Clinical Oral Investigations

https://doi.org/10.1007/s00784-020-03195-7

ORIGINAL ARTICLE

Influence of crown–implant ratio on implant success rate

of ultra-short dental implants: results of a 8- to 10-year retrospective
study
Luciano Malchiodi 1 & Giulia Ricciardi 1 & Anna Salandini 1 & Riccardo Caricasulo 1 & Alessandro Cucchi 2 & Paolo Ghensi 3

Received: 7 June 2018 / Accepted: 3 January 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Objectives The use of short implants has been suggested in recent years as an option for facilitating prosthetic restoration in
resorbed jawbones. The aim of the present study was to determine how implant success rate is affected in the long term when
ultra-short implants are rehabilitated with fixed restorations, resulting in a crown to implant (C/I) ratio of more than 3:1.
Materials and methods The study was conducted as an analysis on all patients operated from December 2005 to November 2007
with ultra-short dental implants. All implants were sintered porous-surfaced (SPS) with a length of 5 mm and a diameter of 5 mm
(5 × 5 mm) and were restored with a single crown or a fixed dental prosthesis (FDP). Data collected included implant positioning
site, crestal bone levels (CBL), and clinical and anatomical C/I ratios, and pre-established success criteria were used to evaluate
the success rate of the implants. Statistical analysis was used to determine any significant differences or correlations (p = 0.05).
Results Forty-one patients completed the follow-up and were eligible for this retrospective study on a total of 50 ultra-short SPS
implants. The mean follow-up was 9.5 years (range 8.3 to 10.2 years). Three of the 50 implants failed because they were lost due
to peri-implantitis, while all the other 47 met the pre-established success criteria giving an overall implant success rate of 94%.
During the follow-up period, the mean peri-implant bone loss (PBL) was 0.41 + 0.36 mm.
Conclusions This study shows that ultra-short SPS implants can prove a reliable solution for prosthetic restoration in patients with
severe alveolar bone atrophy. In selected patients with a sufficient bone width, ultra-short implants with a resulting C/I ratio of
more than 3:1 presented no contraindications.
Clinical relevance In selected cases, ultra-short implants may represent an alternative to bone augmentation procedures and a
long-term predictable solution.

Keywords Ultra-short dental implants . Sintered porous-surfaced (SPS) . Long-term follow-up . Success rate . Peri-implant bone
loss

Introduction discomfort; however, that can be avoided by using implant-

Partial posterior jaw edentulism is not unusual and often treat-
ed with removable partial dentures to replace the missing
teeth. This solution poses problems of instability and
* Luciano Malchiodi
research.univr@hotmail.it
1
Department of Surgery, Dentistry, Paediatrics and Gynaecology,
University of Verona, Verona, Italy
2
Department of Biomedical and Neuromotor Science, University of
Bologna, Bologna, Italy
3
Department CIBIO (Cellular, Computational and Integrative
Biology), University of Trento, Trento, Italy
supported fixed prostheses instead. The posterior jaw may
lack the bone height needed to insert dental implants of “ad-
equate” length, presenting anatomical issues such as a risk of
inferior alveolar nerve damage or a pneumatized maxillary
sinus [1]. Several strategies have been suggested over the
years to overcome the dimensional limitations of the bone
available for implant placement. These include bone augmen-
tation surgery, possibly involving bone grafts, guided bone
regeneration, distraction osteogenesis, sinus floor elevation,
and mandibular nerve transposition [2]. Such techniques re-
portedly have generally high success rates in implantology,
but the outcomes have varied and proved rather unpredictable.
Many patients are also unable or unwilling to submit to this
type of surgical approach because it is costly and demands
multiple surgical procedures, or due to poor general health

