SYSTEMATIC REVIEW

The influence of crown-to-implant ratio in single crowns on

clinical outcomes: A systematic review and meta-analysis
Eduardo Piza Pellizzer, DDS, MS, PhD,a Jéssica Marcela de Luna Gomes, DDS, MS,b
Cleidiel Aparecido Araújo Lemos, DDS, MS,c Lurian Minatel, DDS,d João Pedro Justino de Oliveira Limírio, DDS,e
and Sandra Lúcia Dantas de Moraes, DDS, MS, PhDf

Implant-supported restora- ABSTRACT

tions are an established treat-
ment for completely or
partially edentulous patients.1
However, clinicians must plan
treatment according to the
amount of vertically and hori-
zontally available bone, the
presence of anatomical fea-
tures (including the maxillary
sinus and mandibular nerve),
and region of rehabilitation,
among others, to achieve
long-term, stable treatment.2
Short implants can be
considered to simplify treat-
ment with lower morbidity
compared with bone aug-
mentations methods.3 How-
ever, short implants will
increase the crown-to-implant
(C/I) ratio compared with
conventional implant lengths.4
Thus, longer lever arms with
higher C/I ratios will apply nonaxial force causing more
stress to the peri-implant bone, a higher rate of implant
failures, and prosthetic complications. However, a
Statement of problem. A consensus about the effect of crown-to-implant (C/I) ratio in single
crowns regarding the implant survival rate and marginal bone loss (MBL) is lacking.
Purpose. The purpose of this systematic review and meta-analysis was to evaluate the influence of
C/I ratio in implant-supported single crowns on clinical outcomes.
Material and methods. The search was made in the PubMed/MEDLINE, Scopus, and the Cochrane
Library databases following the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses criteria and registered with the International Prospective Register of Systematic Reviews
(PROSPERO: CRD42018095711). The focused question was “Does the crown-to-implant ratio
influence clinical outcomes for implant-supported single crowns?”
Results. Five direct comparative studies were included (C/I ratio 1 or >1, or 2 or >2), including a
total of 262 participants with a mean age of 54.5 years. The meta-analysis comparing C/I ratio
between 1 or >1 revealed no significant differences (P=.18; risk difference:-0.05; 95%
confidence interval: -0.11 to 0.02) in terms of implant survival rate; the same was true for C/I
ratio between <2 or 2 (P=.05; risk difference:-0.06; 95% confidence interval: -0.12 to -0.00), both
analysis were made with a mean follow-up period was 36 months. The mean MBL was
calculated based in the qualitative data for each C/I ratio: 1 (0.15 mm [-0.34 to 0.34]); >1 (0.07
mm [-0.29 to 0.22]); <2 (1.32 mm [0.38-0.9]); and 2 (1.37 mm [-0.02 to 0.91]). The qualitative
data reported that the most common mechanical complication was screw loosening, and the
most common biological complication was peri-implantitis.
Conclusions. The meta-analysis revealed no relationship between categories of C/I ratio for
implant survival rate. The qualitative data also suggested that MBL increased as the C/I ratio
increased. (J Prosthet Dent 2020;-:---)
consensus regarding the effect of C/I ratio on these
outcomes is lacking because some studies4,5 have re-
5
ported no differences when evaluating different C/I

Supported by the National Council for Scientific and Technological Development (CNPq) #grant 306288/2016-8.
a
Full Professor, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.
b
Postgraduate student, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.
c
Postgraduate student, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.
d
Postgraduate student, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.
e
Postgraduate student, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.
f
Adjunct Professor, Faculty of Dentistry, Pernambuco University (UPE), Camaragibe, Brazil.

