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Importance of crown to root and crown to implant ratios

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 Continuing Education

Course Number: 135

Importance of Crown to Root

and Crown to Implant Ratios
Authored by Gary Greenstein, DDS, MS, and
John S. Cavallaro Jr, DDS

Upon successful completion of this CE activity 2 CE credit hours may be awarded

A Peer-Reviewed CE Activity by

Approved PACE Program Provider

FAGD/MAGD Credit Approval
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Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of
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courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to
contact their state dental boards for continuing education requirements.

Recommendations for Fluoride Varnish Use in Caries Management
Importance of Crown to Root
and Crown to Implant Ratios
Effective Date: 03/1/2011 Expiration Date: 03/1/2013
LEARNING OBJECTIVES
After reading this article, the individual will learn:
• The clinical importance of crown to root ratios (CRRs)
and crown to implant ratios (CIRs).
• Suggestions for restoring teeth and implants based on
a search of the literature focusing on CRRs and CIRs.
ABOUT THE AUTHORS
Dr. Greenstein is clinical professor,
Department of Periodontology, College
of Dental Medicine, Columbia University;
Private Practice, Surgical Implantology
and Periodontics, Freehold, NJ. He is a
board Diplomate and Fellow of the
American Academy of Periodontology, and has authored
more than 100 articles on periodontal and implant therapy.
He can be reached via e-mail at ggperio@aol.com.
Disclosure: Dr. Greenstein reports no disclosures.
Dr. Cavallaro is clinical director of the
Implant Fellowship Program, College of
Dental Medicine, Columbia University,
New York, NY; private practice, surgical
implantology and prosthodontics, Brook-
lyn, NY. He is a member of the Academy
of Osseointegration and a former Fellow of the Greater New
York Academy of Prosthodontics. He can be reached at
docsamurai@si.rr.com.
Disclosure: Dr. Cavallaro reports no disclosures.
INTRODUCTION
Historically, crown to root ratios (CRRs) of teeth were used
as a parameter to help decide if teeth should be restored
with or without splinting to adjacent teeth or employed as
1
Continuing Education
abutments in dental prostheses. However, guidelines were
based upon empiricisms rather than scientific data. This
resulted in teeth being extracted that could have been
retained. With respect to dental implants, the desire to
reduce crown to implant ratios (CIRs) could result in an
area being unnecessarily bone augmented to provide
additional support for a longer implant. Therefore, it would
be advantageous if an assessment of the dental literature
provided guidance as to the survival of restored teeth and
implants with elevated crown to root or CIRs.
Fixed denture prostheses (FDPs) can be retained by
teeth, dental implants, or a combination of both. In either
scenario, a FDP needs an adequate number and size of
abutments to provide support for a restoration. The number
of abutments to retain a prosthesis is dependent on
numerous clinical variables, including size and design of
the prosthesis, number of missing teeth, occlusal and
parafunctional forces, opposing dentition, amount of
available bone around abutments, and cost. With respect to
providing adequate support for a prosthesis, the issue of
root or implant length needs to be considered.
The objective of this article is to discuss the importance
of CRRs and CIRs based on a search of the literature
focusing on 4 overlapping topics: (1) relevance of Ante’s law
to reconstructive dentistry, (2) CRR and CIRs, (3) the utility
of short versus long dental implants, and (4) the concept of
vertical cantilevers.
ANTE’S LAW
In 1926, it was suggested that the total periodontal
membrane area of abutment teeth must equal or exceed
the membrane area of teeth to be replaced.1 This was
referred to as Ante’s Law, but it actually was an opinion that
was never scientifically validated. Unfortunately, application
of this concept precluded employing numerous teeth as
abutments, because they had lost periodontal support.
Thus, teeth were extracted that might have had a better
prognosis than expected.2 In this regard, a systematic
review (6 publications) by Lulic, et al3 surveyed the
literature from 1966 to 2006. They evaluated the survival of
FDPs when periodontally healthy teeth whose periodontium
was severely reduced were incorporated into prostheses.
To be included in the review the restorations had to be in

Importance of Crown to Root and Crown to Implant Ratios
function for 5 years. While not specifically stated in the text,
it is reasonable to presume that teeth with reduced
periodontiums incorporated into FDPs often demonstrate
increased CRRs. Lulic, et al3 reported that among 579
FDPs, the survival rate was 96.4% and 92.9% after 5 years
and 10 years, respectively. These findings are similar to
data concerning survival of FDPs fabricated on teeth with
good periodontal support.4,5
In summary, considering the data from long-term
clinical trials, it can be concluded that the concept referred
to as Ante’s Law with respect to teeth has been refuted.
Furthermore, since teeth and implants are retained by 2
different mechanisms (periodontal ligament versus
osseointegration), the concept of extrapolating guidelines
for patient care with one type of support to the other would
be inappropriate.
CROWN TO ROOT RATIOS AND CROWN TO IMPLANT
RATIOS
Teeth
Frequently, the CRR is used to determine if a tooth could
function as a suitable abutment. The term refers to a ratio
calculated from a radiograph with respect to length of the
tooth not within bone divided by the portion of the tooth in
alveolar bone.6 When forces are applied to a single-rooted
tooth with a complete periodontium, the tooth’s center of
rotation, or fulcrum, is in the center of the root, two thirds
down the root within the bone.6 The main reason for
increased CRRs is fabrication of taller crowns on teeth or
pontics subsequent to alveolar bone loss. This results in the
crown portion of the prosthesis providing a greater lever arm
and the root providing less resistance. When there is
additional bone loss, the center of rotation moves apically.6
With regard to CRRs discussed in the literature, a variety
of ratios were reported. Ideally, the ratio should be 1:2 or 0.5;
however, this is rarely seen in clinical practice.7 Dykema, et
al7 indicated that a CRR of 1:1.5 is desirable. Similarly,
Shillingburg, et al8 suggested a 1:1.5 ratio as most favorable
for an abutment and a CRR of 1:1 as a minimum for a tooth
abutment. Several procedures alter the CRR as follows:
overdentures with a small attachment9 and extrusion of teeth
to provide additional bone both decrease the CRR, whereas
2
Continuing Education
an increase in vertical dimension of occlusion and surgical
crown lengthening or ridge reduction to make room for an
implant abutment increase the CRR.6 After assessing the
literature, Grossmann and Sadan6 concluded that no
definitive recommendations could be established for an
optimal CRR concerning teeth.
To compensate for increased forces on prostheses due
to increased CRRs, clinicians have splinted teeth
together.10 This may shift the center of rotation and transmit
less horizontal forces to individual abutments or alter the
response to the applied forces.11,12 However, no objective
criteria exist to define the need or extent of splinting to
assuage the effect of an increased CRR. 13
Dental Implants
A consensus conference defined a desirable crown height
space for a fixed prosthesis to be between 8 to 12 mm
(bone level to opposing dentition).14 This height leaves 3
mm for soft tissue (includes biologic width and soft-tissue
coverage of implant collar), 2 mm for occlusal porcelain,
and an abutment ≥ 5-mm high. However, it was cautioned
as the height of the prosthesis increases there is increased
risk of component and material fracture due to elevated
forces on the restoration.14 Therefore, increased crown
height should be considered as a factor that can affect
clinical outcomes both technically and biologically.
In this regard, a projected increased CIR can be reduced
by increasing the bone height surgically with ridge
augmentation or distraction osteogenesis. On the other hand,
if increased CIRs were proven to be safe to use, it would
provide a variety of advantages including avoiding some
guided bone regeneration procedures, abridged treatment
time, facilitating a greater number of patients to be treated,
and decreased fees. Therefore, the literature was searched
to determine if increased CIRs enhance therapy or induce
additional stress that eventually has a deleterious effect on
bone adjacent to implants supporting prostheses or
prostheses’ components.
PERFORMANCE OF IMPLANTS WITH RESPECT TO
CROWN TO IMPLANT RATIOS
An elevated CIR has been described as a type of non-
axial loading, which can detrimentally affect a prosthesis
 Continuing Education

