Survival of Implants Using the Osteotome Technique

With or Without Grafting in the Posterior Maxilla:

A Systematic Review
Jun-Yu Shi, MDS1/Ying-Xin Gu, PhD2/Long-Fei Zhuang, PhD2/Hong-Chang Lai, PhD3

Purpose: The aim of this review was to systematically appraise survival rates of implants placed using the
osteotome technique with and without grafting in the published literature. Materials and Methods: An
electronic search was conducted to identify prospective and retrospective studies on osteotome sinus floor
elevation published between January 1, 2000 and October 30, 2015. Studies were included that (1) involved
use of the osteotome technique with or without grafting; (2) provided data regarding the implant survival
rates, residual bone height (RBH), and grafting materials; and (3) reported mean follow-up of at least 1 year
after functional loading and included a minimum of 10 patients. The mean weighted cumulative implant
survival rates were used to compare the two treatment strategies—grafted or nongrafted. The influence of
RBH and implant length on weighted cumulative implant survival was also evaluated. Results: After search
and evaluation of the literature according to the inclusion criteria, 34 studies involving 1,977 patients and
3,119 implants were included. Eighty-four out of 102 implant failures documented in the studies occurred
within 1 year of functional loading. Statistically significant differences in the cumulative survival rates were
found in the graft and nongraft groups (95.89% and 97.30%, respectively; P = .05). In the nongraft group,
no statistically significant difference in the cumulative survival rate was found when implants were placed
at RBH < 5 mm or ≥ 5 mm (95.04% and 97.63%, respectively; P = .12). In the graft group, however, a
statistically significant difference was found when implants were placed at RBH < 5 mm or ≥ 5 mm (92.19%
and 97.59%, respectively; P < .01). Significantly lower weighted mean cumulative implant survival rates were
found in the shorter (< 8 mm) implant group than in the longer (≥ 8 mm) implant group (83.33% and 96.28%,
respectively; P < .01). Conclusion: The cumulative survival rates were significantly higher in the nongraft
group than in the graft group. Early failures (< 1 year functional loading) accounted for the vast majority of the
implant failures. The cumulative survival rates in the graft group were significantly lower when the RBH was
< 5 mm, while the cumulative survival rates in the nongraft group demonstrated no statistically significant
difference based on RBH. Shorter (< 8 mm) implants demonstrated significantly lower cumulative survival
rates than longer implants. Int J Oral Maxillofac Implants 2016;31:1077–1088. doi: 10.11607/jomi.4321

Keywords: dental implants, osteotome technique, survival rates, systematic review

I mplant placement in the posterior region of the max-

1Resident, Department of Oral and Maxillofacial Implantology,
Shanghai Ninth People’s Hospital, School of Medicine,
Shanghai Jiaotong University, Shanghai, China.
2 Attending, Department of Oral and Maxillofacial Implantology,
Shanghai Ninth People’s Hospital, School of Medicine,
Shanghai Jiaotong University, Shanghai, China.
3 Professor, Department of Oral and Maxillofacial Implantology,
Shanghai Ninth People’s Hospital, School of Medicine,
Shanghai Jiaotong University, Shanghai, China.
Drs Jun-Yu Shi and Ying-Xin Gu contributed equally to this work.
Correspondence to: Prof Hong-Chang Lai, Department of
Oral and Maxillofacial Implantology, Shanghai Ninth
People’s Hospital, Shanghai Key Oral Laboratory,
School of Medicine, Shanghai Jiaotong University,
639 Zhizaoju Road, Shanghai, 200011, China.
Fax: +86 2153073068. Email: lhc9@hotmail.com
©2016 by Quintessence Publishing Co Inc.
illa is often a significant challenge due to its poor
bone quality and quantity. The transalveolar sinus
floor elevation or osteotome sinus floor elevation, first
introduced by Tatum et al,1 was demonstrated to be
a predictable procedure for implant placement in the
posterior maxilla.
Later, a modification to the technique, bone-add-
ed osteotome sinus floor elevation, was described
by Summers et al.2 In the technique, bone was com-
pressed using osteotomes with increased diameters
and lifted in a vertical direction to elevate the sinus
membrane. The osteotome technique has been dem-
onstrated to be highly predictable in both short-term
and long-term studies.3–5 In comparison to the lateral
window technique, the osteotome technique may be

