A Systematic Review and Meta-Analysis On The Effect of Implant Length On The Survival of Rough-Surface Dental Implants

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A Systematic Review and Meta-Analysis on the Effect of Implant Length on

the Survival of Rough-Surface Dental Implants
Article in Journal of Periodontology · November 2009

DOI: 10.1902/jop.2009.090107 · Source: PubMed
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Volume 80 • Number 11
Review
A Systematic Review and Meta-Analysis on the Effect
of Implant Length on the Survival of Rough-Surface
Dental Implants
Sotirios Kotsovilis,* Ioannis Fourmousis,† Ioannis K. Karoussis,† and Christina Bamia‡
Background: A meta-analysis on the survival of short im-

plants compared to conventional implants has never been per-
formed. Therefore, the aim of this study was to address the
focused question ‘‘Is there a significant difference in survival
between short (£8 or <10 mm) and conventional (‡10 mm)
rough-surface dental implants placed in 1) totally or 2) partially
edentulous patients?’’ by conducting a systematic review and
T
meta-analysis of prospective studies published in the dental lit- he placement of dental implants
erature in the English language up to and including August is an efficacious method for the
2007. replacement of missing teeth in
Methods: PubMed and the Cochrane Central Register of totally1,2 and partially3,4 edentulous pa-
Controlled Trials (CENTRAL) databases were scanned elec- tients as documented by systematic
tronically, and seven journals were searched manually. In the reviews.5-9 During the early years of im-
first phase of selection, titles and abstracts, and in the second plant therapy and along the lines of the
phase, full texts, were evaluated autonomously and in duplicate Brånemark protocol,10 the use of im-
by two reviewers. Extensive contact with authors was carried plants with the highest feasible length
out in search of missing, unclear, or unpublished data. was advocated based on the axiom that
Results: The electronic and manual search provided, re- longer implants would exhibit higher
spectively, 1,056 and 14,417 titles and abstracts. In the second survival rates and more favorable prog-
phase of selection, the complete text of 300 articles was exam- nosis.11 However, in many clinical
ined, and 37 articles reporting on 22 patient cohorts were cases, placement of long implants was
selected. Meta-analyses revealed no statistically significant problematic due to limitations, such as
difference in survival between short (£8 or <10 mm) and con- the location of the canal of the inferior
ventional (‡10 mm) rough-surface implants placed in totally alveolar nerve, the pneumatization of
or partially edentulous patients. the maxillary sinus, and alveolar ridge
Conclusions: Within the limitations of this systematic review, deficiencies.12-17
the placement of short rough-surface implants is not a less effi- To overcome such conditions, the cli-
cacious treatment modality compared to the placement of con- nician today often continues to increase
ventional rough-surface implants for the replacement of the height of the alveolar ridge using ad-
missing teeth in either totally or partially edentulous patients. vanced surgical techniques,12-17 such as
J Periodontol 2009;80:1700-1718. guided bone regeneration, block graft-
ing, maxillary sinus floor elevation, and
KEY WORDS distraction osteogenesis, or bypasses
Dental implants; meta-analysis; systematic review. anatomic structures, for instance by al-
veolar nerve transposition.12 Neverthe-
less, these surgical procedures are case
* Private practice, Athens, Greece. sensitive, technically demanding, time
† Department of Periodontology, School of Dentistry, University of Athens, Athens, Greece.
‡ Department of Hygiene, Epidemiology and Medical Statistics, Medical School, University consuming, and might increase the
of Athens. post-surgical morbidity and the total cost
and duration of therapy. The placement
of short implants has been introduced
as an alternative treatment strategy to
doi: 10.1902/jop.2009.090107
1700
J Periodontol • November 2009 Kotsovilis, Fourmousis, Karoussis, Bamia
deviate from advanced surgical techniques.18-20 ‘‘Oral’’) AND ‘‘Implant*’’ AND (‘‘Length’’ OR ‘‘Short’’
There is no consensus in the dental literature on the OR ‘‘Shorter’’).
definition of short implants, which in various reviews Manual search of journals. The following journals
have been considered to have a length £7 mm,18 were searched manually up to and including August
£8 mm,20 or <10 mm.19 2007 for the periods of time shown in parentheses:
For many years, the effect of the length of dental Clinical Oral Implants Research (1990 to 2007); Im-
implants on their short- and long-term prognosis plant Dentistry (1994 to 2007); The International
has been a controversial issue. Some clinicians have Journal of Oral and Maxillofacial Implants (1992 to
inculcated the dogma that short implant length results 2007); International Journal of Oral and Maxillofa-
in reduced bone-to-implant contact, and thus, short cial Surgery (1986 to 2007); The International Jour-
implants would be expected to exhibit lower survival nal of Periodontics and Restorative Dentistry (1991
and/or success rates compared to longer implants. to 2007); Journal of Clinical Periodontology (1981 to
According to another hypothesis, short implants 2007); and Journal of Periodontology (1981 to 2007).
may demonstrate short-term survival and/or success Other data sources. The reference lists of all iden-
rates comparable with those of conventional im- tified articles related to the topic were subjected to
plants, but on a long-term basis, short implants would close scrutiny. The authors attempted to search for
be more likely to fail if peri-implantitis occurred due to the maximum possible number of proceedings of past
the lower quantity of bone support. workshops, position papers, and theses. Whenever
The comprehensive review18 by Hagi et al. was the deemed essential, missing, unclear, or unpublished
first systematic approach to produce the radical reap- data was sought by contact with authors.
praisal that ‘‘clearly, surface geometry (machined
versus rough) plays a major role in performance of en- Inclusion/Exclusion Criteria and Selection
dosseous dental implants of lengths 7 mm or less,’’ of Studies
confirming previous original research reporting that In the first phase of study selection, the titles and ab-
‘‘the rough [. . .] implant surface [. . .] may have com- stracts of all identified publications were screened au-
pensated for the shorter implant length.’’21 Similarly, tonomously and in duplicate by two reviewers (SK and
subsequent systematic reviews19,20 reported compa- IKK) to evaluate their eligibility for selection in this
rable survival rates for short and conventional rough- systematic review on the basis of predetermined in-
surface implants. However, a meta-analysis on the clusion and exclusion criteria.
effect of implant length on the survival of rough-surface
The following inclusion criteria were accepted by all
implants has not been performed.
reviewers:
Therefore, the objective of this study was to address
the focused question ‘‘Is there a significant difference 1) Publications in the dental literature in the English
in survival between short (£8 or <10 mm) and conven- language.
