The Journal of Indian Prosthodontic Society

: 2021  |  Volume : 21  |  Issue : 3  |  Page : 217--228

Clinical success between tilted and axial implants in edentulous maxilla: A systematic review and meta-analysis

Shruti Parthiv Mehta, Priyanka Vaibhav Sutariya, Mansoorkhan Rafikahmed Pathan, Hemil Hitesh Upadhyay, Surbhi Ravi Patel, Nidhi Dhaval Gupta Kantharia 
 Department of Prosthodontics, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India

Correspondence Address:
Mansoorkhan Rafikahmed Pathan
Department of Prosthodontics, College of Dental Sciences and Research Centre, Opposite Pleasure Club, Ghuma-Bopal Road, Ahmedabad - 380 052, Gujarat


Aim: This systematic review and meta-analysis evaluated the clinical survival of axial and tilted implants in atrophic edentulous maxilla after three years of immediate loading and also the corresponding marginal bone loss. Setting and Design: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines (PRISMA). Materials and Methods: The relevant studies were retrieved from MEDLINE(PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL), Science Direct, Google Scholar databases. The search was limited to studies published in the English language with no date restrictions. A further hand search was conducted on individual journals and reference lists of studies. The risk of bias in included studies was assessed by using the Evidence Project risk of bias tool. Statistical Analysis Used: Statistical meta-analysis was conducted using RevMan 5.4 software. The assessment for the level of evidence was done using GRADEpro software. Results: Eleven studies were finalised. All were included in the meta-analysis for implant survival, while only seven studies were included in the meta-analysis of marginal bone loss. After three years, the meta-analysis results for implant survival showed no statistical difference between axial and tilted implants, with the forest plot neither favouring axial nor tilted implants (RR = 1.00 (95% CI: 0.98-1.01); P-value = 0.59). After three years, the meta-analysis results for marginal bone showed no statistical difference between axial and tilted implants, with the forest plot neither favouring axial nor tilted implants (MD = -0.02; 95% CI; -0.09-0.06; P-value = 0.69). Conclusion: In the immediately loaded rehabilitation of completely edentulous atrophic maxillae, tilting of implants did not induce any significant alteration in their survival and their corresponding marginal bone loss levels compared to conventionally placed axial implants even after three years of function.

How to cite this article:
Mehta SP, Sutariya PV, Pathan MR, Upadhyay HH, Patel SR, Kantharia ND. Clinical success between tilted and axial implants in edentulous maxilla: A systematic review and meta-analysis.J Indian Prosthodont Soc 2021;21:217-228

How to cite this URL:
Mehta SP, Sutariya PV, Pathan MR, Upadhyay HH, Patel SR, Kantharia ND. Clinical success between tilted and axial implants in edentulous maxilla: A systematic review and meta-analysis. J Indian Prosthodont Soc [serial online] 2021 [cited 2021 Oct 23 ];21:217-228
Available from:

Full Text


For partial or total edentulism, dental implants are a safe and effective therapeutic option.[1] The potential height and the available width of the residual alveolar ridge are critical for successful implant placement. The loss of posterior teeth, especially at an early age, causes alveolar bone loss, making implant placement difficult in the preferred positions in the dental arches.[2] Since the resorption of the jaw's alveolar processes depends on the existence of teeth, alterations in their morphology are more pronounced in fully edentulous people. These variations in the shape and size of the ridge contour occur at different rates in different people and at different times in the same person.[3] The rehabilitation of atrophied edentulous ridges with endosseous implants in the posterior regions is frequently hampered by physiological issues such as bone resorption, poor bone quality, the presence of maxillary sinuses, pneumatization of maxillary sinuses, and a relative surfacing of the inferior alveolar nerve in the mandible, all of which make implant placement in the posterior region difficult.[4] The densest bone is found in the anterior-most part of the mandibular arch, and it becomes more fragile in the posterior maxilla. Maximum clinical failures are found in the posterior maxilla because of the resulting high masticatory forces and insufficient density of the supporting bone.[5]

