RESEARCH

Crown-to-Implant Ratios of
Short-Length Implants
Hardeep Birdi, DMD, MS1*
John Schulte, DDS, MSD1
Alejandro Kovacs, DDS, MS1
Meghan Weed, RDH2
Sung-Kiang Chuang, DMD, MD3

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Excessive crown-implant ratios have been cited in the literature as being detrimental to long-
term implant survival. However, unfavorable crown-implant ratios have not yet been
established. The primary aim of this study was to determine the crown-implant ratios of
single-tooth implant-supported restorations on short-length implants in a clinical practice,
and to evaluate the health of these implants via mesial and distal first bone-to-implant
contact levels. Additionally, the relationship between crown-implant ratios and proximal first
bone-to-implant contact levels will be evaluated. In this retrospective cohort study, the
cohort was composed of 194 patients who possessed at least 1 single 5.7 mm or 6 mm
length plateau design implant-supported restoration that had been surgically placed
between February 1997 and December 2005. A chart review was performed to acquire the
most recent radiographs in which both the entire crown and the implant were visible. The
length of the crown and implant was measured directly from the radiographs using
consistent magnification to calculate the crown-implant ratio. Mesial and distal first bone-to-
implant contact levels were measured using 3 times magnification and were mathematically
corrected for distortion. The last available radiograph was used to measure bone levels.
Follow-up time was calculated from the day of implant placement to the date of the last
available radiograph. Statistical analyses with analysis of variance mixed models were used.
Data from 309 single implant-supported fixed restorations were tabulated and included in
the study. The mean (SD) follow-up time was 20.9 (23.2) months, with a range of 15.6 to
122.8 months. The mean crown length (SD) was 13.4 (2.6) mm, with a range of 6.2 to
21.7 mm. The mean (SD) crown-implant ratio was 2.0 (0.4) and ranged from 0.9 to 3.2. The
average mesial and distal first bone-to-implant contact levels (SD) measured from the
radiographs were 20.2 (0.7) mm and 20.2 (0.9) mm, respectively. No statistically significant
relationship was observed between increasing crown-implant ratios and decreasing mesial
and distal first bone-to-implant contact levels around the implant with P values of .94 and
.57, respectively. In this investigation, mesial and distal first bone-to-implant contact levels
on short-length implants fall within the established guidelines for success. Also, there are no
associations between crown-implant ratios and first bone-to-implant contact levels.

Key Words: crown-implant ratios, proximal bone-to-implant contact

1
University of Minnesota School of Dentistry, Minneapolis, Minn.
2
Implant Dentistry Center, Boston, Mass.
3
Department of OMFS, Massachusetts General Hospital and the Harvard School of Dental Medicine, Boston, Mass.
* Corresponding author, e-mail: bobbirdi@gmail.com
DOI: 10.1563/AAID-JOI-D-09-00071

Journal of Oral Implantology 425

Crown-to-Implant Ratios

INTRODUCTION

T
he use of endosseous dental
implants as tooth replacements
has become an accepted treat-
ment modality in dentistry today.
As a result, clinicians often use
certain guidelines associated with natural
teeth and apply them to implant dentistry.
One of these guidelines is crown-to-root
ratio. The crown-to-root ratio is defined as
the physical relationship between that por-

