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. 2024 Dec 31;24:1574. doi: 10.1186/s12903-024-05377-1

A network meta-analysis comparing treatment modalities of short and long implants in the posterior maxilla with insufficient bone height

Yixuan Zhang 1,2,#, Xiaoyue Tang 1,#, Yue Zhang 1,#, Can Cao 1,✉
PMCID: PMC11686903  PMID: 39741292

Abstract

Objective

Based on the critical role of implant length and placement timing in treatment success, this study aimed to compare clinical outcomes (implant failure, marginal bone loss, biological and mechanical complications) between short implants (4–8 mm) versus long implants (≥ 8 mm) with sinus floor elevation, and between delayed versus immediate placement of long implants in the posterior maxilla.

Methods

This network meta-analysis was prospectively registered in the PROSPERO database (CRD42023495027). Adhering to PRISMA-NMA guidelines, we systematically reviewed eligible studies from January 2014 to November 2024 was conducted across major databases, such as the Cochrane Library, PubMed, Embase, Scopus and Web of Science. The main focus of this NMA was to determine the rate of implant failure, as well as to assess marginal bone loss and the occurrence of biological and mechanical complications related to the implants.

Results

Data from 17 studies, involving 1,076 patients and 1,751 implants, was collected and examined. Long implants have lower failure rates (OR = 1.26; 95% CI = 0.53, 3.00) and short dental implants showed a trend towards lower biological (OR = 0.47; 95% CI = 0.19, 1.18) and mechanical (OR = 0.94; 95% CI = 0.45, 1.94) complications rates, although this trend was not statistically significant. Additionally, compared to longer implants, short implants resulted in a significant reduction in marginal bone loss, regardless of whether long implants were immediately (MD=-0.17; 95%CI: -0.29, -0.05) or delayed (MD = 0.35; 95%CI: 0.05, 0.64) placed following sinus floor elevation. The analysis of cumulative ranking probabilities revealed that delayed placement of long implants with SFE demonstrated the highest efficacy in reducing implant failure (73.9%). SIs were found to excel in reducing marginal bone loss (88.7%) and biological complications (88.2%%), while short implants with SFE proved to be the most effective in preventing mechanical complications (66.0%%).

Conclusion

Short implants achieved comparable clinical outcomes to long implants with sinus floor elevation in posterior maxilla with limited vertical bone height. Given the limitations of the network meta-analysis and included studies, treatment selection should be individualized based on specific patient conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-024-05377-1.

Keywords: Posterior maxilla, Short dental implants, Sinus floor elevation, Implant failure, Network meta-analysis

Introduction

Oral implantology is now recognized as a vital choice for replacing missing teeth. Nevertheless, the process is notably difficult when it comes to the back upper jaw, as intricate anatomical structures and a frequent insufficiency of sufficient bone density and volume make implant placement more complicated [1].

The most effective treatment method, which involves the positioning of dental implants to restore the posterior maxilla with insufficient bone volume, is currently being studied and discussed in the field [2, 3]. One such technique involves using short dental implants (SIs) instead of long implants (LIs) with bone augmentation procedures and maxillary sinus floor elevation (SFE) to increase vertical bone height [4–6]. Short dental implants provide a simplified, less invasive, and cost-efficient method for replacing missing teeth in certain clinical cases. This approach reduces the duration of treatment and discomfort after surgery by eliminating the requirement for extra surgical procedures [7–9].

Recent research has shown that the survival rates of short implants (4–8 mm) and long implants (≥ 8 mm) placed in augmented sinus sites are similar over a period of 1–5 years [10–12]. Nevertheless, the effectiveness and durability of SIs may be hindered by factors such as decreased bone-to-implant contact and higher crown-to-implant ratios, leading to heightened mechanical stress [13]. On the other hand, SFE techniques have been shown to effectively regenerate alveolar bone volume, allowing for the placement of standard-length implants using grafting materials and membrane barriers. However, SFE necessitates more complex surgical procedures, lengthier recuperation periods, and higher financial expenses [5]. Additional research is required to investigate the performance of implants in native posterior maxillary bone compared to those placed in mature augmented sites [14].

