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Volume 80 • Number 11

Review
A Systematic Review and Meta-Analysis on the Effect of Implant Length on the Survival of Rough-Surface Dental Implants
Sotirios Kotsovilis,* Ioannis Fourmousis,† Ioannis K. Karoussis,† and Christina Bamia‡

Background: A meta-analysis on the survival of short implants compared to conventional implants has never been performed. Therefore, the aim of this study was to address the focused question ‘‘Is there a significant difference in survival between short (£8 or <10 mm) and conventional (‡10 mm) rough-surface dental implants placed in 1) totally or 2) partially edentulous patients?’’ by conducting a systematic review and meta-analysis of prospective studies published in the dental literature in the English language up to and including August 2007. Methods: PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were scanned electronically, and seven journals were searched manually. In the first phase of selection, titles and abstracts, and in the second phase, full texts, were evaluated autonomously and in duplicate by two reviewers. Extensive contact with authors was carried out in search of missing, unclear, or unpublished data. Results: The electronic and manual search provided, respectively, 1,056 and 14,417 titles and abstracts. In the second phase of selection, the complete text of 300 articles was examined, and 37 articles reporting on 22 patient cohorts were selected. Meta-analyses revealed no statistically significant difference in survival between short (£8 or <10 mm) and conventional (‡10 mm) rough-surface implants placed in totally or partially edentulous patients. Conclusions: Within the limitations of this systematic review, the placement of short rough-surface implants is not a less efficacious treatment modality compared to the placement of conventional rough-surface implants for the replacement of missing teeth in either totally or partially edentulous patients. J Periodontol 2009;80:1700-1718. KEY WORDS Dental implants; meta-analysis; systematic review.

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* Private practice, Athens, Greece. † Department of Periodontology, School of Dentistry, University of Athens, Athens, Greece. ‡ Department of Hygiene, Epidemiology and Medical Statistics, Medical School, University of Athens.

he placement of dental implants is an efficacious method for the replacement of missing teeth in totally1,2 and partially3,4 edentulous patients as documented by systematic reviews.5-9 During the early years of implant therapy and along the lines of the ˚ nemark protocol,10 the use of imBra plants with the highest feasible length was advocated based on the axiom that longer implants would exhibit higher survival rates and more favorable prognosis.11 However, in many clinical cases, placement of long implants was problematic due to limitations, such as the location of the canal of the inferior alveolar nerve, the pneumatization of the maxillary sinus, and alveolar ridge deficiencies.12-17 To overcome such conditions, the clinician today often continues to increase the height of the alveolar ridge using advanced surgical techniques,12-17 such as guided bone regeneration, block grafting, maxillary sinus floor elevation, and distraction osteogenesis, or bypasses anatomic structures, for instance by alveolar nerve transposition.12 Nevertheless, these surgical procedures are case sensitive, technically demanding, time consuming, and might increase the post-surgical morbidity and the total cost and duration of therapy. The placement of short implants has been introduced as an alternative treatment strategy to

doi: 10.1902/jop.2009.090107

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’’21 Similarly. the objective of this study was to address the focused question ‘‘Is there a significant difference in survival between short (£8 or <10 mm) and conventional (‡10 mm) rough-surface dental implants placed in 1) totally or 2) partially edentulous patients?’’ by conducting a systematic review and meta-analysis of prospective studies published in the dental literature in the English language up to and including August 2007. short implants would be more likely to fail if peri-implantitis occurred due to the lower quantity of bone support. . However. position papers. 5) A clear report of (or report of data allowing the calculation of) the total number of implants placed/ surviving. the titles and abstracts of all identified publications were screened autonomously and in duplicate by two reviewers (SK and IKK) to evaluate their eligibility for selection in this systematic review on the basis of predetermined inclusion and exclusion criteria. . a meta-analysis on the effect of implant length on the survival of rough-surface implants has not been performed. 4) The report of information on the characteristics of study participants (principally inclusion and/or exclusion criteria) in the text of the study. was the first systematic approach to produce the radical reappraisal that ‘‘clearly. The electronic search was carried out by applying the following terms and key words: (‘‘Dental’’ OR ‘‘Oral’’) AND ‘‘Implant*’’ AND (‘‘Length’’ OR ‘‘Short’’ OR ‘‘Shorter’’). .] implant surface [. The authors attempted to search for the maximum possible number of proceedings of past workshops.J Periodontol • November 2009 Kotsovilis. and thus. The comprehensive review18 by Hagi et al. The International Journal of Periodontics and Restorative Dentistry (1991 to 2007).18-20 There is no consensus in the dental literature on the definition of short implants. the effect of the length of dental implants on their short. The following inclusion criteria were accepted by all reviewers: 1) Publications in the dental literature in the English language. Journal of Clinical Periodontology (1981 to 2007). 3) The presence of at least five patients in each and every group of the study and five rough-surface dental implants with lengths <10 mm. which in various reviews have been considered to have a length £7 mm. . Whenever deemed essential. In the event of a study comprising a mixed population with totally and partially edentulous patients. The reference lists of all identified articles related to the topic were subjected to close scrutiny. 2) Only prospective studies. but on a long-term basis. Manual search of journals. studies lacking rough-surface implants of conventional length were not eligible for inclusion in this systematic review).20 or <10 mm. the study was not included. Therefore. and a literature search was accomplished with a personal computer on articles published in English up to and including August 2007. Fourmousis. subsequent systematic reviews19. Articles available online in electronic form before their publication in material form were considered eligible for inclusion in the present article. The PubMed database of the United States National Library of Medicine and the Cochrane Central Register of Controlled Trials (CENTRAL) of the Cochrane Collaboration were used as electronic databases. surface geometry (machined versus rough) plays a major role in performance of endosseous dental implants of lengths 7 mm or less. short implants would be expected to exhibit lower survival and/or success rates compared to longer implants.18 £8 mm. and theses. short implants may demonstrate short-term survival and/or success rates comparable with those of conventional implants. all preceding data had to be provided separately for totally and partially edentulous patients either in the published manuscript or after contact with the authors. Implant Dentistry (1994 to 2007). Inclusion/Exclusion Criteria and Selection of Studies In the first phase of study selection. 1701 . Karoussis.’’ confirming previous original research reporting that ‘‘the rough [. unclear. as well as at least five rough-surface implants with lengths ‡10 mm (therefore. or unpublished data was sought by contact with authors. Some clinicians have inculcated the dogma that short implant length results in reduced bone-to-implant contact. Other data sources.] may have compensated for the shorter implant length.and long-term prognosis has been a controversial issue. MATERIALS AND METHODS Search Strategy for Identification of Studies Electronic search. missing. According to another hypothesis.20 reported comparable survival rates for short and conventional roughsurface implants. Bamia deviate from advanced surgical techniques. otherwise. International Journal of Oral and Maxillofacial Surgery (1986 to 2007). The International Journal of Oral and Maxillofacial Implants (1992 to 2007). and Journal of Periodontology (1981 to 2007). either in totally edentulous or partially edentulous patients for implant lengths a) <10 mm and b) ‡10 mm. The following journals were searched manually up to and including August 2007 for the periods of time shown in parentheses: Clinical Oral Implants Research (1990 to 2007).19 For many years.

and rough-surface implants. an agreement was reached by discussion. Quality Assessment of Selected Studies The quality assessment of the selected studies was carried out autonomously and in duplicate by two reviewers (SK and IKK) using certain criteria proposed in the dental literature. and B) completeness of follow-up (specified reasons for withdrawals and dropouts in each study group) (grading: 0 = no/not mentioned/not clear. a clear report of (or report of data allowing the calculation of) the survival of rough-surface implants was mandatory. 1 = yes/withdrawals or dropouts did not occur). Any disagreement ensuing among the reviewers would be resolved by discussion. as well as the full text of articles without abstracts or 1702 articles with inadequate information in the title and abstract to allow a clear assessment. Quantitative Data Synthesis (statistical analysis) The primary outcome measure/variable was the percentage of implants surviving out of the total number . study design. interventions. likewise. methods. immunocompromised patients (e. The following exclusion criteria were agreed by all reviewers: 1) Studies with an unclear or mixed design (for example: mixed prospective and retrospective data or if dental implants had been already placed before the commencement of the study). otherwise. 6) A clear report of the surface characteristics (smooth or rough) of implants used. unless the authors explicitly stated that these parameters did not correlate to implant survival rate or if all implants (100%) in the study eventually survived. If the definitions of a totally edentulous patient and a partially edentulous patient in an examined study were clearly different from the definition applied in this systematic review. the complete articles of all studies already selected in the first phase. and outcome measures/variables) and outcomes of studies.Short Versus Conventional Implants Volume 80 • Number 11 An implant was defined as surviving if it was not lost.. it would be mentioned and analyzed in this systematic review. Any patient clearly reported in an examined study as totally edentulous in one jaw and partially edentulous in the other jaw was considered to be partially edentulous. If more than one article corresponded to the same clinical study. these studies were evaluated independently and twice by two reviewers (SK and IKK) based on the criteria for study selection/exclusion. If the divergence persisted. Agreement between the two reviewers (SK and IKK) with regard to quality-assessment scores for each quality criterion was determined by the proportion (%) of inter-reviewer agreement and. by k score. 4) Dental implant placement in periodontally compromised patients without previous implementation of periodontal therapy. leukocyte dysfunction and deficiencies. the different assessments of the study quality would be mentioned and explained in this article.. the study was not included. positive for human immunodeficiency virus). the study was not included.24 a standardized process of extracting data from studies selected using specially designed data-extraction forms was performed in duplicate and independently by two reviewers (SK and IKK) regarding the main characteristics (e. 1 = yes). 3) Medical or systemic diseases or conditions potentially negatively affecting implant survival. such as malignant tumors or past or current radiotherapy in the cervico-facial area. only the most recent data acceptable under the inclusion/exclusion criteria applied in this systematic review were used.28-31 In the event of any discrepancy between the reviewers (SK and IKK). with particular emphasis on implant survival data. contact with the authors of studies was carried out before final exclusion. which additionally incorporated an adjustment for the degree of agreement to be expected entirely by chance. the study was not included. were acquired.g. even if regarded as totally edentulous in the original study. Subsequently. Any other information deemed scientifically interesting was also recorded. For all exclusion criteria (1 through 4). participants.’’ If the definition of implant survival or implant loss in an examined study was different from the definitions applied in this systematic review. In the second phase of selection.23. If a study comprised both smooth. 7) A follow-up period ‡12 months. Authors of studies were contacted for clarification or missing information.22 according to which the loss of implants was ‘‘defined as implant mobility of previously clinically osseointegrated implants and removal of non-mobile implants due to progressive peri-implant marginal bone loss and infection.25-27 The unanimously accepted criteria for quality assessment were as follows: A) a clear definition of inclusion and/or exclusion criteria (grading: 0 = no. 2) Smoking (>10 cigarettes/day). and diabetes not under metabolic control. Totally edentulous patients were defined as those having no natural teeth in either jaw. Data Extraction In accordance with previous systematic reviews.g. chemotherapy. The definition used in this article was provided by another systematic review. otherwise. Exclusion of a study based on criteria 2 through 4 was applied.

