Clinical Oral Investigations (2022) 26:6681–6698

https://doi.org/10.1007/s00784-022-04628-1

ORIGINAL ARTICLE

Short versus standard implants at sinus augmented sites: a systematic

review and meta‑analysis
Manuel Toledano1 · Enrique Fernández‑Romero1 · Cristina Vallecillo1 · Raquel Toledano1 · María T. Osorio1 ·
Marta Vallecillo‑Rivas1

Received: 25 March 2022 / Accepted: 12 July 2022 / Published online: 7 September 2022
© The Author(s) 2022

Abstract
Background Short implants are proposed as a less invasive alternative with fewer complications than standard implants
in combination with sinus lift. The aim of this systematic review and meta-analysis was to state the efficacy of placing
short implants (≤ 6 mm) compared to standard-length implants (≥ 8 mm) performing sinus lift techniques in patients with
edentulous posterior atrophic jaws. Efficacy will be evaluated through analyzing implant survival (IS) and maintenance of
peri-implant bone (MBL).
Methods Screening process was done using the National Library of Medicine (MEDLINE by PubMed), EMBASE, the
Cochrane Oral Health, and Web of Science (WOS). The articles included were randomized controlled trials. Risk of bias was
evaluated according to The Cochrane Collaboration’s tool. Weighted means were calculated. Heterogeneity was determined
using Higgins (I2). A random-effects model was applied. Secondary outcomes such as surgical time, patient satisfaction,
mucositis and peri-implantitis, pain, and swelling were analyzed.
Results Fourteen studies (597 patients and 901 implants) were evaluated. IS was 1.02 risk ratio, ranging from 1.00 to 1.05
(CI 95%) (p = 0.09), suggesting that IS was similar when both techniques were used. MBL was higher in patients with
standard-length implants plus sinus lift elevation (p = 0.03). MBL was 0.11 (0.01–0.20) mm (p = 0.03) and 0.23 (0.07–0.39)
mm (p = 0.005) before and after 1 year of follow-up, respectively, indicating that the marginal bone loss is greater for
standard-length implants.
Discussion Within the limitations of the present study, as relatively small sample size, short dental implants can be used
as an alternative to standard-length implants plus sinus elevation in cases of atrophic posterior maxilla. Higher MBL was
observed in the groups where standard-length implants were used, but implant survival was similar in both groups. Moreo-
ver, with short implants, it was observed a reduced postoperative discomfort, minimal invasiveness, shorter treatment time,
and reduced costs.
Clinical Clinical relevance The low MBL promoted by short implants does contribute to a paradigm shift from sinus grafting
with long implants to short implants. Further high-quality long-term studies are required to confirm these findings.

Keywords Short · Implants · Survival · Bone · Loss · Review

Introduction sinus floor elevation has become the most reliable, com-
monly used procedure to increase bone height in the pos-
Postextraction alveolar ridge remodeling frequently terior maxilla [2, 3].
results in reduced bone dimension or even in severe ridge Patients with extremely atrophic posterior maxillae not
atrophy [1], coupled with age-liked sinus pneumatiza- only require for rehabilitation with fixed prostheses, dental
tion [2] that usually compromises bone height. Maxillaris implants after sinus lift procedures. They also, very often,
are in need of zygomatic implants and sometimes titled or
* Cristina Vallecillo pterygoid implants [4]. In particular, the posterior maxilla
[email protected] is a challenging area for dental implants’ placement [1, 2].
Complications, such as postoperative sinusitis, partial, or
1
Faculty of Dentistry, University of Granada, Colegio total graft failure, may occur after sinus floor elevation,
Máximo de Cartijo S/N, 18071 Granada, Spain

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appearing up to 38% of patients, and implants fail in up to analyzed. A total of seven randomized controlled clinical
17% of patients within 3 years [2]. Augmentation procedures trials (RCTs) involving 310 patients were included. The
may, even more, require hospitalization and longer times follow-up reached more than 3 years for several studies.
(up to 1 year) for rehabilitating the patients [5]. Therefore, Authors declared that no significant differences with regard
evidence of these complications together with the increas- to MBL and IS rate were found between each group at each
ing predictability of less invasive alternatives for implant time of the follow-up, 1 up to 3 years and more than 3 years.
placement might reserve the use of sinus floor elevation No consensus has been reached on the controversial
procedures only for cases of minimum height of alveolar issue that whether the length of implants is considered as
bone [6, 7]. short or standard implant. According with the last Euro-
The placement of short dental implants instead of sinus pean Association of Dental Implantologists consensus in
floor elevation technique in atrophic posterior maxillae 2016, ultrashort implants are defined as < 6 mm and dental
(6 mm ≤ residual bone height < 8 mm), without jeopardiz- implants with length of 8 mm or more (≥ 8 mm) could be
ing stability, has been a long-time waiting hope in dental accepted as standard-length implants [1, 21]. Pending more
implantology [8]. The application of such short implants long-term studies, the success rates of short implants in the
could eliminate the need of sinus floor elevation and reduce posterior maxillae are still controversial [22]. The aim of
the associated complications, treatment time, and cost, while this systematic review was, therefore, to address the follow-
increasing patients’ acceptance [1]. A short implant is an ing focused question: In patients with edentulous posterior
implant with its designed intrabony length < 8 mm [8]. Short atrophic jaws, what is the efficacy of placing short implants
dental implants are currently used, besides, as an alternative (≤ 6 mm) compared to standard-length implants (≥ 8 mm)
to longer implants in purposely augmented bone, in case of performing sinus lift techniques, in terms of implant survival
reduced bone volume [9], to support fixed prosthesis in the and maintenance of peri-implant bone?
rehabilitation of atrophic jaws [10]. In addition, narrow and
short implants can be used as an alternative to longer and
wider implants in augmented zones with reduced bone vol-
Material and methods
ume [11, 12]. In cases of suspected graft infection, moreo-
ver, it may be wiser to remove the graft completely and use
Protocol and registration
short implants instead [5].
Questions were raised, however, whether shorter dental
The study protocol of the present systematic review and
implants might replace sinus elevation procedures in con-
meta-analysis was prepared following the model propose
junction with longer dental implants. While longer implants
in the PRISMA statement and looking for the greatest
might have a better long-term prognosis in non-augmented
transparency structured according to the PRISMA check-
bone, the long-term prognosis of short implants compared to
list [23]. The developed protocol was previously registered
longer implants placed in augmented bone is still unknown
and allocated with the registration number 295642 in the
[5]. The most frequently reported criteria for implant suc-
International Prospective Register of Systematic Reviews
cess are based on the implant level, i.e., survival rates (IS)
(PROSPERO).
and marginal bone loss (MBL) [13]. Implant survival is
defined as the implant remaining in situ at the follow-up
examination [14]. The marginal bone loss is measured by Focused question
the radiographic bone level, i.e., the distance between the
implant shoulder and the bottom of the defect at bone-level This review intends to answer the following focused query
implants [15]. designed in accordance with the PICO question [24]: In
Short implants could be a simpler, cheaper, less invasive, patients with edentulous posterior atrophic jaws, what is
and faster alternative if they could provide similar clinical the efficacy of placing short implants (≤ 6 mm) compared
outcomes to longer implants placed in augmented bone [16]. to standard-length implants (≥ 8 mm) performing sinus lift
Despite the tendency for increased early failure of short techniques, in terms of implant survival and maintenance of
implants in smokers, machined surface implants, and severe peri-implant bone?
reabsorbed posterior maxilla [17, 18], it has been previously The PICOs elements were as follows:
reported that no statistically significant differences in IS or
MBL were found after placement of ≤ 8 mm implants com- • Population (P): Patients not affected by systemic con-
pared with standard-length implants > 8 mm, after 3 years ditions, older than 18 years, with edentulous posterior
of functional implant loading [19]. Even more, in another atrophic jaws requiring implant rehabilitation.
systematic review [20], short (< 6 mm) and longer implants • Intervention (I): Implant rehabilitation with extra-short
(> 10 mm) with sinus floor elevation were compared and and short implants (≤ 6 mm).

