Short Implant in Limited Bone Volume PDF

Periodontology 2000, Vol.
66, 2014, 7296

Printed in Singapore. All rights reserved
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
Short implant in limited bone

volume
DAVID NISAND & FRANCK RENOUARD
Introduction
Rehabilitation of severely resorbed jaws with dental
implants remains a surgical and prosthetic challenge
for clinicians (25, 53). Several advanced surgical techniques have been developed over the years to restore
bone volume, allowing the placement of dental
implants and improving esthetic outcomes. The same
surgical techniques have also been applied to
improve crown-to-implant ratios, to allow the placement of longer implants and to optimize the positioning of implants for adequate load distribution.
However, the latter indications remain controversial,
and the increased treatment time, cost and risk of
complications should be analyzed in line with the
expected benets.
Sinus lift elevation, guided bone regeneration,
onlay bone grafting, distraction osteogenesis and displacement of the inferior alveolar nerve were developed and applied for the management of reduced
alveolar bone height. Some of these techniques, such
as sinus lift elevation, are supported by a large number of publications and display excellent survival rates
for dental implants (18). On the other hand, less data
are available for surgical displacement of the inferior
alveolar nerve, vertical augmentation or distraction
osteogenesis (26, 94, 107). Moreover, long-term follow-up studies of dental implants placed in augmented bone are not available for each technique.
Even for the well-documented technique of sinus lift
elevation, it should be remembered that the best
results, obtained with rough surface implants and
biomaterial, are based only on short-term follow-up
studies (87).
Complex surgical techniques are often associated
with complications (42). Complications may occur
during surgery (such as bleeding (Fig. 1), perforation
of the Schneiderian membrane (Fig. 2AD) or nerve
injury) or postoperatively (including transiently or
72
permanently altered mandibular sensation (25), graft

and/or membrane exposure (Fig. 3), infections (122)
and increased peri-implant bone loss (88)). Even
when the risk for complications is limited, advanced
surgical techniques may be contraindicated in some
patients for medical or anatomic reasons. As an alternative to complex surgeries (those performed to allow
the placement of longer implants or for biomechanical reasons), the use of dental implants with reduced
length should be considered. Along with their simplicity, short-length implants allow for less expensive
and faster treatment with reduced morbidity (43, 44).
However, both survival rate and indications are still
controversial. In the past, short-length implants were
often associated with increased failure rates (125),
which were explained by reduced implant primary
stability and bone-to-implant contact, as well as by
unfavorable crown-to-implant ratios. As a consequence, the use of short-length implants was mainly
restricted to rescue situations.
The purpose of this review was to evaluate the data
available on the survival rate of short and extra-short
implants and to discuss the impact of an increased
crown to implant length ratio on biological and technical complications. Indications and clinical procedures for short-length implants in clinical practice are
also reviewed, along with a discussion on the selection of the implant length. The paper also introduces
a new concept in implant dentistry: stress-minimizing
surgery.
Denition
There is still some controversy over the exact denition of a short-length implant. According to Striezel
& Reichart (112), an implant of 11 mm is considered as short, whereas Tawil & Younan (114) stated
that an implant must be 10 mm to be regarded as
Short implant in limited bone volume
Fig. 1. Clinical view of the alveolar artery that may lead to

bleeding complications during sinus lift procedures.
short. In one recent systematic review (116) and in

one recent meta-analysis (89), all implants of
<10 mm were dened as short implants. For the
purposes of this review, a short implant will be
dened as an implant with a designed intrabony
length of 8 mm (92) (Fig. 4) and an extra-short
implant as a device with a designed intrabony
length of 5 mm.
Survival rates of short-length

implants
Short implants
The survival rate of short-length implants has mostly
been evaluated in case series with either a retrospective or a prospective design. A case series design can
be dened as a collection of patients in whom dental

implants of different lengths were placed and monitored for a specied period of time (95). The impact
of implant length, among other parameters, was evaluated with respect to implant failure and/or bone loss
(Table 1).
In the rst group of papers, some publications
report an increased failure rate with shorter implants
compared with longer implants (6, 7, 63, 65, 82,
123125). Of these, Winkler et al. (124) reported an
overall survival rate of 74.4% for 7-mm-long implants
and Herrmann et al. (63) revealed an overall survival
rate of 78.2% for 7-mm-long implants. A second
group of papers, although concluding that failure
rates increased with short implants, still listed adequate survival rates for short-length implants (51, 64,
70, 121). For example, in the paper by van Steenberghe et al. (121), only three failures were reported
among 120 placements of 7-mm-long implants, leading to an overall survival rate of 97.5% after 1 year of
follow-up. Some descriptive studies have reported
that the outcome with short-length implants is similar to that for longer implants (20, 21, 40, 46, 61, 67,
71, 83, 98, 99, 111, 118).
A structured review explained differences, among
studies, in the survival rates of short-length implants
according to the following parameters: implant primary stability related to surgical bone preparation;
operators learning curve; implant surfaces; and the
quality of the patients bone (92). More recently, case
series dedicated to short-length implants were
Fig. 2. (A) Clinical view of a full-thickness ap elevation reaching the buccal wall of the sinus in order to perform a sinus
lift procedure. (B) The trap door is created using piezosurgery to reduce the risk of membrane perforation. (C) Clinical view
showing the trap door. (D) Clinical view of membrane perforation (despite the use of piezosurgery).
73
Nisand & Renouard
Fig. 3. Exposure of a titanium-reinforced membrane used

for a vertical augmentation procedure in the posterior
mandible.
Fig. 4. Periapical radiograph of a short (8 mm) implant

after 5 years of loading.
performed with either a retrospective or a prospective

design (Table 2). Among this group of publications,
there is great discrepancy in the denition of a short
implant. Some authors only included implants with a
designed intrabony length of 8 mm, whereas others
included longer implants (13, 32, 33, 54, 103, 110, 114,
119).
One of the rst case series with a special emphasis
on short-length implants was published by Texeira
et al. (119). They followed 67 implants, with a mean
length of 8.3 mm and placed in the posterior mandible, over a period of 5 years and reported a cumulative survival rate of 94%. The efcacy of short-length
implants in the restoration of the posterior mandible
was also conrmed by many other authors (1, 2, 33,
37, 38, 5558, 75, 86, 114). Positive outcomes were
also reported with severely resorbed edentate mandibles by several authors (34, 52, 60, 110) . Friberg et al.
(52) followed 49 edentulous patients restored with
260 short implants (67 mm in length) and reported
cumulative survival rates of 95.5% and 92.3% after 5
and 10 years, respectively. In 1998, a multicenter
study, with 17 years of follow-up, was performed by
ten Bruggenkate et al. (117), who evaluated the survival rate of 253, 6-mm-long implants in a group of
126 patients. They reported a cumulative survival
74
rate of 94%. Of the seven implants removed, six were

