RESEARCH

THE CHALLENGE OF IMPLANT THERAPY IN THE

POSTERIOR MAXILLA: PROVIDING A RATIONALE
FOR THE USE OF SHORT IMPLANTS

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Marianne Morand, DMD; Tassos Irinakis, DDS, MSc, FRCD(C)

Rehabilitating patients with a resorbed maxilla presents several challenges when the desired
treatment plan involves the placement of endosseous implants. Correct diagnosis requires
knowledge on jaw healing patterns, systemic effects, and the impact of bone quality changes on
implant success rates. Appropriate treatment planning requires an in-depth understanding of the
materials and methods available to the contemporary implant surgeon. The clinician must be able to
persist on evidence-based techniques and adhere to those proven methods. Successful surgical
placement requires correct use of the available armamentarium and acceptance of the limitations
that implant dentistry still presents. Especially challenging is the implant treatment of maxillary
molars due to the plethora of complicating factors such as limited bone availability, interarch space
challenges, sinus problems, etc. These are just a few of the factors that may lead us to placement of
short implants in these sites. An extensive review of the literature that is available for short implants
(implants ,10 mm in length) indicates that although they are commonly used in areas of the mouth
under increased stress (posterior region), their success rates mimic those of longer implants when
careful case selection criteria have been used. The available studies and case-series offer a valid
rationale for placement of short implants so long as one understands the limitations, indications, risk
factors, and limited studies that actually follow-up success rates of short implants for over 5 years.
This review of the literature will provide the reader an in-depth view of the evidence in using short
implants as an alternative treatment modality for the maxillary molar region.

Key Words: short implants, sinus lift, maxilla, sinus augmentation, bone grafting, surface

INTRODUCTION

Marianne Morand, DMD, is a private practitioner in Quebec,
Canada.
Tassos Irinakis, DDS, MSc, FRCD(C), is associate clinical
professor in periodontics and director of graduate periodontics
and implant surgery at the University of British Columbia,
Vancouver, British Columbia, Canada. He is also director of the
Institute for Dental Education and Advanced Surgeries and a
periodontal surgeon and consultant at Vancouver General
Hospital; a fellow of the Royal College of Dentists of Canada; a
certified specialist in periodontics; and a private practitioner in
Coquitlam, British Columbia, Canada. Address correspondence to
Dr Irinakis at University of British Columbia, 2199 Wesbrook Mall,
Vancouver, BC, V6T 1Z3 (e-mail address: bone.grafting@gmail.
com).
C
onventionally, surgeons aim for place-
ment of the longest possible implant in
any given site as long as its placement
does not hinder the final prosthetic
result in terms of esthetics. This was
especially crucial in the past, when
implants presented a machined surface and the most
common way to increase implant-to-bone contact was
to increase the surface area available by placing a
wider or longer implant. The longer and wider
implants were clearly associated with higher success
rates at that time (when placed in similar intraoral