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2 Volume
Clinical Implications
Direct comparative studies found that C/I ratio does
not influence survival but may increase marginal
bone loss. Thus, this should be taken into
consideration, especially when short implants are
used in a region with lower bone density, as this
impacts the long-term treatment outcome.
ratios.4,5 In addition, although previous systematic re-
views6-8 have evaluated the influence of C/I ratio, a
systematic review based only on studies that made a
direct comparison is lacking. Therefore, the purpose of
this systematic review and meta-analysis was to evaluate
the influence of C/I ratio in single crowns on clinical
outcomes. The review question was Does the crown-to-
implant ratio influence clinical outcomes in single-unit
crowns?
MATERIAL AND METHODS
This systematic review followed the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
(PRISMA) checklist. The study was registered with the
International Prospective Register of Systematic Reviews
(PROSPERO, CRD42018095711).
The review question, established by the eligibility
criteria, was “Does the crown-to-implant ratio influence
clinical outcomes in single-unit crowns?” The population
were participants rehabilitated with implant-supported
single crowns; the intervention C/I ratio of crowns 1
or 2, compared with <1 or 2. The outcomes were implant
survival rate (primary) and marginal bone loss
(secondary).
Inclusion criteria were randomized controlled trials
(RCTs), prospective studies, and studies that performed a
direct comparison of the effect of C/I ratio in the same
study. Exclusion criteria were retrospective studies, case-
series, case reports, animal studies, in vitro studies, and
studies with only a comparative group.
The searches were performed by 2 reviewers (E.P.P.,
J.M.L.G.), independently; when there was disagree-
ment, a third reviewer (S.L.D.M.) was consulted. The
databases included were MEDLINE/PubMed, Scopus,
and The Cochrane Library, and a manual search was
performed in dental journals with a scope that included
dental implantology and prosthodontics. The search
was performed by using the keywords: (dental implant)
AND (crown-to-implant ratio OR crown implant ratio
OR crown-implantratio OR crown ratio OR crown-to-
rootratios OR crown-implant OR C-I ratio), combined
by Boolean operator.
One author (C.A.A.L.) collected the data from the
articles and were checked by 2 other authors (L.M.,
THE JOURNAL OF PROSTHETIC DENTISTRY
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J.P.J.O.L.). An inter-examiner test (Kappa [K]) was used
to evaluate the agreement between searches by each one
of the reviewers. The K values were obtained
for MEDLINE/PubMed (K=0.89), Cochrane (K=1), and
Scopus (K=0.86).
Two authors (C.A.A.L., J.P.J.O.L.) performed risk of
bias analysis on the included RCTs using the Cochrane
risk of bias tool,9 verifying selection, performance, attri-
tion, reporting, and other biases. The Newcastle-Ottawa
scale (NOS)10 was used for nonrandomized studies. The
NOS verifies 3 elements: selection, comparability, and
outcome for cohort studies. The scale classifies studies
with a maximum of 9 stars, being >6 stars indicate a low
risk of bias and scores  5 stars indicate a high risk of
bias.
The meta-analysis was based on the inverse variance
method.9 The implant survival rate was the outcome
measure evaluated according to risk difference (RD) with
corresponding 95% confidence interval (CI) (a=.05). As
the meta-analysis revealed significant heterogeneity
(P<.10), a random-effects model was adopted, whereas
the fixed-effect model was used when heterogeneity was
not statistically significant. A software program (Reviewer
Manager v5; Cochrane Group) was used for the meta-
analysis.
RESULTS
The database search identified 3101 studies, including
1484 from PubMed/MEDLINE, 1518 from Scopus, and
99 from The Cochrane Library. Duplicates were removed.
After evaluation of titles and abstracts, 37 full-text articles
were selected for eligibility criteria assessment (Fig. 1).
After the articles were read, 18 were excluded (Table 1).
Five studies (1 RCT and 4 prospective studies) were ul-
timately included with a total of 262 participants (mean
age 54.5 years) and a 36-month follow-up. A total of 369
implant-supported single crowns were evaluated with a
mean follow-up period of 36 months. The C/I ratio
evaluated in the included studies varied from 1
compared with >15,21,22 and <2 compared with 2.5,23,24
Three studies21,22,24 evaluated the clinical C/I ratio,
whereas 2 assessed the clinical and anatomical C/I ra-
tios5,23; thus, in the present study, data collected from the
clinical C/I ratio were considered. Characteristics of the
included studies are reported in Table 2.
All included studies5,21-24 investigated implants with
an internal connection. The retention systems were
cement-retained 21,23,24 and screw-retained,22 and one
study used both.5 The shortest implant used had 6.0 mm
length, whereas the longest had 10 mm length. Only 2
studies reported the implant diameter (4.1 mm10 and
5 mm22).
Most of the studies evaluated the posterior region in
both jaws, except the study by Ghariani et al21 which
Pellizzer et al
- 2020 3