Importance of Crown to Root and Crown to Implant Ratios

(Figure 1).15,16 Ten studies were found in the dental Figure 1. Single Tooth
Implant: tooth position No.
19. Radiograph of a
literature that addressed the survivability of implants in
relation to CIRs (Table 1).17-26 Seven investigations are restored dental implant with
a millimeter ruler
superimposed on the film.
succinctly addressed, because they all have different
characteristics; the latter 3 pertain to cantilevered pros- It should be noted that to
compute the crown to
implant ratio (CIR) in this
theses and the data are summarized in Table 1.
Schulte, et al17 assessed survival of 889 restorations in and the other figures, the
following was recorded:
more than an average of 2.3 years (range 0.1 to 7.4 years). clinical crown length was
the restored crown plus the
abutment collar height plus
The average survival rate was 98.2%, and these implants
(Bicon) had a mean CIR of 1.3 (range 0.5:1 to 3:1). More the part of the implant body
that was not encased in
bone; implant length was
than 400 prostheses had a CIR ≥ 1.2. Among the 889
restorations that were monitored, 16 implants failed, and the part of the implant
encased in bone. In Figure
1, the part of the implant
these prostheses manifested a mean CIR ratio of 1.4.
Similarity of CIRs between failed and successful implants encased in bone is 7 mm.
The portion of the implant
coronal to the bone plus
implies that the crown to implant ratio was not a critical
the abutment and crown
measure 12 mm. This
determinant with respect to implant survival.
Concerning the relationship between CIR and bone loss results in a clinical CIR of
around implants, Tawil and Younan18 evaluated 262 machined 12/7 = 1.7.
surfaced implants (Brånemark) in 109 patients in more than 53 1.1 and 2 was 78.9%. Implants with a CIR >2 (n = 20) were
months. Bone loss was not related to CIRs and the survival rate followed for approximately 3 years. Different sized implants
of restored implants was 99.9%. The reported CIRs and the had the following CIRs (indicated in brackets): 5 mm (2.6),
number of cases (in brackets) were as follows: <1 (30), 1 to 1.2 7 mm (1.8), 9 mm (1.4) and 12 mm (1.0). There were no
(70), 1.21 to 1.4 (58), 1.41 to 1.6 (29), 1.6 to 2.0 (39) and >2 (8). statistically significant relationships between CIRs and
Blanes, et al19 appraised the impact of CIRs on the bone loss. The data underscored that short implants with a
survival of rough surfaced implants (N = 142, Straumann im- sintered surface which manifested elevated CIRs did not
plants) in more than a 10-year period. They divided the result in their failure or bone loss.
patients into 3 groups with respect to CIR: 0 to .99, 1 to 1.99, Nedir, et al21 reported after a 7-year monitoring period
and ≥ 2. The mean clinical CIR was 1.77 and increased CIRs that the survival rate of short (< 10 mm) and longer implants
were not found to be associated with additional bone loss. The (Straumann implants) (10 to 13 mm) (N = 276) used to
success rate with a CIR of >2 was 94.1% (48 of 51 implants). support single crowns or short prostheses were 100% and
They concluded that implant restorations with a CIR between 99%, respectively. They provided the CIR for each length of
2 and 3 could be successfully used in posterior regions of the implant and the number of placed implants: 6-mm long,
dentition. However, it should be noted that the majority of CIR-1.97, n = 6; 8-mm long, CIR-1.59, n = 97; 9-mm long,
these implants were splinted (81.3%), which furnished an CIR-1.55, n = 8; 10-mm long, CIR-1.3, n = 194; 11-mm
improved distribution of forces between implants. long, CIR-1.17, n = 71. In general, these data corroborated
The impact of CIRs pertaining to bone loss around the predictable use of short implants to support prostheses.
sintered porous surfaced implants (Endopore) was However, note that 6-mm implants were splinted to longer
evaluated by Rokni, et al.20 They monitored (N = 198) implants to support prostheses. In contrast, Rossi, et al22
implants for 4 years that were 5- to 7-mm long (short monitored for 2 years 35 patients who received a total of 40,
implants) and implants 9- to 12-mm long (long implants). 6-mm long implants (Straumann) (19 with a 4.1-mm di-
Overall, implant restorations had a 1.5 CIR and ameter; 29 with a 4.8-mm diameter) that were not splinted
demonstrated a 98.2% survival rate. The range of CIRs was together. Their mean implant CIR was 1.5 (range 0.8 to 2.3)
0.81 to 3:1. The percentage of implants with a CIR between and the implant survival rate was 95%. The mean bone loss