The timing of implantation can have a significant impact on outcomes. Following the principles established in Misch’s Contemporary Implant Dentistry [15], particularly regarding the SA-4 classification with very limited bone height which recommends staged implant placement, delayed implant placement (DIP) at 6–9 months after SFE allows for optimal graft integration and maturation, while immediate implant placement (IIP) during the initial surgery may not provide the same level of integration and maturation [16]. Nevertheless, the use of DIP necessitates an extra procedure and lengthens the time limit for prosthetic loading. The scientific community has demonstrated a growing interest in distinguishing between IIP and DIP [17]. Inspired by Misch’s SA-4 classification system, which emphasizes the importance of delayed implantation in cases of severe vertical bone deficiency. Attaining optimal implant placement following bone grafting can be extremely challenging when long implants are used to restore the posterior maxilla. As a result, executing DIP requires surgical training and experience [18]. In order to gain a more comprehensive understanding of the risk‒benefit profile of different approaches, it is crucial to conduct further high-quality studies that directly compare these treatments. Currently, clinicians face significant challenges in determining optimal treatment strategies for insufficient residual bone height in the posterior maxillary region, particularly regarding implant length selection, sinus floor elevation necessity, and implant placement timing. While various approaches have shown clinical success, comprehensive evidence comparing their relative effectiveness remains limited [1, 6, 19].

This network meta-analysis aims to evaluate four specific treatment modalities for posterior maxilla rehabilitation, utilizing a comprehensive assessment framework that includes implant failure rate as the primary indicator, alongside biological and mechanical complications and marginal bone loss as prognostic parameters. By employing network meta-analysis methodology, which enables simultaneous comparison of multiple treatment options, this study provides a more systematic foundation for evidence-based clinical decision-making and long-term treatment protocols.

Methods

Protocol and Registration

This network meta-analysis (NMA) followed the PRISMA-NMA guidelines [20]. The study protocol was registered in advance in the PROSPERO database (CRD42023495027).

Search strategy

The researchers conducted a comprehensive search of PubMed (MEDLINE), the Cochrane Library, and Embase to identify studies published until November2024. The final search was performed on November 2024. The search terms consisted of a combination of keywords: “short implant” OR “long implant”, “sinus floor elevation” OR “sinus augmentation”, and “dental implant”. In addition, the reference lists of the identified articles were examined to find additional relevant studies. The detailed search strategy can be found in Supplementary Table S1.

Research question and eligibility criteria

The research question was formulated as follows: " In adult patients with limited vertical bone height undergoing posterior maxillary rehabilitation, will the use of short implants (< 8 mm) result in better implant survivability, compared to long implants?”

The inclusion criteria were defined using the PICOS framework

Patients (P): Individuals with less than 8 mm of residual bone height in the posterior maxilla opting for implant-supported prostheses. Interventions (I): Posterior maxilla implant placement was performed with at least two of the following methods: (1) implants (4–8 mm) without sinus floor elevation (SIs); (2) short implants with SFE (SIs-SFE); and (3) delayed placement of long implants (≥ 8 mm) with SFE (LIs-SFE + DIP). Comparator (C): Immediate placement of long implants with SFE (LIs-SFE). Outcomes (O): The incidence of implant failure was the principal outcome. Among the secondary consequences were marginal bone loss, both biological and mechanical complications. Study Design (S): Randomized controlled trials, including both split-mouth and parallel designs, as well as retrospective studies reporting relevant outcomes at a minimum of one year after implantation. Time (T): Studies were required to have a follow-up period of more than a year.

The exclusion criteria included

Case-control studies, cross-sectional studies, case reports, and systematic reviews are diverse types of research studies. Preclinical studies conducted in laboratory settings or on animals; Short implants are typically defined as implants that exceed a length of 8 mm. Studies with inadequate or unobtainable data.