tional (‡10 mm) rough-surface dental implants 2) Only prospective studies.
placed in 1) totally or 2) partially edentulous pa- 3) The presence of at least five patients in each and
tients?’’ by conducting a systematic review and every group of the study and five rough-surface dental
meta-analysis of prospective studies published in implants with lengths <10 mm, as well as at least five
the dental literature in the English language up to rough-surface implants with lengths ‡10 mm (there-
and including August 2007. fore, studies lacking rough-surface implants of con-
ventional length were not eligible for inclusion in
this systematic review).
MATERIALS AND METHODS 4) The report of information on the characteristics
Search Strategy for Identification of Studies of study participants (principally inclusion and/or ex-
Electronic search. The PubMed database of the United clusion criteria) in the text of the study.
States National Library of Medicine and the Cochrane 5) A clear report of (or report of data allowing the
Central Register of Controlled Trials (CENTRAL) of the calculation of) the total number of implants placed/
Cochrane Collaboration were used as electronic data- surviving, either in totally edentulous or partially
bases, and a literature search was accomplished with a edentulous patients for implant lengths a) <10 mm
personal computer on articles published in English up and b) ‡10 mm. In the event of a study comprising
to and including August 2007. Articles available online a mixed population with totally and partially edentu-
in electronic form before their publication in material lous patients, all preceding data had to be provided
form were considered eligible for inclusion in the pres- separately for totally and partially edentulous patients
ent article. either in the published manuscript or after contact
The electronic search was carried out by applying with the authors; otherwise, the study was not in-
the following terms and key words: (‘‘Dental’’ OR cluded.
1701
Short Versus Conventional Implants Volume 80 • Number 11
An implant was defined as surviving if it was not lost. articles with inadequate information in the title and
The definition used in this article was provided by an- abstract to allow a clear assessment, were acquired.
other systematic review,22 according to which the loss Subsequently, these studies were evaluated indepen-
of implants was ‘‘defined as implant mobility of previ- dently and twice by two reviewers (SK and IKK) based
ously clinically osseointegrated implants and removal on the criteria for study selection/exclusion.
of non-mobile implants due to progressive peri-im- If more than one article corresponded to the same
plant marginal bone loss and infection.’’ If the definition clinical study, only the most recent data acceptable
of implant survival or implant loss in an examined under the inclusion/exclusion criteria applied in this
study was different from the definitions applied in this systematic review were used.
systematic review, the study was not included. Any disagreement ensuing among the reviewers
Totally edentulous patients were defined as those would be resolved by discussion. If the divergence
having no natural teeth in either jaw. Any patient persisted, it would be mentioned and analyzed in this
clearly reported in an examined study as totally eden- systematic review.
tulous in one jaw and partially edentulous in the other
jaw was considered to be partially edentulous, even if Data Extraction
regarded as totally edentulous in the original study. If In accordance with previous systematic reviews,23,24
the definitions of a totally edentulous patient and a par- a standardized process of extracting data from studies
tially edentulous patient in an examined study were selected using specially designed data-extraction
clearly different from the definition applied in this sys- forms was performed in duplicate and independently
tematic review, the study was not included. by two reviewers (SK and IKK) regarding the main
6) A clear report of the surface characteristics characteristics (e.g., study design, methods, partici-
(smooth or rough) of implants used. If a study com- pants, interventions, and outcome measures/varia-
prised both smooth- and rough-surface implants, a bles) and outcomes of studies, with particular
clear report of (or report of data allowing the calcula- emphasis on implant survival data. Any other infor-
tion of) the survival of rough-surface implants was mation deemed scientifically interesting was also
mandatory; otherwise, the study was not included. recorded. Authors of studies were contacted for clar-
7) A follow-up period ‡12 months. ification or missing information.
The following exclusion criteria were agreed by all
reviewers: Quality Assessment of Selected Studies
The quality assessment of the selected studies was
1) Studies with an unclear or mixed design (for ex- carried out autonomously and in duplicate by two re-
ample: mixed prospective and retrospective data or if viewers (SK and IKK) using certain criteria proposed
dental implants had been already placed before the in the dental literature.25-27 The unanimously ac-
commencement of the study). cepted criteria for quality assessment were as follows:
2) Smoking (>10 cigarettes/day). A) a clear definition of inclusion and/or exclusion cri-
3) Medical or systemic diseases or conditions po- teria (grading: 0 = no; 1 = yes); and B) completeness
tentially negatively affecting implant survival, such of follow-up (specified reasons for withdrawals and
as malignant tumors or past or current radiotherapy dropouts in each study group) (grading: 0 = no/not
in the cervico-facial area, chemotherapy, leukocyte mentioned/not clear; 1 = yes/withdrawals or dropouts
dysfunction and deficiencies, immunocompromised did not occur).
patients (e.g., positive for human immunodeficiency Agreement between the two reviewers (SK and
virus), and diabetes not under metabolic control. IKK) with regard to quality-assessment scores for
4) Dental implant placement in periodontally com- each quality criterion was determined by the propor-
promised patients without previous implementation tion (%) of inter-reviewer agreement and, likewise, by
of periodontal therapy. k score, which additionally incorporated an adjust-
For all exclusion criteria (1 through 4), contact with ment for the degree of agreement to be expected en-
the authors of studies was carried out before final ex- tirely by chance.28-31 In the event of any discrepancy
clusion. Exclusion of a study based on criteria 2 between the reviewers (SK and IKK), an agreement
through 4 was applied, unless the authors explicitly was reached by discussion; otherwise, the different
stated that these parameters did not correlate to im- assessments of the study quality would be mentioned
plant survival rate or if all implants (100%) in the study and explained in this article.
eventually survived.
In the second phase of selection, the complete ar- Quantitative Data Synthesis (statistical analysis)
ticles of all studies already selected in the first phase, The primary outcome measure/variable was the per-
as well as the full text of articles without abstracts or centage of implants surviving out of the total number
1702
placed. It should be noted that the primary outcome RESULTS

