Ting et al. International Journal of Implant Dentistry (2015) 1:28
DOI 10.1186/s40729-015-0030-2
REVIEW
Open Access
A meta-analysis on the effect of implant
characteristics on the survival of the
wide-diameter implant
Miriam Ting1, Matthew Palermo1*, David P. Donatelli1, John P. Gaughan2, Jon B. Suzuki1 and Steven R. Jefferies1
Abstract
The purposes of the study are to study the implant survival of the wide-diameter implant and to analyze if the length,
the implant surface, or the placement location has any effect on its survival. Electronic databases were searched from
inception to Dec 2014. Studies included in the review had implants placed in areas of adequate bone width and had
clear inclusion and exclusion criteria for patient selection. Immediately placed and immediately loaded implants were
excluded. A meta-analysis was done using the “random effects” model on the included studies. And, a meta-regression
was used to evaluate the effects of location, length, and surface on the implant survival. Of the six studies selected, three
evaluated surface-treated implants and three machined implants. The overall pooled survival rate of the wide implant is
96.3 %. The meta-regression showed that when using a wide implant, neither its surface nor its length nor its position
in the maxilla or mandible adversely affected its survival (P > 0.05). This meta-analysis concluded that the
location, length, and surface of the wide-diameter implant did not affect its survival and therefore suggested
that when the conditions of the implant site corresponded to the inclusion criteria of our meta-analysis,
choosing a wide-diameter implant in the posterior mandible or maxilla, where implant length may be limited
by the nerve or the sinus, the use of a short implant regardless of its surface would not affect its survival.
Keywords: Wide-diameter implants, Surface-treated or machined implants, Short implants or long implants,
Implants in the mandible or maxilla
Review
Introduction
Endosseous implants were used reliably in the treatment
of various degrees of edentulism [1–7]. In restoring the
edentulous ridge, the clinician could be faced with difficult bony situations. The wide-diameter implant could
be used in these situations to improve primary stability
by increasing the surface area available for osteointegration [8–10]. Biomechanically, the wide-diameter implant
engaged maximal bone, increased initial stability, and
improved stress distribution in the supporting bone [11].
In restoring a large molar, the wide implant has the
added advantage of increasing the load bearing capacity
and emergence profile of the final restoration [10]. It has
been shown to be three to six times stronger than the
* Correspondence: palermom@temple.edu
1
Kornberg School of Dentistry, Temple University, 3223 North Broad Street,
Philadelphia, PA 19140, USA
Full list of author information is available at the end of the article
standard implant [12]. Wide-diameter implants were
also used as rescue fixtures to replace fractured or nonintegrated implants [8]. Thus, the wide-diameter implants could become the implant of choice when faced
with these challenging situations.
The aims of this review were to research the literature
published till Dec. 15, 2014, on wide-diameter implants
and to perform a meta-analysis to study (1) the widediameter implant survival of different lengths, (2) the
wide-diameter implant survival of modified surface compared to machined surface, and (3) the implant survival
of wide-diameter implants placed in the maxilla compared to the mandible.
Materials and methods
Focused question
1. Does length of the wide-diameter implant influence
its survival?
© 2015 Ting et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Ting et al. International Journal of Implant Dentistry (2015) 1:28
2. Does the surface modification influence its survival
compared to machined implant surfaces?
3. Does the implant placement in the maxilla or the
mandible influence its survival?
Literature search and study design
The database on PubMed, Web of Science, and
Cochrane Central Register of Controlled Trials was
searched from inception to December 15, 2014. The
keywords for the search were “dental implants or dental implant” and “wide,” and a reference librarian was
consulted as to the most effective strategy. Gray literature was also searched on Google Scholar using advance search to find articles with all of the words
“wide, dental, implants, endosseous, clinical, patients,
survival” and without the words “animal, graft, augmentation, immediate, review”. Hand searching was
conducted on the reference lists of identified widediameter implant articles and was limited to articles
not already identified in the above search strategy. Implant representatives of implant manufacturers were
also contacted for any ongoing research pertaining to
wide-diameter implants, and researchers were invited
to clarify research information.
Inclusion/exclusion criteria
1. Randomized controlled trials, controlled clinical
trials, cohort, and case series reporting on the
implant survival of wide-diameter endosseous
titanium implants with different surface modifications
were included. Only prospective data were included.
Case reports, conventional reviews, and systemic
reviews were excluded.
