Clinical Oral Investigations (2021) 25:6045–6068

https://doi.org/10.1007/s00784-021-04095-0

REVIEW

Clinical performance of short versus standard dental implants

in vertically augmented bone: an overview of systematic reviews
Patrícia Pauletto1   · Edwin Ruales‑Carrera2   · Luis André Mezzomo3   · Cristine Miron Stefani4   ·
Mario Taba Jr.5   · Reginaldo Bruno Gonçalves6 · Carlos Flores‑Mir7   · Graziela De Luca Canto8 

Received: 2 May 2021 / Accepted: 20 July 2021 / Published online: 16 August 2021
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Objective  To answer the question: What do we know so far about the clinical performance of short implants (≤ 7 mm)
when compared to standard length implants in vertically augmented bone, as well as which is the overall confidence of the
systematic reviews (SRs) about this topic?
Materials and methods  An overview of SRs was conducted. The searches were performed in six electronic databases and
grey literature. SRs about short (≤ 7 mm) versus standard dental implants performance in vertically augmented bone were
included. The assessed outcomes were marginal bone loss (MBL), implant survival (IS), prosthetic (PC) and biological
complications (BC), costs, surgical time, and patient satisfaction. AMSTAR 2 was used to evaluate the overall confidence
of included SRs.
Results  Thirteen SRs were included. Nine of twelve SRs reported a lower MBL for the short implant group. All the included
SRs showed no difference in the IS between groups. A higher rate of BC was reported for standard-length implants in four
out of five SRs. No differences regarding PC were reported in four of five SRs. Information related to patient preference,
cost, and surgery time were underreported. The confidence evaluation of the SRs was stratified as low for five SRs and criti-
cally low for eight SRs.
Conclusions  In an overall low-to-very low confidence levels, short implants appear to perform better in the mid-term (up to
5 years) than standard dental implants associated with vertical bone augmentation regarding MBL and BC, but they have a
similar performance regarding IS rates and PC. There is an imperative need to improve the methodological quality of SRs,
and efforts should focus on conducting RCTs to broaden the knowledge on this topic.
Clinical relevance  Short implants could represent a viable, simpler, and less invasive treatment when available bone height
is limited.

Keywords  Short implants · Systematic review · Overview

Introduction
The replacement of missing teeth by dental implants is a
very well-established dental treatment for partially [1, 2]
or totally edentulous patients [3]. However, the insertion
of standard-length implants in some oral regions may be
impaired due to insufficient bone height. In this sense, sev-
eral randomized clinical trials (RCT) [4–6] have described
the performance of short implants compared to long
implants. Nonetheless, there are two clinical scenarios to
* Luis André Mezzomo
lmezzomo@hotmail.com
Extended author information available on the last page of the article
perform this comparison. The first is when the bone height
is limited, and there would be the need for vertical bone
augmentation [4, 5, 7], and the second is when the objective
is to compare short and long implants in similar conditions
(enough native bone available for both options) [8–10].
In cases of insufficient bone height, several surgical tech-
niques for augmenting severely resorbed ridges have been
suggested in the literature, such as inlay and onlay bone
grafts [11, 12], sinus elevation [13], distraction osteogen-
esis [14], sandwich osteotomy technique [15], and guided
bone regeneration [16]. In the mandible, lateralization and
transposition procedures of the inferior alveolar nerve could
also be performed [17, 18].

