Long-term Outcomes of Immediate Loading of Short

Implants: A Controlled Retrospective Cohort Study

Eduardo Anitua, DDS, MD, PhD1/Javier Flores, DDS2/Carlos Flores, DDS2/
Mohammad Hamdan Alkhraisat, DDS, PhD2

Purpose: Short implants (≤ 8.5 mm in length) have presented predictable outcomes. However, there is
paucity in the long-term evaluation of immediate loading of short implants. The objective of this study
was to assess the effect of the immediate loading of short implants on treatment outcomes. Materials
and Methods: Patients having short implants inserted before December 2010 that were immediately
loaded were selected. A database was then created to include the patient’s data as well as implant- and
prostheses-related outcomes. Long implants inserted at the same surgery and immediately loaded by the
same prosthesis formed the control group. The proximal bone loss and the survival rates of implants and
prostheses were assessed. Results: Forty-nine short and 38 long implants were placed in 30 patients.
The mean follow-up time was 5.2 ± 0.8 years after loading, and three implants (two short and one long)
failed. The differences in marginal bone loss and implant survival between short and long implants were not
statistically significant. Three prosthetic complications occurred. Two prostheses failed, and the survival rate
was 95.8%. Conclusion: The immediate loading of short implants is not a risk factor for treatment success.
This could be related to the good bone quality and the achievement of adequate primary stability. Int J Oral
Maxillofac Implants 2016;31:1360–1366. doi: 10.11607/jomi.5330

Keywords: dental prosthesis, immediate loading, implant survival, marginal bone loss, short dental implants

T he osseointegration of dental implants is a desir-

able foreign body reaction to the titania surface
that is governed by the bone type and implant prima-
ry stability.1 Adequate primary stability prevents ex-
cessive implant micromovements and ensures healthy
bone remodeling toward osseointegration.2 Several
studies have indicated that the tolerated threshold of
micromovements is between 50 and 150 µm.3–7 This
understanding has initialized the study of shortening
the waiting time before implant loading.
Since the first publication on immediate loading of
dental implants, an increasing number of research and
systematic reviews have been published. In 2000, a
review of the available clinical and experimental stud-
ies accepted the idea of immediate implant loading
and recommended the type of fixation that minimizes
the implant micromovements.8 In a Cochrane review,
1Private Practice in Oral Implantology, Eduardo Anitua
Foundation, Vitoria, Spain; Clinical Researcher, Eduardo
Anitua Foundation, Vitoria, Spain.
2Clinical Researcher, Eduardo Anitua Foundation, Vitoria,
Spain.
Correspondence to: Dr Eduardo Anitua, Eduardo Anitua
Foundation, C/ Jose Maria Cagigal 19, 01007 Vitoria, Spain.
Email: eduardoanitua@eduardoanitua.com
©2016 by Quintessence Publishing Co Inc.
Esposito et al concluded that immediate implant load-
ing does not present a higher failure index for implants
and prostheses during the first year.9 Crestal bone loss
is lower for immediately loaded implants, although the
differences with conventional loading have not been
statistically significant.9 The review found a correla-
tion between implant failure and the implant inser-
tion torque. A recommendation of an insertion torque
higher than 35 Ncm9 or between 20 and 45 Ncm10 has
been established.
The use of short dental implants may limit the need
for bone augmentation. The predictability of short im-
plants was assessed in a recent survey of randomized
clinical trials of implants placed in an augmented si-
nus.11 Short (length ≤ 8 mm) implants have presented
predictable survival rates and have resulted in intraop-
erative complications that were three times lower than
long implants.11 In a meta-analysis that included four
randomized clinical trials, Nisand et al found similar
survival rates of implants and prostheses when short
dental implants were compared with standard im-
plants placed in vertically augmented bone.12 In an-
other meta-analysis, the 1-year and 5-year cumulative
survival rates of short implants were 98.7% and 93.6%,
respectively.13 The rates for long implants were 98.0%
and 90.3%, respectively.13 No statistically significant
differences were found between the two groups in
success rates, failure rates, or complications.13 Short

