italic>expandable dental implant</italic> system in a heterogeneous study cohort. We found in the present pilot study an overall 3-year implant success rate of 93.3%, which is comparable with recent literature [<xref ref-type="bibr" rid="CR39">39</xref>]. To the best of our knowledge (PubMed), the present clinical study is the first published investigation about the usage of an <italic>expandable short dental implant system</italic>. Therefore, directly comparable data from other clinical studies are missing.</p><p id="Par35">Several investigators analysed the preferred indications of short dental implants in the posterior mandible or maxilla and outlined the cost efficiency compared to additional vertical augmentations. In the present trial, we used a new short implant in both jaws and nearly all possible indication categories were represented, which proves the broad versatility (Table <xref rid="Tab4" ref-type="table">4</xref>).</p><p id="Par36">In our study, two implant failures occurred early in the prosthetic period and under loading. In a former systematic review, 11 studies reported more short implant failures <italic>before</italic> loading, while 7 studies reported more implant failures <italic>after</italic> loading [<xref ref-type="bibr" rid="CR39">39</xref>]. Regarding the implant success rate in the present study, it must be considered that the lost implants were associated with difficult surgical conditions. Besides biological failures, in this study cohort, no technical complications were observed. In accordance with earlier comparative studies, it is evident that when using short implants, there is a lower risk of complications compared to augmentation [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR7">7</xref>, <xref ref-type="bibr" rid="CR8">8</xref>] and nerve lateralisation [<xref ref-type="bibr" rid="CR40">40</xref>].</p><p id="Par37">Why design modifications? This is a matter of reduction of the healing period [<xref ref-type="bibr" rid="CR46">46</xref>], the gain of stability under difficult conditions and increased bone-to-implant contact [<xref ref-type="bibr" rid="CR27">27</xref>, <xref ref-type="bibr" rid="CR49">49</xref>–<xref ref-type="bibr" rid="CR51">51</xref>] and the fact that most complications of short implants occur in the <italic>preprosthetic period</italic> [<xref ref-type="bibr" rid="CR39">39</xref>]. It is also a question of long-term crestal bone stability. Earlier biomechanical finite-element studies confirmed that apical expansion results in favourable stress reduction in the <italic>crestal bone</italic> of nearly 10% [<xref ref-type="bibr" rid="CR52">52</xref>]. It is assumable that additionally to the microthread and platform-switching concept [<xref ref-type="bibr" rid="CR53">53</xref>], the periimplant bone strain could be reduced by apical expansion. This issue requires separate consideration in further studies. The employed implant design (especially its 7-mm length) combines several favourable biomechanical features, which were considered in this study (Fig. <xref rid="Fig1" ref-type="fig">1a, d</xref>).</p><p id="Par38">According to Gehrke and co-authors, and in relation to the present study, the <italic>apical implant design</italic> influences the implant stability and bone-to-implant contact [<xref ref-type="bibr" rid="CR54">54</xref>]. The expansion procedure presents an additional bicortical anchorage [<xref ref-type="bibr" rid="CR17">17</xref>] in the oro-vestibular direction. In hard bone, this might be a disadvantage and lead to asymmetrical expansion. Manufacturers’ recommendations for hard bone should be strongly considered.</p><p id="Par39">Regarding resonance frequency analysis, the values are related to bone quality and quantity as well as the exposed implant height above the alveolar crest, which depends on the type of implant and insertion technique [<xref ref-type="bibr" rid="CR55">55</xref>–<xref ref-type="bibr" rid="CR57">57</xref>]. Our results (primary stability in the maxilla 66.9 ± 8.9 ISQ units and in the mandible 72.5 ± 11.1 ISQ units; secondary stability in the maxilla 66.4 ± 10.0 ISQ units and in the mandible 73.0 ± 9.7 ISQ units) are comparable with the results from Becker and co-authors (standard-length implants): primary stability 72.1 ISQ units and secondary stability 72.6 ISQ units [<xref ref-type="bibr" rid="CR58">58</xref>]. These values are marginally lower than those of short implants inserted only in the <italic>posterior mandible</italic> (79.0 ISQ units) [<xref ref-type="bibr" rid="CR12">12</xref>]. Other authors measured in the <italic>posterior maxilla</italic> 68.2 ISQ units (6-mm implants) [<xref ref-type="bibr" rid="CR15">15</xref>]. Altogether, our mean results (Fig. <xref rid="Fig2" ref-type="fig">2a, b</xref>) represent high stability values [<xref ref-type="bibr" rid="CR34">34</xref>]. Huré and co-authors [<xref ref-type="bibr" rid="CR47">47</xref>] measured in their animal study the following stability values (expandable implant of ≥ 10-mm length): for primary stability, 53.6 ± 3.0 ISQ units, and for secondary stability (3 months after insertion), 59 ± 4.5 ISQ units. The evaluation of stability values during the osseointegration period was not possible in our trial due to submerged healing. The question, whether the level of implant stability achieved at insertion can be maintained during the early healing period, remains. This should be analysed separately for all bone types in front of the known lowest stability values at 3–4 weeks after placement for all bone types [<xref ref-type="bibr" rid="CR59">59</xref>–<xref ref-type="bibr" rid="CR61">61</xref>] and the recent attempts of immediate [<xref ref-type="bibr" rid="CR14">14</xref>] or early (6 weeks) functional loading of other short implant systems [<xref ref-type="bibr" rid="CR28">28</xref>]. In relation to the results by McCullough and Klokkevold [<xref ref-type="bibr" rid="CR62">62</xref>], who found that the macrothread design appears to play a positive role in implant stability in the early healing period, this can also be assumed for the employed implant system. Additionally, with regard to the results by Marković and co-authors [<xref ref-type="bibr" rid="CR61">61</xref>], a critical stability drop down due to bone remodeling after bone condensing (implant site preparation and/or using expandable implants) should not be suspected; the opposite can be expected. The authors analysed the implant stability (4.1 × 10-mm screw implant) in the posterior maxilla in vivo depending on the implant site preparation (bone condensing vs. bone drilling) and confirmed that, after bone condensing, significantly higher implant stability results were achieved, immediately after implant insertion as well as during the whole observation period of 6 weeks. Especially in the third week in both groups, the following results were measured: 66.7 ± 1.64 vs. 57.1 ± 1.45 (<italic>p</italic> < 0.001). [<xref ref-type="bibr" rid="CR61">61</xref>]. In the present study, we measured in the posterior maxilla 66.3 ± 10.4 ISQ units for primary stability and 66.9 ± 12.0 ISQ units for secondary stability, respectively.</p><p id="Par40">Contrary to conventional hollow-screw implants (only marginal gap), a problem of the expandable implant is the presence of gaps down to the apical region. Former microbial assessment of different implant-abutment interfaces displayed that none of the marginal connections had the capacity to prevent microbial leakage [<xref ref-type="bibr" rid="CR63">63</xref>–<xref ref-type="bibr" rid="CR65">65</xref>]. Therefore, an apical microleakage (comparable to distractable implants and endodontically treated teeth) might be a disadvantage of the evolved implant system [<xref ref-type="bibr" rid="CR66">66</xref>, <xref ref-type="bibr" rid="CR67">67</xref>]. However, according to the manufacturer’s information, a microbiological study revealed no microbial leakage through the expanded implants. Over the follow-up period, we equally did not observe any inflammatory signs in the apical region, neither clinically nor radiologically (Figs. <xref rid="Fig4" ref-type="fig">4b</xref> and <xref rid="Fig5" ref-type="fig">5c–d</xref>). Nevertheless, this aspect should be analysed under mechanical loading in vitro. Based on an earlier animal histologic study [<xref ref-type="bibr" rid="CR47">47</xref>], as well as a clinical up-to-40-month study [<xref ref-type="bibr" rid="CR46">46</xref>], which referred to comparable apically expandable implants, authors did not report any periapical inflammatory complications. To eliminate the potential risk of deep intrabony microleakage, it is questionable whether equal biomechanical stability values can be achieved only by the macrothread design avoiding any deep microgaps.