Change in Crown-to-Implant Ratio of Implants Placed in

Grafted and Nongrafted Posterior Maxillary Sites:

A 5-year Prospective Randomized Study
Rabah Nedir, DMD1/Nathalie Nurdin, PhD2/Guy Huynh-Ba, DDS, MS3/Mark Bischof, DMD4

Purpose: The aim of this study was to evaluate the performance of implants placed for 5 years in grafted
vs nongrafted sinuses in relation to crown-to-implant ratio. The measurements of crown and implant lengths
took into account changes in both endo-sinus and crestal bone levels over 5 years. Materials and Methods:
Enrolled patients required one or two implants in at least one sinus and presented a residual bone height
of posterior maxilla ≤ 4 mm. Individual sinuses were randomly allocated either to be grafted or not before
surgery. Implants of 8 mm in length were placed using osteotome sinus floor elevation (OSFE). After 10
weeks of healing, they were loaded functionally using definitive single crowns. Radiographic measurements
were made on periapical radiographs taken at surgery, prosthetic steps, and 5 years. The implant length
was measured between the most apical and coronal contact of bone and implant, and the crown length was
measured between the most occlusal point of the crown and the crestal bone. Data were analyzed using
mixed linear models. Results: Twenty implants were placed in grafted sinuses and 17 in native bone (12
patients). One of the 35 restored implants failed. Immediately after surgery, the mean lengths of the implants
placed in grafted and nongrafted sites were 2.4 ± 0.8 and 2.7 ± 0.9 mm, respectively (P = .351). At loading,
the mean crown-to-implant ratios were 3.8 ± 0.8 and 4.6 ± 2.0 (P = .033), respectively, whereas at 5 years,
they were 2.0 ± 0.8 and 2.1 ± 0.4, respectively (P = .341). Conclusion: The use of grafting material is not
necessary to restore posterior maxilla ≤ 4 mm with OSFE and simultaneous implant placement. Over 5
years, all restored implants but one were functional. Despite unfavorable conditions in terms of initial bone
anchorage and height of single crown restoration, a high initial crown-to-implant ratio did not compromise
the long-term survival of implants placed in grafted or nongrafted sinuses. Int J Oral Maxillofac Implants
2019;34:1231–1236. doi: 10.11607/jomi.6766

Keywords: atrophic posterior maxilla, crown-to-implant ratio, dental implants, grafting material, osteotome
sinus floor elevation, proximal bone-to-implant contact

T he crown-to-root ratio is defined as the length of

the crown from the most incisal or occlusal position
to the crestal bone, divided by the length of the root
1Clinical Director, Swiss Dental Clinics Group, Ardentis Clinique
Dentaire Vevey, Vevey, Switzerland.
2Senior Scientist, Swiss Dental Clinics Group, Ardentis Clinique
Dentaire Vevey, Vevey, Switzerland.
3Associate Professor, University of Texas Health Science
Center San Antonio, Department of Periodontics, San Antonio,
Texas, USA.
4 Clinical Director, Swiss Dental Clinics Group, Ardentis Clinique
Dentaire Lausanne, Lausanne, Switzerland.
Correspondence to: Dr Rabah Nedir, Swiss Dental Clinics
Group, Ardentis Clinique Dentaire Vevey, Rue du Collège 3, CH-
1800 Vevey, Switzerland. Email: publications@ardentis.ch
Submitted November 9, 2017; accepted May 10, 2019.
©2019 by Quintessence Publishing Co Inc.
in the bone.1 Where the height of the alveolar bone
decreases, the harmful lateral forces acting on the
coronal part of the tooth are greater. Although Ante
postulated that “the total periodontal surface of the
abutment teeth must equal or exceed that of the teeth
to be replaced,”2 the optimal ratio for a tooth used as
an abutment for a fixed partial denture is 1:2. More fre-
quently, it is approximately 2:3, with the minimal ac-
ceptable ratio being 1:1.3 From these principles, it has
been deduced that the crown-to-implant ratio should
not be greater than the crown-to-root ratio.
Implants ≤ 10 mm in length are frequently associat-
ed with lower levels of predictability than longer ones,
particularly in posterior regions showing a low bone
quality and height.4 Consequently, it is recommended
that the bone should be augmented sufficiently for the
placement of an implant ≥ 10 mm in length. However,
the evolution of the design of the implants and sur-
faces has meant that limitations in length have been