10). Concerning quality criterion A. Fourmousis.5 was added to the values of all cells in such cases.6%).63-72 implant survival data were provided for partially edentulous patients (Table 3). According to the second reviewer (IKK).47 provided separate survival data both for totally and partially edentulous patients (Tables 2 and 3).45. with the associated 95% confidence intervals. the first reviewer (SK) was of the opinion that all 22 selected studies had clearly defined inclusion/exclusion criteria. the calculation of the k score was deemed § Stata/SE 8. were obtained through meta-analyses performed separately for totally and partially edentulous patients.35 Heterogeneity among the selected studies was assessed using the Q-statistic test. It should be noted that the primary outcome measure was not implant survival rate but. Karoussis.39. Throughout this procedure.55-58. the remaining 20 studies had clearly defined inclusion/exclusion criteria.45. Stata. During the manual search of dental journals. whereas another study69 had clearly defined too few inclusion/exclusion criteria. Eventually.056 titles and abstracts that were deemed potentially relevant to the influence of dental implant length on implant survival. By definition. 2003.91% and 95. were excluded (Table 1). indicating an ‘‘excellent’’30 level of agreement in both cases.41-43. following the suggestions by Gart and Zweifel34 and Fleiss.J Periodontol • November 2009 Kotsovilis. The associations of the survival of implants with their lengths (short versus conventional) were expressed as risk ratios (RRs).33 The Begg and Mazumdar’s funnel plot of the log RRs versus their standard error was calculated for studies reporting on short versus conventional rough-surface implants placed in totally or partially edentulous patients. 0. College Station.68 The overall proportion of inter-reviewer agreement was 90.65. 14.55-72 reporting on 17 patient cohorts. in 23 articles41. In the second phase of study selection. All statistical analyses were carried out using a commercially available software program. with the exception of three studies. No secondary outcome measures/variables were used. respectively.45. the reasons for patient withdrawals/dropouts were clearly reported in the published text of the majority of selected studies. With respect to quality criterion B. Three studies41. TX.417 titles and abstracts were totally examined.36. and answers were kindly provided by the authors of 72 articles (57. implant survival risk because total exposure time of each and every implant (included in studies selected) was not available.0 for Windows. The pooled RRs from combinations of studies.41.45-48. Number of Studies Excluded After Second Phase of Selection Inclusion Criterion Not Fulfilled 1 2 3 4 5 6 7 Total Exclusion Criterion Fulfilled 1 2 3 4 Studies (n) 0 41 75 0 69 2 1 188 Studies (n) 14 4 11 3 32 1703 . RR >1 indicated a higher percentage of surviving short implants than conventional implants. Publication bias was examined by using the Begg and Mazumdar’s rank correlation test32 and the Egger regression asymmetry test. the complete text of 300 articles was retrieved and subjected to close scrutiny.45% for quality criteria A and B. 263 articles. Results of Quality Assessment of Selected Studies With respect to quality criterion A. Because the calculation of RR is undefined if the values of one or more cells in the cross table are equal to zero.49 implant survival data were provided for totally edentulous patients (Table 2). additional information was sought through electronic mail for 125 articles. A randomeffects model (DerSimonian-Laird method) of metaanalysis was used in the presence of heterogeneity (P <0. 37 articles36-72 reporting on 22 patient cohorts were selected (Tables 2 and 3).55. rather. These articles were further subdivided into two categories according to the type of edentulism (total or partial) of their participants: in 19 articles36-54 reporting on eight patient cohorts. one study55 did not have clearly defined inclusion/exclusion criteria (the term ‘‘high-risk conditions’’ was not defined clearly). Table 1. Bamia placed. corresponding to 220 studies. which additionally were too vague and thus failed to provide a sufficiently explicit description of the characteristics of the study population included.§ RESULTS Study Selection and Classification (Tables 1 through 3) The electronic search in both databases (PubMed and CENTRAL) provided a total of 1.47.47. Results of Contact With Authors In total.

All implants were placed in the anterior mandible. 200041† i 48 [12 to 84]† 35/36† (97.Short Versus Conventional Implants Volume 80 • Number 11 Table 2. Main Characteristics and Outcomes of Selected Prospective Studies Including Totally Edentulous Patients Follow-Up (months. 4.. 2..95%) 1. 1995. No single-tooth implants. No statistical comparison between short and conventional implants. All implants were placed in the mandible. survival of short < conventional implants. 199636† (Boerrigter et al. No single-tooth implants.22%) 153/172† (88. data were not sufficient for subgroup analysis.. Correlation implant survivallocation: only 1 short implant was lost in a totally edentulous patient in the posterior maxilla. 4. 2. all short implants survived...08%) 1. No statistical comparison between short and conventional implants. mean [range]) 12 [12 to 12] Surviving/ Placed (%) Implants With L £8 mm 19/19† (100%) Surviving/ Placed (%) Implants With L <10 mm 19/19† (100%) Surviving/ Placed (%) Implants With L ‡10 mm 62/63† (98. Brocard et al. b) implantsupported fixed full-arch (complete) restorations. 3. a) Implant-retained overdentures on ‡2 implants using clips as retentive elements.† thus.37 Kwakman et al. 199838) Implant Type ‡ Other Information* 1. Implant-retained overdentures on 2 to 4 implants using magnets as retentive elements. 3. Implant-retained overdentures on two implants using a single bar clip attachment. Walmsley and Frame. No statistical comparison between short and conventional implants. c) implant-supported fixed partial restorations (dentures/ bridges) in totally edentulous patients.41%) Reference(s) Geertman et al.† 4.† 1704 . 3.22%) 49/51† (96. 199739† (Walmsley et al. No single-tooth implants in totally edentulous patients.92%) 15/23† (65. 199340) § 60 [60 to 60] 10/13† (76.22%) 35/36† (97. 2.