</p><p id="Par41">In the present study, the crestal bone changes under loading in the first year exceeded that of the second year. Moreover, the differences between the maxilla and mandible in each year were not statistically significant, which only partially agrees with previous findings in the literature [<xref ref-type="bibr" rid="CR7">7</xref>, <xref ref-type="bibr" rid="CR58">58</xref>]. Besides microbiological conditions, there are several biomechanical aspects which influence maintenance of periimplant crestal bone. Conical and parallel surfaces of the implant-abutment connection (internal hexagon) provide rotational stability and reduce microgaps and micromovement [<xref ref-type="bibr" rid="CR68">68</xref>]. Another important factor is the thickness of the implant shoulder [<xref ref-type="bibr" rid="CR69">69</xref>], which might be a weak point in the design of a short implant due to elastic deformity under <italic>extra-axial</italic> loading. This fact might be the reason for non-inflammatory periimplant crestal bone loss. We addressed this aspect by splitting adjacent implants wherever possible [<xref ref-type="bibr" rid="CR50">50</xref>, <xref ref-type="bibr" rid="CR51">51</xref>]. According to Brenner and co-authors [<xref ref-type="bibr" rid="CR30">30</xref>] as well as Pommer and co-authors [<xref ref-type="bibr" rid="CR50">50</xref>], the following <italic>prosthodontic factors</italic> are to be considered to avoid screw loosening, component fracture, loss of marginal bone or even loss of osseointegration: crown-to-implant ratio (extra-axial loading), cantilever length, status of opposing dentition, splinting of adjacent implants, occlusal surface relief and dimensions.</p><p id="Par42">Comparable studies displayed at 24 months a crestal bone loss of 0.5–0.6 mm [<xref ref-type="bibr" rid="CR15">15</xref>]. Other authors reported at 2, 3 and 5 years a mean loss of 0.57, 0.55 and 0.53 mm, respectively, in the mandible (without significant change after 1 year) [<xref ref-type="bibr" rid="CR10">10</xref>]. On the other hand, randomised controlled trials demonstrated 1 year after loading periimplant marginal bone loss of 0.7 mm [<xref ref-type="bibr" rid="CR70">70</xref>] and 1.1 mm [<xref ref-type="bibr" rid="CR7">7</xref>] in the mandible which is the same value measured in the present study.</p><p id="Par43">Within the limitations of a pilot study design, low number of implants, single-arm study and short-term follow-up, the results show a basic improvement of functional rehabilitation especially for elderly patients with compromised general and local conditions for implantation. Controversial questions [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR71">71</xref>] remain on whether (a) short implants are suitable for irradiated patients and (b) there is a need for expandable short implants in the D1 bone. Furthermore, potential bias should be eliminated in future studies by a randomised controlled trial.</p></sec><sec id="Sec10"><title>Conclusion</title><p id="Par44">Initial results of the ongoing study confirm the feasibility and safety of the employed system. The implant type seems to be useful for all bone qualities and shows high initial and secondary biomechanical stability in the maxilla and mandible. Long-term follow-up will be needed in validating these initial results in a larger 3-year clinical trial. Crestal bone changes should be evaluated in a larger study cohort. The novel system might extend the spectrum in functional rehabilitation.</p></sec><sec sec-type="supplementary-material"><title>Additional files</title><sec id="Sec11"><p><supplementary-material content-type="local-data" id="MOESM2"><media xlink:href="40729_2017_107_MOESM2_ESM.sav"><label>Additional file 2:</label><caption><p>Dataset presenting relevant raw data. (SAV 3 kb)</p></caption></media></supplementary-material></p></sec></sec></body><back><glossary><title>Abbreviations</title><def-list><def-item><term>D1, D2, D3, D4</term><def><p id="Par5">Bone quality (density)</p></def></def-item><def-item><term>FDI</term><def><p id="Par532">World Dental Federation</p></def></def-item><def-item><term>ISQ</term><def><p id="Par6">Implant stability quotient</p></def></def-item><def-item><term>RFA</term><def><p id="Par7">Resonance frequency analysis</p></def></def-item></def-list></glossary><fn-group><fn><p><bold>Electronic supplementary material</bold></p><p>The online version of this article (10.1186/s40729-017-0107-1) contains supplementary material, which is available to authorized users.