measure was not implant survival rate but, rather, im- Study Selection and Classification (Tables
plant survival risk because total exposure time of each 1 through 3)
and every implant (included in studies selected) was The electronic search in both databases (PubMed and
not available. No secondary outcome measures/var- CENTRAL) provided a total of 1,056 titles and ab-
iables were used. The associations of the survival of stracts that were deemed potentially relevant to the in-
implants with their lengths (short versus conven- fluence of dental implant length on implant survival.
tional) were expressed as risk ratios (RRs). By defini- During the manual search of dental journals, 14,417
tion, RR >1 indicated a higher percentage of surviving titles and abstracts were totally examined.
short implants than conventional implants. In the second phase of study selection, the com-
Publication bias was examined by using the Begg plete text of 300 articles was retrieved and subjected
and Mazumdar’s rank correlation test32 and the Egger re- to close scrutiny. Throughout this procedure, 263 ar-
gression asymmetry test.33 The Begg and Mazumdar’s ticles, corresponding to 220 studies, were excluded
funnel plot of the log RRs versus their standard error (Table 1).
was calculated for studies reporting on short versus Eventually, 37 articles36-72 reporting on 22 patient
conventional rough-surface implants placed in totally cohorts were selected (Tables 2 and 3). These articles
or partially edentulous patients. were further subdivided into two categories according
The pooled RRs from combinations of studies, with to the type of edentulism (total or partial) of their par-
the associated 95% confidence intervals, were ob- ticipants: in 19 articles36-54 reporting on eight patient
tained through meta-analyses performed separately cohorts,36,39,41-43,45,47,49 implant survival data were
for totally and partially edentulous patients. Because provided for totally edentulous patients (Table 2); in
the calculation of RR is undefined if the values of one 23 articles41,45-48,55-72 reporting on 17 patient co-
or more cells in the cross table are equal to zero, 0.5 horts,41,45,47,55-58,63-72 implant survival data were
was added to the values of all cells in such cases, fol- provided for partially edentulous patients (Table 3).
lowing the suggestions by Gart and Zweifel34 and Three studies41,45,47 provided separate survival
Fleiss.35 Heterogeneity among the selected studies data both for totally and partially edentulous patients
was assessed using the Q-statistic test. A random- (Tables 2 and 3).
effects model (DerSimonian-Laird method) of meta-
analysis was used in the presence of heterogeneity Results of Contact With Authors
(P <0.10). All statistical analyses were carried out us- In total, additional information was sought through
ing a commercially available software program.§ electronic mail for 125 articles, and answers were
kindly provided by the authors of 72 articles (57.6%).
Results of Quality Assessment of Selected Studies
With respect to quality criterion A, the first reviewer
(SK) was of the opinion that all 22 selected studies
Table 1.
had clearly defined inclusion/exclusion criteria. Ac-
Number of Studies Excluded After Second cording to the second reviewer (IKK), one study55
Phase of Selection did not have clearly defined inclusion/exclusion crite-
ria (the term ‘‘high-risk conditions’’ was not defined
Inclusion clearly), whereas another study69 had clearly defined
Criterion Exclusion too few inclusion/exclusion criteria, which addition-
Not Studies Criterion Studies ally were too vague and thus failed to provide a suffi-
Fulfilled (n) Fulfilled (n) ciently explicit description of the characteristics of the
study population included; the remaining 20 studies
1 0 1 14 had clearly defined inclusion/exclusion criteria.
2 41 2 4 With respect to quality criterion B, the reasons for
patient withdrawals/dropouts were clearly reported
3 75 3 11 in the published text of the majority of selected stud-
4 0 4 3 ies, with the exception of three studies.55,65,68
The overall proportion of inter-reviewer agreement
5 69 was 90.91% and 95.45% for quality criteria A and
6 2 B, respectively, indicating an ‘‘excellent’’30 level of
agreement in both cases. Concerning quality crite-
7 1 rion A, the calculation of the k score was deemed
Total 188 32
§ Stata/SE 8.0 for Windows, 2003, Stata, College Station, TX.
1703
Table 2.
Main Characteristics and Outcomes of Selected Prospective Studies Including Totally
Edentulous Patients
Surviving/ Surviving/ Surviving/