[3]. Inferior alveolar nerve transposition procedures also raise
the risk of paresthesia [4]. Using short implants has been sug-
gested as an alternative to such surgical options for prosthetic
restoration in resorbed jawbones, and this approach can be a
solution in many such cases. Short implants offer the advan-
tage of limiting the number of surgical procedures required
and minimizing the surgical trauma involved. Patients benefit
from less morbidity and less postoperative discomfort [5].
The concept of “short implant” is rather vague in the liter-
ature: authors have used this term for implants up to 11 mm
[6], or 8 mm [7], or 7 mm long [8], but it is generally agreed
that implants less than 10 mm in length can be definitely
defined as short [9]. The recently introduced extra-short im-
plants have been defined as having an intrabony length of no
more than 5 mm [10]. There were initially numerous reports of
higher failure rates with shorter implants, but more recent
findings, in conjunction with the gradual diffusion on the mar-
ket of the best performing rough surfaces to replace the ma-
chined ones, indicate success rates comparable with those of
longer implants [4, 7]. Regarding this point, it is important to
underline the different meaning existing between “success”
and “survival,” where “success” is denoted if a particular im-
plant meets the success criteria it is being evaluated with,
while “survival” simply means the implant exists in the
mouth.
In a literature review in 2006, Misch et al. [4] investigated
the failure rates associated with posterior jaw dental implants
less than 10 mm long inserted from 1991 to 2003. In a sample
of 2837 short implants, 85.3% were successful, most of the
failures occurred after prosthetic loading, and the failure rate
was uninfluenced by implant length, as shown by other au-
thors too [11–21]. Several authors concerned about the length
of implants empirically established years ago that, to avoid
overloading, the maximum crown to implant ratio should
not exceed 1:1 [22–24]. Since then, it has been demonstrated
that even a crown–implant ratio of more than 2:1 does not
negatively affect the short- and long-term outcome of the
prosthetic rehabilitation [25–28].
The specific aim of the present retrospective study was to
determine how implant success rate is influenced in the long
term when ultra-short (5 × 5 mm), sintered porous-surfaced
(SPS) implants with a resulting C/I ratio of more than 3:1
are used to support fixed prosthetic restorations.
Materials and methods
Study design
This study was a monocenter retrospective analysis on all
patients treated using ultra-short SPS dental implants from
December 2005 to November 2007. This retrospective clinical
non-interventional study was performed during the clinical
Clin Oral Invest
routine without any further consequences for the patient.
According to this and in accordance with the 1964
Declaration of Helsinki on medical protocol and ethics, no
approval by the local ethics committee was necessary.
At the time of implant insertion, the decision to use ultra-
short sintered porous-surfaced implants was made after a dis-
cussion with the patients and after obtaining informed written
consent. The following criteria were used to select patients in
whom SPS implants could achieve successful results:
& Inclusion criteria: single edentulism or partial edentulism
(< 4 missing teeth), bone height > 3 mm in the maxilla and
> 5 mm in the mandible, bone width > 5 mm, patient’s
agreement to undergo treatment based on ultra-short SPS
implants, predictably adequate compliance with the fol-
low-up, patient’s decision to rehabilitate his/her
edentulism by means of a fixed prosthesis supported by
the implants
& Exclusion criteria: very poor oral hygiene, smoking more
than 20 cigarettes/day, alcohol or drug abuse, acute oral
infections, ASA 4 or 5, remote or recent radiation therapy
in the oro-maxillo-facial district, recent chemotherapy,
pregnancy
Data collection
The records of patients treated between December 2005 and
November 2007 were queried to obtain data of the following:
age, sex, medical and dental history, smoking habits (number
of cigarettes a day), type of edentulism, type of implant sys-
tem, implant site, number of implants per patient, date of in-
sertion, date of functional loading, type of prosthetic rehabil-
itation, any presence of platform-switching, condition of an-
tagonist dentition, and date of the latest clinical and radio-
graphic follow-up (Fig. 1). The patient’s crestal bone level
(CBL) was measured for each implant, considering the lowest