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 Continuing Education

Importance of Crown to Root and Crown to Implant Ratios

Table 1. Crown to Implant Ratios (CIRs) of Implant Supported Prostheses
(Single Crowns, Fixed Partial Denture [FPD], Cantilevered Bridges)

CIRs of Implant Supported Single Crowns or FPD

Study Number of Implants CIR Percent Survivability
Schulte, et al17 889 1.3 mean 98.2%
Tawil and Younan18 262 a 99 %
30 <1 -
70 1 to 1.2 -
58 1.21 to 1.4 -
29 1.41 to 1.6 -
39 1.61 to 2 -
8 >2 -
Blanes, et al19 1.77 mean -
8 0 to 0.99 -
133 1 to 1.99 -
51 > 2b 91.4%
Rokni, et al20 1.5 mean 98.2%
22 0.81 to 1 -
156 1.1 to 2 -
20 >2 -
Nedir, et al21 111 1.55 to 1.97c 100
Rossi, et al22 40 1.5 mean 95%
range 0.8 to 2.3
Urdaneta, et al23 326 1.6 mean 98%
40 ≥2 95%
206 1.0 to 1.99 -
11 < 1.0 -
a mean CIR for all the implants was not provided, survival percentage is for all groups combined
b survival rates only provided for CIRs ≥ 2.
c CIR was computed related to specific implant lengths—6-mm long, CIR-1.97, n = 6; 8-mm long, CIR-1.59, n = 97; 9-mm long, CIR-1.55,
n = 8, 10-mm long.

CIRs of Implant Supported Cantilevered Prostheses

Study Number of Implants CIR Mean Length of Implants or Percent
Range of Sizes Survivability
Wennstrom, et al24 68 1.60 12.7 97%
Brägger, et al25 33 1.84 not recorded 98.4%
Hälg, et al26 46 1.65 6 to 12 mm 95.7%

for implants that lost bone (29 of 38 implants) between Recently, Urdaneta, et al23 assessed the effect of
loading and the 2-year followup was 0.43 mm. Two implants increased CIR with respect to bone loss and other prosthetic
failed and were removed before restorations were placed. complications. In more than a 70-month period, they

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 Continuing Education

Importance of Crown to Root and Crown to Implant Ratios

monitored 326 implants (Bicon)
whose mean CIR was 1.6. Forty a b
patients had a CIR > 2. They
concluded that an increased CIR did
not result in an increased amount of
bone loss, implant failure, or crown
failures, but there was an increased
amount of prosthetic problems
associated with an increased CIR
(eg, crown loosening [21/326] and

Figures 2a and 2b. Radiographs of unilateral fixed implant prosthesis (straight line splint). The
fracture of 2-mm wide posterior
abutments [3/61]). implant in the No. 21 position is 11.5-mm long and is encased in approximately 9.5 mm of bone. The
Another study specifically evalu- clinical crown is 11-mm long plus an abutment which has a 2 mm collar height. This results in a CIR
of 11 mm + 2 mm + 2 mm = 15 mm/9.5 mm = 1.57:1. The implant in the No. 19 position is 10-mm
ated bone loss related to CIRs (no long and is encased in 8 mm of bone while supporting an abutment with a cuff height of 1 mm plus a
survival data provided). Gomez-Polo, clinical crown, which is 12-mm long. This results in a crown to implant ratio of 12 mm + 1 mm + 2 mm
= 15 mm/8 mm = 1.87. The implant in the No. 18 position is 8-mm long and is encased in 6 mm of
et al27 assessed the correlation bone while supporting an abutment with a 1-mm cuff height and a crown which is 12-mm long. This
results in a CIR which is 12 mm + 1 mm + 2 mm = 15 mm/6 mm = 2.5. These implants benefit from
between crown-implant ratios and the fact that the definitive PFM prosthesis is splinted—at least in a straight line fashion.
Figure 2c. Intraoral
bone resorption in 69 patients with 85
view of the completed
c
cemented PFM splint.
implants. After 5.7 years, they reported that CIRs of 0.43 to
1.5 were not associated with peri-implant bone loss.
A systematic review by Blanes28 that addressed CIRs
included only 2 of the above studies,18,19 because
investigations did not meet their inclusion criteria (eg,
monitoring for > 4 years). They concluded that CIRs do not
Figure 3a. Maxillary Arch
Reconstruction. Intraoral
affect peri-implant crestal bone loss. In addition, they a
view of long custom
abutments attached to
reported that the survival rate of prostheses with a CIR of
more than 2 was 94.1%. Three other studies contained data short implants. The implant
lengths are in brackets
next to the corresponding
with respect to CIRs when implants were used to support
tooth: No. 5 (8 mm), No. 6
short span cantilevered bridges. 24-26 The reported CIRs, the
(10 mm), No. 7 (8 mm),
No. 10 (8 mm), No. 11
percentages of implant survival after 5 years, the number of
assessed implants for each study, and the mean or range (10 mm), No. 12 (8 mm).
of implant sizes are listed in Table 1. Elevated CIRs on b Figure 3b. The restored
lateral incisor is 20-mm long
and is supported by an
abutments for cantilevered bridges associated with
successful prostheses further support the concept that implant which is 8 mm long
(as part of a splinted
prosthesis). The restored
implant restorations can successfully tolerate CIR values
that were considered risky ratios for teeth. length of the tooth is in
excess of twice the length of
the corresponding implant
From a different perspective, there are still unanswered
questions. For instance, Blanes28 questioned if the fulcrum (CIR is 2.5). In actuality, the
abutment adds 2 additional
point for prostheses with a large CIR is at the crown implant milli-meters to the “crown”
results in larger CIRs (Figures 1, 2a portion of the equation,
rendering the crown to root
connection or at the most coronal bone-implant contact
area. Most studies used the former for measurements, and to 2c, and 3a to 3g). The authors ratio 22/8 = 2.75:1. Since
suggested that the bone-implant this 8 mm implant is approx-
imately 7 mm in bone on
only his investigation19 used the bone-implant contact area
as the fulcrum point to calculate CIRs. Obviously, the latter contact area was probably the the radiograph, the ultimate
CIR is about 2.87:1.