Follow-Up Placed (%) Placed (%) Placed (%)
(months; Implants Implants Implants
Implant mean With With With
Reference(s) Type [range]) L £8 mm L <10 mm L ‡10 mm Other Information*
Geertman et al., 199636† ‡ 12 19/19† 19/19† 62/63† 1. No statistical comparison between

(Boerrigter et al.. 1995;37 [12 to 12] (100%) (100%) (98.41%) short and conventional implants.
Kwakman et al., 199838) 2. All implants were placed in the
mandible; all short implants survived.
3. Implant-retained overdentures
on two implants using a single
bar clip attachment.
4. No single-tooth implants.
Walmsley and Frame, 199739† § 60 10/13† 15/23† 49/51† 1. No statistical comparison
(Walmsley et al., 199340) [60 to 60] (76.92%) (65.22%) (96.08%) between short and conventional
implants.
2. All implants were placed in the
anterior mandible; survival of short
< conventional implants.
3. Implant-retained overdentures on
2 to 4 implants using magnets as
retentive elements.
Brocard et al., 200041† i 48 35/36† 35/36† 153/172† 1. No statistical comparison between
[12 to 84]† (97.22%) (97.22%) (88.95%) short and conventional implants.
2. Correlation implant survival-
location: only 1 short implant was
lost in a totally edentulous patient
in the posterior maxilla;† thus,
data were not sufficient for
subgroup analysis.
3. a) Implant-retained overdentures
on ‡2 implants using clips as
retentive elements; b) implant-
supported fixed full-arch (complete)
restorations; c) implant-supported
fixed partial restorations (dentures/
bridges) in totally edentulous
patients.†
4. No single-tooth implants
in totally edentulous patients.†
1704
Table 2. (continued)
Edentulous Patients

Meijer et al., 200442† ‡ 107.8 6/6† 6/6† 48/52† 1. No statistical comparison between
[0 to 120]† (100%) (100%) (92.31%) short and conventional implants.
anterior mandible; all short implants
survived.
on 2 implants using a round-shaped
bar and a clip retention system.
43† † † †
Stellingsma et al., 2004 ‡ 24 56/56 56/56 24/24 1. Statistical comparison between
(Stellingsma et al., 200344) [24 to 24]† (100%) (100%) (100%) short and conventional implants not
required/obviously NS.
anterior mandible; all implants
survived.
3. Implant-retained overdentures on
4 short implants using a triple bar
with a clip retention system (study
group III).
45† † † †
Fischer and Stenberg, 2006 i 36 8/8 8/8 34/34 1. Statistical comparison between
(Fischer and Stenberg, [36 to 36] (100%) (100%) (100%) short and conventional implants not
200446) required/obviously NS.
2. All 42 implants were placed
in the maxilla; all implants
survived.
3. Implant-supported fixed full-arch
(complete) restorations on 5 or 6
implants.
47† † † †
Romeo et al., 2006 i 76.8 25/26 25/26 43/44 1. No statistical comparison between
(Romeo et al., 200448) [36 to 168] (96.15%) (96.15%) (97.73%) short and conventional implants.
2. All lost implants had been placed
in type III or IV bone, but their
number was limited; NS.
3. Implant-supported fixed complete
restorations in totally edentulous
patients.†
4. No single-tooth implants
in totally edentulous patients.
1705
Edentulous Patients

Stoker et al., 200749† i 100 60/62† 60/62† 217/221† 1. No statistical comparison between
(Wismeijer, 1996;50 [18 to 118]† (96.77%) (96.77%) (98.19%) short and conventional implants.
Wismeijer et al., 1997,51,52 2. All implants were placed in the
1999;53 mandible; tendency for survival of
Timmerman et al., 200454) short implants < conventional.
on 2 (with a bar or ball attachments)
or 4 (with a bar) implants.
¶ ¶ ¶
Total in systematic review [0 to 168] 8 studies 8 studies 8 studies
219/226 224/236 630/661
(96.90%) (94.92%) (95.31%)
Total in meta-analyses 6 studies# 6 studies# 6 studies#
155/162 160/172 572/603
(95.68%) (93.02%) (94.86%)
L = length; NS = no significant difference in survival between short and conventional implants.
Articles in parentheses are sequenced according to publication year and, in the same year, alphabetically.
* Other information includes: 1) statistical analysis (short versus conventional implants) in the original study; 2) survival of short versus conventional
implants according to implant location; 3) type of restoration; and 4) surviving/placed (%) splinted and non-splinted single-tooth short (L <10 mm) and
conventional (L ‡10 mm) implants.
† Information retrieved after contact with the authors of the study.
‡ IMZ, Friatec, Friedrichsfeld, Mannheim, Germany.
§ Astra Meditec, Astra Tech, Mölndal, Sweden.
i Straumann, Institute Straumann, Waldenburg, Switzerland.
¶ References 36, 39, 41-43, 45, 47, and 49.
# References 36, 39, 41, 42, 47, and 49.
meaningless (k = 0) because of the complete absence lengths <10 mm placed in partially edentulous pa-
of cases with a score of 0 (zero) as applied by one re- tients) is illustrated in Figure 1.
viewer (SK), suggesting that, from a purely mathe-
Meta-Analyses (Tables 2 through 4; Figs. 2 and 3)
matic point of view, the chance-expected proportion
Survival of short versus conventional implants in
of inter-reviewer agreement coincided with the overall
totally edentulous patients (Tables 2 and 4; Fig. 2).
proportion of inter-reviewer agreement. Accordingly,
When short implants were defined £8 or <10 mm
the actual inter-reviewer agreement might theoreti-
long, six36,39,41,42,47,49 of eight studies previously
cally be explained purely on the basis of chance.30,31
selected (Table 2) were included in the meta-analysis
Regarding quality criterion B, the k score was 0.775 –
(Table 2, last row, and Table 4; Fig. 2). The remaining
0.309, representing a ‘‘substantial’’29 level of agree-
two studies43,45 were not included because all short
ment beyond chance.
and conventional implants survived and, thus, the
Results of Publication-Bias Evaluation (Fig. 1) RR could not be estimated (Fig. 2). For both defini-
For both definitions of short implants (length £8 or <10 tions of short implants, no statistically significant dif-
mm), no evidence of publication bias (P >0.05 for both ference (P = 0.978) in survival was demonstrated
the Begg and Mazumdar’s rank correlation test and between short and conventional rough-surface im-
the Egger regression asymmetry test) was demon- plants placed in totally edentulous patients (Table
strated for studies on totally or partially edentulous 4; Fig. 2).
patients. A typical example of the Begg and Mazum- Survival of short versus conventional implants in
dar’s funnel plot for one of these cases (for selected partially edentulous patients (Tables 3 and 4; Fig.
studies reporting on rough-surface implants with 3). When short implants were defined as £8 mm long,
1706
Table 3.
Main Characteristics and Outcomes of Selected Prospective Studies Including Partially
Edentulous Patients