Sinus augmentation, bone regeneration, short implants, distal cantilever pontics, or implants placed in certain areas such as the pterygoid, tuberosity, and zygomatic regions are some of the therapeutic options available to address these flaws.[4] Either of these procedures requires surgical and prosthetic expertise and present with their own set of risks, including membrane perforation, postoperative wound infection, bony sequestrum formation, hematoma, maxillary sinusitis, oro-antral fistula, wound dehiscence, bone graft loss, dental implant displacement into the maxillary sinus, longer healing time, and patient discomfort.[6] To avoid these problems, a tilt in the implant position is introduced to engage the maximum amount of accessible bone and put longer distal implants at the same time. The fundamental benefit of placing the tilted implant in the maxilla is that it allows the fixed implant-connected prosthesis to be extended more distally, reducing the length of the cantilever without the need for a sinus floor elevation treatment. Tilting distal implants have shown the same clinical effectiveness rate as axial implants. It also aids in the posterior positioning of the distal implant platform.[7],[8],[9],[10],[11],[12],[13] The region of congruity between bone and implant grows with the introduction of longer implants, providing enhanced primary stability to the implant. Anchorage from more than one cortical layer is used to produce increased primary stability.[14],[15] These aids in the immediate loading of the implants, therefore shortening the treatment time.

The benefits achieved by immediately loading dental implants in the mandibular jaw have motivated many clinicians to use them in the maxillary jaw. Despite the exponential growth of dentistry, the predictability of immediately loaded implants over a long duration of function in the resorbed maxillary, particularly in the posterior region, is not studied. A meta-analysis of maxillary rehabilitations that employed tilted and axial implants were previously reported, concentrating mainly on their 1-year performance.[16] This highlighted the necessity for a more extensive follow-up period and analysis based on strong and healthy clinical evidence.

As a result, this systematic review aimed to assess the 3-year clinical survival of axial and tilted immediately loaded implants in the atrophic edentulous maxilla, as well as the marginal bone loss associated with them. The null hypothesis assumed that when axial and tilted implants rehabilitating completely atrophic edentulous maxilla were loaded immediately, there would be a difference in implant survival and marginal bone loss levels.


Guidelines provided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed for carrying out this systematic review.[17],[18] The PICOS structure was used to develop the search strategy [Figure 1].{Figure 1}

Search strategy

A thorough electronic literature search was undertaken via PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Science Direct, and Google Scholar. The search was conducted solely in English, with no time constraints. All databases were searched using the following MeSH terms, search phrases, and combinations: Dental implants, edentulous jaws, maxilla, tilted implants, angled implants, atrophy, immediate dental implant loading, survival analysis, alveolar bone loss combined with the Boolean operators OR, AND. Relevant studies were included after hand-searching the reference list of shortlisted articles.

Studies that matched the following inclusion criteria were included in the current systematic review:

Human clinical trials having at least a 3-year follow-up periodCompletely edentulous atrophic maxilla rehabilitated using axial and tilted implantsImmediately loaded after surgery (within 48 h)Amount of marginal bone loss indicated or calculable from data provided for axial and tilted implantsArticles with a full text published in English.

This systematic review included human clinical trials, prospective clinical trials, and retrospective research. The participants in the study were not restricted by any age restrictions. The following criteria were used to assess implant survival in the studies that were included:

Clinical stability and function without any discomfortAbsence of suppuration, infection, pain at the implant site, or any other persistent pathologyIn evident peri-implant radiolucency.

In the included studies, intra-oral periapical radiographs and panoramic radiographs were used to assess the bone levels surrounding the margins of axial and tilted implants.

Screening for selection

Two separate investigators were responsible for examining the titles and abstracts of the searched articles for their inclusion in the analysis. The investigators then got the complete texts of all potentially relevant research for independent review. A new investigator was brought in to resolve the conflict between the two investigators; if any disagreement regarding inclusion occurred.

Data extraction

Two investigators worked independently to obtain data by filling out a data extraction form. Each included trial provided data on (1) the author and year of publication, (2) the study design, (3) the type of loading and timing of prosthetic loading, (4) the number of patients treated, (5) the number of axial implants, (6) the number of tilted implants, (7) the type of definitive prosthesis, and (8) the follow-up period.