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 Continuing Education

Importance of Crown to Root and Crown to Implant Ratios

fulcrum, because components connected to the implant c
were stronger than the cortical bone. Another issue not
resolved relates to how different prosthetic designs (eg,
single crowns (Figure 1), fixed partial dentures, straight-line Figure 3c. Intraoral
retracted view of the
cemented PFM
splinting (Figures 2a to 2c), splinting around a curve of an
arch (Figures 3a to 3g) impact on the relationship between prosthesis described in
CIRs and peri-implant bone loss, technical problems and Figure 3b.

survival of prostheses.
The authors of this review paper agree with Blanes28
with respect to defining the clinical crown portion as the
restored crown plus the abutment collar plus the part of the
implant not encased in bone (Figures 1 to 3g). In other
words, the level of the bone is considered the fulcrum for
computing CIRs. This does not preclude that a potential
weak point of prosthetic failure may occur at the abutment-
implant interface. However, the most important fulcrum
point exists at the level of the most coronal bone to implant
contact. This is the location where the applied forces and
strains they create are resisted by the bone.
SHORT VERSUS LONG DENTAL IMPLANTS
In general, finite elemental analysis studies indicated that
forces on dental implants are transferred to the bone crest
adjacent to implants29,30 and a small amount of stress is
conveyed to the apical region.30 These data provide an
important premise supporting the use of short implants.
Namely, if stresses are placed at the crest after
osseointegration occurred, then the length of the implant
might not be the crucial factor with regard to distributing
d
Figure 3d. Smile-line of
the definitive prosthesis
in place.
prosthetic loads to the interface between bone and the
implant. Accordingly, it is important to assess the survival of
short implants, which usually have increased CIRs when
restored. However, there are many variables (Table 2)31 that
make it difficult to compare success rates in different studies.
Nevertheless, the preponderance of data indicate that short
implants are very successful and that survival rates for short
textured implants are comparable to longer implants.31-34
In this regard, 4 review papers evaluated survivability of
short dental implants and concluded that they could
predictably be employed to support prostheses.31-34 Recently,
a systematic review concluded that there was no statistically
significant difference in survival rates between short (≤ 8 or ≤
10 mm) and conventional (> 10 mm) rough surfaced implants
placed in totally or partially edentulous patients.35

Table 2. Variables and Confounding Factors When Comparing Studies With Respect to Survivability
of Short Implants31
PATIENT: Systemic health, smoking status, periodontal status, parafunction, personal hygiene, professional
maintenance
IMPLANTS: Type, length, width, surface characteristics, shape, internal connection, external connection
BONE TYPE: I, II, II, IV
SURGERY: Skill of surgeon, bone grafting or not
PROSTHESIS: Splinted or not, crown to implant ratio, fixed partial denture, cantilever
SURVIVAL RATE: Size of the study, duration of monitoring period
Modified from Morand and Irinakis31

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Importance of Crown to Root and Crown to Implant Ratios

Historically, studies indicated longer implants had a e
greater survival rate than shorter implants when a 10-mm
length was used as the cut point.36 Renouard and Nisand32
documented that 11 of 12 investigations reported a higher
failure rate with short implants than longer implants when
machine surface implants were used.37-47 The 12th study
employed machined and hydroxyapatite-coated implants.48
In contrast, Renouard and Nisand32 reported that 9 studies
indicated that implant length did not affect the survival rate
and 6 of the 9 investigations included in their assessment
used textured surface implants.49-54
Many older studies and 7 recent investigations published
between 2006 and 201033,55-60 all indicated that short implants
had a high survival rate and could predictably be used to
support crowns and prostheses (Table 3).18,21,33,52,55-63
Currently, textured surface implants are usually employed.33
f
VERTICAL CANTILEVER FORCES
With regards to the biomechanics of increasing the crown to
root or implant ratio, as a crown becomes larger, bending
moments can detrimentally affect a prosthesis. To compute the
magnitude of a force moment, it is necessary to multiply the
force by the perpendicular distance (moment arm) from the
fulcrum to the endpoint of the lever arm.64 Conceptually, the
occlusal height of a crown should not affect the force moment
along the vertical axis, because if it is centered, its effective
moment arm is nonexistent.64 However, noncentered occlusal
contacts or lateral loads are prevalent and can induce
considerable moment arms, thereby torquing the prosthesis.
Therefore, as the clinical crown to implant length increases, g
there is a greater lever arm that potentially can amplify stress
on the restoration. It is evident that with a larger clinical crown
and smaller implant there potentially will be a bigger lever arm.
Bidez and Misch65 indicated that when a crown height is
Maxillary right, anterior,
Figures 3e, 3f, and 3g.
increased from 10 to 20 mm there is a 100% increase of force
and left side radiographs
of the patient depicting
on the implant. In addition, angulation is a force magnifier and
Misch and Bidez66 noted that a 12° angle increased the force the CIRs. These implants
benefit from the cross-
arch splinting of the
on an implant by 20%.
Increased stress has the potential to decrease definitive prosthesis.
survivability of prostheses or create biological and technical that usually manifest an increased CIR have demonstrated
problems. Fortunately, prostheses with increased CIRs high survival rates (Table 3). The precise height that cannot
from one to 2 have demonstrated a high survivability rate be exceeded to avoid de-osseointegration or fracture of an
(Table 1). Similarly, short implants that support prostheses implant is unknown and will be affected by factors such as

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Importance of Crown to Root and Crown to Implant Ratios

Table 3. Studies Dedicated to Assessing Survival Rates of Short Dental Implantsa

Study n No. of implants Length Type Surface Survival Rate Time

Anitua, et al56 293 532 7 to 8.5 mm BTI rough 99.2% 31 months

Arlin, et al55 not reported 35 6 mm ITI rough 94.3% 2 years

not reported 141 8 mm 99.3%

Fugazzotto33 1,774 2,073 6 to 9 mm ITI rough 98.4% 36.2 months

Goene, et al61 188 311 7 to 8.5 Osteotite acid etched 95.8% 3 years

Grant, et al57 124 355 8 mm Nobel not reported 99% < 1 to ≥2 years

Griffin, et al58 167 168 8 mm SO, Nobel HA coated 100% 34.9 months

Malo, et al59 237 408 7 and 8.5 mm Nobel machined/TiUnite 96 to 97% 5 years

Misch, et al60 273 715 9 mm BTI rough 99.2% 12 to 60 months

30 7 mm

Nedir, et al21 236 264 6 to 9 mm ITI TPS 100% 7 years

264 SLA

Tawil, Younan18 111 269 7 to < 10 mm Nobel machined 95.5% 12 to 92 months

Testori et al52 not reported 31 7 to 8.5 mm Osteotite acid-etched 96.7% 4 years

van Steenberghe, et al62 - 10 8 mm Astra rough 100% 2 years

- 6 9 mm

ten Bruggenkate, et al63 126 253 6 mm ITI TPS 97% 1 to 7 years

a Studies listed alphabetically.

