The Use Of Tilted Implant For Posterior Atrophic Maxilla
The Use of Tilted Implant for PosteriorAtrophic MaxillaEitan Barnea, DMD;* Haim Tal, PhD;† Joseph Nissan, DMD;‡ Ricardo Tarrasch, PhD;§Michael Peleg, DMD, PhD;¶ Roni Kolerman, DMD**ABSTRACTPurpose: To retrospectively analyze the influence of implant inclination on marginal bone loss at freestanding implantsupported fixed partial prostheses (FPPs) over a medium-term period of functional loading.Materials and Methods: Twenty-nine partially edentulous patients with freestanding FPDs supported by two implantsplaced in a two-stage procedure comprised the study group. The anterior implant was placed axially, and the posterior tilteddistally. Mesial or distal inclination of each implant was measured in relation to the vertical axis perpendicular to theocclusal plane. Average bone loss was compared between straight and tilted implants, smokers, and nonsmokers.Results: Mean angulation of the anterior axial-positioned implant was 3.45 degrees distally (range 0–8) and of the distalimplants was 32.83 degrees distally (range 20–50 degrees). Average bone loss after 1, 3, and 5 years was 0.89 (SD 0.73),1.18 (SD 0.74), and 1.50 (SD 0.81), respectively, for axial implants, and 0.98 (SD 0.69), 1.10 (SD 0.60) and 1.50(SD 0.67) for tilted implants, with no significant correlation between implant angulation and bone loss. A significantcorrelation between implant angulation and annual bone loss was obtained for tilted implants only (r 0.52,p .004).Using Albrektsson criteria, the success rate was 89.6% (26 out of 29 implants) for straight and 93.1% (27 out of29) for tilted implants.Conclusion: The study demonstrates no effect of implant angulation on peri-implant bone loss in the posterior maxilla.KEY WORDS: bone loss, tilted implantsINTRODUCTIONcritical determinant for successful implant placement issufficient height and width of the residual ridge of bone.Ideally, implants should be placed parallel to the otherone and to adjacent teeth and be aligned vertically withaxial forces. Rehabilitation of edentulous posteriormaxilla with endosseous implants is often associatedwith anatomic limitations, mainly loss of the alveolarbone and pneumatization of the maxillary sinus.1Although grafting the maxillary sinus is a common surgical intervention aimed to augment bone height priorto or simultaneous with the placement of endosseousdental implants, this procedure has disadvantages suchas increased morbidity, possible surgical complications,high cost, and a longer healing period of time.2 Alternative treatment options for fixed restorations of the atrophic posterior maxilla without bone grafting includeimplant-supported fixed partial denture with a distalcantilever, use of short implants, and implant placementin the zygoma or the tuberosity.3,4 Another option is theplacement of a distally tilted posterior implant immediately anterior to the maxillary sinus.4Dental implants have tremendously changed treatmentplanning for partially edentulous patients. However, a*Prosthdontist, Private Practice, Tel Aviv, Israel; †professor and head,Department of Periodontology and Dental Implantology, TheMaurice and Gabriela Goldschleger School of Dental Medicine, TelAviv University, Tel Aviv, Israel; ‡associate professor, Department ofOral Rehabilitation, The Maurice and Gabriela Goldschleger Schoolof Dental Medicine, Tel-Aviv University, Tel Aviv, Israel; §seniorteacher, School of Education and Sagol School of Neuroscience, TelAviv University, Tel Aviv, Israel; ¶professor of surgery and director,Residency Program and Oral Implantology and Implant Research,University of Miami Jackson Memorial Hospital, Miami, FL, USA;**lecturer, Department of Periodontology and Dental Implantology,The Maurice and Gabriela Goldschleger School of Dental Medicine,Tel-Aviv University, Tel Aviv, IsraelCorresponding Author: Dr. Roni Kolerman, Department of Periodontology and Dental Implantology, The Maurice and GabrielaGoldschleger School of Dental Medicine, Tel-Aviv University, MalcheiIsrael 17, Tel-Aviv 64389, Israel; e-mail: l 2015 Wiley Periodicals, Inc.DOI 10.1111/cid.123427881
2Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015 Tilted Implant for Posterior Atrophic MaxillaThe main advantage of tilted implant design (TID)is the extension of the fixed implant-connected prostheses further distally, thus reducing the length of cantileverwithout the need for sinus floor elevation procedure.4Using this technique, the posterior implant is usuallytilted along, anterior, and parallel to the anterior borderof the maxillary sinus, while the anterior implant isplaced perpendicular to the occlusal plane.4 The use ofTID may provide several clinical advantages: (1) Itenables the placement of longer implants, thus increasing bone-to-implant contact area and implant stability;(2) it creates a wider distance between the anteriorimplant and the posterior one resulting in improvedload distribution; and (3) it significantly reduces thedistal cantilever size or completely eliminates it. Theseadvantages simplify the surgical procedure and reducemorbidity, time, and cost, thus availing treatment to agreater number of patients.4The TID requires the use of angled abutments.Several studies have suggested that angled abutmentsresult an increased stress on the supporting implants andthe adjacent bone.5–10 This strain has been claimed toincrease with decreasing osseous density.7 It appears thatdespite a 3.0- and 4.4-fold stress increase on 15 and 25 angled abutments respectively, the stress on bone usuallyremain within physiological limits, compared withstraight abutments.7 In spite of the ample in vitro datathat exist regarding stress distribution using different implant angulations, bone density, and loading forces,6,8,9,11it is difficult to extrapolate this information to humans.Several articles addressed the survival rate ofimplants and prostheses involving the use of angledabutments.12–15 Most of the studies dealt with full archrestorations with but a few including partial archcases.4,13–18 All of these studies reported high implantsurvival rate, and three studies reported radiographicdata15,16,18 and a few related to prosthetic complications.13–15 Therefore, the purpose of present study was toanalyze the long-term effect of the inclination of functionally loaded implants on the marginal bone loss,based on clinical and radiographic findings. Prostheticcomplications were also recorded.MATERIALS AND METHODSCase SelectionThe study consisted of 29 consecutively treated patientswho met the inclusion criteria requiring restoration of789the posterior maxilla. Patients were treated during theyears 1996 to 2013 by the senior author (E.B.). Patientswere selected from a group that was initially consideredas candidates for posterior upper implant placementand sinus augmentation procedures. The opposingmandibular occlusal surfaces were natural teeth in 21(72.4%) patients or implant-supported fixed restorations in eight (27.6%). Each subject signed an informedconsent form regarding implant treatment, and adetailed explanation regarding the treatment and otheroptional treatments was given.The study was approved by the ethics committee ofTel-Aviv University.Exclusion criteria were as follows: uncontrolled diabetes, immune diseases, radiation therapy to the headand neck region, chemotherapy during 12 monthsbefore proposed implant placement, untreated pathologies in the anterior teeth, uncontrolled periodontaldisease, and psychological problems. Seventeen patientswho presented limited bone volume requiring heightand/or width augmentation to allow the placement oftwo implants in the posterior maxilla were excluded inthose a one- or two-stage lateral sinus elevation procedure was performed.Twenty-nine patients met the inclusion criteria.Ages varied between 40 and 83 years (Table 1). Eachpatient received two dental implants: The posterior onewas installed along the anterior sinus wall at anglesranging between 20 and 50 degrees in relation to theocclusal plane and one implant anterior to it that wasplaced perpendicular to the occlusal plane (0–8 degreeof angulation). The tilted implant required for appropriate fabrication of an implant restoration. Fifty-eight(58) threaded, self-tapping dental implants (BiocomMIS Implant technologies, Bar Lev Industrial Park,Israel) were placed in these patients; 29 implants wererestored with preangled or custom-angled abutment,and 29 were restored with standard abutments (Table 1).Implant evaluation was conducted at the time of prosthesis placement and at the time of data collection.Treatment ProtocolA thorough presurgical evaluation including full mouthperiodontal chart, occlusal analysis, study of themounted casts, and diagnostic wax up was performed.Initial periodontal therapy including oral hygieneinstructions and training, scaling, and root planningwherever indicated was carried out. Patients were
790Clinical Implant Dentistry and Related Research, Volume 18, Number 4, 2016Tilted Implant for Posterior Atrophic MaxillaTABLE 1 Data of Implants with Regard to Position, Length, Diameter, and Angle to Occlusal PlaneGenderAge 333333CantileverAngle toOcclusal NoYesNoNoNoNoNoNoNoNoNo3
4Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015 Tilted Implant for Posterior Atrophic MaxillaFigure 1 Preoperative panoramic x-ray demonstratinginsufficient bone for implant placement in the posterior rightmaxilla.reevaluated, and wherever indicated, additional periodontal therapy aimed to reduce periodontal probingdepth and bleeding on probing, and improvement ofplaque control to achieve hygiene index (HI) below 10%was carried out.19 All patients presented an initial fullmouth periapical radiographs and panoramic radiographs (Figure 1) or CT scans prior to implant placement. Periapical radiographs of the implants wererepeated 6 months after implant placement, beforeimplant exposure, and immediately at FPP installationand then at the annual follow-up examinations.Patients were maintained by a trained oral hygienistevery 3 to 6 months. Each visit included a clinical examination and periodontal charting, oral hygiene instructions, and scaling and root planning wherever needed.The implants were considered successful if they fulfilledthe criteria set up by Albrektsson and Zarb.20 One hourbefore surgery, the patients were premedicated with875 mg amoxicillin and clavulanic acid (Augmentin,GlaxoSmithKlein, Brentford, UK). Penicillin-sensitivepatients were premedicated with clindamycin HCL(Dalacin-C, Pfizer NV/SA, Belgium) 150 mg bid.Patients rinsed with 0.2% chlorhexidine solution(Tarodent, Taro Pharmaceutical Industries, Yakum Business Park, Yakum, Israel) for 1 minute before initiationof the surgical procedure.surgical access. The entrance point of the distal implantwas interpreted by measuring the distance from theanterior tooth with a dental caliperγ using a CT scan ora panoramic radiograph (Figures 2 and 3, A and B). Theosteotomy angle and direction were made after locatingthe position of the anterior wall of the sinus, using apilot drill, 2.0 mm in diameter (Figure 3C). At this stage,a periapical x-ray was performed, aimed to check andprecisely determine the accuracy of the drilling in orderto avoid perforation of the sinus wall.This was followed by successive drilling according tothe planned implant length and width and insertion ofthe distal tilted implant (Figure 4, A and B). The anteriorimplant was placed in the available bone between thedistal tooth present and the posterior implant, parallel tothe tooth and roughly perpendicular to the bone crest, asdetermined best by the surgeon (Figures 5 and 6).Implants were placed manually in a supracrestalmanner (leaving the smooth neck of the implantssupracrestally).Postoperative ManagementFollowing surgery, patients were administered with875 mg amoxicillin with clavulanic acid (Augmentin)bid. Penicillin-sensitive patients were administered withclindamycin HCL (Dalacin-C) 150 mg bid. Antibiotictherapy was continued during the first week postoperatively. Whenever needed, analgesic drug (Naxyn,naproxen 250 mg, Teva Pharmaceutical Industries,Petah Tikva, Israel) was given twice a day; 0.2%Chlorhexidine mouth rinse (Tarodent) was prescribedSurgical TechniqueFull-thickness flaps were raised under local anesthesia,using a mid-crestal incision, and mesial and/or distalreleasing incisions when required to improve visual or791Figure 2 Clinical view of the edentulous posterior rightmaxilla.
792Clinical Implant Dentistry and Related Research, Volume 18, Number 4, 2016Tilted Implant for Posterior Atrophic Maxilla5Healing TimeImplants were exposed 6 months after placement.Depending on the width of the crestal masticatorymucosa, either a midcrestal or a paracrestal (palatal),incision was made, intending to achieve at least 3 mm ofkeratinized mucosa on the implants buccal aspect.Prosthetic ProceduresThree weeks after implants uncovering, impressionswere taken using the open tray technique. Impressioncopings were screwed and connected to each other withan auto polymerizing acrylic resin (pattern resin, GCFigure 3 A, Planning of the osteotomy entrance of the distalimplant. B, Transferring the measurements from the panoramicx-ray to the surgical site. C, A parallel pin demonstrating thelocation and angulation of the distal tilted implant.twice daily for 1 minute over a 3-week period of time.Patients were instructed to avoid the use of a removableprosthetic devises until after the sutures were removed(i.e., 10 to 14 days postoperatively).Figure 4 A, Clinical view of the distal implant, immediatelyafter placement. B, Radiographic verification of the distalimplant position and its relationship with the surroundinganatomic landmarks, especially the anterior wall of the sinus.
6Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015 Tilted Implant for Posterior Atrophic MaxillaFigure 5 The mesial implant is placed in the remaining spacebetween the distal implant and the anterior tooth.America, Alsip, IL USA). Impressions were taken usingputty and silicone wash (Express, 3M ESPE dental products, ST. Paul, MN, USA) in plastic stock trays. A mastermodel was prepared, and interarch relations wererecorded. At the following appointment, abutmentswere connected (Figure 7), and the metal frameworkwas tried.At this stage, a silicone pick-up impression of themetal framework in situ was taken, and acrylic resinprovisional bridges were fitted. The permanent threeunit porcelain fused to metal fixed partial denturewas cemented after occlusal adjustment and glazingFigure 6 Radiographic verification of the relationships betweenthe implants, and the neighboring tooth/sinus.793Figure 7 Prefabricated abutments connected to implants.(Figure 8, A and B), with temporary cement (TempBond Kerr Corporation, West Collins Avenue, CA,USA).Survival CriteriaImplants were evaluated and classified in a three-fieldtable, according to the criteria suggested by Albrektssonand Zarb20 in 1998 namely: Success: implant immobility,lack of peri-implant radiolucency, bone loss not exceeding 1.5 mm during the first year of service, and 0.2annually in the successive years, and absence of persistent and/or irreversible signs and symptoms such aspain, infections, and neuropathies. Survival: implantsthat were stable but did not meet the bone loss criteriamentioned above. Failure: implants that had to beremoved for any reason.Radiographic Measurements. Postoperative radiographic examinations were performed at FPP installation and at the annual follow-up examinations.Standardized radiographs, with the film kept parallel(Kodak Ektaspeed Plus, Eastman Kodak Co., RochesterNY, USA) and the x-ray beam perpendicular tothe implant, were taken using plastic film holders(Dentsply-Rinn Corporation, Elgin, IL, USA).Bone level associated with the implants was evaluated on parallel periapical x-rays using computerizeddigital radiography (Schick Technologies, New York, NY,USA) (Figure 9).Radiographic evaluation was made by measuringthe distance between the alveolar bone crest and implantshoulder mesial and distal to the implant. Radiographic
794Clinical Implant Dentistry and Related Research, Volume 18, Number 4, 2016Tilted Implant for Posterior Atrophic Maxilla7distortion was calculated by dividing the radiographicimplant width by the actual one. Bone loss (mesial distal\2) was measured initially at the time of FPPsinstallation (7–8 months after implant placement) andat 1, 3, 5, and 10 years and once again at the time of datacollection (up to 17 years) (Table 2). The difference(D-delta) between final and initial measurements wascalculated accordingly.Implant angulation was measured by tracing linesthrough the occlusal plane and parallel with the longaxis of the implants. Angulation between each implantand the occlusal plane was calculated by reducing theangle of the intersection from 90 degrees (Figure 10).Prosthodontic Complications. Prosthodontic complications during the study period were recorded.Statistical AnalysisFigure 8 A, Clinical view of final rehabilitation. B, Narrowocclusal pattern of final porcelain fused to metal (PFM) bridge.Statistical analysis was performed with the SPSS 20.0statistical analysis software (SPSS Inc., Chicago, IL,USA). The primary outcome variable in this study wasthe change in peri-implant marginal bone level from thetime of FPD placement to the latest follow-up examination. Comparison between axial and tilted positionedimplants was performed by the use of t-tests for dependent samples. Descriptive statistics for continuous variables were summarized as the mean value 1 standarddeviation. t-Tests for independent samples were used tocompare smokers and nonsmokers as well as womenand men; the Pearson correlation coefficient test wasused to test for correlation between age, and outcomemeasures p value equal or less than .05 was consideredstatistically significant.RESULTSFigure 9 Periapical view 9 years after loading.The files of 29 patients (16 males; 13 females) met theinclusion criteria (Table 1). In these, 58 implants wereplaced, two at each site. Age ranged between 40 and 83years (avg 64.5, SD 9.8). The relevant individualdata of each patient in the study group, including parafunctional habits (bruxism), site, and type of eachimplant, are shown in Table 1. Implant’s diameter variedbetween 3.75 and 4.2 mm (mean 3.85, SD 0.19)(Table 1).Twenty-nine pairs of implants were restored; ineach pair, there is one with a standard abutment andone with an angled abutment (Table 1). Angulationsbetween axial implants and the occlusal plane varied
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(SD 0.67) for tilted implants, with no significant correlation between implant angulation and bone loss. A significant correlation between implant angulation and annual bone loss was obtained for tilted implants only (r 0.52, p .004).Using Albrektsson criteria, the success rate was 89.6% (26 out of
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9. Straumann PURE Ceramic Implant Monotype 35. 9.1 Design 37. 10. Surgical procedure for Straumann PURE Ceramic Implant Monotype 38. 10.1 Preoperative planning 38 10.2 Basic implant bed preparation 42 10.3 Fine implant bed preparation 45 10.4 Implant insertion 46. 11. Prosthetic procedure for Straumann PURE Ceramic Implant Monotype 49
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