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tion of the tooth within the alveolar bone
and that portion not within alveolar bone, as
determined by a radiograph.1 The crown-to-
root ratio is determined by dividing the
length of the tooth coronal to the bone by
the length of the root that resides in bone
(Figure 1).
Dentists use the crown-to-root ratio as an
important prognostic indicator to determine
the suitability of a tooth to act as an
abutment for a fixed or removable partial
denture. Furthermore, the crown-to-root
ratio is used as a prime indicator of the
long-term prognosis of a given tooth.2–4 It
extrapolates the biomechanical concept of a
class I lever for evaluating abutment teeth
with the fulcrum lying in the middle portion
of the root residing in alveolar bone. As
progressive bone loss occurs, the fulcrum
moves apically, and as a result, the tooth is
more susceptible to harmful lateral occlusal
forces.5 Newman et al6 reinforce this by
stating that because of disproportionate
crown-to-root ratios and the reduced root
surface available for periodontal support, the
periodontium may be more susceptible to
injury by occlusal forces. McGuire and Nunn7
in a prospective 8 year study on predicting
tooth loss for 100 periodontal patients also
concluded that an unfavorable crown-to-
root ratio is a significant factor for clinicians
to consider when predicting the long-term
prognosis for a tooth.
Prosthodontic textbooks consider the
ideal crown-to-root ratio for a potential
FIGURE 1. Crown-to-root ratio calculated.
abutment supporting a fixed or removable
partial denture to be 1:2 or smaller.2–4
However, crown-to-implant ratio guidelines
have not yet been established. Misch8 states
that the crown-to-implant ratio should not
be considered the same way as a crown-to-
root ratio. He further states that an implant
does not rotate around a center located two-
thirds down the endosteal/root portion and
affirm that implant length is not related to
mobility and does not affect its resistance to
lateral force.
Many studies have addressed the issue of
implant length as a predictor of implant
survival. These publications have expressed
conflicting results.9–35 Excessive crown-to-
implant ratios have been cited in the
literature as being detrimental to long-term
implant survival.9–17 Conversely, dispropor-
tionate crown-to-implant ratios have been
associated with high implant survival, espe-
cially with short implants.18–35 Anitua et al18
found the 5 year retrospective survival rate
of 532 short (7 and 8.5 mm) implants to be
99.2%. Schulte et al19 conducted a retro-
spective case series study and found the

