Shortimplants: Their Role in Implant Reconstruction

Short Implants
Their Role in Implant Reconstruction
Raza A. Hussain, BDS, DMDa,b,c,*, Jennifer B. Cohen, DDS

a,b
,
Benjamin Palla, DMD, MDb,c,1
KEYWORDS
Dental implants Short implants Complications Reconstruction
KEY POINTS
Minimally invasive surgical techniques are being advocated for in all specialties.
The prevalence of short dental implants is increasing in various clinical scenarios.
Short implants have many advantages over standard length implants.
Various factors (surgical, biomechanical, and restorative) lead to improved success rates
of short implants.
While more long-term studies are needed, the literature indicates success rates of short
implants are comparable to those of longer length implants.
INTRODUCTION
Since Branemark’s discovery of titanium dental implants in the 1960s, the process of
replacing missing dentition has evolved significantly due to improvements in implant
design, as well as surgical and restorative techniques. Modern day dental implants
come in a variety of lengths which, among other factors, can influence the long-term
success rate. The discussion of short versus conventional length implants has created
controversy in the sense that there are conflicting opinions on where to draw the line be-
tween these 2 categories. The definition of a short implant in particular is variable, but
generally considered to be less than 10 mm. Many of the earlier cases of endosseous
implant placement in edentulous mandibles involved 13-16 mm transmandibular im-
plants,1 which were placed in a bicortical fashion (Fig. 1). As time went on, the use of
shorter implants became more common. In some of Brånemarks original studies, the
length of dental implants used was 10 mm.2 In 2006, the State of the in Implant Dentistry
(SSID) Conference defined short implants as those with 8 mm or less of Designed
a
Jesse Brown VA Medical Center, 820 South Damen Avenue, Chicago, IL 60612, USA; b Dental/
OMS Service, 4th Floor Damen; c Department of Oral & Maxillofacial Surgery, University of Il-
linois Chicago, Chicago, IL, USA
1
Present address: 820 South Damen Avenue, Chicago, IL 60612.
* Corresponding author. Jesse Brown VA Medical Center, 820 South Damen Avenue, 4th Floor
Damen, Chicago, IL 60612.
E-mail address: raza.hussain@va.gov
Dent Clin N Am 68 (2024) 47–54

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48 Hussain et al
Fig. 1. Transmandibular implant (Infected).
Intrabony length (DIL).3 Renouard also defined a short implant as one being less than
8 mm, and an ultrashort implant being < 5 mm.4,5 Benefits of short implants specifically
revolve around the ability to avoid bone augmentation and overcome anatomic limita-
tions. Therefore, short implants can be considered less invasive, less complex, and
both time and cost-saving.6 For the purposes of our discussion we will consider short
implants as any implant with a length of less than 10 mm.
WHAT IS A SHORT IMPLANT?
As previously stated, short dental implants are 2-piece implants of standard width and
less than 10 mm in length. They are placed via osteotomy preparation and have various
integration times based on anatomic location. Short dental implants were developed
with the purpose of acting as “permanent” replacements for missing dentition, not to
be confused with mini dental implants which have a narrow diameter and are designed
to temporarily retain a preliminary prosthesis. Short implants less than 5-6 mm are
commonly referred to as ultrashort. An implant less than 4 mm begins to encroach on
the internal implant components that allow attachment to the clinical crown.
ADVANTAGES OF SHORT IMPLANTS