Implant mean With With With Other
Reference(s) Type [range]) L £8 mm L <10 mm L ‡10 mm Information*
Buchs et al., 199655 † NR 83/83 83/83 339/340 1. No statistical comparison between

[0 to 36] (100%) (100%) (99.71%) short and conventional implants.
posterior mandible; all short
implants survived.
3. Implant-supported fixed partial
restorations (dentures).
Deporter et al., § NR None placed 13/13 7/7 1. Statistical comparison between short
199856‡ [6 to 24]‡ (100%) (100%) and conventional implants not
maxilla; all implants survived.
3. Implant-supported single-tooth
restorations (crowns).
4. All implants were non-splinted
single-tooth.
Brocard et al., 200041‡ i 48 202/211‡ 202/211‡ 588/603‡ 1. No statistical comparison between
[0 to 84]‡ (95.73%) (95.73%) (97.51%) short and conventional implants.
2. Correlation implant survival-location:
out of nine short implants lost in
partially edentulous patients: two in
anterior maxilla, three in posterior
maxilla, one in anterior mandible,
three in posterior mandible.‡
3. a) Implant-supported single-tooth
restorations (crowns); b) implant-
supported fixed partial restorations
(dentures/bridges) in partially
edentulous patients.‡
4. 112 single-tooth implants, all non-
splinted (42/42 = 100% short and
70/70 = 100% conventional survived
in partially edentulous patients).‡
van Steenberghe ¶ 24 10/10 16/16 34/34 1. Statistical comparison between short
et al., 200057‡ [24 to 24] (100%) (100%) (100%) and conventional implants not
2. All implants survived, both in maxilla
and mandible.
restorations (dentures).‡
4. No single-tooth implants.‡
1707
Edentulous Patients

Deporter et al., § 34.6 46/46 132/135 15/16 1. Univariate analyses/no detectable

200158‡ [5.1 to 68.6] (100%) (97.78%) (93.75%) correlation between crestal bone
(Deporter et al., 1999,59 loss and implant length (7, 9, or
2000,60 2002;61 12 mm).
Rokni et al., 200562) 2. All implants were placed in the
maxilla; survival percentage of short
implants was higher than
conventional implants.
(dentures).
4. 66 non-splinted single-tooth implants
(61/61 short and 5/5 conventional
survived).‡
Mericske-Stern i 51.6 46/49 46/49 60/60 1. No statistical comparison between

et al., 200163‡ [>12 to 108]‡ (93.88%) (93.88%) (100%) short and conventional implants.
2. Correlation implant survival-location:
NR; number of lost short implants
too low to allow a correlation.
3. Implant-supported single-tooth
restorations (crowns).
4. All implants were non-splinted
single-tooth.
Roccuzzo i 12 16/16 16/16 120/120 1. Statistical comparison between short
et al., 200164‡ [12 to 12] (100%) (100%) (100%) and conventional implants not
2. All implants survived, both in maxilla
and mandible.
3. a) Non-splinted implant-supported
single-tooth restorations (crowns);
b) two splinted (attached) implant-
supported single-tooth restorations
(crowns); c) implant-supported fixed
partial restorations (dentures)
(3- or 4-unit).
splinted (22/22 short and 24/24
conventional survived).‡
1708
Edentulous Patients

Cochran et al., i NR‡ 68/70 68/70 312/313 1. No statistical comparison between

200265‡ [0 to 24] (97.14%) (97.14%) (99.68%) short and conventional implants.
Ongoing 2. All implant losses occurred in the
study; no mandible; NS.
more recent
(>24 months) 3. a) Implant-supported fixed partial
follow-up restorations (dentures) on ‡2
data have implants; b) implant-supported
been removable denture restorations on
published‡ ‡4 implants.
Roccuzzo and i 12 9/9 9/9 26/27 1. No statistical comparison between
Wilson, 200266‡ [12 to 12] (100%) (100%) (96.30%) short and conventional implants.
posterior maxilla; all short implants
survived.
supported fixed partial restorations/
dentures (short-span); c) implant/
tooth-supported fixed partial
restorations/dentures (long-span).
splinted and conventional, all
survived.‡
Romeo et al., 200267‡ i 46 11/11 11/11 115/119 1. No statistical comparison between
[0 to 84]‡ (100%) (100%) (96.64%) short and conventional implants.
2. All short implants survived; all losses
of conventional implants occurred in
the posterior mandible.
3. Single-tooth restorations (crowns).
4. All implants (short and conventional)
were single-tooth.
Romeo et al., 200368‡ i 47 9/9‡ 9/9‡ 70/71‡ 1. No statistical comparison between