located in the maxilla, and the authors recommended that short implants should be used in conjunction with longer implants in low-density bone.
The possibility of using short implants for the rehabilitation of the posterior maxilla was further evaluated in a 2-year retrospective study (91) involving 96
short implants (of 68.5 mm) placed in 85 patients.
A cumulative survival rate of 94.6% was obtained. Several publications have also reported favorable outcomes for the use of short implants in the posterior
maxilla (1, 2, 5, 28, 5456, 58, 74, 80). Fugazzotto
et al. (54), who analyzed the possibility of using short
implants to restore single crowns in the posterior
maxilla, reported a cumulative survival rate of 95.1%
in a group of 979 implants. The usefulness of short
implants to support single crowns in the posterior
maxillary region was also conrmed by Lai et al. (69),
with a follow-up period of 510 years. In severely
resorbed ridges, with <5 mm of available bone
height, some authors also reported favorable outcomes using short implants combined with crestal
sinus lifts (23, 32, 35, 50) .
Whereas most publications devoted to short-length
implants used a conventional loading protocol, Rossi
et al. (102) performed a prospective case series study,
in which 40, 6-mm-long implants were loaded with a
single crown, 6 weeks after placement. The authors
reported a cumulative survival rate of 95%, 2 years
after loading (102). A similar loading protocol was also
used by Van Assche et al. (120) in the rehabilitation of
edentulous maxilla using four long implants and two
distal 6-mm-long implants to support an overdenture. Similar outcomes were reported in this study for
long and short implants, 2 years after loading (120).
Favorable outcomes were reported in only one publication (31) that used short implants (<10 mm) with
an immediate loading protocol.
As a result of their descriptive nature, case series
studies of short-length implants only allow proofof-principle to be to established (59). More recently,
experimental research, such as randomized controlled trials, was performed to allow comparison
between short and longer implants (Table 3). For ethical reasons, no direct comparison between short and
longer implants in an adequate bone volume can be
performed. As a consequence, randomized controlled
trials were performed to compare short-length
implants with both advanced surgical procedures and
longer implants. Two randomized controlled trials
were performed by the same team (44, 47) to compare the outcomes of short-length implants in the
posterior mandible with longer implants placed in
Table 1. Case series in which implant length was evaluated among other parameters
Authors (ref. no.)
No. of patients (no.

of implants)
Follow-up, in months
(mean)
Cumulative survival
rate <10 mm, %
Cumulative survival
rate >10 mm, %
van Steenberghe et al.

1990 (121)
159 (558)
(12)
97.5
97.4
Jemt 1991 (64)
384 (2199)
12
94.7
Friberg et al. 1991 (51)
889 (4641)
From stage 1 to
connection of the
prostheses
94.5
99.4
Bahat 1993 (6)
213 (732)
570 (30.3)
92.6 (Bone type IIIII)

86.7 (Bone type IV)
95.9 (Bone type IIIII)

94.5 (Bone type IV)
Jemt & Lekholm 1995

(65)
150 (801)
(60)
75.8
91.8
Buser et al. 1997 (21)
1003 (2359)
1296
91.4
95
Ellegard et al. 1997 (40)
68 (124)
384
Wyatt et al. 1998 (125)
77 (230)
12144
75
95 (only 13-mm
implants were
included)
Gunne et al. 1999 (61)
23 (69)
(120)
89
100 (only three implants

were included)
Lekholm et al. 1999 (70) 127 (461)
(120)
93.5
91.5 (only 13-mm

implants were
included)
Winkler et al. 2000 (124) (2917)
(36)
74.4 (7 mm)
87 (8 mm)
94.3 (only 13-mm

implants were
included)
Bahat 2000 (7)
202 (660)
60144
83
95
Brocard et al. 2000 (20)
440 (1022)
1284
80.3 ( 8 mm)
83.7 ( 12 mm)
Testori et al. 2000 (118)
181 (485)
(52.6)
Naert et al. 2002 (82)
660 (1956)
(66)
81.5
Stellingsma et al. 2003

(110)
60 (240)
(12)
Weng et al. 2003 (123)
493 (1179)
(72)
74 (7.0 mm)
81 (8.5 mm)
93.1
Romeo et al. 2004 (98)
250 (759)
1684
Feldman et al. 2004 (46) (4891)
2460
91.6 (10-mm machined 93.8 (machined)

98.4 (Osseotite)
implants were
included)
97.7 (10-mm Osseotite
implants were
included)
Nedir et al. 2004 (83)
236 (528)
1284
Herrmann et al. 2005

(63)
487 (487)
(60)
78.2 (7 mm)
95.7
Koo et al. 2010 (67)
489 (521)
1260
100
95.1
75
Nisand & Renouard
Table 2. Case series devoted to short-length implants

Authors (Ref. no.)
No. of patients (no. of Follow-up, in

implants)
months (mean)
Implant length
Lai et al. 2013 (69)
168 (231)
6012 (86)
Intrabony length 8 mm 98.7 (5 years)

98.3 (10 years)
Draenert et al. 2012 (38)
(47)
(44)
9 mm
98
De Santis et al. 2011 (37) 46 (107)
1236
8.5 and 7.0 mm
98.1
Perelli et al. 2011 (86)
40 (55)
60
7 and 5 mm
84
et al. 2012 (60)

Gulje
12 (48)
12
6 mm
96
Van Assche et al. 2012

(120)
12 (72)
24
1014 and 6 mm (two

One short-implant
short implants and four failure
long implants to
support an overdenture)
Rossi et al. 2010 (102)
35 (40)
24
6 mm
95
Anitua & Orive 2010 (2)
661 (1287)
1102 (47.9)
8.5, 7.5, 7.0 and 6.5 mm
99.3
s et al.
Sanchez Garce
2012 (103)
(273)
18144 (81)
10 or <10 mm
92.82 (10 mm)

92.5 (<10 mm)
Grant et al. 2009 (57)
124 (335)
24
8 mm
99
Corrente et al. 2009 (28)
48 (48)
36
<10 mm (13 implants

with crestal sinus
elevation)
97.92
Fugazzotto 2008 (55)
1774 (2073)
1296
<10 mm (9, 8, 7 and

6 mm)
98.1 (single crown)

99.7 (short-span xed
prostheses)
Anitua et al. 2008 (1)
293 (532)
459 (31)
8.5, 7.5 and 7.0 mm
99.2
et al. 2007 (74)

Malo
237 (408)
12108
8.5 and 7.0 mm
96.2 (7.0 mm) (5 years)

97.1 (8.5 mm) (5 years)
Degidi et al. 2007 (31)
(133)
36144
<10 mm
97.7 (immediate loading

protocol)
Romeo et al. 2006 (99)
129 (265)
36168
10 and 8 mm
97.9 (8 mm) (14 years)

97.1 (10 mm) (14 years)
Arlin 2006 (5)
(176)
64.683.7
8 and 6 mm
94.3 (6 mm) (2 years)

99.3 (8 mm) (2 years)
Misch et al. 2006 (80)
273 (745)
1260
9 and 7 mm
98.9
Renouard & Nisand 2005 85 (96)

