Int. J. Oral Maxillofac. Surg.

2014; 43: 1484–1492

http://dx.doi.org/10.1016/j.ijom.2014.08.003, available online at http://www.sciencedirect.com

Clinical Paper
Dental Implants

Clinical evaluation of S. K. Nemli, M. B. Güngör,

C. Aydın, H. Yılmaz, İ.Türkcan,
H. Demirköprülü

submerged and non-submerged Department of Prosthodontics, Faculty of

Dentistry, Gazi University, Ankara, Turkey

implants for posterior

single-tooth replacements: a
randomized split-mouth
clinical trial
S. K. Nemli, M. B. Güngör, C. Aydın, H. Yılmaz, İ. Türkcan, H. Demirköprülü:
Clinical evaluation of submerged and non-submerged implants for posterior
single-tooth replacements: a randomized split-mouth clinical trial. Int. J. Oral
Maxillofac. Surg. 2014; 43: 1484–1492. # 2014 International Association of Oral
and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this study was to evaluate clinical and radiographic results of
submerged and non-submerged implants for posterior single-tooth replacements
and to assess patient-based outcomes. Twenty patients were included in the study. A
split-mouth design was used; implants inserted using a submerged technique were
compared to those inserted with a non-submerged technique. Implants were restored
with metal–ceramic crowns after 3 months. Reconstructions were examined at
baseline, 6, 12, and 24 months. Standardized radiographs were made. Radiographic
crestal bone level changes were calculated, as well as soft tissue parameters,
including pocket probing depth, bleeding on probing, plaque index, and gingival
index. Results were analyzed by two-way repeated measures of variance (ANOVA).
To evaluate patient-based outcomes, patients were asked to complete a
questionnaire at the 6-month follow-up; the Wilcoxon paired signed rank test was
used to compare scores. The data of 18 patients were reviewed. During 24 months,
non-submerged implants (0.57  0.21 mm) showed significantly lower bone loss
Key words: dental implant; single tooth repla-
than submerged implants (0.68  0.22 mm) (P < 0.01). Patient satisfaction with
cement; submerged implant; non-submerged
non-submerged implants (median 87.5) was significantly higher than with implant; clinical evaluation..
submerged implants (median 81.5) (P < 0.01). Non-submerged implants showed
comparable clinical results to submerged implants and resulted in higher patient Accepted for publication 13 August 2014
satisfaction due to decreased surgical intervention. Available online 6 September 2014

0901-5027/01201484 + 09 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Submerged and non-submerged implant placement 1485