implant diameter, splinting of implants, and magnitude,
duration, frequency, and direction of occlusal forces.
Studies have indicated that with increased CIRs there
was no additional bone loss compared to locations that did
not have increased CIRs.17-20,24,26 In general, there is a
dearth of information that addresses how often technical
complications occur around restorations with increased CIRs
pertaining to various prosthetic designs: single tooth, straight-
line splint, or fixed restorations that have cross arch
stabilization. Of the 7 studies listed in Table 1 that discussed
CIRs, only 2 reported the occurrence of technical
problems.18,23 Tawil and Younan18 noted the incidence of
screw loosening (7.8%) and porcelain fractures (5.2%)
among teeth with increased CIRs. These data are within the
23% technical complication rate for implant supported FDPs
noted in the systematic review by Berglundh, et al.67
Urdaneta, et al23 reported 3 fractures (3/61) of the 2-mm wide
abutments used in the posterior areas when the CIR was 1.47
and no fractures among 3-mm wide abutments (184/184)
when there was an increased CIR. They also noted that 21 of
326 crowns loosened during the observation period and 90%
of the time this occurred in the maxillary anterior region. It was
suggested that splinting of multiple adjacent implants might
have avoided these undesirable sequelae.
Several studies that assessed the utility of horizontal
cantilevers also recorded increased CIRs (Table 1).24-26
These investigations usually reported minor technical
problems associated with short span cantilevered bridges
that had increased CIRs (see Aglietta, et al68 for review).
While both vertical and horizontal cantilevers may in-
crease stress on implants and the prosthesis that they
support, the resultant problems may not be exactly similar.
For instance, a prosthesis with an increased CIR due to a
vertical cantilever may be supported on both ends with a
terminal abutment and this may alter the types of technical
problems that may occur.
Other investigations that assessed the survival of
short implants did not address technical problems that
may occur if an increased CIR was created upon
prosthesis fabrication. 32-35 At present, no definitive

8

Importance of Crown to Root and Crown to Implant Ratios
Table 4. Clinical Suggestions for Restoring Teeth With Increased
Crown to Implant Ratios
1. In posterior areas, restore the occlusal surfaces of teeth in such a
manner that the patient’s incisal or canine guidance discludes the
posterior teeth and minimizes lateral contact in mandibular
excursions.60
2. Increase the number of implants supporting the prosthesis. This adds
to the surface area where occlusal forces are transmitted.
3. Increase the bone implant contact area with wider implants.
4. Reduce the occlusal width of posterior teeth and have centric contacts
centered over the implants.31
5. Avoid elevated CIR in bruxers or over engineer the case with
additional implants and splint around the turn of the arch with the
restoration when possible.
6. Patients can wear a night guard to reduce nocturnal stresses on the
prosthesis.
7. Short implants should be splinted together to maximize their support
of the prosthesis and provide cross arch stabilization when
possible.12,65
8. Use textured-surfaced implants that have a higher percentage of bone
implant contact.
9. Flatten cuspal inclines.31
10. Employ implants with decreased thread pitch (distance between the
threads), thereby resulting in an increased number of threads per
unit length and an increased surface area.60 However, there are no
data that the thread pitch altered the survival rate of prostheses with
increased CIRs.
REFERENCES
1.
statements can be made about an increased rate of
technical problems associated with increased CIRs, since
2.
this issue has not been highly documented in studies.
CONCLUSIONS
3.
The available data (Table 1) demonstrate that prostheses
with increased CIRs up to 2 have a high survival rate.
Furthermore, increased CIRs did not result in additional
peri-implant bone loss.17,19,20,23-26 Therefore, when there is
4.
a dearth of bone or anatomic structures that preclude
placement of longer implants, treatment planning a
prosthesis that results in an increased CIR is a reasonable,
predictable procedure. Furthermore, since placement of
9
Continuing Education
short implants often results in increased CIRs,
the clinical implication is that short implants (<
10 mm) can be used to support a prosthesis
and do not result in early demise of a
restoration. Ultimately, when necessary,
utilization of short implants and prostheses
with increased CIRs provide greater flexibility
when treatment planning patients.
These conclusions are in agreement with
recent statements by the European Association for
Osseointegration,69 which indicated the following:
 Consensus statement: “Restorations with
a CIR up to 2 do not induce peri-implant
bone loss.”
 Clinical implications: “A FDP or single-tooth
restoration with a CIR up to 2 is an accep-
table prosthetic option.”
Nevertheless, it is recognized that a
prosthesis with an increased CIR is subject to
increased occlusal forces. This can result in
amplified stress on the prosthesis and the
surrounding bone.70,71 Accordingly, it is
advantageous to reduce forces on restorations
with an increased CIR. Ten suggestions are
listed in Table 4 for how to diminish stresses on
prostheses with an increased CIR, thereby
possibly reducing biological and technical
complications and increasing the survivability
of these constructs.
Ante IH. The fundamental principles of abutments.
Mich State Dent Soc Bull. 1926;8:232-257.
Greenstein G, Greenstein B, Cavallaro J. Prerequisite for
treatment planning implant dentistry: periodontal prognosti-
cation of compromised teeth. Compend Contin Educ Dent.
2007;28:436-447.
Lulic M, Brägger U, Lang NP, et al. Ante’s (1926) law revisited:
a systematic review on survival rates and complications of
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periodontal tissue support. Clin Oral Implants Res.
2007;18(suppl 3):63-72.
Pjetursson BE, Tan K, Lang NP, et al. A systematic review of
the survival and complication rates of fixed partial dentures
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Cantilever or extension FPDs. Clin Oral Implants Res.
2004;15:667-676.