(91)
2448 (37.6)
8.5, 7.0 and 6.0 mm
94.6
Goene et al. 2005 (56)
188 (311)
36
8.5 and 7.0 mm
95.8
Deporter et al. 2005 (35)
70 (104)
(37.6)
7 mm (with crestal sinus Two short implants

elevation)
failed
Fugazzotto et al. 2004

(54)
979 (979)
084
9, 8 and 7 mm
95.1
Grifn & Cheung 2004

(58)
167 (168)
(34.9)
8 mm
100
Tawil & Younan 2003

(114)
111 (269)
1292
10.0, 8.5, 8.0, 7.0 and

6.0 mm
95.5
52 (156)
120
10 and 7 mm
92.7
76
Cumulative survival
rate, %
Table 2. (Continued)
Authors (Ref. no.)
No. of patients (no. of Follow-up, in

implants)
months (mean)
Implant length
Cumulative survival
rate, %
24 (48)
8.25.3 (32.6)
9 and 7 mm
100
16 (26)
636 (11 .1)
9, 7 and 5 mm (with
crestal sinus elevation)
100
Friberg et al. 2000 (52)
49 (260)
12168 (96)
7 and 6 mm
95.5 (5 years)
92.3 (10 years)
Stellingsma et al. 2000

(110)
17 (68)
6097 (77)
10, 7 and 6 mm
88
ten Bruggenkate et al.

1998 (117)
126 (253)
1284
6 mm
94
Texeira et al. 1997 (119)
26 (67)
(60)
11 and 8 mm
94
Bernard et al. 1995 (13)
48 (100)
(36)
>10, 10, 8 and 6 mm
99
Table 3. Randomized controlled trials comparing short implants and longer implants with advanced surgical procedures
Authors
(ref. no.)
Patients
(no. of
implants)
Mean
length of
follow-up
(months)
Area and
number of
implants
Test
Control
Cumulative
survival rate
Remark
Esposito 60 (121)
et al.
2011 (44)
36
6.3 mm
Partially
edentulous
mandible
One to
three
implants
9.3 mm and
vertically
augmented
bone
Test: two short

implants failed
Control: three
long implants
failed;
augmentation
procedure failed
in two patients
Statistically signicantly
more complications in
augmented patients.
Short implants
experienced statistically
signicantly less bone
loss. Short implants
could be an interesting
alternative to vertical
augmentation as the
treatment is faster,
cheaper and associated
with less morbidity
Felice
28 (178)
et al.
2011 (48)
5 months
after
loading
5.0
11.5 mm
Fully
edentulous 8.5 mm
maxillae.
Four to
eight
implants
Test: two short

implants failed
Control: one
long implant
failed and one
bilateral sinus
lift procedure
failed
Signicantly more
complications occurred
in augmented patients.
This pilot study suggests
that short implants may
be a suitable, cheaper
and faster alternative to
longer implants placed
in augmented bone
Felice
60 (121)
et al.
2010 (47)
12
Partially
7 mm
edentulous
mandible
10 mm and
Test: one short
vertical
implant failed
augmentation Control: three
long implants
failed, and two
augmentation
procedures
failed
Short implants might be

preferable compared
with vertical
augmentation, reducing
the chair time, cost and
morbidity
77
Nisand & Renouard
vertically augmented bone. The authors reported a

similar survival rate along with increased treatment
time and morbidity for the graft group. Moreover, in
one paper (44) a signicant increase in peri-implant
bone loss was reported for longer implants. One randomized controlled trial was also performed by the
same team (48) to compare the outcome of shortlength implants in the edentulous atrophic maxilla
with longer implants placed in augmented bone. Five
months after loading, similar survival rates were

reported for both techniques, with less morbidity for
the short-length implant group.
A large number of systematic reviews and metaanalyses (Table 4) have also been performed on
short-length implants (3, 30, 62, 66, 68, 78, 79, 84,
89, 90, 92, 100, 113, 116). According to these papers,
there is fair and growing evidence that short-length
implants can be used successfully in atrophied jaws
Table 4. Systematic review and meta-analysis on short-length implants

Authors
(ref. no.)
Type of
studies
(search time)
Number of papers
included
Denition
of short
implants
Annibali
Systematic
Two randomized
<10 mm
et al. 2012 review and
controlled trials and 14
(3)
meta-analysis observational studies
Main results
Main conclusions
The provision
6193 short implants
from 3848 participants. of short implant-supported
prostheses in patients with
The observational
atrophic alveolar ridges
period was 3.2
appears to be a successful
1.7 years.
treatment option in
Cumulative survival
rate was 99.1% (95% CI: the short term; however,
more scientic evidence is
98.899.4).
needed for the long term
A higher cumulative
survival rate was
reported for implants
with a rough surface
<10 mm
2611 short implants (5.0

9.5 mm) with a mean
follow-up of 3.7 years.
The estimated survival
rate after 2 years
ranged from 93.1%
(95% CI: 79.7100) for
5-mm implants to
98.6% (95% CI: 94.6
100) for 9.5mm implants
There is growing evidence

that placement of short
(<10 mm) implants can be
successful in the partially
edentulous patient
54 publications included <10 mm

Systematic
Pommer
(89)
meta-analysis
of
observational
studies (1998
2008)
19,083 implants
included. In the
mandible, no impact of
reduced implant length
on failure was observed
within the rst year of
prosthetic loading.
A signicant impact of
implant length for short
machined implants was
observed in the anterior
(odds ratio = 5.4) and
posterior (odds
ratio = 3.4) maxilla.
Short rough-surface
implants demonstrated
increased failure rates
in the anterior
maxillary sites (1.4% vs.
0.0%)
In areas of reduced alveolar

bone height the use of short
dental implants may reduce
the need for invasive bone
augmentation procedures
Jokstad
2011 (66)
78
One randomized
Systematic
review (1980 controlled trial and 28
prospective cohort
2009)
studies
(See
Telleman
et al. 2011
(116))
Authors
(ref. no.)
Type of
studies
(search time)
Number of papers
included
Denition
of short
implants
Main results
Main conclusions
Telleman
Systematic
29 studies
et al. 2011 review (1980
(116)
2009)
<10 mm
2611 short implants (5.0