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Shi et al
considered less invasive, less time-consuming, and
more cost-effective.6
Previously, many studies showed that grafting ma-
terials, including autogenous bone, allogeneic bone,
and xenogeneic bone, should be used to maintain
the space below the elevated sinus membrane. These
studies reported high survival rates when the osteo-
tome technique was used with simultaneous graft-
ing.7–9 Subsequently, some clinicians tried to apply
the osteotome technique without using any grafting
materials. High success rates were reported in these
studies as well.10–13 Osteogenic activation after sinus
floor mini-fracture and osteogenic activity of the sinus
membrane may be possible rationales for endosinus
bone formation.14 A previous systematic review re-
ported a 3-year estimated survival rate of 92.8% using
the osteotome technique.15 However, no statistical
analysis could be performed with regard to grafting
materials because of significant heterogeneity.
Residual bone height (RBH) is a major consideration
when determining implant treatment strategies for
the posterior maxilla. One systematic review that in-
cluded 19 studies assessed the influence of RBH on im-
plant survival rates using the osteotome technique.16
The mean weighted cumulative implant survival rates
were 92.7% for 331 implants with < 5 mm RBH and
96.9% for 2,525 implants with ≥ 5 mm RBH. The differ-
ence was significant.
On the other hand, several studies have reported
favorable results using the osteotome technique with
or without grafting in severely resorbed maxillae. A
prospective study showed the 5-year survival rates us-
ing the osteotome technique without grafting were
94.59% in severely atrophic maxillae (RBH ≤ 4 mm).17
A retrospective study showed that the osteotome
technique combined with hydroxyapatite grafting was
a predictable option in severely atrophic maxillae (RBH
< 4 mm).18 The study included 35 patients with 40 im-
plants, and 100% survival rates were reported with a
mean follow-up of 29.5 months.
Implant length also plays an important role in de-
ciding implant treatment strategies for the posterior
maxilla. Telleman et al defined the short implant as one
with a designed intrabony length < 8 mm.19 A system-
atic review has demonstrated that implant length is no
longer considered to be a crucial factor in influencing
implant success.20
The aim of the present review was to systematically
analyze the scientific literature regarding implant sur-
vival rates using the osteotome technique with and
without grafting. The influence of RBH and implant
length on implant survival rates was also analyzed.
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MATERIALS AND METHODS
Search Strategy
A PubMed and Cochrane Central Register of Con-
trolled Trials search of articles published between
January 1, 2000 and October 30, 2015 was performed.
The search was limited to human trials and used the
following search criteria: (“sinus floor elevation” or
“sinus lift” or “sinus augmentation” or “sinus graft” or
“osteotome sinus floor elevation” or “bone-added os-
teotome sinus floor elevation” or “internal sinus floor
elevation” or “indirect sinus floor elevation” or “tran-
screstal sinus floor elevation”); (“dental implants” or
“dental implantation” or implant); and not (trauma or
tumor or injuries or cancer) were added to exclude
any off-topic studies.
Additional hand searches of bibliographies of full-
text articles and related reviews were also performed.
A hand search of the following journals published be-
tween January 1, 2000 to October 30, 2015 was per-
formed: Clinical Oral Implants Research; Clinical Implant
Dentistry and Related Research; International Journal of
Oral & Maxillofacial Implants; European Journal of Oral
Implantology; Journal of Oral Implantology; Journal of
Oral Rehabilitation; Journal of Prosthetic Dentistry; Jour-
nal of Periodontology; Journal of Clinical Periodontology;
Implant Dentistry; Journal of Dental Research; Interna-
tional Journal of Prosthodontics; European Journal of
Oral Sciences; and Journal of Dentistry.
Inclusion and Exclusion Criteria
The inclusion criteria for the study selection were: (1)
studies involving the osteotome technique performed
with or without grafting; (2) studies providing data re-
garding the implant survival rates, RBH, and grafting
materials; (3) studies reporting a mean follow-up of at
least 1 year after functional loading; (4) studies with ≥
10 patients; and (5) publications in the dental literature
that were based on human trials.
The exclusion criteria for the study selection were:
(1) studies with multiple publications on the same
patient cohort (the latest article on the same patient
cohort was included); (2) studies that concerned the
lateral window technique; and (3) studies that did not
report details of the grafting materials and RBH.
Selection of Studies
Titles and abstracts of the searches were initially
screened by two independent reviewers. The full texts
of all studies that were possibly relevant were then as-
sessed independently. Any disagreement was resolved
by discussion. Figure 1 shows the process of identify-
ing the included studies.
 Shi et al