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• Comparison (C): Implant rehabilitation with standard 4. Studies that consider as short implants those with more
implants (≥ 8 mm) associated with maxillary sinus eleva- than 6 mm of length.
tion.
• Outcome (O): Outcomes measuring survival rate of the Study selection and data extraction
implants (implants lost during study follow-up), and
mean differences of marginal bone loss as primary out- Two authors (EF, CV) independently screened the titles
comes and secondary variables such as implant charac- and abstracts derived from the online search considering
teristics, implant stability, periodontal health parameters, the inclusion and exclusion criteria. The complete articles
and patient-reported outcome. sourced via eligible titles and abstracts were obtained and
• Study (S): Randomized controlled clinical trials. examined independently to determine eligibility. Disagree-
ments between these reviewers related to the selection and
Search strategy inclusion of any specific paper were discussed until either
a consensus was reached, or a third reviewer (MT) led to
An electronic search across the National Library of Med- an agreement and determined inclusion or exclusion. All
icine (MEDLINE by PubMed), the Cochrane Oral Health reports excluded at this stage were formally recorded, as
Group Trials Register, EMBASE, and Web of Science well as the reason/s for their exclusion. Cohen’s kappa coef-
(WOS) was performed for clinical studies. Only studies ficient was calculated as a measure of agreement between
published in English between 1993 and February 2022 the two readers.
were considered. Reference lists of the previous reviews Two investigators (EF and CV), independently, extracted
and included studies were screened trying to search for the data from included articles and assessed the risk of bias
relevant manuscripts that were missing after the elec- in duplicate and thereafter discussed to find an agreement.
tronic screening. Bibliographies of eligible articles were In case of disagreement, the judgment of a third reviewer
manually searched. (MT) was decisive. Data extracted were the following: (1)
The search strategy included the following word com- authors and year of publication; (2) number of patients
binations: ((ultra-short dental implant) OR (extra short and implants; (3) follow-up periods; (4) implant treatment
dental implant) OR (short dental implant) OR (< 6-mm modality; (5) implant survival; (6) marginal bone loss; (7)
dental implant) OR (5-mm dental implant) OR (4-mm summary results; (8) sinus lift surgery; and (9) type of res-
dental implant)) AND ((atrophic posterior maxilla) OR toration. To complete the search, information regarding sec-
(sinus lift) OR (sinus floor elevation) OR (sinus mem- ondary outcomes [diameter, implant stability quotient (ISQ),
brane elevation) OR (sinus floor augmentation). buccal bone thickness (BBT), bleeding on probing (BoP),
probing depth (PD), surgical time (ST), patient satisfaction,
Eligibility: inclusion and exclusion criteria peri-implantitis/mucositis, pain/swelling, and complications]
for studies were also reported.

In order to increase the quality, the following inclusion cri- Assessment of risk of bias
teria have been chosen:
Methodological quality and risk of bias were evaluated by
1. Randomized controlled clinical trials. two reviewers according to the Cochrane Collaboration’s
2. Comparisons between short implants (≤ 6 mm) with- tool [25]. The assessment criteria were separately prepared
out maxillary sinus augmentation and standard-length for different domains. For each domain, the risk of bias was
implants (≥ 8 mm) with maxillary sinus augmentation graded as high, low, or unclear, and studies were classified
in the same study. as “High risk,” “Some concerns,” or “Low risk.” When there
3. Studies that consider short implants, those with a length was a major disagreement, a third reviewer participated in
equal or less than 6 mm. the discussion until a consensus was reached.

Studies meeting at least one of the following criteria were Data analyses
excluded:
For the primary outcomes, implant survival (in terms of
1. In vitro and pre-clinical studies, case series or case number of implants that exceed the follow-up periods), and
reports, retrospective studies, systematic reviews. marginal bone loss [in terms of MBL (mm)], descriptive
2. Full-text publications not available in English language. statistics were used. For MBL, weighted means (CI 95%)
3. Studies with less than 6 months of follow-up. were calculated, including total sample size, inverse vari-
ance, and standard error of the treatment effect. For IS,

