Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 414e420

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Journal of Cranio-Maxillo-Facial Surgery

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Analysis of implant-failure predictors in the posterior maxilla: A

retrospective study of 1395 implants
Andreas Max Pabst a, *, Christian Walter a, Sebastian Ehbauer a, Isabella Zwiener b,
Thomas Ziebart a, Bilal Al-Nawas a, Marcus Oliver Klein a, c
a

Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Obere Zahlbacher Strasse 69, 55131 Mainz,
Germany
c
Private Practice, Oral and Maxillofacial Surgery, Stresemannstrasse 7-9, 40210 Dsseldorf, Germany
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Paper received 11 October 2014
Accepted 13 January 2015
Available online 22 January 2015

The aim of this study was to analyze predictors for dental implant failure in the posterior maxilla.
A database was created to include patients being treated with dental implants posterior to the
maxillary cuspids. Independent variables thought to be predictive of potential implant failure included
(1) sinus elevation, (2) implant length, (3) implant diameter, (4) indication, (5) implant region, (6)
timepoint of implant placement, (7) one-vs. two-stage augmentation, and (8) healing mode. Cox
regression analysis was used to evaluate the inuence of predictors 1e3 on implant failure as dependent
variable. The predictors 4e9 were analyzed strictly descriptively.
The nal database included 592 patients with 1395 implants. The overall 1- and 5-year implant
survival rates were 94.8% and 88.6%, respectively. The survival rates for sinus elevation vs. placement into
native bone were 94.4% and 95.4%, respectively (p 0.33). The survival rates for the short (<10 mm), the
middle (10e13 mm) and the long implants (>13 mm) were 100%, 89% and 76.8%, respectively (middle-vs.
long implants p 0.62). The implant survival rates for the small- (<3.6 mm), the middle- (3.6e4.5 mm)
and the wide diameter implants (>4.5 mm) were 92.5%, 87.9% and 89.6%, respectively (p 0.0425).
None of the parameters evaluated were identied as predictor of implant failure in the posterior
maxilla.
2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

Keywords:
Implant
Implant failure predictor
Posterior maxilla
Sinus elevation
Implant length
Implant diameter

1. Introduction
Dental implantation in the edentulous patient is widely recognized as a successful procedure with predictable outcomes when
performed on sites with normal bone volume and mechanical
quality such as is typical in the interforaminal region of the lower
jaw, for example.
There exist numerous new developments and techniques in
dental implantology, which continuously improve the outcomes,
such as nano-crystalline diamond-coated titanium implants, uoridated implants and platelet-rich brin (PRF) as sole grafting
material (Metzler et al., 2013; Dasmah et al., 2014; Jeong et al.,
2014).

* Corresponding author. Tel.: 49 6131 173761; fax: 49 6131 176602.

E-mail address: andreas.pabst@web.de (A.M. Pabst).

Nevertheless, the implant-supported masticatory restoration of

the posterior maxilla represents a specic challenge, due to specic
anatomical and biological conditions. Reduced residual bone volume after tooth loss in combination with poor bone density, as well
as its proximity to the maxillary sinus, are common limitations that
inuence implant placement in the posterior maxilla, especially if
the tooth loss occurred a long time ago (Morand and Irinakis, 2007).
Consequently, the atrophic posterior maxilla has been a challenge
to restore with dental implants for an extended period of time
(Schmidlin et al., 2004).
A number of innovative surgical procedures are well established
for successful bone management with consecutive implant placements in the posterior maxilla:
Sinus elevation represents the surgical approach most
commonly used to increase the vertical amount of bone in the
posterior maxilla, and it carries predictable implant survival rates of
more than 90% over 3e5 years (Jensen et al., 1996; Khoury, 1999;

http://dx.doi.org/10.1016/j.jcms.2015.01.004
1010-5182/ 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

