Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e5

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Journal of Cranio-Maxillo-Facial Surgery

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Trends in techniques to avoid bone augmentation surgery: Application

of short implants, narrow-diameter implants and guided surgery
Bernhard Pommer*, Dieter Busenlechner, Rudolf Fürhauser, Georg Watzek,
Georg Mailath-Pokorny, Robert Haas
Academy for Oral Implantology, Vienna, Austria

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Minimally invasive implantology using reduced implant dimensions as well as virtual
Paper received 9 October 2015 treatment planning and CAD/CAM stereolithographic templates has gained popularity in recent years.
Accepted 15 August 2016 The aim of the present investigation was to analyze prevailing trends in clinical utilization of these
Available online xxx
graftless therapeutic options.
Material and methods: A total of 12.865 dental implants were placed in 5.365 patients at the Academy for
Keywords:
Oral Implantology in Vienna, of which 5.5% were short (length < 10 mm), 19.5% narrow
Dental implants
(diameter < 3.75 mm) and 10.6% template-guided. Application trends were analyzed using linear
Implant length
Implant diameter
regression and compared between jaw location and dentition subgroups.
Guided implant placement Results: Use of short implants and guided surgery increased significantly in all subgroups. Narrow-
Flapless surgery diameter implants were most frequent in single-tooth gaps (24.1%), however, upward trends could
Bone augmentation only be observed in partially and completely edentulous patients. Short implants were predominantly
used in the mandible (9.9% vs. 2.5%, P < 0.001) while guided surgery was favored in the maxilla (14.2% vs.
5.4%, P < 0.001).
Conclusion: Short implants (most frequent in partial edentulism) and guided implant surgery (most
frequent in complete edentulism) represent uprising and promising surgical approaches to avoid patient
morbidity associated with bone graft surgery.
© 2016 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.

1. Introduction surgery to allow placement of longer and wider implants (or a

Osseointegrated dental implants represent a highly predictable
and widespread therapy for rehabilitation of the incomplete
dentition with long-term implant success rates of up to 97%
(Busenlechner et al., 2014). In oral health care there has been an
obvious trend during the past decade towards techniques to pro-
vide optimum service for patients yet with the minimal amount of
treatment (Christensen, 2005). In the field of oral implantology, in
particular, interest in minimally invasive surgical procedures as a
standard treatment is notably growing (Papaspyridakos et al.,
2012). Per definition, the option of a minimally invasive tech-
nique appeals to a greater number of potential implant patients and
is also frequently associated with economic benefits (Gibney, 2001).
Modification of the patient's jaw anatomy via bone augmentation
* Corresponding author. Academy for Oral Implantology, Lazarettgasse 19/DG,
A-1090 Vienna, Austria. Fax: þ43 1 402 8668 10.
E-mail address: pommer@implantatakademie.at (B. Pommer).
greater number of implants) in optimized locations has been
generally considered the best treatment strategy in the past
(Renouard and Nisand, 2006), however, adaptation of implant di-
mensions and positions to the prevailing patient anatomy may
represent an alternative approach in cases of severe atrophy of the
residual alveolar bone (Cho et al., 2007; Pommer et al., 2012;
Sivolella et al., 2013; Esposito et al., 2015). Implant surgery is
termed “minimally invasive” referring to avoidance of bone grafts
(Scotti et al., 2010; Nkenke and Neukam, 2014), and/or prevention
of intra- and postoperative patient morbidity in terms of pain
(Fortin et al., 2006), swelling (Balshi et al., 2006), bleeding (Brodala,
2009), or expended operating time (Erickson et al., 1999).
Bone augmentation surgery may be avoided either by reduction
of the size of implants used, i.e. application of short and narrow-
diameter implants (Javed and Romanos, 2015; Sanz et al., 2015;
Nedir et al., 2016), or else by guided implant surgery via virtual
treatment planning software and CAD/CAM surgical templates
(Pommer et al., 2014a). These techniques aim to circumvent bone

http://dx.doi.org/10.1016/j.jcms.2016.08.012
1010-5182/© 2016 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.