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Vol.:(0123456789)
6046
However, these are considered complex surgical proce-
dures, which can result in intra- and post-operative compli-
cations with an associated increased reluctance of the patient
to undergo them [19, 20]. Additional costs and extended
treatment duration are other factors to be considered when
implants are placed in association with bone regeneration
procedures [21]. Thus, short implants have been suggested
as a predictable and more affordable treatment for some
patients, with apparent good results, low morbidity, and low
incidence of complications [22, 23].
Short implants were initially considered those < 10 mm
[22, 24]. Other authors have suggested that 8 mm or less
would be appropriate to define short implants [25], while
others have determined them as ≤ 6  mm [26]. Although
there is still controversy and not a clear definition regarding
the length of short implants, there is a clear trend towards
shorter lengths.
Given the need for clinicians to provide predictable long-
term treatments with the greatest comfort and lowest pos-
sible morbidity, there is a need for a better understanding of
the available scientific basis for clinical decision-making.
The synthesis of knowledge facilitates the delivery of perti-
nent information, reachable to the clinician in a single docu-
ment, facilitating reading and understanding on a particular
subject. Knowledge synthesis can be defined as contextual-
ization and integration of individual research results within
a broader range of knowledge on the subject [27]. This can
be used to interpret the results of individual studies within
the global context of evidence and bridge the gap between
research and decision-making [28].
Several systematic reviews (SRs) [29–36] have been pub-
lished on the performance of short implants compared to
standard-length implants associated with bone augmentation
procedures, especially in recent years. Consistent concord-
ance in their conclusions has not been observed. A general
synthesis and evaluation of these SRs have not yet been
carried out. Therefore, the purpose of this overview was to
summarize the available evidence and answer the following
focused question: “What do we know so far about the clini-
cal performance of short implants (≤ 7 mm) when compared
to standard length implants in vertically augmented bone,
as well as which is the overall confidence of the systematic
reviews assessing this topic?”.
Methods
Protocol and registration
An overview protocol was performed based on the Pre-
ferred Reporting Items for Systematic Reviews and Meta-
Analysis Protocols (PRISMA-P) [37] and registered in the
13
Clinical Oral Investigations (2021) 25:6045–6068
Prospective Register of Systematic Reviews (PROSPERO)
[38]. The register is publicly available under the number
CRD42020149144. In addition, the report of this study is
based on the PRIO-harms (Preferred Reporting Items for
Overview of Systematic Reviews Checklist) [39].
Ethics approval was not required for this overview.
Eligibility criteria and outcomes of interest
The included studies were SRs with or without meta-analy-
sis that evaluated primary studies comparing short (≤ 7 mm)
implants against standard length implants in vertically aug-
mented bone, with at least 3-year follow-up, regarding mar-
ginal bone loss, implant survival, prosthetic and biological
complications, costs, surgical time, and patient satisfaction.
There is still no consensus on the definition of short
implants in terms of length. However, in both academic and
clinical settings, there is a growing trend towards shorter
lengths. Therefore, to address this concern, the authors con-
sidered including SRs reporting on short implants (≤ 7 mm).
Only SRs that met the minimum criteria proposed by the
Cochrane Handbook for SRs of Interventions [40] were con-
sidered (Box 1):
Box 1 Criteria proposed by the Cochrane Handbook for
SRs of Interventions.
Cochrane Handbook for SRs of Interventions
1. A clearly stated set of objectives with pre-defined eligibility crite-
ria for studies;
2. A systematic search that attempts to identify all studies that meet
the eligibility criteria;
3. An explicit, reproducible methodology;
4. An assessment of the validity of the findings of the included stud-
ies, for example through the assessment of the risk of bias;
5. A systematic presentation, and synthesis, of the characteristics and
findings of the included studies.
No time and language restrictions were applied.
The exclusion criteria comprised:
1. Narrative reviews, rapid reviews, intervention studies,
observational studies, pre-clinical and basic research,
abstracts, commentaries, case reports, protocols, per-
sonal opinions, letters, and posters.
2. Systematic Reviews with or without meta-analysis that
considered the short implant length > 7 mm.
3. Studies that did not meet the minimum criteria for SRs
as proposed by the Cochrane Handbook for SRs of Inter-
ventions.
4. Required data not available after three attempts within a
30-day interval to contact the corresponding author by
email.
Clinical Oral Investigations (2021) 25:6045–6068
5. Systematic reviews with or without meta-analysis with-
out comparison with standard implants associated with
vertical bone augmentation.
6. Systematic reviews with or without meta-analysis with
primary studies other than randomized controlled trials.
7. Systematic reviews with or without meta-analysis with
follow-up time < 3 years.
Information sources, search strategy, and additional
search for primary studies
An electronic search was performed on January 11, 2021,
in six databases (Cochrane, Embase, Lilacs, PubMed, Sco-
pus, Web of Science). The grey literature was also consulted
through Google Scholar, Proquest Dissertations and Theses,
and OpenGrey. Additionally, reference lists of the included
studies and experts were screened. The articles found were
exported to a reference manager software (EndNote X7®,
Thomson Reuters, Philadelphia, PA), and the duplicated arti-
cles were deleted. The search strategy adopted for each data-
base is found in Appendix 1 in the Supplementary Informa-
tion. A search update was performed on the 9th of July.
Data management and selection process
The identified articles were inserted into the Rayyan® Online
Software (Qatar Computing Research Institute, Qatar). The
selection of the studies was performed in two phases. In phase
1, studies were selected independently by two reviewers (P.P.
and E.R.C.) by reading the title and abstract. Thereafter, phase
2 was performed, which consisted of full-text reading, per-
formed independently by the two reviewers. A third reviewer
(L.A.M.) was consulted in case of disagreements.
Data collection process and data items
Data from the studies were collected independently in dupli-
cate through a previously formulated table by two reviewers
(P.P. and E.R.C.). Data were cross-checked and disagree-
ments were resolved by the third reviewer (L.A.M.). The
following information was extracted from selected articles:
authors, year of publication, journal, and impact factor; pop-
ulation; interventions and comparators; outcomes; design
of primary studies; PRISMA; PROSPERO; and Grading of
Recommendations Assessment, Development and Evalua-
tion (GRADE) mention, if a meta-analysis was performed,
reported review limitations, research question or objectives,
databases searched and date, follow-up period, type of pros-
thetic reconstruction, length of implants, main results, and
main conclusions.
6047
Assessment of methodological quality, quality
of evidence, and meta‑bias(es)
Assessment of methodological quality of included SRs was
independently assessed in duplicate by two reviewers (P.P.
and E.R.C.) using the AMSTAR 2 (A MeaSurement Tool to
Assess systematic Reviews) checklist [41]. The AMSTAR
2 evaluates the methodological quality of SRs through 16
questions that can be answered by three possible answers:
“yes,” “no,” or “partially yes.” The overall confidence (high,
moderate, low, and critically low) rating on studies was
evaluated as suggested by Shea et al. [41]: high: no or one
non-critical weakness; moderate: more than one non-critical
weakness; low: one critical flaw with or without non-critical
weaknesses; and critically low: more than one critical flaw
with or without non-critical weaknesses.
Summary measures
We considered the results that were shown with a mean
difference for continuous data, such as marginal bone loss.
For implant failure rate, relative risk and odds ratio were
accepted. For biological, prosthetic, and undefined compli-
cations, the relative risk was accepted as a measure of effect.
Patient preference, cost, and surgery time were evaluated by
descriptive analysis.
Data synthesis
The summary of evidence was performed according to
the Joanna Briggs Institute [42]. The main results of the
included SRs were summarized, categorizing their findings
within the following topics: marginal bone loss, implant sur-
vival, biological complications, prosthetic complications,
patient preference, cost, and surgery time (Tables 1 and 2).
A visual indication was generated through a traffic light,
where green represents the treatment with better results, red
the treatment with worst results, and amber indicates that
there are no differences between the compared groups [42]
(Tables 3 and 4). Numerical data such as mean difference
and relative risk are found in the same tables.
Results
Review and primary study selection
Electronic database search retrieved 1221 references, and
486 remained after removing duplicates. Also, papers iden-
tified from grey literature (15), experts (one), and reference
lists (none) were added. In phase 1, the title and abstract
of identified studies were evaluated, and 56 articles were
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6048
considered eligible for full-text reading. Thereafter, nine
SRs were included, and four additional SRs were found in
the search update. Finally, thirteen SRs were included for
qualitative synthesis. Reasons for the exclusion of SRs can
be found in Appendix 2 in the Supplementary Information.
The complete process of studies identification and selection
is provided in Fig. 1.
Review and study characteristics
Included SRs were published between 2015 and 2021 in
11 different journals. All SRs were published in English.
They were conducted in China [33, 43], Denmark [32, 35],
France [36], Germany [44], Italy [29, 31, 45, 46], Lithuania
[47], Spain [48], and the USA [30]. More information on the
characteristics of the SRs can be found in Tables 1 and 2.
Assessment of methodological quality and quality
of evidence
Five SRs [29, 33, 45, 46, 48] were judged as having low
confidence, whereas the other 8 SRs [30–32, 34–36, 44,
47] were judged as having critically low confidence. The
domains considered most critical were in relation to the
explanation about selection of study design of included
studies (domain 3) and regarding the mention of sources
of funding of the studies included in the SRs (domain 10),
neither SRs fulfilled these criteria. In relation to an adequate
investigation of publication bias, three SRs complied with
this question [30, 33, 45]. Further information on method-
ological quality assessment can be assessed in Fig. 2 and
Appendix 3 in the Supplementary Information.
Overlapping
A total of 32 primary studies were identified within the SRs.
Out of these, approximately 90.6% of the primary studies
were included in more than one SR. One study was included
nine times, four studies were included eight times, three were
included six times, five were included five times, three stud-
ies were included four times, five studies were included three
times, eight studies were included two times, and three stud-
ies were included a single time. More information regard-
ing the overlapping and characteristics of primary studies is
available in Appendix 4 in the Supplementary Information.
Synthesis of results
The results will be presented according to the outcome.
More information regarding the results can be seen in
Tables 3 and 4.
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Clinical Oral Investigations (2021) 25:6045–6068
Marginal bone loss
Nine out of twelve SRs [29–34, 36, 47, 48] indicated lower
bone loss for the short implant group (Table 3). Three SRs
[35, 36, 46] did not show statistical differences between
the groups analyzed, but two showed the results only in the
descriptive form [36, 46]. The mean difference in marginal
bone loss between short and standard implants in augmented
bone ranged from − 0.07  mm (CI: − 0.12 to − 0.02) [35]
to − 0.60 mm (CI: 0.36 to 0.83) [31]. One SR [36] descrip-
tively reported a mean bone loss of 1.23 mm (range 0.94
to 1.49 mm) for short implants and 1.51 mm (range 1.03
to 2.34 mm) for standard implants associated with vertical
bone augmentation. Carosi et al. [46] descriptively reported
a mean range bone loss of − 0.51 to − 2.30 mm for short
implants and − 0.77 to − 2.64  mm for standard implants
associated with vertical bone augmentation. Starch-Jensen
and Nielsen [32] presented their results in a descriptive sum-
mary indicating that the sandwich osteotomy associated with
delayed implant placement demonstrated greater long-term
peri-implant marginal bone loss compared to short implants.
Implant survival
All the included SRs reported no difference in the survival
rate of short implants compared to standard length implants
associated with bone augmentation procedures. Ten SRs
[29–31, 33–35, 44, 45, 47, 48] meta-analyzed the results.
The risk ratio ranged from 0.65 (CI: 0.22 to 1.92) at the
3-year follow-up [44] to 1.85 (CI: 0.61 to 5.62) at the 5-year
follow-up [29]. Nisand et al. [36] descriptively presented
the results and reported a proportion of implant survival of
96.24% (range 91.6 to 100%) for short implants and 95.09%
(range 93.61 to 96.15%) for standard implants. Carosi et al.
[46] found a proportion range of implant survival of 92 to
96.9% for short implants and 84.8 to 100%.
Biological complications
Four out of five SRs [30, 32, 34, 36] reported differences
favoring the short implant group concerning biological
complications. Three SRs meta-analyzed the results. The
risk ratio ranged from 0.11 (CI: 0.14 to 0.31) [34] to 0.46
(CI: 0.22 to 0.95) [48]. One SR [48] did not report sta-
tistical differences between the assessed groups. Nisand
et al. [36] mentioned that 13 patients out of 85 (15.29%)
presented temporary paresthesia in the short implant group,
against 47 patients out of 85 (55.29%) in the standard
implant group associated with vertical bone augmentation.
Starch-Jensen and Nielsen [32] concluded that sandwich
osteotomy and delayed implant placement demonstrated
Clinical Oral Investigations (2021) 25:6045–6068 6049

EMBASE LILACS PubMed Scopus Web of Science Cochrane

(n=337) (n=05) (n=278) (n=376) (n=219) (n=06)

Records idenfied through first database searching

Identification

(n=1,221)

Records aer duplicates removed

(n=486)

Hand search of the reference list of Google Scholar OpenGrey ProQuest

selected studies (n=02) (n=0) (n=13)
(n=7)

Records screened from reference list

Records screened from grey literature
(n=0)
(n=15)
Screening

Records screened from experts

(n=1)

Records screened and potenally useful

(n=56)

Full arcles excluded with reasons

(n=47)
Full-text arcles assessed
for eligibility in phase 2 (1) Another type of study than systemac

(n=56)
Eligibility

reviews (SRs); (2) SRs that considering the short

implant length > 7 mm; (3) SRs that did not meet

the minimum criteria proposed by the Cochrane

Handbook for Systemac Reviews of

Intervenons; (4) Required data not available

aer 3 aempts to contact by email; (5) SRs

without comparison with standard implants

Included

associated with vercal bone augmentaon; (6)

Update Search
(n=4) SRs with primary studies other than randomized

controlled trials; (7) SRs meta-analysis with

follow-up me < 3 years.