Journal of Oral Implantology 257

CHALLENGE OF IMPLANT THERAPY IN POSTERIOR MAXILLA
sites).1,2 However, the posterior maxilla presents a
uniquely challenging site for implant placement due
to several complicating factors.3 Some of the factors
that lead to difficulties in implant placement and
success in the maxillary molar region are:
 Difficult and challenging access
 Limited visibility
 Commonly reduced interarch space
 Postextraction resorption that leads to extensive tis-
sue loss over time, as well as sinus pneumatization4–13
 Poor (type IV) bone quality (thin layer of cortical bone
surrounding a core of low-density trabecular bone)
associated with the least favorable success rates2,14–23
To compensate for the poor bone quality, research
teams have improved implants’ texture and design to
facilitate osseointegration. Using different techniques
(eg, acid etching, grit blasting, titanium plasma
spraying, surface coating), implant companies today
have replaced the traditional polished surface on
implants with ‘‘rough’’ surfaces that have led to
significantly better long-term results.24 These tech-
niques result in implant surface irregularities in height,
wave length, and spatial dimension. Arguments in
favour of rough implant surfaces25–29 include:
 Increased contact area to offer better mechanical
stability between bone and implant immediately
following insertion
 Provides surface configuration that properly retains
the blood clot
 Stimulates the bone healing process
An additional way to compensate for the limited bone
height that is commonly present in the posterior
edentulous maxilla was sinus lift augmentation using
autogenous bone or bone substitutes. More experi-
enced maxillofacial surgeons would also proceed with
total or segmental bone onlays and Le Fort I
osteotomy with interpositional bone grafts30–33. The
implant industry contributed to resolving the problem
of bone height with the fabrication of zygomatic and
short implants. Zygomatic implants are associated
with some controversy and are not the topic of this
paper. This article will focus on the treatment option
of using short implants in the posterior upper jaw.
SINUS AUGMENTATION WITH BONE GRAFTING
Prior to analyzing the evidence on use of short
implants—as supported by the literature—it is impor-
tant to mention the difficulties associated with sinus
augmentation. This is the procedure of choice for
surgeons that do not elect to use short implants or
258 Vol. XXXIII / No. Five /2007
when short implants are contra-indicated. The maxil-
lary subantral augmentation procedure (techniques of
hinge osteotomy; lateral window; complete osteoto-
my), is a well-proven procedure that is used to
increase the bone volume in the deficient molar
maxilla. However, there are times that it is not prudent
to proceed with such techniques due to chronic
history of sinusitis, excessive tobacco abuse, patho-
logic lesions, odontogenic infections, and large
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prominent septa.34–36 If short implants can provide a
successful alternative, then in some cases the operator
will have more options when clinically judging the
situation.
CURRENT UPDATE ON SHORT IMPLANTS
The minimal length for predictable success was always
considered that of 10 mm and thus implants of this
length are commonly referred to as ‘‘standard length
implants.’’37 As a result, any implant under 10 mm in
length has come to be referred to as a ‘‘short’’
implant38,39 (Figures 1 through 4). Before freely
advising the use of short implants, the authors
decided to research the answers to the most
commonly asked questions from other colleagues.
For example, why would a surgeon offer this option
when there are other proven methods of success?
What are the advantages and what are the difficulties
of short implants? How do they overcome certain
challenges associated with their reduced length? Do
they offer success rates comparable to those of
‘‘longer’’ implants?
Advantages
There are several advantages associated with the use
of short implants as a treatment option in the severely
resorbed posterior maxilla (Table 1). Patients don’t
necessarily need to invest in additional pre-surgical
diagnostic tests such as computerized tomography
(CT) when perhaps ‘‘bone sounding’’ may prove
adequate in cases where the sinus is to be avoided.
Tests such as CT scans lead to additional costs, time,
and radiation exposure. These scans are most com-
monly requested when investigating a borderline 10-
mm implant case or when researching the option of a
sinus augmentation surgery. In many cases, when the
bone height is sufficient, short implants will allow the
operator to avoid sinus lifts entirely, along with the
complications and challenges associated with such
procedures.40–42 In return, these advantages offer
motivation to patients and an increased acceptance
rate of implant-based treatment plans. Therefore, if it
can be proven through the available follow-up clinical
 Marianne Morand, Tassos Irinakis

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FIGURE 1. A Nobel Replace Tapered Groovy implant 8 mm in length
and 5 mm wide by Nobel Biocare. The surface of this implant is
‘‘rough’’ (acid etched) named ‘‘Ti-Unite.’’ This implant has an
internal abutment connection system; namely the ‘‘tri-channel’’
connection.

studies that it is prudent to use short implants in

certain scenarios, there will be an additional treatment
option in the inventory of treatments for the implant
surgeon.

Disadvantages
If we take into account the advantages mentioned in
Table 1, it would seem reasonable to assume that
short implants would be part of mainstream implant
dentistry by now. However, there is still controversy FIGURES 2 and 3. A Straumann-ITI implant 6 mm in length and 4.8 mm
on their indications due to several challenges that in width with a 6.5 mm wide neck collar. The surface of this implant
have been associated with them: is ‘‘rough’’ SLA (Sand blasted; Large grit; Acid etched). This implant
has an internal abutment connection system; namely the ‘‘morse-

taper’’ connection.
Reduced implant surface; thus leading to less bone-
to-implant contact after osseointegration.