observed point of crestal bone in intimate contact with the
implant. The measurements were obtained mesially and dis-
tally to each implant by means of a calibrated examination of
standardized periapical radiographs with the aid of a digital
software [29]. The CBL was calculated at several points in
time, i.e., at the time of implant insertion (CBL-0), on pros-
thetic loading (CBL-PL), and at the latest follow-up (CBL-
CTRL). The measurement was rounded up or down to the
nearest 0.1 mm using a 7× magnification. Periapical x-rays
were obtained using customized occlusal templates in con-
junction with Rinn holder devices and standard long-cone
paralleling techniques (Fig. 2). Different radiographic settings
(kV and mA) were used, depending on the area of the jawbone
involved.
After measuring the bone level, the anatomical crown to
implant ratio (anatomical C/I ratio) and clinical crown to
Clin Oral Invest
Fig. 1 Orthopantomography before dental extraction of tooth 1.6
implant ratio (clinical C/I ratio) were calculated on the radio-
graphic images as follows: anatomical and clinical C/I ratios
on prosthetic loading (C/I ratio-PL) and clinical C/I ratio at the
latest follow-up (C/I ratio-CTRL). Because the “C/I ratio” was
defined as the ratio of the length of the restoration to the length
of the implant, for the anatomical C/I ratio, the fulcrum is
established at the interface between the implant shoulder and
the crown–abutment complex, while for the clinical C/I ratio,
this fulcrum is positioned at the most coronal bone–implant
contact, as described by Blanes [27].
Implants
The implants used in this retrospective study had a
sintered porous surface (Endopore Dental System,
Innova Corporation, Toronto, ON, Canada) and were pur-
chased from the manufacturer by the authors. They were
all made of Ti-6Al-4V, machined to form a truncated
cone, with an added porous surface consisting of multiple
layers of Ti-6-Al-4V microspheres of preset size (ranging
in diameter from 45 to 150 lm) obtained by sintering at
high pressure and temperature. The implants were 5 mm
long, with a maximum (coronal) diameter of 5 mm and a
standard external hex connection with a 0.7-mm thread.
The most coronal 1-mm segment of the implant length
was prepared as a machined collar, whereas the remaining
4-mm implant length carried the SPS layer.
Fig. 2 Pre-operative periapical x-ray
Surgical and prosthetic procedures
Each patient underwent clinical and radiographic examination
to plan the most appropriate treatment. Orthopantomography
and periapical x-rays were used primarily to assess the bone
height available for implant surgery. Computed tomography,
in dental scan mode, was requested in all cases of alveolar
atrophy to obtain accurate information on bone height and
width. The purpose of the clinical examination was to assess
oral hygiene, tissue health, keratinized mucosa, residual tooth
stability, and many other factors capable of influencing the
treatment being planned.
Antibiotics were prescribed for prophylaxis and therapy,
involving amoxicillin plus clavulanic acid 2 g/day for 6 days,
starting an hour before surgery (or clindamycin 600 mg/day
for 6 days in patients allergic to penicillin). Anti-inflammatory
therapy with NSAIDs was also recommended, consisting in
nimesulide 200 mg/day for 3 days, starting with 200 mg 1 h
before surgery. Local anesthesia was administered with
articaine plus adrenaline (1:50,000 at the implant site and
1:100,000 at other sites).
The SPS implants were inserted according to a “two-stage
function” approach, as described by the manufacturer. A full-
thickness mucoperiosteal flap was raised to reveal the under-
lying alveolar bone and place the implants in exactly the right
position. Implant site was prepared using either implant burs
under copious internal and external sterile irrigation or appro-
priately sized implant osteotomes, depending on bone density.
The shoulder of the cone-shaped portion of the gage should be
flushed with or just below the CBL. The implant was carefully
removed from its sterile packaging and inserted in the pre-
pared site using only the attached white delivery tool. Then
it was pressed by hand into the bleeding site and lodged in its
definitive position by tapping it firmly a few times with the
punch tip and mallet, to ensure a tight fit between the implant
and bone. The part of the implant with the SPS plus the 0.5-
mm smooth coronal portion always had to be fully immersed
in the bone tissue, and the implant had to be immobilized.
Fig. 3 Postoperative periapical x-ray after the insertion of an ultra-short
(5 × 5 mm) sintered porous-surfaced (SPS) dental implant