2. Implant diameter greater or equal to 4.7 mm were
considered wide-diameter implants.
3. Only articles with specific documentation for
wide-diameter implants were included. This
documentation includes implant length, location/
site, loading times, and specific failure data such
as length, location, and timing of failure for
wide-diameter implants.
4. Articles with information on implants placed in sites
deemed to have adequate bone height and width,
and did not require site development, were included.
Articles with grafted sites and/or unclear description
of how sites were selected were excluded.
5. Only articles with data on wide implants loaded
after least 1–3 months of healing after implant
placement were included; data on immediate
placement in extraction sites and immediately
loading implants were not covered in this review.
6. Wide-diameter implants used in immediate
replacement of failed implants were excluded.
Page 2 of 8
7. Studies with at least 1-year follow-up and included
at least 10 implants regardless of diameter and
length were included.
8. Patients with adequate health to undergo implant
surgery and patients with controlled medical
conditions were not excluded.
9. Smoking status of subjects was not considered a
criterion for exclusion.
10.Non-English articles or articles without English
translations were excluded due to language
limitations.
Screening and selection
Two reviewers participated in selection of studies (MT
and MP). At the initial phase of selection, abstracts and
titles of articles were screened by one reviewer (MT) to
exclude articles that clearly were not related to widediameter dental implants. The previously described inclusion and exclusion criteria were applied when including
articles for full-text screening. When there was a doubt as
to the relevance of the article, due to insufficient information in the abstract, the full-text article was analyzed
together with a second reviewer (MP).
Search results
The search yielded 553 potentially relevant articles in
PubMed, 303 in Web of Science, 35 in Cochrane Central
Register of Controlled Trials, 64 from Google Scholar,
and 19 not identified in the above search strategies from
hand searching of reference lists of selected articles
(Fig. 1). After screening the abstracts of the articles, 38
articles were selected for full-text screening from
PubMed, 26 from Web of Science, 6 from Cochrane
Central Register of Controlled Trials, 16 from Google
Scholar, and 17 from hand searching of reference list.
After elimination of duplicate articles, a total of 57 articles were selected for full-text screening.
Predetermined inclusion and exclusion criteria were
applied to the selected full text by two reviewers (MT
and MP); article selection was completed independently
and then in unison. Areas of ambiguity were resolved
through discussion. As for two articles that needed clarification of patient selection criteria, the authors were
contacted via email and given 2 weeks to respond. One
author responded with the requested information. Six
articles remained for further review.
A total of 51 studies were excluded after the full-text
review. These included 19 studies that did not document
different lengths of wide implants studied, 15 studies
that used graft materials in or around the implant sites,
4 studies that immediately placed implants in extraction
sites or upon removal of failed implants, 2 studies that
immediately loaded the implants, 10 studies that were
Ting et al. International Journal of Implant Dentistry (2015) 1:28
Page 3 of 8
Fig. 1 Study selection for wide-diameter implant articles
Table 1 Wide-diameter implants
Implant diameter Implant
(mm)
lengths
No. of implants Implant type
(total)
Implant
surface
Prospective
clinical study
Placement follow-up/
mean (range)
Implant survival Age range
(%)
(years)
4.7
8, 10,
13, 16
117
Zimmer (Screw
vent, Paragon)
Acid-etched, Khayat et al.
uncoated
2001 [13]
5.0
7
14
Endopore
(Innova Corp)
Sintered
porous
Deporter et al. 32.6 months
2001 [18]
100
25–76
(53.7)
5.0
8.5, 10,
11.5
15
Mark III WP
(Nobel Biocare)
Ti-unite
Schincaglia
3–4 months healing
et al. 2008 [17] plus
100
35–68
(49.2)
5.0
6
13
Brånemark
(Nobel Biocare)
Machined
Friberg et al.
2000 [14]
8 years (1–14 years)
100
38–93 (63)
5.0
6, 7, 8,
8.5, 10
109
Brånemark
(Nobel Biocare)
Machined
Tawil and
Younan 2003
[15]
Healing plus
24 months loading
94.5
22–80
(53.6)
5.0
7, 8.5,
10, 11.5
38
Brånemark
(Nobel Biocare)
Machined
Polizzi et al.
