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2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
Introduction
Rehabilitation of severely resorbed jaws with dental
implants remains a surgical and prosthetic challenge
for clinicians (25, 53). Several advanced surgical techniques have been developed over the years to restore
bone volume, allowing the placement of dental
implants and improving esthetic outcomes. The same
surgical techniques have also been applied to
improve crown-to-implant ratios, to allow the placement of longer implants and to optimize the positioning of implants for adequate load distribution.
However, the latter indications remain controversial,
and the increased treatment time, cost and risk of
complications should be analyzed in line with the
expected benets.
Sinus lift elevation, guided bone regeneration,
onlay bone grafting, distraction osteogenesis and displacement of the inferior alveolar nerve were developed and applied for the management of reduced
alveolar bone height. Some of these techniques, such
as sinus lift elevation, are supported by a large number of publications and display excellent survival rates
for dental implants (18). On the other hand, less data
are available for surgical displacement of the inferior
alveolar nerve, vertical augmentation or distraction
osteogenesis (26, 94, 107). Moreover, long-term follow-up studies of dental implants placed in augmented bone are not available for each technique.
Even for the well-documented technique of sinus lift
elevation, it should be remembered that the best
results, obtained with rough surface implants and
biomaterial, are based only on short-term follow-up
studies (87).
Complex surgical techniques are often associated
with complications (42). Complications may occur
during surgery (such as bleeding (Fig. 1), perforation
of the Schneiderian membrane (Fig. 2AD) or nerve
injury) or postoperatively (including transiently or
72
Denition
There is still some controversy over the exact denition of a short-length implant. According to Striezel
& Reichart (112), an implant of 11 mm is considered as short, whereas Tawil & Younan (114) stated
that an implant must be 10 mm to be regarded as
Fig. 2. (A) Clinical view of a full-thickness ap elevation reaching the buccal wall of the sinus in order to perform a sinus
lift procedure. (B) The trap door is created using piezosurgery to reduce the risk of membrane perforation. (C) Clinical view
showing the trap door. (D) Clinical view of membrane perforation (despite the use of piezosurgery).
73
74
Table 1. Case series in which implant length was evaluated among other parameters
Authors (ref. no.)
Follow-up, in months
(mean)
Cumulative survival
rate <10 mm, %
Cumulative survival
rate >10 mm, %
159 (558)
(12)
97.5
97.4
384 (2199)
12
94.7
889 (4641)
From stage 1 to
connection of the
prostheses
94.5
99.4
213 (732)
570 (30.3)
150 (801)
(60)
75.8
91.8
1003 (2359)
1296
91.4
95
68 (124)
384
77 (230)
12144
75
95 (only 13-mm
implants were
included)
23 (69)
(120)
89
(120)
93.5
(36)
74.4 (7 mm)
87 (8 mm)
202 (660)
60144
83
95
440 (1022)
1284
80.3 ( 8 mm)
83.7 ( 12 mm)
181 (485)
(52.6)
660 (1956)
(66)
81.5
60 (240)
(12)
493 (1179)
(72)
74 (7.0 mm)
81 (8.5 mm)
93.1
250 (759)
1684
2460
236 (528)
1284
487 (487)
(60)
78.2 (7 mm)
95.7
489 (521)
1260
100
95.1
75
Implant length
168 (231)
6012 (86)
(47)
(44)
9 mm
98
1236
98.1
40 (55)
60
7 and 5 mm
84
12 (48)
12
6 mm
96
12 (72)
24
35 (40)
24
6 mm
95
661 (1287)
1102 (47.9)
99.3
s et al.
Sanchez Garce
2012 (103)
(273)
18144 (81)
10 or <10 mm
124 (335)
24
8 mm
99
48 (48)
36
97.92
1774 (2073)
1296
293 (532)
459 (31)
99.2
237 (408)
12108
(133)
36144
<10 mm
129 (265)
36168
10 and 8 mm
(176)
64.683.7
8 and 6 mm
273 (745)
1260
9 and 7 mm
98.9
2448 (37.6)
94.6
188 (311)
36
95.8
70 (104)
(37.6)
979 (979)
084
9, 8 and 7 mm
95.1
167 (168)
(34.9)
8 mm
100
111 (269)
1292
95.5
52 (156)
120
10 and 7 mm
92.7
76
Cumulative survival
rate, %
Table 2. (Continued)
Authors (Ref. no.)