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risk ratio (RR) (CI 95%) was assessed using chi-square test The IS, when comparing the experimental and control
[Mantel–Haenszel (M-H)]. Due to the clinical heterogene- groups, was 1.02 (RR), ranging from 1.00 to 1.05 (CI 95%),
ity detected between studies, a random-effects model was suggesting that implant survival is similar when both tech-
applied, in order to analyze effect sizes. For MBL analysis, niques are used. Heterogeneity was low I2 = 0% and signifi-
two subgroups were established. Hence, comparisons were cance of the random-effect model was p = 0.09 (Fig. 3). IS
performed between the experimental and control groups forest plot graph is displayed in Fig. 3. Systematic heteroge-
considering the time of follow-up (≤ 1 year, > 1 year). Data neity is reflected at the funnel plot graph (Fig. 4).
were analyzed with RevMan 5.4 (The Cochrane Collabora- The comparative studies performed in the two subgroups,
tion, Oxford, UK). Statistical significance was set at 0.05. a follow-up of less than or equal to 1 year and a follow-up
of more than 1 year, show significant differences when the
Risk of bias across studies control and the test groups were compared. In the first sub-
group, MBL was 0.11, ranging from 0.01 to 0.20 (CI 95%)
The variation across the included studies, or heterogeneity, (p = 0.03), indicating that the marginal bone loss is greater
was determined using Higgins (I2). Funnel plot was pro- for standard implants with sinus lift elevation. Heterogene-
duced by RevMan 5.4 to represent systematic heterogeneity ity was high I2 = 78% and significance of the random-effects
and publication bias. model was p = 0.03 (Fig. 5). After 1 year of follow-up, MBL
was 0.23, ranging from 0.07 to 0.39 (CI 95%) (p = 0.005),
indicating that the marginal bone loss is greater for standard-
Results length implants with sinus lift elevation. Heterogeneity was
high I2 = 74% and significance of the random-effects model
Search results was p = 0.005 (Fig. 5). MBL forest plot graph is displayed
in Fig. 5. Systematic heterogeneity is displayed at the funnel
Search results based on the PRISMA guidelines are pre- plot graph (Fig. 6).
sented in Fig. 1. The electronic and manual searches yielded Secondary outcomes were also determined in the present
1932 references in total (PubMed: 602; EMBASE: 587; research (Table 3). All papers reviewed in the present manu-
Cochrane Library: 126; WOS: 617; manual search in other script reported information regarding implant diameters. The
sources: 4). Subsequent to duplicate removal and after most common diameter that was used corresponded to 4 mm
reading of titles and/or abstracts, 31 articles were selected. [2, 5, 9, 13, 16, 45] and the less usual diameter was 3.3 mm
Then the full text of all the selected articles was reviewed [42]. Implant stability was analyzed in three studies [1, 2,
for the inclusion criteria. Following the evaluation and deep 22]. Only Bechara et al. [2] reported significant differences
read of articles, 17 were excluded. Therefore, 18 articles at 3 years of follow-up.
were included in the final selection and reserved for data Three articles reported that the implant surface was sand-
extraction. The reasons for exclusion of articles from the blasted and acid-etched (SLA) [22, 42, 43]. Nielsen et al.
study were as follows: 3 studies defined implants > 6 mm in [3], Schincaglia et al. [9], Guljé et al. [45], and Thoma et al.
length as short implants, and 14 studies presented patients [13] treated chemically modified with fluor the surface of the
or data repeated in other articles included (Table 1). The implants (OsseoSpeed®). Hydroxyapatite (HA) blasting and
inter-reviewer agreement in the screening and inclusion soft etching (Xpeed®) was employed to modify the implant
process corresponded to 0.95 with de Cohen’s kappa for surface in Esposito et al. [10] and Bechara et al. [2]. Blasting
assessment of the title and abstract, and full-text evaluation. with alumina and cleaning with inert solvents (SInergy®)
The extracted data for each reviewed article are shown in was employed by Felice et al. [5]. Bolle et al. [16] used
Table 2. sandblasting and etching to treat the implant surface (SA2).
One paper (Gastaldi et al. [4]) treated the implant surface
Studies quality assessment and bias risk with dual acid-etching (Osseolite®). No information con-
cerning the treatment of the implant surface was provided
The results of quality assessment and bias risk of the selected in Magdy et al. [1].
studies are summarized in Fig. 2. Most of the selected papers Only one article [1] published information regarding buc-
were considered as having low risk of bias. cal bone thickness without showing significant differences
between groups. One out of the fourteen revised manu-
Primary and secondary outcomes scripts showed significant differences between groups, 53%
and 38% in the test and control groups, respectively, when
Fourteen studies (616 patients and 901 implants) examined bleeding on probing was assessed [9]. Surgical time required
both the IS and MBL. General characteristics of the included was almost twice longer when standard-length implants were
studies are displayed in Table 2. compared with short implants in Schincaglia et al. [9]. When

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Fig. 1  PRISMA flow diagram for studies inclusion process

Table 1  Excluded studies and Article Reason for exclusion

reason for exclusion
Pohl 2017 [26], Esposito 2016 [27], Zhang 2017 [8], Shi 2015 [28], Esposito Studies that correspond to
2014 [29], Guljé 2014 [30], Pistilli 2013a, 2013b [31, 32], Felice 2013 [33], the shorter or longer fol-
Felice 2012 [34], Esposito 2012 [35], Felice 2011 [36], Esposito 2011 [37], low-up of an included
Felice 2009 [38] study
Taschieri 2018 [39], Esposito 2015 [40], Thoma 2015 [41] Studies that consider as
short implants those
with more than 6 mm of
length

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 Table 2  General overview of the included studies
6686

Nº Author Follow-up Group Treatment modality Implant survival Marginal bone loss Summary results Sinus surgery and restora-
(%) n (m ± SD) tion