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Nedir et al
overcome in augmented posterior maxillae.5 The use of
an implant with a tapered shape and a reduced thread
pitch can improve its primary stability and maintain
the bone crest at the level of the machined-threaded
junction of the implant, particularly in view of the lim-
ited bone support of the posterior maxillary regions.6
One way of increasing bone height is via the osteo-
tome sinus floor elevation technique (OSFE), which
involves a crestal approach for elevating the sinus
membrane and possibly filling using a grafting mate-
rial. Implants can then be placed simultaneously.7–9 At
the time of placement, the implants would then pro-
trude into the sinus, especially when grafting material
is not inserted.
In the present study, 8-mm-long tapered implants
were placed using OSFE in extremely resorbed pos-
terior maxillae in grafted or nongrafted sinuses.8 The
initial maxillary residual bone height was ≤ 4 mm.
Therefore, at least 4 mm of the implants placed were
initially not encased in bone. The study investigated
the changes in crown-to-implant ratio with increasing
endo-sinus bone gain over time. The performance of
the implants and their prosthetic restoration was as-
sessed, from their loading to 5 years after treatment.
It was hypothesized that an unfavorable initial crown-
to-implant ratio and an absence of grafting material
do not compromise long-term survival of implants in
atrophic posterior maxillae.
MATERIALS AND METHODS
Patient Entry
The Ethics Committees of the Geneva and Lausanne
University Hospitals (Switzerland) approved the study
protocol (references 06-089 and 245/06). Criteria for
patient inclusion were as follows:
• Patients required 1 or 2 implants per sinus.
• Tooth extractions at the sites of concern were
performed ≥ 4 months before surgery.
• Measurement of the initial maxillary bone height by
panoramic radiograph was ≤ 4 mm.
• The sinuses were augmented using OSFE and
grafted, or not, according to a randomized process.
• Tapered and hydrophilic-surfaced implants of 8 mm
in length were placed.
• Wearing a removable partial denture during the
healing period was not allowed.
Exclusion criteria were active periodontal disease,
metabolic bone disease, diabetes, or a history of acute
or chronic sinusitis.8
If only one sinus could be treated, it was random-
ized by allocation of a sealed, independently prepared
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envelope attributing the procedure. If both maxillary
sides were treatable, the randomization attributed one
procedure to the right side, whereas the other proce-
dure was applied to the left side.
Implant Placement and Prosthetic Restoration
The procedures for implant placement and prosthetic
restoration were described previously.8 Surgery was
performed under antibiotic prophylaxis. Full muco-
periosteal flaps were elevated following midcrestal in-
cision without vertical or periosteal releasing incisions.
Access to the sinus floor was obtained by marking the
cortical bone with round burs of 1.4 to 3.1 mm in di-
ameter, as well as using an initial osteotome 2.8 mm in
diameter (Straumann). The sinus membrane was ele-
vated by tapping the osteotome lightly. An osteotome
of 3.5 mm in diameter allowed enlargement of the os-
teotomy site. If the sinus was randomized to be graft-
ed, it was filled with Bio-Oss (Geistlich Pharma). One or
two implants (TE SLActive; length: 8 mm; smooth neck
length: 1.8 mm; Straumann) were seated in the grafted
or nongrafted site, up to the mesial and distal limits of
the rough surface. Hence, the implant neck protruded
above the bone crest. The implants were left to heal
transmucosally and prosthesis-free for 8 weeks. An im-
pression was then made, and single porcelain-fused-
to-metal, screw-retained crowns were fabricated.
Clinical and Radiographic Controls
Examinations took place after implant placement at
1 week (suture removal), 8 weeks (making of impres-
sion), 10 weeks (loading step), and at 1, 3, and 5 years.
Implants were considered to have survived if they were
still in the mouth and functional. Prosthetic complica-
tions were recorded including loosening of the crown
or abutment, loosening of the screw, and fracture of
the abutment and porcelain veneer.
Standardized periapical radiographs were taken
without prosthesis immediately after surgery, at the
prosthetic steps, and at 5 years.8 Three interthread dis-
tances were measured for internal calibration on each
radiograph prior to analysis (2.4 mm). The implant
length was defined as the part of the implant in con-
tact with bone. It reflected the anchorage of bone and
integrated changes in the endo-sinus and crestal bone
levels (Fig 1).
Non-standardized periapical radiographs with pros-
theses in place were also obtained both at the pros-
thetic step and at 5 years (Fig 2). Internal calibration
was performed on each radiograph by setting the total
implant length to 9.8 mm. The crown length was the
distance measured from the most occlusal point to the
crestal first contact of bone and implant. The crown-
to-implant ratio was obtained by the division of the
crown length by the implant length.
 Nedir et al