1. Overcome anatomic limitations: Such anatomic structures include the maxillary si-
nus, nasopalatine canal, and inferior alveolar canal (Fig. 2).
2. Avoid complex surgery: Prior to the development of short implants many patients
underwent extensive grafting or reconstructive procedures in preparation for dental
implant placement. These procedures could be as extensive as major autogenous
bone graft procurement from sites such as the anterior iliac crest. LeFort I osteot-
omies with interpositional bone grafting were also at times utilized in order to
Fig. 2. Right side with nerve lateralization and standard length implants, left side with short
implants.
Short Implants 49
provide sufficient bone for maxillary implant placement (Fig. 3). Additionally, nerve
lateralization procedures have been proposed for the posterior mandible when
minimal vertical bone stock exists. These procedures are technique sensitive
and risk transient nerve injury (Fig. 4).
3. Shorter treatment time: In the case of an atrophic mandible, for example, the elim-
ination of ridge augmentation via short implant placement leads to faster loading
and restoration.
4. Fewer post-op complications: Naturally with fewer surgical steps, post-op compli-
cations are less likely to arise
5. More cost-effective: For both the clinician and patient
In a study by Stellingsma in 2003, the authors compared 3 different implant treat-
ment methods for implant overdentures in the severely resorbed mandible.7 The first
group received transmandibular implants, the second received bony augmentation
and axial implants, and the third group received short implants without augmentation.
The authors found all 3 methods improved the patient’s quality of life, but the treat-
ment time and morbidity from autologous grafting was the least favorable option by
the subjects.7
In the 4th European Association of Osseointegration (EAO) Conference in 2015,
three systematic reviews evaluated the role of short implants in immediate extraction
sites, as well as the posterior maxilla and mandible with or without bone augmenta-
tion.8 The Conference concluded both options were viable, but that the placement
of short implants had fewer complications.8
A systematic review in 2016 analyzed 14 RCTs comparing implant restoration in the
posterior mandible with either short implants, or long implants following vertical bony
augmentation.9 The study found no differences in implant failure or prosthetic failure,
however, complications were higher with vertical bony augmentation (OR 8.3).9
FACTORS FOR SUCCESS
There are numerous factors which contribute to a successful outcome of an implant.

For a short implant to have comparable success rates to standard length implants,
biomechanics must be optimized and a thoughtful restorative plan must be incorpo-
rated. With the use of standard-length dental implants, excessive forces can often
be countered via increased implant length and engaging buttress bone for additional
stability. Short implants, on the other hand, do not have this advantage and therefore
the clinician must utilize different techniques to offset occlusal forces.
1. Implant surface design: Increased surface area is more optimal, especially for im-
plants lacking length. This can be accomplished by increasing the number of
Fig. 3. Maxillary reconstruction with LeFort I osteotomy and Interpositional Ilium graft
(Raza A. Hussain, BDS, DMD, FACS).
50 Hussain et al
Fig. 4. Nerve lateralization procedure prior to implant placement.
threads, increasing the depth, and using a square thread design as opposed to
v-shaped.
2. Bone quality: In general, all implants will be more stable and have greater long-term
success if placed in Type I or Type II bone. If a short implant needs to be placed in
an area of lower quality bone (for example, in the posterior maxilla to avoid sinus
lift), there are certain biomechanical factors, as discussed later in discussion,
that can compensate and enhance success.
Lekhom and Zarb Classification of Bone Quality10:
Type I- Homogenous Cortical Bone.
Type II- Thick cortical bone with marrow cavity.
Type III- Thin cortical bone with dense trabecular bone of good strength.
Type IV- Very thin cortical bone with low-density trabecular bone of poor strength.
3. Increased number of implants: Increasing the number of implants provides addi-
tional implant-to-bone contact, leading to improved stability. This is especially
important in areas where standard length implants are not ideal (Fig. 5).
4. Implant Diameter: Studies have shown that occlusal forces are localized and pri-
marily impact the coronal 3-5 mm of a dental implant.11 Increasing the diameter al-
lows for improved distribution of forces at the bone-implant interface. Therefore,
utilizing a wider implant is another means of providing additional stability to a
shorter length implant.
5. Splinting: While controversial among providers, splinting can be a useful technique
when restoring short implants in that it distributes excess forces across multiple in-
terfaces (Figs. 6 and 7).
6. Crown-to-Implant Ratio: It was previously assumed that a greater crown-to-implant
ratio could result in bone loss and potential failure. More recent studies have shown
that even short implants with a higher crown-to-implant ratio are not associated
with higher failure rates.2,12
Fig. 5. Multiple splinted implants with lower left short implants for full arch reconstruction.
Short Implants 51
Fig. 6. Splinted short implants. (Courtesy Raza A. Hussain, BDS, DMD, FACS.)
PATIENT SELECTION
When considering whether a patient is a good candidate for implant surgery, the same
criteria applies to implants of all length. In patients with complex medical issues, such
as uncontrolled diabetes, heart disease, and immunosuppressive disorders, implant
placement may not be the most ideal treatment plan.13 Implants are typically not ideal
in patients who have undergone head and neck radiation, or have a history of antire-
sorptive therapy. In addition, smoking can have negative effects on the long-term
outcome of an implant. An advantage of short implants, as opposed to longer stan-
dard length implants, is that they allow for patients with medical issues a less invasive,
safer approach to restoring their dentition (Fig. 8).
Fig. 7. Multiple short implants in function for between 5 and 10 years. (Courtesy Raza A.
Hussain, BDS, DMD, FACS.)
52 Hussain et al
Fig. 8. Short implants placed in an elderly patient with mandibular atrophy (Raza A. Hus-
sain, BDS, DMD, FACS).
LONG-TERM SUCCESS RATES OF SHORT VERSUS LONG IMPLANTS
A prospective study in 32 patients evaluated ultra-short implants (4 mm Straumann

