Tilted Implants For The Rehabilitation Of Edentulous Jaws .
Tilted Implants for the Rehabilitation ofEdentulous Jaws: A Systematic Reviewcid 288612.621Massimo Del Fabbro, BSc, PhD;* Chiara M. Bellini, MSEng;† Davide Romeo, DDS, PhD;‡Luca Francetti, MD, DDS§ABSTRACTPurpose: The aim of this review was to evaluate the survival rate of upright and tilted implants supporting fixed prostheticreconstructions for the immediate rehabilitation of partially and fully edentulous jaws, after at least 1 year of function.Materials and Methods: An electronic search of databases plus a hand search on the most relevant journals up to December2009 was performed. The articles were selected using specific inclusion criteria, independent of the study design.Results: The literature search yielded 347 articles. A first screening based on the title and abstract identified 25 eligiblestudies. After full-text review of these studies, 10 articles were selected for analysis. Seven were prospective single-cohortstudies and three had a retrospective design. A total of 462 patients have been rehabilitated with 470 immediately loadedprostheses (257 in the maxilla, 213 in the mandible), supported by a total of 1,992 implants (1,026 upright and 966 tilted).Twenty-five implants (1.25%) failed in 20 patients within the first year. All failures except one occurred in the maxilla. Nosignificant difference in failure rate was found between tilted and upright implants, nor between maxillary and mandibularimplants. No prosthesis failure was reported. Limited peri-implant bone loss was reported with no difference betweenupright and tilted implants. Full patients’ satisfaction for function, phonetics, and esthetics was reported in three studies,based on questionnaires.Conclusions: The use of tilted implants to support immediately loaded fixed prostheses for the rehabilitation of edentulousjaws can be considered a predictable technique, with an excellent prognosis in the short-medium term. However, randomized long-term trials are needed to determine the efficacy of this surgical approach.KEY WORDS: dental implants, immediate loading, mandible, maxilla, tilted implantsINTRODUCTIONjaws. The long-established Brånemark protocol recommended the implants to be placed in an upright position, often resulting in a distal cantilever length of even20 mm.1–3 This may lead to high bending moments andhigh stress levels at both the implants and the surrounding bone,4 which in turn may sustain marginal boneresorption, thus compromising implant survival.5 Amatter to face with when inserting dental implants in anatrophic edentulous mandible is the presence of themandibular nerve. In this instance, bone grafting andother regenerative procedures could represent a solutionin order to increase bone volume prior to implant placement. However, these types of intervention are poorlyaccepted by patients. With regard to the maxilla, successrates can be significantly different with respect to themandible.6 The rehabilitation of the edentulous maxillawith osseointegrated implants is often associated withseveral problems. In many cases, sufficient alveolar crestvolume is found in the anterior region, while in thepremolar and molar region, severe bone resorption canImplant-supported fixed prostheses represent today acommon treatment for the rehabilitation of edentulous*Researcher, Head of Section of Oral Physiology, Department ofHealth Technologies, Center of Research in Oral Implantology, University of Milano, Milan, Italy, and IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; †IRCCS Istituto Ortopedico Galeazzi, Milan, Italy;‡dental clinician, Department of Health Technologies, Center ofResearch in Oral Implantology, University of Milano, Milan, Italy, andIRCCS Istituto Ortopedico Galeazzi, Milan, Italy; §professor, head ofthe Center of Research in Oral Implantology, Department of HealthTechnologies, Center of Research in Oral Implantology, University ofMilano, Milan, Italy, and IRCCS Istituto Ortopedico Galeazzi, Milan,ItalyReprint requests: Prof. Massimo Del Fabbro, Department of HealthTechnologies, Istituto Ortopedico Galeazzi, University of Milan, ViaR. Galeazzi 4, 20161 – Milano, Italy; e-mail: massimo.delfabbro@unimi.it 2010 Wiley Periodicals, Inc.DOI 10.1111/j.1708-8208.2010.00288.x612