2000 [16]
36 months
92
29–69
Healing 3–6 months
95
plus 17 months loading
(11–21 months)
–
12 months loading
Ting et al. International Journal of Implant Dentistry (2015) 1:28
Page 4 of 8
Table 2 Wide surface-treated Implants
Study
Implant surface
Implant type
Implant length
No. of implants
No. failed
% survived
Khayat et al. 2001 [13]
Acid-etched, uncoated
Zimmer (Screw vent, Paragon)
8
29
2
93.1
10
45
4
91.1
13
28
0
100
16
15
0
100
7
14
0
100
Deporter et al. 2001 [18]
Sintered porous
Endopore (Innova Corp)
Schincaglia et al. 2008 [17]
Ti-unite
Mark III WP (Nobel Biocare)
retrospective, and 1 study that did not receive a clarification from the author.
Data extraction
One researcher (MT) extracted the data, and a second
researcher (DPD) independently checked the data extraction for accuracy and completeness. The disagreements were resolved by discussion. The data extraction
form was pilot tested on a representative sample before
applying it to the selected articles.
Statistical analysis
The forest plot was used to determine pooled widediameter implant survival rate of the selected studies.
The funnel plot was used to determine the possibility of
publication bias of the selected studies. Heterogeneity of
the data was analyzed to determine if the data from the
selected studies can be analyzed and if the random effects model can be used in the meta-analysis. In
addition, a meta-regression (type III test of fixed effects)
was used to evaluate the effects of location, length, and
surface on the implant survival.
Results
Of the six studies selected, three evaluated surfacetreated implants and three machined implants (Table 1).
8.5
5
0
100
10
5
0
100
11.5
5
0
100
The included studies all used similar criteria for implant
survival, which was defined as the absence of mobility,
pain, and radiolucent lesions. The implant survival was
based on the percentage of implants evaluated, and the
implant lengths in the studies range from 6 to 16 mm
(Tables 2 and 3). The number of patients receiving wide
implants was not specified in three studies which also
evaluated other diameter implants [13–15]. Only data
on the wide-diameter implants in those studies were included in the meta-analysis. Three studies evaluated only
wide-diameter implants. The number of patients evaluated in these studies was as follows: Khayat et al. [13]
studied 71 patients, Polizzi et al. [16] studied 34 patients,
and Schincaglia et al. [17] studied 15 patients. Schincaglia
et al.’s study was a randomized controlled trial evaluating
immediate-loading versus delay-loading of wide-diameter
implants; only data of the control group that was not immediately loaded was included in the meta-analysis. The
mean patient follow-up of the six studies ranged from 1 to
8 years. The location of the implants placed in the selected
studies (Table 4) was as follows: two studies evaluated implants placed in the posterior mandible [17, 18], one study
in the edentulous mandible [14], and three studies in various areas of the maxilla and mandible [13, 15, 16].
The forest plot (Fig. 2) showed a pooled wide implant
survival rate of 96.3 % (Table 5). The funnel plot (Fig. 3)
Table 3 Wide machined implants
Study
Implant surface
Implant type
Implant length
No. of implants
No. failed
Polizzi et al. 2000 [16]
Machined
Brånemark (Nobel Biocare)
7
2
0
% survived
100
8.5
8
1
87.5
10
15
1
93.3
11.5
13
1
92.3
Friberg et al. 2000 [14]
Machined
Brånemark (Nobel Biocare)
6
13
0
100
Tawil and Younan 2003 [15]
Machined
Brånemark (Nobel Biocare)
6
16
0
100
7
3
0
100
8
27
1
96.3
8.5
8
2
75.0
10
55
3
94.5
Ting et al. International Journal of Implant Dentistry (2015) 1:28
Page 5 of 8
Table 4 Implants used in the maxilla and mandible
Study
Implant surface
Implant type
No. of implants in
maxilla (no. failed)
No. of implants in mandible
(no. failed)
% survived in
maxilla
% survived in
mandible
Khayat et al.
2001 [13]
Acid-etched,
uncoated
Zimmer (Screw vent,
Paragon)
49 (2)
62 (4)
95.9
93.5
Deporter et al.
2001 [18]
Sintered porous
Endopore (Innova Corp)
0
14 (0)
–
100
Schincaglia et al.
2008 [17]
Ti-Unite
Mark III WP (Nobel Biocare)
0
15 (0)
–
100
Polizzi et al.
2000 [16]
Machined
Brånemark (Nobel Biocare)
4 (0)
34 (3)
100
91.2
Friberg et al.