Identification
PubMed searching (n = 988) Manual searching added
CENTRAL searching (n = 52) (n = 2)

Records after duplicates removed

(n = 995)
Screening

Records screened Records excluded

(n = 995) (n = 967)
Eligibility

Full-text articles assessed

Full-text articles excluded
for eligibility
(n = 15)
(n = 49)
Included

Studies included in
qualitative synthesis
(n = 34)

Fig 1   Search strategy.

Data Extraction were added for full-text evaluation. Ultimately, 34 arti-

Two independent reviewers extracted data using a
data extraction form. Any disagreement regarding
data extraction was resolved by discussion. General
information, implant systems, follow-up, RBH, grafting
material, number of patients, number of implants, in-
tervention, and drop-out rate were retrieved.
cles were selected for full-text evaluation.9–13,17,18,21–47
Table 1 shows the general characteristics of the in-
cluded studies. The ĸ values were 0.79 and 0.82 at the
abstract and full-text article levels, respectively. Fifteen
studies were excluded.14,48–61 Table 2 shows the rea-
sons for those studies’ exclusion.

Statistical Analysis Implant Survival Rates

Data analysis was performed using a statistical soft-
ware package (STATA, version 11.0; StataCorp). The
level of significance was set at α = .05. Weighted cu-
mulative implant survival rates were estimated as the
weighted average of implant survival rate in each in-
cluded study.16 The mean weighted cumulative im-
plant survival rates were used to compare the two
treatment strategies, grafted or nongrafted. The influ-
ences of RBH and implant length on weighted cumula-
tive implant survival were also evaluated.
RESULTS
For the present study, 34 studies involving 1,977 pa-
tients (two studies did not report the number of pa-
tients) and 3,119 implants were included. The mean
follow-up ranged from 12 to 125 months. In 20 studies,
2,118 implants were placed following the osteotome
technique with grafting, and the implant survival rates
ranged from 82.86% to 100%. In another 20 studies,
1,001 implants were placed following the osteotome
technique without grafting, and the implant survival
rates ranged from 94.12% to 100% (Table 3).
In all, 31 of the 34 studies reported the time of im-
plant failures; of these, 84 out of 102 implant failures
occurred within 12 months of functional loading.

Included and Excluded Studies Grafting

In all, 1,040 titles and abstracts for possible inclusion Table 4 shows the weighted mean cumulative implant
in the review were retrieved in the electronic search. survival rates with and without grafting. Statistically
After the hand search was performed, six more studies significant differences were found among the grafted

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Shi et al

Table 1  General Characteristics of Included Studies

Follow-up
Study Year Study design (mo) Implant system
Cosci and Luccioli24 2000 Retrosp 72 Integral Sulzer-Calcitek
Cavicchia et al23 2001 Prosp 35 (6–90) IMZ, 3i, Frialit-2
Winter et al47 2002 Retrosp 22 Frialit, Osseotite
Toffler46 2004 Prosp 27.9 (1–84) 3i, Astra Tech Osseotite Frialit-2
Deporter et al26 2005 Retrosp 37.7 Endopore
Leblebicioglu et al35 2005 Prosp 24.6 NR
Diserens et al27 2005 Prosp 14.4 Straumann

Ferrigno et al9 2006 Prosp 59.7 (12–144) Straumann

Stavropoulos et al45 2007 RCT 12 3i
Krennmair et al33 2007 Retrosp 44.5 (> 24) Frialit-2 Straumann Camlog
Kermalli et al32 2008 Retrosp 5–84 Endopore
Diss et al28 2008 Prosp 12 Astra Tech
Jurisic et al31 2008 Retrosp 36 Straumann, Nobel Biocare
Schmidlin et al41 2008 Retrosp 17.6 Straumann
Pjetursson et al40 2009 Prosp 38.4 Straumann