Importance of Crown to Root and Crown to Implant Ratios
5. Tan K, Pjetursson BE, Lang NP, et al. A systematic review of
the survival and complication rates of fixed partial dentures
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Conventional FPDs. Clin Oral Implants Res. 2004;15:654-666.
6. Grossmann Y, Sadan A. The prosthodontic concept of
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7. Dykema RW, Goodacre CJ, Phillips RW. Johnston’s Modern
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WB Saunders; 1986:8-21.
8. Shillingburg HT Jr, Hobo S, Whitsett LD, et al. Fundamentals
of Fixed Prosthodontics. 3rd ed. Chicago, IL: Quintessence
Publishing; 1997:89-90.
9. Langer Y, Langer A. Root-retained overdentures: Part I—
Biomechanical and clinical aspects. J Prosthet Dent.
1991;66:784-789.
10. Schluger S, Yuodelis RA, Page RC, et al. Periodontal
Occlusal and Restorative Interrelationships. 2nd ed.
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Philadelphia, PA: Lea & Febiger; 1990:405-412.
11. Faucher RR, Bryant RA. Bilateral fixed splints. Int J
Periodontics Restorative Dent. 1983;3:8-37.
12. Guichet DL, Yoshinobu D, Caputo AA. Effect of splinting and
interproximal contact tightness on load transfer by implant
restorations. J Prosthet Dent. 2002;87:528-535.
13. Grossmann Y, Finger IM, Block MS. Indications for splinting
implant restorations. J Oral Maxillofac Surg. 2005;63:1642-1652.
14. Misch CE, Goodacre CJ, Finley JM, et al. Consensus
conference panel report: crown-height space guidelines for
implant dentistry—part 2. Implant Dent. 2006;15:113-121.
15. Rangert BR, Sullivan RM, Jemt TM. Load factor control for
implants in the posterior partially edentulous segment. Int J
Oral Maxillofac Implants. 1997;12:360-370.
16. Glantz PO, Nilner K. Biomechanical aspects of prosthetic
implant-borne reconstructions. Periodontol 2000.
1998;17:119-124.
17. Schulte J, Flores AM, Weed M. Crown-to-implant ratios of single
tooth implant-supported restorations. J Prosthet Dent. 2007;98:1-5.
18. Tawil G, Younan R. Clinical evaluation of short, machined-
surface implants followed for 12 to 92 months. Int J Oral
Maxillofac Implants. 2003;18:894-901.
19. Blanes RJ, Bernard JP, Blanes ZM, et al. A 10-year
prospective study of ITI dental implants placed in the
posterior region. II: Influence of the crown-to-implant ratio
and different prosthetic treatment modalities on crestal bone
loss. Clin Oral Implants Res. 2007;18:707-714.
20. Rokni S, Todescan R, Watson P, et al. An assessment of
crown-to-root ratios with short sintered porous-surfaced
implants supporting prostheses in partially edentulous
patients. Int J Oral Maxillofac Implants. 2005;20:69-76.
21. Nedir R, Bischof M, Briaux JM, et al. A 7-year life table
analysis from a prospective study on ITI implants with
special emphasis on the use of short implants. Results from
a private practice. Clin Oral Implants Res. 2004;15:150-157.
22. Rossi F, Ricci E, Marchetti C, et al. Early loading of single
10
Continuing Education
crowns supported by 6-mm-long implants with a moderately
rough surface: a prospective 2-year follow-up cohort study.
Clin Oral Implants Res. 2010;21:937-943.
23. Urdaneta RA, Rodriguez S, McNeil DC, et al. The effect of
increased crown-to-implant ratio on single-tooth locking-taper
implants. Int J Oral Maxillofac Implants. 2010;25:729-743.
24. Wennström J, Zurdo J, Karlsson S, et al. Bone level change at
implant-supported fixed partial dentures with and without
cantilever extension after 5 years in function. J Clin Periodontol.
2004;31:1077-1083.
25. Brägger U, Karoussis I, Persson R, et al. Technical and
biological complications/failures with single crowns and fixed
partial dentures on implants: a 10-year prospective cohort
study. Clin Oral Implants Res. 2005;16:326-334.
26. Hälg GA, Schmid J, Hämmerle CH. Bone level changes at
implants supporting crowns or fixed partial dentures with or
without cantilevers. Clin Oral Implants Res. 2008;19:983-990.
27. Gomez-Polo M, Bartens F, Sala L, et al. The correlation
between crown-implant ratios and marginal bone resorption: a
preliminary clinical study. Int J Prosthodont. 2010;23:33-37.
28. Blanes RJ. To what extent does the crown-implant ratio
affect the survival and complications of implant-supported
reconstructions? A systematic review. Clin Oral Implants
Res. 2009;20(suppl 4):67-72.
29. Lum LB. A biomechanical rationale for the use of short implants.
J Oral Implantol. 1991;17:126-131.
30. Rieger MR, Mayberry M, Brose MO. Finite element analysis of
six endosseous implants. J Prosthet Dent. 1990;63:671-676.
31. Morand M, Irinakis T. The challenge of implant therapy in the
posterior maxilla: providing a rationale for the use of short
implants. J Oral Implantol. 2007;33:257-266.
32. Renouard F, Nisand D. Impact of implant length and
diameter on survival rates. Clin Oral Implants Res.
2006;17(suppl 2):35-51.
33. Fugazzotto PA. Shorter implants in clinical practice: rationale
and treatment results. Int J Oral Maxillofac Implants.
2008;23:487-496.
34. Misch CE. Short dental implants: a literature review and
rationale for use. Dent Today. 2005;24:64-68.
35. Kotsovilis S, Fourmousis I, Karoussis IK, et al. A systematic
review and meta-analysis on the effect of implant length on the
survival of rough-surface dental implants. J Periodontol.
2009;80:1700-1718.
36. Goodacre CJ, Campagni WV, Aquilino SA. Tooth preparations
for complete crowns: an art form based on scientific principles.
J Prosthet Dent. 2001;85:363-376.
37. van Steenberghe D, Lekholm U, Bolender C, et al. Applicability
of osseointegrated oral implants in the rehabilitation of partial
edentulism: a prospective multicenter study on 558 fixtures. Int J
Oral Maxillofac Implants. 1990;5:272-281.
38. Friberg B, Jemt T, Lekholm U. Early failures in 4,641
consecutively placed Brånemark dental implants: a study from
stage 1 surgery to the connection of completed prostheses. Int
J Oral Maxillofac Implants. 1991;6:142-146.
39. Jemt T. Failures and complications in 391 consecutively