9.5 mm) An increase in
implant length was
associated with an
increase in implant
survival (from 93.1% to
98.6%). The estimated
survival rate after
2 years for the different
implant lengths was
93.1% (95% CI: 79.7
100) for 5-mm
implants, 97.4% (95%
CI: 94.4100) for 6-mm
CI: 96.3 98.8) for 7-mm
CI: 97.899.0) for 8-mm
CI: 98.299.6) for 8.5mm implants, 98.0%
(95% CI: 96.499.0) for
9-mm implants and
98.6% (95% CI: 94.6
100) for 9.5-mm
implants
There is fair evidence that

short (<10 mm) implants
can be placed successfully in
the partially edentulous
patient, although with a
tendency toward an
increasing survival rate per
implant length, and the
prognosis may be better in
the mandible of nonsmoking
patients
Sun et al.
Systematic
35 studies
2011 (113) review (1980
2009)
10 mm
14,722 implants
included, of which 659
failed (failure
rate = 4.5%). The
failure rates
of implants with
lengths of 6.0, 7.0, 7.5,
8.0, 8.5, 9.0 and
10.0 mm were 4.1, 5.9,
0, 2.5, 3.2, 0.6 and 6.5%,
respectively. There was
no statistically
signicant difference
between the failure
rates of short dental
implants and
standard implants or
between those placed
in a single stage and
those placed in two
stages (multivariate
analysis). There was a
tendency toward higher
failure rates for the
maxilla and for dental
implants with a
machined surface.
The heterogeneity and
low quality of the
included studies made
meta-analysis
impossible
Among the risk factors

examined, most failures
of short implants can be
attributed to poor bone
quality in the maxilla and a
machined surface.
Although short implants in
atrophied jaws can achieve
similar long-term prognoses
as standard dental
implants with a reasonable
prosthetic design according
to this review, stronger
evidence is essential to
conrm this nding
79
Nisand & Renouard
Authors
(ref. no.)
Type of
studies
(search time)
Number of papers
included
Menchero- Systematic
Cantalejo
review and
et al. 2011 meta-analysis
(78)
(20002010)
Neldam &
Pinholt
2012 (84)
Denition
of short
implants
Main results
10 mm
In view of the results

The majority of the
analyzed, rehabilitations
studies obtain a
cumulative success rate with short implants are a
reliable treatment; however,
similar to that of
longer implants (92.5% the lack of consistency in the
study designs as well as the
and 98.42% for
presence of bias in all of the
machined and roughstudies reviewed make it
surface implants,
difcult to analyze the data
respectively). The
studies that record
lower cumulative
success rates are later
studies that
analyze implants with
a machined surface
8 mm
Systematic
15 prospective
review (1992 nonrandomized
2009)
studies, 11
retrospective
nonrandomizedstudies
and one review
Data on 6-mm implants Short implant length was not

related to observation time,
were few (Straumann
installment region, failures,
implants representing
and dropouts were not
441 out of 549
specied; subsequently, it
implants). Br
anemark
was not possible to perform
implants, 7 mm in
length, comprised 1607 a meta-analysis
implants out of 1808.
Straumann implants,
8 mm in length,
comprised 2040 out of
2352 implants. Failures
varied between 0 and
14.5%, 0 and 37.5% and
0 and 22.9% for 6-, 7-,
and 8-mm-long
implants, respectively
Romeo
Literature
13 studies
(100)
2008)
The treatment planning is a

The recent literature
key factor for success in the
has demonstrated a
similar survival rate for use of short implants. It can
be assumed that a careful
short and standard
implants. Older articles treatment planning can lead
the clinician to obtain a
have demonstrated a
successful rehabilitation
lower survival rate for
short implants
37 studies reporting on
Kotsovilis
Systematic
22 patient cohorts
(68)
meta-analysis
(19812007)
<10 mm or There is no signicant

Within the limitations of this
8 mm
systematic review, the
difference in survival
placement of short roughbetween short (8
surface implants is not a less
or < 10 mm) and
conventional (10 mm) efcacious treatment
rough-surface implants modality compared with the
placement of conventional
in totally or partially
rough-surface implants for
edentulous patients
the replacement of missing
teeth in either totally or
partially edentulous
patients
Raviv et al. Literature

2010 (90)
review
80
Main conclusions
Authors
(ref. no.)
Type of
studies
(search time)
Denition
of short
implants
Main results
Main conclusions
Renouard & Structured

53 studies
Nisand
review (1990
2006 (92)
2005)
8 mm
A relatively high number

of published studies
(12) indicated an
increased failure rate
with short implants
which was associated
with operators learning
curves, a routine
surgical preparation
(independent of the
bone density), the use
of machined-surfaced
implants and implant
placement in sites with
poor bone density.
Recent publications
(22) reporting an
adapted surgical
preparation and the use
of textured-surfaced
implants have
indicated that survival
rates of short implants
are comparable with
those obtained with
longer implants
The use of a short implant

may be considered in sites
thought to be unfavorable
for implant success, such as
those associated with bone
resorption or previous injury
and trauma. Whilst in these
situations implant-failure
rates may be increased,
outcomes should be
compared with those
associated with advanced
surgical procedures such as
bone grafting, sinus lifting
and the transposition of the
alveolar nerve
das Neves Structured

33 studies
(30)
2004)
10 mm
16,344 implants were

included, of which 786
failed (failure
rate = 4.8%).
Implants 3.75-mm
wide and 7-mm long
failed at a rate of 9.7%,
compared with 6.3% for
implants 3.75-mm wide
and 10-mm long.
Finally, 66.7% of all
failures were attributed
to poor bone quality,
45.4% to the location
(maxilla or mandible),
27.2% to occlusal
overload, 24.2% to
location within the jaw
and 15.1% to infections
(an implant could be
associated with
multiple risk factors)
Short implants should be

considered as an alternative
to advanced boneaugmentation surgeries, as
surgery can involve higher
morbidity, require extended
clinical periods and involve
higher costs to the patient
<10 mm
Misch 2005 Literature

(79)
review
Number of papers
included
81
Nisand & Renouard
Authors
(ref. no.)
Type of
studies
(search time)
Number of papers
included
Hagi et al.
2004 (62)
Structured
12
review (1985
2001)
Denition
of short
implants
Main results
Main conclusions
7 mm
Machined
surface implants
experienced greater
failure rates than did
textured
surface implants.
With the exception of
sintered poroussurface implants, 7mm-long dental
implants appear to
have higher failure
rates than those >7 mm
in length
Dental implant surface

geometry is a major
determinant in how well
short dental implants
performed
(3, 66, 68, 78, 90, 100, 116), reducing both the need
for invasive and complex surgery (30, 89, 92, 113)
and treatment morbidity (30, 92). However, there is
a tendency for increased failure rates with
machined surface implants (89, 92, 113), placement
in smokers (116) and placement in specic locations, such as the severely resorbed posterior maxilla (113, 116) and the anterior maxilla (89). Longer
follow-up times of up to 10 years are also needed
to conrm these ndings and to evaluate the
impact of annual marginal bone loss on survival
rate (3, 92, 113).
Extra-short implants
Three case series (36, 86, 108) and one randomized
controlled trial (43) were recently performed to evaluate the survival rate of extra-short implants supporting xed partial dentures in severely resorbed
posterior jaws. In the paper by Slotte et al. (108),
three to four 4-mm implants were inserted in the
posterior mandibles of 24 patients (87 implants in
total) to support xed partial dentures. Two years
after loading, a survival rate of 92.3% was reported.
Using a split-mouth design, Esposito et al. (43)
compared 5-mm implants with 10-mm implants in
augmented bone (with either interpositional bone
blocks in the mandible or sinus lift in the maxilla)
to restore either the posterior mandible (15 patients)
or the posterior maxilla (15 patients). They report
similar outcomes for both techniques. The use of
extra-short implants allows patients to be treated
with lower cost and less morbidity. However, so far
only sparse short-term data are available. Further
82
studies are needed to evaluate the long-term