2. All short implants survived.
restorations (dentures) with a mesial
or distal cantilever.
4. Nine single-tooth implants (1/1 short
and 8/8 conventional survived).‡
1709
Edentulous Patients

Frei et al., 200469‡ i 16 11/11‡ 11/11‡ 66/66‡ 1. Statistical comparison between short
[16 to 16] (100%) (100%) (100%) and conventional implants not
posterior mandible; all implants
survived.
3. NR.‡
4. NR.‡
Bornstein et al., 200570‡ i 58.59 12/12‡ 12/12‡ 88/89‡ 1. No statistical comparison between
[0 to 60]‡ (100%) (100%) (98.88%) short and conventional implants.
2. All implants were placed in posterior
(maxillary or mandibular) regions;
all short implants survived; one
conventional implant was lost in
the mandible.
(dentures).
4. 82 single-tooth implants. (43 splinted,
39 non-splinted) (NR‡ non-splinted
short, 37/39 = 94.87% non-splinted
conventional, 12/13 = 92.31%
splinted short, and NR‡ splinted
conventional survived).‡
Chiapasco et al., 200671‡ i 20.4 8/8‡ 8/8‡ 85/87‡ 1. No statistical comparison between
2. All short implants survived.
(dentures).
4. NR.‡
1710
Edentulous Patients

Fischer and Stenberg, 200645‡ i 36 18/19‡ 18/19‡ 79/81‡ 1. No statistical comparison between
(Fischer and Stenberg, 200446) [36 to 36] (94.74%) (94.74%) (97.53%) short and conventional implants.
2. 17 patients had partially edentulous
mandibles at the 3-year follow-up;‡
unclear relation of survival to implant
location.
3. In the maxilla: Implant-supported
fixed full-arch (complete)
restorations (dentures) on five or six
implants. In the mandible: One
patient with partially edentulous
mandible who lost implants before
loading had a mandibular full-arch
restoration; no implant restoration in
the remaining patients with partially
edentulous mandibles.‡
Romeo et al., 200647‡ i 76.8 82/85‡ 82/85‡ 107/110‡ 1. Multiple linear analysis/NS differences
(Romeo et al., 200448) [36 to 168] (96.47%) (96.47%) (97.27%) in marginal bone loss and probing
depth values were observed
between short and standard
implants (P >0.05).
2. All implants lost had been placed in
type III or IV bone; NS.
supported fixed partial restorations/
dentures (without cantilevers); c)
implant-supported fixed partial
restorations/dentures with a mesial
or a distal cantilever; d) implant/
tooth-supported fixed partial
restorations/dentures in partially
edentulous patients.
4. 58 single-tooth implants: 29/29 =
100% short and 28/29 = 96.55%
conventional survived in partially
edentulous patients.‡
1711
Edentulous Patients

Strietzel and Reichart, 200772‡ # 26.7 None placed‡ 35/35‡ 132/134‡ 1. Original study statistics not
‡
[11 to 51] (100%) (98.51%) meaningful in the context of this
review/in this study, definition of
short implants included
11-mm implants.
2. All short implants survived;
conventional implant losses were not
related to implant location (anterior/
posterior or maxilla/mandible).
(dentures); c) implant-retained
removable partial dentures; d)
implant-retained overdentures on
2 implants.‡
splinted (4/4 = 100% short and
36/37 = 97.30% conventional
survived).‡
Total in systematic review [0 to 168] 17 studies** 17 studies** 17 studies**
631/649 771/792 2,243/2,277
(97.23%) (97.35%) (98.51%)
Total in meta-analyses 12 studies†† 13 studies‡‡ 12 studies††
594/612 715/736 1,884/1,916
(97.06%) (97.15%) (98.33%)
13 studies‡‡
2,016/2,050
(98.34%)
L = length; NS = no significant difference in survival between short and conventional implants; NR = not reported.
Articles in parentheses are sequenced according to publication year.
* Other information includes: 1) statistical analysis (short versus conventional implants) in the original study; 2) survival of short versus conventional
implants according to implant location; 3) type of restoration; and 4) surviving/placed (%) splinted and non-splinted single-tooth short (L <10 mm) and
conventional (L ‡10 mm) implants.
† Steri-Oss, Nobel Biocare, Yorba Linda, CA.
‡ Information retrieved (or not retrieved) after contact with the authors of the study.
§ Endopore Implant System, Innova, Toronto, ON.
i Straumann, Institute Straumann, Waldenburg, Switzerland.
¶ Astra Tech Implant Systems, Astra Tech AB, Mölndal, Sweden.
# Camlog, Camlog Biotechnologies, Wimsheim, Germany.
** References 41, 45, 47, 55-58, and 63-72.
†† References 41, 45, 47, 55, 58, 63, 65-68, 70, and 71.
‡‡ References 41, 45, 47, 55, 58, 63, 65-68, and 70-72.
1712
Overall Completeness, Quality, and Applicability