426 Vol. XXXVI/No. Six/2010


crown-to-implant ratios of 889 plateau-de-
sign single-tooth implants to be 1.3 on
average, with an average survival rate of
98.2% over 2.3 years.
The 5 accepted and recognized criteria
for implant success were established in 1986
by Albrektsson et al.36 Smith et al37 later
reinforced these criteria and made reference
to Adell et al38 in establishing that the mean
bone loss for Branemark osseointegrated
implants was 1.5 mm in the first year,
followed by a mean bone loss of 0.1 mm
per year. Zarb et al39 also further refined the
criteria for implant success in the Toronto
Consensus Report in 1998. Therefore, based
on the criteria established in the literature, to
be considered successful, an implant must
meet the following requirements:
1. The resultant implant support does not
preclude the placement of a planned
functional and esthetic prosthesis that is
satisfactory to both patient and dentist.
2. No pain, discomfort, altered sensation, or
infection is attributable to the implants.
3. Individual unattached implants are im-
mobile when tested clinically.
4. The mean vertical bone loss is less than or
equal to 1.5 mm in the first year and less
than 0.2 mm annually thereafter.
Today, implants are placed with both
nonsubmerged and submerged approaches.
With submerged implants, it is safe to
assume that the highest possible first bone-
to-implant contact at the time of implant
placement would occur at the top of
the implant-abutment connection. There-
fore, with this level used as a baseline,
measurements of subsequent first bone-to-
implant contact levels can be related to
vertical bone loss as stated above. Hence,
the primary aims of this study were to
determine the crown-to-implant ratios of
single implant-supported restorations on
short-length plateau-design implants in a
clinical practice, and to evaluate the success
Birdi et al
of these implants via mesial and distal first
bone-to-implant contact levels. Additionally,
the relationship between crown-to-implant
ratios and proximal first bone-to-implant
contact levels was to be evaluated.
MATERIALS AND METHODS
Study design and sample
A retrospective cohort study design was
utilized to address the specific aims of this
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investigation. The sample used in this study
was derived from a population of patients who
had been treated with 5.7 mm or 6 mm length
plateau design implants (Bicon, Boston, Mass)
placed by practitioners at the Implant Den-
tistry Center at Faulkner Hospital (IDC-FH), in
Boston, Massachusetts, between February
1997 and December 2005. All subjects who
had 1 or more single-tooth 5.7 mm or 6 mm
long plateau-design implants placed and
restored (cement retained, nonsplinted) with
use of the locking-taper design were eligible
for inclusion in the study. A total of 309
implants placed in 194 patients met the
inclusion criteria. Implants were placed by a
periodontist, 2 oral surgeons, and a prostho-
dontist. They were subsequently restored by 2
general dentists and a prosthodontist. In-
formed consent was attained from all patients
who participated in the study.
A chart review was conducted to attain
the most recent digital periapical radiographs
in which the entire crown and the implant
were visible. Accurate measurements of peri-
apical radiographs have been demonstrated in
the literature to be reliable.40 All radiographs
were made using the paralleling technique.
Periapical radiographs taken with the parallel-
ing technique minimize the problem of
dimensional distortion; however, some minor
distortion may still exist.41 Vertical distortion
occurs equally in the crown and the implant of
the radiograph, and because the crown-to-
implant ratio is not dependent on absolute
values, the effect of vertical distortion on a
Journal of Oral Implantology 427
Crown-to-Implant Ratios
FIGURE 2. Summary of radiographic measurements.
ratio is minimal.42 Radiographs with gross
distortion and inadequate contrast and dis-
playing poor definition of crown and implant
outlines were eliminated from the study, along
with all other data pertaining to these
implants. No other exclusion criteria were
utilized in this investigation. Crown-to-implant
ratios were measured using a software pro-
gram (DIGORA, Soredex, Tuusula, Finland)
measuring tool in conjunction with a magni-
fication tool. Each image was measured from
the bottom of the implant to the crown base
and then from the crown base to its highest
point. The mesial and distal first bone-to-
implant contact levels were measured from
the top of the implant-abutment connection
to the highest level of bone-to-implant con-
tact. All measurements were recorded to the
nearest 0.1 mm (Figure 2).
Descriptive variables
Descriptive variables were grouped into the
following categories:
428 Vol. XXXVI/No. Six/2010
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1. Demographics: The gender and age of
the patient at the time of implant
placement were recorded.
2. Implant Variables: The implant width and
location and the type of tooth replaced
were recorded.
3. Surgical Staging: The staging of implant
surgery (1-stage or 2-stage) was recorded.
Outcome variables
Crown-to-implant ratios were calculated by
dividing the digital length of the crown by
the digital length of the implant. The time
between implant placement and the date of
last follow-up was used to calculate the
follow-up time.
Statistical analysis
A Microsoft Excel database (Microsoft, Red-
mond, Wash) was used to tabulate all data
recorded from the chart review. SAS statis-
tical software (SAS Institute, Cary, NC) was
utilized to evaluate the data and to perform
 Birdi et al

TABLE 1
Follow-up time and crown-to-implant ratios
Average Follow-up Average Radiographic Average Radiographic Average Crown-to-
Variable Time, mo Crown Length, mm Implant Length, mm Implant Ratio

Value 20.9 13.3 6.8 2.0:1

SD 623.2 62.6 60.5 60.4
Range 15.6–122.8 6.2–21.7 4.7–9.4 0.9–3.2

the statistical analyses. Descriptive statistics restored had crown-to-implant ratios of

were calculated for all descriptive variables. equal to or greater than 1.5, and more than
Statistical analyses with analysis of variance 45% of restored implants possessed crown-
(ANOVA) mixed models were used to eval- to-implant ratios of equal to or greater than