prognosis.
Stress repartition and crown-toimplant length ratio

A dogma (4) states that the prognosis of abutment
teeth and prosthetic rehabilitation is related to the
crown-to-root ratio. According to this statement, it is
assumed that for successful prosthetic rehabilitation
the crown-to-root ratio should always be 1. However, this statement was not supported in a recent
systematic review (72) which reported similar outcomes for abutment teeth with or without a history of
periodontal bone loss. Nevertheless, this empirically
based crown-to-root ratio guideline is commonly
applied for dental implant-supported restorations,
frequently resulting in the placement of the longest
implant possible. In areas of reduced bone volume,
in which short implants must be placed, bone resorption is often accompanied by increased maxillomandibular space, with the prosthetic consequence of
excessive crown height (Fig. 5). In such sites, clinicians
tend to perform advanced surgical procedures to
allow the placement of longer implants, thus lowering
the crown-to-implant ratio. According to the denition provided by Blanes et al. (16), two types of
crown-to-implant ratio can be established: the anatomical crown-to-implant ratio, in which the transition line is located at the level of the implant
shoulder; and the clinical crown-to-implant ratio, in
which the transition line is located at the level of the
bone crest.
Indications and clinical procedures

Short implants
Fig. 5. Periapical radiograph showing a 7-mm-long

implant with a crown-to-implant ratio of >1.5 after 7 years
of loading.
To the best of our knowledge, there are only a few

descriptive studies (Table 5) that have evaluated the
impact of the crown-to-implant ratio on peri-implant
bone loss (15, 16, 97, 104, 115) , implant survival rate
(16, 104, 106) or the occurrence of biological and
technical complications (104). Among this group of
publications, three studies involved only single-tooth
implant-supported restorations (15, 104, 106), thus
avoiding the bias of better occlusal force distribution
in studies involving mainly splinted implant restorations (16, 97, 115). These three studies (15, 104, 115)
demonstrated that marginal bone loss was not related
to the crown-to-implant ratio, whereas two studies
(16, 97) indicated that implant restorations with
higher crown-to-implant ratios displayed statistically
lower marginal bone loss than did implant restorations with lower crown-to-implant ratios. According
to Blanes et al. (16), the latter might be explained by
the stimulatory nature of bone stress.
Similar survival rates have been reported for
implant restorations with high and low crown to
implant ratios (16, 104, 106). The crown-to-implant
ratio has also been found to have no statistically signicant inuence on the occurrence of biological and
technical complications (104). These results are in
accordance with the outcomes of a systematic review
performed by Blanes (17) on the impact of the crownto-implant ratio on the survival and complication
rates of implant-supported reconstructions. However,
it should be remembered that the crown-to-implant
ratios of most of the implant-supported restorations
included were between 1.0 and 2.0, and very few data
are available on crown-to-implant ratios of >2.0.
Therefore, further studies should investigate the
impact of crown-to-implant ratios of >2.0 on marginal bone loss, the implant survival rate and the
occurrence of biological and technical complications.
Short-length implants may be indicated without any

dogma in areas of reduced bone height (such as the
posterior maxilla and the posterior mandible) following tooth extraction. Bone height in the premolar and
molar regions of the maxilla may be reduced by sinus
expansion. A remaining bone height of 7 mm may
indicate that short implants should be used (Fig. 6A
D). With 56 mm of available bone, the decision to
use short implants should be based on bone quality
and existing risk factors for marginal bone loss over
time (e.g. a history of periodontitis and smoking), as
well as the patients age. With <5 mm of available
bone below the oor of the sinus, a sinus bone-grafting procedure is recommended (Table 6) (Fig. 7AE).
Bone height in premolar and molar regions of the
mandible may be limited by the inferior alveolar
nerve. As a distance of at least 2 mm should be maintained between the implant and the inferior alveolar
nerve, short-length implants may be considered only
when the available bone above the nerve is 8 mm
(Fig. 8AD). With <8 mm of bone, advanced surgical
procedures may be indicated to allow the placement
of dental implants (Table 7).
Short-length implants may be indicated to support
single- and multiple-xed reconstructions in the posterior jaws. For multiple tooth replacement, no strong
recommendation can be made with respect to splinting or with regard to the optimal number of implants
per prosthetic unit. Short-length implants may also
be recommended in the treatment of a severely resorbed edentulous mandible, with four short-length
implants used to support an overdenture or six short
implants used to support a xed reconstruction. In
the edentulous maxilla, two short-length implants
additionally placed in the distal area, together with
longer implants in the premaxilla, may be indicated
to support a maxillary overdenture or a xed reconstruction.
From a clinical point of view, high short-implant
survival rates may be obtained using a surgical bone
preparation adapted to the patients bone quality
and the implant design in order to reach sufcient
initial primary stability. Moreover, a micro-rough
implant surface should be selected to improve periimplant bone growth, bone-to-implant contact and
bone anchorage, thus reducing the time between
mechanical primary stability and biological secondary stability.
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Nisand & Renouard
Table 5. Studies on the impact of crown-to-implant ratio

Authors (ref. No. of
no.)
patients
(no. of
implants)
Follow-up
(months)
Type of
prosthesis
Rokni et al.
2005 (97)
74 (199)
46
61.8% single
1.5
crowns
38.2% splinted
restorations
0.8 to <3.0
78.9% with a
crown-toimplant ratio
of 1.12.0
Crown-to-implant
ratio 1: 0.4 0.3
Crown-to-implant
ratio > 1 to 2:
0.4 0.4
Crown-to-implant
ratio > 2: 0.3 0.5
Tawil et al.
2006 (115)
109 (262)
53
0.92.4
12.6% single
crowns
87.4% splinted
restorations
12 and > 2
83.8% with a
between 1
and 2; 3.4%
with a
of > 2
Crown-to-implant
ratio < 1: 0.88 0.74
Crown-toimplant ratio 11.20:
0.75 0.71
Crown-to-implant
ratio 1.211.40:
0.73 0.58
Crown-to-implant
ratio 1.41
1.60: 0.77 0.71
Crown-to-implant
ratio 1.612.0: 0.66
0.54
Crown-to-implant
ratio > 2: 0.74 0.65
Blanes et al. 83 (192)

2007 (16)
12
13.5% single
1.8
crowns
86.5% splinted
restorations
26.5% with a 94.1

of 2
4.2% with a
of > 3
Crown-to-implant
ratio < 1: 0.34 0.27
Crown-toimplant ratio
1 to < 2:
0.03 0.15
Crown-to-implant
ratio 2: 0.02 0.26
Schulte et al. 294 (889)