A.M. Pabst et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 414e420

Huynh-Ba et al., 2008; Zinser et al., 2013). However, a highlycontroversial issue is whether implant survival rates are higher in
augmented sites versus non-augmented sites (Zinser et al., 2013).
Some have described that implants positioned in augmented bone
are ve times more likely to fail than implants placed in nonaugmented sites (Carr et al., 2003), while others have found an
implant survival rate of 97.5% for implants in grafted sinuses,
compared to 90.3% survival rate for implants placed in the posterior
maxilla in native bone (Olson et al., 2000; Zinser et al., 2013). Other
studies comparing implants placed in grafted sinuses to implants
placed in the anterior maxilla found comparable survival rates
(Tidwell et al., 1992; Blomqvist et al., 1996).
Since augmentation procedures are also associated with complications, many authors advocate the optimal utilization of preexisting, native bone. Angled placement of implants in cases with
which only limited residual bone volume in the posterior maxilla is
available (Del Fabbro et al., 2004), while short (<10 mm) and
reduced diameter implants (<3.6 mm) may be used as well. A potential risk factor for implant loss may be narrow diameter implant
size which limits the magnitude of occlusal forces that are
acceptable (Romeo et al., 2010). The question of whether shorter
implants are associated with higher failure rates is still contested
(Zinser et al., 2013). Renouard and Nisand performed a study
analyzing the survival rates of short implants (6e8.5 mm) in the
severely atrophied maxilla and found the cumulative 2-year survival rate to be 94.6%. The authors concluded that short implants
may be used for prosthetic tting in the severely atrophied maxilla
as an alternative to complex surgical procedures (Renouard and
Nisand, 2005), which is similar to other studies (Nedir et al.,
2004; Anitua et al., 2008). Conversely, recent studies showed that
shorter and reduced diameter implants have higher failure rates
compared to longer and wider implants, and therefore should be
used only for selected indications (Bergendal and Engquist, 1998;
Winkler et al., 2000; Ferrigno et al., 2002). Buser et al. designed a
multicenter study to detect the impact of implant length on
implant survival rate. The authors demonstrated that short 8 mm
implants had an 8-year cumulative success rate of 91.4%. By comparison, 10 mm and 12 mm implants had success rates of 93.4% and
95.0%, respectively (Buser et al., 1997). Therefore, no general conclusions can be made regarding sinus elevation or the use of short
and reduced diameter implants as predictors of implant failure in
the posterior maxilla. However, the need to identify predictors
associated with implant failure in the posterior maxilla is becoming
increasingly important, especially in light of the rising rate of dental
implantat procedures.
The aim of this retrospective study was to identify predictors of
implant failure for implants placed in the posterior maxilla.
2. Materials and methods
2.1. Data collection
A database was created including all patients who received one
or more implants in the posterior maxilla posterior to the cuspids in
the period from January 2002 to December 2007, at the Department of Oral and Maxillofacial Surgery of the University Medical
Center Mainz. The criterion for study inclusion was that the posterior maxillary implant placement had to have been performed in
our department. Exclusion criteria included patients with a history
of head and neck cancer in whom implants were placed in the
reconstructed maxilla as well as patients with large block
augmentation procedures from the iliac crest. Multiple implant
systems were used in the study.
Subjects were identied by searching the electronic dental record systems (VISIdent, BDV Branchen-Daten-Verarbeitung GmbH,