Please cite this article in press as: Pommer B, et al., Trends in techniques to avoid bone augmentation surgery: Application of short implants,
narrow-diameter implants and guided surgery, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.08.012
2 B. Pommer et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e5
grafting procedures by maximum use of the residual alveolar ridge
as well as anatomical buttresses and are frequently associated with
tilted implant positioning (Krekmanov et al., 2000) and flapless
implant insertion (Pommer and Watzek, 2009). As apparent from
the quantity of systematic reviews and meta-analyses on these
topics (Lee et al., 2014; Monje et al., 2013; Klein et al., 2014; Ortega-
Oller et al., 2014; Nickenig et al., 2012; Schneider et al., 2009),
avoidance of bone grafts has undoubtably gained popularity,
however, detailed insights into paradigm changes are not available
to date. Furthermore, it has never been investigated whether
treatment trends and clinical results are related to jaw location
(maxilla or mandible) or the state of dentition (single-tooth gaps,
partial or complete edentulism). Thus, the aim of the present study
was to analyze clinical utilization as well as survival of short im-
plants, narrow-diameter implants and guided implant placement.
2. Materials and methods
2.1. Patients and implants
In 5.365 patients (3.142 woman, 2.223 men, mean age: 58.6
years, age range: 18e102 years) a total of 12.865 dental implants
were placed at the Academy for Oral Implantology (Vienna, Austria)
in the years 2005e2012. Implants from various manufacturers
were used (mainly Nobel Biocare, Gothenburg, Sweden; Dentsply,
Mannheim, Germany; and Biomet 3i, West Palm Beach, FL, USA).
Short implants were defined as less than 10 mm in length (Pommer
et al., 2011), resulting in a total of 708 implants of reduced length
(implant length ranging between 5.0 and 9.5 mm) corresponding to
5.5% of all fixtures placed. Short implants were applied mainly in
posterior regions presenting with advanced crestal bone resorption
or pneumatization of the maxillary sinus. The threshold for reduced
implant diameter was set as below 3.75 mm in width (Degidi et al.,
2008), thus a total of 2.509 implants were classified as narrow-
diameter implants (implant diameters ranging between 3.0 and
3.5 mm) corresponding to 19.5% of all fixtures placed. Reduced
implant diameters were used in cases of horizontal bone loss, i.e.
compromised buccopalatal alveolar dimension, as well as single-
tooth gaps in the central incisor (16.3%), lateral incisor (30.1%),
canine (6.4%), first premolar (26.7%), second premolar (17.7%) or
molar region (2.8%). Guided implant surgery was performed using
cone-beam computed tomographic scans (Classic i-CAT, Imaging
Sciences International, Hatfield, PA, USA, 0.25 voxel mode, high
resolution) via the double scan technique (Fürhauser et al., 2015),
computer-assisted implant treatment planning software (Nobel-
Clinician™, Nobel Biocare, Gothenburg, Sweden) and custom sur-
gical templates with precision titanium tubes (NobelGuide™, Nobel
Biocare, Gothenburg, Sweden). A total of 1.362 implants were
placed using guided surgery corresponding to 10.6% of all fixtures
placed. Guided surgery was performed in edentulous cases to
optimize the anterior-posterior spread as well as in the esthetic
zone to avoid elevation of mucoperiosteal flaps. Regarding supra-
structures, fixed cross-arch bridges were used in 96.6% of edentu-
lous cases (the remainder receiving overdentures) and partially
edentulous patients were restored via fixed partial dentures in
86.9% and single crowns in 13.1%.
2.2. Statistical analysis
Absolute and relative application frequencies were computed
based on the total number of implants placed as well as the total
number of patients treated. Trends over the years 2005e2012 were
analyzed using linear regression with publication year as predictor
variable and implant-based relative application frequency as
response variable for the total sample of short, narrow and guided