2007 (106)
27.6
Single crowns
Success
implant:
crown-toimplant
ratio = 1.3
Failed
implant:
crown-toimplant
ratio = 1.4
0.5 to < 3
98.2
Birdi et al.
2010 (15)
194 (309)
20.9
Single crowns
2.0 0.4
0.93.2
0.2
Schneider
et al. 2012
(104)
70 (100)
60
Single crowns
Clinical
crown-toimplant ratio:
1.50.4
Anatomical
1.0 0.3
95.8
Clinical
0.83.2
Anatomical
0.62.0
84
Mean crown- Crown-toSurvival

to-implant
implant ratio rate (%)
ratio
range
Bone loss (mm)
0.008
Table 6. New classication for treatment of the resorbed maxilla

Alveolar ridge
height*
Therapeutic options
Bone type I, II, Bone type IV, history
III
of periodontitis,
smokers, patient age
<5 mm
Sinus lift
Sinus lift
5 to 6 mm
Short implants
Sinus lift
6 mm
Short implants
Short implants
*This classication is suitable for a residual alveolar ridge width of at least

5 mm.
The long-term prognosis of short-length implants

may be altered by marginal bone loss over time. Until
now, available data are too scarce to draw any denitive conclusions with regard to the impact of platform-switching,
micro-thread
and
types
of
connections on the peri-implant bone level of short
implants. Therefore, it is strongly recommended that
patients should be included in supportive therapy
(96) to improve both the survival rate and the maintenance of the marginal bone level. Long-term prognosis of short-length implants may also be affected by
peri-implantitis. However, it should be remembered
that the removal of a short implant is a relatively sim-
ple procedure with minimal bone destruction compared with the removal of a long implant, which may
jeopardize adjacent teeth or the replacement of the
implant.
Implant length selection

For years, clinicians have tended to place the longest
implants possible to improve bone-to-implant contact, implant primary stability and the crown-toimplant ratio. However, recent knowledge in implant
dentistry has shown that bone-to-implant contact
may also be improved by the use of micro-rough surfaces, and adequate implant primary stability can be
achieved through the use of an adapted surgical preparation and new implant designs. Similarly, recent
publications have shown that marginal bone loss, the
implant survival rate and the incidence of complications are not related to the crown-to-implant ratio.
The placement of the longest implant possible
may have some drawbacks. It increases bone preparation time, exacerbating the risk of bone overheating and inappropriate bone preparation (oversized
bone preparation), which ultimately could reduce
implant primary stability (8). Using the longest
implant possible also increases the risk for nerve
injury or sinus perforation. Lastly, in the esthetic
Fig. 6. (A) Preoperative cone beam computed tomography

scan of a missing right secondary molar showing 8 mm of
available bone below the oor of the sinus. (B) Soft tissue
healing 2 months after the placement of a short-length
implant (8 mm in length and 4 mm in diameter). (C) Periapical radiograph 2 years after loading. (D) Clinical view
of the prosthetic restoration after 2 years of loading.
85
Nisand & Renouard

A

scan of a missing right maxillary second premolar and
molars showing 13 mm of available bone below the oor
of the sinus. (B) Preoperative cone beam computed tomography scan showing maxillary septa that may complicate
Schneiderian membrane elevation. (C) The trap door is
created and the Schneiderian membrane is elevated without perforation, despite the presence of an incomplete septum. (D) Postoperative cone beam computed tomography
scan 6 months after the sinus lift procedure. (E) Periapical
radiograph of the implant-supported xed partial denture
after 4 years of loading.
anterior area (Fig. 9AE), the use of the entire available bone may lead to overly angulated implants,
thus increasing the risk for gingival retraction and
the need for a cemented restoration. In the posterior
area, the use of the longest implant possible may be
associated with incorrect implant angulation or posi-
tion, with the occlusal consequence of inadequate

load repartition. Therefore, there are clinical situations in which the entire available bone should not
be used, to allow the surgeon to focus his limited
resources on optimal three-dimensional implant
positioning.
86
Table 7. New classication for treatment of the resorbed mandible

Alveolar ridge height*
Therapeutic options
therapeutic decisions. It seems that, to promote the

best overall patient outcomes, other factors, such as
feasibility and morbidity, should be considered when
making a therapeutic choice (Fig. 10AQ).
Bone type I, II, III and IV

<8 mm
Advanced surgical techniques
Feasibility
8mm
Short implants
Experience
*This classication is suitable for a residual alveolar ridge width of at least

5 mm.
A new concept in implant dentistry:

the stress-minimizing surgery
In 2011, the European Association of Dental Implantologists concluded its consensus conference on short
implants with the following recommendation to avoid
complications: the implant surgeon and restorative
dentist should have adequate clinical experience
(12). From this recommendation, one may legitimately wonder whether this conclusion encourages
practitioners to avoid complications by focusing on
complex bone-reconstruction solutions in order to
place longer implants, or to promote alternative treatments such as partial dentures or long-span dental
bridges. The statement is symptomatic of the decision-making process in implant dentistry, which
rarely considers the complexity of procedures and
instead tends to be based solely on success or survival
rates. Thus, a few percentage points higher or lower
in survival rate may be deemed sufcient to guide
The actual feasibility of a large number of more complex surgical protocols is never touched upon in
many discussions surrounding therapeutic options. It
seems that much effort is expended to omit the reality
of clinical life for the vast majority of practitioners.
Worldwide, the average number of implants placed
annually by most practitioners is estimated to be
fewer than 50. This gure seems to be quite minimal
in terms of gaining the surgical experience required
for the implementation of complex protocols.
Studies of neurocognitive activity show that the
part of the brain that manages both complex and
novel procedures lies in the prefrontal cortex, the
most anterior region of the brain (39, 73). Tasks utilizing the prefrontal cortex require conscious effort and,
importantly, consume vast cognitive resources (105).
Complex tasks, such as surgical procedures, as well as
tasks that are unfamiliar, require the prefrontal cortex
to remain active and the brains full resources to
remain accessible. However, under some conditions,
specically stress, fatigue and burnout, this access
becomes impaired. Advanced surgeries represent particularly high-stress activities for less-experienced

scan of a missing left rst molar showing 9.5 mm of available bone above the inferior alveolar nerve. (B) Soft tissue
healing 2 months after the placement of a short-length
implant (8 mm in length and 5 mm in diameter). (C) Periapical radiograph 3 years after loading. (D) Clinical view
of the prosthetic restoration after 3 years of loading.
87
Nisand & Renouard