Risk of bias in individual studies

In both randomized and nonrandomized intervention trials, the Evidence Project risk of bias tool was used to assess the risk of bias.[19] Eight domains were used to assess the risk of bias: (1) cohort, (2) control or comparison group, (3) pre-post intervention data, (4) random assignment of participants to the intervention, (5) random selection of participants for assessment, (6) follow-up rate of 80% or more, (7) comparison groups equivalent on sociodemographic, and (8) comparison groups equivalent at the baseline on outcome measures.

Statistical analysis

The differences between axial and tilted implants were investigated through meta-analysis, focusing, particularly on the survival of implants and levels of bone loss around the margins after 3 years. Relative risks (RRs) were calculated for implant survival, and the differences of the mean (MD) values reported for marginal bone loss, both with 95% confidence intervals (CIs), were considered to be effective measures. If the RR values were obtained >1, the tilted implants would be failing more than the axial implants. Similarly, if the MD values were larger than 0, then the tilted implants would be presenting more marginal bone loss than axial implants. To summarize these effects and fabricate the forest plots for the presentation of the overall analysis, RevMan 5.4 software was used (Review Manager (RevMan) [computer program]. Version 5.4, The Cochrane Collaboration, 2020).

Summary of findings

The GRADE-pro software was used to assess the current systematic review and meta-analysis (GRADE-pro Guideline Development Tool [Software]. McMaster University, 2020).


Study selection

A total of 135 studies were found via an electronic search of databases and manual investigation. After the deletion of duplicates, 93 full-text papers were evaluated, with 56 studies being eliminated by both investigators. When the remaining 37 full-text studies were evaluated for eligibility, 26 more research were eliminated for various reasons. Finally, the current systematic review and meta-analysis included 11 studies [Figure 2].{Figure 2}

Study characteristic

There were eleven included researches, which were published between 2007 and 2017. The research comprised eight prospective clinical studies (73%) and three retrospectives, nonrandomized comparative trials (27%). In total, 351 patients had 1545 implants placed in their maxilla. There were 648 titled implants (41.94%) and 897 axial implants (58.06%) among these implants. All eleven articles published data on implant survival after 3 years of implantation. Only 1148 implants were documented after the 3rd year of follow-up, with 510 (44.42%) being titled implants and 638 (55.58%) being axial implants [Table 1].{Table 1}

Risk of bias within studies

Three studies[20],[21],[23] (27%) have a moderate risk of bias, according to the Evidence Project's risk of bias tool. The remaining eight studies (73%) revealed a low risk of bias.[22],[24],[25],[26],[27],[28],[29],[30] The included studies indicated a low risk of bias in the cohort domain, control or comparison group domain, and pre-/post-intervention data domain. Except for one,[25] all of the studies demonstrated a high risk of bias in the assessment domain's random selection of participants. In a follow-up rate of 80% or more domain, there was a low risk of bias in eight studies,[22],[24],[25],[26],[27],[28],[29],[30] and a high risk of bias in three studies.[20],[21],[23] [Table 2] and [Figure 3].{Table 2}{Figure 3}

Meta-analysis 1: Survival of axial and tilted implants

One thousand one hundred and forty-eight implants were reported for follow-up after 3 years of placement. Among them, 510 (44.42%) were titled implants, and 638 (55.58%) were axial implants. Studies performed by Roberto Crespi[25] and Enrico L. Agliardi[28] had reported failure of tilted implants. Roberto Crespi et al.[25] reported failure of only one tilted implant out of 48 tilted implants due to periimplantitis. Similarly, Enrico L. Agliardi et al.[28] also reported failure of two tilted implants out of 128 tilted implants owing to periimplantitis only after 6 months of loading.

A total of three titled implants had failed, while no failure of the axial implant was reported. There was survival of 507 implants (99.41%) out of 510 implants for titled implants and 638 implants (100%) out of 638 implants for axial implants.