Literature Review of Tilted Implantsoccur as a consequence of tooth loss.7 The presenceof the maxillary sinus and a limited ridge dimensionmust also be considered when placing implants in thisregion.8,9 During the past decades, various alternativeclinical procedures have been proposed to placeimplants in the posterior atrophic maxilla; one of themis the maxillary sinus augmentation procedure. In spiteof the excellent outcomes of this procedure,10–13 it isassociated with several possible complications like morbidity at the donor site, sinusitis, fistulae, loss of the graftor the implants, and osteomyelitis. Grafting proceduresare generally demanding for both clinicians and patientsand are often associated with increased surgical risksand financial cost as well. Another alternative therapeutic option in case of limited available bone is representedby the use of implants of reduced length.14,15 However, inthe posterior maxilla, a minimum ridge height of 6 to7 mm should be present for a safe placement of implantsshorter than 8 mm. On the other hand, in the case ofextremely atrophic posterior mandible, where superficialization of the alveolar nerve is often present, the useof short implants may be contraindicated because of therisk of violating the nerve.The adoption of tilted implants for the rehabilitation of both edentulous mandibles and maxillae hasbeen proposed in the recent years. In the mandible,tilting of the distal implants may prevent damage to themandibular nerve. In the edentulous maxilla, implanttilting is an alternative to bone grafting procedures.Implants of conventional length can be placed, allowingengagement of as much cortical bone as possible, thusincreasing primary stability.16 Furthermore, increasingthe interimplant distance and reducing cantileverlength, a better load distribution may be achieved.Several computational studies suggested possible biomechanical advantages of implant tilting in full-archrestorations.17–19Implant tilting associated with immediate loadingfor the treatment of partial and complete edentulism,especially in the presence of atrophic ridge, is progressively spreading among clinicians. The performance ofimmediately loaded dental implants supporting partialand full restorations has been evaluated in recent systematic reviews and meta-analyses.20–22 Such reviewsshowed that immediate implant loading does not impairtreatment success and pointed out the influence ofimplant micromorphology and patient selection on thetreatment outcomes.613The purpose of the present review was to evaluatethe prognosis of immediately loaded prostheses supported by both upright and tilted implants, after at least1 year of function. A further aim was to compare thesurvival rate of upright and tilted implants for theimmediate rehabilitation of partially and fully edentulous arches.MATERIALS AND METHODSSearch MethodsThe following electronic databases were searched:MEDLINE (with a time limit from 1990 to March 2009);Embase (from 1990 to December 2009); CochraneCentral Register of Controlled Trials (December 2009).Keywords such as “dental implant,*” “tilted implant,*”“angled implant,*” “angulated implant,*” “offsetimplant,*” “upright implant,*” “axial implant,*” “edentulous patient,*” “edentulous mandible,” “edentulousmaxilla,” “immediate loading,” and “immediate function” were used alone or in combination. Furthermore,the following journals in the field of implant dentistrywere hand-searched for further articles not detected bythe electronic search (from January 2000 to December2009): Clinical Implant Dentistry and Related Research,Clinical Oral Implants Research, Implant Dentistry, European Journal of Oral Implantology, International Journalof Oral and Maxillofacial Surgery, International Journal ofProsthodontics, Journal of Implantology, Journal of Oraland Maxillofacial Surgery, Journal of Periodontology,Journal of Prosthetic Dentistry, The International Journalof