Study selection and data extraction

Two reviewers, namely Y.X.Z. and C.C., independently assessed the titles and abstracts to ascertain the compliance with the criteria. Subsequently, the reviewers evaluated the full-text articles’ eligibility in a separate and unbiased manner. Any inconsistencies were resolved through a dialogue with a third impartial researcher (Y.Z.). The data extracted consisted of the name of the first author, the year of publication, the study design, the sample size, the residual bone height of the participants, the details of the intervention such as the length of the implant, and the duration of the follow-up. Any data not mentioned or extracted from the references was replaced with “NA”, which stands for “not available”.

Outcome variables

The primary outcome of this study was implant failure, where any occurrence of implant loss was considered as a failure.

Secondary outcomes were evaluated using the following methods:

  1. Marginal bone loss (MBL): The measurement of crestal bone height changes from baseline to the follow-up period. MBL measurements were standardized in millimeters (mm) through radiographic assessment, specifically measuring bone height changes at the implant neck region using the implant itself as a reference point. For studies reporting multiple measurement sites, we performed pooling. For studies with single measurements, these values were directly used as the mean bone height changes in the maxillary sinus region at the implant level.

  2. Mechanical complications: This metric evaluates hardware-related issues at the implant level, including: crown/prosthetic complications (chipping, fracture), abutment screw loosening, prosthetic screw loosening, prosthesis detachment.

  3. Biological complications: This metric assesses tissue-related adverse events at the implant level, including peri-implant mucositis (reversible soft tissue inflammation), peri-implantitis (progressive bone loss with inflammation), soft tissue complications (inflammation, recession), post-operative infection.

All complications were systematically recorded during follow-up visits and analyzed as dichotomous variables. For studies reporting complications at both patient and implant levels, implant-level data was prioritized for consistency in analysis.

Quality assessment and risk of bias

The evaluation of the quality of the studies included RCTs was performed independently using ROB 2 [20, 21], which was developed by the Cochrane Collaboration (Mountain View, California, United States). The studies were categorized based on their risk of bias as “low”, “some concerns “, or “high”. Most of the selected studies were deemed to have a low risk of bias. The quality of the retrospective studies was evaluated using the Newcastle‒Ottawa Scale (NOS) [22].

Publication bias

To identify publication bias, visual examination of comparison-adjusted funnel plots was conducted. If a substantial discrepancy was detected, a meta-regression analysis was performed, considering variables such as the average age of the participants, the specific type of sinus surgery conducted, and the length of time for outcome evaluation.

Data synthesis and analysis

Stata 17 software (StataCorp LP, College Station, Texas, USA), Review Manager 5.4 were used to produce a network diagram based on all included studies in order to inform the analysis plan, presented the data in forest plots, and obtained a treatment hierarchy using the surface under the cumulative ranking curve (SUCRA). And the associated software packages utilized were st0410, st0411, and st0156-2. To determine the relative risk for dichotomous outcomes, the number of events in each participant group was recorded and tabulated. The frequency of occurrence in each participant group was documented to evaluate the relative risk. Continuous outcomes are reported using the mean difference (MD) and standard deviation (SD). If P < 0.01, the comparison results are considered statistically significant. If there were no statistically significant differences observed in the interventions, a ranking plot was created to analyze the most effective measures.

Inconsistency analysis

STATA 17 was used to analyze the consistency of outcomes by comparing direct and indirect evidence using node-splitting method and inconsistency factors (IF). Consistency and transitivity assumptions are closely related; when good consistency is achieved, transitivity is typically considered strong, indicating high credibility of direct and indirect comparisons between studies. Consistency was determined when the value of P > 0.01, and conclusions made based on consistency models were considered trustworthy. Nevertheless, in the case where P < 0.01, sensitivity analyses were conducted to identify potential sources of inconsistency. The loop-specific approach was employed to demonstrate discrepancies when P < 0.01. IF was computed for each iteration by measuring the absolute difference between the direct and indirect estimates for a specific comparison within the iteration. IF was calculated with a 95% confidence interval (95% CI).