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uate any relationship between crown-to- 2.0 (Figure 4). Average mesial and distal first
implant ratios and the highest mesial and bone-to-implant contact levels (SD) mea-
distal bone-to-implant contact levels mea- sured from the digital radiographs were
sured from the most recent radiograph in 20.2 (0.7) mm and 20.2 (0.9) mm, respec-
which the entire crown and implant were tively.
visible. The descriptive statistics are summarized
in Table 3. The mean age of the sample was
61.3 years (range, 21 to 88 years) with even
RESULTS
distribution between males and females. The
During the study interval from February 1997 implants were spread almost equally between
to December 2005, a total of 309 single- the maxilla and the mandible (45.0% and
tooth implants from 194 patients were 55.0%, respectively), and were placed pre-
measured and investigated. The measured dominantly in the posterior regions (93.2%).
results are summarized in Tables 1 and 2. Implant diameters varied between 5 and
The mean (SD) follow-up time for each 6 mm, with most being 5 mm in diameter
implant was 20.9 (23.2) months, with a range (71.2%). The types of teeth replaced were
of 15.6 to 122.8 months. The mean measured predominantly premolars (32.7%) and molars
crown length (SD) was 13.3 (2.6) mm, with a (60.5%). Nearly all implants were placed with
range of 6.2 to 21.7 mm. The mean (SD) a 2-stage surgical regimen (96.1%).
measured implant length was 6.8 (0.5) mm. Statistical analyses utilizing ANOVA mixed
Thus, the mean (SD) crown-to-implant ratio models were used to evaluate any relationship
calculated was 2.0 (0.4) and ranged from 0.9 between crown-to-implant ratios and prox-
to 3.2. The distribution of the measured imal first bone-to-implant contact levels. No
crown-to-implant ratios is shown graphically statistically significant relationships were
in Figure 3. More than 93% of the implants found between increasing crown-to-implant
ratios and decreasing mesial and distal first
TABLE 2
bone-to-implant contact levels around the
Average proximal first bone-to-implant
contact levels
implant, with P values of .94 and .57,
Average Mesial Average Distal
respectively.
First Bone First Bone
Contact Level, Contact Level,
Variable mm mm
DISCUSSION
Value 20.2 20.2
SD 60.7 60.9 The aims of this study were (1) to determine
Median 20.3 20.3
the crown-to-implant ratios of single-tooth

Journal of Oral Implantology 429

Crown-to-Implant Ratios

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FIGURE 3. Frequency of crown-to-implant ratios.

short-length plateau-design implant-sup-

TABLE 3
ported restorations, (2) to interpret the
Descriptive statistics
success of these implants via mesial and
Variable N %
distal first bone-to-implant contact levels,
Demographics
and (3) to evaluate any relationship between
Mean age (n 5 187) 61.3
crown-to-implant ratios and proximal first Minimum 20.6
bone-to-implant contact levels. Maximum 88.0
Gender (n 5 194)
The average crown-to-implant ratio found Male 96 49.5
in this study (2.0:1) far surpasses what Female 98 50.5
Implant variables
Jaw location (k 5 309)
Maxilla 139 45.0
Mandible 170 55.0
Anteroposterior location (k 5 309)
Anterior 21 6.8
Posterior 288 93.2
Jaw and anteroposterior location (k 5 309)
Anterior maxilla 17 5.5
Posterior maxilla 122 39.5
Anterior mandible 4 1.3
Posterior mandible 166 53.7
Implant diameter (k 5 309)
5.0 mm 220 71.2
6.0 mm 89 28.8
Type of tooth replaced (k 5 309)
Incisor 12 3.9
Canine 9 2.9
Premolar 101 32.7
Molar 187 60.5
Surgical staging
Staging of implant surgery (k 5 306)
One stage 12 3.9
Two stage 294 96.1
FIGURE 4. Crown-to-implant ratio of greater than 2.