2000 [14]
Machined
Brånemark (Nobel Biocare)
0
13 (0)
–
100
Tawil and Younan
2003 [15]
Machined
Brånemark (Nobel Biocare)
22 (2)
87 (4)
90.9
95.4
was analyzed for publication bias. No publication bias
was found in the selected studies. The meta-analysis heterogeneity statistics were shown in Table 6. The Q statistic was a measure of the total variance of the studies
and along with the p-value showed that the studies do
not differ significantly from the mean effect. The I2 statistic along with the 95 % uncertainty interval measured
the degree of inconsistency among the studies and
showed no inconsistencies among the studies. τ2 was a
measure of the between study variance and was defined
as 0 if the Q value was less than the expected variance
(Number of studies -1). The results showed no significant heterogeneity among the included studies. Within
the meta-analysis using a random effects model, a metaregression showed that the fixed effects of location,
length and surface did not have a significant effect
(P > 0.05) on survival (Table 7).
Fig. 2 Forest plot
Discussion
The present meta-analysis was limited to prospective clinical studies and utilized a rigorous inclusion and exclusion
criteria. Studies included in the analysis were limited to
cases in which implants placed in sites with adequate bone
volume without grafting. Implants were placed in healed
sites and loaded after at least 1–3 months of healing. All
studies had at least 1-year follow-up. Patients were required to have adequate health to undergo implant surgery. Controlled medical conditions and smoking status
were not excluded. Excluded were studies where implants
were placed in sites that were initially deemed to have adequate bone; however, at the time of implant surgery, required the use of bone graft. Data from these studies
could not be analyzed due to unclear documentation of
which implants were grafted, thus preventing separation
of the data for the analysis [19, 20]. The data from some
Ting et al. International Journal of Implant Dentistry (2015) 1:28
Table 5 Meta-analysis implant data—pooled analysis
Authors
Number
Polizzi et al. [16]
38
Friberg et al. [14]
Success
Page 6 of 8
Table 6 Heterogeneity statistics
ci−
ci+
Weight (%)
Q
P
0.921
0.810
0.990
12.71
2.7008
0.7460
13
1.000
0.872
1.000
4.46
I2
ci−
ci+
Tawil and Younan [15]
109
0.945
0.893
0.981
36.14
0.00 %
0.00 %
74.62 %
Khayat et al. [13]
111
0.946
0.895
0.982
36.80
τ2
ci−
ci+
Deporter et al. [18]
14
1.000
0.881
1.000
4.79
0.0000
0.0000
0.0069
Schincaglia et al. [17]
15
1.000
0.888
1.000
5.12
300
0.963
0.934
0.985
100
of the survival studies were not able to be analyzed due to
the lack of a clear description of implant length. The
exclusion of these studies along with the rigorous inclusion criteria limited our meta-analysis to six studies. These
six studies were well-documented with clear data on implant length, surface, and location.
The overall survival rate of wide-diameter implants
based on the pooled data of the included six studies was
96.3 %, and this was within the reported range of widediameter [21] and regular-diameter [22] implant survival
rates. Machined implants functionally integrate with the
surrounding bone via a macroscopic interlock of the implant threads with the bone. Surface treatment of the machined threads increases the effectiveness of the interlock
resulting in an improved bone-to-implant interface [23,
24]. However, our meta-analysis found no significant difference between the implant survivals of machined compared to surface-treated wide-diameter implants.
Similarly, Al-Nawas et al. [25] also reported no significant
difference between machined and double-etched surfacetreated standard-diameter implant survival. Conversely,
Fig. 3 Funnel plot
Maló and Araújo Nobre [26] reported significantly more
failures for machined compared to surface-treated narrow
(3.3-mm diameter) implants. This suggests that the implant surface characteristics may have an impact on implant survival rate based on the implant diameter, and as
the diameter of the implant is increased, as in the widediameter implant, this impact may not be statistically significant. It should be noted that stringent inclusion criteria
were applied including non-grafted sites, controlled medical conditions, and adequate bone volume.
In the present meta-analysis, the location of widediameter implants did not impact survival. This was in
agreement with Degidi et al. [27] whose study did not
find a statistically significant difference in the survival of
wide-diameter implants in varying bone densities in the
maxilla and mandible. However, this was contrary to
some studies [16, 28] that reported a lower widediameter implant survival in the posterior mandible
compared to the maxilla. This was postulated to be due
to the low marginal bone vascularity of the mandible
[29, 30]. And, this was also contrary to some other studies [31, 32], which reported a better outcome for immediately placed implants placed in the mandible because
of better bone density and quality.