Oral & Maxillofacial Implants, The InternationalJournal of Periodontics & Restorative Dentistry. Finally,the authors of the included studies were contacted toknow whether further unpublished or ongoing studieswere available to be included in the present review.Inclusion CriteriaThe search was limited to studies involving human subjects. Restrictions were not placed regarding the studydesign and the language usage. Further inclusion criteriawere a minimum of 10 patients treated, loading appliedwithin 48 hours of implant surgery, a minimumfollow-up duration of 1 year, fewer than 10% patientslost during follow-up, survival rate for tilted and uprightimplants clearly indicated or calculable from dataprovided.Publications that did not meet the above inclusioncriteria and those that were not dealing with original
614Clinical Implant Dentistry and Related Research, Volume 14, Number 4, 2012clinical cases (eg, reviews, technical reports) wereexcluded. Multiple publications of the same pool ofpatients were also excluded from the database. Whenpapers from the same group of authors, with verysimilar databases of patients, materials, methods, andoutcomes were identified, the authors were contactedfor clarifying if the pool of patients was indeed the same.In case of multiple publications relative to consecutivephases of the same study, only the most recent data(those with the longer follow-up) were considered.dence intervals (CI). The statistical evaluation was conducted considering both the implant and the patient asthe analysis unit. Comparisons among studies were performed by meta-analysis. When sufficient homogeneitywas detected, RRs were combined using a randomeffects model. Pearson’s chi-square analysis was used toinvestigate the effect of implant location and angulationon the treatment outcome; p .05 was considered as thesignificance level.OutcomesThe electronic search yielded a total of 347 articles. Aftera first screening of the titles and abstracts, 24 articleswere selected, which reported results of clinical studiesin which edentulous patients have been rehabilitatedusing prostheses supported by upright and tiltedimplants. The results of two further unpublished studieswere provided by the authors of an included study. Afterexamining the full text of the 26 articles, 16 of them wereexcluded from the review (Table 1).3,16,23–36 Of the 10remaining articles, 7 reported the results of prospectivestudies and 3 of retrospective studies (Table 2).37–46 Themain outcomes of these studies are reported in Table 3.A total number of 1,992 implants, of which 11 (0.55%)with machined surface, were inserted in 462 patientsrehabilitated with 12 partial and 458 full fixed prostheses(257 in the maxilla, 213 in the mandible). Of the placedimplants, 1,026 were upright and 966 tilted.The following outcomes were extracted from each study,where available: type of study design; number ofpatients; gender; age; proportion of smokers; totalnumber of implants; number, type, and location of theprostheses; follow-up duration; number of tilted andupright implants; number of failed implants and details(time after loading, location, reason for failure); prosthesis success rate; bone loss around tilted and uprightimplants; soft tissue outcomes; occurrence of complications. The effect of implant location (maxilla ormandible) and angulation (tilted or upright) on the outcomes was evaluated.Statistical AnalysisThe estimates of the effects of an intervention wereexpressed as risk ratio (RR) together with 95% confi-RESULTSTABLE 1 Excluded Studies and Reasons for ExclusionExcluded StudiesMattsson, 199923Krekmanov, 20003Krekmanov, 200024Aparicio et al., 200116Aparicio et al., 200225Fortin et al., 200226Malò et al., 200327Koutouzis and Wenstrom, 200728Malò et al., 200729Rosén and Gynther, 200730Bedrossian et al., 200831Bilhan, 200832Khatami et al., 200833Testori et al., 200834Agliardi et al., 200935Pomares, 200936Reason for ExclusionDelayed loadingDelayed loadingDelayed loadingDelayed loadingDelayed loadingDelayed loadingInadequate reportInadequate report, delayed loadingInadequate report, redundant publicationDelayed loadingCase report (2 patients)Case report (1 patient)Case report (1 patient)Redundant publicationRedundant publicationInadequate report; delayed loading of some implants