Over the past 35 years, endosseous dental present study was designed to evaluate mucosal or bone lesions; not being a heavy
implants have demonstrated predictable clinical and radiographic results of sub- bruxer or clencher; single-tooth bilateral
results when used to support restorations merged and non-submerged implants for edentulous sites in the canine, premolar, or
that replace missing teeth.1–6 Currently, single-tooth replacements in the same pa- molar region with adequate bone width
probably the most common indication for tient using a split-mouth technique and to and similar bone height at the implant
implant placement is restoration of a miss- assess patient-based outcomes with the sites; at least 2 months since tooth extrac-
ing or failing single tooth.7,8 Success rates two treatment protocols. The hypothesis tion; good arch stability (or an occlusal
for single-tooth replacements supported was that there would be no difference in scheme that allowed the establishment of
by implants have been very promising results between the two surgical methods identical occlusal cusp/fossa contacts).
in terms of both implant survival and concerning implant survival, clinical pa- A total of 20 patients were treated
prosthetic outcomes.9–11 The results of rameters, and patient satisfaction. according to the study protocol. The sur-
implant-supported single-tooth replace- gical procedure was performed under local
ments are commonly evaluated indepen- anaesthesia. Each patient received two
dently, because there are differences Materials and methods implants (IDcam implants; IDI, Paris,
between edentulous and partially edentu- A split-mouth study was designed to de- France). The main features of the implant
lous patients that may have an impact on termine any differences in outcome be- include a threaded, tapered shape, with a
the final result.12 Single implant restora- tween implants installed using the Morse taper implant–abutment connec-
tions are more prone to biomechanical submerged surgical technique and those tion, and a concave-shaped apex design
complications because they are subjected installed using the non-submerged tech- (CSO; concave securit osseo-wedging)
to greater functional forces than splinted nique. The study protocol was reviewed (Fig. 1). The CSO apex has been designed
implants.13,14 Furthermore the replace- and approved by the clinical research to act as a bone reservoir for bone grafting
ment of one tooth may be a great aesthetic ethics board of the faculty. The CON- (with its concave shape), to limit the risks
challenge, particularly in the anterior re- SORT statement (http://www.consort-sta- of damaging the sinus membrane and
gion. In contrast to the majority of patients tement.org) was used as a guide for nerve (with its ‘securit’ round-shaped
with edentulous jaws, single-tooth repla- reporting the present clinical study. end), and to increase the apical bone re-
cements are frequently performed in Twenty patients (nine men and 11 wom- tention surface (with its peripheral and
young patients. en) ranging in age from 23 to 51 years wedging groove). For implant placement,
The original Brånemark concept pre- (mean age 38.4 years) were included in the it was considered to provide a minimal
scribed two-stage surgery with a sub- study. The surgical and prosthetic treat- 0.5 mm bone thickness around the inserted
merged healing period of 3 months in ments and follow-up visits were per- implants.
the mandible and 6 months in the maxilla formed between September 2009 and Midcrestal incisions and vertical releas-
in order to optimize the process of new October 2012. All patients received oral ing incisions were used and full thickness
bone formation and remodelling following and written information about the study flaps were reflected. One side was selected
implant installation.1 The outcome of the and those who agreed to participate gave at random to be restored with the sub-
submerged technique was verified in sev- their written consent. merged technique and the other with the
eral clinical studies, which reported high Inclusion criteria were the following: non-submerged technique. To perform
success rates.1–5 However, recent studies good general health for implant surgery; within-subject comparisons, left–right ran-
have shown that osseointegration can be no untreated periodontal disease or other domization was done directly after implant
achieved using single-stage surgery where
the implants are left to heal non-sub-
merged.15,16 Non-submerged implant
placement has gained interest since it
reduces the number of surgical interven-
tions, thus reducing the surgical time and
patient discomfort; it also results in a
healed and healthy peri-implant mucosa
at the time of prosthetic rehabilitation.17,18
However, the submerged technique is
preferable in combination with bone aug-
mentation, because it prevents overload-
ing of the implants and secures an
infection-free environment during the
healing period.18 Some studies on the
non-submerged technique have imple-
mented exclusion criteria such as bruxism
and heavy smoking.15,19,20 Although
promising results have been reported for
non-submerged implant installa-
tion,16,17,19–24 divergent results have also
been presented.18,25
Clinical studies comparing submerged
and non-submerged techniques have gen-
erally been performed in edentulous and
partially edentulous patients.16–25 The Fig. 1. IDcam implants used in this study.
1486 Nemli et al.