13
1 Magdy et al. 2021 [1] 1 year Test Short implants (5.5 mm) 87.5% (3 failed) 1 yr: 21 (0.91 ± 0.69) IS: No SS results OSFE
(n = 24 I) (n = 24) MBL: SS results (< short SC
Control SFE + Standard-length 95.8% (1 failed) 1 yr: 23 (1.44 ± 0.72) implants)
(n = 24 I) implants (10 mm) (n = 24)
2 Shi et al. 2021 [42] 3 years Test Short implants (6 mm) 91.8% (6 failed) 3 yr: 61 (0.53 ± 0.35) IS: SS results (< short OSFE
(n = 67 I) (n = 67) implants) SC
Control OSFE + Standard-length 97.08% (1 failed) 3 yr: 61 (0.50 ± 0.30) MBL: No SS results
(n = 62 I) implants (8 mm) (n = 62)
Control OSFE + Standard-length 100% (0 failed) 3 yr: 70 (0.53 ± 0.28)
(n = 70 I) implants (10 mm) (n = 70)
3 Rossi et al. 2021 [43] 2 years Test Short implants (4 mm) 100% (0 failed) 1 yr: 12 (0.21 ± 0.35) IS: No SS results LWT + Graft + RCM
(n = 12 I) (n = 12) 2 yr: 12 (0.44 ± 0.37) MBL: No SS results FPDs
Control SFE + Standard-length 100% (0 failed) 1 yr: 10 (0.58 ± 0.44)
(n = 10 I) implants (10 mm) (n = 10) 2 yr: 10 (0.84 ± 0.68)
4 Nielsen et al. 2021 [3] 1 year Test Short implants (6 mm) 100% (0 failed) 1 yr: 20 (0.60 ± 0.17) IS: No SS results LWT + Graft + RCM
(n = 20 I) (n = 20) MBL: No SS results SC
Control SFE + Standard-length 100% (0 failed) 1 yr: 17 (0.51 ± 0.14)
(n = 17 I) implants (13 mm) (n = 17)
5 Esposito et al. 2019 5 years Test Short implants (5 mm) 97.2% (1 failed) 1 yr: 36 (1.16 ± 0.3) IS: No SS results LWT + Graft + RCM
[10] (n = 36 I) (n = 36) 5 yr: 35 (1.58 ± 0.38) MBL: SS results (< short SC and FPD
Control SFE + Standard-length 100% (0 failed) 1 yr: 37 (1.53 ± 0.59) implants)
(n = 37 I) implants (≤ 10 mm) (n = 37) 5 yr: 37 (2.11 ± 0.66)
6 Felice et al. 2019 [5] 5 years Test Short implants (6 mm) 95.5% (2 failed) 1 yr: 39 (1.41 ± 0.31) IS: No SS results LWT + Graft + RCM
(n = 39 I) (n = 39) 5 yr: 37 (1.93 ± 0.54) MBL: SS results (< short SC and FPD
Control SFE + Standard-length 100% (0 failed) 1 yr: 44 (1.53 ± 0.29) implants)
(n = 44 I) implants (≤ 10 mm) (n = 44) 5 yr: 44 (2.28 ± 0.46)
7 Felice et al. 2019 [44] 5 years Test Short implants (5 mm) 91.2% (3 failed) 1 yr: 34 (1.06 ± 0.53) IS: No SS results LWT + Graft + RCM
(n = 34 I) (n = 34) 5 yr: 31 (1.65 ± 0.63) MBL: SS results (< short SC
Control SFE + Standard-length 97.4% (1 failed) 1 yr: 38 (1.43 ± 0.47) implants)
(n = 38 I) implants (≤ 10 mm) (n = 38) 5 yr: 37 (2.10 ± 0.52)
8 Guljé et al. 2019 [45] 5 years Test Short implants (6 mm) 94.7% (1 failed) 1 yr: 21 (0.10 ± 0.20) IS: No SS results LWT + Graft
(n = 21 I) (n = 21) 5 yr: 20 (0.12 ± 0.36) MBL: No SS results SC
Control SFE + Standard-length 100% (0 failed) 1 yr: 20 (0.04 ± 0.33)
(n = 20 I) implants (11 mm) (n = 20) 5 yr: 20 (0.14 ± 0.63)
9 Thoma et al. 2018 5 years Test Short implants (6 mm) 98.5% (1 failed) 5 yr: 55 (0.45 ± 0.79) IS: No SS results LWT + Graft + RCM
[13] (n = 60 I) (n = 60) MBL: No SS results SC
Control SFE + Standard-length 100% (0 failed) 5 yr: 56 (0.45 ± 0.91)
(n = 64 I) implants (11–15 mm) (n = 64)
10 Bolle et al. 2018 [16] 1 year Test Short implants (4 mm) 91.9% (3 failed) 1 yr: 34 (0.63 ± 0.15) IS: No SS results LWT + Graft + RCM
(n = 37 I) (n = 37) MBL: No SS results SC and FPD
Control OSFE + Standard-length 82.9% (7 failed) 1 yr: 35 (0.72 ± 0.25)
(n = 41 I) implants (10 mm) (n = 41)
Clinical Oral Investigations (2022) 26:6681–6698
 Table 2  (continued)
Nº Author Follow-up Group Treatment modality Implant survival Marginal bone loss Summary results Sinus surgery and restora-
(%) n (m ± SD) tion

11 Bechara et al. 2017 3 years Test Short implants (6 mm) 100% (0 failed) 1 yr: 45 (0.146) IS: No SS results LWT + Graft
[2] (n = 45 I) (n = 45) 3 yr: 44 (0.201) MBL: SS results (< short SC and FPD
implants)
Control SFE + Standard-length 95.6% (2 failed) 1 yr: 43 (0.201)
(n = 45 I) implants (≤ 10 mm) (n = 45) 3 yr: 43 (0.273)
12 Gastaldi et al. 2017 3 years Test Short implants (5–6 mm) 100% (0 failed) 1 yr: 16 (0.78 ± 0.16) IS: No SS results OSFE/
[4] (n = 16 I) (n = 16) 3 yr: 16 (0.96 ± 0.21) MBL: No SS results LWT + Graft + RCM
Control SFE + Standard-length 100% (0 failed) 1 yr: 18 (0.95 ± 0.24) SC
(n = 18 I) implants (10 mm) (n = 18) 3 yr: 14 (1.15 ± 0.30)
13 Shi et al. 2019 [22] 1 year Test Short implants (6 mm) 100% (0 failed) 1 yr: 74 (0.51 ± 0.23) IS: No SS results OSFE
(n = 75 I) (n = 75) MBL: No SS results SC
Clinical Oral Investigations (2022) 26:6681–6698

Control OSFE + Standard-length 100% (0 failed) 1 yr: 70 (0.47 ± 0.43)

(n = 75 I) implants (8 mm) (n = 75)
Control OSFE + Standard-length 100% (0 failed) 1 yr: 73 (0.52 ± 0.26)
(n = 75 I) implants (10 mm) (n = 75)
14 Schincaglia et al. 1 year Test Short implants (6 mm) 100% (0 failed) 1 yr: 65 (0.39 ± 0.62) IS: No SS results LWT + Graft + RCM
2015 [9] (n = 67 I) (n = 67) MBL: No SS results SC
Control SFE + Standard-length 100% (0 failed) 1 yr: 69 (0.22 ± 0.32)
(n = 70 I) implants (11–15 mm) (n = 70)

IS, implant survival; MBL, marginal bone loss; I, implants; SFE, sinus floor elevation; SS, statistically significant; OSFE, osteotome-mediated sinus floor elevation; SC, single crown; LWT, lat-
eral window technique; RCM, resorbable collagen membrane; FPD, fixed partial denture.