121255 (33–82)13 (6–21)20 (4–35)22.4 (6–43)20 (13–28)27 (12–55)30.1 (20–48)12128189342921262481116168032 (128)44 (166)41 (246)18 (72)21 (126)–21 (111)61 (244)––9 (23)24 (96)5 (20)–62 (248)–93 (372)20 (80)12 partialand 7 fullFullFullFullFullFullFullFullFullFull–19 ProspectiveNR not o andTomatis, 200537Malò et al., 200538Malò et al., 200639Capelli et al., 200740Malò et al., 200741Agliardi et al., 200842Francetti et al., 200843Tealdo et al., 200844Agliardi et al., in press45Weinstein et al., in 863.0466.15NR42.8654.8447.6253.906064 (51–76) Heavy smokersexcluded55.1 (NR)NR52.2 (32–78)34.7859.2 (28–83)15.38NRNR58 (44–68)38.1056 (35–77)40.3258NR58 (35–80)27.860 (47–77)2061.1118Study TypeArticles38.89Men(%)No. ofPatientsTABLE 2 Characteristics of the Included StudiesWomen(%)AgeSmokers(%)No. ofImplantsNo. Maxillary No. )Type ofRestorationFollow-UpDuration, Months(Range)Literature Review of Tilted Implants615A total number of 25 implants (1.25%) failed in 20patients during the first year of function. The reason forfailure was infection (n 10, 40%) or lack of osseointegration (n 7, 28%), while for eight of them (32%) noreason was reported. Two implant failures were reportedto occur later than 1 year but before 18 months of function. Of the implants failed within 12 months, 11 wereupright and 14 tilted, and all but one were placed in themaxilla. Two of them had machined surface.37 One-yearimplant survival was 97.9% and 99.9% for the maxillaand the mandible, respectively. No prosthesis failure wasreported in any of the evaluated studies. Given such anoutcome, no further analysis was performed at prosthesis level.The results of the random effects meta-analyses forimplant failures at 1 year are presented as forest plot inFigures 1–4. Considering the outcome of tilted versusupright implants in both jaws, no significant difference(RR 1.46, 95% CI: 0.63, 3.39) and no heterogeneitywas found (Figure 1). No significant difference(RR 2.49, 95% CI: 0.64, 9.64) and no heterogeneitywas found when considering maxillary versus mandibular implants in the four studies that included both jaws(Figure 2). For this comparison, on a patient basis, nosignificant difference nor heterogeneity was found(RR 3.00, 95% CI: 0.79, 11.35) (Figure 3). As most ofthe failed implants were located in the maxilla, a furthermeta-analysis was conducted, excluding mandibularimplants. Again, no significant difference (RR 1.58,95% CI: 0.66, 3.78) and no heterogeneity was foundwhen considering maxillary tilted versus uprightimplants (Figure 4).Marginal bone level was reported separately forboth tilted and upright implants in seven trials (seeTable 3).37,40,42–46 Bone loss values were rather homogenous for both upright and tilted implants as well as formaxillary and mandibular implants, with the exceptionof Calandriello and Tomatis,37 where lower bone lossvalues for tilted implants were found, as compared withupright ones.Fracture of the temporary acrylic prosthesis andscrew loosening were the most common complicationsdescribed (see Table 3). No significant relation with thearch was found for these complications. Some authorsobserved wear patterns in the opposing dentition.41Most of patients that experienced prosthesis fracture orprosthetic screw loosening were reported as being bruxers38,40 or having a short face morphotype.43,45