Fig 1  Measurements of crestal bone

level and implant length on standardized
periapical radiographs. Crestal bone level:
Distance A, parallel to the implant axis and
between the most coronal bone-to-implant
contact and the most apical thread of the
implant, was measured on both sides of
each implant and averaged. A decrease in
these mean values measured at loading
and after 5 years was indicative of crestal
bone loss (negative value). Conversely, an
increase indicated crestal bone gain (posi- A A
tive value). Implant length: Distance I, be- I I
tween the most coronal and apical contact
of bone and implant, was measured on
both sides of each implant and averaged.

Implant in nongrafted site Implant in grafted site

Fig 2  Patient 3. Radiographic evolution

of crown length (C) and implant length
(I) on nonstandardized periapical radio-
graphs taken at (a) loading and (b) after
5 years. I I
I I

C C
C C

a b

Statistical Analysis Two implants that were placed in fused cortices

Radiographic measurements were presented with
descriptive statistics and analyzed using mixed linear
models. These models included a random effect for
each patient and a fixed effect for the treatment group
and year. The P values took into account the random
effects factor. The statistically significant threshold was
set at P < .05.
RESULTS
Among nine women and three men (mean age
57.6 ± 4.7 years), the inclusion criteria were met at 32
molars and five premolars with residual bone height
≤ 4 mm. Seven patients were treated in both sinuses
(one sinus grafted and the other nongrafted) and a
single sinus was involved in five patients. Twenty im-
plants were placed in grafted and 17 in nongrafted
sinuses. Antagonists in contact with the planned
crowns were natural teeth or restored implants, and
the indication for all patients except one was free-end
edentulism. The patients did not wear night guards
because none suffered from parafunction or mus-
cular hypertrophy at the initial preoperative clinical
examination.
showed mobility before the loading step and failed
(patient 2, maxillary right first molar implant in grafted
site; patient 12, maxillary left second molar implant
in grafted site).8 Consequently, restorations were per-
formed on 35 implants with single crowns. The mean
healing time of the implants was 2.6 ± 0.9 months. One
prosthetic complication, a ceramic fracture, occurred
2.5 years after loading (patient 7, maxillary right first
molar implant in nongrafted site). In addition, the fail-
ure of that same implant occurred at 2.7 years because
of the recurrence of periodontal disease that had been
treated before implant placement.10 After 5 years, 34
of 35 restored implants survived without prosthetic
complications.
Table 1 shows implant length, crestal bone level,
crown length, and crown-to-implant ratio for each pa-
tient. Immediately after surgery, the mean lengths of
implants placed in grafted and nongrafted sites were
2.4 ± 0.8 and 2.7 ± 0.9 mm, respectively. There was no
significant difference between the grafted and non-
grafted sites (P = .351). At loading, implant lengths were
3.7 ± 0.8 and 3.5 ± 1.3 mm in grafted and nongrafted
sites, respectively (P = .405), while at 5 years, they were
7.0 ± 1.1 and 6.4 ± 0.9 mm, respectively (P = .002). The
mean implant length increased significantly between