Implant-retained overdentures on 4 short implants using a triple bar with a clip retention system (study group III). 2. all implants survived. 4. All lost implants had been placed in type III or IV bone. Bamia Table 2.. No single-tooth implants. mean [range]) 107.. 2004 (Stellingsma et al. All implants were placed in the anterior mandible. 4. NS. All implants were placed in the anterior mandible. No single-tooth implants in totally edentulous patients. all short implants survived. 3. 200344) 43† ‡ 24 [24 to 24]† 56/56 (100%) † 56/56 (100%) † 24/24 (100%) † 1.73%) † 1. Karoussis. Romeo et al. Fischer and Stenberg.8 [36 to 168] 25/26 (96. 4. Stellingsma et al.. 2. No single-tooth implants.15%) † 43/44 (97. 2006 (Romeo et al. 3. Implant-supported fixed complete restorations in totally edentulous patients. No statistical comparison between short and conventional implants. Statistical comparison between short and conventional implants not required/obviously NS.† 4. Implant-retained overdentures on 2 implants using a round-shaped bar and a clip retention system. No statistical comparison between short and conventional implants. All 42 implants were placed in the maxilla. Fourmousis. Implant-supported fixed full-arch (complete) restorations on 5 or 6 implants. 200448) 47† i 76. No single-tooth implants. 2. (continued) Main Characteristics and Outcomes of Selected Prospective Studies Including Totally Edentulous Patients Follow-Up (months. Statistical comparison between short and conventional implants not required/obviously NS.8 [0 to 120]† Surviving/ Placed (%) Implants With L £8 mm 6/6† (100%) Surviving/ Placed (%) Implants With L <10 mm 6/6† (100%) Surviving/ Placed (%) Implants With L ‡10 mm 48/52† (92. 2006 (Fischer and Stenberg. 2. 200446) 45† i 36 [36 to 36] 8/8 (100%) † 8/8 (100%) † 34/34 (100%) † 1. 200442† Implant Type ‡ Other Information* 1. 3.. 1705 .31%) Reference(s) Meijer et al. all implants survived. but their number was limited.J Periodontol • November 2009 Kotsovilis. 3..15%) † 25/26 (96.

39. 1) For both definitions of short implants (length £8 or <10 mm). six36. last row. Survival of short versus conventional implants in partially edentulous patients (Tables 3 and 4. and 4) surviving/placed (%) splinted and non-splinted single-tooth short (L <10 mm) and conventional (L ‡10 mm) implants. Friedrichsfeld. ‡ IMZ. 47. no statistically significant difference (P = 0.51.77%) Surviving/ Placed (%) Implants With L <10 mm 60/62† (96. 2 and 3) Survival of short versus conventional implants in totally edentulous patients (Tables 2 and 4.77%) Surviving/ Placed (%) Implants With L ‡10 mm 217/221† (98. 200454) Implant Type i Other Information* 1. Astra Tech. 3).86%) L = length. The remaining two studies43.02%) 6 studies# 572/603 (94. alphabetically. the chance-expected proportion of inter-reviewer agreement coincided with the overall proportion of inter-reviewer agreement. 2) survival of short versus conventional implants according to implant location. 42. No single-tooth implants.53 Timmerman et al. 2). # References 36.52 1999. A typical example of the Begg and Mazumdar’s funnel plot for one of these cases (for selected studies reporting on rough-surface implants with 1706 lengths <10 mm placed in partially edentulous patients) is illustrated in Figure 1. suggesting that. All implants were placed in the mandible.50 Wismeijer et al. Fig.775 – 0.90%) ¶ 8 studies 224/236 (94. NS = no significant difference in survival between short and conventional implants. Implant-retained overdentures on 2 (with a bar or ball attachments) or 4 (with a bar) implants. 200749† (Wismeijer. the k score was 0. Friatec.978) in survival was demonstrated between short and conventional rough-surface implants placed in totally edentulous patients (Table 4. ¨ lndal.49 of eight studies previously selected (Table 2) were included in the meta-analysis (Table 2. Results of Publication-Bias Evaluation (Fig. 2. Meta-Analyses (Tables 2 through 4.. 3) type of restoration. and 49. 41. and Table 4. Fig.05 for both the Begg and Mazumdar’s rank correlation test and the Egger regression asymmetry test) was demonstrated for studies on totally or partially edentulous patients. Fig. ¶ References 36. and 49. Fig. representing a ‘‘substantial’’29 level of agreement beyond chance. 2).92%) ¶ 8 studies 630/661 (95.31 Regarding quality criterion B. 47.39. 41-43. 45.45 were not included because all short and conventional implants survived and. 4. 39. from a purely mathematic point of view.42. the actual inter-reviewer agreement might theoretically be explained purely on the basis of chance. 2). Mo i Straumann. * Other information includes: 1) statistical analysis (short versus conventional implants) in the original study. the RR could not be estimated (Fig. (continued) Main Characteristics and Outcomes of Selected Prospective Studies Including Totally Edentulous Patients Follow-Up (months. 1996. Sweden. . § Astra Meditec.. Accordingly. For both definitions of short implants. No statistical comparison between short and conventional implants. Figs. Total in systematic review [0 to 168] 8 studies 219/226 (96. Germany. no evidence of publication bias (P >0.31%) ¶ Total in meta-analyses 6 studies# 155/162 (95. mean [range]) 100 [18 to 118]† Surviving/ Placed (%) Implants With L £8 mm 60/62† (96. † Information retrieved after contact with the authors of the study. Switzerland.30.309.. When short implants were defined as £8 mm long.68%) 6 studies# 160/172 (93. in the same year. 1997. Articles in parentheses are sequenced according to publication year and.19%) Reference(s) Stoker et al. Institute Straumann. thus. When short implants were defined £8 or <10 mm long.41. 3. tendency for survival of short implants < conventional.Short Versus Conventional Implants Volume 80 • Number 11 Table 2. meaningless (k = 0) because of the complete absence of cases with a score of 0 (zero) as applied by one reviewer (SK). 2). Mannheim. Waldenburg.47.