Results

Study selection and article characteristics

Two authors independently conducted a thorough screening of potential studies using the Medline (PubMed), Cochrane Library, Web of Science, Scopus and Embase databases up until November 2024. We found 3515 articles from various sources and 2 more articles through manual screening. Language restrictions were applied to include only English-language trials. After deduplication, 1722 articles underwent title and abstract screening, leading to the full-text review of 68 articles. 17studies [4, 11, 23–37] met the inclusion criteria and were eligible for the final analysis (Fig. 1), comprising 14 RCTs and 3 retrospective studies.

Fig. 1.

Fig. 1

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PRISMA flow diagram

The included studies, characterized in Table 1, employed a parallel-group design, with some studies adopting a split-mouth approach. Collectively, these studies included 1,076patients and 1,751 implants.

Table 1.

Basic characteristics of the included studies

Studies Study design RBH
(mm)		 Experimental group Control group Follow-up
(years)
Sample size (Patients/Implants) Implant length (mm) Treatment Modalities Sample size (Patients/Implants) Implant length (mm) Treatment Modalities
Guljé et al.,2023[11] RCT-parallel group 6–8 20/21 6 IIP + LSFE 18/20 11 IIP + LSFE 10
Felice et al.,2015[29] RCT-parallel group 1–3 30/66 11/13/15 IIP + OSFE 30/69 11/13/15 DIP + OSFE 1
Barausse et al.,2021[23] RCT-parallel group 4–5 20/37 4 IIP 20/41 10 IIP + LSFE 5
Esposito et al., 2019[26] RCT-parallel group 4–6 20/36 5 IIP 20/37 10 IIP + LSFE 5
Gastaldi et al.,2017[30] RCT-parallel group 5–7 10/16 5/6 IIP 10/18 10 IIP + OSFE 3
Felice et al.,2019,A[27] RCT-parallel group 4–6 15/34 5 IIP 15/38 10 DIP + LSFE 5
Felice et al.,2019,B[28] RCT-parallel group 5–7 20/39 6 IIP 20/44 10 IIP + LSFE 5
Thoma et al.,2018[36] RCT-parallel group 5–7 50/67 6 IIP 51/70 11–15 IIP + LSFE 5
Yu et al.,2017[37] RCT-parallel group 4–5 20/38 6.5 IIP + OSFE 18/41 11-12.5 IIP + LSFE 3
Bechara et al.,2016[24] RCT-parallel group ≥ 4 33/45 6 IIP 20/45 10–15 IIP + LSFE 3
Nielsen et al.,2021 [34] RCT-parallel group ≥ 5.5 20/24 6 IIP 17/21 13 IIP + LSFE 1
Lombardo et al.,2022 [32] retrospective study NA 44/132 5/6 IIP + OSFE 7/23 8 IIP + OSFE 5
Schiegnitz et al.,2021 [4] retrospective study NA 84/126 4.5-8 IIP 156/312 8.5–14 DIP + LSFE/OSFE 10
Magdy et al.,2021 [33] RCT-parallel group 7–8 24/24 5.5 IIP 24/24 10 IIP + OSFE 1
Shi et al.,2021 [35] RCT-parallel group 6–8 67/67 6 IIP 132/132 8/10 IIP + OSFE 3
Durrani, 2024 [25] Prospective observational study ≤ 8 6/7 6–8 IIP 6/7 10-11.5 DIP + LSFE/OSFE 1
Hadzik, 2021 [31] RCT-parallel group 6–7 15/15 6 IIP 15/15 11,13 IIP + LSFE 7
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RBH: residual bone height; IIP: immediate implant placement; DIP: delayed implant placement; LSFE: lateral sinus Floor elevation; OSFE: osteotome sinus Floor elevation; NA: not applicable

Implant failure analysis

Implant failure was assessed in 17 studies, encompassing1,697 implants across these 4 implantation methods for the posterior maxilla. The overall rate of implant failure was 6.0%, with individual failure rates of 7.1% (SIs), 4.7% (SIs-SFE), 3.6% (LIs-SFE), and 8.2% (LIs-SFE + DIP). Figure 2a illustrates the network geometry associated with implant failure. Figure 3 shows that the 99% confidence intervals (99%CI) for these comparisons contained the null value, suggesting that there were no statistically significant differences. The SUCRA rankings for the lowest risk of implant failure were as follows: LIs-SFE + DIP, LIs-SFE, SIs-SFE, and SIs. The rankogram illustrating these rankings is shown in Fig. 4a.

