J Oral Maxillofac Surg

68:414-419, 2010

Influence of Diameter and Length of

Implant on Early Dental Implant Failure
Sergio Olate, DDS, MSc,*
Mariana Camilo Negreiros Lyrio, DDS, MSc,†
Márcio de Moraes, DDS, MSc, PhD,‡
Renato Mazzonetto, DDS, MSc, PhD,§ and
Roger William Fernandes Moreira, JD, DDS, MSc, PhD㛳

Purpose: To relate diameter and length of implants with early implant failure.
Patients and Methods: Implants with a cylindrical design and surface treatment by removal of
titanium via acidification from 3 different manufacturers were used in this study. Two surgical proce-
dures for submerged implants were evaluated—the placement of the implants (first surgical phase) and
the procedure for reopening (second surgical phase)— before the installation of the prosthetic system.
The length of the implants was classified as short (6-9 mm), medium (10-12 mm), or long (13-18 mm),
and the diameter was classified as narrow, regular, or wide. The statistics were computed with SAS
statistical software (SAS Institute, Cary, NC). Step-wise and ␹2 analyses were used, in addition to
univariate and multivariate logistic regression.
Results: In this retrospective study, 1,649 implants (807 maxillary and 821 mandibular) were placed in
650 patients (mean age, 42.7 years) in different areas: anterior maxilla (458), posterior maxilla (349),
anterior mandible (270), and posterior mandible (551). The early survival rate for all 1,649 implants was
96.2%. Regarding diameter, the largest loss was observed in narrow implants (5.1%), followed by regular
(3.8%) and wide (2.7%) implants. Regarding length, the largest loss was observed in short implants
(9.9%), followed by long (3.4%) and medium (3.0%) implants. Early loss occurred in 50 implants, 31
(4.3%) of which were installed in anterior areas and 19 (2.8%) in posterior areas. According to step-wise
analyses and the ␹2 test, short implant (P ⫽ .0018) and anterior installation of implant (P ⫽ .0013)
showed associations with early loss.
Conclusion: A significant relationship of early implant loss was observed with short implants. No
relationships between early loss of implants and the osseous quality or diameter of implants were
observed. These findings may be attributed to the operator’s experience with different implant designs,
learning curves, or changes in technique and indications for the use of short implants from 1996 to 2004.
© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:414-419, 2010

The clinical use of several designs of endosseous oral ing in length, diameter, and shape have been contin-
implants has become highly predictable in recent uously introduced.1
decades, related to limitations of the geometry and Choice of implant depends on the type of edentu-
volume of the alveolar bone. New implant types vary- lism, the volume of residual bone, the amount of

*PhD Student, Oral and Maxillofacial Surgery, Piracicaba Den-
tal School, State University of Campinas, Piracicaba, Brazil, and
Professor of Medicine School, University of La Frontera, Te-
muco, Chile.
†PhD Student, Oral and Maxillofacial Surgery, Piracicaba Dental
School, State University of Campinas, Piracicaba, Brazil.
‡Associate Professor, Division of Oral Maxillofacial Surgery, Pi-
racicaba Dental School, State University of Campinas, Piracicaba,
Brazil.
§Full Professor, Division of Oral Maxillofacial Surgery, Piracicaba
Dental School, State University of Campinas, Piracicaba, Brazil.
㛳Associate Professor, Division of Oral and Maxillofacial Surgery,
Piracicaba Dental School, State University of Campinas, Piracicaba,
Brazil.
Address correspondence and reprint requests to Dr Moreira:
Piracicaba Dental School, State University of Campinas, Av
Limeira 314, Piracicaba, São Paulo, Brazil; e-mail: roger@fop.
unicamp.br
© 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6802-0028$36.00/0
doi:10.1016/j.joms.2009.10.002