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implants placed in posterior partial edentulism pre-
sented a high initial survival rate similar to long im-
plants.14 From all the above, shorter dental implants
may be the preferred treatment in atrophic alveolar
bone, as they have been associated with lower biolog-
ic complications, and decreased morbidity, costs, and
surgical time.11
The predictability of immediate implant loading
and short implants has raised the question of whether
immediate loading of short implants is predictable
as well. To answer this question, short (≤ 8.5 mm)
implants were immediately loaded and periodically
assessed. The null hypothesis was that immediate
loading has no effect on the proximal bone loss and
the survival rate of short implants. The main outcome
was the implant survival. The secondary variables were
the proximal bone stability and the prosthetic compli-
cations and survival.
MATERIALS AND METHODS
STROBE (Strengthening the Reporting of Observation-
al studies in Epidemiology) guidelines were followed
during the preparation of the manuscript.15 The study
was performed in a single center in Vitoria, Spain. The
records were revised retrospectively, and those cases
that met the following criteria were selected:
• Age higher than 18 years
• Placement of short (length ≤ 8.5 mm) implants be-
fore December 2010
• Immediate implant loading within the first 48 hours
after placement
Patients/implants were excluded from the study if
they did not fulfill all the inclusion criteria. No specific
exclusion criteria were established.
The principal outcome was the survival rate of short
implants, and the secondary outcomes were marginal
bone stability, prosthetic complications, and the pros-
thesis survival rate. The short (length ≤ 8.5 mm) im-
plants that fulfilled the inclusion criteria formed the
experimental group, and the long implants (≥ 10 mm)
that were inserted at the same surgery and immedi-
ately loaded by the same prosthesis formed the con-
trol group.
Outcome Assessment
To assess the principal outcome, implants were fol-
lowed clinically and radiographically to identify any
implant failure (implant not physically available at
the time of evaluation). The proximal bone loss was
measured on the most recent radiograph by com-
puter software (Sidexis, Sirona). To do that, linear
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Anitua et al
measurements were calibrated by the known implant
length. Then, the measurement was performed be-
tween the most coronal point of the implant and the
first bone-to-implant contact. As a reference, the bone
margin at the placement of the provisional prosthesis
was considered.
The records were screened for prosthetic complica-
tions (fracture of screw, abutment, implant, or prosthe-
sis; loosening of screw, abutment, or prosthesis; and
fracture/chipping of veneering ceramics). A failure of
the prosthesis was considered if it was replaced by a
new one. These outcomes were described according
to the short implants.
Surgery
Patients received a routine periodontal treatment be-
fore implant surgery. The plan of treatment was set
after clinical examination and the study of the diag-
nostic wax-up and cone beam computed tomography
(CBCT) scans. A surgeon prepared the implant site us-
ing a low-speed drilling procedure (125 rpm) without
irrigation, and the diameter of the last bone drill was
determined according to the bone density (obtained
from a CBCT scan).16,17 The implants were wetted by
Plasma Rich in Growth Factors (PRGF-Endoret, Biotech-
nology Institute BTI). For placing the dental implant,
the surgical motor was set at 25 Ncm, and the implants
were finally seated manually by a calibrated torque
wrench (BTI Biotechnology Institute) to measure the
final insertion torque.
Transepithelial abutments (Multi-Im, BTI Biotech-
nology Institute) were then immediately placed.
A prosthodontist performed the prosthetic reha-
bilitation of the patients. Polyether impression mate-
rial (Impregum Penta, 3M ESPE) and the open-tray
technique were used for impression making. A screw-
retained fixed prosthesis was then placed during the
first 48 hours after implant placement. When the status
(stability and morphology) of peri-implant soft tissue
was acceptable for the prosthodontist, an impression
was made for the construction of a definitive fixed
prosthesis. The occlusal schemes used were maximum
intercuspation for partially edentulous patients and
centric occlusion for completely edentulous patients.
Mutual protection was the occlusal scheme.
The follow-up visits were normally at 1 week, 1, 3,
and 6 months after intervention, and then once a year.
The implant health status and complications were
evaluated clinically and radiographically (panoramic
and periapical radiographs; Fig 1).
Statistical Analysis
Data collection and analysis were performed by two in-
dependent examiners (other than the restorative den-
tist and surgeon). A descriptive statistical analysis of
The International Journal of Oral & Maxillofacial Implants 1361
Anitua et al