placement. One clinician performed the crestal bone level changes were calculat- between the zero and the X. The question-
random allocation of implants in each pa- ed. Standardized radiographs were per- naire contained two VAS for each ques-
tient and followed-up the patients between formed with an individualized custom- tion, one for the submerged implant and
implant insertion and the beginning of the made bite block using a long cone parallel one for the non-submerged implant
prosthetic procedure (abutment connec- technique. The films were placed parallel (Fig. 3). The responses were recorded.
tion). For implants allocated to the sub- to the implant long axis to provide the The results of mean marginal bone loss
merged technique, a cover screw was perpendicular direction of the beam to the and soft tissue parameters including PD,
applied and the flaps were adapted to film. Radiographs were taken at implant BOP, PI, and GI were analyzed statisti-
achieve primary closure. For the non-sub- insertion, after 6 months, 12 months, and cally by two-way repeated measures of
merged group, a healing abutment was 24 months from the placement of crowns. variance (ANOVA), with the surgical
secured to the implant and the flaps were For the evaluation of the marginal bone technique (submerged and non-sub-
adapted. During the primary healing peri- level, the radiographs were digitized. The merged) and time as independent vari-
od, chemical plaque control was recom- most coronal edges of the implant plat- ables. The Bonferroni test was used to
mended via rinsing with a 0.1% form mesially and distally were chosen as determine any significant differences
chlorhexidine solution twice daily for 1 reference points (Fig. 2). The length of the among the groups. To evaluate patient-
week. implant was used as an internal reference based outcomes with the two techniques,
Sutures were removed after 7 days. The to calibrate the measurements for distor- the mean scores obtained from the ques-
implants were allowed to osseointegrate tions. Distal and mesial bone distances tionnaire were compared using the Wil-
for 3 to 4 months. The patients did not use from the implant shoulder and marginal coxon paired signed rank test (IBM SPSS
layering provisional restorations during bony crest were measured and averaged Statistics for Windows, version 20.0; IBM
the osseointegration period. At the end for each implant. Mean bone loss values Corp., Armonk, NY, USA). All results
of osseointegration period, gingival re- were calculated from baseline to the 6-, were evaluated at the 0.05 level of signifi-
moval and abutment connection was per- 12-, and 24-month follow-ups. cance.
formed for the submerged implants To evaluate patient-based outcomes with
(second-stage surgery), and healing abut- the two techniques, each patient was asked
ment removal and abutment connection to complete a questionnaire including eight Results
was performed for the non-submerged questions at the 6-month follow-up visit. A A total of 20 patients received implants.
implants. The abutments were tightened 100-mm visual analogue scale (VAS) was Two patients were excluded from the
with a torque control device, up to used to measure patient satisfaction. Parti- study; one did not attend follow-up exam-
30 N cm. cipants were asked to answer a question by inations and the other experienced failure
Provisional restorations were placed 2 marking an X on the 100-mm horizontal of one (non-submerged) implant. Data of
weeks after the second-stage surgery. The line at the point that best reflected their the remaining 18 patients were gathered
patients used the provisional restorations perceived experience. The line was an- and evaluated in the present study. The
for 2 months; both implants were then chored by words describing the two mean age of the 18 patients (eight male
restored with metal–ceramic crowns. To extremes, e.g. 0 = completely dissatisfied and 10 female) was 38.4  8.7 years
avoid unfavourable loading of the and 100 = completely satisfied. (range 23–51 years). Five of the patients
implants, the occlusal scheme was A participant’s score was obtained by were smokers. Patient and implant data are
designed to have only light centric occlu- measuring the distance, in millimetres, summarized in Table 1.
sion, and no lateral guidance was created
at the implant crowns. All prosthetic pro-
cedures from abutment connection to ce-
mentation of the crowns were performed
by one experienced prosthodontist who
was blinded to the study assignment.
The reconstructions were examined ra-
diographically and clinically at baseline,
6, 12, and 24 months. Probing depth (PD)
measurements were recorded at the mesio-
buccal, midbuccal, distobuccal, mesiolin-
gual, midlingual, and distolingual surfaces
using Williams probes. The PD was
assessed as the longest distance between
the gingival margin and the base of the
gingival sulcus. The full mouth gingival
index (GI)26 and plaque index (PI)27 were
also determined. Bleeding on probing
(BOP) was recorded as positive if it oc-
curred within 30 s of probing. Clinical
examinations were conducted by a single,
experienced dental examiner who was not
involved in the treatment procedures and
was blinded to the study assignment.
Standardized peri-apical radiographs of
Fig. 2. Marginal bone levels on the radiograph.
the implants were taken and radiographic
 Submerged and non-submerged implant placement 1487

Fig. 3. Visual analogue scale (VAS).