414
OLATE ET AL
space available for the prosthetic reconstruction, the
emergence profile, and the type of occlusion.2 Al-
though some studies have reported promising results,
others have shown survival rates below those that
are clinically acceptable. Wide-diameter implants
were introduced in 1993 with indications for their use
associated with 1) poor bone quality, 2) inadequate
bone height, and 3) immediate replacement of non-
osseointegrated fixtures or fractured fixtures.3
Stress and bone-implant contact influence the sta-
bility and survival of implants. A biological impedi-
ment to the use of wide-diameter implants can be a
lower blood supply because of minimum existing
cancellous bone.4 Consequently, the total bone-
implant contact may be greater, compensating for the
lack of height or bone density. However, wider im-
plants are used when bone is scarce and the influence
of diameter on bone-implant contact may not trans-
late into a clinical advantage.5
On the other hand, the usefulness of small-diameter
implants has to be discussed with an awareness of
their potential limitations. It has been estimated that a
3.3-mm-diameter, screw-shaped, commercially pure
titanium implant possesses 25% less resistance to frac-
ture when compared with a similar regular-diameter
implant.6 Decreasing the diameter also means increas-
ing the risk for implant fracture because of reduced
mechanical stability and increasing the risk for over-
load.7
Clinical research shows a 91% survival rate for
3.3-mm cylindrical implants compared with a 95%
survival rate for 4.0-mm cylindrical implants.8 Simi-
larly, the survival rate of 3.25-mm self-tapping tita-
nium implants (93.8%) was lower than that of
3.75-mm implants (100%) over a 3-year observation
period.9
Bone height restrictions are more common in the
posterior regions of the maxilla and the mandible,
because of either bone absorption resulting from
tooth loss or even anatomic limitations, such as the
position of the inferior alveolar nerve or inferior wall
of the maxillary sinus.10
Information on the relationship between implant
length and survival, however, is limited. A study of
fixed single-unit restorations showed that a relation-
ship between implant length and success may not
exist, especially over 13 mm in length.11 No relation-
ship between initial mobility and implant length has
been established, and mechanical analyses have sup-
ported the view that increasing the implant length
may only increase the success rate to a certain ex-
tent.12 Block et al13 analyzed pullout force in a dog
mandible bone and showed that after 3 months of
implant installation, no significant differences were
observed between the pullout force and the variation
in diameter; however, they showed a significant dif-
415
ference related to length: 4-mm-length implants pre-
sented significantly smaller forces of extraction than
the longer 8- or 15-mm implants.
Several factors have been suggested for the study of
implant length survival: implant primary stability,
practitioner’s learning curve, implant surface, and os-
seous quality.5,14 Alterations in the preparation of the
surgical site to ensure greater primary stability in sites
of poor bone quality may affect implant survival.14
Feldman et al15 evaluated cumulative survival rates
between short machined-surface implants and stan-
dard machined-surface implants and showed survival
rates of 91.6% and 97.7%, respectively, with a statis-
tically significant difference. They also showed that
short dual acid– etched implants provided better out-
comes than machined-surface implants. Surface treat-
ment has been associated with higher rates of os-
seointegration, showing that porous surface implants
are more effective in stimulating peri-implant osteo-
genesis.16 Several studies have attempted to minimize
bone resorption and increase bone-implant contact
by using different designs of implants; thread config-
uration, apical and cervical design, and surface treat-
ment are used to maximize initial contact, improve
initial stability, increase implant surface area, and help
dissipate interfacial stress.17,18 Processes that involve
the addition of hydroxyapatite13 and plasma spray-
ing19 or the removal of titanium via acidification or
sandblasting have been studied with satisfactory re-
sults. In clinical studies the long-term results show
high success rates, with a shortened time for implant
loading with stability of the bone-implant unit.20
The aim of this study was to collect and summarize
clinical data, for a period of 8 years, of patients treated
by use of implants with surface treatment by removal
of titanium via acidification with different implant
diameters and lengths for single- and multiple-tooth
restorations in a university environment, with an out-
come assessment of early dental implant failure.
Patients and Methods
STUDY DESIGN/SAMPLE
The study was based on a retrospective analysis of
patients who received implants between July 1996
and July 2004. We analyzed the clinical files of all
patients who underwent dental implant placements
at the Division of Oral and Maxillofacial Surgery, State
University of Campinas, Piracicaba, São Paulo, Brazil.
The inclusion criterion was dental implant place-
ment in patients who had undergone the second
surgical phase. All implants analyzed in the study
followed the protocol of 2 surgical procedures (sub-
merged implants), and the implants were evaluated
from the placement of the implants (first surgical
416
phase) until the procedure of reopening (second sur-
gical phase). The time between the first surgical
phase and the second phase was computed in days.
Because this was a study of early failure of implants,
no evaluation of the prosthetic system or any situation
occurring after the reopening second surgery was
performed.
Patients were excluded from the study for the fol-
lowing reasons:
● The patients had missing or incomplete files.
● The patients were still in treatment and had not
yet undergone implant placement by the time
the data were collected.
● The implants had not undergone the second sur-
gical phase.
● The patients had implants placed but had aban-
doned the treatment, and their implants were
placed by a nonsubmerged protocol.
STUDY VARIABLES AND STATISTICAL ANALYSIS
The implant placement regions were grouped ac-
cording to 4 locations: incisors and canines (A) and
bicuspids and molars (B) in maxillary locations and
incisors and canines (C) and bicuspids and molars (D)
in mandibular locations.
In this study a 2-stage protocol used cylindrical-
design implants from 3 manufacturers in Brazil (Neo-
dent, Curitiba, Brazil; Conexão, São Paulo, Brazil; and
SIN–Implant System, São Paulo, Brazil); all of them
had undergone surface treatment by removal of tita-
nium via acidification.
The length of the implants was classified as short
(6-9 mm), medium (10-12 mm), or long (13-18 mm),
and the diameter platform of the implants was classi-
fied as small, regular, or wide.
Data were tabulated and analyzed by use of Mi-
crosoft Excel Software 2003 (Microsoft, Redmond,
WA). Initially, we performed a descriptive analysis,
after an exploratory analysis of variance for homoge-
neity, outliers, and type and grade of samples. Finally,
we used a step-wise analysis to identify variables with
significant relationships with P less than .05; thereaf-
ter the data were analyzed with the ␹2 test. Data with
P less than .05 were subjected to univariate and lo-
gistic regression analysis with SAS statistic software,
version 8.21 (SAS Institute, Cary, NC).
Results
The study consisted of 650 patients ranging in age
from 13 to 84 years (mean, 42.7 years). The mean
follow-up period was 249 days between the first- and
second-stage surgery. Male patients comprised 34% of
the sample (median age, 41.2 years), and female pa-
tients comprised 66% (median age, 43.2 years). A total
EARLY DENTAL IMPLANT FAILURE
of 1,649 implants were installed, with a median of 2.5
per patient. Some differences could be observed be-
tween implants in terms of apical angulation and
thread design, with the Neodent implant presenting a
larger-sized thread than the Conexão and SIN im-
plants. The platform and implant connection were
conventional internal and external hexagons, with no
analysis performed because the implant was sub-
merged and not submitted to dental load.
We placed 295 wide-diameter implants, 1,217 reg-
ular-diameter implants, and 137 narrow-diameter im-
plants. With regard to length, there were 131 short
implants, 635 medium implants, and 883 long im-
plants.
The early survival rate for all 1,649 implants was
96.2%. The largest loss was observed in narrow-
diameter (5.1%) implants, followed by regular-diame-
ter (3.8%), and wide-diameter (2.7%) implants. Re-
garding length, the largest loss was observed in short
implants (9.9%), followed by long (3.4%) and medium
(3.0%) implants.
MAXILLA
There were 807 implants (49.6%) placed in the
maxilla, with 458 (28.1%) in the anterior area and 349
(21.4%) in the posterior area. Of the implants in the
maxilla, 28 (3.5%) were lost, 21 in the anterior area
and 7 in the posterior area. Regarding diameter, 109
implants (13.5%) had a narrow diameter, 631 (78.2%)
had a regular diameter, and 67 (8.3%) had a wide
diameter. The majority of implants used in the maxilla
were long (510 [63.2%]), followed by medium (255
[31.6%]) and short (42 [5.2%]) implants.
MANDIBLE
There were 821 implants (50.4%) placed in the
mandible, with 270 in the anterior area (16.6%) and
551 (33.9%) in the posterior area. Of the implants in
the mandible, 22 (2.8%) were lost, 10 in the anterior
area and 12 in the posterior area. Regarding diameter,
26 implants (3.2%) had a narrow diameter, 572
(69.7%) had a regular diameter, and 223 (27.1%) had
a wide diameter. The majority of implants used in the
mandible were long (377 [45.9%]), followed by me-
dium (356 [43.4%]) and short (88 [10.7%]) implants.
STATISTICAL RELATIONSHIPS
Demographic variables such as gender and age did
not show significant statistical differences. Step-wise
analyses showed significant relationships between
length of implant (P ⫽ .0018) and early loss of im-
plant and between site of installation (P ⫽ .0013) and
early loss of implant. Univariate analysis showed too
significant a relationship between short and anterior
localization of implant and early loss. When a ␹2
analysis was done, short implants presented a signif-
OLATE ET AL
icant relationship, where the possibility of early loss
of implant was increased by 0.16 per unit. Early loss
of implant did not show a significant statistical differ-
ence with maxillary or mandibular installation (P ⫽
.4535), but in agreement with the step-wise analysis,
it did show a difference based on anterior or posterior
site of installation (P ⫽ .0187): 31 implants (4.3%)
with early loss were present in anterior areas and 19
(2.8%) in posterior areas.
Discussion
Implants may be lost before a second-stage proce-
dure (early failures) or after prosthetic rehabilitation
(late failures). The rates of early failures have been
reported to vary between 1.5% and 21%.11 Implant
failures have been associated with factors such as
poor bone quality, parafunction, insufficient jawbone
volume, initial implant instability, and overload. Re-
lated to the site of placement (anterior or posterior),
we found a relationship with early loss of the implant
using step-wise and ␹2 analysis, but when univariate
and multivariate logistic regression were used, this
variable did not present a relationship; in fact, type of
bone (maxilla or mandible) did not show significant
statistical differences. This finding can be related with
the osseous quality identified at the time of surgery,
promoting a change in surgical technique. On the