All implants were non-splinted single-tooth. mean [range]) NR [0 to 36] Surviving/ Placed (%) Implants With L £8 mm 83/83 (100%) Surviving/ Placed (%) Implants With L <10 mm 83/83 (100%) Surviving/ Placed (%) Implants With L ‡10 mm 339/340 (99. All implants were placed in the maxilla. 2. 3. 199655 Implant Type † Other Information* 1. Main Characteristics and Outcomes of Selected Prospective Studies Including Partially Edentulous Patients Follow-Up (months.. Brocard et al.‡ 1707 . b) implantsupported fixed partial restorations (dentures/bridges) in partially edentulous patients. 199856‡ § NR [6 to 24]‡ None placed 13/13 (100%) 7/7 (100%) 1.‡ 3. one in anterior mandible.. Correlation implant survival-location: out of nine short implants lost in partially edentulous patients: two in anterior maxilla. both in maxilla and mandible. 3. 4. 112 single-tooth implants. all implants survived. three in posterior mandible.‡ 4. All implants survived.J Periodontol • November 2009 Kotsovilis. 3. Implant-supported fixed partial restorations (dentures).71%) Reference(s) Buchs et al. No statistical comparison between short and conventional implants.73%) 202/211‡ (95. Bamia Table 3.. 200057‡ ¶ 24 [24 to 24] 10/10 (100%) 16/16 (100%) 34/34 (100%) 1. all short implants survived. a) Implant-supported single-tooth restorations (crowns). 200041‡ i 48 [0 to 84]‡ 202/211‡ (95.73%) 588/603‡ (97. 4. Statistical comparison between short and conventional implants not required/obviously NS.‡ 4. All implants were placed in the posterior mandible. No single-tooth implants. all nonsplinted (42/42 = 100% short and 70/70 = 100% conventional survived in partially edentulous patients). Fourmousis. Implant-supported single-tooth restorations (crowns). Statistical comparison between short and conventional implants not required/obviously NS. Implant-supported fixed partial restorations (dentures).‡ van Steenberghe et al. Karoussis. Deporter et al. No single-tooth implants. 2. three in posterior maxilla.51%) 1. 2. 2. No statistical comparison between short and conventional implants..

2.‡ Mericske-Stern et al. Roccuzzo et al. 3. number of lost short implants too low to allow a correlation. c) implant-supported fixed partial restorations (dentures) (3. 46 single-tooth implants. Statistical comparison between short and conventional implants not required/obviously NS. mean [range]) 34.. survival percentage of short implants was higher than conventional implants. 2. a) Implant-supported single-tooth restorations (crowns). No statistical comparison between short and conventional implants. 200158‡ (Deporter et al. a) Non-splinted implant-supported single-tooth restorations (crowns). All implants survived.or 4-unit). 1999. Correlation implant survival-location: NR.6 [5. 3.Short Versus Conventional Implants Volume 80 • Number 11 Table 3. Implant-supported single-tooth restorations (crowns). All implants were non-splinted single-tooth. 9.. 200164‡ i 12 [12 to 12] 16/16 (100%) 16/16 (100%) 120/120 (100%) 1..75%) Reference(s) Deporter et al. 4. 66 non-splinted single-tooth implants (61/61 short and 5/5 conventional survived).60 2002. 200163‡ i 51. Univariate analyses/no detectable correlation between crestal bone loss and implant length (7.88%) 60/60 (100%) 1.61 Rokni et al.59 2000. or 12 mm).‡ 1708 .6 [>12 to 108]‡ 46/49 (93. both in maxilla and mandible. 200562) Implant Type § Other Information* 1.78%) Surviving/ Placed (%) Implants With L ‡10 mm 15/16 (93. 2. All implants were placed in the maxilla.88%) 46/49 (93..1 to 68. 3. all nonsplinted (22/22 short and 24/24 conventional survived). 4. (continued) Main Characteristics and Outcomes of Selected Prospective Studies Including Partially Edentulous Patients Follow-Up (months. b) two splinted (attached) implantsupported single-tooth restorations (crowns).6] Surviving/ Placed (%) Implants With L £8 mm 46/46 (100%) Surviving/ Placed (%) Implants With L <10 mm 132/135 (97. 4. b) implantsupported fixed partial restorations (dentures)..

59%) 1. 3. No single-tooth implants. Fourmousis. no more recent (>24 months) follow-up data have been published‡ 12 [12 to 12] Surviving/ Placed (%) Implants With L £8 mm 68/70 (97. 200368‡ i 47 [12 to 84] 9/9‡ (100%) 9/9‡ (100%) 70/71‡ (98. 200265‡ Implant Type i Other Information* 1.14%) Surviving/ Placed (%) Implants With L <10 mm 68/70 (97. b) implant-supported removable denture restorations on ‡4 implants. Implant-supported fixed partial restorations (dentures) with a mesial or distal cantilever.14%) Surviving/ Placed (%) Implants With L ‡10 mm 312/313 (99. 2.68%) Reference(s) Cochran et al. (continued) Main Characteristics and Outcomes of Selected Prospective Studies Including Partially Edentulous Patients Follow-Up (months. 3. All implants were placed in the posterior maxilla. 200267‡ i 46 [0 to 84]‡ 11/11 (100%) 11/11 (100%) 115/119 (96. a) Implant-supported single-tooth restorations (crowns). 2. 4. All short implants survived. all short implants survived. 4. a) Implant-supported fixed partial restorations (dentures) on ‡2 implants. 2. No statistical comparison between short and conventional implants. b) implantsupported fixed partial restorations/ dentures (short-span).64%) 1. all losses of conventional implants occurred in the posterior mandible. No statistical comparison between short and conventional implants.‡ Romeo et al. Romeo et al. 3. Bamia Table 3. No statistical comparison between short and conventional implants.J Periodontol • November 2009 Kotsovilis. Karoussis. Nine single-tooth implants (1/1 short and 8/8 conventional survived). 3. All implant losses occurred in the mandible. mean [range]) NR‡ [0 to 24] Ongoing study. All short implants survived.‡ Roccuzzo and Wilson. 2.. all survived. Single-tooth restorations (crowns).‡ 1709 .30%) 1.. c) implant/ tooth-supported fixed partial restorations/dentures (long-span). All implants (short and conventional) were single-tooth. NS. all nonsplinted and conventional. No statistical comparison between short and conventional implants. 4.. 11 single-tooth implants. 4. 200266‡ i 9/9 (100%) 9/9 (100%) 26/27 (96.