Importance of Crown to Root and Crown to Implant Ratios
inserted fixed prostheses supported by Brånemark implants in
edentulous jaws: a study of treatment from the time of
prosthesis placement to the first annual checkup. Int J Oral
Maxillofac Implants. 1991;6:270-276.
40. Bahat O. Treatment planning and placement of implants in the
posterior maxillae: report of 732 consecutive Nobelpharma
implants. Int J Oral Maxillofac Implants. 1993;8:151-161.
41. Jemt T, Lekholm U. Implant treatment in edentulous
maxillae: a 5-year follow-up report on patients with different
degrees of jaw resorption. Int J Oral Maxillofac Implants.
1995;10:303-311.
42. Wyatt CC, Zarb GA. Treatment outcomes of patients with
implant-supported fixed partial prostheses. Int J Oral
Maxillofac Implants. 1998;13:204-211.
43. Lekholm U, Gunne J, Henry P, et al. Survival of the
Brånemark implant in partially edentulous jaws: a 10-year
prospective multicenter study. Int J Oral Maxillofac Implants.
1999;14:639-645.
44. Bahat O. Brånemark system implants in the posterior
maxilla: clinical study of 660 implants followed for 5 to 12
years. Int J Oral Maxillofac Implants. 2000;15:646-653.
45. Naert I, Koutsikakis G, Duyck J, et al. Biologic outcome of
implant-supported restorations in the treatment of partial
edentulism. Part I: a longitudinal clinical evaluation. Clin
Oral Implants Res. 2002;13:381-389.
46. Weng D, Jacobson Z, Tarnow D, et al. A prospective
multicenter clinical trial of 3i machined-surface implants:
results after 6 years of follow-up. Int J Oral Maxillofac Implants.
2003;18:417-423.
47. Herrmann I, Lekholm U, Holm S, et al. Evaluation of patient
and implant characteristics as potential prognostic factors for
oral implant failures. Int J Oral Maxillofac Implants.
2005;20:220-230.
48. Winkler S, Morris HF, Ochi S. Implant survival to 36 months as
related to length and diameter. Ann Periodontol. 2000;5:22-31.
49. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term
evaluation of non-submerged ITI implants. Part 1: 8-year life
table analysis of a prospective multicenter study with 2359
implants. Clin Oral Implants Res. 1997;8:161-172.
50. Ellegaard B, Baelum V, Karring T. Implant therapy in
periodontally compromised patients. Clin Oral Implants Res.
1997;8:180-188.
51. Brocard D, Barthet P, Baysse E, et al. A multicenter report on
1,022 consecutively placed ITI implants: a 7-year
longitudinal study. Int J Oral Maxillofac Implants.
2000;15:691-700.
52. Testori T, Wiseman L, Woolfe S, et al. A prospective multicenter
clinical study of the Osseotite implant: four-year interim report.
Int J Oral Maxillofac Implants. 2001;16:193-200.
53. Feldman S, Boitel N, Weng D, et al. Five-year survival
distributions of short-length (10 mm or less) machined-
surfaced and Osseotite implants. Clin Implant Dent Relat
Res. 2004;6:16-23.
54. Romeo E, Lops D, Margutti E, et al. Long-term survival and
success of oral implants in the treatment of full and partial
arches: a 7-year prospective study with the ITI dental implant
11
Continuing Education
system. Int J Oral Maxillofac Implants. 2004;19:247-259.
55. Arlin ML. Short dental implants as a treatment option: results
from an observational study in a single private practice. Int J
Oral Maxillofac Implants. 2006;21:769-776.
56. Anitua E, Orive G, Aguirre JJ, et al. Five-year clinical
evaluation of short dental implants placed in posterior areas: a
retrospective study. J Periodontol. 2008;79:42-48.
57. Grant BT, Pancko FX, Kraut RA. Outcomes of placing short
dental implants in the posterior mandible: a retrospective study
of 124 cases. J Oral Maxillofac Surg. 2009;67:713-717.
58. Griffin TJ, Cheung WS. The use of short, wide implants in
posterior areas with reduced bone height: a retrospective
investigation. J Prosthet Dent. 2004;92:139-144.
59. Maló P, de Araújo Nobre M, Rangert B. Short implants
placed one-stage in maxillae and mandibles: a retrospective
clinical study with 1 to 9 years of follow-up. Clin Implant
Dent Relat Res. 2007;9:15-21.
60. Misch CE, Steignga J, Barboza E, et al. Short dental implants
in posterior partial edentulism: a multicenter retrospective 6-
year case series study. J Periodontol. 2006;77:1340-1347.
61. Goené R, Bianchesi C, Hüerzeler M, et al. Performance of
short implants in partial restorations: 3-year follow-up of
Osseotite implants. Implant Dent. 2005;14:274-280.
62. van Steenberghe D, De Mars G, Quirynen M, et al. A
prospective split-mouth comparative study of two screw-shaped
self-tapping pure titanium implant systems. Clin Oral Implants
Res. 2000;11:202-209.
63. ten Bruggenkate CM, Asikainen P, Foitzik C, et al. Short (6-mm)
nonsubmerged dental implants: results of a Multicenter clinical trial
of 1 to 7 years. Int J Oral Maxillofac Implants. 1998;13:791-798.
64. Bidez MW, Misch CE. Biomechanics. In: Misch CE.
Contemporary Implant Dentistry. 3rd ed. St. Louis, MO:
Mosby; 2008:557-598.
65. Bidez MW, Misch CE. Force transfer in implant dentistry: basic
concepts and principles. J Oral Implantol. 1992;18:264-274.
66. Misch CE, Bidez MW. Implant-protected occlusion: a
biomechanical rationale. Compendium. 1994;15:1330-1334.
67. Berglundh T, Persson L, Klinge B. A systematic review of the
incidence of biological and technical complications in implant
dentistry reported in prospective longitudinal studies of at least
5 years. J Clin Periodontol. 2002;29(suppl 3):197-212.
68. Aglietta M, Siciliano VI, Zwahlen M, et al. A systematic
review of the survival and complication rates of implant
supported fixed dental prostheses with cantilever extensions
after an observation period of at least 5 years. Clin Oral
Implants Res. 2009;20:441-451.
69. Sanz M, Naert I; Working Group 2. Biomechanics/risk
management (Working Group 2). Clin Oral Implants Res.
2009;20(suppl 4):107-111.
70. Akça K, Iplikçio lu H. Finite element stress analysis of the
effect of short implant usage in place of cantilever
extensions in mandibular posterior edentulism. J Oral
Rehabil. 2002;29:350-356.
71. Tawil G, Aboujaoude N, Younan R. Influence of prosthetic
parameters on the survival and complication rates of short
implants. Int J Oral Maxillofac Implants. 2006;21:275-282.
 Continuing Education

