Franck Renouard Impact of implant length and diameter

David Nisand
on survival rates

Authors’ affiliations: Key words: biomechanical aspects, dental implants, implant diameter, implant length
Franck Renouard, Private Practice, Paris, France
David Nisand, Department of Periodontology,
University of Paris 7, Paris, France Abstract
Introduction: Despite the high success rates of endosseous oral implants, restrictions have
Correspondence to:
Franck Renouard been advocated to their placement with regard to the bone available in height and volume.
Private Practice The use of short or nonstandard-diameter implants could be one way to overcome this
26 Avenue Kléber
limitation.
75116 Paris
France Material and methods: In order to explore the relationship between implant survival rates
e-mail: franck@renouard.net and their length and diameter, a Medline and a hand search was conducted covering the
period 1990–2005. Papers were included which reported: (1) relevant data on implant
length and diameter, (2) implant survival rates; either clearly indicated or calculable from
data in the paper, (3) clearly defined criteria for implant failure, and in which (4) implants
were placed in healed sites and (5) studies were in human subjects.
Results: A total of 53 human studies fulfilled the inclusion criteria. Concerning implant
length, 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
the placement in sites with poor bone density. Recent publications (22) reporting an
adapted surgical preparation and the use of textured-surfaced implants have indicated
survival rates of short implants comparable with those obtained with longer
ones.Considering implant diameter, a few publications on wide-diameter implants have
reported an increased failure rate, which was mainly associated with the operators’
learning curves, poor bone density, implant design and site preparation, and the use of a
wide implant when primary stability had not been achieved with a standard-diameter
implant. More recent publications with an adapted surgical preparation, new implant
designs and adequate indications have demonstrated that implant survival rate and
diameter have no relationship.
Discussion: When surgical preparation is related to bone density, textured-surfaced
implants are employed, operators’ surgical skills are developed, and indications for implant
treatment duly considered, the survival rates for short and for wide-diameter implants has
been found to be comparable with those obtained with longer implants and those of a
standard diameter. The use of a short or wide implant may be considered in sites thought
unfavourable for implant success, such as those associated with bone resorption or previous
injury and trauma. While in these situations implant failure rates may be increased,
outcomes should be compared with those associated with advanced surgical procedure
such as bone grafting, sinus lifting, and the transposition of the alveolar nerve.
To cite this article:
Renouard F, Nisand D. Impact of implant length and
diameter on survival rates.
Clin. Oral Imp. Res. 17 (Suppl. 2), 2006; 35–51
The clinical use of several endosseous oral However, their use may be restricted
r 2006 The Authors
implants designs has become highly pre- where there are limitations imposed by
Journal compilation r Blackwell Munksgaard 2006 dictable in recent decades. the geometry and volume of the alveolar

35
Renouard & Nisand . Impact of implant length and diameter on survival rates
bone. These restrictions are more common
in the posterior regions of the maxilla and
the mandible.
It is generally claimed that the best
treatment in these situations is surgical
modification of the patient’s anatomy by
bone grafting techniques, alveolar distrac-
tion or inferior alveolar nerve transposition
to allow the placement of longer and wider
implants. However, the adaptation of the
implant to the existing anatomy through
the use of short and/or narrow- or wide-
diameter implants should now be consid-
ered as a more appropriate procedure.
In the present review, a ‘short’ implant
was defined as a device with a designed
intra-bony length of 8 mm or less, a ‘wide’
implant as one in which the stated dia-
meter was 4.5 mm or more, and a ‘narrow’
implant as one in which this was less than
3.5 mm.
This review was conducted within the
above parameters and evaluated, through a
Medline search, the survival rate of oral
implants related to their length and dia-
meter.
Material and methods
Studies to be included in this structured
review had to fulfill the following inclusion
criteria: (1) relevant data on implant
lengths and diameters, (2) implant survival
rates were either clearly indicated or calcul-
able from data reported in the paper, (3)
criteria for implant failure had been clearly
defined, (4) implants were placed in healed
sites, (5) human-derived data were re-
ported.
If more than one publication referred to
the same data, the most recent report was
used.
No restrictions were placed concerning
study design, and randomized and nonran-
domized clinical trials, cohort studies, case
control studies and case reports were all
considered for inclusion in the review.
A Medline search was performed to
identify clinical articles published between
January 1990 and December 2005. The
following search terms were used: ‘dental/
oral implant’ and ‘length’, ‘diameter’,
‘shape’, and ‘short dental implant’.
In addition, a manual search of the
following journals from 1990 to 2005 was
performed: Clinical Oral Implant Re-
36 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51
search, International Journal of Oral and
Maxillofacial Implants, Clinical Implant
Dentistry and Related Research, Journal
of Periodontology, Journal of Clinical
Periodontology, International Journal of
Periodontics & Restorative Dentistry.
A further manual search was conducted
through the bibliographies of all relevant
papers and review articles.
Two examiners reviewed the titles and
abstracts according to the inclusion criteria.
When necessary, the complete text of the
article was obtained for further assessment
of inclusions. Full texts of all papers that
were considered suitable for inclusion by
the two examiners were then obtained.
Disagreements between the two examiners
were resolved by discussion.
Data extracted from the review were
classified as follows:

studies dedicated to short-length im-
plants;

studies with data available on length;

studies mainly dedicated to wide-dia-
meter implants;

studies dedicated to narrow-diameter
implants;

studies with data available on diameter.
Results
The Medline search provided a total of 182
articles for ‘dental/oral implant’ and
‘length’, 103 articles for ‘dental/oral im-
plant’ and ‘diameter’, 39 articles for ‘den-
tal/oral implant’ and ‘shape’, and 102
articles for ‘dental/oral implant’ and ‘short
dental implant’ of which 67 were screened
as full text articles.
A total of 53 human studies fulfilled the
inclusion criteria and were divided as fol-
lows: 13 articles dedicated to short-length
implants, 21 articles with data available on
implant length, nine articles mainly dedi-
cated to wide-diameter implants, seven
articles dedicated to narrow-diameter im-
plants and eight articles with data available
on diameter.
The selected articles embodied a wide
range of approaches to study design, data
reporting, definition of terms, implant
geometry and surface, methods of statisti-
cal analysis, success and survival criteria,
and follow-up time. Consequently no
attempt was made to apply a meta-analytic
technique.
Implant length
Tables 1a and 1b display the data obtained
from the 21 articles which provided infor-
mation on implant length. In most of these
studies (12), a higher failure rate was docu-
mented for shorter implants (van Steen-
berghe et al. 1990; Friberg et al. 1991;
Jemt 1991; Bahat 1993; Jemt & Lekholm
1995; Wyatt & Zarb 1998; Lekholm et al.
1999; Bahat 2000; Winkler et al. 2000;
Naert et al. 2002; Weng et al. 2003; Herr-
mann et al. 2005). The worst results with
short implants have been documented by
Wyatt & Zarb (1998) with an overall sur-
vival rate of 75% for 7-mm-long implants
(of the 12 implants placed, three were lost),
Winkler et al. (2000) with an overall survi-
val rate of 74.4% for 7-mm-long implants
(of the 43 implants placed, 11 were lost)
and Herrmann et al. (2005) with an overall
survival rate of 78.2% for 7-mm-long im-
plants (of the 55 implants placed, 12 were
lost).
However, only a few of these studies
analysed the statistical differences between
short and longer implants (Bahat 1993;
Jemt & Lekholm 1995; Winkler et al.
2000; Weng et al. 2003; Herrmann et al.
2005). Thus, Winkler et al. (2000) demon-
strated that shorter implants tended to fail
significantly more often following unco-
vering and after loading than longer im-
plants. Using logistic regression analyses,
implant length was found to be a signifi-
cant factor for survival over the observation
period. In the same way, Weng et al. (2003)
reported that 60% of all failed implants
were short (  10 mm), and that the cumu-
lative success rate for these short implants
was significantly lower than the cumula-
tive success rate for all implants. In the
study by Herrmann et al. (2005), a signifi-
cant correlation was demonstrated between
shorter implants and failure rate. In addi-
tion, comparing the two groups of short
implants, a significant difference was
found between the 7- and 10-mm im-
plants.
Moreover, it is of interest to note that
some of theses studies, although conclud-
ing that shorter implants had higher failure
rates than longer ones, still indicated ac-
ceptable survival rates for the former. As
such, van Steenberghe et al. (1990)
 Table 1a. Studies on oral implants with information on length available
N patients Follow-up Patients  13 mm 11.5 and 12 mm 10 mm 8.5 mm 8 mm 7 mm 6 mm CSR CSR CSR
(N implants) in months lost to (o10 mm) (410 mm) (all length)
(mean) follow- (%) (%) (%)
up (I)