Studies included in qualitave synthesis

(n=13)

Fig. 1  Flow diagram of literature search and selection criteria

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6050
Fig. 2  Summary of author’s judgments for each included study,
assessed by the critical appraisal tool for systematic reviews:
AMSTAR 2 and graphically represented by “traffic light” plot, gen-
higher long-term biological complications compared with
short implants. The main biological failures described by
the studies were bleeding, graft infection/resorption, pain,
swelling [48], and perforation of the maxillary sinus mem-
brane [34, 48]. More information about this outcome can
be seen in Tables 2 and 4.
Prosthetic complications
Five SRs offered information regarding this outcome. Four
of them [32, 34, 46, 48] did not find differences between
the assessed groups. Three SRs meta-analyzed the results
and reported a relative risk ranging from 1.22 (CI: 0.33
to 4.49) [34] to 2.66 (CI: 1.12 to 6.34) [30]. Only one SR
demonstrated better results for the standard implants group
[30] (Table 4). The SR by Starch-Jensen and Nielsen [32]
did not describe differences between short implants com-
pared with the sandwich osteotomy and delayed placement
of standard-length implants. The most reported prosthetic
complications were fracture and loss of screws of abutments
[34, 48] and decementations [34]. Nisand et al. [36] men-
tioned the occurrence of 6 prosthetic failures in the group
of short implants and nine prosthetic failures in the group
of standard implants associated with bone augmentation.
Carosi et al. [46] reported a range proportion of prosthetic
complications of 0 to 9.1% in short implants group and 0 to
10% in standard implants.
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Clinical Oral Investigations (2021) 25:6045–6068
erated using robvis (visualization tool) where green means answer
“yes,” yellow answer “partially yes,” and red answer “no.” Blank cells
represent the non-conduct of meta-analysis
Complications
Four SRs used the generic term “complications” [29, 31, 33,
47] without differentiating biological or prosthetic complica-
tions. The relative risk ranged from 0.43 (CI: 0.15 to 1.25)
[33] to 4.72 (CI: 2.43 to 9.17) [31]. More information can
be seen in Table 4.
Patient‑reported outcome measures/costs/surgical
time
Only two SRs addressed the “Patients preference” outcome.
The SR of [35] described no differences between the short
and the standard-length implant groups. The SR of Starch-
Jensen and Nielsen [32] pointed to greater satisfaction in
patients treated with short implants. Regarding costs, two
SRs [30, 35] addressed this outcome, and only one SR [35]
assessed the surgical time. Lower cost and shorter surgical
time were described for the treatment with short implants.
Discussion
The assessment of the performance of short versus standard
length implants in vertically augmented sites has been a topic
of research interest in recent years. Several RCTs and SRs
have addressed this issue by offering evidence supporting
the use of short implants. However, the performance of short
implants might be influenced by different clinical scenarios.
 Table 1  Summary of overall descriptive characteristics of included systematic reviews (n = 13) part I
Author (year) Population Interventions and comparators Primary studies Mention of the Reported review limitations
following items:
1. PRISMA
2. PROSPERO
3. GRADE
4. Meta-analysis

Posterior regions
Bitinas and Bardijevskyte (2021) Partially or completely toothless
[47] patients whose upper or lower
jaw (or both) is atrophied but
the vertical height is sufficient
to place a short implant but
Intervention: Placing one or
more short implants into the
atrophied lower or upper jaw
(or both) without lifting the
sinus in the upper jaw or verti-
RCT (21) 1. Yes A high degree of heterogeneity
2. No was noted in the meta-analyses.
3. No All complications were counted
4. Yes together, without taking into
account and disaggregating their
Clinical Oral Investigations (2021) 25:6045–6068

is not sufficient for a normal
implant
Chen et al. (2019) [33] Patients who received den-
tal implant prosthetics for
edentulous posterior jaws with
both single or splinted crowns,
and who did not have a severe
systematic disease
Iezzi et al. (2020) [29] Patients with atrophic edentulous Intervention: short implants
ridge of 4 to 8 mm residual
height, candidate for fixed
prosthesis supported by dental
implants
cal bone augmentation in the
lower jaw
Control: Placing one or more,
normal or long implants into
the lower or upper jaw (or
both) after sinus lift surgery on
the upper jaw or augmentation
of the vertical height of the
lower jaw, using any technique
Intervention: short implants
(5–7 mm)
Control: standard implants
(≥ 10 mm) with augmentation
in the atrophic jaw
RCT (13)
(< 7 mm)
Comparison: standard implants
(≥ 7 mm) inserted in atrophic
edentulous ridges regener-
ated through augmentation
procedures
RCT (10)
The authors reported separately
the analysis of 9 studies using
short implants (> 8 mm)
origins. Short implants should
be broken down into short and
extra-short. The follow-up
period should be more than
5 years
1. Yes All included studies had a follow-
2. Yes up period of at least 1 year, with
3. No a maximum follow-up of 5 years.
4. Yes Several of the included studies
were from non-repetitive groups
by the same research institution,
which were heavily weighted
and might be influenced by the
overall level of implant insertion
skills in this study institution
1. Yes Mainly due to methodological
2. Yes limits, heterogeneity of results
3. Yes among studies, and to limited
4. Yes cumulative sample size, espe-
cially at the 5-year follow-up,
the quality of evidence was esti-
mated to be moderate or low at
most analyses, thereby limiting
the strength of recommendations

13
6051
 Table 1  (continued)
Author (year)
13
Nisand et al. (2015) [36]
Posterior maxilla
Carosi et al. (2021) [46]
Lozano-Carrascal et al. (2020)
[48]
Nielsen et al. (2018) [35]
Ravidà et al. (2019) [30]
Population
Healthy patients receiving
implants with fixed reconstruc-
tion with 5–8 mm of residual
bone height
Patients who received dental
implant in the posterior area of
the maxilla
Patients who received at least
one dental implant in the pos-
terior area of the maxilla
Healthy patients with atrophy of Intervention: short implants
the posterior maxilla
Any patient receiving one or
more short dental implant(s)
(≤ 6 mm) and one or more
long implant(s) (≥ 10 mm)
with a transcrestal sinus floor
elevation or lateral sinus floor
elevation procedure
6052
Interventions and comparators Primary studies Mention of the Reported review limitations
following items:
1. PRISMA
2. PROSPERO
3. GRADE
4. Meta-analysis
Intervention: short implants RCT (4) 1. Yes Small sample size and short
(5–6.6 mm) 2. No follow-up time
Comparison: standard implants 3. No The included studies were derived
(> 8 mm) placed in the verti- 4. No from the same clinical and
cally augmented bone research group
The vertical bone augmentation
technique was the same for all
the included studies
Intervention: short dental RCT (9) 1. Yes The main limitations of this
implants in severe posterior 2. No study are the follow-up of the
maxillae atrophy 3. No included studies, ranging from 1
Comparison: bone augmentation 4. Yes to 5 years, and the overall risk of
procedures and regular dental bias classified as unclear or high
implants in severe posterior in some included studies
maxillae atrophy
Intervention: one or more short RCT (8) 1. Yes Heterogeneity of the publica-
implants (4–6 mm) 2. Yes tions reviewed and the lack of
Comparison: standard implants 3. No information
(≥ 8 mm) placed simultane- 4. Yes
ously or deferred with lateral
sinus floor elevation
RCT (3) 1. Yes Not reported
(5–6 mm) 2. Yes
Comparison: standard implants 3. No
(≥ 10 mm) in conjunction with 4. Yes
maxillary sinus floor augmen-
tation
Intervention: short implants RCT (12) 1. Yes None of the studies reached
(≤ 6 mm) 2. Yes 5 years of follow-up
Comparison: standard implants 3. No
(≥ 10 mm) placement after a 4. Yes
sinus floor elevation (lateral/
transcrestal)
Clinical Oral Investigations (2021) 25:6045–6068
 Table 1  (continued)
Author (year) Population Interventions and comparators Primary studies Mention of the Reported review limitations
following items:
1. PRISMA
2. PROSPERO
3. GRADE
4. Meta-analysis

Yan et al. (2019) [34]
Partially edentulous patients in Intervention: one or more short RCT (7) 1. Yes The evidence included in this
the premolar and molar regions implants (≤ 6 mm) 2. Yes systematic review was only of
of the maxilla, with sufficient Comparison: one or more stand- 3. Yes moderate or low quality
bone height for the insertion of ard implants placed in the pos- 4. Yes Serious risks of bias were found
a short implant (≤ 6 mm) but terior maxilla after sinus floor within and across studies. Lim-
insufficient for the insertion of elevation by any technique ited number of participants and
longer implants follow-up period
Clinical Oral Investigations (2021) 25:6045–6068