SLActive) and found the survival rate to be 95.7% at 2 years.14 In a subsequent pub-
lication of this same group, Slotte found the 5 year survival rate was 92.2%.15 These
findings were consistent with 4-mm implants placed in the posterior jaws to support
fixed partial dentures which had a 97.5% survival rate at 1 year.16 Other systematic
reviews have found that long implants (>6 mm) had higher complication rates when
compared to short implants (6 mm), 32.8% versus just 6.8% respectively.16 A sys-
tematic review in 2018 by the International Team for Implantology (ITI) included 10
RCTs, and over 1,200 implants.16 Short implants (6 mm) performed similar to long
implants (>6 mm), with a survival rate at 1-5 years of 96% versus 98% respectively.16
The authors speculated this was related to the need for simultaneous bone augmen-
tation with longer implants. Felice and colleagues17 compared short (5 mm) implants
with the bony augmentation and placement of 10 mm implants in the posterior
mandible in a split mouth study. Results showed similar implant survival, and patients
had no preference for one treatment option versus the other.
SUMMARY
The prevalence of short dental implants is increasing across various dental specialties.
They provide an option to patients that involve less surgical trauma, lower cost, and
decreased treatment time. While the placement of longer length implants may require
additional surgical procedures such as ridge augmentation or maxillary sinus lift, the
use of short implants can avoid these procedures altogether, benefitting both the pa-
tient and clinician. Strict adherence to reliable surgical and restorative principles is
essential for an ideal outcome, among other factors such as patient compliance
and medical history. As implant placement in general has evolved over time, there
has been a considerable amount of literature comparing the success rates of various
implant lengths. Compared to early literature, more recent studies have shown a
similar rate of success in short versus long implants. While the use of short implants
remains somewhat controversial, it has been proven that they can offer a long term,
predictable outcome for almost any clinical scenario.
CLINICS CARE POINTS
The use of short dental implants for many different clinical scenarios in dentistry is rapidly
increasing.
Short Implants 53
With many of the non-surgical based specialties in dentistry now offering dental implant
placement the thought of decreasing potential significant complications is very appealing.
Short dental implants can be complete with less surgical trauma and often in less time.
The clinician must take into consideration each particular scenario and ensure that short
dental implant placement is in the patient’s best interest.
Strict adherence to tried and true surgical and prosthodontic principles is key for an ideal
outcome.
Short dental implants can offer a long term, predictable outcome for almost any clinical
scenario.
DISCLOSURE
All authors have no financial conflicts of interest to disclose.
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2014;66(1):72–96.
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Clin Oral Implants Res 2006;17(Suppl 2):35–51.
6. Pistilli R, Felice P, Cannizzaro G, et al. Posterior atrophic jaws rehabilitated with
prostheses supported by 6 mm long 4 mm wide implants or by longer implants
in augmented bone. One-year post-loading results from a pilot randomized
controlled trial. Eur J Oral Implantol 2013;6(4):359–72.
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pects of patients with an extremely resorbed mandible treated with implant-
retained overdentures. A prospective, comparative study. Clin Oral Implants
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systematic review. Br J Oral Maxillofac Surg 2022;60(4):422–9.
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Shortimplants: Their Role in Implant Reconstruction

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Short Implants

Their Role in Implant Reconstruction

Raza A. Hussain, BDS, DMDa,b,c,*, Jennifer B. Cohen, DDS

Dent Clin N Am 68 (2024) 47–54

Fig. 1. Transmandibular implant (Infected).

WHAT IS A SHORT IMPLANT?

ADVANTAGES OF SHORT IMPLANTS

FACTORS FOR SUCCESS

There are numerous factors which contribute to a successful outcome of an implant.

Fig. 4. Nerve lateralization procedure prior to implant placement.

LONG-TERM SUCCESS RATES OF SHORT VERSUS LONG IMPLANTS

A prospective study in 32 patients evaluated ultra-short implants (4 mm Straumann

CLINICS CARE POINTS

All authors have no financial conflicts of interest to disclose.

1. Bosker H, van Dijk L. The transmandibular implant: a 12-year follow-up study.

13. Shokouhi B, Cerajewska T. Radiotherapy and the survival of dental implants: a

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