Implant length
Cumulative survival
rate, %
24 (48)
8.25.3 (32.6)
9 and 7 mm
100
16 (26)
9, 7 and 5 mm (with
crestal sinus elevation)
100
49 (260)
12168 (96)
7 and 6 mm
95.5 (5 years)
92.3 (10 years)
17 (68)
6097 (77)
10, 7 and 6 mm
88
126 (253)
1284
6 mm
94
26 (67)
(60)
11 and 8 mm
94
48 (100)
(36)
99
Table 3. Randomized controlled trials comparing short implants and longer implants with advanced surgical procedures
Authors
(ref. no.)
Patients
(no. of
implants)
Mean
length of
follow-up
(months)
Area and
number of
implants
Test
Control
Cumulative
survival rate
Remark
Esposito 60 (121)
et al.
2011 (44)
36
6.3 mm
Partially
edentulous
mandible
One to
three
implants
9.3 mm and
vertically
augmented
bone
Statistically signicantly
more complications in
augmented patients.
Short implants
experienced statistically
signicantly less bone
loss. Short implants
could be an interesting
alternative to vertical
augmentation as the
treatment is faster,
cheaper and associated
with less morbidity
Felice
28 (178)
et al.
2011 (48)
5 months
after
loading
5.0
11.5 mm
Fully
edentulous 8.5 mm
maxillae.
Four to
eight
implants
Signicantly more
complications occurred
in augmented patients.
This pilot study suggests
that short implants may
be a suitable, cheaper
and faster alternative to
longer implants placed
in augmented bone
Felice
60 (121)
et al.
2010 (47)
12
Partially
7 mm
edentulous
mandible
10 mm and
Test: one short
vertical
implant failed
augmentation Control: three
long implants
failed, and two
augmentation
procedures
failed
77
Type of
studies
(search time)
Number of papers
included
Denition
of short
implants
Annibali
Systematic
Two randomized
<10 mm
et al. 2012 review and
controlled trials and 14
(3)
meta-analysis observational studies
Main results
Main conclusions
The provision
6193 short implants
from 3848 participants. of short implant-supported
prostheses in patients with
The observational
atrophic alveolar ridges
period was 3.2
appears to be a successful
1.7 years.
treatment option in
Cumulative survival
rate was 99.1% (95% CI: the short term; however,
more scientic evidence is
98.899.4).
needed for the long term
A higher cumulative
survival rate was
reported for implants
with a rough surface
<10 mm
19,083 implants
included. In the
mandible, no impact of
reduced implant length
on failure was observed
within the rst year of
prosthetic loading.
A signicant impact of
implant length for short
machined implants was
observed in the anterior
(odds ratio = 5.4) and
posterior (odds
ratio = 3.4) maxilla.
Short rough-surface
implants demonstrated
increased failure rates
in the anterior
maxillary sites (1.4% vs.
0.0%)
Jokstad
2011 (66)
78
One randomized
Systematic
review (1980 controlled trial and 28
prospective cohort
2009)
studies
(See
Telleman
et al. 2011
(116))
Table 4. (Continued)
Authors
(ref. no.)
Type of
studies
(search time)
Number of papers
included
Denition
of short
implants
Main results
Main conclusions
Telleman
Systematic
29 studies
et al. 2011 review (1980
(116)
2009)
<10 mm
Sun et al.
Systematic
35 studies
2011 (113) review (1980
2009)
10 mm
14,722 implants
included, of which 659
failed (failure
rate = 4.5%). The
failure rates
of implants with
lengths of 6.0, 7.0, 7.5,
8.0, 8.5, 9.0 and
10.0 mm were 4.1, 5.9,
0, 2.5, 3.2, 0.6 and 6.5%,
respectively. There was
no statistically
signicant difference
between the failure
rates of short dental
implants and
standard implants or
between those placed
in a single stage and
those placed in two
stages (multivariate
analysis). There was a
tendency toward higher
failure rates for the
maxilla and for dental
implants with a
machined surface.
The heterogeneity and
low quality of the
included studies made
meta-analysis
impossible
79
Table 4. (Continued)
Authors
(ref. no.)
Type of
studies
(search time)
Number of papers
included
Menchero- Systematic
Cantalejo
review and
et al. 2011 meta-analysis
(78)
(20002010)
Neldam &
Pinholt
2012 (84)
Denition
of short
implants
Main results
10 mm
8 mm
Systematic
15 prospective
review (1992 nonrandomized
2009)
studies, 11
retrospective
nonrandomizedstudies
and one review
Romeo
Literature
13 studies
et al. 2010 review (2000
(100)
2008)
37 studies reporting on
Kotsovilis
Systematic
22 patient cohorts
et al. 2009 review and
(68)
meta-analysis
(19812007)
80
Main conclusions
Table 4. (Continued)
Authors
(ref. no.)