Posterior mandible
Carosi et al. (2021) [46]
Esposito et al. (2019) [4]
Starch-Jensen and Nielsen (2018) Healthy patients (> 18 years)
[32]
Terheyden et al. (2021) [44]
Patients who need implant in the Intervention: short implants
posterior edentulous mandible
Patients with atrophic mandibles Intervention: short implants
receiving partial implant-
supported prostheses
with partially edentulous
atrophic posterior mandible
Patients in need of dental
implants with a mandibular
unilateral or bilateral free end
situation and vertical bone
atrophy
RCT (5) 1. Yes The main limitation is that the
(4–5 mm) 2. No longer follow-up is only at
Comparison: standard implants 3. No 5 years in function
after bone augmentation 4. No
procedures
RCT (4) 1. Yes Not reported
(5–6.6 mm) 2. No
Comparison: implants placed 3. No
in vertically augmented bone 4. Yes
according to any bone type
augmentation procedure
Intervention: short implants RCT (6) 1. Yes Only one long-term randomized
(4–6.6 mm) 2. Yes controlled trial with a 5-year
Comparison: prosthetic 3. No observation period after func-
rehabilitation of the partially 4. No tional loading was included in
edentulous atrophic posterior the present systematic review
mandible with the sandwich
osteotomy and delayed place-
ment of standard implants
Intervention: treatment with RTC (17) 1. Yes The limited multi-center founda-
short implants ≤ 7 mm and no 2. No tion of the data should be
vertical bone augmentation 3. No considered. All but one of the
Comparison: vertical bone 4. Yes studies included in the meta-
augmentation followed analysis were performed by the
by placement of dental same author group and were
implants > 7 mm published in the same journal,
for which the senior author was
also the editor in chief

Legend: RCT, randomized clinical trials

13
6053
 Table 2  Summary of overall descriptive characteristics of included systematic reviews (n = 13) part II
6054

Author (year) Objectives Databases searched Follow-up Outcomes/main results Main conclusions
Country Date assessed as up Type of prosthetic

13
Journal to date reconstruction
Journal impact factor Imsplant length

Posterior regions
Bitinas and Bardijevskyte To review the literature and
(2021) [47] determine whether short
Lithuania implants can be an effective
Australian Dental Journal alternative to standard-
(1.401) length implants after bone
augmentation
Chen et al. (2019) [33] To compare the survival rate, Cochrane, Embase,
China marginal bone loss changes,
Journal of Oral Rehabilitation and complications between Not reported
(2.051) short implants (5–8 mm) and
long implants (≥ 10 mm)
with a bone-augmented pro-
cedure in the posterior jaw
PubMed/Medline 1–5 years Marginal bone loss Short dental implants may be a
February 2021 Fixed/single crowns MD: − 0.08 (CI: − 0.10 to − 0.05) I2 = 0%, suitable alternative to stand-
4–6 mm p =  < 0.00001, 1 year ard-length dental implants
MD: − 0.19 (CI: − 0.31 to − 0.06) I2 = 56%, after bone augmentation. The
p = 0.003, 3 years risk of their complications
MD: − 0.45 (CI: − 0.87 to − 0.02) I2 = 81%, is possibly lower because
p = 0.005, 5 years of the lack of need for bone
Significantly less in the SH than ST implants augmentation
Implant survival
RD: − 0.04 (CI: − 0.12 to 0.03) I2 = 77%,
p = 0.27, 1 year
RD: − 0.01 (CI: − 0.04 to 0.03) I2 = 0%,
p = 0.67, 3 years
RD: 0.03 (CI: − 0.07 to 0.13) I2 = 0%,
p = 0.52, 5 years
No significant differences between groups
Complications
RD: − 0.21 (CI: − 0.34 to − 0.07) I2 = 93%,
p = 0.002, 1 year
RD: − 0.14 (CI: − 0.33 to 0.06) I2 = 86%,
p = 0.18, 3 years
RD: − 0.39 (CI: − 0.92 to 0.14) I2 = 95%,
p = 0.15, 5 years
Significant differences only in 1 year in favor
of short implants
1–5 years Marginal bone loss No difference between the sur-
PubMed Splinted and MD: − 0.12 (CI: − 0.18 to − 0.05) I2 = 55%, vival rates and complications
unsplinted crowns p = 0.0006 of short implants (5–8 mm)
5–7 mm Significantly less in the SH than ST implants and long implants (≥ 10 mm).
Implant survival The marginal bone loss
RR: 1.00 (CI: 0.98 to 1.03) I2 = 0%, p = 0.67 changes in short implants
Complications are lower than those in long
RR: 0.43 (CI: 0.15 to 1.25) I2 = 74%, p = 0.12 implants
No significant differences in the survival rate
and complications between the two groups
Clinical Oral Investigations (2021) 25:6045–6068
 Table 2  (continued)
Author (year) Objectives Databases searched Follow-up Outcomes/main results Main conclusions
Country Date assessed as up Type of prosthetic
Journal to date reconstruction
Journal impact factor Imsplant length

Iezzi et al. (2020) [29] To compare clinical and radio- PubMed/Medline, 1–5 years Marginal bone loss Short implants represent today
Italy graphic outcomes of < 7-mm Scopus, Web of Fixed prostheses MD: − 0.11 mm (CI: − 0.17 to − 0.04), I2 = 76, a valid alternative to more
Clinical Implant Dentistry and short implants inserted in Science 4–6.5 p = 0.0009, 1 year invasive augmentation pro-
Related Research native bone versus longer May 2020 MD: − 0.18 mm (CI: − 0.29 to − 0.06), I2 = 67, cedures for fixed rehabilita-
(3.22) implants placed in vertically p = 0.003, 3 years tions of partially edentulous
augmented partially edentu- MD: − 0.47 mm (CI: − 0.69 to − 0.24), I2 = 65, and posterior atrophic jaws.
lous posterior jaws p < 0.000, 5 years The advantages of 5- to
There is a trend for a lower marginal bone 6-mm-long implants over ST
loss associated with SH implants implants, especially in terms
Clinical Oral Investigations (2021) 25:6045–6068

Implant survival of reduced MBL, and equally

RR: 0.81 (CI: 0.39 to 1.70) I2 = 0%, p = 0.58, effective survival rate, are
1 year well-documented by studies
RR: 0.89 (CI: 0.36 to 2.21) I2 = 0%, p = 0.80, with 5 years of function or
3 years longer. Conversely, studies
RR: 1.85 (CI: 0.61 to 5.62) I2 = 0%, p = 0.28, with at least 5-year follow-up
5 years are urgently needed to con-
There is no evidence of a difference in sur- firm the promising outcomes
vival rates between SH and ST implants observed with less than
Biological or technical complications 5-mm-long fixtures
RR: 0.29 (CI: 0.13 to 0.63) I2 = 54%,
p = 0.002, 1 year
RR: 0.53 (CI: 0.28 to 1.01) I2 = 76%, p = 0.05,
3 years
RR: 0.69 (CI: 0.34 to 1.40) I2 = 81%, p = 0.30,
5 years
A lower incidence of complications in favor
of SH implants at both 1 and 3 years was
evidenced, while no differences at 5 years

13
6055
 Table 2  (continued)
6056

Author (year) Objectives Databases searched Follow-up Outcomes/main results Main conclusions
Country Date assessed as up Type of prosthetic