415

Holzwickede, Germany; DOCconcept Praxis 5.00, DOCexpert

Gruppe, Bamberg, Germany; SIDEXIS, Sirona Dental Systems
GmbH, Bensheim, Germany; impDAT 3.04 Dental-Software, Kea
cking, Germany).
Software GmBH, Po
Reecting the recommendations of the German Society for
Dental and Oral Medicine (DGZMK), the information retrieved from
the dental records was divided into independent (continuous and
categorical) patient-, bone- and implant-related variables, in order to
ensure adequate description of the data (Schliephake and Neukam,
2000).
Patient-related variables included patient age (years) at implant
placement, gender, and the indication (edentulous maxilla, saddle
area >1 tooth unit, free-end gap, single tooth replacement) were
also recorded. A specic sub-classication for a single-tooth
replacement in a free-end gap situation has not been performed.
The two bone-related variables included type of bone (native
bone or sinus elevation) and one-vs. two-stage augmentation.
Eight implant-related variables included implant placement
(time after tooth extraction, time of implant failure), implant region
(rst premolar, second premolar, rst molar, second molar, third
molar), implant system, implant length (<10 mm, 10e13 mm,
>13 mm), implant diameter (<3.6 mm, 3.6e4.5 mm, >4.5 mm),
healing mode (submerged, transmucosal), uncovering time, and
data for the survival function (date of the last recall, state of the
implant: in situ vs. lost).
The primary endpoint of this study was implant failure
(dependent variable). Implant failure was dened as the removal of
an implant for any reason (Zinser et al., 2013). An implant was
considered successful when it remained in situ at the time of most
recent follow-up, with no indication for removal (e.g., clinical
mobility, pain, infection) and no radiographic evidence of periimplant osteolysis or implant fracture (Naert et al., 1992).
Implant survival was ascertained from the dental records, or
directly from clinical evaluations and radiographs. If no recall
radiograph was available, the patient was called in for a recall visit,
which included clinical evaluation of implants, as well as radiographs when indicated. During the recall visit, implant survival was
evaluated based on the criteria mentioned above.
2.2. Statistical analysis
Initially, descriptive statistics were calculated for all independent
variables. After a review of the literature, the following three predictors seemed to be very important for an implant failure and
were regarded with particular attention: (1) sinus elevation, (2)
implant length, and (3) diameter. Further focus was given to the
predictors: (4) indication, (5) implant region, (6) implant placement, (7) one-vs. two stage augmentation, and (8) healing mode.
The 1- and 5-year survival rates of the implants were analyzed
using KaplaneMeier estimates. The survival time of an implant was
dened as the time between implantat placement and removal for
any reason, or to the time of last follow-up, whichever came rst.
Cox regression analysis was performed to determine the single
contribution of the predictors 1e3 on implant failure, and to
identify the statistical value of these predictors with a global signicance level of p  .05. As a result of the multiple testing, a
Bonferroni-correction with a local signicance level of p 0.0167
(0.05/3) was implemented. P-values 0.0167 were regarded as
statistically signicant. The analysis of predictors 4e8 was performed strictly descriptively. To accommodate correlation analysis
of patients with multiple implants, we introduced a patient frailty
term within the Cox regression analysis.
The statistical analysis was carried out with Microsoft Excel
(Microsoft Ofce 2007), SPSS (version 15.0 for MS Windows), and
with R (version 2.12.0 for MS Windows).

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A.M. Pabst et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 414e420

3. Results

3.3. Implant distribution

3.1. Population characteristics

3.3.1. Implant-related variables

Table 2 summarizes the data for continuous, implant-related
variables. In total, 1395 implants were placed (770 implants in
women [55.2%]; 625 implants in men [44.8%]). The majority of
implants were placed more than 10 weeks after tooth loss (1074
implants, 77.0%). One thousand two hundred fty seven implants
(90.1%) had a length between 10 and 13 mm and 917 implants
(65.7%) had a diameter between 3.6 and 4.5 mm. Nine hundred
ninety two implants (71.1%) healed submerged and 300 implants
(21.5%) healed transmucosally.
Most of the implants were placed into the rst premolar, second
premolar, and rst molar regions (1230 implants, 88.2%). The
preferred implant system was Nobel Biocare (427, 30.6%), followed
by Astra Tech (296, 21.2%) and Straumann (240, 17.2%).

3.1.1. Patient-related variables

In total, 592 subjects (318 women, 53.7%; 274 men, 46.3%), aged
between 14 and 84 years (mean age: women 54 years, men 58
years), were included in the study. The indications for implant
placement included 141 subjects (23.8%) with a completely edentulous maxilla, 236 subjects (39.9%) with an edentulous posterior
maxilla and 74 subjects (12.5%) with a partially edentulous posterior maxilla with at least one natural tooth posterior to the implant
site. One hundred twenty seven subjects (21.5%) had a single
implant. Fourteen subjects (2.4%) had insufcient records to
determine the indication for implant placement.
3.2. Bone bed characteristics