Records identified through Additional records identified

Identification
database searching through other sources
(n=569) (n=0)

Records after duplicates removed

(n=367)
Screening

Records screened Records excluded

(n=202) (n=186)

Full-text articles assessed Full-text articles excluded

for eligibility (n=11)
(n=16)
Eligibility

Studies included in
qualitative synthesis
(n=5)
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n=4)

Figure 1. Study design.

Table 1. Reason for study exclusion

Reason References
Without investigation data Anitua et al11; Lee et al12; Hingsammer et al13; Malchiochi et al4; Malchiochi et al14; Mendoza-Azpur15; Sahramann et al16;Tawil
et al17; Villarinho et al18
Same design and population Malchiochi et al14; Malchiochi et al4; Rossi et al19; Rossi et al20

evaluated only the mandible. The antagonist arch (teeth
or implant-prostheses) was reported only in the study by
Naenni et al.22
Meta-analysis revealed that implant survival for
implant-supported single crowns comparing C/I ratio 1
with >1 reported no significant difference (RD -0.05 [95%
CI -0.11 to -0.02]; P=.18) (Fig. 2). The implant survival
rate for implant-supported single crowns comparing C/I
ratio <2 or 2 reported no significant difference (RD
-0.06 [95% CI -0.12 to 0.00]; P=.055) (Fig. 3).
Meta-analysis was not performed for marginal bone
loss because of insufficient data. The mean marginal
bone loss, however, was calculated for each C/I ratio 1
(0.15 mm [-0.34 to 0.34]); >1 (0.07 mm [-0.29 to
0.22]); <2 (1.32 mm [0.38-0.9]); and 2 (1.37 mm [-0.02
to 0.91]), indicating that increases in C/I ratio increased
the mean values of marginal bone loss.
Complications were reported in only 2 studies22,24
reporting similar mechanical complications (minor chip-
ping and screw loosening); the biological complication
was peri-implantitis.24 Thus, there was a lack of infor-
mation to make complications (mechanical and biolog-
ical) a secondary outcome.
The risk of bias to the RCT study22 was assessed by
using the Cochrane Risk of Bias Scale. Low risk of bias
was identified in sequence generation, incomplete
outcome data, selective outcome reporting, and other
sources of bias. Studies that did not explicitly describe the
blinding of participants, personnel, and outcome asses-
sors had a high risk of bias (Table 3).22 The other pro-
spective studies5,9,21,22 were analyzed by using the
Newcastle-Ottawa risk of bias tool, and all studies pre-
sented a low risk of bias for selection, comparability, and
outcome assessment (Table 4).

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Table 2. Characteristic of included studies

Outcomes
Study Patients Mean Follow-up Prosthesis Implant Short Implant Mean Crown-to Marginal Bone Implant Survival
Author/Year Type (n) Age (y) (mo) Type (n) Length (mm) Implant Ratio Loss (mm) Rate (%)
Blanes et al, Prospective 83 N.R. 12 Single G1: 8 d G1: 0-0.99 G1: -0.34 ±0.27 G1: 100%
2007 crown G2: 133 G2: 1-1.99 G2: -0.03 ±0.15 G2: 100%
G3: 51 G3: 2 G3: -0.02 ±0.26 G3: 94.1%
Ghariani et al, Prospective 12 N.R. 12 Single G1: 7 6 G1: <2 G1: 0.944 G1: 100%
2016 crown G2: 5 G2: 2 G2: 0.918 G2: 100%
Hadzik et al, Prospective 30 45.5 36 Single G1: 15 6 G1: 1 G1: 0.34 ±0.24 G1: 100%
2018 crown G2: 15 G2: >1 G2: 0.22 ±0.46 G2: 100%
Mangano Prospective 51 59.8 60 Single G1: 39 6.5 G1: <2 G1: 0.38 G1: 100%
et al, 2016 crown G2: 10 G2: 2 G2: 0.48 G2: 90%
Naenni et al, RCT 86 58.2 60 Single G1: 40 6 G1: 1 G1: -0.15 G1: 100%
2018 crown G2: 46 G2: >1 G2: -0.29 G2: 91%