13
Journal to date reconstruction
Journal impact factor Imsplant length

Nisand et al. (2015) [36]
France
Clinical Oral Implant
Research
(3.825)
Posterior maxilla
Carosi et al. (2021) [46]
Italy
International Journal of Oral
& Maxillofacial Surgery
(2.068)
To assess if short implants
are comparable to longer
implants placed in vertically
augmented bone in terms of
survival and complication
rates of implants and recon-
structions, radiographic
bone levels, and patient-
reported outcome measures
To evaluate survival rate of
short dental implants placed
in the posterior area of the
maxilla
PubMed 1–5 years Marginal bone loss Implant and prosthetic survival
January 2015 Fixed partial denture SH: 1.23 mm (0.94 to 1.49 mm) rates seem to be similar
5–6.6 mm ST: 1.51 mm (1.03 to 2.34 mm) between short implants and
Implant survival longer implants placed in aug-
SH: 96.24% (91.66 to 100%) mented bone. Nevertheless,
ST: 95.09% (93.61 to 96.15%) bone augmentation would be
Biological complications associated with an increased
SH: 13 patients of 85 (15.29% temporary treatment time, cost, and
paresthesia) complications
ST: 47 patients of 85 (55.29% temporary
paresthesia)
11 grafting procedures failed
Prosthetic failure
SH: 6 prosthetic restorations
ST: 9 prosthetic restorations
Cochrane, Embase, 1–5 years Implant survival Based on the evidence of
Medline NR SH: 91.9 to 100% the included studies, short
NR 5–6 mm ST: 82.9 to 100% implants (≤ 6 mm) reported
RR: 1.24 (CI: 0.63–2.45) p = 0.52 high survival rates over
short-to-medium follow-up
in posterior maxilla, but the
long-term success is as yet not
demonstrated
Clinical Oral Investigations (2021) 25:6045–6068
 Table 2  (continued)
Author (year) Objectives Databases searched Follow-up Outcomes/main results Main conclusions
Country Date assessed as up Type of prosthetic
Journal to date reconstruction
Journal impact factor Imsplant length

Lozano-Carrascal et al. (2020) To compare the survival
[48] rate, marginal bone loss,
Spain and complications associ-
Medicina Oral Patología Oral ated with short implants
y Cirurgía Bucal (< 8 mm) versus longer
(1.475) implants (≥ 8 mm) placed
with lateral sinus floor eleva-
tion in posterior atrophic
maxillae
Cochrane, Embase, 1–5 years Marginal bone loss Prosthetic rehabilitations with
Medline NR RR: 0.86 (CI:0.75 to 0.98) I2 = 97.9%, short implants (< 8 mm) in
NR 4–6 mm p = 0.025 posterior maxilla are a reliable
Favorable for SH treatment option as an alterna-
Implant survival tive to lateral wall sinus floor
RR: 1.08 (CI: 0.42 to 2.83) I2 = 0%, p = 0.8 augmentation
Complications
RR: 0.60 (CI:0.25 to 1.47) I2 = 60.2%,
p = 0.262
Clinical Oral Investigations (2021) 25:6045–6068

Intra-operative complications
RR: 0.51 (CI:0.16 to 1.63) I 2 = 22.9%,
p = 0.258
Post-operative complications
RR: 0.76 (CI:0.33 to 1.74) I2 = 36.1%,
p = 0.517
Biological complications
RR: 0.46 (CI: 0.22 to 0.95) I2 = 0.0%,
p = 0.037
Prosthetic complications
RR: 1.52 (CI: 0.91 to 2.54) I2 = 0.0%,
p = 0.110

13
6057
 Table 2  (continued)
6058

Author (year) Objectives Databases searched Follow-up Outcomes/main results Main conclusions
Country Date assessed as up Type of prosthetic

13
Journal to date reconstruction
Journal impact factor Imsplant length

Nielsen et al. (2018) [35]
Denmark
International Journal or Oral
and Maxillofacial Surgery
(1.521)
To assess if there are differ-
ences in the long-term final
implant treatment outcome
between the two treat-
ment modalities involving
short implants compared to
standard-length implants in
conjunction with maxillary
sinus floor augmentation
Cochrane, Embase, 3 years Marginal Bone Loss The insertion of short implants
Medline Splinted crowns, MD: − 0.07 (CI: − 0.12 to − 0.02) I2 = 62.1%, in the posterior part of the
June 2017 single crowns p = 0.072 maxilla seems to be a suitable
5–6 mm Implant survival alternative to the installation
OR: 0.90 (CI: 0.15 to 5.44) I2 = 0%, p = 0.369 of standard-length implants
Biological complication in conjunction with maxillary
SH: 3 membrane perforation, 1 peri-implant sinus floor augmentation. Fur-
mucositis ther RCTs with larger patient
ST: 1 membrane perforation, bleeding, pain, samples and observation peri-
swelling, 1 loss of graft material ods of more than 3 years are
Prosthetic complication needed before one treatment.
SH: 2 decementation, 8 abutment screw Modality might be considered
loosening superior to the other
ST: 1 decementation, 2 abutment screw loos-
ening or fracture of abutment screw
Patient satisfaction
PROMS were assessed in one study that
reported no statistically significant differ-
ence between the two treatment modalities
Time and costs
One study reported that the treatment involv-
ing standard-length implants in conjunction
with maxillary sinus floor augmentation
was significantly more time-consuming
and patients receiving short implants were
significantly more fully satisfied with the
cost of the treatment
Clinical Oral Investigations (2021) 25:6045–6068
 Table 2  (continued)
Author (year) Objectives Databases searched Follow-up Outcomes/main results Main conclusions
Country Date assessed as up Type of prosthetic
Journal to date reconstruction
Journal impact factor Imsplant length

Ravidà et al. (2019) [30] To compare the clinical and
USA patient-reported outcomes
Implant Dentistry of ≤ 6-mm implants with
(1.214) those of ≥ 10-mm implants
placed after both lateral
and transcrestal sinus floor
elevation
Cochrane, Embase, 1–3 years Marginal Bone Loss The placement of short
PubMed N/R MD: − 0.14 (CI: − 0.22 to − 0.06) I2 = 51.57%, implants is a predictable
February 2018 4–6 mm p = 0.001, 1 year option in treating patients
MD: − 0.23 (CI: − 0.38 to − 0.07) I2 = 65.97%, with maxillary atrophy up to
p = 0.004, 3 years a 3-year follow-up. Studies
Short implant showed fewer changes in MBL with a longer observational
Implant survival period are needed to study
SH: 98.1%, 1 year the long-term performance of
ST: 95.1%, 1 year these implants
Clinical Oral Investigations (2021) 25:6045–6068

RR = 1.01 (CI:0.98 to 1.04) I2 = 0%, p = 0.62

SH: 97.8%, 3 years
ST: 98.8%, 3 years
RR: 0.99 (CI: 0.96 to 1.02) I2 = 0%, p = 0.36
No statistically significant differences
Biological complications
RR = 0.26 (CI:0.11 to 0.54) I2 = 0%, p = 0.003,
1 year
RR = 0.22 (CI: 0.05 to 1.02) I2 = 58.66%,
p = 0.005, 3 years
Short implants displayed fewer biological
complications
Prosthetic complications
RR = 0.58 (CI:0.23 to 1.43) I2 = 0%, p = 0.24,
1 year
RR = 2.66 (CI: 1.12 to 6.34) I2 = 0%, p = 0.03,
3 years
More prosthetic complications for the SH
group at 3 years
Costs
Two studies that addressed this outcome
showed a nearly twofold increase in price
for the procedures including sinus elevation,
p < 0.01

13
6059
 Table 2  (continued)
6060

Author (year) Objectives Databases searched Follow-up Outcomes/main results Main conclusions
Country Date assessed as up Type of prosthetic