other hand, a second hypothesis might be that osse-
ous class does not influence the early loss of implants
but might have an influence later when implants are
loaded prosthetically. Degidi et al2,21 did not find a
significant difference associated with bone quality
(maxilla or mandible) when evaluating survival of
narrow- or wide-diameter implants. They did, how-
ever, find a different success rate according to length
and diameter, with a better outcome with regard to
reduced crestal bone loss over time for shorter (⬍13
mm) or narrower (5.0 and 5.5 mm) implants.21
Our study related early implant loss with length of
implant but not diameter, and our results are in agree-
ment with the literature review. Univariate signifi-
cance for early loss was found at P ⬍ .001, and the
logistic regression showed that 6- to 9-mm short im-
plants have a 0.16 times increased chance of early
failure. In the long term, the length of the implant
could be more important than the diameter, because
before oral cavity exposure and loading, vertical os-
seous loss is present, and it can be close to 0.2 mm
per year; in the future, the implant may lose impor-
tant contact between bone and implant surface.3,8
The surface treatment is an important issue. Some
studies have related surface treatment with more os-
seointegration of the implant16,19; indeed, osseointe-
gration requires less time with enhanced surfaces,
and the implant can be loaded in the early stages.22
417
Loaded implants or stress support characteristics
were not evaluated in this study, because all of the
implants were submerged before early loss analysis.
In this clinical study, bone-implant contact was not
evaluated, limiting this evaluation to loss of implant
because of absence of osseointegration. Schierano et
al16 reported greater bone-implant contact in implants
with surface treatment; we believed that such a treat-
ment could be applied to implants used in this study.
These implants underwent surface treatment by
removal of titanium via acidification; generally, the
manufacturers do not present the particular char-
acteristics of surface treatment, and this study is no
exception.
Implant design was not included in this analysis
because it is more associated with the impact of
forces related to prosthesis use.23,24 This report re-
lates cylindrical implant status in the submerged
phase until the second surgery.
LENGTH OF IMPLANT
Some articles showed clearly that short implants
failed more often than longer implants.25-27 However,
others reported that implant length did not appear to
significantly influence the survival rate.15,28,29 Several
factors have been suggested to explain this, such as
the implant’s primary stability, the practitioner’s
learning curve, and the quality of the patient’s bone.
In addition, it should be noted that some of the
studies that reported lower survival rates with short
implants used a routine surgical protocol indepen-
dent of bone density.18,30,31
For this study, short implants showed significant
statistical differences with early loss of implant. The
implant procedures were performed by students en-
rolled in a program in oral and maxillofacial surgery or
implant dentistry. We can speculate that operators’
learning curves could be a reason for the different
reported outcomes with short or long implants be-
tween the studies. Stellingsma et al32,33 showed dif-
ferent cumulative survival rates in 2 studies, with 88%
in the first and 100% in the second. The learning
curve could be the reason for this difference. Instal-
lation of short implants is done when insufficient
bone is present; quality and angulation of burn can
influence implant stability and early loss of implants.
DIAMETER OF IMPLANT
When one is considering narrow-diameter im-
plants, it should be noted that all the studies included
in this structured review have reported low failure
rates. These figures could be explained by adapted
and atraumatic preparation techniques, as well as the
careful patient selection in terms of biomechanical
conditions and bone density. In addition, narrow-
diameter implants would have been considered in
418
clinical situations in which limited space or bone
availability disallowed the use of standard-diameter
implants. Ivanoff et al5 suggested that the increased
failure rate of 5-mm-diameter implants was associated
with the operators’ learning curves, poor bone den-
sity, implant design, and the use of this implant diam-
eter when primary stability could not be achieved
with a standard-diameter implant. This view was sup-
ported by the study of Hultin-Mordenfeld et al,34 in
which wide-diameter implants were placed in unfa-
vorable situations, such as poor bone density and
compromised bone volume.
In a study by Krennmair and Waldenberger35 with
114 patients followed up for 12 to 114 months, only
2 maxillary implants lost osseointegration, but no
implant had a length of less than 10 mm; no differ-
ences were found between the wide-diameter im-
plants and the standard- or smaller-diameter implants.
Renouard and Nisand36 showed that these controver-
sial results occur because initial studies have not pro-
vided clear technical indications regarding short or
wide implants and because of limited experience
with new implant designs (short- and wide-diameter
implants), operator’s learning curve, and the use of
machined-surface implants. Regarding early loss of
implants with different designs, few data exist and
more research is necessary. In our study, the diameter
of the implant did not influence early loss.
In this retrospective longitudinal study, the length
of the implant and anterior installation area influ-
enced early implant loss. This influence was not ob-
served for diameter in terms of early implant failure.
Acknowledgment
The authors thank Dr Erika Harth-Chu for helpful revision of the
manuscript.
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