</p></fn></fn-group><ack><title>Acknowledgements</title><p>The authors are grateful to the DenTack Company for providing some of the implants and components used in this study. The courtesy of Oz Vachtenberg is acknowledged for providing Fig. <xref rid="Fig1" ref-type="fig">1</xref>a–f and the movie clip. There are no financial supports or conflicts of interest associated with this publication that could have influenced its outcome. We thank the Osstell Company, which supplied the RFA device and Smartpegs used in this study. We acknowledge American Journal Experts (AJE) for providing English language editing (certificate verification key: 06DA-C0B2-2672-4103-A251). In addition, the authors thank the dental technicians from the dental laboratory Rübeling and Klar, Berlin, Germany, for their kind support in manufacturing all dental prostheses. Furthermore, we thank all involved members of the surgical and prosthodontic teams.</p><sec id="FPar10"><title>Funding</title><p id="Par100">No funding received.</p></sec><sec id="FPar1"><title>Availability of data and materials</title><p id="Par45">The dataset supporting the conclusions of this article is included within the article and its additional files.</p></sec></ack><notes notes-type="author-contribution"><title>Authors’ contributions</title><p>WR was responsible for the preparation of the study protocol, surgical treatment, data acquisition, statistics and preparation of the manuscript. RS was responsible for prosthetic treatment. CH was responsible for surgical treatment, radiological analysis and statistics. JH was responsible for preparation of the study protocol, prosthetic treatment and interpretation of the data. BA was responsible for interpretation of the data and approval of the final manuscript version to be submitted. AWE was responsible for the approval of the study protocol and interpretation of the data. All authors read and approved the final manuscript.</p></notes><notes notes-type="COI-statement"><sec id="FPar2"><title>Authors’ information</title><p id="Par46">WR is a senior physician at the University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Oral and Plastic Maxillofacial Surgery, Halle/Saale, Germany.</p><p id="Par47">RS is a clinical research associate at the University School of Dental Medicine, Department of Prosthetic Dentistry, Martin Luther University Halle-Wittenberg, Halle/Saale, Germany.</p><p id="Par48">CH is a consultant at the University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Oral and Plastic Maxillofacial Surgery, Halle/Saale, Germany.</p><p id="Par49">JH is an assistant professor at the University School of Dental Medicine, Department of Prosthetic Dentistry, Martin Luther University Halle-Wittenberg, Halle/Saale, Germany.</p><p id="Par50">BA is professor and the head of the department at the University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Oral and Plastic Maxillofacial Surgery, Halle/Saale, Germany.</p><p id="Par51">AWE is a senior assistant professor at the University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Oral and Plastic Maxillofacial Surgery, Halle/Saale, Germany.</p></sec><sec id="FPar3"><title>Ethics approval and consent to participate</title><p id="Par52">All procedures performed in the study were in accordance with the ethical standards of the institutional research committee (date of issue 21 August 2014, registration number 2014-60) and with the 1964 Helsinki declaration and its later amendments.</p><p id="Par53">Informed consent was obtained from all individual participants included in this study.</p></sec><sec id="FPar4"><title>Consent for publication</title><p id="Par54">Not applicable</p></sec><sec id="FPar5"><title>Competing interests</title><p id="Par55">Waldemar Reich, Ramona Schweyen, 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