and NR‡ splinted conventional survived). all short implants survived.‡ Chiapasco et al. a) Implant-supported single-tooth restorations (crowns). b) implantsupported fixed partial restorations (dentures). All short implants survived. 3. all implants survived.59 [0 to 60]‡ 12/12‡ (100%) 12/12‡ (100%) 88/89‡ (98.87% non-splinted conventional. 2..‡ Bornstein et al.88%) 1. 82 single-tooth implants. All implants were placed in posterior (maxillary or mandibular) regions. No statistical comparison between short and conventional implants.70%) 1. NR.. 39 non-splinted) (NR‡ non-splinted short. 37/39 = 94. 4. b) implantsupported fixed partial restorations (dentures). (43 splinted. 3. 12/13 = 92. 200671‡ i 20.. NR. a) Implant-supported single-tooth restorations (crowns). 2. mean [range]) 16 [16 to 16] Surviving/ Placed (%) Implants With L £8 mm 11/11‡ (100%) Surviving/ Placed (%) Implants With L <10 mm 11/11‡ (100%) Surviving/ Placed (%) Implants With L ‡10 mm 66/66‡ (100%) Reference(s) Frei et al.‡ 1710 . NR. 3. 4.31% splinted short. No statistical comparison between short and conventional implants. 200469‡ Implant Type i Other Information* 1. one conventional implant was lost in the mandible. All implants were placed in the posterior mandible. Statistical comparison between short and conventional implants not required/obviously NS. 2.4 [12 to 36] 8/8‡ (100%) 8/8‡ (100%) 85/87‡ (97. (continued) Main Characteristics and Outcomes of Selected Prospective Studies Including Partially Edentulous Patients Follow-Up (months.Short Versus Conventional Implants Volume 80 • Number 11 Table 3. 200570‡ i 58.‡ 4.

47%) 82/85‡ (96.53%) Reference(s) Fischer and Stenberg. mean [range]) 36 [36 to 36] Surviving/ Surviving/ Surviving/ Placed (%) Placed (%) Placed (%) Implants Implants Implants With With With L £8 mm L <10 mm L ‡10 mm 18/19‡ (94. 200448) i 76.05). 58 single-tooth implants: 29/29 = 100% short and 28/29 = 96.74%) 79/81‡ (97. d) implant/ tooth-supported fixed partial restorations/dentures in partially edentulous patients. Karoussis. 200446) Implant Type i Other Information* 1. All implants lost had been placed in type III or IV bone.‡ unclear relation of survival to implant location.47%) 107/110‡ (97.‡ Romeo et al.‡ 1711 . 3. In the mandible: One patient with partially edentulous mandible who lost implants before loading had a mandibular full-arch restoration. No statistical comparison between short and conventional implants.J Periodontol • November 2009 Kotsovilis.74%) 18/19‡ (94. In the maxilla: Implant-supported fixed full-arch (complete) restorations (dentures) on five or six implants..8 [36 to 168] 82/85‡ (96. b) implantsupported fixed partial restorations/ dentures (without cantilevers). no implant restoration in the remaining patients with partially edentulous mandibles.‡ 4. 2. 3. 2. No single-tooth implants. Fourmousis. 4.27%) 1. 17 patients had partially edentulous mandibles at the 3-year follow-up.55% conventional survived in partially edentulous patients. Multiple linear analysis/NS differences in marginal bone loss and probing depth values were observed between short and standard implants (P >0.. 200647‡ (Romeo et al. (continued) Main Characteristics and Outcomes of Selected Prospective Studies Including Partially Edentulous Patients Follow-Up (months. a) Implant-supported single-tooth restorations (crowns). Bamia Table 3. c) implant-supported fixed partial restorations/dentures with a mesial or a distal cantilever. NS. 200645‡ (Fischer and Stenberg.

3) type of restoration. 55. 1712 . b) implantsupported fixed partial restorations (dentures). 58. 45. and 70-72. (continued) Main Characteristics and Outcomes of Selected Prospective Studies Including Partially Edentulous Patients Follow-Up (months. 41 single-tooth implants. ‡‡ References 41.15%) (98.30% conventional survived).884/1. 47.33%) 13 studies‡‡ 2. 55.35%) (97. Innova. Nobel Biocare. All short implants survived.277 771/792 631/649 (98. 55-58. 70. i Straumann. § Endopore Implant System. 65-68. all nonsplinted (4/4 = 100% short and 36/37 = 97.23%) 12 studies†† 594/612 (97. 200772‡ Other Information* 1. ON. 47. Sweden.050 (98. and 4) surviving/placed (%) splinted and non-splinted single-tooth short (L <10 mm) and conventional (L ‡10 mm) implants. 2. 47.51%) Reference(s) Strietzel and Reichart. 63. definition of short implants included 11-mm implants. ‡ Information retrieved (or not retrieved) after contact with the authors of the study. Germany. CA. Original study statistics not meaningful in the context of this review/in this study.Short Versus Conventional Implants Volume 80 • Number 11 Table 3.‡ 26. 58. Toronto. NR = not reported. c) implant-retained removable partial dentures. a) Implant-supported single-tooth restorations (crowns). Institute Straumann. * Other information includes: 1) statistical analysis (short versus conventional implants) in the original study. Switzerland. Wimsheim. ** References 41. Yorba Linda.243/2. 63.06%) 13 studies‡‡ 12 studies†† 715/736 1. ¨ lndal. 3. Waldenburg.916 (97. conventional implant losses were not related to implant location (anterior/ posterior or maxilla/mandible).‡ 4. 2) survival of short versus conventional implants according to implant location. NS = no significant difference in survival between short and conventional implants. Camlog Biotechnologies. † Steri-Oss.7 None placed‡ ‡ [11 to 51] Total in systematic review [0 to 168] 17 studies** 17 studies** 17 studies** 2. Articles in parentheses are sequenced according to publication year. 65-68. Astra Tech AB. and 63-72.016/2. d) implant-retained overdentures on 2 implants. 45. mean Implant [range]) Type # Surviving/ Placed (%) Implants With L £8 mm Surviving/ Placed (%) Implants With L <10 mm 35/35‡ (100%) Surviving/ Placed (%) Implants With L ‡10 mm 132/134‡ (98. Mo # Camlog. 45. and 71.34%) Total in meta-analyses L = length. †† References 41. ¶ Astra Tech Implant Systems.51%) (97.