N CSR N CSR N CSR N CSR N CSR N CSR N CSR

(%) (%) (%) (%) (%) (%) (%)

van Steenberghe 159 (558) (12) (35) 192 97.4z / / 246 93.9z / / / / 120 97.5z / / – – 95.8z
et al. (1990)
Jemt (1991) 384 (2199) 12 11 (62) – – – – – – – – – – 270 94.7zy / / – – 98.1z
Friberg et al. 889 (4641) From stage 0 3848 (implants 99.4 (implants / / / / 793 94.5z / / 94.5 z 99.4z 98.5z
(1991 1 to the 10–20 mm) 10–20 mm) (7 mm only)
connection
of prostheses
Bahat (1993) 213 (732) 5–70 (30.3) 4 – – – – – – / / / / – 90.5zn / / 92.6 z 95.9z 95.2zn
(in bone type (in bone type
II–III)z II–III)
86.7z (in bone 94.5z (in bone
type IV)z type IV)
Jemt & Lekholm 150 (801) (60) 19 (100) 212 – / / 291 – / / / / 298 – / / 75.8n 91.85n 71.2–92.1
(1995)
Buser et al. 1003 (2359) 12–96 63 (127) 26 – 1091 95w 814 93.4w / / 389 91.4w / / 39 – – – 96.7
(1997)
Ellegaard et al. 68 (124) 3–84 – 16 – 21 – 26 – 5k – 56 – / / / / – – 95–100z
(1997)
Wyatt et al. 77 (230) 12–144 (64.9) – 124 95nn / / 93 92 1 100 / / 12 75z / / – – 94z
(1998)
Gunne et al. 23 (69) (120) 3 (9) 3 100 / / 29 86w / / / / 37 89w / / – – 88.4
(1999)
Lekholm et al. 127 (461) (120) 38 (123) 176 91.5zww / / 207 88zzz / / / / 101 93.5zzz / / – – 92.6z
(1999)
Winkler et al. (2917) (36) – 1966 94.3 yyn / / 770 89.1n / / 138 87n 43 74.4n / / – – 93.1z
(2000)
Bahat (2000) 202 (660) 60–144 (97) at 341 – 6 – 210 – 3 – 8 – 84 – 8 – 83zzz 95z 93.4 (at 10
5 years (10–15 mm)zz years)
100 (18–

37 |
20 mm)zz
Brocard et al. 440 (1022) 12–84 (30) 18 – 276 – 480 – / / 232 – / / 16 – 80.3w (8 mm or 83.7w 92.2
(2000) less) (12 mm or (C Success :
more) 83.4%)
Testori et al. 181 (485) (52.6) 16 (39) 306 – 26 – 122 – 24 – / / 7 – – – – – 98.7
(2001)
Naert et al. 660 (1956) (66) 73 (204) 1047 – 15 – 719 – 39 – 19 – 110 – 7 – 81.5z – 91.4
(2002)
Stellingsma 60 (240) (12) 2 (8) 4 short (8 or 11 mm) – – 94.6z
et al. (2003) implants to support an
overdenture in 20
patients with an
extremely resorbed
mandible. One patient
lost to follow-up and
no implant loss.

Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

Renouard & Nisand . Impact of implant length and diameter on survival rates
38 |
Table 1a. Continued
N patients Follow-up Patients  13 mm 11.5 and 12 mm 10 mm 8.5 mm 8 mm 7 mm 6 mm CSR CSR CSR
(N implants) in months lost to (o10 mm) (410 mm) (all length)
(mean) follow- (%) (%) (%)
up (I)

N CSR N CSR N CSR N CSR N CSR N CSR N CSR

(%) (%) (%) (%) (%) (%) (%)

Weng et al. 493 (1179) (72) (222) 607 / / / 475 91z 70 81z / / 27 74z / / 89 (10 mm 93.1n 91.1 (6 years)
(2003) included) n
Romeo et al. 250 (759) 16–84 (46.2) 49 (82) 49 – 236 – 402 – / / 72 – / / / / – – 96.1 (FPD)
(2004)
Feldman et al.  (4891) 24–60 (316 kk) 2547 – 329 – 1447 – 425 – / / 143 – / / Machined 91.6 Machined 93.8n –

Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

(2004) (10 mm
included)n
Osseotite 97.7 Osseotite 98.4w
(10 mm
included)w
Herrmann et al. 487 (487) (60) 80 (80) 259 95.7znnn / / 159 89.9zwwwn / / / / 55 78.2zwwwn / / – – 92.4
(2005)
Lemmerman & 376 (1003) (63.6) – – – – – – – – – – – – – – – – – 94z
Renouard & Nisand . Impact of implant length and diameter on survival rates

Lemmerman
(2005)