Fig. 4 Implant’s second stage surgery
The mucoperiosteal flap was put back in place with a
tension-free suture to ensure healing by first intention and
facilitate the osseointegration of the SPS implants. Patients
were asked to adopt a fluid diet for a fortnight, then a soft diet
for another 2 weeks. They were advised to ensure a good oral
hygiene, and chlorhexidine 0.2% three times daily was rec-
ommended. Patients used no removable prostheses with mu-
cosal support that might come to bear on the implant site. A
provisional tooth-supported fixed prosthesis was used in a few
cases. All implants were submerged at the time of their im-
plantation. The SPS implants were allowed to heal for around
3 months in the mandible, or 4 months in the maxilla (Fig. 3).
For the second surgical procedure, a paracrestal or crestal
flap was elevated, shifting the keratinized tissue buccally as
far as possible to widen the buccal keratinized mucosa around
the implants (Fig. 4). The head of the implant was exposed
and the healing screw was tightened by hand using a 1.25-mm
hex driver, taking care to avoid applying too much torque at
the bone–implant interface. An impression was obtained 1 or
2 weeks after reentry surgery in cases requiring a provisional
prosthesis, or 3 to 4 weeks later if a definitive prosthesis was to
be prepared. Master models were made at the laboratory for
the purpose of producing custom abutments and provisional
and/or definitive prostheses. Provisional prostheses were
made at the laboratory and rebased directly in the mouth,
Fig. 5 Periapical x-ray at prosthetic loading
Clin Oral Invest
Fig. 6 Periapical x-ray at 3-year follow-up
using flowable acrylic resin. The occlusion was checked to
prevent any pre-contact or interference during centric and ec-
centric movements. After 3 months, the provisional prosthesis
was removed, and the final impression was obtained to pro-
duce a definitive prosthesis, which was positioned on the im-
plant few days later, at which point the treatment was com-
plete. The definitive rehabilitation involved single crowns or
fixed dental prostheses (FDPs) placed in occlusion. The oc-
clusal plane was modeled accurately to ensure contact with
reduced areas during lateral and protrusive excursions in order
to limit the dislocating components. Several contacts were
maintained in maximal intercuspation.
Implant success
Patients attended a clinical follow-up twice a year as part of
their routine oral hygiene program. X-rays were taken at the
time of surgery, at the time of prosthetic loading (Fig. 5), after
1 year, and then yearly, based on a routinely used protocol
(Figs. 6, 7, and 8).
Implant success was judged on the basis of criteria sug-
gested by Buser et al. [30] and modified by Albrektsson and
Zarb [31], which included (i) no persistent pain, dysesthesia or
paresthesia in the implant area; (ii) no peri-implant infection,
with or without suppuration; (iii) no perceptible implant mo-
bility; and (iv) no persistent peri-implant bone resorption >
1.5 mm during the first year of loading and > 0.2 mm/year
Fig. 7 Periapical x-ray at 7-year follow-up
Clin Oral Invest
Fig. 8 Periapical x-ray at 9-year follow-up
thereafter. All implants meeting these criteria were classed as
“successful,” while functioning implants that did not satisfy
all these criteria were classed as “surviving.”
Patients were interviewed to identify any clinical compli-