Gabbert et al29 2009 Prosp 14 (9–43) Straumann

Nedir et al38 2009 Prosp 12 Straumann
Calvo-Guirado et al21 2010 Prosp 36 NR
Lai et al34 2010 Prosp 12 Straumann

Nedir et al39 2010 Prosp 60 Straumann

Crespi et al25 2010 Prosp 36 NR
Senyilmaz et al13 2011 Prosp 24 Straumann
Fermergård et al11 2012 Retrosp 36 Astra Tech
Bruschi et al12 2012 Retrosp 125 (60–192) Frialit, PILOT
He et al30 2013 Retrosp 25 BEGO, Osstem
Fornell et al10 2012 Prosp 12 Straumann
Si et al42 2013 RCT 36 Straumann

Cannizzaro et al22 2013 RCT 60 Zimmer

Gonzalez et al18 2014 Retrosp 29.5 (6–100) Dentium

Spinato et al44 2015 Retrosp 12–72 Zimmer

(Epub 2014)
Gu et al17 2016 (Epub 2014) Prosp 60 Straumann
Nedir et al36 2014 Prosp 12 Straumann

Soydan et al43 2015 Retrosp 95 Straumann

Nedir et al37 2016 RCT 36 Straumann
(Epub 2015)
NR = not reported; Prosp = prospective study; Retrosp = retrospective study; ABG = autogenous bone graft; DFDBA = demineralized free-dried
bone allograft; CS = collagen sponge; DBBM = deproteinized bovine bone mineral; HA = hydroxyapatite; β-TCP = β-tricalcium phosphate;
PRF = platelet-rich fibrin; OSFE = osteotome sinus floor elevation.

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 Shi et al

No. of patients/
Residual bone height (mm) Grafting material implants Intervention Dropout (%)
4–10 ABG + DFDBA + β-TCP NR/265 Cosci’s OSFE NR
<5 ABG + CS NR/97 OSFE NR
2.87 (0.6–4) CS 34/58 OSFE NR
7.1 (3–10) ABG + DBBM 167/276 OSFE NR
4.2 DBBM 70/104 OSFE NR
9.1 None 40/75 OSFE 0
5.78 None 33/17 OSFE 0
ABG + DBBM 33/27
6–9 DBBM 323/588 OSFE 0.62
2–9 ABG+ Bioglass 26/35 Two-stage OSFE 0
9.6 DBBM 14/14 OSFE 0
7.2 (4–12) ABG+DBBM 45/57 OSFE NR
6.5 PRF 20/35 OSFE 3.2
6–9 None 33/40 OSFE 0
5.0 None 24/24 OSFE 0
8.1 None 181/164 OSFE NR
DBBM 181/88
3–7.9 None 36/92 OSFE 13.9
3.8 (1–6) None 32/54 OSFE 0
5–8 Porcine bone 30/60 OSFE with no dilators 3.62
5.6 None 202/191 OSFE NR
β-TCP+ABG 202/89 
5.4 (1–8) None 17/25 OSFE 5.89
6.62 (≥ 5) None 20/30 OSFE NR
5–10 None 17/27 OSFE 0
6.6 None 36/53 OSFE 0
2.1 None 46/66 Two-stage OSFE NR
6.7 (4.1–8) None 22/27 OSFE 0
5.6 None 21/21 OSFE 0
4.67 None 20/20 OSFE 8.89
4.58 ABG+DBBM 21/21
4.46 (3–6) None 20/20 OSFE 0
<4 β-TCP + HA 35/40 OSFE NR
≥4 67/69
3.79 (2.0–4.9) Allograft 70/70 Cosci’s OSFE 2.86

2.81 (2–4) None 25/37 OSFE 3.85

7 (6–10) None 4/4 OSFE 0
3.6 (2–5) Bioglass 9/20
1–8 DBBM 59/82 OSFE NR
2.6 None 12/17 OSFE 0
2.2 DBBM 12/20