Fig. 2.

Fig. 2

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Network diagram- extended network, for implant failure (a), marginal bone loss (b), mechanical complications (c), and biological complications (d). The size of each node represents the number of patients included in studies featuring that device. The thickness of the lines connecting the nodes is proportional to the number of head-to-head studies in each comparison. Network diagram was made by risk of bias (3 categories) Key: green = low; yellow = some concern; red = high overall risk of bias for the contrast

Fig. 3.

Fig. 3

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Forest plot comparing implant failure between: (a) short implants (SIs) and long implants with sinus floor elevation (LIs-SFE); (b) delay placement of long implants with sinus floor elevation (LIs-SFE + DIP) and short implants (SIs); (c) short implants with sinus floor elevation (SIs-SFE) and long implants with sinus floor elevation (LIs-SFE); (d) long implants with sinus floor elevation (LIs-SFE) and delay placement of long implants with sinus floor elevation (LIs-SFE + DIP)

Fig. 4.

Fig. 4

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Plots of the surface under the cumulative ranking curve (SUCRA) for implant failure (a), marginal bone loss (b), mechanical complications (c), and biological complications (d). SUCRA showed the possibility of each intervention being the best

Marginal bone loss (MBL)

A comprehensive analysis was conducted on 16 studies, including 1,355 implants. Figure 2b depicts the network geometry for MBL. The SUCRA ranking for the lowest risk in MBL is as follows: SIs, SIs-SFE, LIs-SFE, and LIs-SFE + DIP. Figure 4b displays the corresponding rankogram. The network meta-analysis showed that SIs effectively reduced the risk of MBL when compared to LIs-SFE (MD=-0.17; 95%CI: -0.29, -0.05; P = 0.0003) and LIs-SFE + DIP (MD = 0.35; 95%CI:0.05, 0.64; P = 0.002), with statistical significance. No other comparisons showed statistical significance (P > 0.01, Fig. 5).

Fig. 5.

Fig. 5

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Forest plot comparing marginal bone loss between: (a) short implants (SIs) and long implants with sinus floor elevation (LIs-SFE); (b) delay placement of long implants with sinus floor elevation (LIs-SFE + DIP) and short implants (SIs); (c) short implants with sinus floor elevation (SIs-SFE) and long implants with sinus floor elevation (LIs-SFE); (d) long implants with sinus floor elevation (LIs-SFE) and delay placement of long implants with sinus floor elevation (LIs-SFE + DIP)

Mechanical and biological complications

Most of the studies reported complications at the patient level. However, one article specifically examined complications at the implant level, while two studies provided data on complications at both the patient and implant levels. Due to the scarcity of articles, we combined data from implant-level reports with patient-level studies for analysis.

For biological complications, 15 studies with a collective patient count of 810 were analyzed to discern the effects of different implantation methods in the posterior maxilla, and 151 patients had complications. The overall incidence of biological complications was 18.6%. Regarding mechanical complications, the analysis included 11 studies and 713 implants, for which the complication rates were 12.5%. Figure 2c and d depicts the network geometry associated with complications. According to the SUCRA ranking (Fig. 4c and d), the SIs-SFE treatment had the lowest risk of mechanical complications, followed by SIs, LIs-SFE + DIP, LIs-SFE. The SUCRA ranking for biological complications was highest for SIs, followed by LIs-SFE + DIP, SIs-SFE, and LIs-SFE. The comparison among the four groups did not provide clear conclusions because the 99%CI included the null value. This suggests that there were no significant differences in both biological and mechanical complications (P > 0.01, Figs. 6 and 7).