13
Journal to date reconstruction
Journal impact factor Imsplant length

Yan et al. (2019) [34] To compare the use of short Cochrane, Embase, 1–3 years Marginal bone loss The survival rate of short
China implants (≤ 6 mm) in PubMed Single crowns or MD: − 0.13 (CI: − 0.21 to 0.05) I2 = 87%, implants (≤ 6 mm) was
BMJ Open atrophic posterior maxilla May 2018 splinted fixed dental p = 0.001, 1–3 years comparable to that of longer
(2.376) versus longer implants prostheses MD: − 0.25 (CI: − 0.40 to 0.10) I2 = 0%, implants (≥ 10 mm) with
(≥ 10 mm) with sinus floor 4–6 mm p = 0.001, 3 or more years sinus floor elevation
elevation Favorable for SH Short implants (≤ 6 mm) show
Implant survival significantly less MBL and
RR: 1.01 (CI: 0.97 to 1.04) I2 = 0%, p = 0.74, post-surgery reactions. Short
1–3 years implants (≤ 6 mm) are, there-
RR: 1.00 (CI: 0.97 to 1.04) I2 = 0%, p = 0.79, fore, the promising alternative
3 or more years to sinus floor elevation for
Biological complications posterior maxilla with insuf-
Post-surgery reaction ficient bone volume
RR: 0.11 (CI: 0.14 to 0.31) I2 = 40%, Additional high-quality stud-
p < 0.001 ies are needed to evaluate
Favorable for SH the long-term effectiveness
Sinus perforation or infection and safety of short implants
RR: 0.11 (CI: 0.02 to 0.63) I2 = 0%, p = 0.01 (≤ 6 mm)
Favorable for SH
Implant mobile
RR: 0.34 (CI: 0.06 to 2.06) I2 = 0%, p = 0.01
Prosthetic complications
Screw loosening
RR: 2.66 (CI: 0.93 to 7.60), p > 0.05
Crown loosening, decementation, or chipping
RR: 1.22 (CI: 0.33 to 4.49, p > 0.05)
Short implant posterior mandible
Carosi et al. (2021) [46] To systematically review the Cochrane, Medline, 1–5 years Marginal bone loss It seems that short dental
Italy literature concerning implant Embase Fixed prostheses SH: ranged from − 0.51 to − 2.30 mm implants are a valid thera-
The International Journal survival rates, marginal bone NR 4–5 mm ST: ranged from − 0.77 to − 2.64 mm peutic choice to rehabilitate
of Oral & Maxillofacial levels, and prosthetic suc- Implant survival severe mandibular atrophy in
Implants cess of short dental implants SH: 92 to 96.9% the medium-to-long term
(2.068) used for severe posterior ST: 84.8 to 100%
mandibular atrophy reha- Prosthetic complications
bilitation SH: 0 to 9.1%
ST: 0 to 10%
Clinical Oral Investigations (2021) 25:6045–6068
 Table 2  (continued)
Author (year) Objectives
Country
Journal
Journal impact factor
Esposito et al. (2019) [4] To compare the clinical
Italy outcome of fixed prostheses
International Journal of Oral supported by 4- to 8-mm
Implantology implants with prosthe-
(2.619) ses supported by longer
implants placed in verti-
cally augmented atrophic
mandibles after a follow-up
of 5 years in function
Starch-Jensen and Nielsen To test the hypothesis of no Cochrane, Embase,
(2018) [32] difference in the prosthetic PubMed
Denmark rehabilitation of the par-
Journal of Oral & Maxillofa- tially edentulous atrophic
cial Research posterior mandible with
(Not available) short implants (≤ 8 mm)
compared with the sandwich
osteotomy and delayed
placement of standard-
length implants (> 8 mm)
13
Databases searched Follow-up Outcomes/main results Main conclusions
Date assessed as up Type of prosthetic
to date reconstruction
Imsplant length
Cochrane, Medline 5 years Marginal bone loss In the presence of 5 to 8 mm of
September 2018 Fixed prostheses MD: − 0.60 (CI:0.36 to 0.83) I2 = 45%, vertical residual bone above
5–6.6 mm p < 0.00001 the mandibular canal, 5 years
Favorable for SH after loading, prosthetic and
Prosthesis failures implant failures were similar
RR: 1.46 (CI:0.52 to 4.09) I2 = 0%, p = 0.47 between the short implants
Implant survival and vertical bone augmenta-
RR: 1.00 (CI:0.31 to 3.21) I2 = 0%, p = 1.00 tions with interpositional
Complications blocks of bone substitutes to
Clinical Oral Investigations (2021) 25:6045–6068
RR: 4.72 (CI:2.43 to 9.17) I2 = 1%, place implants at least 10 mm
p < 0.00001 long, but complications and
Favorable for SH peri-implant marginal bone
loss were higher and more
severe at longer implants
placed in vertically aug-
mented mandibles
1–5 years Marginal bone loss Short implants and the
Fixed prosthesis or Sandwich osteotomy and delayed implant sandwich osteotomy with
May 2018 single crowns placement demonstrated higher long-term the delayed placement of
4–6.6 mm peri-implant marginal bone loss standard-length implants
Implant survival appear to result in predictable
There were no differences in the implant outcomes in terms of high
survival rate between short implants and survival rate of superstruc-
standard implants tures and implants after
Biological complications prosthetic rehabilitation of the
Sandwich osteotomy and delayed implant partially edentulous atrophic
placement demonstrated higher long-term posterior mandible
peri-biological complications compared
with short implants
Prosthetic complications
There were no statistically significant differ-
ences in the survival rate of superstructures
after prosthetic rehabilitation with short
implants compared with the sandwich oste-
otomy and delayed placement of standard-
length implants
Patient preference
Patients significantly favored prosthetic reha-
bilitation with short implants
6061
 Table 2  (continued)
6062

Author (year) Objectives Databases searched Follow-up Outcomes/main results Main conclusions
Country Date assessed as up Type of prosthetic

13
Journal
Journal impact factor
Terheyden et al. (2021) [44] To perform a systematic
Germany review and meta-analysis of
International Journal of Oral randomized controlled trials
& Maxillofacial Surgery comparing the outcomes
(2.068) of short dental implants
(7 mm) versus vertical bone
augmentation followed by
regular dental implants
(> 7 mm) in the deficient
posterior mandible
to date reconstruction
Imsplant length
PubMed 1–8 years Marginal bone loss In the deficient atrophic poste-
September 2019 NR RR: − 0.09 (CI: − 0.22 to 0.04) I2 = 97%, rior mandible, short implants
4–6.6 mm p = 0.17, 1 year and regular implants demon-
RR: − 0.32 (CI: − 0.44 to − 0.19) I2 = 0%, strate comparable outcomes
p < 0.00001, 3 years within the first 5 years
RR: − 0.65 (CI: − 0.86 to − 0.43) I2 = 21%,
p < 0.00001, 5 years
RR: − 0.88 (CI: − 1.26 to − 0.50) NR,
p < 0.00001, 8 years
Implant survival
RR: 0.41 (CI: 0.20 to 0.85) I2 = 0%, p = 0.02,
1 year
RR: 0.65 (CI: 0.22 to 1.92) I2 = 0%, p = 0.43,
3 years
RR: 1.08 (CI: 0.45 to 2.58) I2 = 0%, p = 0.72,
5 years
RR: 1.53 (CI: 0.41 to 5.71) NR, p = 0.52,
8 years
No significant difference between groups
Complications
RR: 0.34 (CI: 0.19 to 0.60) I2 = 71%,
p = 0.0002, 1 year
Significant lower risk of experiencing compli-
cations in the SH implant group compared
to the bone augmentation with ST implant
group

Legend: SH short implants, ST standard implants, OR odds ratio, CI confidence interval, RCT randomized controlled trials, RR relative risk, MD mean difference
Clinical Oral Investigations (2021) 25:6045–6068
Clinical Oral Investigations (2021) 25:6045–6068 6063

Table 3  Marginal bone loss Marginal Bone Loss

Follow-up at Studies for
and implant survival results Systematic Review Region SH ST Reported Results
comparison comparison
graphically represented by Bitinas & Bardijevskyte,
Posterior
2
MD: -0.19 (CI: -0.31 to -0.06) I =56%, p=0.003 3y 7
color, where green represents 2021 MD: -0.45 (CI: -0.87 to -0.02) I2=81%, p=0.005 5y 3
(Chen et al., 2019) Posterior MD: -0.12 (CI: -0.18 to -0.05) I2=55%, p=0.0006 1-5y 9
the treatment with better results, MD: -0.18 (-0.29 to -0.06) I2=67%, p=0.003 3y 9
(Iezzi et al., 2020) Posterior
red the treatment with worst MD: -0.47 (-0.69 to -0.24) I2=65%, p<0.0001 5y 5
results, and amber indicates SH: 1.23mm (0.94 to 1.49mm)
(Nisand et al., 2015) Posterior ST:1.51mm (1.03 to 2.34mm) 1-5 y 4
that there are no differences Descriptive analysis
between the compared (Lozano-Carrascal et al., Posterior
RR: 0.86 (CI:0.75 to 0.98) I2=97.9%, p=0.025 1-5y 8
groups (SH = short implants; 2020) Maxilla
Posterior
ST = standard implants in (Nielsen et al., 2018)
Maxilla
MD: -0.07 (CI: -0.12 to -0.02) I2=62.1%, p=0.072 3y 3
vertically augmented bone) (Ravidà et al., 2019)
Posterior
MD: -0.23 (CI: -0.38 to -0.07) I =65.97%, p=0.004
2
3y 6
Maxilla
Posterior MD: -0.13 (CI: -0.21 to 0.05) I2=87%, p=0.001 1-3y 6
(Yan et al., 2019)
Maxilla MD: -0.25 (CI: -0.40 to 0.10) I2=0%, p=0.001 ≥3y 3
SH: -0.51 to -2.30 mm
Posterior
Carosi et al., 2021 ST: -0.77 to -2.64 mm 1-5y 5
Mandible
Descriptive analysis
Posterior
(Esposito et al., 2019) MD: -0.60 (CI:0.36 to 0.83) I2=45%, p<0.00001 5y 4
Mandible
(Starch-Jensen & Nielsen, Posterior
Descriptive analysis 1-5y 6
2018) Mandible
Posterior RR: -0.32 (CI: -0.44 to -0.19) I2=0%, p<0.00001 3y 4
Terheyden et al. (2021)
Mandible RR: -0.65 (CI: -0.86 to -0.43) I2=21%, p<0.00001 5y 4