Type of
studies
(search time)
Denition
of short
implants
Main results
Main conclusions
8 mm
10 mm
<10 mm
Number of papers
included
81
Table 4. (Continued)
Authors
(ref. no.)
Type of
studies
(search time)
Number of papers
included
Hagi et al.
2004 (62)
Structured
12
review (1985
2001)
Denition
of short
implants
Main results
Main conclusions
7 mm
Machined
surface implants
experienced greater
failure rates than did
textured
surface implants.
With the exception of
sintered poroussurface implants, 7mm-long dental
implants appear to
have higher failure
rates than those >7 mm
in length
(3, 66, 68, 78, 90, 100, 116), reducing both the need
for invasive and complex surgery (30, 89, 92, 113)
and treatment morbidity (30, 92). However, there is
a tendency for increased failure rates with
machined surface implants (89, 92, 113), placement
in smokers (116) and placement in specic locations, such as the severely resorbed posterior maxilla (113, 116) and the anterior maxilla (89). Longer
follow-up times of up to 10 years are also needed
to conrm these ndings and to evaluate the
impact of annual marginal bone loss on survival
rate (3, 92, 113).
Extra-short implants
Three case series (36, 86, 108) and one randomized
controlled trial (43) were recently performed to evaluate the survival rate of extra-short implants supporting xed partial dentures in severely resorbed
posterior jaws. In the paper by Slotte et al. (108),
three to four 4-mm implants were inserted in the
posterior mandibles of 24 patients (87 implants in
total) to support xed partial dentures. Two years
after loading, a survival rate of 92.3% was reported.
Using a split-mouth design, Esposito et al. (43)
compared 5-mm implants with 10-mm implants in
augmented bone (with either interpositional bone
blocks in the mandible or sinus lift in the maxilla)
to restore either the posterior mandible (15 patients)
or the posterior maxilla (15 patients). They report
similar outcomes for both techniques. The use of
extra-short implants allows patients to be treated
with lower cost and less morbidity. However, so far
only sparse short-term data are available. Further
82
83
Follow-up
(months)
Type of
prosthesis
Rokni et al.
2005 (97)
74 (199)
46
61.8% single
1.5
crowns
38.2% splinted
restorations
0.8 to <3.0
78.9% with a
crown-toimplant ratio
of 1.12.0
Crown-to-implant
ratio 1: 0.4 0.3
Crown-to-implant
ratio > 1 to 2:
0.4 0.4
Crown-to-implant
ratio > 2: 0.3 0.5
Tawil et al.
2006 (115)
109 (262)
53
0.92.4
12.6% single
crowns
87.4% splinted
restorations
12 and > 2
83.8% with a
crown-toimplant ratio
between 1
and 2; 3.4%
with a
crown-toimplant ratio
of > 2
Crown-to-implant
ratio < 1: 0.88 0.74
Crown-toimplant ratio 11.20:
0.75 0.71
Crown-to-implant
ratio 1.211.40:
0.73 0.58
Crown-to-implant
ratio 1.41
1.60: 0.77 0.71
Crown-to-implant
ratio 1.612.0: 0.66
0.54
Crown-to-implant
ratio > 2: 0.74 0.65
12
13.5% single
1.8
crowns
86.5% splinted
restorations
Crown-to-implant
ratio < 1: 0.34 0.27
Crown-toimplant ratio
1 to < 2:
0.03 0.15
Crown-to-implant
ratio 2: 0.02 0.26
27.6
Single crowns
Success
implant:
crown-toimplant
ratio = 1.3
Failed
implant:
crown-toimplant
ratio = 1.4
0.5 to < 3
98.2
Birdi et al.
2010 (15)
194 (309)
20.9
Single crowns
2.0 0.4
0.93.2
0.2
Schneider
et al. 2012
(104)
70 (100)
60
Single crowns
Clinical
crown-toimplant ratio:
1.50.4
Anatomical
crown-toimplant ratio:
1.0 0.3
95.8
Clinical
crown-toimplant ratio:
0.83.2
Anatomical
crown-toimplant ratio:
0.62.0
84
0.008
Therapeutic options
Bone type I, II, Bone type IV, history
III
of periodontitis,
smokers, patient age
<5 mm
Sinus lift
Sinus lift
5 to 6 mm
Short implants
Sinus lift
6 mm
Short implants
Short implants
ple procedure with minimal bone destruction compared with the removal of a long implant, which may
jeopardize adjacent teeth or the replacement of the
implant.
implant (8 mm in length and 4 mm in diameter). (C) Periapical radiograph 2 years after loading. (D) Clinical view
of the prosthetic restoration after 2 years of loading.