3.4. Implant survival functions

3.2.1. Bone-related variables

Three hundred twenty four out of 592 subjects (54.7%) were
treated with a sinus elevation; of which 269 (45.4%) were treated
with an external sinus elevation procedure and 53 (9.0%) with an
internal sinus elevation procedure. In two patients (0.3%), the kind
of sinus elevation was unknown. Four hundred ninety six implants
(35.6%) were placed in native bone and 852 implants (61.0%) were
placed into a sinus lift grafted maxilla. With regard to the sinus
elevation (852 implants), 497 implants (58.3%) were placed in a
one-stage procedure, and 355 implants (41.7%) were placed in a
two-stage procedure. With regard to the graft material for the sinus
elevation, 639 implants (45.8%) were placed in elevated sinuses
lled with bone substitutes. The bone substitute most often used
was BioOss (343 implants [24.6%]). Six hundred and three implants (43.2%) were placed in elevated sinuses lled with autogenous bone. The donor region for the autogenous bone most often
used was the mandibular angle (226 implants [16.2%]). The inuence of the used bone substitute as well as the donor region of the
autogenous bone in the elevated sinuses has not been analyzed as a
possible predictor for implant failure in the further evaluation.
Table 1 presents an overview of the used bone substitutes and the
donor regions of autogenous bone.

The follow-up period ranged from 0 to 6.1 years. Sixty two (4.4%)
of the 1395 implants were lost, most commonly within the rst
year. The 1-year implant survival rate was 94.8% (women: 96.1%,
men: 93.7%) and the 5-year implant survival rate was 88.6%
(women: 89.4%, men: 87.9%; Fig. 1). At the time of analysis, 740 of
the 770 implants placed in women (96.1%), and 593 of the 625
implants placed in men (94.9%) were still in situ.
3.5. Sinus oor elevation
Eight hundred thirteen (95.4%) of the 852 implants placed in a
grafted sinus, and 518 (95.7%) of the 541 implants without sinus
oor elevation were still in situ (Table 3). The 1- and 5-year survival
Table 2
Executive summary of the implant-related variables (implant placement:
delayed up to 2 months after tooth loss; late more than 2 months after tooth
loss).
Implants [n]
Indication

Implant region
Table 1
Executive summary of the used bone substitutes and the donor regions of autogenous bone.
Bone substitutes

Implants [n] sinus

elevation

Bio-Oss
Cerasorb
ChronOs
BioBase
BoneCeramic
NanoBone
BIORESORB Macro Pore
Algipore
Bonit
Unknown

343 (24.6%)
82 (5.9%)
61 (4.4%)
37 (2.7%)
7 (0.5%)
2 (0.1%)
4 (0.3%)
16 (1.1%)
11 (0.8%)
76 (5.4%)

Donor region of autogenous bone

Implants [n] sinus

elevation
192 (13.8%)
226 (16.2%)
13 (0.9%)
4 (0.3%)
3 (0.2%)
2 (0.1%)
165 (11.8%)

Drilling chips
Mandibular angle
Tuber maxillae
Crista zygomaticoalveolaris
Alveolar crest
Autologous blood
Unknown

Implant system

Implant placement

Implant Length

Implant diameter

Healing mode

Edentulous maxilla
Free-end gap
Saddle area
Single-tooth replacement
14 and 24
15 and 25
16 and 26
17 and 27
18 and 28
Nobel Biocare
Astra Tech
Straumann
Camlog
Biomet 3i
DENTSPLY Friadent
Zimmer
SPI
Heraeus
BPI
Unknown
Immediate
Delayed
Late
<10 mm
10e13 mm
>13 mm
<3.6 mm
3.6e4.5 mm
>4.5 mm
Submerged
Transmucosal

398
643
183
144
405
377
448
157
8
427 (30.6%)
296 (21.2%)
240 (17.2%)
219 (15.7%)
100 (7.2%)
90 (6.5%)
4 (0.3%)
3 (0.2%)
3 (0.2%)
2 (0.1%)
9 (0.7%)
55
54
1074
36
1257
65
242
917
192
992
300

A.M. Pabst et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 414e420

Fig. 1. KaplaneMeier survival curve demonstrating 1- and 5-year overall implant

survival rates of 94.8% and 88.6% (blue line).

rates for implants placed in a grafted sinus were 94.4% and 85.6%,
respectively. The 1- and 5-year survival rates for implants placed in
native bone were 95.4% and 91.4%, respectively (Fig. 2). No signicant difference between the two groups was detected (p 0.33).
3.6. Implant length
Thirty six of the 36 short implants (100%), 1199 of the 1257
middle implants (95.4%), and 62 of the 65 long implants (95.4%)
were successful (Table 3). The 1-and 5-year survival rates, respectively, were 100% for the short implants, 94.5% and 89.0% for the
middle implants, and 96.1% and 76.8% for the long implants (Fig. 3).
Although there was no signicant difference in the survival times
between the middle- and long-implant groups (p 0.62), we
observed a tendency towards a better survival time of the short
implants. Unfortunately, the hazard ratio for the short implants vs.
middle or long could not be estimated with Cox regression analysis,
since there were no implant failures in this group.
3.7. Implant diameter