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Shi et al
Table 2  Reasons for Exclusion of Studies
Study Reason
Fugazzotto 200251
Chen and Cha 200549
Zijderveld et al 200561
Nedir et al 200654
Levine et al 200752
Fermergård and Astrand 200850
Nedir et al 200955
Nedir et al 200953
Pjetursson et al 200956
Zijderveld et al 200960
Tetsch et al 201059
Bernardello et al 201148
Tajima et al 201357
Teng et al 201358
Anitua et al 201514
Reasons:
1 = study reporting sinus floor elevation with lateral approach;
2 = study without enough patients or follow-up;
3 = study without details of grafting materials;
4 = study without details of RBH;
5= study with the same patients cohort.
and nongrafted groups (95.89% and 97.30%, respec-
tively; P = .05). Six of the 34 studies directly compared
the implant survival rates in the grafted and nongraft-
ed groups.27,34,36,37,40,42 All six studies showed similar
implant survival rates among the two groups.
Residual Bone Height
Of the 34 studies, 26 reported detailed information on
RBH and implant survival rates (Table 5). Among the
nongrafted group, weighted mean cumulative implant
survival rates were 95.04% for 275 implants placed in
< 5 mm RBH and 97.63% for 507 implants placed in ≥
5 mm RBH. The difference was not significant (P = .12).
Among the grafted group, weighted mean cumulative
implant survival rates were 92.19% for 448 implants
placed in < 5 mm RBH and 97.59% for 1,287 implants
placed in ≥ 5 mm RBH. The difference was statistically
significant (P < .01).
Implant Length
Of the 34 studies, 18 reported the influence of implant
length on survival rate (Table 6). Among implants
placed in atrophic posterior maxillae, 2,258 out of 2,282
were ≥ 8 mm, while only 24 were < 8 mm. Weighted
mean cumulative implant survival rates were 83.33%
for the short implant group and 96.28% for the longer
implant group. The difference was statistically signifi-
cant (P < .01).
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DISCUSSION
The present review focused on examining survival
4 rates of implants in the posterior maxilla placed us-
4 ing the osteotome technique, both with and without
1 grafting. Instead of performing a formal quality assess-
5 ment of the included studies and a sensitivity analy-
4 sis, this review used stringent inclusion criteria. Only
5
studies that reported detailed information on RBH and
grafting materials were included.
5
Based on the 34 included studies reporting on
5
1,977 patients and 3,119 implants, high implant surviv-
5 al rates could be achieved if the osteotome technique
1 was used with and without grafting, both in the short
4 and the long term. This indicated that the osteotome
3 technique is predictable whether performed with or
2 without grafting. This result was also in line with a pre-
3
vious systematic review.62 In that review, 25 studies ex-
amining 3,092 implants were included, and the failure
2
rate was 3.85%.
In the present review, survival rates for implants
placed in the posterior maxilla using the osteotome
technique were significantly higher in the nongrafted
group than the grafted group. There was a statistically
significant difference, but it may have no clinical signif-
icance; both groups’ survival rates (97.30% in the non-
grafted group and 95.89% in the grafted group) could
be considered acceptable. From this point of view,
implant survival rates using the osteotome technique
with and without grafting in the posterior maxilla can
be considered comparable.
In this review, early failures (≤ 1 year after functional
loading) were reported to account for the vast major-
ity of the implant failures. Early failures are complex,
multifactorial, and stochastic problems associated with
many aspects of the treatment procedure. Jemt et al
analyzed early implant failures in 11,074 operations
over a period of 28 years.63 Of these, it was reported
that 616 operations resulted in early implant failures
(5.6%). Statistically significant differences among sur-
geons, gender of surgeons, and types of treated jaws
and implant surfaces were observed. Only a few late
failures (> 1 year after functional loading) were found
in this review, which may demonstrate the predictabil-
ity of the two treatment strategies from another point
of view.
It is believed that RBH plays an important role in the
clinical survival of implants placed in atrophic poste-
rior maxillae. Previous evidence recommends limiting
use of the osteotome technique to cases where RBH ≥
5 mm.15,64 Yet many clinicians have tried to expand the
indication of the osteotome technique to include more
compromised cases (RBH < 5 mm). Recently, favorable
implant survival rates among implants in severely
atrophic maxillae (RBH < 4 mm) using the osteotome
 Shi et al