cations such as pain, dysesthesia, or paresthesia. Any peri-
implant infection, with or without suppuration, and implant
mobility were assessed visually, probing, and by applying
pressure. Radiographic evidence of complications, such as
excessive peri-implant bone resorption or radiolucencies,
was assessed on periapical radiographs.
Implants with the presence in one or more sites of both
clinical inflammation (redness, swelling, bleeding, suppura-
tion) and radiographic evidence of more than 2 mm bone loss
since the first year of prosthetic loading were diagnosed as
peri-implantitis.
Statistical analysis
The statistical analysis on the data collected took into account
that the observations were not independent because some pa-
tients had more than one implant inserted. Comparisons were
drawn assuming that a p value < 0.05 was statistically signif-
icant. The Wilcoxon–Mann–Whitney and Kruskal–Wallis
tests were used to examine the interaction between the CBL
and the dependent nominal variables. The Wilcoxon test was
used to compare two averages in paired samples. Spearman’s
test was used to examine the interaction between the CBL and
the dependent quantitative variables. Bivariate and multiple
linear generalized estimating equation (GEE) models were
used with robust standard errors to test the relationship
Table 1 Characteristics of failed
implants Implant Site Type of prosthesis
1 15 FPD splint
2 26 Single crown
3 47 FPD splint
FPD fixed partial dentures
between peri-implant bone loss (PBL) (in mm) and the
anatomical/clinical C/I ratios, and other selected variables.
Results
Patients
Of a sample of 56 patients consecutively treated between
December 2005 and November 2007 initially considered, 41
completed the follow-up program and met the inclusion and
exclusion criteria for this retrospective study. They included
19 males and 22 females, with a mean age of 57.6 + 9.6 years
(range 32–78). Three patients had diabetes and 12 were
smokers (only one was a heavy smoker, reportedly smoking
more than 10, but less than 20 cigarettes/day). These 41 pa-
tients received a total of 50 ultra-short (5 × 5 mm) SPS im-
plants, with a mean of 1.23 + 0.6 implants per patient: a single
implant was fitted in 35 patients, two implants in 4 patients,
three implants in 1 patient, and four implants in 1 patient.
Implants
A total of 50 of the original 71 ultra-short 5 × 5 mm SPS
implants inserted were followed up in this study. Thirty-six
of the 50 implants were placed in the upper jaw, 27 (75%) in
the molar region, and 9 (25%) in the premolar region. The
other 14 were fitted in the lower jaw, 11 (64.3%) in the molar
region, and 3 (35.7%) in the premolar region. The antagonists
were natural teeth or dentally supported rehabilitations in the
case of 31 implants (62%), while 19 (38%) were opposed to
implant-supported rehabilitations.
Prostheses
The implants were used to support different types of prosthe-
sis: single crowns were used to restore 18 implants (36%),
while the other 32 implants (64%) were restored with FDPs.
Success rate
For all 50 implants considered, the mean follow-up was
9.5 years (range 8.3 to 10.2 years). As at June 2016, all 50
implants had been followed up for at least 8.3 years, and they
Antagonist dentition C/I ratio–BL Failure time
Implant-supported restoration 2.07 4 years
Implant-supported restoration 3.08 5 years
Natural dentition 2.23 8 years
 Clin Oral Invest