417

Fig. 2. KaplaneMeier survival curve demonstrating 1- and 5-year survival rates for
implants placed in grafted sinuses of 94.4% and 85.6% (blue line) as well as 95.4% and
91,4% for implants placed in native bone (green line).

year survival rates, respectively, for the small diameter implants

were 92.5% and 92.5%, for the middle diameter implants 95.8% and
87.9%, as well as 92.5% and 89.6% for the wide diameter implants
(Fig. 4).
Univariate analysis could not demonstrate any signicant differences in the implant survival rate between the different implant
diameters (p 0.0425).
Table 4 summarizes the implant survival rates dependent on the
indication, region of placement, chronological order, and healing
mode.
4. Discussion
The aim of this retrospective study was to analyze dental implants placed into the posterior maxilla, and to evaluate predictors
of implant failure. Altogether, 1395 implants were placed in 592
patients at the University Medical Center Mainz between January
2002 and December 2007 with an overall 1- and 5-year survival

Two hundred thirty of the 242 small diameter implants (95.0%),

879 of the 917 middle diameter implants (95.9%), and 182 of the
192 wide implants (94.8%) were successful (Table 3). The 1-and 5-

Table 3
Implant survival rates with regard to sinus elevation, implant length, and diameter.
Concerning the implant length, the p-value (p 0.62) only describes the comparison
between the middle- and long-implants. The hazard ratio for the short vs. middle or
long implants could not be estimated, since there were no implant failures in this
group.
Implants [n]
Total Loss %
Gender

Woman
770 30
Men
625 32
Sinus
Yes
852 39
elevation No
541 23
Implant
<10 mm
36 0
length
10e13 mm 1257 58
>13 mm
65 3
Implant
<3.6 mm
242 12
diameter 3.6e4.5 mm 917 38
>4.5 mm
192 10

p-value
5-year
1-year
Survival Survival
(%)
(%)

96.1 95.7
94.9 93.7
95.4 94.4
95.7 95.4
100
100
95.4 94.5
95.4 96.1
95
92.5
95.9 95.8
94.8 92.5

89.4
87.9
85.6
91.4
100
89
76.8
92.5
87.9
89.6

P 0.33

p 0.62

p 0.0425

Fig. 3. KaplaneMeier survival curve demonstrating 1- and 5-year survival rates for the
short implants of 100% and 100% (blue line), for the middle implants of 94.5% and
89.0% (green line) as well as 96.1% and 76,8% for the long implants (brown line).

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A.M. Pabst et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 414e420

Fig. 4. KaplaneMeier survival function demonstrating 1- and 5 year survival rates for
the small diameter implants of 92.5% and 92.5% (blue line), for the middle diameter
implants 95.8% and 87.9% (green line), as well as 92.5% and 89,6% for the wide diameter
implants (brown line).

rate of 94.8% and 88.6%. No signicant risk factor of higher implant

failure in the posterior maxilla could be detected.
The literature describes implant survival rates of 85e95% for
implants placed in grafted maxillary sinuses (Ludwig et al., 1997;
Sullivan et al., 2001; Davarpanah et al., 2002; Mazor et al., 2004),
which is in accordance with this study. No signicant difference
could be detected between implants placed in grafted sinuses and
native bone. Jensen et al. described survival rates of 90.0% of 2997
implants placed in 1014 sinus elevations (Jensen et al., 1999). Also,
Cho-Lee et al. reported a cumulative implant survival rate of 93.0%
in grafted sinuses after 5 years (Cho-Lee et al., 2010), and others
have reported implant survival rates after sinus elevation of nearly
98.0% (Bornstein et al., 2008). In a systematic review, Del Fabbro
et al. analyzed implant survival rates after osteotome-mediated
maxillary sinus augmentation. The authors included 19 studies
with 1822 patients and 3131 implants. The overall implant survival
rates were 92.7% for 331 implants placed in <5 mm ridge height
and 96.9% for 2525 implants inserted in 5 mm ridge height (Del
Fabbro et al., 2012). Tuna et al. also performed a literature review
including 67 articles concerning the prognosis of implants after
lateral sinus elevation. In this review, the success rates of implants
were between 96.3% and 100% and the survival rates were between