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probing depth was measured, only Magdy et al. [1] found than the control group. In addition, it has been previously
significant differences, but within each study group when reported that short implants could be a simpler, cheaper,
different follow-up periods were compared. The level of and faster alternative inducing less morbidity when com-
patient satisfaction was significantly higher in those cases pared to standard-length implants placed after sinus eleva-
treated with short implants, as Felice et al. [5] and Shi et al. tion, if they could provide similar success rates [10].
[22] stated. When comparing both techniques, mucositis and One of the former studies with short implants reported
peri-implantitis were not different throughout the fourteen 100% survival rate with no implant failures in the group of
revised papers. Pain and swelling were reported in 14 out short implants, after 3 years of follow-up [2]. Patients lost
53 patients in Bechara et al. [2], and swelling significantly an average of 1.02 mm of MBL around short implants and
appeared more frequently in the group of the standard-length 1.54 mm around standard-length implants. A mean crestal
implants, as published by Magdy et al. [1]. More complica- bone loss of more than 1.5 mm after the first year of function
tions were reported in patients with standard-length implants and a MBL higher than 0.2 mm per year were considered
[1–3, 5]. as threshold values to determine implant success [9, 48]. In
one of the analyzed papers [1], it has been recently reported
that MBL is significantly lower in ultrashort (5.5 mm)
Discussion implants comparing to standard-length implants (10 mm),
after 12 months of follow-up period. However, in this study,
This systematic review and meta-analysis was aimed to three short implants failed, in contrast to the standard-length
identify the most reliable scientific information in regard implants group, where only one implant failed (Table 2).
to the implant survival (IS) and the MBL comparing short Even shorter implants were analyzed by Esposito et al. [10]
implants (≤ 6 mm) to standard-length implants (≥ 8 mm) obtaining lower MBL (0.5 mm less in short implants). In
performing sinus lift techniques. Attained results support this study, 5 × 5 mm (ultrashort) implants were placed and
that short dental implants (≤ 6 mm) promoted less MBL loaded after a follow-up of 5 years, only one failed of a test
than standard-length dental implants (> 6 mm) used in implant was reported (Table 2).
cases of posterior atrophic maxilla that required lateral Any observed bone loss may be influenced by several
sinus lifting (Figs. 5a and 5b). When comparing MBL, factors in addition to the length of the implant, including
the funnel plot (Fig. 6) shows an asymmetric distribution implant’s geometry and design, surface configuration, crown
of the included studies, which tend to be placed in the fixation system, and surgical preparation [1]. Implants with
upper side of the vertical axis. It is speculated that the a platform switching connection show significantly less
lack of precision in studies with non-significant results MBL compared to implants with a butt joint connection
may be the reason for this behavior. The average 0.11 mm [49]. Micro-threaded design in the most coronal aspect of
(≤ 1 year of follow-up) and 0.23 mm (> 1 year of follow- the implant or extended to the neck of the implant leads
up) of differences between groups was statistically sig- to improved MBL. On the contrary, it has been stated that
nificant, though it may have a slight clinical significance. tissue level implants with smooth neck can lead to low peri-
Therefore, the null hypothesis must be partially accepted. implant rates, though sandblasting plus acid-etched surface
Fourteen RCT studies comprised the present research. A may also have influenced [22]. The fluoride-modified micro-
total of 901 implants in 616 patients have been analyzed. rough implant surfaces may play a role in providing a sta-
Previously, similar objectives were proposed, but only ten ble MBL [9]. The machined surface (1.5 mm in ultrashort
RCTs with 775 patients [46] and seven RCTs involving implants) [1] is advocated as one of the proposed causes
310 participants [20] were analyzed in both systematic for the decreased marginal bone loss [50]. Rough surface
review and meta-analysis, respectively. The control group, and wide diameter achieve higher bone-to-implant contact.
in our research, included three studies where OSFE and Moreover, implant stress significantly raises with implant
SC were performed. Bone graft was employed in studied length [51]. It has been assumed that an increased crown-
patients of two papers. Bone graft and resorbable collagen to-implant ratio might also create loading forces that could
membrane were used in patients analyzed of in nine of the affect marginal bone stability [9]. Recently, it has been
tested papers. stated that a higher crown-to-implant ratio is not associated
Measurements of MBL have been utilized trying to ana- with increased risk of MBL [3]. Thereby, long-term study
lyze the long-term performance of dental implants [9], is needed to confirm the favorable design for predictability
and it is a generally accepted parameter to assess the bone of short implants in the posterior maxilla. Another reason
response around dental implants [47]. To guarantee long- that can make the interpretation of results difficult is the
term clinical service, the maintenance of a stable MBL fact that authors can consider the bone level at the implant
becomes critical when short implants are used. Yan et al. placement as reference, instead of considering the bone level
[20] also obtained significantly less MBL at any follow-up at the restoration placement [45]. Surgeon’s experience may

13
Clinical Oral Investigations (2022) 26:6681–6698 6689

Fig. 2  Assessing risk of bias in included studies by Robins-II Tool. The risk of bias of the included studies were judged as low (green), some
concerns (yellow), or high (red)

Fig. 3  Forest plot for standard implants with sinus lift elevation ity was determined using Higgins (I2). In all the analysis, a random-
(control group) versus short implants (test group) when comparing effects model was applied. Statistical significance was set at 0.05
implant survival. Weighted mean is presented at CI 95%. Heterogene-

also condition the clinical outcomes of the different treat- It is important to emphasize that a hypothetical bone loss
ment options [22]. Nevertheless, other papers revised in the of 2 mm around a 6 mm length is a clinical scenario which is
present research did not find significant differences when not comparable to a 2 mm of bone loss around a 10–12 mm
both groups were compared within similar RCTs [4, 16, 22] implant in terms of chance to re-create the lost tissues. In the
(Table 2). first case, the bone-to-implant contact is relatively limited