Table 2 Wilcoxon–Mann–Whitney and Kruskal–Wallis tests on the Table 4 Bivariate GEE linear regression between peri-implant bone
influence of qualitative variables on PBL loss and clinical and anatomical C/I ratios

p value Coefficient p value

Sex 0.6435 Anatomical C/I ratio 0.088 0.392

Diabetes 0.6166 Clinical C/I ratio BL 0.044 0.581
Smoking habit 0.2950
Antagonist dentition 0.7313
Type of prosthesis (splint/no splint) 0.7565 Anatomical and clinical C/I ratios
Site (upper/lower) 0.2951
Site (UP, UM, LP, LM) 0.3680 The mean anatomical C/I ratio was 2.44 + 0.36 (median 2.43;
range 1.73–3.29). The mean clinical C/I ratio at prosthetic
loading (C/I ratio-PL) was 2.87 + 0.50 (median 2.80; range
1.98–4.21), and at the latest follow-up (C/I ratio-CTRL), it
were assessed in terms of the previously mentioned criteria at
was 3.34 + 0.66 (median 3.11; range 2.42–4.81).
the latest follow-up appointment.
Three of the 50 implants failed, giving an overall success
rate of 94%. The proportion of successful and surviving im-
Statistical analysis
plants coincided because the three failed implants were lost.
The statistical analysis revealed no significant correlations be-
None of the remaining implants was the object of peri-implant
tween the PBL values and the qualitative and quantitative
bone resorption incompatible with established criteria for
variables considered, with p values all > 0.05 (Tables 2 and 3).
judging an implant successful. The success rate was similar
The bivariate and multiple linear generalized estimating
for the upper and lower jaws, i.e., 94.4% and 92.9%, respec-
equation (GEE) models used to test the relationship between
tively (p > 0.05).
PBL and the anatomical/clinical C/I ratios and other selected
variables again identified no significant linear relations and no
statistical correlations (Tables 4 and 5).
Failed implants

The three implants that failed were lost 4, 5, and 8 years after
prosthetic loading as a consequence of peri-implantitis
Discussion
(Table 1).
This retrospective study, which aimed to evaluate the long-
term clinical outcomes of ultra-short dental implants, demon-
strated that this kind of surgical option can be considered a
Crestal bone level and peri-implant bone loss
very reliable solution in patients with severe alveolar bone
atrophy. Despite a resulting C/I ratio greater than 3:1, implant
The mean CBL-0 was 0.19 + 0.22 mm (median 0.06 mm;
success rate and crestal bone levels of ultra-short implants
range 0.00–0.90 mm); the mean CBL-PL was 0.78 +
were not adversely affected even after a mean follow-up of
0.24 mm (median 0.78 mm; range 0.43–1.64 mm); and the
nearly 10 years.
mean CBL-CTRL was 1.20 + 0.44 mm (median 1.14 mm;
The literature published to date defines dental implants as
range 0.53–3.15 mm).
“short” if their intrabony length is ≤ 8 mm, and “ultra-short” if
The mean PBL occurring from implant insertion to pros-
it is ≤ 5 mm [10, 32, 7]. The main indication for the choice of
thetic loading was 0.60 + 0.25 mm (median 0.55 mm; range
0.08–1.12 mm); from prosthetic loading to the latest follow- Table 5 Univariate and multiple linear GEE regression models on the
up, it was 0.41 ± 0.36 mm (median 0.29 mm; range 0.04– influence of anatomical C/I ratio and other variables on peri-implant bone
1.97 mm); and from implant insertion to the latest follow-up, loss
it was 1.01 ± 0.45 mm (median 1 mm; range 0.34–2.72 mm).
Coefficient p value

Table 3 Spearman’s test Anatomical C/I ratio 0.278 0.242

on the influence of p value
Clinical C/I ratio BL − 0.084 0.614
quantitative variables on
PBL Age 0.149 Site = UP − 0.121 0.587
Follow-up 0.234 Site = LP − 0.321 0.109
Anatomical C/I ratio 0.639 Site = UM − 0.250 0.202
Clinical C/I ratio BL 0.401 Site = LM − 0.231 0.299
Clin Oral Invest

Table 6 Survival rates (SSR) e

success rates (SR) of short and Paper Length (mm) Follow-up (years) PBL (mm) SSR SR
ultra-short implants in the
literature Bruggenkate (1998) 6 6 – 97.0% 93.8%
Friberg (2000) 6–7 10 0.9 ± 0.6 92.3% –
Malò (2007) 7 1–9 (7) 1.8 ± 0.8 (5 years) 98.1% 96.2%
Anitua (2010) 6.5–8.5 1–8 – 99.3% –
Lai (2013) 6–8 10 0.63 ± 0.68 98.3% –
Sivolella (2013) 7–8.5 5–16 (mean = 9) 1.37 ± 0.5 97.2% 95.2%
Anitua (2013) 7–8.5 10–12 M = 1 ± 0.7 98.9% 98.9%
D = 0.9 ± 0.6
Rodrigo (2013) 6 1–6 – 96.4% –
Slotte (2015) 4 1–6 0.53 ± 0.08 92.2% –
Rossi (2015) 6 5 0.7 ± 0.6 - 95%
Rossi (2016) 6 5 0.14 - 86.7%
Present study 5 8–10 0.41 ± 0.36 94% 94%