n
Significant differences between short and long implant in the same study.
wNo significant difference between short and long implant in the same study.
zOverall survival rate.
yData concerning the maxilla only.
zOnly implants 7 mm length included.
kImplants of 9 mm length.
nnOnly implants 13 mm length included (for implants 15 mm length, the success rate was 98% and 100% for implants 18 and 20 mm length).
wwOnly implants 13 mm length included (absolute survival rate);. Implants 15, 18, and 20 mm length present a 100% absolute survival rate.
zzOnly implants 3.75 mm wide included (absolute survival rate).
yyOnly implants 13 mm length included.
zzOnly implants 3.75 mm wide included (absolute survival rate).
kkIn the short-implant group (no data concerning the number of implant lost to follow-up in the long-implant group).
nnnOnly implants 3 .75 mm wide and 13 mm length were evaluated (wider implants were excluded).
wwwOnly implants 3.75 mm wide were evaluated.
CSR, cumulative survival rate.
 Table 1b. Studies on oral implants with information on length available
Authors Type of study Submerged/ Implant type Implant failures
nonsubmerge
Before After Mandible Maxilla Comments
technique
loading loading (%) (%)
(%) (%)
van Steenberghe Prospective multicentre Submerged Machined 87 13 3.5 5 Longer fixtures failed to a lesser extent compared with
et al. (1990) the shorter standard implants (7-, 10-, and 13-mm long)
Jemt (1991) Retrospective study Submerged Machined 66 34 0.4 2.9 The edentulous patients were provided with
Brånemark implants according to routine surgical
protocol. The 7-mm implant failed more often (5.3%)
than any other size of implant in the maxilla. A
corresponding pattern was not found in the mandible
Friberg et al. Retrospective, Submerged Machined 100 / 0.6 (2.7% for 2.9 (6.9% A majority of failures associated with advanced
(1991) multicentre 7 mm implant) for 7 mm) resorption.
Length of the implants may indicate the state of jaw
bone resorption.
No relation between implant length and failures in
partially edentulous patients.
Edentulous patients frequently wore removable
dentures (preloading of implants)
Bahat (1993) Retrospective study Submerged Machined – – – – 7-mm implants had a higher failure rate than those of
all other length. 60% of the failing 7-mm molar
implants were the only implants in that segment of the
jaw
Jemt & Lekholm Retrospective study Submerged Machined – – / 7.9–28.8 Factors of significance for implant failures in patients
(1995) were found to be age, ratio of 7-mm implants and
bone quality
Buser et al. Prospective, multicentre Nonsubmerged TPS 26.5 73.5 5.9 (anterior) 12.2 (anterior) Analysis demonstrated a trend for better results with
(1997) 4.6 (posterior) 13.3 (posterior) increasing implant length
This trend was however not statistically significant
8-mm implants were predominantly inserted in
posterior segment
Ellegaard et al. Retrospective Nonsubmerged (93), TPS (93), – – 7.7 2.7 The length of the implant varied between 8 and 14 mm,
(1997) Submerged (31) TiOblast (31) with 45% being 8 mm. Most implants were placed in
the maxilla in periodontally compromised patients. A
total of three implants had failed. Two were of 8 mm

39 |
implants and one concerned a 10 mm implant
Wyatt et al. Longitudinal study Submerged Machined 50 50 57% (of the 43% (of the The higher failure rate documented for shorter
(1998) failed implants) failed implants) implants (25% failure of the 7-mm implants placed)
compared with longer ones may be related to
compromised placement in restricted anatomic sites.
Alternatively, the effect of the same amount of bone
loss on a short and long implant may result in dramatic
differences in their survival rates
Gunne et al. Longitudinal study Submerged Machined 12.5 87.5 11.6 / Success rates reported in this study were achieved
(1999) despite the use of short implants (54% of the implants
were 7 mm) and the failure rate was similar for 7- and
10-mm implants
Lekholm et al. Prospective multicentre Submerged Machined 47 53 6.3 9.8 According to Cox regression analysis, the only
(1999) relationship between failures and implant
characteristics was seen with regard to implant length,
in that shorter implants failed more often than longer

Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

Renouard & Nisand . Impact of implant length and diameter on survival rates

ones
 Table 1b. Continued

40 |
Authors Type of study Submerged/ Implant type Implant failures
nonsubmerge
Before After Mandible Maxilla Comments
technique
loading loading (%) (%)
(%) (%)
Winkler et al. Longitudinal study Submerged Machined and – – – – Shorter implants tended to fail significantly more often
(2000) HA-coated following uncovering and post-loading than longer
implants. Using logistic regression analyses, implant
length was found to be a significant factor for surviving
for the overall period of observation
Bahat (2000) Retrospective study Submerged Machined 37 63 / 6.6 As expected, the longer implants were more likely to
survive than the shorter ones. However, the failure rate
of the 7-mm-long implants was similar to that of longer
ones when the 7-mm implant was not the most distal in
a series
Brocard et al. Longitudinal multicentre Nonsubmerged TPS 19.1 80.9 – – The implants were divided into three groups according

Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

(2000) to their length with success rate for each group being
comparable. Implant length did not significantly
influence the results, especially for 8–12-mm implants
Testori et al. Prospective multicentre Submerged Osseotite 100 0 0.6 (posterior) 1.6 (posterior) Short implants, defined for this report as 10 mm or
(2001) 0 (anterior) 2.4 (anterior) shorter, represented 31.5% (153) of the implants placed
in this investigation. There is a tendency for shorter-
length (  10 mm) machined-surface implants to fail
more often than longer implants. This tendency was
Renouard & Nisand . Impact of implant length and diameter on survival rates

not observed for the shorter implants placed in this

study. Of the 153 short implants placed, only one 7-mm
implant, which was placed in the posterior maxilla in a
site recorded as soft bone, failed to osseointegrated. It
is possible that the difference in biologic response
between the machined implant surface and the micro-
textured surface is responsible for the difference in the
survival rates for short implants
Naert et al. Longitudinal study Submerged Machined – – 6.7 10.1 A two-stage surgical intervention was performed
(2002) according to a standard protocol. The shorter the
implant length, the higher the hazard rate. Decreasing
the implant length by 1 mm increases the hazard rate
0.16 times
Stellingsma Prospective Submerged Machined 0 0 0 / The objective of this report was to study the effect of
et al. (2003) three different treatment modalities (short implants,
transmandibular implants, augmentation, and long
implants) in edentulous patients with an extremely
resorbed mandible. Differences among the three
groups were not significant. However, in terms of
discomfort and pain during the surgical phase as well
as the length of this phase, the augmentation using an
autologous bone graft from the iliac crest appeared
the least favourite option.
Weng et al. Prospective, multicentre Submerged Machined 83.7 16.3 – – 23.2% of all implants in the post-maxilla
(2003) CSR implants in the post-maxilla (all length) ¼ 86.2%
CSR implants  10 mm in post-maxilla ¼ 80.6%
Romeo et al. Prospective Nonsubmerged TPS (703), SLA (56) 6.2 93.8 47% of the 53% of the Implant failure did not appear to be significantly
(2004) failed implants failed implant influenced by length. Only 20% of failed implants were
8-mm long
 Renouard & Nisand . Impact of implant length and diameter on survival rates

reported only three failures among 120

Short-length dual-acid-etched implants perform as well

such as longer drilling time; lesser ability of coolant to

demonstrated between the 7- and the 10-mm implants,

No correlation (no effect on failure rate) was found for

matched standard-length machined-surfaced implants.

multilevel analyses, no statistical significance regarding

length could indirectly be regarded as a patient-related

implant length. Longer implants are not accompanied

implants (412). This could be due to operator factors

(jawbone quality and jaw shapes). Therefore, implant

by an increased success rate in this study. If anything,

any of the new combinations could be demonstrated
7-mm-long implants leading to an overall

implants and failure rate: the failure rate for shorter

factor, since it is related to the bone volume present

A significant correlation was found between shorter
implants was especially compromised in the maxilla

penetrate the osteotomy; or inadvertent, increased

implants was 13.1%. Comparing the two groups of
The performance of these short machined-surfaced

respectively. When adding length as a level for the

as standard DAE implants. Short-length machined- survival rate of 97.5%. Friberg et al. (1991)
surfaced implants did not perform as well against

the rate of failure went up about 3% with long

in a study on 4641 implants obtained an
overall survival rate of 94.5% for 7-mm-

and under conditions of poor-quality bone

short implants, a significant difference was

drilling force to get a deeper osteotomy

long implants. Jemt (1991) in a study on
2199 implants reported an overall survival