A

scan showing internal resorption of a left central incisor.
(B) Gingival retraction and inammation around the
left central incisor. (C) Six weeks after a apless tooth
extraction, the implant is placed together with a guided
bone-regeneration procedure. The implant is inserted in
the correct three-dimensional position to allow insertion
of a screw-retained prosthesis and to avoid gingival

retraction. (D) Periapical radiograph 6 months after the
placement of a provisional crown. A shorter implant
(11.5 mm in length and 3.5 mm in diameter) was used to
allow the placement of a screw-retained prosthesis. (E)
Soft tissue healing around the provisional crown after
6 months.
practitioners, and the prefrontal cortex becomes inaccessible in precisely the complex situations where its
use is a priority. Over time and with repetition, complex tasks become more routine and the advanced
processing abilities of the prefrontal cortex are
needed less and less to perform them. By repeatedly
practicing a single type of intervention, practitioners
described as experts have gradually transferred the
new gesture, which was initially managed by the prefrontal cortex, to the limbic brain. The limbic brain is
a group of brain structures consisting of multiple
subcortical entities such as the hippocampus, the

amygdala and the hypothalamus. It is located in the
middle part of the brain. This part of the brain is
involved in emotions and manages routine actions.
This automatic mental mode requires far fewer
resources and is thought to be used for as much as
80% of all activities performed.
It takes time and large amounts of repetition
before a complex act can be made partially routine
while still being accomplished with a high success
rate. Moreover, experience is necessarily obtained by
88
the occurrence of errors and failures, which are then

analyzed, primarily unconsciously, by the anterior
cingulate cortex (22), allowing the brain gradually to
adjust and routinize the procedure. This phenomenon is made possible as a result of brain plasticity,
allowing the brain to restructure itself continuously
upon exposure to new stimuli (29). Learning leads to
a cerebral reprogramming that is based on successes
but mainly on failures. This long learning process is
necessary to transfer portions of the work of the prefrontal cortex to the limbic brain. The aim is that the
majority of gestures are accomplished without having to think about them. This can occur for an
entire, or for only part of, a procedure. Unconsciously, the operator uses both parts of the brain
simultaneously. The act of transferring some of the
workload to the limbic brain allows an individual
both to conserve limited mental resources (93) and
to make room in the prefrontal brain to handle new
parameters from sensory input in complex situations, such as the observations that this dissection is
difcult, the patient is becoming stressed, the
patient is bleeding more than usual or the patient
has a voluminous tongue that is interfering with surgery. These additional parameters add to the complexity of the situation, placing new demands on the
prefrontal cortex.
The novice practitioner who performs this type of
surgery only a few times a year will not have enough
experience to routinize the procedure. Therefore,
every act will require signicant cognitive effort, with
the risk of quickly overloading the prefrontal brain.
The immediate consequence of this is to induce
stress, with the corollary being a signicant decline in
operating efciency, which, in turn, further increases
the stress level. A vicious cycle is created, eventually
leading to an uncontrolled intervention that is more
likely to generate complications.
Whatever the scope is, expertise is created over a
long learning period, estimated at about 10 years.
The more a protocol is simplied and perfectly codied, the easier it is for large numbers of people to
learn. The use of short implants ts perfectly into this
cognitive analysis of surgical difculty. While the ideal
would be to rebuild all patients ad integrum, we must
accept that in reality relatively few surgeons can
acquire the necessary level of experience and expertise required to perform this type of intervention with
a high and consistent success rate.
Nontechnical human factors
Many nontechnical parameters, such as stress, fatigue, overcondence (14) and the lack of preparation
or organization (81), can inuence the outcome of a

procedure. In this vein, a study of 9,830 surgical procedures in a London hospital demonstrates the
importance of nontechnical factors in the occurrence
of surgical complications (45). Stress is probably one
of the complicating factors shared most widely by
dental and maxillofacial surgeons. It is difcult for
most practitioners to manage both the technical and
emotional aspects of a patient who is usually under
local anesthesia. The emotional impact of the relationship with the patient is a layer of complexity on
top of the purely technical aspect of the procedure,
making the whole treatment even more complex and
demanding even more in terms of cognitive
resources. Nevertheless, the stress and commensurate increased risk of complication generated by
implementing complex procedures is rarely mentioned in discussions about treatment decision-making. Stress occurs when there is a mismatch between
an individuals perception of the constraints imposed
by the environment and that individuals perception
of his or her own resources to cope with it (10, 11, 85).
We may also explain stress as a conict of resource
mobilization and accessibility: when knowledge exists
but it is not immediately available when needed,
stress occurs. We now understand that it is not the
situation that is stressful per se, but the individuals
reaction to the situation. Stress in humans is 90%
endogenous. Accordingly, a surgeon with less experience and little practice will be more stressed and will
tend to approach complex surgeries in a more negative cognitive state. Hence, the level of alertness of
the less-experienced practitioner is more likely to be
affected by cognitive overload during these unusual
events.
Under heavy stress, practitioners or therapeutic
team members may see their cognitive abilities
diminish until they become incapable of making
rational decisions (76, 77, 109). This state is termed
mental tunneling (27, 93). Overwhelmed by stress, the
practitioner is unable to analyze the situation and the
surroundings. The practitioner may even be subject
to regression, namely the implementation of solutions learned previously and now managed by the
limbic brain, forgetting recent knowledge gains. The
overstressed practitioner will then react in one of two
ways: with anxiety; or simply with the urge to avoid
the situation. This is an instance of the ght-or-ight
response (19, 24). Physically unable to leave the operating theater, the surgeon may have the impulse to
get the surgery over with, regardless of the consequences of mistakes, oversights or surgical shortcuts.
Instead of prioritizing the use of their prefrontal
89
Nisand & Renouard

A
90
Fig. 10. (A) Othopantomogram of a 66-year-old patient,

with moderate chronic periodontitis and missing maxillary
left premolars and molars, treated with anticoagulant
therapy. The treatment plan included nonsurgical and surgical periodontal treatment before restoration with
implants. (B) Preoperative cone beam computed tomography scan showing adequate bone volume for the replacement of the rst premolar. (C) Preoperative cone beam
computed tomography scan showing 23 mm of available
bone below the oor of the sinus (for replacement of the
rst molar). (D) Clinical view showing one straight implant
in the rst premolar position and one angulated implant
in the rst molar position to restore a three-unit xed partial denture. The use of an angulated implant avoids the
need for a sinus lift procedure. (E) Clinical view of a threeunit xed partial denture, 8 years after loading, to replace
missing rst and second premolars and rst molars. (F)
Fracture of the right central incisor in the same patient.
(G) Soft tissue healing 6 weeks after apless tooth extraction (a removable denture was used during the healing
time) at the time of implant placement. The implant was
placed together with a guided bone regeneration technique. (H) Periapical radiograph after 5 years of loading.
(I) Postoperative cone beam computed tomography scan

after 5 years of loading. A shorter implant was inserted to
replace the maxillary central incisor in order to allow the
placement of a screw-retained prosthesis. Placement of
the longest implant possible, to use all the available bone,
would have led to a cemented restoration. (J) Clinical view
after 5 years showing the implant-supported restoration
inserted to replace the right maxillary central incisor. (K)
Periapical radiograph in the same patient showing bone
healing 3 months after extraction of the right maxillary
rst molar. Nine years after the periodontal treatment,
only two teeth were lost and only one because of the progression of periodontal disease. (L) Soft tissue healing
3 months after extraction of the right maxillary rst molar.
(M) Preoperative cone beam computed tomography scan
showing 7 mm of bone available below the oor of the
sinus. (N) Placement of a short-length implant (7 mm in
length and 5 mm in diameter) in one-step surgery. (O)
Periapical radiograph after 3 years of loading. (P) Clinical
view of the implant-supported single crown to restore the
right maxillary rst molar after 3 years of loading. (Q) Orthopantomogram 9 years after the start of treatment.
brains, required to solve new and complex problems,