an ultra-short implant is for the rehabilitation of atrophic jaws,
when inserting a longer implant would be surgically more
demanding. Clinical studies have demonstrated that ultra-
short SPS implants are a valid option thanks to their three-
dimensional anchorage to the bone and uniform distribution of
the load on their truncated cone profile [33, 34].
Our present sample of 50 ultra-short SPS implants inserted
in 41 patients was followed up for a mean 9.5 years, with
implant success and survival rates (94%) comparable with
those of other reports on short and ultra-short implants with
a similar follow-up (Tables 6 and 7). In the studies identified
by our literature review, the implant survival rate ranged be-
tween 84 and 100% and the success rate between 83.3 and
98.9% [28, 35–53]. When speaking of short and ultra-short
implants, the success rate and the survival rate tend to coincide
because any peri-implant bone loss has a much more severe
negative fallout on the proportion of implants correctly
osseointegrated than in the case of long implants [54].
In our sample, there was only a minimal difference in the
failure rates between implants positioned in the upper versus
the lower jaw (5.6% and 7.1%, respectively). Deporter et al.
and Bruggenkate et al. both found higher failure rates for short
implants in the maxilla, with 14.3% and 13%, respectively
[32, 35]. A literature review conducted by Neldam and
Pinholt identified a higher failure rate in the upper jaw, and
the authors attributed this to the lower density of the maxillary
bone and to the occlusal loading in the posterior region [50].
The reason for our slightly different results probably lies in
our very scrupulous bone width assessment before the im-
plants were inserted. According to Deporter et al., a vestibular
and palatal/lingual width of at least 1 mm is needed to avoid
excessive crestal bone loss. For implants 5 mm in diameter, it
is essential to have a bone width ≥ 8 mm to ensure good
clinical results in the mandible. In the maxilla, in the other
hand, our surgical protocol envisages the use of osteotomes
to expand the bone if necessary [51]. Spray et al. recommend-
ed a vestibular bone width of at least 1.4 mm after inserting the
implant, and said that a greater bone thickness can prevent
excessive bone resorption [52].
The failure rate in our sample was 6%, after three implants
were lost due to rapid-onset peri-implantitis. One case report
in 2010 documented a rapidly progressive peri-implantitis
around a short SPS implant, which led to implant failure in
60 days. The peri-implantitis had occurred in a non-smoker
with a good oral hygiene and compliance with the mainte-
nance program. The infection was unresponsive to therapy

Table 7 Survival rates (SSR) and

success rates (SR) of short and Paper Length (mm) Follow-up (years) MBL (mm) SSR SR
ultra-short SPS implants in the
literature Deporter (1999) 7–8–9–10 5–6 0.08 93.4% 83.3%
Deporter (2002) 7–8–9–10 10 1.18 92.7% –
Deporter (2008) 5 1–8 – 92.3% –
MacDonald (2009) – 7–9 – – 92.9%
Perelli (2011) 5–7 5 – 84% –
Deporter (2012) 7–9 10 1.2 95.5% 95.5%
Malchiodi (2013) 5–7–9–12 3 0.48 ± 0.29 98.8% 98.1%
Malchiodi (2015) 5–7–9–12 3 0.48 ± 0.29 98.8% 98.1%
Present study 5 8–10 0.41 ± 0.36 94% 94%