of Evidence
The selected studies fulfilled the objective of the re-
view. However, certain types of patients as defined
by exclusion criteria 2 through 4 were not taken into
account. In that respect, the selected cohorts ex-
hibited a certain divergence from the general patient
population treated in everyday clinical practice. The
amount (number of selected studies, patients, and
implants) and quality (as revealed by the process
of quality assessment) of evidence appears to allow
robust conclusions.
The results of the review seem to have signifi-
cant clinical implications. Hence, the placement of
rough-surface short implants appears to be an effica-
Figure 1. cious treatment modality for the replacement of miss-
Funnel plot of the log RR versus its standard error calculated for
selected studies (n = 13) reporting on short (length <10 mm) versus
ing teeth in totally or partially edentulous patients.
conventional (length ‡10 mm) implants placed in partially edentulous
patients. Potential Biases in the Review Process
The present systematic review applied a series of
strategies in the search and selection of studies, as
12 studies41,45,47,55,58,63,65-68,70,71 out of 17 previ- well as data extraction and analyses, to prevent or
ously selected (Table 3) were included in the meta- minimize bias. An extensive manual search was un-
analysis (Table 3, last row, and Table 4; Fig. 3). dertaken because too many relevant articles con-
Two studies56,72 were excluded because they did tained survival data for short implants in their text
not include implants with lengths £8 mm, whereas and tables, but not in their title and abstract, and the
the other three studies57,64,69 were excluded because only way of retrieving those data was through a man-
all short and conventional implants survived; there- ual search. Contact with the authors of 125 articles
fore, the RR could not be estimated. allowed the identification of relevant articles initially
When short implants were defined as <10 mm long, not depicted through electronic and manual searches
the aforementioned 12 studies41,45,47,55,58,63,65-68,70,71 and the retrieval of a significant amount of missing,
were included in the meta-analysis, and additionally, unpublished, or unclear data in a form suitable for
the study by Strietzel and Reichart72 was also included subsequent meta-analysis (Tables 2 and 3). Because
because it reported data for short implants with periodontal pathogens may be transmitted from teeth
lengths <10 mm, thus providing a total of 13 studies to implants in partially edentulous patients, and peri-
(Table 3, last row, and Table 4; Fig. 3). odontal pockets may serve as reservoirs for bacterial
For both definitions of short implant length (£8 and colonization around implants,73 whereas in totally
<10 mm), no statistically significant difference (P = edentulous patients such a transmission is not feasi-
0.145 and 0.173, respectively) in survival was dem- ble, it was deemed methodologically appropriate to
onstrated between short and conventional rough-sur- perform separate meta-analyses, according to the
face implants placed in partially edentulous patients type of patient edentulism. This approach is also jus-
(Table 4; Fig. 3). tified by the difference between totally and partially
edentulous patients with regard to the type of restora-
DISCUSSION tion placed (Tables 2 and 3). Furthermore, exclusion
Summary of Main Results criteria 2 through 4 aimed at preventing the introduc-
In the present study, a systematic review and meta- tion of potential confounders and, therefore, system-
analyses of prospective studies published in the den- atic bias (selection bias) into the meta-analyses. From
tal literature in the English language were conducted a statistical point of view, no significant heterogeneity
to address the focused question ‘‘Is there a significant among selected studies was revealed in the majority of
difference in survival between short (£8 or <10 mm) separate meta-analyses; furthermore, no evidence of
and conventional (‡10 mm) rough-surface dental im- publication bias existed.
plants placed in 1) totally or 2) partially edentulous However, specific limitations were also present.
patients?’’ Meta-anaylses revealed that no statisti- Survival risks were used as estimates of actual survival
cally significant difference in survival existed between rates; therefore, the impact of total exposure time of
short and conventional rough-surface implants in ei- each implant within the oral cavity upon implant sur-
ther totally or partially edentulous patients. vival was not taken into account. Unfortunately, the
1713
Table 4.
Summary of Meta-Analyses Comparing Survival of Short Versus Conventional Implants
Statistical
Studies Pooled RR P Value Heterogeneity Model
(n) (weighted mean [95% CI]) for RR P Value (method)
Totally edentulous patients

L £8 mm versus L ‡10 mm 6 1.01 [0.97, 1.04] 0.978* 0.175† Fixed effects
L <10 mm versus L ‡10 mm 6 0.99 [0.94, 1.06] 0.978* 0.036 Random effects
Partially edentulous patients
L £8 mm versus L ‡10 mm 12 0.99 [0.98, 1.00] 0.145* 0.919† Fixed effects
L <10 mm versus L ‡10 mm 13 0.99 [0.98, 1.00] 0.173* 0.964† Fixed effects
CI = confidence intervals; L = length.
* No statistically significant difference in primary outcome variable between short and conventional implants (P >0.05).
† No statistically significant heterogeneity among studies (P >0.10).
statistical analysis was hampered