Importance of Crown to Root and Crown to Implant Ratios

POST EXAMINATION INFORMATION
To receive continuing education credit for participation in 2. With respect to teeth, the following procedures
this educational activity you must complete the program reduce the CRRs:
post examination and receive a score of 70% or better. a. A low profile overdenture abutment.
b. Tooth extrusion.
Traditional Completion Option:
c. Both A and B.
You may fax or mail your answers with payment to Dentistry
d. Occlusal onlays.
Today (see Traditional Completion Information on following
page). All information requested must be provided in order 3. Strategies to consider when fabricating fixed dental
to process the program for credit. Be sure to complete your prostheses with increased CIRs include the
“Payment,” “Personal Certification Information,” “Answers,” following:
and “Evaluation” forms. Your exam will be graded within 72 a. Minimize lateral excursions on posterior prostheses
hours of receipt. Upon successful completion of the post- and increase the number of supporting implants.
exam (70% or higher), a letter of completion will be mailed b. Increase clinical crown height.
to the address provided. c. Employ textured surfaced implants.
Online Completion Option: d. Both A and C.
Use this page to review the questions and mark your 4. In this review paper, the authors define the clinical
answers. Return to dentalcetoday.com and sign in. If you crown as:
have not previously purchased the program, select it from a. The sum of the restored crown plus the abutment
the “Online Courses” listing and complete the online collar plus the portion of the implant coronal to the
purchase process. Once purchased the program will be bone.
added to your User History page where a Take Exam link b. The height of the titanium abutment minus 2 mm for
will be provided directly across from the program title. biologic width space.
Select the Take Exam link, complete all the program c. The sum of the interarch space plus the height of the
restored crown plus the height of the abutment.
questions and Submit your answers. An immediate grade
report will be provided. Upon receiving a passing grade, d. The height of the restored crown.
complete the online evaluation form. Upon submitting the 5. In the study of increased CIRs by Rossi, et al the
form your Letter Of Completion will be provided assessed implants were:
immediately for printing. a. The 6-mm long implants.
General Program Information: b. The 4.1-mm diameter implants and the 4.8-mm
Online users may log in to dentalcetoday.com any time in diameter implants.
the future to access previously purchased programs and c. Splinted implants.
view or print letters of completion and results. d. Both A and B.

6. To calculate the bending moment, it is necessary to

POST EXAMINATION QUESTIONS multiply the force by what?
a. The perpendicular distance (moment arm) from the
1. Factors which influence the number of abutments to
fulcrum to the endpoint of the lever arm.
support a fixed dental prosthesis (FDP) include
which of the following? b. The perpendicular distance (moment arm) from the
fulcrum to the apex of the tooth.
a. Number of missing teeth.
c. The perpendicular distance (moment arm) from the
b. Anticipated occlusal forces. fulcrum to the cemento-enamel junction.
c. Amount of available bone around abutments. d. The perpendicular distance (moment arm) from the
d. All of the above. fulcrum to closest tooth.

12
 Continuing Education

Importance of Crown to Root and Crown to Implant Ratios

7. In the study pertaining to increased CIRs by Blanes, b. Are very successful and that survival rates for short
et al the assessed implants had which features? smooth surfaced implants are comparable to longer
a. Monitored for 2.5 years. implants.
b. Restored with CIRs of 6 or more. c. Are not very successful and that survival rates for
short textured implants are not comparable to longer
c. Smooth surfaced implants. implants.
d. None of the above. d. Are not very successful.

8. In this review paper, the authors define the location 13. According to Bidez and Misch, when a crown height
of the fulcrum between the clinical crown and the is increased from 10 to 20 mm, the increase of force
implant as: on an implant is how large?
a. Occurring at the junction of the restoration and the a. 25%.
implant abutment.
b. 50%.
b. Occurring at the level of the first bone to implant
contact. c. 75%.
c. Occurring at the implant-abutment interface. d. 100%.
d. Occurring within the body of the implant half way 14. The European Association for Osseointegration
from the osseous crest to the apex of the implant. reached which of the following conclusions?
9. Factors which will affect an implant’s ability to resist a. Restorations with a CIR up to 2 do not induce peri-
biologic and technical complications include: implant bone loss.
a. Increasing implant diameter. b. FDP or single-tooth restoration with a CIR up to 2 is
an acceptable prosthetic option.
b. Use of porcelain fused to metal crowns.
c. Both A and B.
c. Splinting of implants, particularly across the turn of
the arch. d. Restorations with a CIR up to 1 do not induce peri-
implant bone loss.
d. Both A and C.
15. Techniques to reduce forces on restorations with an
10. Which procedures increase the CRR with respect to increased CIR include which of the following?
teeth?
a. Restore the posterior occlusal surfaces of teeth so
a. Increasing vertical dimension. canine guidance discludes the posterior teeth
b. Surgical crown lengthening. and minimizes lateral contact in mandibular
c. Both A and B. excursions.
d. Ridge augmentation. b. Increase the number of implants supporting the
prosthesis.
11. Urdaneta, et al demonstrated that an increased CIR c. Increase the bone implant contact area with wider
resulted in what effect on bone around the dental implants.
implants? d. All of the above.
a. Additional bone loss.
16. What is the precise crown to implant ratio that
b. No additional bone loss.
cannot be exceeded to avoid deosseointegration or
c. Bone apposition. fracture of an implant?
d. Increased osseous density of bone. a. Unknown.
12. The preponderance of data in Table 3 indicate that b. 1.
short implants demonstrate which characteristic? c. 1.5.
a. Are very successful and that survival rates for short d. 2.
textured implants are comparable to longer implants.

13
 Continuing Education

Importance of Crown to Root and Crown to Implant Ratios

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