Fig. 6.

Fig. 6

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Forest plot comparing mechanical complications between: (a) short implants (SIs) and long implants with sinus floor elevation (LIs-SFE); (b) delay placement of long implants with sinus floor elevation (LIs-SFE + DIP) and short implants (SIs); (c) short implants with sinus floor elevation (SIs-SFE) and long implants with sinus floor elevation (LIs-SFE); (d) long implants with sinus floor elevation (LIs-SFE) and delay placement of long implants with sinus floor elevation (LIs-SFE + DIP)

Fig. 7.

Fig. 7

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Forest plot comparing biological complications between: (a) short implants (SIs) and long implants with sinus floor elevation (LIs-SFE); (b) delay placement of long implants with sinus floor elevation (LIs-SFE + DIP) and short implants (SIs); (c) short implants with sinus floor elevation (SIs-SFE) and long implants with sinus floor elevation (LIs-SFE); (d) long implants with sinus floor elevation (LIs-SFE) and delay placement of long implants with sinus floor elevation (LIs-SFE + DIP)

Publication bias and risk of bias assessment

Funnel plots were employed to enhance the detection of potential publication bias in this network meta-analysis. Based on a visual inspection, the plots suggest that there is a low probability of publication bias (Fig. 8).

Fig. 8.

Fig. 8

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Funnel plots for implant failure (a), marginal bone loss (b), mechanical complications (c), and biological complications (d). In the absence of publication bias and heterogeneity, the studies expected to lie within the pseudo 95% CIs and hence inverted funnel plot shape

The risk of bias in 14 RCTs were evaluated using ROB 2, and the findings are presented as a percentage of compliance for each domain, as depicted in Supplementary Figure S1-S4. The studies covered a wide range of domains, but some concerns were raised about deviations from intended interventions, missing outcome data and selection of the reported result. The risk of bias in all studies was defined as “low risk” or “some concern”. Only one study was defined as “high risk”, because no dropped-out during follow-up, and two cases of missing data attributed to implant failure. Furthermore, each of the 3 retrospective studies was assigned a score of 7 points, upon evaluation through the Newcastle–Ottawa Scale. (Supplementary Table S3).

Consistency test

No inconsistencies or transitivity assumption violations were detected within the network (P > 0.01, Supplementary Table S2).

Discussion

This study is the first network meta-analysis that incorporates delayed implant placement (DIP) as an independent treatment option, with respect to the Misch classification of bone quantity, comprehensively comparing various treatment approaches for restoring the posterior maxilla with inadequate bone height.

Our research yielded three significant findings. Shorter implants demonstrate a notable reduction in marginal bone loss compared to both immediate (P = 0.0003) and delayed placement of long implants (P = 0.002). Furthermore, we found no significant disparity in biological or mechanical complications across the four treatment methods we evaluated. Furthermore, while not statistically significant (P > 0.01), there is a discernible pattern indicating that the placement of long implants after a delay may be more effective in preventing implant failure compared to using short implants or placing long implants immediately.

The main parameter for assessing the effectiveness of dental implants is their rate of failure. The analysis conducted by Lin et al. [38] demonstrated that short implants have a higher likelihood of survival compared to longer implants (OR = 1.68, 95% CI = 1.15, 2.47). However, other studies suggest that there is no significant difference in survival rates when comparing different implant lengths [39, 40]. Furthermore, the network meta-analysis conducted by Al-Moraissi et al. provided support for the notion that the length of implants does not have a significant impact on survival rates [41] (OR = 1.2, 95% CI = 0.49, 3.34), even when sinus floor elevation is performed. However, it should be noted that these findings are not universally accepted. Our study’s findings are consistent with previous research conducted by Wu et al. [42]. They also noted a higher likelihood of failure in short implants, although this difference did not reach statistical significance. In addition, our network meta-analysis revealed that there were no statistically significant disparities observed between immediate and delayed implant placement after sinus floor elevation in the posterior maxilla (P > 0.01). This finding indicates that the timing of implant placement may not be a crucial determinant of treatment success, aligning with the findings of Canellas et al. [43]. However, it is important to acknowledge that in cases of severe vertical bone loss, a staged approach with delayed implant placement after sinus floor elevation may be more appropriate to ensure adequate graft maturation and implant stability.