Please cite this article in press as: Pommer B, et al., Trends in techniques to avoid bone augmentation surgery: Application of short implants,
narrow-diameter implants and guided surgery, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.08.012
implants as well as for the following subgroups: maxillary vs.
mandibular implants and implants in single-tooth gaps, partial or
complete edentulism. Multiple r-squared (R2) was computed to
assess precision of model fit and the slope of linear relationship (m)
was used to evaluate mean percentage change per year. In addition,
implant survival rates were produced and subgroup comparison
was performed via chi-square tests using absolute frequencies.
Related P values were considered statistically significant below a
level of 0.05. Information regarding implant survival was entered
into a database (impDAT software, version 3.58, Kea Software
GmbH, Po € cking, Germany) based on routine recall examinations. All
calculations were performed using R-project statistical software (R
Foundation for Statistical Computing, Vienna, Austria, Version
3.1.0).
3. Results
The use of short implants increased significantly from 0.8% of
implants in 2005 to 8.7% in 2012 (R2 ¼ 0.90, m ¼ 1.1, P < 0.001,
Table 1) corresponding to 1.1%, 5.6%, 5.5%, 6.2%, 9.0%, 12.1%, 13.4%
and 15.3% of patients treated, respectively (9.6% overall). In the
maxilla 2.5% of implants were short (increase from 0.4% in 2005 to
4.9% in 2012) and 9.9% in the mandible (increase from 1.3% in 2005
to 15.3% in 2012) showing significant differences between the jaws
(P < 0.001). Short implants in single-tooth gaps, partially and
completely edentulous patients accounted for 4.8%, 9.7% and 1.8%,
respectively (Fig. 1a) revealing significant differences regarding
state of dentition (P < 0.001). Significant increase of the percentage
of short implants could be observed in all subgroups (Table 2).
The use of narrow-diameter implants did not demonstrate sig-
nificant changes between 2005 and 2012 (R2 ¼ 0.26, m ¼ 1.2,
P ¼ 0.193) and averaged 20.1% ± 3.0% of fixtures placed (Table 1)
corresponding to 33.9%, 34.9%, 34.2%, 28.6%, 28.9%, 28.3%, 23.6% and
26.0% of patients treated, respectively (28.9% overall). In the maxilla
22.5% of implants were narrow (33.0% in 2005 and 20.4% in 2012,
no significant trend) and 15.2% in the mandible (13.8% in 2005 and
13.4% in 2012, no significant trend) showing significant differences
between the jaws (P < 0.001). Narrow-diameter implants in single-
tooth gaps, partially and completely edentulous patients accounted
for 24.1%, 20.5% and 15.9%, respectively (Fig. 1b) revealing signifi-
cant differences regarding state of dentition (P < 0.001). Significant
increase of the percentage of narrow implants could be observed
only in partially and completely edentulous patients (Table 2).
The use of guided implant surgery increased significantly from
1.5% of implants in 2005 to 10.5% in 2012 (R2 ¼ 0.51, m ¼ 1.3,
P ¼ 0.046, Table 1) corresponding to 3.0%, 6.4%, 6.0%, 8.9%, 8.2%,
9.9%, 9.8% and 11.9% of patients treated, respectively (8.6% overall).
In the maxilla 14.2% of implants were placed template-guided
(increase from 2.8% in 2005 to 12.9% in 2012) and 5.4% in the
mandible (increase from 0.0% in 2005 to 6.2% in 2012) showing
significant differences between the jaws (P < 0.001). Guided im-
plants in single-tooth gaps, partially and completely edentulous
patients accounted for 5.6%, 6.3% and 18.1%, respectively (Fig. 1c)
revealing significantly higher application frequency in edentulous
jaws (P < 0.001), however, no difference between single-tooth gaps
and partially edentulous patients (P ¼ 0.335). Significant increase of
Table 1
Application of short, narrow and guided implants: implant-based percentages of all
fixtures placed between 2005 and 2012.
2005 2006 2007 2008 2009 2010 2011 2012
Short implants 0.8% 3.6% 3.2% 3.1% 4.8% 7.9% 8.1% 8.7%
Narrow implants 24.0% 23.5% 22.9% 19.7% 18.4% 19.1% 15.0% 17.8%
Guided implants 1.5% 9.2% 7.8% 10.4% 13.5% 9.3% 16.7% 10.5%
 B. Pommer et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e5 3