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Nedir et al

Table 1   Values of Implant Length, Crestal Bone Level, Crown Length, and Crown-to-Implant Ratio
Crestal bone Crown length Crown-to-
Implant length (mm) level (mm) (mm) implant ratio
Patient
no. Implant sitea After surgery Loading 5y Loading 5y Loading 5y Loading 5y
1 16 Nongrafted 3.1 3.3 5.1 −0.1 −1.0 14.8 15.1 4.5 3.0
17 Nongrafted 2.6 3.0 7.1 −0.6 −0.9 14.9 15.1 5.0 2.1
2 15 Grafted 4.0 4.0 3.5 −0.1 −4.3 12.7 16.9 3.2 4.8
16 Grafted 0.6 – – – – − − − −
3 16 Nongrafted 2.4 2.1 6.8 −0.6 −0.1 13.6 13.0 6.6 1.9
17 Nongrafted 1.9 2.1 6.2 −0.3 0.6 14.3 13.2 6.9 2.1
26 Grafted 2.2 4.5 6.8 −0.3 −1.3 11.3 12.5 2.5 1.8
27 Grafted 2.4 3.9 8.0 0.1 0.3 12.1 11.5 3.1 1.4
4 16 Nongrafted 2.3 2.7 5.3 −0.2 −1.9 12.4 12.8 4.6 2.4
26 Grafted 3.6 3.3 5.6 −1.0 −2.9 12.0 14.1 3.6 2.5
27 Grafted 3.5 3.1 6.6 −0.9 −1.6 10.3 11.4 3.3 1.7
5 16 Grafted 2.7 4.2 6.9 −0.1 −0.4 14.1 14.1 3.4 2.1
17 Grafted 2.0 3.4 8.0 −0.1 1.0 13.2 12.6 3.9 1.6
6 16 Grafted 2.8 4.1 6.9 −1.0 −0.6 15.0 15.0 3.7 2.2
17 Grafted 1.6 2.8 7.7 −0.2 0.7 16.0 16.1 5.8 2.1
26 Nongrafted 2.7 2.9 7.2 −1.6 −0.5 12.7 12.6 4.3 1.7
27 Nongrafted 1.7 3.2 5.7 −0.4 0.1 12.7 12.1 4.0 2.1
7 16 Nongrafted 2.1 4.2 – −1.3 – 12.7 − 3.0 −
17 Nongrafted 3.0 6.6 5.5 −0.6 −1.8 12.8 14.2 2.0 2.6
8 16 Grafted 2.3 3.4 7.9 −0.6 −0.5 13.0 12.4 3.8 1.6
17 Grafted 1.6 2.3 7.7 −0.4 −0.3 12.2 11.8 5.3 1.5
26 Nongrafted 1.8 1.7 7.8 −0.7 0.5 13.2 11.6 7.8 1.5
27 Nongrafted 1.4 1.6 6.2 −0.4 −0.6 14.9 13.8 9.3 2.2
9 25 Grafted 2.4 3.6 7.2 −0.8 −1.0 12.4 11.9 3.5 1.6
26 Grafted 2.6 3.1 7.2 −0.3 0.8 13.7 14.2 4.5 2.0
10 15 Nongrafted 3.8 4.5 8.0 0.0 0.7 13.1 13.5 3.0 1.7
16 Nongrafted 2.4 2.7 7.3 −0.2 0.3 12.8 12.7 4.7 1.7
25 Grafted 2.1 4.0 7.1 −0.7 −1.3 13.7 13.6 3.4 1.9
26 Grafted 1.4 3.4 8.0 −0.1 0.7 12.3 12.3 3.7 1.5
11 16 Grafted 3.7 5.2 7.8 −0.7 0.2 15.3 14.9 3.0 1.9
17 Grafted 2.2 5.1 7.4 −0.8 0.3 16.5 15.8 3.2 2.1
26 Nongrafted 4.2 4.8 6.5 −1.2 −0.7 13.8 13.1 2.9 2.0
27 Nongrafted 4.0 5.0 5.9 −1.0 −1.4 14.5 14.5 2.9 2.5
12 15 Nongrafted 3.9 4.2 6.2 −1.5 −2.1 14.0 14.3 3.4 2.3
16 Nongrafted 3.3 4.3 6.2 −1.4 −0.9 13.6 13.3 3.2 2.1
26 Grafted 2.7 3.0 6.1 −0.7 −1.8 13.6 14.0 4.6 2.3
27 Grafted 2.1 – – – – − − − −
Mean 2.6 3.6 6.7 −0.6 −0.6 13.4 13.5 4.2 2.1
SD 0.9 1.1 1.0 0.5 1.2 1.3 1.4 1.5 0.6
Mean Grafted 2.4 3.7 7.0 −0.5 −0.7 13.3 13.6 3.8 2.0
SD 0.8 0.8 1.1 0.4 1.4 1.6 1.7 0.8 0.8
Mean Nongrafted 2.7 3.5 6.4 −0.7 −0.6 13.6 13.4 4.6 2.1
SD 0.9 1.3 0.9 0.5 0.9 0.9 1.0 2.0 0.4
aFDI implant numbering system. SD = standard deviation.