0100NR100PSRUpright Tilted (%)FailuresNR not reported; PSR prosthesis success rate.4764124124Tealdo et al.,200844Agliardi et al.,in press45Weinsteinet al.,in press468442Agliardiet al., 200842Francettiet al., 20084346130212469664649327Tilted33UprightMalò et al.,200741Malò et al.,200639Capelli et al.,200740Calandrielloand Tomatis,200537Malò et al.,200538ArticlesInserted Implants0.9 1 0.5 (n 56)0.7 1 0.5 (n 60)0.7 1 0.4 (n 60)0.88 1 0.59 (maxilla;n 42); 0.75 1 0.55(mandible; n 32)0.34 1 0.76 (n 26)Tilted0.8 1 0.4 (n 28)0.95 1 0.44 (maxilla;n 84); 0.82 1 0.64(mandible; n 32)No details by implant typeNo details by implant typeNo details by implant type0.82 1 0.86 (n 32)UprightBone Loss, mm (n of Implants)Light ipoesthesia on the left side ofthe lower lip after surgery,resolved after 6 months(1 patient); fracture of the acrylicprosthesis (7 patients)None reportedFracture of acrylic resin completedenture (8 patients); abutmentscrew loosening (2 patients); 2implants in 2 patients presentedperi-implant pathologyNone reportedFracture of the acrylic bridge (1patient) that probably leads toimplant failureFracture of prosthesis in 4 bruxingpatients, of whom 2 werepatients who lost 1 implant eachProsthetic screw loosening in 6patients (bruxers)None reportedComplicationsMaxilla0.62 mesial (n 61); 0.860.92 mesial (n 61);distal (n 42)1.04 distal (n 42)Mandible (1) 0.9 1 0.7 (maxilla; n 204);0.9 1 0.7 (maxilla; n 204);Fracture of the acrylic prosthesismaxilla (4)1.2 1 0.9 (mandible; n 292)1.2 1 0.9 (mandible; n 292)(23 patients)–0.6 1 0.3 (n 36)0.7 1 0.4 (n 36)None ocationof FailedImplantsTABLE 3 Main Outcomes of the Included Studies after 1 Year of Function616Clinical Implant Dentistry and Related Research, Volume 14, Number 4, 2012
Literature Review of Tilted Implants617Review:Immediate loadingComparison: 02 tilted vs upright max mandOutcome:01 12-months implant survivalStudyor subcategoryMalò et al. 2005Malò et al. 2006Weinstein et al.*Calandriello 2005Capelli et al. 2007Malò et al. 2007Agliardi et al. 2008Francetti et al. 08Tealdo et al. 2008Agliardi et al.*Tilted implantsn/NUpright /3080/640/930/401/332/2121/460/420/1243/644/308RR (random)95% al (95% CI)Total events: 14 ( Tilted implants), 11 (Upright implants)22Test for heterogeneity: Chi 4.91, df 6 (P 0.56), I 0%Test for overall effect: Z 0.87 (P 0.38)100.00RR (random)95% CI7.00 [0.37, 132.83]4.85 [0.24, 99.59]Not estimable1.22 [0.08, 18.64]0.82 [0.07, 8.90]1.00 [0.06, 15.51]Not estimableNot estimable2.27 [0.57, 9.03]0.25 [0.03, 2.22]1.46 [0.63, 3.39]0.001 0.01 0.1110 100 1000favors tilted favors uprightFigure 1 Forest plot for the comparison between tilted and upright implants in both arches. (CI confidence interval; df degreesof freedom; RR risk ratio.)Plaque and bleeding scores progressively improvedduring the first year.42,43,45,46 High level of patients’ satisfaction for function, phonetics, and esthetics after 1 yearof loading was reported by a few studies.42,43,46DISCUSSIONIn this review, no statistically significant difference inimplant success was observed considering tilted versusupright implants. Because of the absence of randomizedcontrolled clinical studies, definitive conclusions cannotbe drawn on the efficacy of immediate rehabilitationsupported by a combination of upright and tiltedimplants. However, based on the available includedstudies, the present review suggests that the prognosis ofsuch therapeutic approach is excellent as only 1.25% ofthe implants was lost during the first year of loading,while only two failures were recorded thereafter. Suchvalue is in line with a previous sy
The adoption of tilted implants for the rehabilita-tion of both edentulous mandibles and maxillae has been proposed in the recent years. In the mandible, tilting of the distal implants may prevent damage to
tal implants OR 4 dental implants OR dental AND (tilted implants OR axial implants OR distal tilted implants OR distal angulated implants OR distal inclined implants OR distal angle implants OR axial dental implants OR axia-lly
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The term tilted implants refers to implants placed at an angle of normally 30 degrees or more with respect to axially or vertically positioned implants. According to many authors, the use of tilted implants in the posterior maxillary sector offers advantages over axial implants. The placement of
The use of tilted distal implants to avoid or redu-ce the length of the cantilevers showed a success rate of 98.7% over a total of 156 implants, 92 axial medial implants (100%) and 64 tilted distal implants (96.87%) NALDINI, P.; FERNANDEZ-BODEREAU, E. & BESSONE, L. Use of tilte
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