Journal of Oral Implantology 259

CHALLENGE OF IMPLANT THERAPY IN POSTERIOR MAXILLA
FIGURE 4. A Branemark implant 7 mm in length and 5 mm wide by
Nobel Biocare with a Ti-Unite surface. This implant has an external
connection system; namely the ‘‘external hex.’’

Reduced surface of force distribution after loading;
more pressure at the crestal bone; more resorption
leading to more threads exposed, decreasing the
surface of osseointegrated implant
 Compromised crown-to-implant ratio
So how can we overcome the challenges associated
with short implants?
REDUCED IMPLANT SURFACE
The area of contact is determined by 4 factors: the
length, diameter, taper, and texture of the implant
surface. The average surface area of roots of a
maxillary first molar is 533 mm2, compared to 256
mm2 for a threaded 18-mm Nobel Biocare implant 43
260 Vol. XXXIII / No. Five /2007
TABLE 1
Advantages of short implants in the resorbed
posterior maxilla
1. Minimizes the need for CT (when ‘‘bone sounding’’ is deemed
adequate in determining ridge width and a sinus lift is going
to be avoided), thus resulting in:
 Lower cost
 Less presurgical time
 Less radiation exposure
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2. Reduces indications for sinus lift procedures, thus reducing:
 Costs for surgery and materials
 Waiting period for treatment completion
 Complications that result from advanced grafting procedures
3. Improves surgery options by not pressing the surgeon into
placing the longest possible implant in borderline cases
 Increases patient’s acceptability
 Less surgeries involved
 Lower costs
 Fewer complications
 Quicker rehabilitation time
(polished 3.75-mm diameter implant). It seems logical,
therefore, to always strive for the longest possible
implant. If we consider that a root form implant is
approximately cylindrical, the surface is grossly esti-
mated by 2pr2 þ 2prL, where L is the length in mm and
‘‘r’’ is the radius in mm. When the length or the radius
increases, the surface area increases.44 However, in
cases with compromised bone height where short
implants seem to be the only solution, to compensate
for a shorter length, a wider-diameter implant (5 mm)
can be used.3 In fact, the use of a 5-mm diameter
implant that is 6 mm long increases the surface area
available to contact the bone similar to that of a 3.75-
mm diameter implant that is 10 mm in length. To
reduce the risk of failure of endosseous implants used
in the posterior applications, wide-diameter implants
have been suggested.45
When studying the influence of diameter, length,
and taper on strains in the alveolar crest with a three-
dimensional finite-element analysis, the authors came
to several conclusions.46 The same force (200 N
vertical and 40 N horizontal) was applied to implants
of different lengths (5.75 to 23.5 mm), diameters (3.5
to 6 mm), and taper (0 to 14 degrees). They found
that increasing implant diameter resulted in as much
as a 3.5-fold reduction in crestal strain, increasing
length creates as much as a 1.65-fold reduction, and
increasing taper increases the crestal strain as much
as 1.65-fold, especially in narrow and short implants.
The authors remind us that diameter sizes and
lengths have to be considered together because of
their interactive effects. In low-density bone, short,
narrow, and taper implants should be avoid because