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6690 Clinical Oral Investigations (2022) 26:6681–6698

Fig. 4  Funnel plot graph

illustrating the publication bias
and the systematic heteroge-
neity of the included studies.
The standard error (SE) is
represented in the vertical axis
and the implant survival in the
horizontal axis. The heterogene-
ity was considered low for the
implant survival (I2 = 0%), so
funnel plot did not show asym-
metry, indicating the absence of
publication bias

Fig. 5  Forest plot for standard implants with sinus lift elevation follow-up. Weighted mean is presented at CI 95%. Heterogeneity was
(control group) versus short implants (test group) when comparing determined using Higgins (I2). In all the analysis, a random-effects
marginal bone loss. a One year of follow-up; b more than 1 year of model was applied. Statistical significance was set at 0.05

(one-third) in comparison with the second case (one-fifth). biofilm, the higher prevalence of biological complications,
Even more, before assessing prognosis, several clinical fac- splinted or non-splinted implants, and data concerning oral
tors should be considered such as, for instance, the indi- hygiene. All these features are gathered in the Implant Dis-
vidual susceptibility underlying the host response to the ease Risk Assessment (IDRA) [52], where are referred the

13
Clinical Oral Investigations (2022) 26:6681–6698 6691

Fig. 6  Funnel plot graph

illustrating the publication bias
and the systematic heterogene-
ity of the included studies. The
standard error (SE) is repre-
sented in the vertical axis and
the marginal bone loss in the
horizontal axis. The heterogene-
ity was considered high for the
marginal bone loss (I2 = 78%
and I2 = 74%), so funnel plot
shows asymmetry. The main
reason of the asymmetry
encountered could be due to the
difference in the sample size of
the included studies

history of periodontitis, the percentage of tooth and implant been stated that 10-mm implants combined with osteotome
sites with BOP, the number of tooth and implant sites with sinus floor elevation showed more favorable implant survival
PD ≥ 5 mm, factors of radiographic bone loss in relation in comparison with short-6-mm implants [42]. In contrast,
to age, the periodontitis susceptibility, the compliance of recent systematic reviews have reported that short and long
patients with supportive periodontal therapy, distance from dental implants have the same survival probability [1, 4, 13].
the restorative margin to the bone crest, and factors related Several clinical studies have also confirmed similar survival
to the implant-supported prosthesis. Additionally, the short- rate between both groups [2, 9], tough Karthikeyan et al.
coming of determining the overall patient’s risk, not only the [56] reported survival rates of 80–90% for implants ≤ 7 mm
2 mm bone loss, based only on the targeted 6-mm implant in a systematic review. The possible reasons for the incon-
should be realized. In this aspect, the adhesion to an ade- sistency could be that the study population and implant sys-
quate maintenance care program has been shown to be cru- tems varied in different clinical trials [42].
cial to preserve the obtained results in the long-term [53]. Concerning restoration (Table 2), if short implants were
Moreover, further evidence about the impact of additional splinted or not should also be reported, as interconnected
clinical aspects which were not included in the IDRA tool suprastructure does provide additional stability, influencing
on the occurrence of biological complications and implant the clinical performance. Single units offer a more com-
failure is required. fortable prosthetic approach, but transmitted more stress to
Regarding the survival rate of short implants, the present restoration margins, whereas in splinted restorations, stress
research has shown that implant length has no influence on is mostly distributed to the implant neck [57]. Stress lev-
implant survival, in concomitance with Yan et al. [20]; there- els in the bone tissue surrounding splinted implants were
fore, the null hypothesis must be partially rejected. It has markedly lower than stress levels surrounding uncoupled
been postulated that implant survival in short implants to be implants by a factor of nearly [51, 58]. In the present sys-
comparable to standard-length implants [54], though based tematic review and meta-analysis, nine out fourteen papers
on mid-term data, shorter dental implants rendered high used single crown for restoration. The implant survival,
implant survival rates [55] and less morbidity [13]. Never- in this case, ranges from 100% [3, 4, 9, 22] until 87% [1].
theless, contradictory outcomes may be found in the litera- Only one research utilized fixed partial denture, with a IS of
ture. On the one hand, it has been reported [46] that short 100% [43]. The rest (four manuscripts) placed single crowns
implants exhibit lower predictability regarding survival rates and fixed partial dentures (Table 2), with a IS ranging from
when compared to longer implants (> 6 mm) after a follow- 97.2% [10] until 82.9% [16].
up period ranging between 1 and 5 years. Similarly, it has

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 Table 3  Summary of secondary outcomes collected from included studies
6692

Author Implant diam- Implant Implant BBT BoP PPD (mm) Surgical time Patient satis- MUC/PI Pain and Complications
eter (mm) surface stability (ISQ) faction swelling

13
n ± SD

Magdy et al. 4.0/4.5/5 NR No SS results No SS results NR Test: NR NR NR Pain: No SS Test:

2021 [1] SS results results 0
between 4 Swelling: Control:
and 12 m SS results 1
follow-up (> standard)
Control:
SS results
between 4
and 12 m
follow-up
Shi et al. 2021 4.1/4.8 SLA: sand- Test: NR Test: Test: Test < Control Test > Control MUC NR NR
[42] blasted and T1: 69.6 ± 6.3 16.54% 3.03 ± 0.78 Test:
acid-etched T2: 72.1 ± 5.7 Control 1: Control 1: 18 I
Control 1: 22.45% 3.19 ± 0.67 Control 1:
T1: 68 ± 5.4 Control 2: Control 2: 21 I
T2: 71.9 ± 3.9 15.48% 3.04 ± 0.75 Control 2:
Control 2: No SS results No SS results 13 I
T1: 71.8 ± 4.9 PI
T2: 73.6 ± 5.2 Test:
2I
Control 1:
2I
Control 2:
1I
Rossi et al. 4.1 SLA: sand- NR NR Test: Test: NR Test > Control NR NR NR
2021 [43] blasted and 25% ≤4
acid-etched Control: Control:
10% ≤4
No SS results No SS results
Nielsen et al. NR OsseoSpeed: NR NR Test: Test: NR NR NR Pain and Biological
2021 [3] chemically 24% 2.4 ± 0.5 swelling in complication
modified Control: Control: 4 patients (> standard)
with fluor 22% 2.5 ± 0.6 SS results
No SS results No SS results
Esposito et al. 5 Xpeed: sand- NR NR NR NR NR NR MUC NR Membrane
2019 [10] blasted and Test: perforation
acid-etched 0I and chipping
(SLA) + cal- Control: prosthesis
cium ions 1I (> standard)
Clinical Oral Investigations (2022) 26:6681–6698
 Table 3  (continued)
Author Implant diam- Implant Implant BBT BoP PPD (mm) Surgical time Patient satis- MUC/PI Pain and Complications
eter (mm) surface stability (ISQ) faction swelling
n ± SD