1488 Nemli et al.

Table 1. Characteristics of patients and implants placed. Marginal bone level

Age, years, range/mean  SD 23–51/38.4  8.7 The mean values of mean bone loss and
Gender 8 men, 10 women
the respective standard errors of the mean
Number of implants placed 36
are represented graphically in Fig. 4. Two-
Submerged Non-submerged way ANOVA showed a significant influ-
(n = 18) (n = 18) ence of surgical technique (P < 0.01).
Implant localization Regardless of the measurement time,
1. Premolar 4 3 non-submerged implants represented sig-
2. Premolar 3 4 nificantly lower bone loss than submerged
1. Molar 10 9 implants. During 24 months, non-sub-
2. Molar 1 2 merged implants (0.57  0.21 mm)
Implant length showed significantly lower bone loss than
12 mm 14 15 submerged implants (0.68  0.22 mm)
10 mm 4 3
(P < 0.01). Mean bone loss was signifi-
Implant diameter
3.2 2 2 cantly different between measurement
4.2 16 16 times (P < 0.01) being lowest at 6 months
and highest at 24 months (from baseline).
SD, standard deviation.

Plaque index
PI findings are presented in Fig. 5. The
results of two-way ANOVA indicated that
the interactions between the surgical tech-
nique (submerged and non-submerged)
and time were not significant. At all mea-
surement times, PI values of submerged
and non-submerged implants were not
significantly different (P > 0.05). The PI
values of the implants were not signifi-
cantly different for either submerged or
non-submerged implants at 6 and 12
months, while they were significantly low-
er at 24 months (P < 0.05).

Gingival index

Fig. 4. Mean values of mean bone loss for submerged and non-submerged implants. GI results of submerged and non-sub-
*Within a time of measurement, mean values with different capital letters show statistically significant merged implants are presented in Fig. 6.
differences between submerged and non-submerged groups; two-way ANOVA (P < 0.01). No significant differences were found be-
**Within a surgical technique (submerged and non-submerged), mean values with different lower tween submerged and non-submerged
case letters show statistically significant differences between times of measurement; Bonferroni test implants at 6 and 12 months (P > 0.05).
(P < 0.05). At 24 months, the GI of submerged
implants was significantly higher than that
of non-submerged implants.

Probing depths
PD results of submerged and non-sub-
merged implants are presented in Fig. 7.
Two-way ANOVA showed a significant
influence of the surgical technique
(P < 0.01). Regardless of the time, non-
submerged implants had significantly low-
er PD results than submerged implants
(P < 0.01). The Bonferroni test showed
that, for both surgical techniques, PD was
significantly higher at 12 months than at 6
and 24 months (P < 0.05).

Bleeding on probing
Fig. 5. Plaque index values for submerged and non-submerged implants.*Within a time of
measurement, mean values with different capital letters show statistically significant differences The results of two-way ANOVA indicated
between groups; Bonferroni test (P < 0.05). that the percentages of BOP-positive sites
 Submerged and non-submerged implant placement 1489

merged technique were higher than those

for the submerged technique. Significant
differences were found for postoperative
comfort, comfort in the prosthetic phase,
satisfaction with the prosthesis, aesthetics
of the crown, cleaning ability, and general
satisfaction with the treatment (P < 0.01)
(Table 2). Patient satisfaction with non-
submerged implants (median 87.5) was
generally significantly higher than with sub-
merged implants (median 81.5) (P < 0.01).