the RR could not be estimated. Fig. Furthermore. An extensive manual search was undertaken because too many relevant articles contained survival data for short implants in their text and tables. However. For both definitions of short implant length (£8 and <10 mm). whereas the other three studies57. it was deemed methodologically appropriate to perform separate meta-analyses. Potential Biases in the Review Process The present systematic review applied a series of strategies in the search and selection of studies. Two studies56.63.63. and the only way of retrieving those data was through a manual search. Overall Completeness. last row.65-68. The results of the review seem to have significant clinical implications. DISCUSSION Summary of Main Results In the present study. to prevent or minimize bias. specific limitations were also present. as well as data extraction and analyses. unpublished. the selected cohorts exhibited a certain divergence from the general patient population treated in everyday clinical practice.45. a systematic review and metaanalyses of prospective studies published in the dental literature in the English language were conducted to address the focused question ‘‘Is there a significant difference in survival between short (£8 or <10 mm) and conventional (‡10 mm) rough-surface dental implants placed in 1) totally or 2) partially edentulous patients?’’ Meta-anaylses revealed that no statistically significant difference in survival existed between short and conventional rough-surface implants in either totally or partially edentulous patients. but not in their title and abstract. no statistically significant difference (P = 0.47. last row. or unclear data in a form suitable for subsequent meta-analysis (Tables 2 and 3).73 whereas in totally edentulous patients such a transmission is not feasible. patients. Funnel plot of the log RR versus its standard error calculated for selected studies (n = 13) reporting on short (length <10 mm) versus conventional (length ‡10 mm) implants placed in partially edentulous patients.58.71 out of 17 previously selected (Table 3) were included in the metaanalysis (Table 3. the placement of rough-surface short implants appears to be an efficacious treatment modality for the replacement of missing teeth in totally or partially edentulous patients. thus providing a total of 13 studies (Table 3. therefore. no evidence of publication bias existed. Contact with the authors of 125 articles allowed the identification of relevant articles initially not depicted through electronic and manual searches and the retrieval of a significant amount of missing. exclusion criteria 2 through 4 aimed at preventing the introduction of potential confounders and. 3). Hence.65-68. Karoussis. therefore. and periodontal pockets may serve as reservoirs for bacterial colonization around implants. Unfortunately. Fourmousis.J Periodontol • November 2009 Kotsovilis. When short implants were defined as <10 mm long. and Table 4. systematic bias (selection bias) into the meta-analyses. This approach is also justified by the difference between totally and partially edentulous patients with regard to the type of restoration placed (Tables 2 and 3). Quality.71 were included in the meta-analysis. From a statistical point of view. the 1713 12 studies41. The amount (number of selected studies. Fig. no significant heterogeneity among selected studies was revealed in the majority of separate meta-analyses.72 were excluded because they did not include implants with lengths £8 mm.45.70. . therefore. and additionally.55.47. 3).173.69 were excluded because all short and conventional implants survived. furthermore. However. In that respect. and Table 4. and implants) and quality (as revealed by the process of quality assessment) of evidence appears to allow robust conclusions. Bamia Figure 1. according to the type of patient edentulism. 3).64. and Applicability of Evidence The selected studies fulfilled the objective of the review.145 and 0. Survival risks were used as estimates of actual survival rates. Because periodontal pathogens may be transmitted from teeth to implants in partially edentulous patients.70. respectively) in survival was demonstrated between short and conventional rough-surface implants placed in partially edentulous patients (Table 4. certain types of patients as defined by exclusion criteria 2 through 4 were not taken into account. the study by Strietzel and Reichart72 was also included because it reported data for short implants with lengths <10 mm.58. the aforementioned 12 studies41.55. Fig. the impact of total exposure time of each implant within the oral cavity upon implant survival was not taken into account.