a b c
Fig 1   Panoramic radiographs showing (a)
the preoperative clinical situation, (b) the
placement of maxillary and mandibular pro-
visional prosthesis for immediate implant
loading, (c) the placement of a second
provisional prosthesis that splinted all the
inserted implants, (d) the placement of the
definitive prosthesis, and (e) the status of
d e
the implant-supported prosthesis after 5
years of immediate loading. Arrowheads la-
bel the immediately loaded short implants.

of short implants. The implant and prosthesis survival

Table 1 Length and Diameter of Short (≤ 8.5
was assessed by the Kaplan-Meier method. Cox re-
mm) Implants (Experimental Group)
gression analysis compared the implant survival rate
Diameter (mm) between the mandible and the maxilla as well as be-
3.75 4.00 4.25 4.50 5.00 5.50 Total tween the study groups. Windows statistical software
Length (mm) 7.5 4 6 2 0 4 3 19 package (SPSS v15.0; SPSS) was used to perform the
8.5 6 4 2 4 9 5 30 statistical analysis.
Total 10 10 4 4 13 8 49

Table 2 Length and Diameter of the Long

RESULTS
(≥ 10 mm) Implants (Control Group)
In this study, 30 patients participated with 49 short
Length (mm) implants (length ≤ 8.5 mm) and 38 long (length ≥ 10
10.00 11.0 13.0 15.0 Total mm) implants (control group). All implants were insert-
Diameter (mm) 3.00 0 2 1 0 3 ed at the same surgery and were immediately loaded
3.30 1 0 0 0 1 by the same multiunit prosthesis. Eight implants were
3.50 0 1 0 0 1 connected to short implants, 20 to long implants, and
3.75 3 3 3 1 10
21 to short and long implants. The patients’ mean age
was 61 ± 8 years (range: 37 to 75 years) at the time of
4.00 2 2 2 0 6
surgery, and 23 were women. Two patients were mod-
4.50 3 3 0 0 6
erate smokers.
5.00 2 6 2 0 10 The length and the diameter of the short and long
5.50 0 1 0 1 1 implants are shown in Tables 1 and 2, respectively.
Total 11 18 8 1 38 Fourteen short implants were placed in the maxilla
and 35 in the mandible. Figure 2a shows the distribu-
tion of the short implants according to the anatomical
position. Forty-one short implants were placed in pos-
qualitative variables (absolute and relative frequency) terior regions. The positions of the long implants are
and quantitative variables (mean values and standard shown in Fig 2b.
deviations) were performed. According to the variable, There were no statistically significant differences in
the implant or the patient was the unit of analysis. The the type of bone at the implant site nor in the inser-
Shapiro-Wilk test was selected to check the normal dis- tion between the two groups (Table 3). The insertion
tribution of the data. Qualitative variables were com- torque was ≥ 30 Ncm in both groups. The implants
pared by χ2 test. A t test was selected to compare the were followed for 62 ± 10 months (range: 18 to 88
insertion torque between the study groups. The paired months). The follow-up time was ≥ 4 years for 48 short
t test was selected for the comparison of marginal bone implants and ≥ 5 years for 34 short implants.
remodeling. ANOVA analysis was applied to test the ef- Two (5.50 × 8.50 mm) short implants failed (one
fect of antagonist type on marginal bone remodeling in the maxilla and another in the mandible) after 52

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 Anitua et al

6
6
Frequency

Frequency
4
4

2
2

0 0
11 14 15 21 22 23 24 25 26 32 34 35 36 37 42 44 45 46 47 11 13 14 15 21 23 24 25 32 33 34 35 42 43 44 45 47
a Implant position b Implant position
Fig 2   Anatomical location of (a) short (≤ 8.5 mm) implants and (b) long ( ≥ 10 mm) implants. FDI tooth-numbering system.