Four multicentre study (Lekholm et al. 1994, Henry et al. 1996, Jemt et al. 1996, Friberg et al. 1997) reporting on one specific implant design constituted the basis for the research.
rate of 95.5% (of the 270 implants placed,
12 were lost). Lekholm et al. (1999) in a
10-year prospective multicenter study re-
ported an overall survival rate of 93.5%
for 7-mm-long implants compared with
91.5% for 13-mm-long implants.
In some of these studies, the failure rates
of short implants were similar to those of
longer ones. This finding applied to 7-mm-
long implants placed in partially dentate
patients (Friberg et al. 1991), 7-mm-long
implants placed in the mandible (Jemt
1991), and when the 7-mm implant was
not the most distal in a series (Bahat 2000).
6.2

Moreover, of the nine studies which

–

provided data on implant length (Tables

1a and 1b), this was not reported as influ-
encing the survival rate (Buser et al. 1997;
Ellegaard et al. 1997; Gunne et al. 1999;
6
–

Brocard et al. 2000; Testori et al. 2001;

Stellingsma et al. 2003; Feldman et al.
24.5
50

2004; Romeo et al. 2004; Lemmerman &

–

Lemmerman 2005). In a study on 2359

75.5

implants, Buser et al. (1997) reported a

50
–

91.4% cumulative survival rate for 8-

vs. Osseotite (2294)

mm-long implants with a plasma-sprayed

Machined (2597)

Machined (348)

surface as compared with 93.3% for 10-

surface (655)
and rough

mm-long implants and 95% for 12-mm-

Machined

long implants. Feldman et al. (2004), using

dual-acid-etched implants reported a
97.7% cumulative survival rate for short
implants (implant  10 mm) as compared
SLA, sandblasted and acid-etched; TPS, titanium plasma-sprayed.
Submerged and
nonsubmerged

with 98.4% for longer ones. However, in

Submerged

Submerged

the same study, short-length machined-

surfaced implants did not perform as
well against matched standard-length
machined-surfaced implants (91.6% vs.
Analysis of prospective

93.8%, respectively).
Herrmann et al. Research databasen

Tables 2a and 2b display the data ex-

Prospective study

tracted from the 13 articles which are

devoted to short implants. Depending on
multicentre

the definition of short implants among the

authors, these articles involved 6–13-mm-
long implants. Eight of these articles (Ten
Bruggenkate et al. 1998; Deporter et al.
Lemmerman &
Feldman et al.

2000, 2001; Friberg et al. 2000; Fugazzotto

Lemmerman

et al. 2004; Griffin & Cheung 2004; Goen

et al. 2005; Renouard & Nisand 2005) only
(2004)

(2005)

(2005)

dealt with short-length implants. Among

n

the remaining five studies, the definition

41 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

Renouard & Nisand . Impact of implant length and diameter on survival rates

of short implants included those which

92.3 (10 years)

95.5 (5 years)
were 10, 11, 12, and 13 mm long (Bernard

94 (n ¼ 97%)
et al. 1995; Texeira et al. 1997; Stellingsma
et al. 2000; Tawill & Younan 2003; Nedir

11.2 88.8 93.3n 95.9n 95.5nw

95.1n
94.5z 95.8z 95.8
99.1 99.4

94.6
CSR
(%)

100
100

100
99n
et al. 2004).

94

88
Although Ten Bruggenkate et al. (1998)

98.4

99.5

92.3
CSR

(%)

100

100
Md

recommended that short implants should

94

88

95.1 /

94.6 /
be used in combination with longer ones,

42.9 47.4 17.8 82.2 86.7

CSR

(%)

100

100

100
100
six of the above studies, reported the use of
Mx

100 /

/
/

100 /
short implants alone. Moreover, some of
100
100
Md

the studies reported mainly on the use of

65

62
47
%

–
100 /

100 /

100 /
short implants to support single crowns
Mx

35

39.7 27.5 38
53
%

(Deporter et al. 2001; Fugazzotto et al.

–
/

/
/

/
2004; Griffin & Cheung 2004).
100
RD
%

Nine of these studies involved textured-

3

8
81.1 /

/
/
87.7 /

23.8 /
/
93.2 /
84.4 /
surfaced implants, two either machined or
(mm) Single FPD

64

92

17
%

textured-surfaced implants and only two

/

/
crown

reported data concerning machined-sur-

18.9

12.3
32.4
76.2

15.6
100
9.6

6.8
33

83
%5 Mean %

faced implants. One of the studies (Re-

/
/

nouard & Nisand 2005) dealing with both

10.26
8.31

8.25
6.95

7.66

8.42
9.1

6.9

8.1

7.9

wWhen the survival rate of 10-mm implants was compared with those of the shorter implants, no statistical difference was found.
machined and textured-surfaced implants
6

indicated a trend for better results with the

FPD, fixed partial denture; RD, removable denture; CSR, cumulative survival rate; Mx, maxillae; Md, mandible; –, not reported.
7.6

use of textured-surfaced implants com-

/
/
/

/
/

/
/
/
/
/
/
/ 10.5

pared with machined ones (97.6% and

100

100
%6

5.9
1.1
6

5
/

19.1 45.6 /

/
/

92.6% survival rates, respectively); How-

88.5
66.6
10.1

23.9
%7

ever this trend was not statistically signifi-

4.3
5.5
95
/
/
/

/
/

cant.
10.1
18.4

81.6
%8.5 %8

Four of these studies were devoted to the

36
90
/

/
/

/
/

treatment of the mandible, and three solely

17.1

94.5
65.6

treatment of the maxilla. Despite a re-

/
/
/

/
/

/
/

/
/
/

ported increased failure rate of short im-

33.3

14.1
Patient %410 %10 %9

3.9

1.5

plants in the maxilla by Ten Bruggenkate

/
/
/

/
/

/
/

et al. (1998) (six of 45 short implants

35.3

56.8
36.7
55

placed in the maxilla were lost, giving an

/
/

/
/

/
/
/
/

overall survival rate of 86.6%), acceptable

42.2

survival rates in this jaw (94.6–100%) were

10
3

/
/

/
/
/

/
/
/
/

reported in other studies (Deporter et al.

follow-

15 (46)
21 (31)
lost to

2000; Fugazzotto et al. 2004; Renouard &

up (I)
3 (5)
5 (9)

4 (4)
(28)

21

Nisand 2005). The worst cumulative sur-

0

0
0

0
–
–

vival rate of short implants (88%) was

8.2–50.3 (32.6)
6–36 (11.1)

9–68 (34.9)

24–48 (37.6)
12–168 (96)

reported by Stellingsma et al. (2000) in

60–97 (77)
(N implants) in months
Follow-up

the treatment of extremely resorbed mand-

(mean)

0–84
12–84

12–92
12–84

(39.1)

ibles with implant-stabilized overdentures.

(36)
(60)
Table 2a. Studies dedicated to short implants

However, Friberg et al. (2000) reported a

92.3% cumulative survival rate after 10
N patients

48 (100)

126 (253)

49 (260)

(269)
(528)
(168)
(979)
(311)

years using principally short implants in

26 (67)

17 (68)

(26)
(48)

(96)

severely atrophic mandibles, supporting

16
24
111
236

85
167
979
188

fixed prostheses (45) and overdentures (4).