Fig. 1. Application of short implants (a), narrow-diameter implants (b) and guided implant surgery (c): implant-based percentage of maxillary (blue curve) and mandibular im-
plants (orange curve) as well as implants placed in single-tooth gaps (green bars), partially (yellow bars) or completely edentulous patients (red bars).

Please cite this article in press as: Pommer B, et al., Trends in techniques to avoid bone augmentation surgery: Application of short implants,
narrow-diameter implants and guided surgery, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.08.012
4 B. Pommer et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e5

Table 2 implants started later in the maxilla (not before 2009) and
Linear regression analysis regarding jaw location and state of dentition: precision of demonstrated a mean annual growth rate of þ155% while in the
fit (R2) and slope of linear relationship (m) as well as related P value (* indicating
statistical significance).
mandible a steady rise with an annual increase of þ46% could be
noted in the same timespan. Adoption of guided implant surgery,
Short implants Narrow implants Guided implants by contrast, did not reveal substantial differences between the
Maxillary implants 2
R ¼ 0.78 2
R ¼ 0.78 R2 ¼ 0.64 upper and lower jaw (þ30% vs. þ25% annual growth).
m ¼ 0.68 m ¼ 2.05 m ¼ 1.32 The use of all three graftless approaches revealed relevant dif-
P ¼ 0.003* P ¼ 0.747 P ¼ 0.017*
ferences related to the state of residual dentition of patients. Short
Mandibular implants R2 ¼ 0.91 R2 ¼ 0.11 R2 ¼ 0.53
m ¼ 1.86 m ¼ 0.27 m ¼ 1.09 implants are predominantly used in partially edentulous patients
P < 0.001* P ¼ 0.419 P ¼ 0.039* presenting with posterior free end situations or intermediate gaps
Single-tooth gaps R2 ¼ 0.82 R2 ¼ 0.08 R2 ¼ 0.57 because maxillary sinus pneumatization as well as vertical bone
m ¼ 0.92 m ¼ 0.48 m ¼ 0.71
resorption frequently limits available bone height (Pommer et al.,
P < 0.001* P ¼ 0.501 P ¼ 0.029*
Partial edentulism R2 ¼ 0.87 R2 ¼ 0.59 R2 ¼ 0.55
2014b). Reduced implant lengths, however, are also increasingly
m ¼ 1.60 m ¼ 0.97 m ¼ 1.01 applied in non-splinted single-tooth reconstructions and seem to
P < 0.001* P ¼ 0.025* P ¼ 0.034* represent a predictable option (Al-Ansari, 2014) with survival rates
Complete edentulism R2 ¼ 0.78 R2 ¼ 0.77 R2 ¼ 0.45 of 98%. By contrast, the survival of short implants in edentulous
m ¼ 0.53 m ¼ 1.63 m ¼ 1.89
jaws was reduced to 96% and has rarely been evaluated in clinical
P ¼ 0.004* P ¼ 0.004* P ¼ 0.069*
investigation (Van Assche et al., 2012).
Narrow-diameter implants are predominantly applied for
single-tooth replacement in the esthetic zone of the maxilla due to
the percentage of template-guided implants could be observed in
limited mesio-distal space (Hof et al., 2013), however, the present
all subgroups (Table 2). Short implant lengths were significantly
analysis revealed increased use in partially and complete edentu-
less frequent in guided surgery (4.0% vs. 5.7%, P ¼ 0.014) while
lism. It remains to be clarified why significantly lower survival rates
narrow diameters were used significantly more often (23.8% vs.
were recorded in the mandible; one possible explanation may be
18.9%, P < 0.001).
their reduced resistance to loading forces in cases of fixed canti-
Implant survival rates ranged between 91% and 99% (Table 3)
lever bridges or overdenture attachments (Zweers et al., 2015).
and averaged 97.9% for short implants, 96.7% for narrow-diameter
Guided implant surgery as well demonstrated higher success rates
implants and 93.9% for guided implant surgery. No differences
in the maxilla potentially due to advantageous mucosal conditions
regarding the state of dentition could be revealed (P ¼ 0.604,
compared to the common lack of keratinized peri-implant mucosa
P ¼ 0.265 and P ¼ 0.292, respectively). Implant lengths of 5e7 mm
in atrophic regions of the mandible. Surgical templates are most
showed 96.4% survival compared to 98.2% with 8e9.5 mm length,
frequently utilized in edentulous jaws to optimize positions of til-
however, the difference was not significant (P ¼ 0.234). While no
ted implants, e.g. in All-on-4 implant bridges, however, their use to
difference could be determined between short implants in the
guarantee favorable three-dimensional placement of single-tooth
maxilla and the mandible (P ¼ 0.138) narrow and guided implants
implants in the anterior maxilla and thus reduce esthetic compli-
revealed higher survival rates in the maxilla (97.6% vs. 94.7%,
cations (Fürhauser et al., 2015) seems to be indicated and
P < 0.001 and 98.5% vs. 90.7%, P ¼ 0.012, respectively). The majority
increasing.
of implant failures occurred within the first year due to lack of
osseointegration (72.7%) while the remainder were due to peri-
5. Conclusion
implantitis. The overall implant survival rate was 96.9%.
In conclusion, the present investigation revealed that short
4. Discussion
implants and guided implant surgery represent uprising and
promising surgical approaches to avoid patient morbidity associ-
In 2007 the Millennium Research Group provided a prognosis
ated with bone augmentation. In view of the fact that only 61% of
regarding the development of guided surgery technology in the
patients willingly accept bone graft surgery (Hof et al., 2014) these
global dental implant market including Europe, the United States
techniques may help to substantially increase patient satisfaction
and Asia Pacific (Millennium Research Group, 2008). Until 2012
with dental implant treatment.
they forecast a mean annual increase of roughly þ100%. This
compares to an annual growth rate of þ29% observed in the present
Sources of support
study on actual clinical application of guided implant placement.
None.
Comparable estimations regarding short and narrow dental im-
plants are not available, to the best of the authors knowledge;
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