Discussion
Fig. 6. Gingival index values for submerged and non-submerged implants.*Within a time of This prospective, randomized, split-mouth
measurement, mean values with different capital letters show statistically significant differences clinical evaluation study of submerged
between submerged and non-submerged groups; Bonferroni test (P < 0.05).**Within a surgical and non-submerged implants for posterior
technique (submerged and non-submerged), mean values with different lower case letters show
statistically significant differences between times of measurement; Bonferroni test (P < 0.05).
single-tooth replacements was carried out
with the aim of elaborating upon the lim-
ited data available in the literature. Re-
cently, there has been increased interest in
the installation of non-submerged
implants in a variety of clinical situa-
tions.16–24 However, whether non-sub-
merged or submerged healing is better
for the prognosis of dental implants
remains a matter of debate.
The findings of this study are in accor-
dance with those of previously published
clinical studies, indicating that the non-
submerged technique is as predictable as
the submerged technique.18,19,21 On the
other hand, divergent results have also
been reported showing that there may be
a greater risk of implant failure with the
Fig. 7. Probing depth values for submerged and non-submerged implants.*Within a time of non-submerged technique.22,28
measurement, mean values with different lower case letters show statistically significant Earlier clinical studies on non-sub-
differences between submerged and non-submerged groups; Bonferroni test merged implant insertion evaluated im-
(P < 0.05).**Within a surgical technique (submerged and non-submerged), mean values with plant success rates with this
different capital letters show statistically significant differences between times of measurement;
two-way ANOVA (P < 0.01).
technique.19,21,22,24 Most of these studies
showed that there was a tendency towards
greater implant loss with the non-sub-
were not significantly different between Patient satisfaction merged technique,18,22,25 due to the pos-
the two surgical techniques at any time sibility of epithelial down-growth or
The Wilcoxon paired signed rank test
(P > 0.05). BOP values are presented in fibrous encapsulation resulting in failure
showed that the mean scores obtained
Fig. 8. of the implant to osseointegrate.29 Ham-
using the questionnaire for the non-sub-
merle et al.30 investigated submerged and
transmucosal healing with two-piece
implants during a 1-year follow-up period.
It was concluded that tissue integration
and patient satisfaction with the transmu-
cosal implants were as good as with the
submerged implants. The bone level
changes from baseline to 12 months were
0.47  0.64 mm and 0.48  0.65 mm
for submerged and transmucosal implants,
respectively. The results of that study
differ from those of the present study. This
difference may be a result of using differ-
ent implant brands and the location at
which the implants were inserted.
Fig. 8. Bleeding on probing percentages for submerged and non-submerged implants during the Of note, recent studies that have evalu-
24-month study period. There was no statistical difference between the surgical techniques ated not only implant survival but also
within a time of measurement. marginal bone levels around implants
1490 Nemli et al.