1.0 1.0
Cumulative survival rate

Cumulative survival rate

0.9 0.9

0.8 0.8

0.7 0.7

0.6 0.6

0 20 40 60 80 100 0 20 40 60 80
a Follow-up time (mo) b Follow-up time (mo)
Fig 3   The cumulative survival rate of (a) short (≤ 8.5 mm) implants and (b) long ( ≥ 10 mm) implants.

and 55 months of loading, respectively. These implants

Table 3 Outcomes of Immediate Loading of
were replacing the mandibular right first molar and
Short (≤ 8.5 mm) and Long Implants
maxillary left second premolar. The implants were sup-
porting a fixed partial denture and a complete fixed Short Long
Variable implants implants P < .05
denture, respectively. The cumulative survival rate of
immediately loaded short implants was 95.9% (Fig 3a). No. of implants 49 38
The Cox regression analysis indicated the absence of Bone type I 4 2 Noa
II 44 36
statistically significant differences in implant survival
III 1 0
between the mandible (97.1%) and the maxilla (92.9%)
Insertion torque (Ncm) 50 ± 13 54 ± 17 Nob
as well as between fixed partial (96.4%) and complete
(95.2%) prostheses. Follow-up time (mo) 62 ± 10 62 ± 10
One long (5.0 × 11.0 mm) implant failed at the po- Implant failure 2 1 Noa
sition of the maxillary left canine. The cumulative sur- Mesial bone loss (mm) 0.56 ± 0.58 1.0 ± 0.9 Yesc
vival rate of the long implants was 97.4% (Fig 3b). It is Distal bone loss (mm) 0.70 ± 0.63 1.2 ± 0.8 Yesc
worth mentioning that a patient with bruxism, having a χ2 test.
a complete fixed prosthesis, had two implant failures: bt test.
c Paired t test.
one short and one long implant. The differences be-
tween short and long implants were not statistically
significant (Table 3).