low-density cancellous bone already increases the
strains around the implants.47–49 It was further found
that the influence of the diameter on crestal bone
strains dominates over the effects of the length and
taper.
In addition, the surface area increases significantly
simply by altering the texture configurations on rough
implants. Rough implants offer extensive surfaces
for osseointegration and therefore allow the clinician
to consider usage of short implants with some
confidence.39 A rough implant has a micro-texture
that increases the surface area and the anchorage of
the implant to the bone during osseointegration.50
The literature emphasizes the importance of the
geometry of the implant, especially for a short implant
placed in the posterior maxillary. In fact, it has been
demonstrated by Bernard et al, who studied Brane-
mark and ITI implants, that textured implants of
various lengths offer a significantly stronger anchor-
age compared to machined implants.51 Increasing the
diameter of the implant in a poor quality and quantity
bone would be a way to increase tolerance of
occlusal forces, to improve the initial stability and to
provide favorable stress distribution to the surround-
ing bone. Wider implants have shown excellent
clinical results in several studies that included the
posterior jaw.52–56
CROWN-TO-IMPLANT RATIO AND OCCLUSAL FORCES
The crown-to-root ratio in human natural teeth has a
mean value of 0.6 for maxillary teeth and 0.55 for
mandibular teeth.57,58 In treatment planning of
conventional fixed prosthodontic restorations using
natural teeth as abutments, Ante’s law dictates that
‘‘the combined peri-cemental area of all of the
abutment teeth should be equal to or greater than
the peri-cemental area of the teeth to be replaced.’’ As
a result, clinicians would treatment plan implant
supported restorations with long machined fixtures
in an effort to follow Ante’s law. It soon became
evident, though, that a crown-to-implant ratio of 1:1
was extremely successful and completely accept-
able.59 However, in the posterior maxilla, there is
usually natural resorption of the alveolar ridge as a
result of prolonged edentulism that leads to an
amplified inter-arch distance. The consequent limited
available bone leads the implant practitioner to
consider the option of short implants. This would
lead to a poorer 1:2 implant-to-crown ratio. Surpris-
ingly, the improvements of surfaces and implant
systems, along with prosthetic occlusal adjustments,
Marianne Morand, Tassos Irinakis
have allowed such ratios to be applied with success
under certain criteria.40,59
The force in the premolar area is 61.4 N and 82.0 N
in the molar area, while the occlusal table of a molar
crown is approximately 96 mm2, compared with 44
mm2 for a 3.75 mm–wide implant.60 Simple math
dictates that this would lead to challenging loading
forces on the prosthetic table of a 3.75 mm–wide
implant and to an increased buccolingual cantilever.
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Investigating such cases, Tawil et al placed 262
Branemark implants (10 mm or less in length) with
machined surfaces in 109 patients to determine the
influence of some prosthetic factors on the survival
and complications rates.61 The patients were followed
12 to 108 months (mean, 53 months). They found no
significant difference in the marginal bone loss that
they could correlate with the crown-to-implant ratio.
They concluded that when the load distribution is
favorable, increased crown-to-implant ratios are not a
major risk factor. The authors believed that short
implants are long-term viable solutions in sites with
reduced bone height, even when prosthetic parame-
ters exceed the normal values, provided that force
orientation and load distribution are favorable and
parafunction is controlled. A reduced mesiodistal
dimension of the prosthesis compared to the corre-
sponding natural tooth would contribute to a more
favorable load distribution, and potentially more
successful results. The reduction of the occlusal table
and the flattening of the cuspal inclines are principles
used with periodontal prosthesis concepts that can be
used in implant-supported prostheses. Nedir et al
supported these observations in their 7-year study of
ITI implants, where the implant-to-crown ratio ranged
from 1.05 to 1.80, and no detrimental consequences
on the final success rate were noted.40 Tripodization of
implants in the posterior has also been suggested and
strongly supported in the recent past. 62 However, the
overwhelming success rates of short implants replac-
ing natural teeth suggests that tripodization may not
be a significant factor for success any longer.
SHORT IMPLANT SUCCESS RATES
In order to study the success rate of short implants,
many factors have to be considered (Table 2).
Because there are so many variables, it is difficult to
compare the success rate of implants in different
studies. Most of the articles don’t give all the data
necessary to do a thorough systematic analysis of the
successful and the failed implants. Nevertheless, it is
interesting to look at the literature to see what final
Journal of Oral Implantology 261
CHALLENGE OF IMPLANT THERAPY IN POSTERIOR MAXILLA

results previous studies have obtained and their
conclusions.
It has become apparent through reviewing the
literature that the one improvement that had the most
dramatic effect in improving implant treatments was
the evolution of implant surfaces from machined/
polished to rough-textured surfaces. We took this into
account when evaluating the literature, and Table 3
studies had an average length of time of less than 10
years).
The aforementioned success rates become even
more important when one considers the circumstanc-
es under which short implants are selected. For
example, it is more likely that most of the short
implants were placed in the posterior maxilla, where
there commonly is less bone height available with
poor bone quality.16 Poor bone quality is strongly