Felice et al. 4 SInergy: blast- NR NR NR NR NR Test > Control PI NR Membrane

2019 [5] ing with SS results Test: perforation
alumina and 2I and chipping
cleaning Control 1: prosthesis
with inert 0I (> standard)
solvents
Felice et al. 6 RBM: NR NR NR NR NR NR PI NR Membrane per-
2019 [44] HA blasting Test: foration and
and soft 1I decementation
Clinical Oral Investigations (2022) 26:6681–6698

etching Control: (> short)

0I
Guljé et al. NR OsseoSpeed: NR NR Test: Test: NR Test: MUC NR Test:
2019 [45] chemically 0% 2.8 ± 1.0 9.4 ± 0.8 Test: 4
modified Control: Control: Control: 22.2% Control:
with fluor 0% 3.3 ± 0.8 9.2 ± 0.8 Control: 1
No SS results No SS results No SS results 47.42%
Thoma et al. 4 OsseoSpeed: NR NR Test: Test: NR No SS results MUC NR Test:
2018 [13] chemically 40.9% 3.0 ± 1.0 Test: 21
modified Control: Control: 40.9% Control:
with fluor 50% 3.0 ± 0.8 Control: 50% 14
No SS results No SS results PI
Test:
2%
Control:
0%
Bolle et al. 4/4.5 SA2: sand- NR NR NR NR NR NR NR NR Test:
2018 [16] blasting and 4
etching Control:
12
Bechara et al. 4/4.5/5/ > 5 Xpeed: sand- Test: NR NR NR Test < Control No SS results NR Pain and Test:
2017 [2] blasted and T1: 68.2 SS results swelling in 0
acid-etched T3: 71.6 14 patients Control:
(SLA) + cal- Control: (standard) 19
cium ions T1: 67.8 SS results
T3: 72.4
SS results at
T3

13
6693
 Table 3  (continued)
6694

Author Implant diam- Implant Implant BBT BoP PPD (mm) Surgical time Patient satis- MUC/PI Pain and Complications
eter (mm) surface stability (ISQ) faction swelling

13
n ± SD

Gastaldi et al. 5 Osseotite: NR NR NR NR NR NR MUC NR Test:

2017 [4] dual acid- Test: 2
etching 0I Control:
method Control: 1
1I No SS results
Shi et al. 2019 3.3/4.1/4.8 SLA: sand- Test: NR Test: Test: Test: Control < Test NR No SS results NR
[22] blasted and T1: 69.6 ± 6.3 14.2% 3.0 ± 0.57 13.6 ± 2.2 SS results:
acid-etched T2: 72.1 ± 5.7 Control 1: Control 1: Control 1: discomfort
Control 1: 23.2% 2.9 ± 0.50 19.4 ± 3.7 No SS results:
T1: 68 ± 5.4 Control 2: Control 2: Control 2: general over-
T2: 71.9 ± 3.9 19.2% 3.0 ± 0.59 18.3 ± 4.3 view
Control 2: No SS results No SS results SS results
T1: 71.8 ± 4.9
T2: 73.6 ± 5.2
Schincaglia 4 OsseoSpeed: NR NR Test: Test: NR NR NR NR NR
et al. 2015 chemically 53% 2.8 ± 0.9
[9] modified Control: Control:
with fluor 38% 2.3 ± 1.4
SS results No SS results

ISQ, implant stability quotient; BBT, buccal bone thickness; BoP, bleeding on probing; MUC, mucositis; PI, peri-implantitis; NR, not reported; SS, statistically significant; PPD, probing pocket
depth; ISQ 1, ISQ implant placement; ISQ 2, ISQ impressions; ISQ 3, ISQ 3 years; HA, hydroxyapatite.
Clinical Oral Investigations (2022) 26:6681–6698
Clinical Oral Investigations (2022) 26:6681–6698 6695