Our implant failure rates align with those of other systematic reviews, which adds credibility to our findings. Differences in study population and implant systems used may explain the discrepancies observed among systematic reviews [44].

The SUCRA ranking analysis offers valuable insights into the comparative effectiveness of various treatment strategies. While no differences reached statistical significance, the rankings suggest some trends that warrant further discussion: (LIs-SFE + DIP had the lowest risk of implant failure based on the SUCRA ranking. It is important to approach the differences in rankings with caution, as the evidence does not conclusively establish the superiority of one approach over others. One possible reason for the higher failure rates of short implants in the back upper jaw area could be that longer implants have a larger area of bone-to-implant contact (BIC) which improves the integration of the implant with the bone and increases stability [45]. Long implants can effectively alleviate the concentration of stress in the crestal area by transferring stress distributions from the implant to the surrounding cortical and cancellous bones through various mechanisms [46]. It is essential that long implants offer improved primary and secondary stability, reducing micromotion at the bone-implant junction, as excessive movement can result in fibrous encapsulation and implant malfunction [47]. In addition, longer implants can securely attach to cortical bone, which helps prevent implant displacement when subjected to external forces [48]. However, careful consideration of patient-specific factors and proper treatment planning remain essential for optimal outcomes [49]. This biomechanical advantage ostensibly contributes to the survival of the implant. Nonetheless, it is imperative to recognize the multifactorial nature of osseointegration, considering the interplay of various factors beyond implant length [50]. Short implants tended to cause more failures, but this needs to be confirmed with additional research.

Measuring marginal bone loss is a key factor in determining the long-term effectiveness of dental implants [51]. Our network meta-analysis indicates that short implants may outperform long implants in terms of preserving marginal bone height, regardless of whether patients underwent sinus augmentation or the timing of implant placement. The SUCRA ranking shown in Fig. 7 clearly illustrates a noticeable pattern: SIs were ranked the highest. This is consistent with the idea that reducing invasiveness may contribute to reducing long-term postoperative bone remodeling. SIs cause minimal trauma compared to other alternatives. The result of Guida et al. [52] (RR = 0.98, 95% CI = 0.96, 1.00) supported the notion that short implants may be more effective in reducing marginal bone loss compared to delayed placement of long implants.

One factor that could affect this result is the lower ratio between the crown and longer implant. This can worsen bone loss when specific chewing forces are applied, as it increases the stress on the implant. Consequently, this can impact the stability of the nearby bone [53, 54]. Furthermore, research has shown that short implants, even with higher crown-to-implant ratios, can maintain similar rates of implant survival and bone levels as long implants [55]. The second factor is the heightened risk of infection associated with bone augmentation procedures and the typically suboptimal quality of bone grafts, leading to the loss of marginal bone [56]. Furthermore, bone grafts often have suboptimal quality due to inadequate blood supply and reduced density [42]. On the other hand, certain authors have stated that the MBL of implants in augmented bone is comparable to that in native bone [38, 57]. Furthermore, the range of study findings indicates that factors other than just implant length, such as implant shape, surface texture, crown attachment methods, and surgical techniques, also contribute to the preservation of bone around the implant [56] This emphasizes the intricate aspects of preserving bone health around implants and the significance of a comprehensive approach in selecting and positioning implants.