75% and 100% after a follow-up of 12e101 months (Tuna et al.,

2012).
An alternative to augmentative procedures prior to implantation is the use of short- and/or reduced diameter implants. This
avoids the associated risks and costs of bone augmentation, especially for elderly patients.
The literature on implant survival rates in relation to implant
length is heterogenous. Winkler et al. demonstrated a survival rate
of 66.7% for short implants (7 mm) and 96.4% for long implants
(16 mm) after 36 months in situ (Winkler et al., 2000). Another
recent study detected similar survival rates of short and long implants (Raviv et al., 2010). Anitua and Orive demonstrated survival
rates for short implants (<8.5 mm) in the lower and upper jaw of
99.3% (Anitua and Orive, 2010). Renouard and Nisand reported a
survival rate of 94.6% after 2 years in a retrospective study on 85
patients with 94 short implants (Renouard and Nisand, 2005).
Annibeli et al., 2012 published a systematic review including clinical studies of short implants (<10 mm) placed in the maxilla and
the mandible (6193 implants in 3848 participants). The authors
reported an overall cumulative survival rate of 99.1% (Annibeli et al.,
2012). Srinivasan et al. reported survival rates ranged from 92.2% to
100%. Interestingly, failures were more often observed in the
maxilla than in the mandible (Srinivasan et al., 2012).
We detected no signicant differences in the survival rate
regarding the different implant diameters, although the literature
describes short and diameter-reduced implants are more likely to
fail, and therefore should be used only for selected indications
(Bergendal and Engquist, 1998). In a recent systematic review, Klein
et al. analyzed the success of narrow-diameter dental implants. The
authors showed survival rates for dental implants <3.0 mm between 90.9% and 100%. For diameters between 3.0 and 3.25 mm,
survival rates ranged between 93.8% and 100%. Implants of
3.3e3.5 mm showed survival rates between 88.9% and 100%. A
meta-analysis was conducted for narrow diameter implants from
3.3 to 3.5 mm, which showed no signicant difference in the
implant survival rate compared to regular diameter implants with
an odds ratio of 1.16 (Klein et al., 2014). The increased short implant
failure in our study can be explained by a low number of short
implant cases (n 55), thus individual implant failures may have a
strong inuence on statistical survival functions. The survival rates
for the free-end gap were marginally lower compared to the
edentulous maxilla, saddle area, and single tooth replacement. The
detected results for single tooth replacement are in accordance
with other studies. Levin et al. described success rates of 93.1% after
3 years for single tooth replacement (Levin et al., 2006).

Table 4
Implant survival rates with regard to indication, implant region, implant placement (delayed up to 2 months after tooth loss; late more than 2 months after tooth loss),
one-vs. two-stage augmentation, and healing mode.
Implants [n]

Indication

Implant region

Implant placement

Augmentation procedure
Healing mode

Edentulous maxilla
Free-end gap
Saddle area
Single-tooth Replacement
14 and 24
15 and 25
16 and 26
17 and 27
18 and 28
Immediate
Delayed
Late
One-stage
Two-stage
Submerged
Transmucosal

Total

Loss

398
643
183
144
405
377
448
157
8
55
54
1074
497
355
992
300

25
31
1
4
14
15
27
5
1
5
1
53
20
20
46
15

93.7
95.2
99.5
97.2
96.5
96
94
96.8
87.5
90.9
98.1
95.1
96
94.4
95.4
95.5

1-year Survival (%)

5-year Survival (%)