Out of these 13 studies, seven provide
Renouard & Nisand (2005)

zIn the posterior sextants.

Griffin & Cheung (2004)
Stellingsma et al. (2000)

Fugazzotto et al. (2004)

data concerning crestal bone loss. Bernard

Tawill & Younan (2003)
Ten Bruggenkate et al.

Deporter et al. (2000)

Deporter et al. (2001)
Bernard et al. (1995)

Overall survival rate.

et al. (1995) reported an average crestal

Friberg et al. (2000)
Texeira et al. (1997)

Goené et al. (2005)

Nedir et al. (2004)

bone loss of 0.96 mm between implant

placement and the final observation at 36
months. In contrast Ten Bruggenkate et al.
Authors

(1998) found no crestal bone loss following

(1998)

abutment connection in 72% of the pa-

n

tients studied, 1 mm loss in 16%, 2 mm

42 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

 Renouard & Nisand . Impact of implant length and diameter on survival rates

bone loss in 9% and more than 3 mm of

70.6% (12I)
100% (1I)

43% (3I)

50% (6I)

40% (4I)
100% (3I)

12.5% (1I)

30% (3I)

40% (2I)
66.7% (2I)
crestal bone loss in 3%. Stellingsma et al.

loading
Failure
(2000) claimed that no severe bone loss was

after
detected after a mean following time of 77

/
/

/
months. Deporter et al. (2001) found no
statistically significant change in the mean

70% (10I)
crestal bone level from baseline to the end

57% (4I)

50% (6I)

60% (6I)
87.5% (7I)

60% (3I)
29.4% (5I)

33.3% (1I)
of the observation time. Friberg et al.
loading
Failure
before

(2000) reported a mean bone loss of

0.5  0.6 mm during the first year of func-
/
/

/
/

/
tion and losses of 0.7  0.8 and
0.9  0.6 mm after 5 and 10 years, respec-
Short implant

implant (%)

tively. In the study by Tawill & Younan

with long

(2003), the mean marginal bone loss was

0.71  0.65 mm; however 8.9% of the

55.2
22.6
–

–
–

– sites lost more than 1.5 mm (ranging from

/

/
/
/
/

1.6 to 3.18 mm). These results were con-

sistent with those of Renouard & Nisand
100 (with 10 mm)

(2005), which indicated a mean marginal

Short implant

bone loss of 0.44  0.52 mm after 2 years

alone (%)

of function.
It is of interest to note that no specific
44.8
77.4
100

100
100
100
100
–

–
–

pattern was observed concerning the time

of failure of short implants. Apart from the
studies from Stellingsma et al. (2000) and
TPS (50%) and SLA (50%)
Porous-sintered-surface
Porous-sintered surface

Goené et al. (2005) which indicated a

Machined (56.2%) and

tendency to failure before loading.

Machined and TPS

In all, these 13 studies involved 2072

Ti unite (43.8%)
Implant type

patients restored with 3173 implants (2141

TPS and SLA
HA coated

HA coated
Machined
Machined

6–9-mm implants) with a mean implant

Osseotite

length of 7.9 mm, follow-up periods of 0–

TPS

TPS

168 months (mean follow-up for the nine

studies providing this data was 47.1
months), a mean percentage of patients
nonsubmerged (18%)

lost to follow-up of 9.5% (for the 10 studies

nonsubmerged (5%)

providing this data), and a mean survival

Submerged and

Submerged and
Submerged and
Nonsubmerged

Nonsubmerged

Nonsubmerged
Nonsubmerged
Nonsubmerged

nonsubmerged
Nonsubmerge

rate of 95.9%.
Submerged/

Submerged

Submerged
Submerged
Submerged

Submerged

Moreover, it should be noted that 46.2%

technique

of these articles had been published

SLA, sandblasted and acid-etched; TPS, titanium plasma-sprayed.

between 2003 and 2005.

Retrospective,

Retrospective,

Retrospective,

Implant diameter
Type of study

Retrospective

Retrospective
Retrospective

Retrospective

Retrospective

Retrospective
Table 2b. Studies dedicated to short implants

multicentre

multicentre

multicentre
Prospective

Prospective
Prospective

Prospective

Table 3a displays the data extracted from

the nine papers, which dealt mainly with
wide-diameter implants. A higher overall
implant failure rate had been indicated by
two of these articles. The study by Eckert
et al. (2001) reported overall survival rates
Renouard & Nisand (2005)
Griffin & Cheung (2004)
Stellingsma et al. (2000)

Fugazzotto et al. (2004)

of 71% and 81% in the maxilla and mand-

Tawill & Younan (2003)
Deporter et al. (2000)
Deporter et al. (2001)
Bernard et al. (1995)

ible, respectively. This failure rate was not

Friberg et al. (2000)
Texeira et al. (1997)

Goené et al. (2005)

Nedir et al. (2004)
Ten Bruggenkate

related to any of the specific risk factors

reviewed. In the same way, Shin et al.
et al. (1998)

(2004) obtained a cumulative survival rate

Authors

of 80.9% with wide-diameter implants (a

significantly lower success rate compared
with 87.5% for 4 mm diameter implants

43 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

 Table 3a. Studies dedicated to wide-diameter implant
Type of Submerged/ Implants N patients Follow-up Patients 5 þ 5 4þ CSR Comments

44 |
study nonsubmerged type (N implants) in months lost to (all )
N CSR N CSR N CSR
techniques (mean) follow- (%)
(%) (%) (%)
up (I)
Bahat & Case studies Submerged Machined 90 (133) 14–37 – / / 133 97.7w / / 97.7w The failure rate for all of the 5-mm implants
Handelsman (paired and unpaired) was 2.3%. The failure
(1996) rate for all double implants (any size) was
1.6%
Aparicio & Orozco Retrospective Submerged Machined 45 (185) 16–55 (32.9) 3 (8) / / 94 97.2 (Mx) / / – The reason for larger failure rate in the
(1998) 83.4 (Md) mandible for posterior 5-mm implants is not
known. The mean bone loss after 48 months
was 0.97 mm
Renouard et al. Retrospective Submerged Machined 74 (98) (12) 0 / / 98 91.8 w / / 91.8w Bone loss around wide diameter implants
(1999) without a smooth collar is comparable to
that reported around standard-diameter
implants. Bone loss that occurred before
second stage surgery was observed primarily

Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

for long implants
Khayat et al. Retrospective Submerged Screw Vent 71 (131) 11–21 (17) 7 (14) / / / / 131 95w 95w Only 2.5% of the implants presented crestal
(2001) (4.7 mm) bone loss beyond the first thread. Survival
rates in the mandible and in the maxilla did
not show a statistically significant difference
Eckert et al. (2001) Longitudinal Submerged Machined 63 (85) 0–734 (286) 0 / / 85 71w (Mx) / / 71 w(Mx) The current report demonstrated a higher
in days 81w (Md) 81w (Md) overall implant failure rate. The failure rate
was not related to any specific risk factors
Renouard & Nisand . Impact of implant length and diameter on survival rates

reviewed.
No relationship was noted between shorter
implants and higher failure rates
Krennmair & Retrospective Submerged – 114 (121) 12–114 (41.8) 0 121 98.3 / / / / 98.3 In 58 of 74 maxillary implants, a sinus lift
Waldenberger (5.5 mm) procedure was performed. Only two
(2004) maxillary implants lost osseintegration
Shin et al. (2004) Retrospective Submerged Machined 82 (128) 12–84 7 / / 64 80.9%n / / – Although, the wide implant suffered a
significantly lower success rate compared
with the standard diameter (87.5% for the
4 mm-wide and 98.2%n for the 3.75 mm-wide
diameter) implant, the 5-mm-diameter WP
implants had a much lower CSR of 73.7%
compared with an overall CSR of 100%
among the 5-mm RP implants
Hultin-Mordenfeld Retrospective Submerged Machined 58 (78) 11–58 (33) 6 / / 78 89.8w / / 89.8 w Better results were seen in the mandible
et al. (2004) (94.5%) compared with the maxilla (78.3%).
All failures occurred within 2 years of the
first surgery. The short group (7 and 8.5 mm-
length) demonstrated significantly more
failures than the long group
Anner et al. Case series Submerged HA-coated 43 (45) 1–54 (23.4) 1 (1) 45 100w / / / / 100w In the present study, only one implant
(2005) (6 mm) presented crestal bone loss beyond the first
thread at the end of the observation period
n
Significant differences in the same study.
wOverall survival rate.
CSR, cumulative survival rate; Mx, maxillae; Md, mandible.
 Table 3b. Studies on narrow-diameter implant
Type of study Submerged/ Implants N patients Follow-up Patients 3.3 3 CSR Comments
nonsubmerged type (N implants) in months lost to (all )
N CSR (%) N CSR (%)
techniques (mean) follow-up (I) (%)
Polizzi et al. Retrospective Submerged Machined 21 (30) 36–89 (63) 0 / / 30 93.3 93.3 One failure occurred after about 66
(1999) and prospective months of function. Thus, the results
show a cumulative survival rate of 93.3%
and an overall survival rate of 96.7%
Vigolo & Givani Retrospective Submerged Machined 44 ( 52) (60) 0 / / 52 (2.9 mm) 94.2n 94.2n During the 5-year period of this study,
(2000) two implants failed at the second surgical
phase
Hallman (2001) Prospective Nonsubmerged TPS 40 (182) (12) 0 160 – / / 99.4n Of the 160 narrow implants, one failure
was registered. After 1 year of loading,
the marginal bone resorption
demonstrated a mean of 0.35 mm.12% of
the placed implants were 8-mm length
(one lost)
Andersen et al. Prospective Submerged Machined 28 (32) (36) 3 (3) 28 (3.25 mm) 93.8 / / – 27 patients received 28 standard-
(2001) diameter implants and 28 patients
received 32 narrow-diameter implants
with 100% and 93.8% of CSR
respectively. 2 narrow-diameter implants
were lost after 6 months but no others
failures were subsequently observed in
any of the groups. In both groups,
marginal bone loss was recorded to be a
mean of 0.4 mm.The CSR in the 2 groups
were equal despite 2 implants were lost
in the narrow-diameter group
Zinsli et al. Prospective Nonsubmerged TPS 154 (298) 12–120 1 (2) 298 96.6 / / 96.6 Three implants were lost during the
(2004) healing phase. Two implant body
fractures were observed. 60 implants
have an 8-mm length (Only one was lost
due to fracture. The 5-year CSR was
98.7% and the 6-year CSR was 96.6%

45 |
Vigolo et al. Retrospective Submerged Machined 165 (192) (84) 0 92 (3.25 mm) – 100 (2.9 mm) – 95.3n No differences between the 2.9-mm and
(2004) 3.25-mm implants, between small
diameter implants used for single-unit
restorations and those included in
multiple-implant restorations were
detected. 67.2% of the implants
presented a marginal bone loss between
0.6-to 1-mm at 7 years
Comfort et al. Prospective Submerged Machined 9 (23) (60) 0 23 96n / / 96n One implant failed at abutment
(2005) connection. The mean marginal bone loss
during the first year was 0.41 mm and
between the 2nd and the 5th year,
0.03 mm
n
Overall survival rate.
CSR, cumulative survival rate; TPS, titanium plasma-sprayed.

Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

Renouard & Nisand . Impact of implant length and diameter on survival rates
 Table 3c. Studies on oral implants with information on diameter available

46 |
Type of study Submerged/ Implants type N patients Follow-up Patients 5þ 5 4þ 4 3.75 3þ CSR Comments
nonsubmerged (N implants) in months lost to (all )
N CSR N CSR N CSR N CSR N CSR N CSR
techniques (mean) follow- (%)
(%) (%) (%) (%) (%) (%)
up (I)

Ivanoff et al. Retrospective Submerged Machined 67 (229) (36–60) 17y / / 97 86.3 (Mx) / / 61 100 (Mx) 141 95.1 (Mx) / / 91w Seven of the 141 implants in the 3.75-mm-diameter
(1999)z 73 (Md) 84.8 (Md) 94.7 (Md) group failed (5%), 2 of 61 in the 4-mm-diameter
group (3%) and 17 of 97 (18%) in the 5-mm-
diameter group. No relationship between the
marginal bone loss and implant diameter was seen
during the first year of loading. Shorter implants
showed higher failure rates, specifically within the
5-mm group (20%). In the 3.75 and 4-mm group,
three of the 47 short implants failed
Lekholm et al. Prospective Submerged Machined 127 (461) (120) 38 (123) / / / / / / 26 100 435 92.2w / / 92.6w Shorter standard-diameter implants were lost more
(1999) multicentre often than longer ones, whereas no wider-diameter
implants whatsoever were lost

Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51

Bahat (2000) Retrospective Submerged Machined 202 (660) 60–144 97 / / 33 – / / 193 – 434 93w / / 93.4 The failure rate of wide implant (4- and 5-mm) was
(at 5 year) (10 years) 5% vs. 7% for the 3.75-mm implants
Winkler et al. Longitudinal Submerged Machined and (2917) (36) – / / / / 222 97.3nw / / / / 2695 92.7nw 93.1w The differences in survival for the 2 groups were
(2000) HA coated statistically significant. The percentage of implant
failure for the 3 þ mm diameter group was higher at
each stage as compared with 4 þ mm diameter
group
Friberg et al. Retrospective Submerged Machined 98 (379) 6–66 (32) 5 / / 157 93.1 / / 76 95.8 146 93.2 / / 95.3w In the 3.75-mm-diameter group, only long implant
(2002)z failed (13–18 mm), while shorter implants (6–10 mm)
predominated among the failures of the wider-
diameter groups (6 failures with 6–8.5-mm-length
among 86 implants placed : ASR ¼ 93%) . All failures
were recorded in the maxilla. The present study
show similar low failure rates for the various
implant diameters. 10 of the 18 failure were
recorded in 2 patients. The 5-mm-diameter implant
group showed significantly less marginal bone loss
than the 3.75- and 4-mm groups
Garlini et al. Retrospective Submerged Osseotite 244 (555) (26) 0 / / 74 – / / / / 470 – 11 (3.25 mm) – 98.5 Eight implants (3.75-mm-diameter) in six patients
(2003) failed before prosthetic treatment. No differences
in success rates were noted among the implants of
different diameter. Length of the implants did not
appear to influence the survival rate of restoration.
No so-called short implant (8.5 mm) failed
Romeo et al. Prospective Non submerged TPS (703) 250 (759) 16–84 49 (82) / / / / 31 93.5%w 579 96.2%w / / 149 (3.3 mm) 94.6w 96.1 (FPD) Implant failure did not appear to be significantly
(2004) SLA (56) (4.8 mm) influenced by length and diameter
Lemmerman & Prospective Submerged and Machined 376 (1003) (63.6) – – – – – – – – – – – – – 94%w No correlation (no effect on failure rate) was found
Lemmerman Nonsubmerged (348), rough- for implant diameter
(2005) surface (655)