G1, group 1; G2, group 2; NR, not reported; RCT, randomized clinical trial.

≤1 >1 Risk Difference Risk Difference

Study or Subgroup Events Total Events Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
Naenni et al, 2018 0 40 4 46 51.8% –0.09 [–0.18, 0.00]
Hadzik et al, 2018 0 15 0 15 29.3% 0.00 [–0.12, 0.12]
Blanes et al, 2007 0 8 0 133 18.9% 0.00 [–0.15, 0.15]

Total (95% CI) 63 194 100.0% –0.05 [–0.11, 0.02]

Total events 0 4
Heterogeneity: Chi2=1.70, df=2 (P=.43); I2=0%
Test for overall effect: Z=1.35 (P=.18) –1 –0.5 0 0.5 1
Favorable [≤1] Favorable [>1]

Figure 2. Forest plot for implant survival rate for implant-supported single crowns comparing C/I ratio 1 with >1 (RD -0.05 [95% CI -0.11 to -0.02];
P=.18). C/I, crown-to-implant; CI, confidence interval; RD, risk difference.

DISCUSSION or biological). The location of the fulcrum arm for clinical

Implant-supported single crowns with short implants
may confer a higher risk for clinical complications
compared with other types of rehabilitative strategies
because of challenges in planning the treatment, so to
avoid overloading in single-unit prostheses the
maximum C/I ratio was established at 1:1.24 However,
this ratio was not corroborated in the present study
because the meta-analysis indicated no difference for
implant survival rate between C/I ratios comparing 1
with >1 and <2 with 2. Different reasons may
contribute to the high survival rate independent of C/I
ratio, including the improvement of implant surfaces for
short implants (6.0-6.5 mm) to maintain function and
stability.21
All included studies5,21-24 used internal connections
that, compared with external connections, improve stress
distribution across the bone tissue and minimize the risk
for complications.25,26 However, the results could be
different if the included studies assessed other type of
implant connection. For example, it has been reported
that external connection are related to a decrease in
clinical success with increased C/I ratio.25,26
The distribution of masticatory forces will be different
according to the type of C/I ratio (clinical and anatomical
C/I ratio is on the crest bone but on the implant shoulder
for the anatomical C/I ratio. All data in this systematic
review were from the clinical C/I ratio and reflects the
clinical reality, being the implant survival rate influenced
by increase in bone loss.5 Only 2 studies5,13assessed both
types of C/I ratio and reported similar implant survival
rates.
The secondary outcome was based in qualitative data
collected from the included studies. Insufficient data from
the included studies did not permit meta-analysis. The
qualitative results of this systematic review reported an
increase in C/I ratio (mean), 1 (-0.15 mm), >1 (-0.07
mm), 2 (1.32 mm), and 2 (1.37 mm), increased marginal
bone loss. A complete bone-to-implant interface in short
implants (6.0 mm) is essential to resist tensile forces
when nonaxial forces are applied.26 The increase in bone
loss will increase the length of the lever arm in the bone
crest, which may result in loss of the rehabilitation.26,27
Incorrect distribution of occlusion contact can cause
loads at the crest bone.27 Other studies25,28 reported that
the solution for a decrease the marginal bone loss related
to C/I ratio is the installation of short implants (6 mm) or
extra-short implants (<5 mm) with a wider diameter
(5 mm).25,28 However, these data were not assessed in
the included studies.