Table 2. VAS scores for the non-submerged and submerged techniques obtained from the gingival index, bleeding on probing), bone
questionnaire. loss, implant mobility, and pocket depth.24
Surgery Mean Min–Max Median P-value In the present study, clinical parameters
Postoperative pain Non-submerged 80.39 56–92 81 0.082 including PI, GI, BOP, and PD were ap-
Submerged 78.17 52–90 80 plied. All of these indices were low in
Postoperative comfort Non-submerged 87.56 72–95 90 0.001a patients during the follow-up period. PI
Submerged 80.67 60–96 81 was not significantly different between the
Comfort in prosthetic phase Non-submerged 92.50 84–100 94 0.000a two surgical techniques, while significant-
Submerged 81.89 68–95 81 ly lower PI values were observed at the 24-
Satisfaction with the prosthesis Non-submerged 95.06 87–100 95 0.006a month follow-up. This may indicate im-
Submerged 91.67 80–100 92 proved oral hygiene over time as the
Aesthetics of the crown Non-submerged 95.22 88–100 95 0.004a
patients were reinstructed on hygiene pro-
Submerged 91.83 80–100 92
Chewing ability Non-submerged 93.50 82–100 94 0.077 cedures at the follow-up visits.
Submerged 91.06 78–100 91 Most clinical studies on implant therapy
Cleaning ability Non-submerged 93.56 88–100 94 0.007a have focused on biological responses to
Submerged 90.06 80–100 90 the implants, with less regard for patient-
General satisfaction Non-submerged 94.50 86–100 95 0.000a based outcomes.8–12,17–22 The gathering of
Submerged 89.44 80–100 90 information on outcomes from the
VAS, visual analogue scale. patient’s perspective in addition to biolog-
a
P < 0.05, statistically significant. ical outcomes may help the clinician to
better inform those considering implant
treatment of the expected outcome. Sev-
and other clinical parameters, have sug- anchorage of the implant. During the first eral attempts have been made to develop
gested that the non-submerged procedure year, mean bone loss is 1 to 1.5 mm, and instruments to measure patient satisfaction
may be as predictable as the conventional 0.2 mm annually is considered acceptable and oral health-related quality of life. The
submerged approach.16,17,19–21,23 Com- in following years.23 The present study VAS, for which patients are asked to mark
parative studies between submerged and revealed marginal bone loss of between a point on the line that best represents their
non-submerged implants are limited in the 0.5 and 0.7 mm at the end of the first year, opinion, has been shown to be a valid,
literature.17,19,22 The differences in study and it did not exceed 0.2 mm at the end of reliable, and reproducible instrument to
design and patient characteristics (edentu- the second year. These findings show that measure patient satisfaction in clinical
lous, partially edentulous, augmented) of the IDcam dental implants, both sub- studies.34,35 The VAS evaluation revealed
these studies make it difficult to compare merged and non-submerged, fulfilled the that patients were more satisfied with their
results. Some studies have been performed success criteria for marginal bone loss in non-submerged implants than with their
in the edentulous jaw.17,18,21,22 Non-sub- this short-term study. The marginal bone submerged implants for all aspects. While
merged implants generally showed lower loss of non-submerged implants was sig- some questions such as those on aesthetic
survival rates compared to submerged nificantly lower than that of submerged satisfaction and cleaning or chewing abil-
implants, and early implant losses before implants at the end of 24 months of fol- ity appear non-relevant to the surgical
loading were observed.18,21,22 This might low-up. The results are in accordance with technique, the higher patient satisfaction
suggest caution with the use of the non- those of previous studies.16–22 for non-submerged implants may reflect
submerged implant insertion technique. Cecchinato et al.31 evaluated sub- the significant advantages of the one-stage
However, when interpreting clinical stud- merged and non-submerged implants in implant insertion technique.18
ies performed in the edentulous jaw to partially dentate patients in the posterior In the authors’ clinical experience,
evaluate the non-submerged technique, part of the dentition. They reported that eliminating a surgical intervention and
the use of a temporary denture during implants supported a small amount of an earlier prosthetic phase enhances the
the healing period, which may lead to radiographic bone loss irrespective of patient’s general satisfaction with the non-
occlusal overload and microbial contami- the surgical protocol; this observation submerged implants. Considering the
nation, should be taken into account.18,21 was valid not only for fixed partial denture results of all clinical findings and higher
Nevertheless, very successful results have restorations but also for single-tooth patient satisfaction with the non-sub-
also been reported for the non-submerged restorations. Cordaro et al.7 indicated that merged implants, it might be concluded
technique in edentulous jaws.16,17,23 In the submerged and non-submerged implants that the non-submerged surgical technique
partially dentate patient including single- supporting single-tooth restorations give can be used successfully for implant-sup-
tooth restorations, more favourable results similar results, even when applied in con- ported single-tooth restorations.
have been reported for non-submerged junction with simultaneous bone augmen- The fundamental strength of this study
implants.7,24,31,32 tation. After 2 years, a small amount of is the split-mouth design, which accounted
One of the most important criteria for bone resorption was found in both groups. for systemic factors and factors affecting
success in the clinical evaluation of dental However, in contrast to our results, the the oral environment. The split-mouth de-
implants and their superstructure is the non-submerged group (0.54  0.76 mm) sign is a special type of randomized clini-
marginal bone level around implants.33 showed significantly higher bone loss than cal trial that has been used in dental
The impact of submerged or non-sub- the submerged group (0.37  0.49 mm). research. In this design, two treatments
merged healing on marginal bone loss is For discussion of the success of implant are assigned randomly to either the right
therefore of great importance to clinicians treatment, a review of the clinical param- or the left half of the dentition, thus re-
in planning the treatment of cases with eters as well as radiographic follow-up is moving a lot of inter-individual variability
dental implants. A pathological decrease necessary. The literature suggests assess- from the estimates of the treatment effect.
in bone level can lead to loss of bone ment of periodontal indices (plaque index, By making within-patient comparisons
 Submerged and non-submerged implant placement 1491

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Tel.: +90 312 2034177;
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Fax: +90 312 2239226
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E-mail: secilkarakoca@yahoo.com
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