[Figure 4] has illustrated a forest plot depicting meta-analysis comparing tilted and axial implant survival rates after 3 years of function. An insignificant difference was obtained between titled and axial implants (RR = 1.00; 95 % CI: 0.98-1.01; P-value = 0.59). Heterogeneity was not found between the studies included (I2 = 0%).{Figure 4}

Meta-analysis 2: Levels of bone loss around the margins of axial and tilted implants

Values for marginal bone loss following a 3-year follow-up period were obtained from seven out of eleven trials. For maxilla, these studies[22],[23],[25],[26],[28],[29],[30] showed separate results of marginal bone loss that occurred for an implant placed with tilt (n = 274) as well as the implant placed axially (n = 293).

A nonsignificant mean difference (MD = −0.02; 95% CI; −0.09–0.06; P value = 0.69) was discovered between tilted and axial implants [Figure 5]. There was some heterogeneity between trials (I2 = 23%), which was discovered. However, there was no difference in the outcomes of fixed and random-effects models.{Figure 5}

Survival of prostheses

The fracture of provisional and/or definitive prosthesis[21],[22],[24],[25],[26],[27] and prosthetic screw-loosening[24],[25],[26],[27] were the most commonly observed complications. Agnini et al.[23] and Cavalli et al.[24] reported breaking of esthetic veneering of the provisional prosthesis. Paulo Malo et al.[26] and Armando Lopes et al.[27] proposed that fracture of the provisional and definitive prosthesis could be resolved by repairing the fracture, followed by adjusting the occlusion and simultaneously providing an occlusal night guard to the patient.

The number of implants used, provisional and definitive prosthetic materials used, prosthesis design, use of a surgical template, performing surgery with a flap retraction, or performing a flapless surgery were some of the differences in the methods followed in different studies.

Most studies employed four implants (two axial implants placed anteriorly, two tilted implants placed distally). Whereas only two studies[20],[30] used more than one axial implant per quadrant, with one distally tilted implant. Depending on the availability of bone and proximity to vital tissues, Agnini et al.[23] used four implants (two axial implants placed anteriorly, two tilted implants placed distally) or six implants (four axial implants placed anteriorly, two tilted implants placed distally) for the maxillary arch. While Agliardi et al.[28] placed two anterior axial and four posterior tilted implants at the same time.

Two of the eleven studies[27],[29] employed computer-guided stents for performing flapless surgery and documented positive results. Patients with insufficient mouth opening (<50 mm) to accommodate the surgical equipment were excluded from these investigations.

All researchers[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30] suggested achieving a primary torque of minimum 30 Ncm to exercise immediate loading.

Three authors[20],[23],[28] documented the use of a provisional prosthesis for the complete arch with a metal substructure and veneering acrylic resin. In contrast, the remaining authors provided an all-acrylic full-arch provisional prosthesis to their patients.[21],[22],[24],[26],[27],[30] Within 24 h of implant insertion, Crespi et al.[25] advocated using the screw-retained full-arch definitive prosthesis. Five investigations[21],[23],[24],[29],[30] reported the use of a fixed provisional prosthesis without distal cantilevers. On the other hand, the other six investigations had not mentioned the use of a distal cantilever.

The use of screw-retained definitive prosthesis was reported in all included articles.[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30]

Summary of findings

The standard of evidence generated was assessed using GRADEpro software and was very low for implant survival and low for marginal bone loss [Figure 6]. The quality of evidence was initially good, but it was then downgraded to poor due to a lack of randomization and blinding, and later to very low due to imprecision. This suggested that more well-controlled research should be conducted in the future to affect the result of the current review.{Figure 6}


This systematic review and meta-analysis aimed to identify axial and tilted implant's 3-year clinical survival rate and the resulting marginal bone loss when they were immediately rehabilitated. Studies that matched the following criteria were included in this systematic review: Clinical studies in humans with a minimum 3-year follow-up, rehabilitation of completely edentulous maxilla supported by axial and tilted implants, immediate loading within 48 h after surgery, marginal bone loss post 3 years for axial and tilted implants indicated or calculable from data provided, full-text articles published in the English language only. The literature search revealed eleven papers that matched the criteria for inclusion. There were no randomized clinical trials found; eight of the included papers were prospective clinical studies (73%), and the remaining three were retrospective, nonrandomized comparative studies (27%). In this systematic review and meta-analysis, the following information was compiled from the findings of eleven studies [Table 3].{Table 3}