Ting et al. International Journal of Implant Dentistry (2015) 1:28
Page 7 of 8
short implant regardless of the implant surface would
not adversely affect its survival.
Table 7 Meta-regression—effect of surface and lengths
Type III tests of fixed effects
Num
Den
Effect
DF
DF
F value
P
Surface
1
11
0.84
0.3787
Length
7
11
0.97
0.4951
Location
1
11
0.00
0.9868
Degree of free (DF) contributes to the determination of P value
The various lengths of wide implants used in the six selected study ranged from 6 to 16 mm, and the following
implant lengths assessed in the meta-regression were 6, 7,
8, 8.5, 10, 11.5, 13, and 16 mm. Unlike our meta-analysis
which focused solely on the wide-diameter implant, very
few studies looked at the effects of different lengths on the
survival rate specific to the wide-diameter implant. Most
studies reported survival rates of the shorter implant
lengths (≤10 mm) with varying diameter implants (3.75, 4,
5, and 6 mm) [33]. Studies by Deporter et al. [18, 34] included different diameter implants and were not limited
to only wide-diameter implants; these studies also found
no significant effect of implant length on implant performance. Conversely, Olate et al. [35], who also included
different diameter implants, observed the largest failure in
their short implants compared to long or medium implants. However, Olate et al. evaluated 1649 implants
retrospectively, 295 were wide-diameter implants (17.9 %),
1217 were regular-diameter (73.8 %), and 137 were
narrow-diameter implants (8.3 %). Thus, their conclusion
would pertain more to the regular-diameter implants
which makes up the majority of implant evaluated in their
study. This would seem to indicate that length may have
an effect on regular-diameter implant survival, but this
would require further investigation. Our meta-regression,
which evaluated the prospective data of a total of 306
wide-diameter implants with lengths ranging from 6 to
16 mm, concluded that wide-diameter implants ranging in
length from 6 to 16 mm would not have any significant effect on the implant survival. It should be stressed that
stringent inclusion criteria were applied for study selection, and hence, these results cannot be generalized to patients with medical or oral compromise.
Conclusions
This meta-analysis concluded that the location, length,
and surface treatment of the wide-diameter implant do
not significantly affect its survival. It is therefore suggested with caution that when the conditions of the
implant site corresponds to the inclusion criteria used
in our meta-analysis, choosing a wide implant in the
posterior mandible or maxilla, where implant length
may be limited by the nerve or the sinus, the use of a
Competing interests
MT, MP, DPD, JPG, and JBS declare that they have no competing interests as
to the content of the manuscript. SRJ holds common stock in the company
DENTSPLY International, York, PA, USA, which markets various dental implant
systems. Nevertheless, the author does not believe that the abovementioned
disclosure presents any apparent conflict of interest with respect to the
content and subject matter of this systematic review.
Authors’ contributions
MT, MP, DPD, JBS, and SRJ contributed to the design of the study. MT, MP,
and DPD contributed to study selection and data extraction. JPG formulated
and performed the statistical analysis. All authors read, revised, and approved
the final manuscript.
Authors’ information
1. Miriam Ting, BDS, MS, Cert. Advanced Periodontology (USC), is in the
Advance standing program at the Temple University Kornberg School of
Dentistry.
2. Matthew Palermo, DMD, is an associate professor from the Department of
Restorative Dentistry at the Temple University Kornberg School of Dentistry.
3. David P. Donatelli, DDS, is an assistant professor from the Department of
Restorative Dentistry at Temple University Kornberg School of Dentistry.
4. John P. Gaughan, MS, PhD, MBA, is an associate professor (emeritus) and a
statistician at the Temple University School of Medicine.
5. Jon B. Suzuki, DDS, PhD, MBA is a professor, chairman, and program
director from the Department of Periodontology and Oral Implantology at
the Temple University Kornberg School of Dentistry.
6. Steven R. Jefferies, DDS, MS, PhD, is a professor from the Department of
Restorative Dentistry at the Temple University Kornberg School of Dentistry.
Acknowledgements
The meta-analysis by the statistician was funded by the Temple University
Research Fund.
Author details
1
Kornberg School of Dentistry, Temple University, 3223 North Broad Street,
Philadelphia, PA 19140, USA. 2School of Medicine, Temple University, 3420 N
Broad St, Philadelphia, PA 19140, USA.
Received: 29 June 2015 Accepted: 13 October 2015
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