Implant Survival
Follow-up at Studies for
Systematic Review Region SH ST Reported Results
comparison comparison
2
Bitinas & Bardijevskyte, RD: -0.01 (CI: -0.04 to 0.03) I =0%, p=0.67 3y 7
Posterior
2021 RD: 0.03 (CI: -0.07 to 0.13) I2=0%, p=0.52 5y 3
(Chen et al., 2019) Posterior RR: 1.00 (CI: 0.98 to 1.03) I2=0%, p=0.67 1-5y 9
RR: 0.89 (CI: 0.36 to 2.21) I2=0%, p=0.80 3y 9
(Iezzi et al., 2020) Posterior
RR: 1.85 (CI: 0.61 to 5.62) I2=0%, p=0.28 5y 4
SH: 96.24% (91.66 to 100%)
(Nisand et al., 2015) Posterior ST: 95.09% (93.61 to 96.15%) 1-5y 4
Descriptive Analysis
Posterior
Carosi et al., 2021 RR: 1.24 (CI: 0.63–2.45, p = 0.52) 1-5 y 5
Maxilla
(Lozano-Carrascal et al., Posterior
RR: 1.08 (CI: 0.42 to 2.83) I2=0% p=0.869 1-5y 8
2020) Maxilla
Posterior
(Nielsen et al., 2018) OR: 0.90 (CI: 0.15 to 5.44) I =0%, p=0.369
2
3y 3
Maxilla
Posterior
(Ravidà et al., 2019) RR: 0.99 (CI: 0.96 to 1.02) I2=0%, p=0.36 3y 6
Maxilla
Posterior RR 1.01 (CI: 0.97 to 1.04) I2=0%, p=0.74 1-3y 7
(Yan et al., 2019)
Maxilla RR 1.00 (CI: 0.97 to 1.04) I2=0%, p=0.79 ≥3y 5
SH: 92% to 96.9%
Posterior ST: 84.8% to 100%
Carosi et al., 2021 1-5 y 5
Mandible
Descriptive Analysis
Posterior
(Esposito et al., 2019) RR: 1.00 (CI:0.31 to 3.21) I2=0%, p= 1.00 5y 4
Mandible
(Starch-Jensen & Nielsen, Posterior
Descriptive Analysis 1-5y 6
2018) Mandible
Terheyden et al. (2021) Posterior RR: 0.65 (CI: 0.22 to 1.92) I2=0%, p=0.43 3y 4
Mandible RR: 1.08 (CI: 0.45 to 2.58) I2=0%, p=0.72 5y 4

Some studies have performed this comparison when limited
bone height is present. On the other hand, some studies have
shown results when there is sufficient native bone height
to place either a short or a standard implant. A recent SR
proceeding from the sixth ITI Consensus Conference evalu-
ated the long-term survival rate of short implants (≤ 6 mm)
compared to implants longer than 6 mm [26]. However, both
the aforementioned scenarios were included in the analysis
without distinction, possibly undermining a fair comparison.
In this sense, several SRs have been published that per-
formed a separate analysis, evaluating the performance of
short implants compared to standard implants associated
with bone augmentation procedures. Therefore, there is a
need to synthesize the information described in these SRs,
as well as to evaluate their methodological quality.
A comprehensive literature search was carried out to
summarize the available SRs about short implants compared
to standard implants associated with vertical augmentation
procedures. Thirteen SRs that met the inclusion criteria were
considered for the analysis. Although SRs are at the top of
the scientific evidence pyramid, they are likely too numerous
biases, and their results should be interpreted with caution.
The SRs included in this overview demonstrated limitations
inherent to the selected primary studies: different implant
systems, implant surface treatments, type of prosthetic plat-
form, follow-up times, implant installation site, bone quality,
type of prosthetic rehabilitation, and different types of bone
grafts and surgical techniques adopted.
In addition, none of the studies included in this overview
revealed a high level of confidence, which could harm the

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6064 Clinical Oral Investigations (2021) 25:6045–6068

Table 4  Biological, Biological Complications

prosthetic complications and Follow-up at Studies for
Systematic Review Region SH ST Reported Results
comparison comparison
complications in general results SH: 15.29%
graphically represented by (Nisand et al., 2015) Posterior ST: 55.29% 1-5y 4
colors, where green represents Descriptive Analysis
the treatment with better results, (Lozano-Carrascal et al.,
2020)
Posterior
Maxilla
RR: 0.46 (CI: 0.22 to 0.95) I2=0.0%, p=0.037 1-5y 8
red the treatment with worst Posterior
(Ravidà et al., 2019) RR: 0.22 (CI: 0.05 to 1.02) I =58.66%, p=0.05
2
3y 6
results, and amber indicates that Maxilla
Posterior
there are no differences between (Yan et al., 2019)
Maxilla
RR: 0.11 (CI: 0.14 to 0.31) I2=40%, p<0.001 1-3y 3
the compared groups (SH, short (Starch-Jensen & Nielsen, Posterior
Descriptive Analysis 1-5y 6
implants; ST, standard implants 2018) Mandible
in vertically augmented bone)
Prosthetic Complications
Follow-up at Studies for
Systematic Review Region SH ST Reported Results
comparison comparison
(Lozano-Carrascal et al., Posterior
RR: 1.52 (CI: 0.91 to 2.54) I2=0.0%, p= 0.110 1-5y 8
2020) Maxilla
Posterior
(Ravidà et al., 2019) RR: 2.66 (CI: 1.12 to 6.34) I2=0%, p=0.03 3y 6
Maxilla
Posterior
(Yan et al., 2019) RR: 1.22 (CI: 0.33 to 4.49) p>0.05 1-3y 5
Maxilla
SH: 0% to 9.1%
Posterior
Carosi et al., 2021 ST: 0% to 10% 1-5y 5
Mandible
Descriptive Analysis
(Starch-Jensen & Nielsen, Posterior
Descriptive Analysis 1-5y 6
2018) Mandible

Complications
Follow-up at Studies for
Systematic Review Region SH ST Reported Results
comparison comparison
Bitinas & Bardijevskyte, RD: -0.14 (CI: -0.33 to 0.06) I2=86%, p=0.18 3y 6
Posterior
2021 RD: -0.39 (CI: -0.92 to 0.14) I2=95%, p=0.15 5y 3
(Chen et al., 2019) Posterior RR: 0.43 (CI: 0.15 to 1.25) I2=74%, p=0.12 1-5y 9
RR: 0.53 (CI: 0.28 to 1.01) I2=76%, p=0.05 3y 8
(Iezzi et al., 2020) Posterior
RR: 0.69 (CI: 0.34 to 1.40) I2=81%, p=0.30 5y 4
Posterior
(Esposito et al., 2019) RR: 4.72 (CI:2.43 to 9.17) I2=1%, p<0.00001 5y 4
Mandible

level of evidence for the results and conclusions offered.
This points to the need for greater rigor in the development
of SRs on this topic. Similarly, a study conducted by Elan-
govan et al. [49] evaluated the methodological quality of
SRs focused on the use of short (< 10 mm) dental implants.
In accordance with their findings, none of the ten reviews
included in their assessment fulfilled all the AMSTAR
guidelines. In addition, a significant structural and meth-
odologic variability among publications was found.
The evaluation of the methodological quality of the SRs
included in this overview was carried out using a current tool
AMSTAR 2, which allows for the opinion-makers to identify
high-quality SRs. A factor that deserves to be emphasized in
relation to the result of the methodological quality is related
to domain numbers 3 and 10 of AMSTAR 2, as none of the
SRs addressed the explanation about the selection of study
design and sources of funding for the included primary stud-
ies, noting the need to include these items in the develop-
ment of future SRs. Another point, little fulfilled by the SRs
of this overview, is the fact of not reporting publication bias.
The study by Koletsi et al. [50] showed the same trend, high-
lighting deficiencies related to the evaluation of publication
bias in SRs in the field of oral health, with publication bias
not evaluated or inappropriately performed in more than half
of meta-analyses.
Although there are many SRs addressing this specific
topic, one should be careful as more than 90% of the stud-
ies in the SRs were included more than once. This means
that the data from included studies were reassessed multiple
times, potentially inflating the perception of what has been
done. In addition, it is essential to note that the primary
studies that were more frequently cited in the SRs mostly
come from the same research group. This may represent a
duplication of efforts in the development of SRs. Although
it could be interesting to carry out new SRs to overcome
methodological limitations as recommended by Moher [51],
due to the high rate of overlapping, much more important
would be to perform well-conducted RCTs, with long-term
follow-up and from different research groups to broaden the
knowledge of this topic.
Summary of evidence
Within the limitations of the SRs included in the present
study, it is possible to summarize and discuss the following
information.
Concerning marginal bone loss, short implants showed
superiority versus standard dental implants in vertically
augmented bone. The fact that short implants are placed
in native rather than augmented bone could influence these