Implant diameters, in the present research, ranged from as reported by previous studies [29, 30, 41] (Table 3). Shi
3.3 [42] to 6 mm [5]. Differences in implant diameter intro- et al. [22] described a ⁓30% lower surgical time with short
duced heterogeneity among studies with respect to MBL. implants than with standard implants. In general terms, the
Buccal bone thickness has been considered a secondary patient satisfaction was higher when short implants were
outcome in the clinical performance of implants, and it is used. Significantly less intra-operative discomfort was
usually measured during implant surgery at several dis- found in the patients with short implants, as Felice et al.
tances from the implant shoulder [1]. BBT was higher in [5] reported. This might indicate that short implants option
the standard-length group than in the short implants group at resulted to be more attractive due to the high cost-effec-
12 months follow-up. Interestingly, ultrashort and standard- tiveness and patient satisfaction during the surgery, as pub-
length implants exhibited an increase in buccal bone thick- lished by some other previous studies [39, 41]. At a whole,
ness at the 0-, 2-, and 4-mm level, when comparing base- complications, such as membrane perforation, mucositis,
line to the follow-ups [1]. Probing depth was measured by chipping prostheses, prostheses screws, and prostheses
Magdy et al. [1] twice, from the gingival margin to the base decementation, occurred more sparingly in patients treated
of the peri-implant sulcus. When PD of short implants were with short implants [2, 3, 5, 10, 20, 44]. Implant migra-
analyzed, significant differences, mesially and distally, were tion into the sinus, often with the co-occurrence of sinus
obtained between 4- and 12-month follow-ups. Nevertheless, infection, has a higher prevalence in the elevation group
any significant difference between both groups appeared, [20]. Only one case in the standard-length group showed
denoting stability of the biological soft tissue seal around all postoperative complications (benign paroxysmal positional
implants [1]. The rest of the analyzed articles did not show vertigo), which improved within 6 weeks, in Magdy et al.
significant differences in PD when compared, or data were [1]. Shorter implants are more prone for technical complica-
not reported (Table 3). tions and should therefore be monitored more closely after
Bleeding on probing showed a statistically significant loading [13], emphasizing in peri-implant health status and
difference between the groups with a higher number of sub- establishment of a balanced functional occlusion combined
jects in the group of short implants. Shi et al. [42] reported with a regular oral hygiene maintenance program [3]. Nev-
18 cases of mucositis and 2 of peri-implantitis in the test ertheless, as a whole, the augmentation procedure is also
(short implants) group, and 34 cases of mucositis and 3 of far more technically demanding than placing short implants
peri-implantitis in the control (standard-length implants) [36]. In general terms, the outcomes of the present study
group. No case of mucositis was found in the test group suggest that both treatments are viable treatment options
and only one in the control group, in Gastaldi et al. and that produce acceptable clinical and radiological outcomes.
Esposito et al. [4, 10]. By contrast, one [5] and two cases Short implants show the advantages of reduced postopera-
[44] of peri-implantitis were found in the test group and tive discomfort, minimal invasiveness, reduced treatment
none in the control group. Mucositis was also assessed in time, and decreased cost [1].
Guljé et al. [45], who reported its presence in ⁓22% of short One of the most remarkable limitations of the present
implants and ⁓47% of standard-length implants. Mucositis study is the small sample size of the analyzed studies and
was diagnosed in around 50% of short and standard-length the common short-term follow-up, 12 months in most of
implants in Thoma et al. [13], and peri-implantitis was pre- the studies [16], though some of them showed 5 years of
sent in 2% of short implants and absent in standard-length follow-up period after loading [10, 44]. Hence, long-term
implants [13]. studies are recommended to evaluate the short implants and
Bechara et al. [2] found that, at 3 years, short implants the long-term prognosis, as reliable evidence on survival
showed a significantly higher mean implant stability quotient will depend on larger studies [1]. Limitations also include
than the standard-length group (72.4 vs. 71.6). Nevertheless, the difficulty to assess the risk of bias in several studies. The
implant stability measurements (mesiodistal and buccolin- survival and success of short implants placed in severely
gual) across the follow-ups showed no significant differ- resorbed jaws should not be compared with those of longer
ence between the two treatment groups, confirming that the implants placed in adequate native bone but rather with the
application of sinus elevation did not have any influence on outcome of implants placed in grafted sites [51]. MBL has
implant stability regardless of the implant length [1, 8]. Pain been calculated on panoramic radiographs. This represents
scores, between treatment groups at all follow-up periods, a limit of the present study, as panoramic radiographs are
were not statistically significant; swelling scores were higher per se subject to a certain degree of distortion. Cone beam
in the standard-length group at 2, 3, and 5 days [1]. Swelling computed tomography (CBCT), instead of 2D X-rays, could
was also detected in 14 out of 45, in Bechara et al. [2], and be a better way to evaluate the radiographic outcomes during
in 4 patients out of 17, in Nielsen et al. [3], in both standard- the observation period [22]. Nevertheless, some authors [53]
length groups. Surgical time was significantly higher in the supported that both clinical and radiographic measurements
control group, ⁓32 min [2], than in the test group, ⁓19 min, did not follow a calibration session. They pointed out that

13
6696 Clinical Oral Investigations (2022) 26:6681–6698

data analysis did not allow generalizability to a population- Acknowledgements The authors are grateful to Pablo Ramos-García
based setting through a statistical examination [59]. Addi- (University of Granada) for the statistical support during the investiga-
tion process.
tional variables, such as patients’ oral hygiene habits, alco-
hol intake, periodontal status, and smoking status, should Author contribution MT: conceptualization; methodology; project
be considered for future studies. At present, only partially administration; supervision; validation; writing — original draft,
edentulous patients were included and a generalization of review and editing.
the results and recommendations for the use of shorter den- EF-R: data curation; formal analysis and investigation; methodol-
ogy; writing — review and editing.
tal implants are limited to the present clinical indication. CV: data curation; formal analysis and investigation; methodology;
Nevertheless, the present study has several strengths: (i) it writing — review and editing.
has been conducted a comprehensive literature search, and RT: investigation; writing — review and editing.
all included studies were RCTs, to accommodate the high- MTO: investigation; writing—review and editing.
MV-R: data curation; formal analysis and investigation; supervi-
est level of evidence and to add additional strength to the sion; methodology; writing — review and editing.
findings; (ii) subgroup analysis by follow-up length was
performed to reduce bias across studies; and (iii) the risk Funding Funding for open access charge: Universidad de Granada /
of bias was low. CBUA This research was funded by the Ministry of Economy and
In order to get centered in the main goal of the present Competitiveness (MINECO) and the European Regional Development
Fund (FEDER), grant number (PID2020-114694RB-I00 MINECO/
manuscript, a lack of reported biological complications com- AEI/FEDER/UE).
prising implant longevity associated to peri-implantitis [60]
has been detected. Peri-implantitis has been defined as a Data availability The data presented in this study are available on
plaque-associated pathological condition occurring in tis- request from the corresponding author.
sues around dental implants, characterized by inflammation
in the peri-implant mucosa and subsequent progressive loss Declarations
of supporting bone [59, 61] which can lead to the implant
loss. It has been recommended [60] that before comparing Ethics approval Not applicable.
biological complications of implants placed in native vs. Consent to participate Not applicable.
augmented bone, the prevalence of peri-implantitis and the
warnings of its interpretation should be discussed. Other Conflict of interest The authors declare no competing interests.
biological complications such as the presence of titanium
particles in the peri-implant soft tissues should also be Open Access This article is licensed under a Creative Commons Attri-
addressed when some procedures, as implantoplasty, are bution 4.0 International License, which permits use, sharing, adapta-
going to be implemented [62]. tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
One of the main limitations of the present systematic provide a link to the Creative Commons licence, and indicate if changes
review and meta-analysis has been the incomplete infor- were made. The images or other third party material in this article are
mation obtained about implant diameters, designs, type of included in the article's Creative Commons licence, unless indicated
bone grafts, and other secondary outcomes, leading to the otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
impossibility of creating subgroups which would increase permitted by statutory regulation or exceeds the permitted use, you will
and complete our data analysis. need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.

Conclusions
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(<10 mm) effective? A meta-analysis on prospective clinical jurisdictional claims in published maps and institutional affiliations.

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