85
created and the Schneiderian membrane is elevated without perforation, despite the presence of an incomplete septum. (D) Postoperative cone beam computed tomography
scan 6 months after the sinus lift procedure. (E) Periapical
radiograph of the implant-supported xed partial denture
after 4 years of loading.
anterior area (Fig. 9AE), the use of the entire available bone may lead to overly angulated implants,
thus increasing the risk for gingival retraction and
the need for a cemented restoration. In the posterior
area, the use of the longest implant possible may be
associated with incorrect implant angulation or posi-
86
Therapeutic options
Feasibility
8mm
Short implants
Experience
The actual feasibility of a large number of more complex surgical protocols is never touched upon in
many discussions surrounding therapeutic options. It
seems that much effort is expended to omit the reality
of clinical life for the vast majority of practitioners.
Worldwide, the average number of implants placed
annually by most practitioners is estimated to be
fewer than 50. This gure seems to be quite minimal
in terms of gaining the surgical experience required
for the implementation of complex protocols.
Studies of neurocognitive activity show that the
part of the brain that manages both complex and
novel procedures lies in the prefrontal cortex, the
most anterior region of the brain (39, 73). Tasks utilizing the prefrontal cortex require conscious effort and,
importantly, consume vast cognitive resources (105).
Complex tasks, such as surgical procedures, as well as
tasks that are unfamiliar, require the prefrontal cortex
to remain active and the brains full resources to
remain accessible. However, under some conditions,
specically stress, fatigue and burnout, this access
becomes impaired. Advanced surgeries represent particularly high-stress activities for less-experienced
implant (8 mm in length and 5 mm in diameter). (C) Periapical radiograph 3 years after loading. (D) Clinical view
of the prosthetic restoration after 3 years of loading.
87
practitioners, and the prefrontal cortex becomes inaccessible in precisely the complex situations where its
use is a priority. Over time and with repetition, complex tasks become more routine and the advanced
processing abilities of the prefrontal cortex are
needed less and less to perform them. By repeatedly
practicing a single type of intervention, practitioners
described as experts have gradually transferred the
new gesture, which was initially managed by the prefrontal cortex, to the limbic brain. The limbic brain is
a group of brain structures consisting of multiple
88
89
90
Morbidity
Morbidity, dened as the set of complications that
may accompany a surgical procedure, is rarely taken
into account during therapeutic choices. However, a
number of publications reported a direct correlation
between morbidity and procedural complexity. Thus,
in a study of 102 pediatric cardiac surgeries, Barach
et al. (9) show that the longer and more complex a
surgical procedure is, the higher the risk of complications. These ndings were conrmed in 2008 by Roselli et al. (101), who analyzed 1,847 cardiovascular
and thoracic surgeries. In 2005, Enislidis et al. (41)
reported an implant survival rate of 96% following 45
distraction surgeries of 37 patients. Nevertheless, the
authors also identied a 65% complication rate, of
which 21% experienced serious complications,
including three mandibular fractures (41). Although
the implant success rate in this study was satisfactory,
it was obtained at the cost of substantial morbidity.
Accordingly, surgical techniques and medical protocols should not be evaluated solely on the basis of
survival and/or success rates. Morbidity and dangerousness accompanying these protocols should also
carry appropriate weight. The dangerousness of a
technique can be characterized as the probability of
occurrence of complications multiplied by the criticality of these complications.
91
Conclusions
Short-length implants can be successfully used to
support single and multiple xed reconstructions in
posterior atrophied jaws, even with increased crownto-implant ratios. The use of short-length implants
allows treatment of patients who are unable to
undergo complex surgical techniques for medical,
anatomic or nancial reasons. For these patients, it
must be clearly understood that the decision is shortimplant-supported xed reconstructions, removabledenture or long-span reconstructions on abutment
teeth or no treatment. Moreover, the use of shortlength implants in clinical practice reduces the need
for complex surgeries, thus reducing morbidity, cost
and treatment time. However, longer follow-up times
of up to 10 years (both for case series and randomized controlled trials) are needed. Additional studies
should also investigate the impact of crown-toimplant ratios of >2.0 and the possibility of using
extra-short implants.
The longest implant possible should not always be
used to improve the three-dimensional positioning of
implants. The use of short implants promotes the
new concept of stress-minimizing surgery, allowing
the surgeon to focus necessarily limited cognitive
92
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