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provides some examples of implant success rates. linked to higher failure rates in implants, although
After studying the literature, it becomes evident rough surfaced implants nowadays have somewhat
that concerns regarding placement of implants under dampened this negative effect.63 In one of the few
10 mm in length have diminished due to the newly studies where length was assessed alone (implant
developed implant surfaces. It is reasonable to assume system, implant width, and implant position were kept
that with careful case selection criteria, the contem- constant) as the only changing factor, Bahat found
short implants to present with 90.5% success (length
porary implant surgeon would be able to achieve
of observation was 5–70 months) compared to 96.2%
long-term success rates that surpass the 90% mark. In for longer implants.64 However, the implants used
fact, in most studies the success rates surpassed 95%, were machined/polished. In a following study, when
closely mimicking the success rates traditionally investigating the 10-year survivability of Branemark
reserved for longer implants (although all mentioned machined implants, he noted that when short (7 mm)
implants were not stand-alone in free-end situations,
they had similar success rates as the longer implants.43
TABLE 2
Various factors that need to be considered when selecting a
case for placement of short implants DISCUSSION
1. Patient Perhaps clinicians should reconsider the way they
 Systemic medical condition
 Smoking habit
view placement of short implants. Short implants can
 Periodontal health be a very successful alternative to sinus grafting (with
 Reason for tooth loss subsequent placement of longer implants). However,
 Parafunction
there are several guidelines/suggestions that should
2. Implants be stressed. The most important aspect of implant
 The type of fixture (subperiosteal, root from, hollow)
 The implant system (Branemark, Nobel Replace, Straumann,
treatment with short implants is ‘‘case selection.’’ For
Astra, 3i, MIS) example, it would seem prudent to follow a 2-stage
 The surface (machined, rough) implant surgery approach when placing short im-
 The shape (straight, tapered)
 Length
plants, since this approach has been linked with
 Diameter (wide, regular, narrow) higher success rates with short implants.39 It may also
3. Bone prove wise to avoid placing short implants in single
 Bone quality (Type I to IV) molar cases in free-end situations but rather splint
 Position into the maxilla them to an additional implant (preferably longer),
 Primary stability
especially when placed in soft bone; type III or type IV.
4. Surgery Soft bone is alone a risk factor, so coupling it with a
 One or two stages/immediate loading
 Bone augmentation technique (lateral augmentation or sinus single short implant only magnifies the potential
lift [lateral window, osteotome]) problem. Most implant failures can be attributed to
 Grafting material/membrane
poor bone quality.38,65 Occlusion is a crucial factor in
 Skills of the surgeon
longevity of implant treatments. Maximal occlusal
5. Prosthesis
forces applied and tolerated vary greatly according to
 Splinted or not
 Tooth-implant prosthesis implant position in the arch, parafunctional habits of
 Cantilever the patient (bruxism/clenching), and nature of the
6. Success/survival rate opposing dentition. Biomechanical overload can easily
 Definition of success rate be rendered with high bending moments, unfavorable
 Definition of survival rate
force distributions, and increased force magnitude
 Duration of the follow-up
regularly seen in the posterior region of the mouth.

