Systematic Review on Success of

Narrow-Diameter Dental Implant

Marc. O. Klein, PD Dr Med, Dr Med Dent/ Eik Shciegnitz, Dr, Med/
Bilal Al-Nawas, Prof Dr Med, Dr Med Dent
OBJECTIVE
To determine the survival and success rates of narrow-
diameter dental implants (NDI) in different clinical
indications compared to standard diameter implants.
Standard diameter implant: 3.75 mm and 4.1 mm
Excellent long-term results
Fracture of the abutment or implant body is a rare condition
Review by
Sanchez-
Perez et al
Risk of two fractures per 1,000 implant
INTRODUCTION
Disadvantage
Standard-diameter
implant
Available horizontal crestal dimensions of the alveolar
ridge is relatively small
Limited spaces between adjacent teeth and dental
implants
Successful dental
implant
At least 1mm residual bone adjacent to the implant
surface
Horizontal crestal alveolar width of 6 mm for a standard
implant
Previous studies:
3 mm inter-implant distance is beneficial for adequate papillary fill
Optimal implant diameter smaller than
standard diameter for many indications?
Narrow-diameter implants (NDI)
WHY?
Decrease rate of augmentation procedures for implant insertion
Beneficial for elderly or medical risk patients
Reduced surgical invasiveness (time-consuming; pain/complications)
Smaller dental or interimplant gaps (premolar/incisor region)
Employment of NDI <3.5 mm
B
E
N
E
F
I
T
S

Biomechanical risk factors for NDI
Stress Crestal cortical bone
Dental implant
diameter
Small diameter
implants
Stress Peaks
Implant-bone
interface
Stress values at the implant-bone interface rise
by reducing the diameter from 4.1 mm to 3.3
mm rather than 4.8 mm to 4.1
Biological Risk Factors
Inadequate overloading of NDI might lead to peri-implant crestal bone
resorption resulting in clinical complications.
Other disadvantages
FATIGUE FRACTURE
Alloy
Less biocompatible in cell cultures and animal
experiments
Titanium-zirconium (TiZr) alloy with increased
fatigue resistance and better biocompatibility
compared to cpTi.

Commercial pure titanium
(cpTi)

How to increase resistance to implant fracture?
Most available NDIs are made of Ti-Al-V
PRESENT USE OF NDI
Re s t r i c t e d I n d i c a t i o n s
MATERIALS AND METHODS
PICO criteria
(Patient, Intervention, Control or Comparison, Outcome and Study type)
Patient
Selection
Healthy patients
*No systemic illness or oral infection
One dental implant into the maxilla/mandible
Insufficient bone volume or limited interdental space requiring diameter
reduced endosseous dental implant
Intervention:
NDI
Studies involving dental implants <3.5 mm in diameter
Implant Diameters Implant Indications
Category 1: <3.0 mm (mini implants)
Category 2: 3.00-3.25 mm (single-
tooth)
Category 3: 3.30 to 3.50 mm (broader
indications)
Edentulous arch (max/mand)
Single-tooth gap without loading of the
prosthesis
Prosthetic loadbearing in the frontal region
Prosthetic loadbearing distal to the canine tooth
Raising of a full-thickness flap
Trans-mucosal implant insertion
Subgingival
Transgingival
Fixed
Overdenture
Control
Groups
Groups with conventional sized dental implants (>3.5 to 4.5 mm)
Outcome
Dental implant Survival:
Follow-up 12 months
In situ or not planned for removal
Implant Success:
Clinical Success (implants in function, no sign of peri-implantitis)
Marginal bone level under functional loading
Selection Criteria
INCLUSION CRITERIA EXCLUSION CRITERIA
Clinical studies of at least 10 treated patients,
published in English
Studies in languages other than English
Prospective: randomized-controlled, non-
randomized-controlled, cohort studies
Studies with < 10 patients, case reports, animal
models, or experimental in vitro studies
Retrospective: controlled, case control, single
cohort
Reviews
Mini-implants for orthodontic anchorage
Studies dealing with simultaneous bone
augmentation procedures
Studies with mean follow-up time < 12 months
Search Strategy for Identification of Studies
Small diameter dental implants: 107 hits
Narrow diameter dental implants: 68 hits
Narrow dental implants: 225 hits
Small dental implants: 720 hits
Diameter dental implants: 1,107 hits
Mini-implants: 767 hits
Study Selection, Data
Extraction, and Quality
Assessment
RESULTS
N. Of selected
articles
Category Diameter Implants
10 1 < 3.0 mm 3,656
12 2 3.0 3.25 mm 672
16 3 3.3 3.5 mm 3,414
Dental Implants by Diameter Category
*< 3mm implants were all made of Ti-Al-V
*Category 3: TiZr alloys were described in three studies
Results of Quality Assessment of
Selected Studies
Quality and level of evidence of the investigated articles were low.
Most of the studies were retrospective analyses
Data interpretation
Drawing general conclusions
out of theses studies
RESULTS
IMPLANT SURVIVAL, IMPLANT SUCCESS, AND MARGINAL
BONE LEVEL UNDER FUNCTIONAL LOADING
Diameter Category 1
Mean follow-up 12-96 months
Indications
Edentulous Arch (I)
Nonloaded frontal region (III)
Narrow tooth gap without loading
5 out of 7 studies: open procedure performed
Survival rates: 90.9% - 100%
Implant success: 92.9% (1 study)
Radiological assessment: average peri-
implant bone loss 0.980.36
Diameter Category 2
Mean follow-up 12-63
months
Indications:
Narrow tooth gap without
loading (III)
Frontal region
Flap was raised for implant
insertion
Survival rates: 93.8%-100%