and the authors attributed the consequent rapid bone resorp-
tion to the implant’s surface morphology, which was easily
contaminated by plaque. The implant was replaced with an
ultra-short (5 × 5 mm) SPS implant to ensure an adequate
vestibular bone width and prevent further bone resorption,
which would have increased the risk of the implant’s surface
being exposed to the oral environment [53].
In the present study, the PBL was a mean 1.01 + 0.48 mm
from the implant’s insertion, and a mean 0.41 + 0.36 mm from
the moment of functional loading to the latest follow-up.
When Deporter et al. monitored marginal bone loss around
7-mm-long SPS implants for 10 years after functional loading
[45], they found that it only reached as far as the smooth/rough
surface junction, then stopped. An initial bone loss of
0.44 mm in the first year was followed by a further resorption
of 0.03 mm annually. The smooth collar was described as a
load screen against stress, which led to bone loss as a result of
non-use atrophy [45, 54, 55]. The PBL seen in our study
followed much the same trend, and our results are very similar
to those reported by Deporter et al.
Using shorter implants naturally means increasing the C/I
ratio. The literature on how this ratio influences implant suc-
cess rates and crestal bone loss around implants is not very
clear. A cohort prospective study was conducted on 259 short
(5 and 7 mm) and long (9 and 12 mm) SPS implants moni-
tored for 3 years found more severe bone loss around implants
with a higher C/I ratio. The authors judged that 3.10 for the
anatomical C/I ratio and 3.40 for the clinical C/I ratio were the
minimum thresholds needed to prevent excessive PBL and
consequent implant failure [27]. On the other hand, a system-
atic literature review of studies on implants ≤ 10 mm long
followed up for at least 6 months found that a higher C/I ratio
protected against PBL [56]. Other studies showed no correla-
tion between the C/I ratio and PBL [26, 57]. Rokni et al.
studied 199 long and short SPS implants and found no asso-
ciation between the C/I ratio, the implant surface area, and
PBL, and the short implants were associated with better clin-
ical results [25]. In the present study, the mean anatomical C/I
ratio was 2.44 + 0.36, and the baseline mean clinical C/I ratio
was 2.87 + 0.50. No statistical correlation between C/I ratio
and peri-implant bone loss was observed, according to
Renouard and Nisand who concluded that marginal bone loss,
the implant survival rate, and the incidence of complications
were unassociated with the C/I ratio [10]. Furthermore, the
sintered porous surface enables a three-dimensional anchor-
age of the implant to the bone and an even distribution of the
load, meaning that short and ultra-short implants behave clin-
ically just as well as longer implants [34, 58]. They conse-
quently seem to be more resistant to any additional forces
deriving from a higher C/I ratio [25].
All the ultra-short (5 × 5) SPS implants considered in the
present study were rehabilitated with single crowns or FDPs
and, when the role of splinting was examined, no statistical
Clin Oral Invest
correlation emerged between splinting and PBL. This seems
consistent with a study conducted by Naert et al., who inves-
tigated PBL around single crowns and FDPs, finding no sta-
tistically significant difference between the two variables [59].
Some authors reported more severe marginal bone loss around
splinted implants than around implants supporting single
crowns [25]. On the other hand, Guichet et al. conducted a
photoelasticity study in vitro, demonstrating that the non-axial
forces were evenly distributed around splinted implants [60].
Using finite element analysis, Wang et al. even found a stress-
relieving effect of the horizontal forces around splinted ele-
ments in low-density bone [61]. In short, some authors would
recommend the splinting of ultra-short implants, while others
have reported better results with single crown rehabilitations
[62].
Conclusions
This retrospective study confirmed that ultra-short SPS im-
plants can achieve stable crestal bone levels and offer predict-
able long-term results when used for the prosthetic restoration
of jaws with severe alveolar bone atrophy. In selected patients
with a sufficient bone width, ultra-short implants resulting in
C/I ratios higher than 3:1 revealed no contraindications and
produced much the same results as longer implants.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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