Table 3  Implant Survival Rates in Included Studies

No. of Implant survival rates (%)
failures
Study Year Grafting (early, late)a 1 year 2 year 3 year 4 year 5 year > 5 year
Cosci and Luccioli24 2000 Y 8 96.98
Cavicchia et al23 2001 Y 11 (10, 1) 89.69 88.66 88.66
Winter et al47 2002 Y 5 (5, 0) 91.38 91.38
Toffler46 2004 Y 18 (13, 5) 95.34 93.55
Deporter et al26 2005 Y 2 98.08
Leblebicioglu et al35 2005 N 2 (2, 0) 97.33 97.33
Diserens et al27 2005 N 0 100.00
Y 0 100.00
Ferrigno et al9 2006 Y 9 (1, 8) 99.83 99.66 99.49 99.49 99.15 98.47
Stavropoulos et al45 2007 Y 6 (6, 0) 82.86
Krennmair et al33 2007 Y 0 100.00 100.00 100.00 100.00
Kermalli et al32 2008 Y 2 (2, 0) 96.49c
Diss et al28 2008 Y 2 (2, 0) 94.29
Jurisic et al31 2008 N 0 100.00 100.00 100.00
Schmidlin et al41 2008 N 0 100.00 100.00
Pjetursson et al40 2009 N 4 (3, 1) 98.17 97.56 97.56
Y 2 (2, 0) 97.73 97.73 97.73
Gabbert et al29 2009 N 4 (4, 0) 95.65
Nedir et al38 2009 N 0 100.00
Calvo-Guirado et al21 2010 Y 2 (2, 0) 96.67 96.67 96.67
Lai et al34 2010 N 5 (5, 0) 97.38
Y 7 (7, 0) 92.13
Nedir et al39 2010 N 0 100.00 100.00 100.00 100.00 100.00
Crespi et al25 2010 N 0 100.00 100.00 100.00
Senyilmaz et al13 2011 N 0 100.00 100.00
Fermergård et al11 2012 N 3 (2, 1) 96.23 96.23 94.34
Bruschi et al12 2012 N 3 (3, 0) 95.45 95.45 95.45 95.45 95.45 95.45
He et al30 2013 N 0 100.00 100.00
Fornell et al10 2012 N 0 100.00
Si et al42 2013 N 1 (1, 0) 95.00 95.00 95.00
Y 1 (1, 0) 95.24 95.24 95.24
Cannizzaro et al22 2013 N 1 (1, 0) 95.00 95.00 95.00 95.00 95.00
Gonzalez et al18 2014 Y 1 99.08 99.08
Spinato et al44 2015 (Epub Y 8 (8, 0) 88.57c
2014)
Gu et al17 2016 N 2 (2, 0) 94.59 94.59 94.59 94.59 94.59
(Epub 2014)
Nedir et al36 2014 N 0 100.00
Y 0 100.00
Soydan et al43 2015 Y 3 (2, 1) 97.56 96.34 96.34 96.34 96.34 96.34
Nedir et al37 2016 N 1 (0, 1) 100.00 100.00 94.12
(Epub 2015)
Y 2 (2, 0) 90.00 90.00 90.00
Mean survival rateb N 97.71 97.61 96.82 95.95 95.95 95.45
Y 96.73 96.72 97.58 98.03 98.81 98.01
aEarlyfailure = ≤ 1 year after functional loading; late failure = > 1 year after functional loading.
bWeighted mean cumulative implant survival rates.
cEstimated mean follow-up.