people under stress tend to favor the lower oors of
the brain, thus reducing their capacity for rational
analysis. The number of errors then increases with a
greater risk of complications.
An alternative response is referred to as vigilance.
This is where one uses the surge of adrenaline in a
demanding situation to heighten awareness and
decision-making skills, the obverse of the typical
ght-or-ight response. It is a state that requires
self-condence, which is generally a function of time
and repetition. Experience, allowing one to acquire
condence, is thus one way to reduce stress. Again,
this leads to the conclusion that complex procedures
are best performed by practitioners who have trained
over time and then practiced sufciently to maintain
their level of expertise.
The use of short implants ts perfectly into this
consideration of human factors in general and stress
in particular. Rather than attempting, in vain, solutions that are best reserved, in the nal analysis, to a
few highly experienced practitioners and therefore to
relatively few patients, it seems preferable to focus on
surgical techniques that do not impose the same
stress loads, such as the use of short implants. By
remaining far from anatomic obstacles and implementing well-described and easily reproducible protocols, the practitioner can focus on the principal
goal of the operation, which is the correct threedimensional placement of the implants. The learning
curve, which is unavoidable, will nevertheless be
shorter in every way than that inherent to preimplant bone grafts.
Morbidity
Morbidity, dened as the set of complications that
may accompany a surgical procedure, is rarely taken
into account during therapeutic choices. However, a
number of publications reported a direct correlation
between morbidity and procedural complexity. Thus,
in a study of 102 pediatric cardiac surgeries, Barach
et al. (9) show that the longer and more complex a
surgical procedure is, the higher the risk of complications. These ndings were conrmed in 2008 by Roselli et al. (101), who analyzed 1,847 cardiovascular
and thoracic surgeries. In 2005, Enislidis et al. (41)
reported an implant survival rate of 96% following 45
distraction surgeries of 37 patients. Nevertheless, the
authors also identied a 65% complication rate, of
which 21% experienced serious complications,
including three mandibular fractures (41). Although
the implant success rate in this study was satisfactory,
it was obtained at the cost of substantial morbidity.
Accordingly, surgical techniques and medical protocols should not be evaluated solely on the basis of
survival and/or success rates. Morbidity and dangerousness accompanying these protocols should also
carry appropriate weight. The dangerousness of a
technique can be characterized as the probability of
occurrence of complications multiplied by the criticality of these complications.
91
Nisand & Renouard
Using these criteria, a surgical technique that has a

satisfactory success rate with a relatively high complication frequency, but low criticality, would be acceptable, whereas a surgical technique that has a higher
success rate with a lower frequency of complications,
but with a very high criticality (e.g. mortality risk),
should be restricted if the indication is not vital. This
concept of morbidity is illustrated particularly well by
Ferrigno et al. (49). Indeed, these authors consider
placing short implants as an act with enough risk of
failure to justify a mandibular alveolar nerve lateralization in order to place long implants. Although this
technique can be effective for an expert, promoting it
to mainstream surgeons should be accompanied with
serious warnings about the level of experience
required to implement it. As above, the concept of
morbidity is intimately related to the level of expertise.
The morbidity of short implants is low, and the loss
of a short implant usually has only minor consequences. Sometimes it is possible to re-implant;
whereas, in other situations the use of advanced surgical techniques becomes necessary. Patients must be
warned about these risks before undergoing implant
treatment.
Conclusions
Short-length implants can be successfully used to
support single and multiple xed reconstructions in
posterior atrophied jaws, even with increased crownto-implant ratios. The use of short-length implants
allows treatment of patients who are unable to
undergo complex surgical techniques for medical,
anatomic or nancial reasons. For these patients, it
must be clearly understood that the decision is shortimplant-supported xed reconstructions, removabledenture or long-span reconstructions on abutment
teeth or no treatment. Moreover, the use of shortlength implants in clinical practice reduces the need
for complex surgeries, thus reducing morbidity, cost
and treatment time. However, longer follow-up times
of up to 10 years (both for case series and randomized controlled trials) are needed. Additional studies
should also investigate the impact of crown-toimplant ratios of >2.0 and the possibility of using
extra-short implants.
The longest implant possible should not always be
used to improve the three-dimensional positioning of
implants. The use of short implants promotes the
new concept of stress-minimizing surgery, allowing
the surgeon to focus necessarily limited cognitive
92
resources on the correct three-dimensional positioning of the implant.
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Periodontology 2000, Vol.

66, 2014, 7296

Short implant in limited bone

permanently altered mandibular sensation (25), graft

Short implant in limited bone volume

Fig. 1. Clinical view of the alveolar artery that may lead to

short. In one recent systematic review (116) and in

Survival rates of short-length

be dened as a collection of patients in whom dental

Nisand & Renouard

Fig. 3. Exposure of a titanium-reinforced membrane used

Fig. 4. Periapical radiograph of a short (8 mm) implant

performed with either a retrospective or a prospective

rate of 94%. Of the seven implants removed, six were

Short implant in limited bone volume

No. of patients (no.

van Steenberghe et al.

Jemt 1991 (64)

Friberg et al. 1991 (51)

Bahat 1993 (6)

92.6 (Bone type IIIII)

95.9 (Bone type IIIII)

Jemt & Lekholm 1995

Buser et al. 1997 (21)

Ellegard et al. 1997 (40)

Wyatt et al. 1998 (125)

Gunne et al. 1999 (61)

100 (only three implants

Lekholm et al. 1999 (70) 127 (461)

91.5 (only 13-mm

Winkler et al. 2000 (124) (2917)

94.3 (only 13-mm

Bahat 2000 (7)

Brocard et al. 2000 (20)

Testori et al. 2000 (118)

Naert et al. 2002 (82)

Stellingsma et al. 2003

Weng et al. 2003 (123)

Romeo et al. 2004 (98)

Feldman et al. 2004 (46) (4891)

91.6 (10-mm machined 93.8 (machined)

Nedir et al. 2004 (83)

Herrmann et al. 2005

Koo et al. 2010 (67)

Nisand & Renouard

Table 2. Case series devoted to short-length implants

No. of patients (no. of Follow-up, in

Lai et al. 2013 (69)

Intrabony length 8 mm 98.7 (5 years)

Draenert et al. 2012 (38)

De Santis et al. 2011 (37) 46 (107)

8.5 and 7.0 mm

Perelli et al. 2011 (86)

et al. 2012 (60)

Van Assche et al. 2012

1014 and 6 mm (two

Rossi et al. 2010 (102)

Anitua & Orive 2010 (2)

8.5, 7.5, 7.0 and 6.5 mm

92.82 (10 mm)

Grant et al. 2009 (57)

Corrente et al. 2009 (28)