by the lack of adequate patient-
related survival data.
Agreements/Disagreements
With Other Reviews
The finding that no statistically
significant difference in survival
existed between short and conven-
tional rough-surface implants in
totally or partially edentulous pa-
tients is in agreement with previ-
ous comprehensive reviews.18,20
CONCLUSIONS
Within the limitations of the pres-
ent systematic review, the follow-
ing conclusions may be drawn.
Figure 2.
Forest plot for selected studies reporting survival of short (length <10 mm) versus conventional General Conclusions/Strength
(length ‡10 mm) implants in totally edentulous patients. Weighted mean of RR and 95% of Evidence
confidence intervals (CI). RR >1 indicates higher survival for short compared to conventional implants.
In general, the process of quality
assessment revealed the meth-
calculation of actual implant survival rates could not odologic quality of the studies included in the meta-
be carried out because, practically, it is too difficult analyses was sufficient. The body of acquired evidence
or virtually impossible to record the total exposure appears to be adequate to draw robust conclusions. In
time of each and every implant included in the meta- the majority of meta-analyses, no significant hetero-
analyses. Such a task would require complete access geneity among selected studies was demonstrated,
to the raw data of all selected studies. Despite this lim- and no evidence of publication bias existed.
itation, it is of interest to note that favorable percent-
Specific Conclusion
ages of survival of short rough-surface implants
There is no significant difference in survival between
(exceeding 95% and being comparable to those of
short (£8 or <10 mm) and conventional (‡10 mm)
conventional implants) have been reported by
rough-surface implants in totally or partially edentu-
seven41,42,47,49,58,67,68 of eight selected long-term
lous patients.
studies, with only one possible exception,63 as demon-
strated in Tables 2 and 3, indicating the efficacy of Implications for Clinical Practice
short implant placement on a long-term basis. Based on the findings of the present article, it seems
Statistical analyses in this review were restricted to reasonable to suggest that, in everyday clinical
implant-related survival data. The use of patient-based practice, clinicians can use short implants as an
1714
Murray Arlin, Weston, Ontario; Kris-

tina Arvidson, Bergen, Norway; Per
Åstrand, Umeå, Sweden; Charles
Babbush, Lyndhurst, Ohio; William
Becker, Los Angeles, California; Urs
Belser, Geneva, Switzerland; Michael
Bornstein, Bern, Switzerland; Gérard
Brunel, Toulouse, France; Daniel
Buser, Bern, Switzerland; Matteo
Chiapasco, Milan, Italy; David Co-
chran, San Antonio, Texas; Douglas
Deporter, Toronto, Ontario; Karl
Dula, Bern, Switzerland; Steven Eck-
ert, Rochester, Minnesota; Alf
Eliasson, Orebro, Sweden; Kerstin
Fischer, Falun, Sweden; Christian
Frei, Bern, Switzerland; Bertil Friberg,
Gothenburg, Sweden; John Gonsol-
ley, Richmond, Virginia; Risto-Pekka
Happonen, Turku, Finland; Torsten
Jemt, Gothenburg, Sweden; Diego
Lops, Milan, Italy; Henry Meijer, Gro-
ningen, The Netherlands; Youji Miya-
moto, Tokushima, Japan; Ignace
Naert, Leuven, Belgium; Rabah Nedir,
Vevey, Switzerland; Marc Quirynen,
Leuven, Belgium; Gerry Raghoebar,
Groningen, The Netherlands; Mario
Figure 3. Roccuzzo, Turin, Italy; Eugenio
Forest plot for selected studies reporting survival of short (length <10 mm) versus conventional
Romeo, Milan, Italy; Kees Stellingsma,
(length ‡10 mm) implants in partially edentulous patients. Weighted mean of RR and 95%
confidence intervals (CI). RR >1 indicates higher survival for short compared to conventional Groningen, The Netherlands; Frank
implants. Peter Strietzel, Berlin, Germany;
Georges Tawil, Beirut, Lebanon; Dam-
ien Walmsley, Birmingham, United
efficacious treatment modality for the replacement of Kingdom; Dietmar Weng, Starnberg, Germany; Göran
missing teeth in totally and partially edentulous pa- Widmark, Mölndal, Sweden; Sheldon Winkler, Philadel-
tients whenever the placement of conventional im- phia, Pennsylvania; Daniel Wismeijer, Amsterdam, The
plants is impossible or not preferable if advanced Netherlands; Chris Wyatt, Vancouver, British Columbia;
surgical procedures would be concomitantly required. and Roland Younan, Beirut, Lebanon. The authors report
no conflicts of interest related to this review.
Implications for Clinical
Research/Systematic Reviews
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1718
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A Systematic Review and Meta-Analysis On The Effect of Implant Length On The Survival of Rough-Surface Dental Implants

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A Systematic Review and Meta-Analysis on the Effect of Implant Length on

Article in Journal of Periodontology · November 2009

Sotirios Kotsovilis Ioannis Fourmousis

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Ioannis K Karoussis Christina Bamia

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The user has requested enhancement of the downloaded file.

Background: A meta-analysis on the survival of short im-

placed. It should be noted that the primary outcome RESULTS

Surviving/ Surviving/ Surviving/

Geertman et al., 199636† ‡ 12 19/19† 19/19† 62/63† 1. No statistical comparison between

Surviving/ Surviving/ Surviving/

Surviving/ Surviving/ Surviving/

Surviving/ Surviving/ Surviving/

Buchs et al., 199655 † NR 83/83 83/83 339/340 1. No statistical comparison between

Surviving/ Surviving/ Surviving/

Deporter et al., § 34.6 46/46 132/135 15/16 1. Univariate analyses/no detectable

Mericske-Stern i 51.6 46/49 46/49 60/60 1. No statistical comparison between

Surviving/ Surviving/ Surviving/

Cochran et al., i NR‡ 68/70 68/70 312/313 1. No statistical comparison between

Romeo et al., 200368‡ i 47 9/9‡ 9/9‡ 70/71‡ 1. No statistical comparison between

Surviving/ Surviving/ Surviving/

Surviving/ Surviving/ Surviving/

Surviving/ Surviving/ Surviving/

Overall Completeness, Quality, and Applicability

Totally edentulous patients

statistical analysis was hampered

Murray Arlin, Weston, Ontario; Kris-

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