Type 3 and type 4 bone morphology, residual ridge resorption, maxillary sinus pneumatization, and the existence of nasal cavities generally limit traditional implant placement axially in the completely edentulous atrophic maxilla.[31] To give the patient enough chewing capacity in the molar region, prostheses with a long distal cantilever are required. Cantilever lengths above 15 mm, on the other hand, are linked to a higher likelihood of implant failure.[32] To resolve these issues, bone augmentation techniques and nongrafting techniques are proposed in the literature. Grafting techniques include sinus lift procedure, ridge split technique, and block grafting procedures. Whereas nongrafting techniques include placement of zygomatic implants, pterygoid implants, short implants, and tilted implants.[33]

Grafting methods have a high rate of complications, a high risk of morbidity, high expenses, and a longer time for prosthetic rehabilitation due to which patient acceptance is low.[34] When compared to implants placed in the grafted bone, Widmark et al.[35] found that maxillary implants implanted in native bone have a higher success rate (87%) after 5 years (74%). Other options for rehabilitating atrophic maxilla include zygomatic and pterygoid implants, which have success rates but need extensive surgical competence and are associated with greater morbidity.[36],[37] Furthermore, adequate bone height (7–8 mm) and a superior bone density of bone become mandatory when planning for short implant placement.[38]

According to the intuitive concepts, dental implants must be placed in the axial plane to achieve and sustain adequate osseointegration. The primitive concept advocated the use of implant placement that was “in-line” or perpendicular to occlusal stresses and claimed that tilted implants would lose bone and eventually “de-osseointegrate.”[39] However, an appealing technique for treating atrophic edentulous maxilla using titled implants was discovered to be a feasible therapeutic option because of technological advancements.[40] Its goal was to get maximum cortical bone involved for support.[41] It has several advantages, including strong primary stability even with low bone volume, longer implant length for more bone to implant contact, more anterior-posterior spread, minimally invasive approach without bone grafting, and ability to place implants close to anatomical structures.[42],[43] Using titled distal implants rather than distal cantilever units has proven biomechanical advantage. The resulting full-arch fixed prosthesis has a bilateral cantilever length of up to 20 mm attributable to distally tilted implants.[44]

Compared to previous grafting treatments, this philosophy of placing implants in preexisting bone applied the therapeutic idea of taking maximum advantage of the naturally available bone, resulting in a simple, more predictable, less expensive, and faster rehabilitation. According to a finite element analysis undertaken by Bevilacqua et al., an individual tilted implant posed higher stress on the surrounding bone than an implant positioned axially straight.[45] However, it was proven that splinting tilted and axial implants with a single unit fixed prosthetic structure reduced peri-implant bone stress significantly when rehabilitating the complete arch.[46],[47] Bevilacqua et al.[47] used different implant inclinations and cantilever lengths to test load transmission to maxillary cortical peri-implant bone (von mises forces). When the distal axial implant was splinted with a fixed denture to the mesial axial implant, the maximum stress observed was 75 MPa. On the contrary, maximum stresses measured for distally tilted implants were lowered to 39.4 MPa (tilt of 30°) and 19.9 MPa, respectively (tilt of 45°).[47] Metal-reinforced prosthetic rehabilitation was indicated to give solid support for the implants and to reduce mechanical problems.[20],[23],[28] Due to improved precision and convenience, computer-guided flapless surgery for implant insertion utilizing stereolithographic templates is becoming increasingly popular among clinicians.[48] The minimally invasive aspect of this surgical technique and the accuracy of implant placement has decreased postsurgical discomfort and shortened the duration of surgical operation.[48] The prosthetic treatment for axially inserted implants can get complicated if a tilt is introduced during the surgical placement, especially for a posterior implant. This tilt can be easily adjusted with the use of angulated abutments.[49]