n
Significant differences in the same study.
wOverall survival rate.
zForty-five percent of these implants were used for rescue purposes (when the standard ones were not considered suitable or did not reach initial stability).
yBased on clinical follow-up. Based on radiographic examination, 48 patients dropped out.
zImplant placement in bone of poor texture was executed utilizing an adapted bone site preparation technique.
FPD, fixed partial denture; CSR, cumulative survival rate; Mx, maxillae; Md, mandible; SLA, sandblasted and acid-etched; TPS, titanium plasma-sprayed.

and 98.2% for 3.75 mm diameter im-
plants).
In two of the studies, survival rates were
dependent on the location of the implant.
Hultin-Mordenfeld et al. (2004) reported a
higher implant failure rate with wide-dia-
meter implants but better results in the
mandible (94.5%) than the maxilla
(78.3%). Aparicio & Orozco (1998) re-
ported a cumulative survival rate of
97.2% for wide-diameter implants in the
maxilla and 83.4% in the mandible.
The remaining five studies indicated
survival rates within the limits of clinical
acceptance. As such, 528 implants with
diameters from 4.7–6 mm were placed in
392 patients, with a follow-up times of 12–
114 months (mean follow-up for the four
studies providing this data was 23.5
months). The mean number of patients
lost to follow-up was 3% for the four
studies providing this data, with a mean
survival rate of 95.6% (91.8–100%).
Bone loss around wide-diameter im-
plants was comparable with that reported
around standard-diameter implants in most
of the studies, and no specific failure pat-
tern could be observed.
Table 3b displays the data provided by
the seven articles, which are mainly de-
voted to narrow-diameter implants. All the
studies included in this structured review
have reported low failure rates with the use
of narrow-diameter implants.
Bone loss around narrow-diameter im-
plants was within the same limits as those
reported around standard-diameter im-
plants in most of the studies, and no
specific pattern could be drawn concerning
the time of failures.
In the study by Vigolo et al. (2004), no
differences were found between the 2.9 and
3.25-mm implants, and between small
diameter implants used for single-unit re-
storations and those included in multiple-
implant restorations.
All together these articles involved 461
patients restored with 809 narrow-dia-
meter implants, with follow-up periods
ranging from 12 to 120 months (mean
follow-up for the six studies providing this
data was 52.5 months), a mean percentage
of patients lost to follow-up of 1.6%, and a
mean survival rate of 95.5% (93.3–99.4%).
Table 3c displays the data obtained from
the eight articles, which provided informa-
tion on implant diameter. Among them,
Renouard & Nisand . Impact of implant length and diameter on survival rates
only two studies indicated a relationship
between implant failure and implant dia-
meter. Ivanoff et al. (1999) reported failure
rates of 5%, 3%, and 18% for 3.75-, 4-, and
5-mm-diameter implants, respectively.
The lowest cumulative survival rates
were seen with 4- and 5-mm-diameter
implants placed in the mandible (84.8%
and 73%, respectively). On the other hand,
Winkler et al. (2000) have reported that the
percentage failure for implants with dia-
meters 43 mm was higher at each stage as
compared with those 44 mm (the differ-
ences in survival for the two groups were
statistically significant).
In the remaining six studies implant
failure did not appear to be significantly
influenced by the diameter (Lekholm et al.
1999; Bahat 2000; Friberg et al. 2002;
Garlini et al. 2003; Romeo et al. 2004;
Lemmerman & Lemmerman 2005). As
such, in the study by Friberg et al. (2002)
the failure rates were 5.5%, 3.9%, and
4.5% for 3.75-, 4-, and 5-mm-diameter
implants, respectively.
No relationship between marginal bone
loss and implant diameter was seen in
most of the studies, which reported rather
low changes in crestal bone levels.
Discussion
This structured review has identified 13
articles dedicated to short implants, 21
with data available on implant length,
nine mainly dedicated to wide-diameter
implants, seven dealing solely with nar-
row-diameter implants and eight with data
available on diameter.
It should be noted, when considering the
outcome of this structured review, that the
level of evidence was somewhat weak. As
such the highest level of evidence (rando-
mized controlled study) has not been
reached in the present analysis.
Implant length
In the light of this literature review, four
main subgroups of outcomes may be high-
lighted.
Some articles showed clearly that short
implants failed more often than longer ones
(Bahat 1993; Jemt & Lekholm 1995; Wyatt
& Zarb 1998; Bahat 2000; Winkler et al.
2000; Naert et al. 2002; Weng et al. 2003;
Herrmann et al. 2005).
47 |
A second group, although concluding
that failure rates increased with short im-
plants, still provided adequate survival
rates (van Steenberghe et al. 1990; Friberg
et al. 1991; Jemt 1991; Lekholm et al.
1999).
A third group of articles reported that
implant length did not appear to signifi-
cantly influence the survival rate (Buser et
al. 1997; Ellegaard et al. 1997; Gunne et al.
1999; Brocard et al. 2000; Testori et al.
2001; Stellingsma et al. 2003; Feldman
et al. 2004; Romeo et al. 2004; Lemmer-
man & Lemmerman 2005).
Finally, a group of articles which focused
specifically on short implants indicated
that these provided similar outcomes to
those reported for longer implants, with
survival rates of 88–100% (Bernard et al.
1995; Texeira et al. 1997; Ten Bruggenkate
et al. 1998; Deporter et al. 2000, 2001;
Friberg et al. 2000; Stellingsma et al. 2000;
Tawill & Younan 2003; Fugazzotto et al.
2004; Griffin & Cheung 2004; Nedir et al.
2004; Goené et al. 2005; Renouard &
Nisand 2005).
There were many differences in the de-
finition of a short implant used in these 34
selected articles (Table 2a). These differ-
ences must be considered for an adequate
evaluation and comparison between the
studies.
With respect to this structured review, it
may be appropriated to define a short im-
plant as a device with a designed intra-bony
length of 8 mm or less.
In an attempt to understand such differ-
ences in terms of survival rates among the
selected studies, several factors have been
suggested: the implant primary stability,
the practitioner’s learning curve, the
implant surface, and the quality of the
patient’s bone.
First, it is of interest to note that some of
the studies which displayed lower survival
rates with short implants used a routine
surgical protocol independent of the bone
density (Jemt & Lekholm 1995;Wyatt
& Zarb 1998; Naert et al. 2002). With
such a standard surgical protocol, which
frequently used a tapping procedure, pri-
mary stability of the freshly inserted im-
plant may have been reduced.
More recent publications dedicated to
short implants have emphasized the use
of an adapted surgical protocol in order to
obtain adequate primary stability. As such,
Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51
Renouard & Nisand . Impact of implant length and diameter on survival rates
Tawill & Younan (2003) indicated that the
preparation of the surgical site was altered
to ensure greater primary stability in sites
of poor bone density. In the same way,
Fugazzotto et al. (2004) did not use the
countersink for implant placement and
Renouard & Nisand (2005) reported the
use of an adapted surgical protocol to en-
hance initial implant stability.