94.1
93.9
99
97.2
96.1
94.9
93.1
95.6
87.5
90.6
97.9
94.1
95
93.7
94.4
95.1

88.7
85.1
99
93.8
94.8
93
80.1
95.6
87.5
82.3
97.9
86.2
86
85.4
88.1
88.4

A.M. Pabst et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 414e420

No difference in the survival rate relating to the implant region

could be detected. Only the rst molar region demonstrated a
marginally lower 5-year survival rate, which may be related to the
position in the masticatory center and high mastication forces.
These ndings were highlighted in the literature (Ridell et al.,
2009). Conrad et al. demonstrated high survival rates in the posterior maxilla after 35.7 months (93.2%) (Conrad et al., 2011), and
Levin et al. demonstrated survival rates of 96.2% in the premolar
region and 95.8% in the molar region after 3 years (Levin et al.,
2006).
Regarding the timepoint of implant placement, immediate
implant placement demonstrated an increased failure rate
compared to delayed implant placement. The literature is divided
on this topic: Some authors describe no signicant effects of the
time-span between tooth extraction and implant placement
(Esposito et al., 2011), whereas older studies have found a higher
risk of implant failure when placed immediately after tooth
extraction (Ibbott and Oles, 1995).
Regarding one-vs. two-stage augmentation, no signicant difference could be detected as well, and these results are better than
previously reported in the literature. Wallace and Froum described
survival rates of 89.7% for the one-stage procedure and 89.6% for
the two-stage procedure (Wallace and Froum, 2003).
No difference could be detected between the two healing modes,
which is in accordance with the literature (H
ammerle et al., 2012).
Cecchinato et al. analyzed 84 patients with respect to the effect of
healing mode on the peri-implant bone loss, and implant success.
At both research focuses, implant loss was about 2% (Cecchinato
et al., 2004).
This study has limitations based on the retrospective study
design and some missing data. Also, the data relating risk factors to
implant failures should be interpreted with care, since the 1-year
overall survival rate of implants placed in the posterior maxilla
was very high at 94.8%. In addition, further predictors for implant
failure in the posterior maxilla (e.g. ASA status, smoking habits,
mechanical bone quality, residual crestal bone height) were not
assessed as risk factors for implant failure, since these factors were
not recorded in the dental records. Another shortcoming of this
study is that the inuence of the used bone substitute as well as the
donor region for autogenous bone in the elevated sinuses was not
analyzed as a possible predictor of implant failure. This was
attributable to the fact that the exact number of sinusus receiving a
combination of bone substitute and autogenous bone was not
documented. Consequently, this topic has been excluded from this
study. This topic seems to be of interest since it is still unclear
whether bone substitutes or autogenous bone for sinus oor
elevation should be preferred (Nkenke and Stelzle, 2009).
Furthermore, the type of prosthesis fabricated on maxillary posterior implants could be an important predictive factor although
many of the implants that failed in this study were removed prior to
being restored prosthetically. This study strictly focused on the
implant survival rate and excluded the success rate. Nevertheless,
this kind of documentation (overall survival rate) has a high scientic and clinical relevance and might ensure the clearest data
presentation in our view. Compared to the current literature and to
the knowledge of the authors, this is the only study analyzing and
summarizing three of the most important possible predictors for
implant failure in the posterior maxilla (sinus elevation, implant
length and diameter) with such a high number of implants and
patients.
5. Conclusions
Within the limitations of this study, our results suggest there are
no detectable predictive risk factors for implant failure in the

419

posterior maxilla. Implants placed in maxillary areas with inadequate bone volume, requiring sinus elevation or short and
diameter-reduced implants, were not statistically correlated with
higher implant failure. Notably, implant placement in grafted sinuses could be used as a secure and effective therapeutic modality
in maxillary posterior sites. Unfortunately, this retrospective study
is based on only a limited number of parameters and does not allow
to get a deeper insight in the aspect of risk factors for implant
survival. Forward-looking, there are still several difcult indications, such as patients with alveolar clefts, bisphosphonate
therapy as well as bula free-ap mandibular reconstructions,
which will require an ongoing and intensive research in dental
implantolgy (Ferrari et al., 2013; Rachmiel et al., 2013; Dikicier
et al., 2014).
Conict of interest statement
There are no conicts of interest.
Role of the funding source
There are no sources of support. T. Ziebart, B. Al-Nawas and M.O.
Klein received funding from the ITI Foundation for different studies.
Acknowledgements
Special thanks to Cristian Valenzuela, MD, (Laboratory of
Adaptive and Regenerative Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA) and Gary F. Bouloux,
MD DDS MDSc, (Division of Oral and Maxillofacial Surgery, The
Emory Clinic, Atlanta, GA, USA) for language help and proofreading.
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