430 Vol. XXXVI/No. Six/2010


clinicians believe would be favorable for
natural teeth. In many instances, a tooth
with a crown-to-root ratio of 2.0:1 would be
recommended for extraction and replace-
ment. However, the results of this study
suggest that a crown-to-implant ratio of 2.0:1
and even greater can produce a stable
favorable outcome. Crown-to-implant ratios
of such large magnitude have not been cited
in the literature thus far. Blanes et al20
evaluated 192 nonsubmerged ITI implants
and reported a mean (SD) clinical crown-to-
implant ratio of 1.77 (0.56), with 51 implants
exhibiting crown-to-implant ratios greater
than or equal to 2.0. The crown height in
that study was measured from the top of the
crestal bone in contact with the implant
to the top of the crown; thus the implant
length was measured from the bottom of the
fixture to the top of the crestal bone in
contact with the implant. This is termed the
‘‘clinical’’ crown-to-implant ratio. The ‘‘ana-
tomic’’ crown-to-implant ratio that was
measured in the present study is measured
from the bottom of the fixture to the
implant-abutment connection and then from
that point to the top of the crown. This is an
important difference because of the fact that
an implant of conventional length (.10 mm)
may exhibit a large crown-to-implant ratio if
the crestal bone has remodeled to a level far
below the implant-abutment connection. It is
important to mention that only 13.5% of the
restorations utilized in the mentioned study
were single-tooth nonsplinted restorations.
Rokni et al21 also reported crown-to-
implant ratios of sintered porous-surfaced
implants. That study included 198 implants
(5–12 mm in length) and reported a mean
(SD) anatomic crown-to-implant ratio of 1.5
(0.4), with 78.9% of the implants having
crown-to-implant ratios between 1.1 and 2.0.
However, calculations of the crown-to-im-
plant ratios were based on measurements of
articulated diagnostic casts; this represents
a prime difference from the present study.
Birdi et al
Another purpose of this study was to
determine the success of the implants
investigated by interpreting mesial and distal
first bone-to-implant contact levels. Ac-
cepted criteria for implant success state that
the mean vertical bone loss of a successful
implant should be less than or equal to
1.5 mm in the first year and then less than
0.2 mm annually thereafter.36–39 With the
top of the implant-abutment connection
used as a baseline, both mesial and distal
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first bone-to-implant contact levels were
measured at 0.2 mm over an average
follow-up time of 20.9 months, which helps
to establish implant success. All implant sites
were devoid of pain and infection, and all
implants were able to be restored and were
immobile. Thus the success of the implants
was further established.
The final purpose of this investigation
was to assess any relationship between
crown-to-implant ratios and proximal first
bone-to-implant contact levels. In this study,
no statistically significant relationship was
found between increasing crown-to-implant
ratios and decreasing mesial and distal first
bone-to-implant contact levels when analy-
sis of variance mixed models were used.
Therefore, a larger crown-to-implant ratio
did not correlate with decreased first bone-
to-implant contact levels. Rokni et al21 also
found no association between crown-to-
implant ratios and first bone-to-implant
contact levels, but did find an association
between decreasing first bone-to-implant
contact levels and increasing implant length,
as well as splinting of restorations. Blanes et
al,20 however, did find a positive correlation
between increasing crown-to-implant ratios
and increasing first bone-to-implant contact
levels over 1 year. Higher clinical crown-to-
implant ratios showed lower average bone
loss when compared with lower crown-to-
implant ratios. This again may be attributed
to the design of the nonsubmerged im-
plants, the clinical crown-to-implant calcula-
Journal of Oral Implantology 431
Crown-to-Implant Ratios
tions, or the fact that most of the restora-
tions were splinted.
The limitations of this study include those
associated with the retrospective design,
lack of clinician calibration, investigation of
only plateau-design implants, and follow-up
duration. Future studies undertaken to
investigate the influence of crown-to-im-
plant ratios on clinical performance should
include numerous implant designs, addi-
tional controls, and studies of longer dura-
tion.
CONCLUSION
The results of this study suggest that crown-
to-implant ratios do not affect the success of
short-length plateau-design implants. The
average (SD) crown-to-implant ratio found
in this study was 2.0 (0.4), which would be
deemed unfavorable for a tooth. The aver-
age (SD) mesial and distal first bone-to-
implant contact levels of 0.2 (0.7) mm and 0.2
(0.9) mm, respectively, establish the health
and success of these implants. Furthermore,
no associations between crown-to-implant
ratio and first bone-to-implant contact levels
were found.
ABBREVIATIONS
ANOVA: analysis of variance
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