Average peri-implant
bone loss after 12
months: 0.780.48
Diameter Category 3
Follow-up of 12-144
months
Indications:
Load-bearing
posterior region
Flap raised for implant
insertion
Survival rates: 88.9%-
100%
Success rates: 91.4%-
97.6%
Radiological assessment:
average peri-implant bone
loss of 0.310.003

Few comparative
prospective clinical
studies
SURVIVAL
OR
SUCCESS
Most of these studies did not
clearly report a follow-up rate
Survival rates of NDI similar compared to regular diameter
implants (>3.5mm)
Survival rates > 95%
No studies reporting <88%
Success of small diameter implants should no be carry out only
by determination of implant survival
Implant success
Changes of the marginal bone level
Factors that impact peri-implant marginal
bone stability
Intrinsic Factors Extrinsic Factors
Quantity and quality of surrounding hard and soft
tissue
Implant design (dimensions, implant-abutment
interface)
Crestal alveolar dimensions Insertion depth
Distances between adjacent teeth and dental
implants
Implant angulation
*Important for maintaining a stable biological
width
Number of inserted implants

Parafunctional activities like bruxism
Category 1 (<3mm, mini implants) Category 2 (3.0 to 3.25 mm) Category 3 (3.3 to 3.5 mm)
Single non-load-bearing teeth,
edentulous arch with an
overdenture
Two-piece implants All indications were described,
including load-bearing posterior
region
No data on implant distribution Non-load-bearing single-tooth gaps Long term studies available
Immediate restoration/loading was
predominantly performed
Few studies reported success rates
No long term success available No long term data
No differences in the implants survival
rate using the flap reflection or flapless
surgery
Implants with a diameter < 3.0 mm
were used in a flapless procedure
Very narrow one piece-screws with
diameter below 2.5 mm are placed in a
flapless procedure with a transgingival
healing mode and immediate loading.
Two-piece dental implants inserted with
flap elevation procedure and a certain
healing period
Lengths of implants used in all studies
were in a normal range
Implant-retained overdentures: number,
distance, and distribution of NDIs might
be significance for implant success and
development of marginal bone
SPLINTED
IMPLANTS
1.8 mm in
diameter
Rigid
superstructure
Decreased the bone
stress level
compared to single
mini implants
Effect of splinting mini-implants on marginal bone loss: a biomechanical model and clinical
randomized study with mandibular overdentures.
Jofre J
1
, Cendoya P, Munoz P.
1
Center for Advanced Prosthodontic and Implantology, CRAI, University of Concepcion, Chile.
jjofre@udec.cl

Splinted mini-implants supporting a mandibular
overdenture showed less marginal bone loss
compared with non-splinted mini-implants
CONCLUSIONS
Dental implants with narrow diameter of 3.3 to 3.5 mm are indicated in all
indications including load-bearing posterior regions
Smaller implants of 3.0 to 3.25 mm in diameter are indicated only for single-
tooth non-load-bearing regions
Mini-implants <3.0 mm in diameter are only documented for the edentulous
arch and single-tooth non-load bearing regions
Long term follow-up times > 1 year are missing
Information on patient specific risk factors are missing