13
Clinical Oral Investigations (2021) 25:6045–6068
results [52], although the evidence is not extensive on this
topic. However, the available literature shows that mar-
ginal bone loss in implants, in general, can be influenced
by different factors, including soft tissue thickness [53],
implant position [54], type of connection [55], and number
of implants involved in fixed restorations [56].
All SRs included in this overview suggested similar
implant survival rates between short- and standard-length
implants associated with vertical bone augmentation. It
is noteworthy that according to the ITI Consensus Report
[57], based on one RCT with a 5-year follow-up (Rossi
et al. [8]), the time in function may reduce the survival rate
of short implants compared to longer implants. However,
this assumption is not in agreement with the findings of
our study since all SRs did not show differences in terms
of implant survival regardless of the different follow-up
times up to 5 years. Similar findings were reported in a
RCT by Felice et al. [59] after an 8-year follow-up. None-
theless, as discussed above, these results could be related
to a specific research group. Therefore, more long-term
studies from different research groups are still needed to
address this issue.
Biological complications were more prevalent in the
group of standard dental implants in vertically augmented
bone. This can be explained by the fact that standard
implants were installed in association with some kind of
grafting. These results are in line with the ITI Consensus
Report of 2018, where it was stated that the rate of surgical
and post-surgical complications is higher in the standard
implant group compared to the short implant group, being
most of these complications related to bone grafting pro-
cedures [57]. Despite these findings, it is important to note
that few SRs provide detailed information on this outcome.
Biological complications can happen over time (mucositis,
peri-implantitis) and even lead to implant failure, but they
can also happen as a result of the surgical procedure itself.
In this sense, a clinical aspect is worth noting. The chances
of successfully treating peri-implantitis in a standard dental
implant versus a short implant may not be comparable. Due
to the rapid progression of the peri-implant disease [60],
its occurrence in a short implant would represent a major
clinical problem when compared to longer implants. The
resection surgery to treat the peri-implantitis is including
contraindicated for short and ultrashort implants [61].
In addition, a better standardization of the definition of
biological complication is necessary. The studies should
make the distinction between intra- and post-operative bio-
logical complications, as well as the abovementioned bio-
logical complications after prosthetic loading.
Regarding prosthetic complications, most of the SRs did
not find differences between groups. Nevertheless, the SR
by Ravidà et al. [30], although rare in both groups, reported
a greater number of prosthetic complications such as crown
6065
chipping and screw loosening in the short implant group.
Therefore, to understand the actual magnitude of this out-
come, a better description of it would be important for future
studies.
Only a few included SRs addressed costs and surgi-
cal time. All of them found that the treatment with short
implants had lower costs as well as lower surgical time.
Another important component of the success of dental
implant treatment is patient satisfaction with the implant-
prosthetic complex [62]. These aspects were not evaluated
by most studies; however, there was a tendency for a pref-
erence for short implants among those that did assess this
variable.
Implications for clinical practice
Short implants could represent a viable, simpler, and less
invasive treatment option capable of reducing the morbidity,
costs, and treatment time associated with the use of stand-
ard-length implants when available bone height is limited
according to treatment plan and clinical diagnosis.
Implications for research
Through this overview, it was possible to observe that
despite a large number of SRs, there is an imperative need
to improve its conduct and reporting. Our suggestion for
future SRs is the observation of tools that guide its develop-
ment, such as quality assessment tools. As well, improving
the selection criteria to obtain more homogeneity of pri-
mary studies with similar clinical characteristics. Regarding
the topic addressed in this overview, due to the high rate
of overlapping, more important than conducting new SRs,
efforts should focus on conducting primary studies (RCTs)
with high methodological rigor so that more faithful results
can be obtained. Therefore, for future RCTs on this topic,
it is advised to follow the guidelines of The Consolidated
Standards of Reporting Trials (CONSORT) [63], detailing
information related to the implants used, bone augmentation
technique, and the type of rehabilitation (single, multiple,
cemented, screwed). An improvement on the definition of
the concepts related to failures, especially biological and
prosthetic failures, which are underreported, is also recom-
mended. In addition, it would be worthy of answering ques-
tions regarding patient-reported outcomes, which are still
little explored.
Conclusions
Within an overall low-to-very low confidence level, short
implants (≤ 7 mm) appear to perform better in the mid-
term (up to 5 years) compared to standard dental implants
13
6066
associated with vertical bone augmentation regarding
marginal bone loss and biological complications. Similar
survival rates and prosthetic complications were found for
short and standard-length implants associated with bone
augmentation procedures. Concerning patient preferences,
costs, and treatment time, the use of short implants would be
the preferred option when available bone height is limited.
There is an imperative need to improve the methodologi-
cal quality of SRs so that their results could be interpreted
with higher confidence. Due to the high rate of overlapping,
efforts should focus on conducting RCTs to broaden the
knowledge on this topic.
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00784-0​ 21-0​ 4095-0.
Author contribution  MSc. Patrícia Pauletto worked on study concep-
tualization, design, data collection, and data analysis; drafted the initial
manuscript; and approved the final manuscript as submitted.
MSc. Edwin Ruales worked on study conceptualization, design,
data collection, and data analysis; drafted the initial manuscript; and
approved the final manuscript as submitted.
Dr. Luis André Mezzomo worked on study conceptualization and
data analysis, and approved the final manuscript as submitted.
Dr. Cristine Miron Stefani worked on study conceptualization,
design, data collection, and data analysis, and approved the final manu-
script as submitted.
Dr. Mario Taba Junior worked on study conceptualization and data
analysis, critically reviewed the manuscript, and approved the final
manuscript as submitted.
Dr. Reginaldo Gonçalves worked on study conceptualization and
data analysis, critically reviewed the manuscript, and approved the final
manuscript as submitted.
Dr. Carlos Flores-Mir worked on study conceptualization and data
analysis, critically reviewed the manuscript, and approved the final
manuscript as submitted.
Dr. Graziela De Luca Canto worked on study conceptualization and
data analysis, critically reviewed the manuscript, and approved the final
manuscript as submitted.
Funding  Patrícia Pauletto and Edwin Ruales-Carrera are supported
with scholarship by Coordination for the Improvement of Higher Edu-
cation Personnel, Brazil.
Declarations  13. Silva L, de Lima VN, Faverani LP et al (2016) Maxillary sinus lift
Ethics approval  Ethics approval was not required for this overview.
Informed consent  The formal consent is not required for this type of
study.
Conflict of interest  The authors declare no competing interests.
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Authors and Affiliations

Patrícia Pauletto1   · Edwin Ruales‑Carrera2   · Luis André Mezzomo3   · Cristine Miron Stefani4   ·

Mario Taba Jr.5   · Reginaldo Bruno Gonçalves6 · Carlos Flores‑Mir7   · Graziela De Luca Canto8 
2
Patrícia Pauletto Center for Education and Research On Dental Implants
patricia.pauletto.p@gmail.com (CEPID), Department of Dentistry, Federal University
of Santa Catarina, Florianópolis, Brazil
Edwin Ruales‑Carrera
3
edwinruales@gmail.com Department of Dentistry, Health Sciences Center, Federal
University of Santa Catarina, Delfino Conti, s/nSanta
Cristine Miron Stefani
Catarina, Trindade, Florianópolis 88040‑900, Brazil
cmstefani@gmail.com
4
Department of Dentistry, University of Brasília, Brasília,
Mario Taba Jr.
Brazil
mtaba@usp.br
5
Department of Oral Surgery and Periodontology, University
Reginaldo Bruno Gonçalves
of São Paulo, Ribeirão Preto, Brazil
reginaldo.goncalves@fmd.ulaval.ca
6
Department of Periodontics, Université Laval, Quebec,
Carlos Flores‑Mir
Canada
cf1@ualberta.ca
7
School of Dentistry, University of Alberta, Edmonton,
Graziela De Luca Canto
Canada
delucacanto@gmail.com
8
Brazilian Centre for Evidence‑Based Research, Department
1
Brazilian Centre for Evidence‑Based Research (COBE), of Dentistry, Federal University of Santa Catarina,
Department of Dentistry, Federal University of Santa Florianópolis, Brazil
Catarina, Florianópolis, Brazil

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