The use of patient-based 1714 General Conclusions/Strength of Evidence In general.98. in everyday clinical practice.01 [0.06] 0. † No statistically significant heterogeneity among studies (P >0. the process of quality assessment revealed the methodologic quality of the studies included in the metaanalyses was sufficient. 1. 1. L = length. calculation of actual implant survival rates could not be carried out because. Despite this limitation.04] 0.05).98.919† 0.67.68 of eight selected long-term studies. In the majority of meta-analyses.18. it is of interest to note that favorable percentages of survival of short rough-surface implants (exceeding 95% and being comparable to those of conventional implants) have been reported by seven41.00] P Value for RR 0.20 CONCLUSIONS Within the limitations of the present systematic review. Summary of Meta-Analyses Comparing Survival of Short Versus Conventional Implants Studies (n) Totally edentulous patients L £8 mm versus L ‡10 mm L <10 mm versus L ‡10 mm Partially edentulous patients L £8 mm versus L ‡10 mm L <10 mm versus L ‡10 mm 6 6 12 13 Pooled RR (weighted mean [95% CI]) 1.10).964† Statistical Model (method) Fixed effects Random effects Fixed effects Fixed effects CI = confidence intervals. RR >1 indicates higher survival for short compared to conventional implants. Forest plot for selected studies reporting survival of short (length <10 mm) versus conventional (length ‡10 mm) implants in totally edentulous patients.175† 0. * No statistically significant difference in primary outcome variable between short and conventional implants (P >0. the following conclusions may be drawn.Short Versus Conventional Implants Volume 80 • Number 11 Table 4.99 [0. Figure 2. The body of acquired evidence appears to be adequate to draw robust conclusions. and no evidence of publication bias existed.58.978* 0. indicating the efficacy of short implant placement on a long-term basis.97.42. it is too difficult or virtually impossible to record the total exposure time of each and every implant included in the metaanalyses. Specific Conclusion There is no significant difference in survival between short (£8 or <10 mm) and conventional (‡10 mm) rough-surface implants in totally or partially edentulous patients.49. it seems reasonable to suggest that.47. 1. with only one possible exception. no significant heterogeneity among selected studies was demonstrated. Statistical analyses in this review were restricted to implant-related survival data.00] 0.036 0.99 [0. Implications for Clinical Practice Based on the findings of the present article. Such a task would require complete access to the raw data of all selected studies. clinicians can use short implants as an .978* 0. statistical analysis was hampered by the lack of adequate patientrelated survival data.99 [0. 1.145* 0. Weighted mean of RR and 95% confidence intervals (CI).94. practically.63 as demonstrated in Tables 2 and 3. Agreements/Disagreements With Other Reviews The finding that no statistically significant difference in survival existed between short and conventional rough-surface implants in totally or partially edentulous patients is in agreement with previous comprehensive reviews.173* Heterogeneity P Value 0.

Ge Brunel. Steven Eckert. Italy. Kees Stellingsma. Sheldon Winkler. The authors report surgical procedures would be concomitantly required. Vancouver. Bern. RR >1 indicates higher survival for short compared to conventional Peter Strietzel. but also crown10:387-416. Karoussis. Bamia Murray Arlin. Lebanon. Germany. Virginia. David Cochran. Fourmousis. Go efficacious treatment modality for the replacement of ¨ lndal. Sweden. Birmingham. Damien Walmsley. Weber HP. William Becker. Lebanon. plants is impossible or not preferable if advanced and Roland Younan. Ontario. France. not only in relation to implant length. Sweden. Norway. Italy.55:243-247. The Netherlands. Chris Wyatt. Milan. Adell R. Belgium. Bra tions in partially edentulous patients using two-part ITI implants (Bonefit) as abutments. Falun. Ignace Naert. Roccuzzo. Adell R. Tokushima. Bertil Friberg. Umea ˚ . Turin. Diego Lops. Eugenio Forest plot for selected studies reporting survival of short (length <10 mm) versus conventional Romeo. The tients whenever the placement of conventional imNetherlands. implants. Bra prognosis (such as peri-implant bleeding on probing. Daniel Buser. Orebro. probing depth. Charles A Babbush. Osseointe1. grated implants in the treatment of the edentulous jaw. Groningen. Alf Eliasson. Switzerland. Beirut. 3. Rochester. Georges Tawil. British Columbia. Youji Miyamoto. systematic reviews will be able to compare short and ˚nemark PI. Toronto. Toulouse. Sweden. Switzerland. Implications for Clinical Research/Systematic Reviews It is desirable that future studies report not only implant REFERENCES survival. Italy. Gothenburg. Bergen. Rabah Nedir. Turku. Weston. Jemt T. Lyndhurst.J Periodontol • November 2009 Kotsovilis. PhiladelWidmark. Karl Dula. Vevey. Leuven. Milan. year study of osseointegrated implants in the treatIt is recommended to report implant survival data ment of the edentulous jaw.16:1-132. The Netherlands. but also all parameters determining implant ˚ nemark PI. Matteo Chiapasco. Switzerland. Leuven. Christian Frei. A 152. Treatment planning. Germany. Marc Quirynen. Sweden. Scand J Plast and radiographic marginal bone level) so that future Reconstr Surg Suppl 1977. San Antonio. Frank confidence intervals (CI). Pennsylvania. Per ˚ strand. John Gonsolley. J Prosthet Dent 1986. United ¨ ran Kingdom. Berlin. Bern. Douglas Deporter. Japan. Italy. et al. Belgium. Switzerland. no conflicts of interest related to this review. Sweden. Texas. Sweden. Torsten Jemt. Richmond. Finland. Groningen. Hansson BO. Minnesota. Modified single and short-span restorations ACKNOWLEDGMENTS The following individuals are gratefully acknowledged for participating in the process of contact with authors: supported by osseointegrated fixtures in the partially edentulous jaw. Weighted mean of RR and 95% Groningen. The Netherlands. Ha ¨ mmerle C. Bern. Int J Oral Surg 1981. (length ‡10 mm) implants in partially edentulous patients. Switzerland. to-root ratio of implants. Fixed reconstruc4. Milan. Michael ´ rard Bornstein. Beirut. Daniel Wismeijer. Dietmar Weng. Ohio. Bra conventional implants with regard to these parameters. and clinical Experience from a 10-year period. clinical attachment level. Geneva. Los Angeles. Kerstin Fischer. Risto-Pekka Happonen. 1715 . Gerry Raghoebar. Henry Meijer. Amsterdam. Switzerland. Urs Belser. California. Ontario. Bern. Gothenburg. Rockler B. Kristina Arvidson. Mo missing teeth in totally and partially edentulous paphia. Starnberg. ¨ gger U. Lekholm U. Mario Figure 3.

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