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<2 ≥2 Risk Difference Risk Difference

Study or Subgroup Events Total Events Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
Blanes et al, 2007 [0-0.99] 0 8 3 51 13.0% –0.06 [–0.22, 0.11]
Blanes et al, 2007 [1-1.99] 0 133 3 51 74.1% –0.06 [–0.13, 0.01]
Ghariani et al, 2016 0 7 0 5 4.6% 0.00 [–0.28, 0.28]
Mangano et al, 2016 0 39 1 10 8.3% –0.10 [–0.31, 0.11]

Total (95% CI) 187 117 100.0% –0.06 [–0.12, –0.00]

Total events 0 7
Heterogeneity: Chi2=0.33, df=3 (P=.96); I2=0%
Test for overall effect: Z=1.97 (P=.05) –0.2 –0.1 0 0.1 0.2
Favorable [Experimental] Favorable [Control]

Figure 3. Forest plot for implant survival rate for implant-supported single crowns comparing C/I ratio <2 or 2 (RD -0.06 [95% CI -0.12 to 0.00];
P=.055). C/I, crown-to-implant; CI, confidence interval; RD, risk difference.

Table 3. Risk of bias of randomized controlled trials-Cochrane Scale

Domains Naenni et al, 2018
Sequence generation YES
Allocation concealment UNCLEAR
Blinding of participants, personnel, and outcome assessors NO
Incomplete outcome data YES
Selective outcome reporting YES
Other sources of bias YES

Table 4. Risk of Bias-Newcastle Ottawa for prospective studies

Selection Comparability Outcome
Exposed NoneExposided Ascertainment Outcome of Interest Not Main Additional Assessment of Follow-Up Adequacy of
Studies Cohort Cohort of Exposure Present at Start Factor Factor Outcome Long Enough Follow-Up Total
Blanes et al, ✰ ✰ ✰ ✰ ✰ ✰ ✰ ✰ ✰ 9
2007
Ghariani ✰ ✰ ✰ ✰ ✰ ✰ ✰ ✰ ✰ 9
et al, 2016
Hadzik et al, ✰ ✰ ✰ ✰ ✰ ✰ ✰ ✰ ✰ 9
2008
Mangano ✰ ✰ ✰ ✰ ✰ ✰ ✰ ✰ ✰ 9
et al, 2016

Quaranta et al8 reported that increased C/I ratio
increased the risk for mechanical complications (screw
loosening, decementation, ceramic chipping).8 However,
because only 2 studies reported on the subject,22,24 a low
number of complications (mechanical and/or biological)
were observed,22,24 and no consensus was reached.
Differences between the present and previous8,27 re-
views included that, in the present review, all included
studies addressed direct comparisons between groups to
reduce the risk of bias, making a meta-analysis possible.
This was consistent with the results of low risk of bias
assessed by using the scales (Cochrane and New-
Castle).21,22 Furthermore, the authors are unaware of a
previous review that addressed implant survival rate as
the primary outcome or included all the clinical outcomes
in a single study.
Limitations of the present investigation included the
low number of comparative studies which did not pro-
vide sufficient data to make a meta-analysis of the
secondary outcome (marginal bone loss). Thus, the
analysis of the secondary outcome was based in the
qualitative data. Therefore, the results must be inter-
preted with caution, and further studies with comparator
groups are warranted.
CONCLUSIONS
Based on the findings of this systematic review and
meta-analysis, the following conclusions were drawn:
1. No relationship was found between C/I ratio and
implant survival.
2. The qualitative data also suggested that MBL
increased as the C/I ratio increased.
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Corresponding author:
Dr Jéssica Marcela de Luna Gomes
Department of Dental Materials and Prosthodontics
Aracatuba Dental School
Sao Paulo State University (UNESP)
Jose Bonifacio St., 1153
Vila Mendonca, Aracatuba, Sao Paulo
BRAZIL
Email: jessicamgomes@hotmail.com
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.06.010
Pellizzer et al