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Anitua et al
1.0
Cumulative survival rate
0.9
0.8
0.7
0.6
0 20 40
Follow-up time (mo)
Fig 4   The cumulative survival rate of the prostheses.
The measurement of marginal bone loss was per-
formed after 52 ± 18 months of loading. The time was
≥ 4 years for 36 short implants. The mesial and distal
bone losses were significantly higher around the long
implants (Table 3).
During the prosthetic rehabilitation, 21 short im-
plants were loaded by a fixed complete denture and 33
by a partial fixed denture. The prostheses were screw-
retained for 47 short implants and cemented for 2
implants. The follow-up time of the definitive prosthe-
ses was 55 ± 11 months (range: 1 to 64 months). Two
prostheses failed after 48 and 51 months of placement,
and the prosthesis survival rate was 95.8% (Fig 4). One
prosthesis was changed due to the removal of one
implant and another due to fracture. Three prosthetic
complications were registered. These complications
were chipping of the prosthetic teeth (one prosthesis),
mastication of buccal mucosa (one prosthesis), and
pyogenic granuloma (one prosthesis). No abutment
screw loosening was registered.
DISCUSSION
The outcomes of this controlled cohort study support
the acceptance of the null hypothesis. The immediate
loading of short implants has not been a risk factor for
proximal bone stability and implant survival. The short
implant and prosthesis survival rates were 95.9% and
95.8%, respectively.
There is a paucity in the studies that assess in de-
tail the outcomes of immediate loading of short im-
plants. Cannizzaro et al reported the 4-year outcomes
of immediate vs early loading of 6.5-mm-long single
implants in a controlled randomized split-mouth clini-
cal trial.18 The insertion torque was > 40 Ncm in both
groups. The implant success rate was 96.7% for both
1364 Volume 31, Number 6, 2016
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groups. In another randomized controlled clinical trial,
the 1-year outcome of immediate loading of 5-mm-
long implants by fixed cross-arch prostheses has been
compared to those of 11.5-mm-long implants.19 The
insertion torque of most of the implants has been >
50 Ncm. Only two failures have occurred in the short
implant group and one in the long implant group. The
differences have not reached statistical significance.
Alvira-González et al placed 7-mm-long implants in
patients with atrophic edentulous free-ends.20 Imme-
diate loading of these short implants has resulted in an
implant survival rate of 96.4% in comparison with de-
layed loading (76.9%). Short implants that have been
60 80
splinted to immediately loaded longer implants have
the highest survival rate (100%).20 In a recent study
about the rehabilitation of the edentulous maxilla,
the survival rate of immediately loaded short implants
(length between 7.0 and 8.5 mm) was 95.7%.21 How-
ever, most of the implants (68 of 74 implants) were
placed at the position of the lateral incisor.21
The outcomes of immediate implant loading are
governed by host-, surgical-, and implant-related fac-
tors.22 Most of the implants in this study were placed
in bone types I and II with a thick cortical bone. In a
randomized clinical trial, significant differences in the
initial implant stability were observed for different
bone types.23 The primary implant stability has been
higher when placed in a denser bone.23 Bone healing
at the implant–cortical bone interface may occur with
little interim formation of woven bone, contributing to
maintain good bone strength around the implant.22,24
The mean insertion torque of the short implants in this
study would minimize the occurrence of excessive mi-
cromovements that jeopardize implant osseointegra-
tion. The use of threaded-type dental implants has also
contributed to enhance implant mechanical retention.
The implant surface in this study was acid-etched and
moderately rough (BTI Biotechnology Institute).25 A
moderately rough implant surface has enhanced im-
plant osseointegration and increased implant second-
ary stability.26–28
Excessive trauma and thermal injury during implant
socket preparation influence implant success.22,29 The
implant site has been prepared by low-speed bone
drilling without irrigation. This drilling protocol has
not caused overheating of bone.17 The good quality
of bone particles that resulted from the drilling at low
speed confirms the absence of bone damage.17,30
Most of the short implants in this study were imme-
diately loaded by metal frame–enforced provisional
prostheses. This form of rigid fixation has been report-
ed to increase the success rate of immediately loaded
implants.31 Splinting of multiple implants has been
shown to reduce lateral forces, improve stress distribu-
tion, and minimize the stress on the implants.32,33

The mean peri-implant marginal bone loss around
the immediately loaded short implants has been less
than 1 mm. The majority of the measurements of bone
loss have been performed after 4 years of loading,
and 41 of 49 implants have been placed in posterior
sectors. Immediately loaded short implants have had
0.4/0.5 mm less marginal bone loss than long implants
(up to 1 year follow-up).19 In another study, the 3-year
marginal bone remodeling for short implants was 1.25
± 0.99 mm.21
This study was limited due to the retrospective de-
sign, and the absence of randomization or blinding. A
1:1 calibration of the panoramic radiograph was per-
formed for proximal bone measurements. This would
reduce the error and make them acceptable for clinical
use.34
CONCLUSIONS
The immediate loading of short implants, supporting a
multiunit prosthesis, is not a risk factor for implant suc-
cess nor for marginal bone stability. Taking measure-
ments that increase the implant primary stability and
minimize implant micromotions would contribute to
the observed outcomes.
ACKNOWLEDGMENTS
Eduardo Anitua is the Scientific Director of BTI Biotechnology
Institute (Vitoria, Spain). He is the head of the Foundation Edu-
ardo Anitua, Vitoria, Spain. Javier Flores and Carlos Flores have
no conflicts of interest. Mohammad Hamdan Alkhraisat is a sci-
entist at BTI Biotechnology Institute (Vitoria, Spain).
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