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Table 4  Implant Survival Rates With and Without Grafting in Included Studies
Grafting
No. of implants
Study Year (failures) Y N
Cosci and Luccioli24 2000 265 (8) 265 (8)
Cavicchia et al23 2001 97 (11) 97 (11)
Winter et al47 2002 58 (5) 58 (5)
Toffler46 2004 276 (18) 276 (18)
Deporter et al26 2005 104 (2) 104 (2)
Leblebicioglu et al35 2005 75 (2) 75 (2)
Diserens et al27 2005 44 (0) 27 (0) 17 (0)
Ferrigno et al9 2006 588 (9) 588 (9)
Stavropoulos et al45 2007 35 (6) 35 (6)
Krennmair et al33 2007 14 (0) 14 (0)
Kermalli et al32 2008 57 (2) 57 (2)
Diss et al28 2008 35 (2) 35 (2)
Jurisic et al31 2008 40 (0) 40 (0)
Schmidlin et al41 2008 24 (0) 24 (0)
Pjetursson et al40 2009 252 (6) 88 (2) 164 (4)
Gabbert et al29 2009 92 (4) 92 (4)
Nedir et al38 2009 54 (0) 54 (0)
Calvo-Guirado et al21 2010 60 (2) 60 (2)
Lai et al34 2010 280 (12) 89 (7) 191 (5)
Nedir et al39 2010 25 (0) 25 (0)
Crespi et al25 2010 30 (0) 30 (0)
Senyilmaz et al13 2011 27 (0) 27 (0)
Fermergård et al11 2012 53 (2) 53 (2)
Bruschi et al12 2012 66 (3) 66 (3)
He et al30 2013 27 (0) 27 (0)
Fornell et al10 2012 21 (0) 21 (0)
Si et al42 2013 41 (2) 21 (1) 20 (1)
Cannizzaro et al22 2013 20 (1) 20 (1)
Gonzalez et al18 2014 109 (1) 109 (1)
Spinato et al44 2015 70 (8) 70 (8)
(Epub 2014)
Gu et al17 2016 37 (2) 37 (2)
(Epub 2014)
Nedir et al36 2014 14 (0) 14 (0)
Soydan et al43 2015 82 (3) 82 (3)
Nedir et al37 2016 37 (3) 37 (3)
(Epub 2015)
Mean survival ratea 3,119 (114) 2,118 (87) 1,001 (27)
95.89% 97.30%
aWeighted mean cumulative implant survival rates.

technique have been reported in both short- and long-
term studies.17,18,37
In the present review, implant survival rate was
found not to be related to RBH (95.04% and 97.63%,
respectively) when no grafting materials were used.
However, the survival rate of implants placed in RBH
< 5 mm was significantly lower when grafting ma-
terials were used (92.19% and 97.59%, respectively).
This result is partially in line with a previous system-
atic review that used a similar assessment method.16 It
reported that the prognosis could be more favorable
when RBH > 5 mm. However, the subgroup analysis

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Table 5  Residual Bone Height (RBH) in Included Studies

RBH
No. of implants
Study Year Grafting (failures) Average, mm < 5 mm ≥ 5 mm
Cavicchia et al23 2001 Y 97 (11) 2.9 97 (11) 0
Winter et al47 2002 Y 58 (5) 2.87 58 (5) 0
Toffler46 2004 Y 276 (18) 7.1 15 (4) 261 (14)
Deporter et al26 2005 Y 104 (2) 4.2 56 (1) 48 (1)
Ferrigno et al9 2006 Y 588 (18) NR 0 588 (18)
Krennmair et al33 2007 Y 14 (0) 9.6 0 14 (0)
Kermalli et al32 2008 Y 57 (2) 7.2 17 (0) 40 (2)
Pjetursson et al40 2009 Y/N 252 (6) 7.5 44 (4) 176 (2)
Calvo-Guirado et al21 2010 Y 60 (2) NR 0 60 (2)
Gonzalez et al18* 2014 Y 109 (1) NR 40 (0) 69 (1)
Spinato et al44 2015 Y 70 (8) 3.79 70 (8) 0
(Epub 2014)
Soydan et al43 2015 Y 82 (3) NR 51 (2) 31 (1)
Leblebicioglu et al35 2005 N 75 (2) 9.1 0 75 (2)
Jurisic et al31 2008 N 40 (0) NR 0 40 (0)
Schmidlin et al41 2008 N 0 36 24 (0) 0
Nedir et al38 2009 N 54 (0) 2.5 54 (0) 0
Crespi et al25 2010 N 30 (0) 6.62 0 30 (0)
Senyilmaz et al13 2011 N 27 (0) NR 0 27 (0)
Bruschi et al12 2012 N 66 (3) 2.1 66 (3) 0
He et al30* 2013 N 27 (0) 6.7 0 27 (0)
Gu et al17 2016 N 37 (2) 2.81 37 (2) 0
(Epub 2014)
Fornell et al10 2012 N 21 (0) 5.6 10 (0) 11 (0)
Fermergård et al11 2012 N 53 (3) 6.3 0 53 (3)
Lai et al34* 2010 N 191 (5) 5.6 19 (2) 68 (5)
Y 89 (7) 4.7 20 (2) 173 (3)
Nedir et al36 2014 N 4 (0) 3.6 4 (0) 0
Y 10 (0) 7 0 10 (0)
Nedir et al37 2016 N 17 (1) 2.6 17 (1) 0
(Epub 2015) Y 20 (2) 2.2 20 (2) 0
Mean survival ratea N 782 (24) 275 (12) 507 (12)
95.04% 97.63%
Y 1,735 (66) 448 (35) 1,287 (31)
92.19% 97.59%b
*The threshold of RBH was 4 mm.
aWeighted mean cumulative implant survival rates.
bSignificant difference between implants placed in RBH < 5 mm and ≥ 5 mm.