Since the tilted implants engage the maximum cortical bone, they are considered to have strong primary stability, which helps in loading them immediately. An implant-supported restoration placed into a function within 48 h of implant implantation is known as immediate loading.[50] Within the limitations of previous evidence (up to 2 years), the immediately loaded implant was proven to have a predictable high survival rate.[50] In terms of patient comfort and esthetics, the immediate loading approach reduced the waiting period required to install a functional prosthesis. This particular gain of reduced duration of the treatment proved to be a financial benefit, particularly for professionally and socially engaged patients. From the aspect of a clinician, the immediate loading approach saved chairside time and lowered treatment costs.[51],[52] The evidence on the performance of axial and tilted implants in function for at least 3 years has been summarized in this systematic review. After 3 years of function, no significant difference in implant survival was observed between axial and tilted implants, according to the meta-analysis findings (P = 0.59). Both implants had a commendable success rate. At the 3rd-year follow-up, three tilted implants failed, whereas 0 axial implants failed out of a total of 1148 implants. Similarly, there was no difference between axial and tilted implants in peri-implant marginal bone loss levels (P = 0.69). As a result, the null hypothesis was rejected in the current systematic review and meta-analysis.

The fracture of the acrylic provisional restoration appeared to be the most prevalent problem. Other complications included:

The loosening of a prosthetic screwChipping off of the provisional prosthesis's esthetic veneeringDetachment of one or more resin teeth.

Only three trials employed a full-arch provisional prosthesis with a metal framework rather than an all-acrylic prosthesis.[20],[23],[28] A metal framework is essential for enhancing the structure's stiffness and rigidity for splinting the implants, contributing to a more favorable occlusal force distribution, allowing for osseointegration.

In 2010, Del Fabbro et al.[53] published a meta-analysis on the effects of tilted implants in immediately loaded rehabilitations. It comprised papers that have been published as recently as March 2009. One study[20] was included in the current review, which was also included by Del Fabbro et al. The current systematic review focused on rehabilitation of completely edentulous atrophic maxilla with a minimum 3-year follow-up period, which was one of the major contrasts between the two systematic studies. Del Fabbro et al., on the other hand, included both maxillary and mandibular arch rehabilitation in their study, with only an 1-year follow-up. Del Fabbro also failed to include a quality and bias assessment of the research he included. A meta-analysis of marginal bone loss surrounding implants was also performed in the present systematic review.

Menini et al.[16] reported a meta-analysis of tilted implant outcomes in immediate loading rehabilitation in 2012. It comprised papers that were published up to August 2011. Three studies[20],[21],[22] that were also included by Menini et al. were included in the current review. The current systematic review focused on rehabilitating completely edentulous atrophic maxilla with a minimum of 3-year follow-up period, one of the major contrasts between the two systematic studies. In contrast, Menini et al. focused on rehabilitation of completely edentulous atrophic maxilla over 1 year. Furthermore, unlike the current review, Menini et al. did not provide a summary of evidence.

In 2021, Gaonkar et al.[54] conducted a systematic review to establish the success rate of axial and tilted implants implanted in edentulous jaws using the All-on-4 technique. There was no meta-analysis done. Six papers were included in the current review,[20],[21],[22],[25],[27],[29] which were also included by Gaonkar et al., on the other hand, did not specify the research's inclusion criteria and arbitrarily chose 25 from the literature up to 2015. For every given period, the quantity of marginal bone loss was not specified. There was also no mention of the variation in implant survival rates between the maxillary and mandibular jaws. In addition, the effects of immediately loaded axial and tilted implants were not addressed.

The effects of distally tilted versus mesial axial implant survival were compared in this study. The minimum angulation required to classify an implant as tilted has yet to be determined. Seven of the eleven studies[21],[22],[23],[24],[26],[27],[28] observed angulation angles ranging from 30° to 45° degrees. According to Roberto Crespi et al.,[25] the degree of angulation for a distally inclined implant is between 30° and 35°. The degree of angulation for a distally inclined implant, according to Luca Francetti et al.[22] and Hilde Browaeys et al.[29] might be up to 30°. A mesiodistal angulation concerning the vertical axis might be defined as implant inclination (perpendicular to the occlusal plane).[55] However, the linguobuccal or palatobuccal inclination, which may significantly impact implant biomechanics and impacts on the surrounding hard and soft tissues, is not included in this description.

Data on the survival of prostheses have been published in several studies with appropriate conclusive findings. Randomized controlled trials on studies using only restorations supported by either axial or tilted implants should be done to provide credible data. When axial and tilted implants are utilized in the same restoration, confounding variables may be added.