the time of loading and 5 years (P < .001). At 5 years, 11
implants that were grafted and 4 implants that were
not grafted showed at least one side that was embed-
ded completely in newly formed bone.
The mean change in crestal bone level showed no
significant difference between the implant groups
(P = .134 at loading; P = .527 at 5 years). Furthermore, it
did not change significantly between the time of load-
ing and 5 years (P = .696).
The mean overall crown length was 13.4 ± 1.3 mm at
loading and 13.5 ± 1.4 mm at 5 years (P = .319) without
significant difference between grafted and nongraft-
ed sites (P = .686 at loading and P = .445 at 5 years).
Hence, at loading, the mean crown-to-implant ratios

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for implants placed in grafted and nongrafted sites
were 3.8 ± 0.8 and 4.6 ± 2.0, respectively, with a range
of 2.0 to 9.3 (P = .033). At 5 years, they were 2.0 ± 0.8
and 2.1 ± 0.4, respectively, with a range of 1.4 to 4.8
(P = .341). There was a significant difference in mean
crown-to-implant ratio measured at loading and 5
years after placement (P = .002). The mean decrease
in crown-to-implant ratio was 1.7 for the grafted sites
and 2.6 for the nongrafted sites. Seven implants placed
in grafted sites and 10 in nongrafted sites presented a
5-year crown-to-implant ratio ≥ 2. Only two implants
(patient 2, maxillary right second premolar implant in
grafted site; patient 7, maxillary right second molar
implant in nongrafted site) showed a large increase in
crown-to-implant ratio between the prosthetic period
and the 5-year control. These two patients showed a
worsening of their periodontal condition, although
they had been successfully treated prior to implant
placement. The mean 5-year crestal bone loss around
these implants was high: −4.3 mm for patient 2 and
−1.8 mm for patient 7.
DISCUSSION
The present study provides an evaluation of the crown-
to-implant ratio over 5 years after implant placement in
grafted and nongrafted sites of the atrophic posterior
maxilla. All patients were recruited using wide inclusion
criteria, reflecting the usual current practice encoun-
tered in private dental offices. The protocol was tailored
to serve the study, particularly by restoring implants
with single crowns and by avoiding the placement of
provisional restorations. An especially low range of
residual bone height was set at ≤ 4 mm. No minimal
height was considered. The purpose of this inclusion
criterion was to evaluate the feasibility of OSFE in ex-
treme cases.8 Although tapered implants were used to
improve initial stability, two implants were mobile 1 to 2
months after placement and failed. These failures were
attributed to the implant sites, composed of fused corti-
ces, regardless of the presence of filling material.8
The low residual bone height conferred an unfa-
vorable initial crown-to-implant ratio (mean value:
4.2 ± 1.5). However, OSFE allowed the formation of
bone within the sinus even where the site was not
grafted. The mean gain in endo-sinus bone was
3.8 ± 1.0 mm for the implants placed in nongrafted
sites and 4.8 ± 1.2 mm in grafted sites after 5 years.10
Hence, the mean osseointegrated implant length was
sufficient to allow implants to perform successfully
over 5 years of functional loading. The mean crown-to-
implant ratio was 4.2 at the time of loading but reached
2.1 after 5 years with the increase of the endo-sinus
bone along the implants. Seventeen implants showed
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Nedir et al
a crown-to-implant ratio ≤ 2 and 14 implants between
2 and 2.5. Two cases of extensive crestal bone loss were
recorded around two implants in patients who did not
strictly attend the appointments for dental hygiene
and maintenance care. This led to one late implant
failure. This further illustrates that implant placement
in atrophic bone should be performed only in patients
who maintain good oral hygiene.11
It should be pointed out that most previously
published studies of crown-to-implant ratio were
retrospective. They reported only one value for the
crown-to-implant ratio taken at a particular time, main-
ly at prosthesis placement. Moreover, no studies of the
evolution of the crown-to-implant ratio over time were
found in the literature. A specific feature of the pres-
ent study was the reporting of two measurements of
crown-to-implant ratio, the first at the prosthetic step
and the second at the 5-year examination. Most stud-
ies used the so-called “anatomical” and/or “clinical”