NR = not reported.

between the grafted and nongrafted groups was not
performed. It remains unknown why the nongrafted
protocol can improve implant survival rates. However,
caution should be taken before making the clinical
recommendation, as the sample size of the nongrafted
group was relatively small compared to the grafted
group (782 and 1,735, respectively).
In the present review, the influence of implant
length on implant survival was also assessed. Signifi-
cantly lower implant survival rates were found among
the shorter (< 8 mm) implant group. This was con-
sistent with a previous retrospective cohort study of
4,591 Straumann implants with up to 10-year follow-
up, which showed that shorter (6-mm) implants in

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Shi et al

Table 6  Implant Lengths in Included Studies

RBH
No. of implants
Study Year (failures) < 8 mm ≥ 8 mm
Cosci and Luccioli24 2000 265 (8) 0 265 (8)
Cavicchia et al23 2001 97 (11) 0 97 (11)
Toffler46 2004 276 (18) 0 276 (18)
Diserens et al27 2005 44 (0) 3 (0) 41 (0)
Ferrigno et al9 2006 588 (18) 0 588 (18)
Diss et al28 2008 35 (2) 0 35 (2)
Schmidlin et al41 2008 24 (0) 2 (0) 22 (0)
Pjetursson et al40 2009 252 (6) 7 (3) 245 (3)
Gabbert et al29 2009 92 (4) 0 92 (4)
Nedir et al38 2009 54 (0) 0 54 (0)
Nedir et al39 2010 25 (0) 0 25 (0)
Crespi et al25 2010 30 (0) 0 30 (0)
Calvo-Guirado et al21 2010 60 (2) 0 60 (2)
Lai et al34 2010 280 (12) 12 (1) 268 (11)
Fornell et al10 2012 21 (0) 0 21 (0)
Fermergård et al11 2012 53 (3) 0 53 (3)
Bruschi et al12 2012 66 (3) 0 66 (3)
Cannizzaro et al22 2013 20 (1) 0 20 (1)
Mean survival ratea 2,282 (88) 24 (4) 2,258 (84)
83.33% 96.28%*
aWeighted mean cumulative implant survival rate.

*P < .05.

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10 years of follow-up.66,67 Different implant systems
and surface modifications may explain the contradic-
tory results. More randomized controlled trials are
needed to confirm the predictability of shorter (< 8
mm) implants in posterior maxillae.
CONCLUSIONS
The cumulative survival rates were significantly higher
in the nongraft group than in the graft group. Early fail-
ures (< 1 year functional loading) accounted for the
vast majority of the implant failures. The cumulative
survival rates in the graft group were significantly lower
when the RBH was less than 5 mm, while the cumula-
tive survival rates in the nongraft group demonstrated
no statistically significant difference based on RBH.
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