Moreover, the operators’ learning curves
have been proposed as a reason for the
different reported outcomes with short im-
plants between the studies.
In the investigation by Stellingsma et al.
(2000), 17 patients were each treated with
four short (8–10 mm) implants placed in
the mandibular interforaminal region, and
restored with an overdenture. This study
reported an 88% cumulative survival rate
after a mean follow-up period of 77
months.
In 2003, the same team, in a study
comparing three modalities of treatment,
included a group of 20 patients who were
treated with the same protocol as the one
used in the previous study. This more
recent publication reported a 100% cumu-
lative survival rate after 12 months follow-
up. It could be argued that this reflects the
difference in the follow-up time between
the two studies, but it should be noted that
in the first study 87.5% of the failed im-
plants were lost before loading.
Hence, it is noteworthy that articles
dedicated to short implants published
from 2003 to 2005 have reported survival
rates ranging from 94.6–99.4%.
With regards to the variations between
studies in the outcomes of treatment with
short implants, these may be explained by
differences in implant surfaces properties.
Out of the 12 studies which have docu-
mented an increased failure rate with short
implants, 11 used of machined-surfaced
implants (van Steenberghe et al. 1990;
Friberg et al. 1991; Jemt 1991; Bahat
1993; Jemt & Lekholm 1995;Wyatt &
Zarb 1998; Lekholm et al. 1999; Bahat
2000; Naert et al. 2002; Weng et al.
2003; Herrmann et al. 2005). The remain-
ing study (Winkler et al. 2000) used
both machined-surfaced and HA-coated
implants.
In the other hand, out of the nine studies
which have indicated that implant length
did not influence the survival rate, six
(Buser et al. 1997; Ellegaard et al. 1997;
48 | Clin. Oral Impl. Res. 17 (Suppl. 2), 2006 / 35–51
Brocard et al. 2000; Testori et al. 2001;
Feldman et al. 2004; Romeo et al. 2004)
were performed with textured-surfaced im-
plants. One of the remaining studies (Lem-
merman & Lemmerman 2005) used
mainly textured-surfaced implants. In the
same way, out of the 13 studies devoted to
short implants, nine used textured-surfaced
implants and two used either machined or
textured-surfaced implants.
In an attempt to compare the 5-year
survival rate of short machined-surfaced
and short dual-acid-etched surfaced im-
plants, Feldman et al. (2004) demonstrated
survival rates of 91.6% and 97.7%, respec-
tively. In this study a statistically signifi-
cant difference in cumulative survival rate
was found between short machined-sur-
faced implants and standard machined-sur-
faced implants. It is noteworthy that this
difference increased dramatically in the
posterior maxilla. For the dual-acid-etched
implants, no statistically significant differ-
ences were demonstrated between short-
and standard-length implants. When com-
paring, the cumulative survival rates in
poor bone density, Feldman et al. (2004)
demonstrated that short dual-acid-etched
implants provided better outcomes than
machined-surfaced implants (96% and
86.5%, respectively).
Additionally, Renouard & Nisand (2005)
have demonstrated a trend for better results
with the use of oxidized implants compared
with machined-surfaced implants. How-
ever, the difference of 5% was not statisti-
cally significant.
Finally, short implants have been routi-
nely placed in anatomical sites with lim-
ited bone volume (Wyatt & Zarb 1998).
When the relationship between implant
length and available jaw bone were exam-
ined, Herrmann et al. (2005) found that
29.4% of the 7-mm implants were placed
in jaws with jaw shape E and 25.5% were
placed in jaw with jaw shape D, according
to Lekholm and Zarb’s classification.
As suggested by Friberg et al. (1991), jaw
shape and bone density must be considered
as the most influential factors in implant
survival. It should be understood that the
length of the implant, in most of the
studies reflects the state of jaw bone
resorption.
In the study by Herrmann et al. (2005),
short implants placed in combination I
bone (consisting of implants placed in jaw
shapes A, B, and C and bone qualities of 1,
2, and 3) had a failure rate of 7.3% com-
pared with 3% for longer implants. For
combination II (jaw shapes D and E and
bone qualities of 1, 2, and 3) and IV (jaw
shapes D and E and bone density 4), the
corresponding figures were 13% (short im-
plants) and 0% (long implants), and 78%
(short implants) and 0% (long implants).
Obviously, in combinations II and IV,
only seven long implants have been placed
in comparison with 55 short implants.
It must be noted that in such sites with
poor bone density and volume, short im-
plants should not be compared with long
implants placed in good bone density, but
with the advanced surgical procedures
which would be required to allow the
placement of longer implants.
Hence, the 96% cumulative survival
rate obtained in poor bone density by Feld-
man et al. (2004), or the 94.6% obtained by
Renouard and Nisand (2005) in the treat-
ment of severely resorbed maxilla should
not be compared with the outcomes of
long implant placed in adequate bone
density. Rather, it should be compared
with the overall survival rate of 91.5%
reported by Del Fabbro et al. (2004) in a
systematic review of implants placed in the
grafted maxillary sinus, or the implant
survival rate of 75.1% reported by Becktor
et al. (2004) in the grafted edentulous
maxilla.
Besides survival rates, when comparing
the outcomes of short implants with ad-
vanced surgical therapy, morbidity must be
evaluated as well in order to allow an
adequate comparison. It should be noted
that neurosensory disturbances were ex-
perienced by 21% of the cases treated by
inferior alveolar nerve transposition (Fer-
rigno et al. 2005), that post-operative com-
plications specifically related to sinus graft
procedures affected 10% of patients
(Schwartz-Arad et al. 2004), and that com-
plications associated with the distraction
procedure affected 75.7% of patients
(Enislidis et al. 2005).
Implant diameter
When considering narrow-diameter im-
plants, it should be noted that all the
studies included in this structured review
have reported low failure rates. These fig-
ures could be explained by adapted and
atraumatic preparation techniques, and

the careful patient selection in terms of
biomechanical conditions and bone
density. As such, narrow-diameter im-
plants would probably have been consid-
ered in clinical situations in which space-
related difficulties or bone availability did
not allow the use of standard-diameter
implants.
However, further studies are needed in
order to clearly define the limits of narrow-
diameter implants with regards to clinical
indications, load-bearing capacity and long-
term fate.
In the study by Ivanoff et al. (1999), it
was suggested that the increased failure
rate of 5-mm-diameter implants was asso-
ciated with the operators’ learning curves,
poor bone density (5-mm-diameter im-
plants were used as a ‘rescue’ implant in
45% of implant sites), implant design, and
the use of this implant diameter when
primary stability could not be achieved
with a standard-diameter implant. This
view was supported by the study of Hul-
tin-Mordenfeld et al. (2004) in which wide-
diameter implants were placed in unfa-
vourable situations such as poor bone den-
sity, and compromised bone volume. As
such, in some studies a trend could be
drawn with a prevalence of early failures
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