crown-to-implant ratio. In both types, the measure-
ment of implant length starts from the apex of the im-
plant because, in standard placement, the implant is
generally totally endosseous. In the present study, the
reported crown-to-implant ratios considered chang-
es at both the crestal and endo-sinus bone levels.
Measurement of crown length took into account the
change in crestal bone level.12,13 The implant length
was regarded as only the part of the implant that had
become integrated into the bone. It corresponded to
the bone anchorage height measured from the crestal
bone to the apical bone juxtaposed to the implant. The
protruding part of the implant within the sinus was not
considered to be osseointegrated.
Some authors report that the crown-to-root ratio of
natural teeth (ie, 1:2 to 1:1) should not be extrapolat-
ed to all cases of implant-supported restorations.14,15
Blanes et al reported an overall clinical crown-to-
implant ratio of 1.77 ± 0.56 in posterior regions.12
Rokni et al described an anatomical crown-to-implant
ratio of 1.5 ± 0.4 (range: 0.82 to 3.24) for 199 implants,
with 78.9% of the implants between 1.1 and 2.0.15
Birdi et al16 and Anitua et al17 measured mean ratios of
2.0 ± 0.4 (range: 0.9 to 3.2) and 1.82 ± 0.42 (range: 1.04
to 3.31), respectively, for implants ≤ 8.5 mm long. The
mean crown-to-implant ratio reported by Malchiodi
et al18 was 2.08 ± 0.80 (range: 0.95 to 4.80). It should
be noted that no value was as high as that obtained in
the present study at the time of loading. At 5 years, the
values of crown-to-implant ratio were consistent with
those found in the literature and could be considered
promising for maintaining appropriate biomechanical
conditions and implant function.
The posterior maxilla region may be at higher risk
for implant complications because of increased occlu-
sal forces. For this reason, implants ≤ 10 mm long have
Nedir et al
been recommended only when two or more implants
were placed and rigidly splinted by the restoration.19
However, implants with an internal conical interface
were reported to improve marginal tissue response
and resistance to micromovement under bending mo-
ments. With such a design and a rough surface, these
implants could be suited to unsplinted restorations in
posterior regions.20 The present study used implant-
supported single crown restorations. In this case, stress
was exerted individually on each implant without re-
distribution to adjacent implants, unlike with splinted
restorations. The main reason for single-crown resto-
rations was to measure the crown-to-implant ratio vs
bone levels around each implant without any influence
on adjacent implants. In the present study, no implant
had preexisting adjacent dentition bilaterally, which
may influence the distribution of the force and may be
beneficial for the implant.21 All were multiple single im-
plants. The regenerated bone within the sinus, grafted
or not, was able to withstand masticatory strains ex-
erted on the implant/single crown system. Among the
35 restored implants, only one prosthetic complication
occurred in the present study. The relationships be-
tween the crown-to-implant ratio and complications of
restorations have not yet been clarified.22,23
The main limitation of the present study was the low
number of studied implants. Furthermore, study specif-
ics were tailored to serve data analysis and to validate
the objectives. They could serve as a model, to be used
in conjunction with the technique of sinus elevation
with osteotomes, but caution must be exercised before
such a protocol can be brought into general use.
CONCLUSIONS
This study resulted in a high 5-year survival rate for re-
stored implants placed in grafted and nongrafted max-
illary sites with ≤ 4 mm residual bone height. Within the
limitations of the study and despite the low initial bone-
to-implant contact height, location (posterior maxilla),
and use of nonsplinted restorations, no influence of the
crown-to-implant ratio was observed. The mean initial
crown-to-implant ratio was high, 4.2 ± 1.5 at the pros-
thetic step. After 5 years, it changed to 2.1 ± 0.6. The use
of grafting material does not seem to be necessary to
rehabilitate a severely atrophic posterior maxilla with
OSFE and simultaneous implant placement.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the International Team for
Implantology (ITI) Foundation for its financial support (grant no
428/2005). They have no conflicts of interest to declare.
1236 Volume 34, Number 5, 2019
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