262 Vol. XXXIII / No. Five /2007

 Marianne Morand, Tassos Irinakis

TABLE 3
Cumulative success rates of short implants vs. 10-mm (or longer) implants
Implant Years after Loading Success
Study Surface Implant Length Implants the Implants Rate

van Steenberghe 199021 Machined ,10 mm (short) 120 1 years

Bahat 199364 Machined ,10 mm (short) Total of 732 0.5–6 years 97.5%
10 mm 90.5%
2
Buser et al 1997 Rough ,10 mm (short) 389 8 years 96.2%
10mm 814 91.4%
Winkler et al 20003 Mostly machined ,10 mm (short) 181 3 years 93.4%

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10 mm 2736 84.0%
72
Friberg et al 2000 Machined ,10 mm (short) 247 8 years 93.7%
Romeo et al 200270 Rough ,10 mm short 11 Up to 7 years 92.3%
10 mm 176 100%
Ferrigno et al 200215 Rough ,10 mm (short) Up to 10 years 96.7%
10 mm 89.6%
69
Ibanez et al 2003 Rough ,10 mm (short) Total of 654 3 years 93.0%
10 mm 100%
Bergkvist et al 200473 Rough Mostly 10 mm 146 2 years 99.2%
Fugazzotto et al 20044 Rough Mostly 10 mm 979 Up to 7 years 96.6%
Griffin et al 200437 Rough ,10 mm (short) 168 Up to 6 years 95.1%
Nedir et al 200440 Rough ,10 mm (short) 111 1–7 years 100%
,10 mm (short) 417 100%
Renouard et al 200574 Rough 10 mm 42 3 years 99.3%
Bischof et al 200671 Rough ,10 mm (short) 102 1–5 years 97.6%
,10 mm (short) 161 98%
Misch et al 200641 Rough 10 mm 745 1–5 years 100%
,10 mm (short) 98.9%

Overloading may lead to loss of osseointegration and
fracture of the implant or the superstructure.66–68
When placing short implants, it has also become
apparent from the literature that compensating with
wider implants is the most reasonable approach.
Crucial decision-making factors are summarized in
Table 4. Dentists should carefully consider these—
along with other factors they deem necessary—prior
to making final decisions in their treatment plans.43
CONCLUSIONS
The literature seems to show that there is good reason
to contemplate the use of short implants even in the

TABLE 4
Important decision making factors when treatment planning the placement of short implants suggested by the authors
Factors Influencing
Our Decision Suggestions

Single implant case Perhaps a second molar does not need to be replaced all together and the patient can function with first molar
occlusion. If a first molar is missing as well, then we should consider splinting a short implant to an additional
implant or placing a longer implant after sinus augmentation.
Diameter of implant If the clinician chooses a short implant, then he or she should strive to place the widest possible fixture. Short and
narrow platform implants have not yet been proven through the literature as stand-alone implants.
Bone quality When suspecting or encountering poor bone quality, consider altering our protocol (eg, wait longer prior to loading,
consider additional implant, two-stage surgery).
Opposing dentition There is a different level of occlusal forces when the opposing dentition is natural dentition than when it’s a removable
prosthesis.
Parafunctional habits Should be addressed with fabrication of a night-guard as part of the treatment plan and long-term maintenance.
Surgical approach Consider a two-stage surgical approach, allowing the short implant undisturbed osseointegration.
Osseointegration period Allow longer periods for osseointegration and avoid immediate loading (unproven in the literature with short implants).
Surgical protocol Site preparation has to be precise with least possible number of entries and minimal soft tissue trauma to allow best
possible vascularity and quicker and superior healing. In addition, screw tapping should be avoided (unless proven
necessary) since it could over-enlarge the osteotomy site.
Primary stability Strive for primary stability under the ideal torque range as suggested by the implant company (eg, 35–45 Ncm is
most commonly suggested)
Maintain hopeless Consider maintaining some of the teeth that you have planned for extraction temporarily to provide support for a
teeth till loading potential fixed provisional prosthesis and avoid transmucosal loading of the implants.

Journal of Oral Implantology 263

CHALLENGE OF IMPLANT THERAPY IN POSTERIOR MAXILLA
posterior maxilla. It is an option we should always
consider and offer to the patient. The literature is not
always consistent, but many recent studies show that
short implants can be quite predictable and have a
success rate similar to longer implants. The research
on implants is very active, and it seems that the
tendency to use shorter implants will become more
and more accepted. Clinicians still have to be cautious
and to select their cases safely and carefully.
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