Our review found that short implants are associated with fewer biological complications, and SIs-SFE are believed to have fewer mechanical complications. However, there was no significant difference in incidence rates among the four treatment modalities, which is consistent with the findings of Guida et al. [52]. Nevertheless, certain studies indicate a reduced occurrence of complications linked to shorter implants [44]. One potential explanation is that the occurrence of complications is linked to the utilization of advanced medical technology and the deliberate upkeep of oral hygiene. Therefore, decreasing the risk associated with long implants necessitates diligent postoperative care, including consistent oral hygiene, to ensure the health and functionality of the implant.

The Misch classification system is a crucial reference in dental implantology. Misch noticed that insufficient vertical bone height can hinder the simultaneous performance of sinus grafting and implant placement [15]. He explained that when there is limited bone volume, it can have negative effects on implant stability and graft health. This is because there is a reduced blood supply, which in turn prolongs the healing process. As a result, a customized surgical approach is necessary [58]. We integrated Misch’s system into our research and introduced the LIs-SFE + DIP group to assess the effectiveness and potential complications of short implants compared to the LIs-SFE + DIP in the maxillary sinus area. Our findings demonstrate similar rates of success between the two methods, implying that the timing of implant placement in the upper jaw’s back region may not significantly affect the outcome or occurrence of complications. This highlights the advantages of using short implants to simplify the implant procedure and reduce the time required for multistage interventions.

The study demonstrated that all four therapeutic modalities being evaluated produce satisfactory clinical and radiological results. However, it is crucial to recognize the inherent limitations of this network meta-analysis, particularly the variation among the studies included, the choice of maxillary sinus lifting approach, the inconsistency in the length of follow-up periods, the absence of certain evaluation measures in some reports, and the potential for distortion present in periapical radiographs when measuring MBL. Future investigations should aim to achieve consistency in tracking time limits and include a wider range of patient-specific factors, such as oral hygiene habits, alcohol intake, periodontal health, and patterns of tobacco use, to improve our understanding of the factors that contribute to the success of implant treatment.

Conclusion

Overall, this network meta-analysis demonstrates that in patients with limited vertical bone height in the posterior maxilla who need dental implants, the use of short implants with sinus lifting and short implants without sinus lifting can yield similar results to long implants with sinus floor elevation. While there may be a slight benefit to placing long implants later, the available evidence does not establish its superiority. Further randomized controlled trials with standardized long-term follow-up periods are necessary to obtain more reliable evidence for comparing these treatment strategies.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (2.1MB, docx)

Acknowledgements

The authors are thankful for the financial support of the Natural Science Foundation of Liaoning Province, China.

Abbreviations

SIs

Short dental implants

LIs

Long dental implants

SFE

Sinus floor elevation

SA

Subantral

DIP

Delayed implant placement

IIP

Immediate implant placement

NMA

Network meta-analysis

PRISMA

Preferred reporting items for systematic reviews and meta-analysis

MBL

Marginal bone loss

RCT

Randomized controlled trial

ROB

Risk of bias

NOS

Newcastle‒ottawa scale

SUCRA

Surface under the cumulative ranking curve

MD

Mean difference

SD

Standard deviation

IF

Inconsistency factor

CI

Confidence interval

BIC

Bone-to-implant contact

Author contributions

Y.X.Z. and C.C. designed the study and developed the retrieval strategy. Y.X.Z. and C.C. executed the systematic evaluation as the first and second reviewers, respectively, searching and screening the summaries and titles, assessing the inclusion and exclusion criteria, generating data collection forms and extracting data, and evaluating the quality of the study. X.Y.T. and Y.Z. performed network meta-analysis. Y.X.Z drafted the article, which was reviewed and revised by C.C.

Funding

Our research was funded by the Natural Science Foundation of Liaoning Province, China. The grant number is 2022-MS-043.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Additional information can be obtained by contacting the corresponding author.

Declarations

Ethics approval and consent to participate

Not applicable.

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Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

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Yixuan Zhang, Xiaoyue Tang and Yue Zhang contributed equally to this study.

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Associated Data

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Supplementary Materials

Supplementary Material 1 (2.1MB, docx)

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Additional information can be obtained by contacting the corresponding author.

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