However, no randomized control experiment was found in the existing literature on this topic. It was highlighted that solely clinical judgment was used to assess implant survival results in all eleven investigations. More reliable approaches such as resonance frequency analysis and the reverse torque method should be used to collect data to verify implant stability.[50],[56],[57]


The current systematic review derived that the rehabilitation of completely edentulous atrophic maxilla with tilting of implants and immediately loading them produced similar results compared to conventional axially placed implants. When the parameters of implant survival and marginal bone loss levels around the implants were studied in the meta-analysis, no significant difference was obtained in contrast to axial implants even after 3 years of function. The impact made on the quality of life of the patients by this alternative treatment modality is tremendous. Hence, it was concluded that tilted implants for restoring completely edentulous atrophic maxilla are a viable therapeutic option with no significant differences in outcome compared to conventional implantology. In future, further randomized clinical trials should be carried out to assess the efficacy of tilted implants as a replacement for grafting procedures, short implants, or implants in specific anatomic areas.


The authors received no financial support and declare no potential conflicts of interest with respect to the authorship and/or publication of this manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Arora A, Upadhyaya V, Parashar KR, Malik D. Evaluation of the effect of implant angulations and impression techniques on implant cast accuracy – An in vitro study. J Indian Prosthodont Soc 2019;19:149-58.
2Chrcanovic BR, Albrektsson T, Wennerberg A. Tilted versus axially placed dental implants: A meta-analysis. J Dent 2015;43:149-70.
3Babu BD, Jain V, Pruthi G, Mangtani N, Pillai RS. Effect of denture soft liner on mandibular ridge resorption in complete denture wearers after 6 and 12 months of denture insertion: A prospective randomized clinical study. J Indian Prosthodont Soc 2017;17:233-8.
4Ali SA, Karthigeyan S, Deivanai M, Kumar A. Implant rehabilitation for atrophic maxilla: A review. J Indian Prosthodont Soc 2014;14:196-207.
5Misch CE. Dental Implants Prosthetics. 2nd ed. St Louis Elsevier Mosby; 2015. p. 11.
6Kumari A, Malhotra P, Phogat S, Yadav B, Yadav J, Phukela SS. A finite element analysis to study the stress distribution on distal implants in an all-on-four situation in atrophic maxilla as affected by the tilt of the implants and varying cantilever lengths. J Indian Prosthodont Soc 2020;20:409-16.
7Mattsson T, Köndell PA, Gynther GW, Fredholm U, Bolin A. Implant treatment without bone grafting in severely resorbed edentulous maxillae. J Oral Maxillofac Surg 1999;57:281-7.
8Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants 2000;15:405-14.
9Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: A clinical, radiologic, and periotest study. Clin Implant Dent Relat Res 2001;3:39-49.
10Fortin Y, Sullivan RM, Rangert BR. The Marius implant bridge: Surgical and prosthetic rehabilitation for the completely edentulous upper jaw with moderate to severe resorption: A 5-year retrospective clinical study. Clin Implant Dent Relat Res 2002;4:69-77.
11Calandriello R, Tomatis M. Simplified treatment of the atrophic posterior maxilla via immediate/early function and tilted implants: A prospective 1-year clinical study. Clin Implant Dent Relat Res 2005;7 Suppl 1:S1-12.
12Maló P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark System implants for completely edentulous maxillae: A 1-year retrospective clinical study. Clin Implant Dent Relat Res 2005;7 Suppl 1:S88-94.
13Koutouzis T, Wennström JL. Bone level changes at axial- and non-axial-positioned implants supporting fixed partial dentures. A 5-year retrospective longitudinal study. Clin Oral Implants Res 2007;18:585-90.
14Palaskar JN, Joshi N, Shah PM, Gullapalli P, Vinay V. Influence of different implant placement techniques to improve primary implant stability in low-density bone: A systematic review. J Indian Prosthodont Soc 2020;20:11-6.
15Rao PL, Gill A. Primary stability: The password of implant integration. J Dent Implants 2012;2:103-9.
16Menini M, Signori A, Tealdo T, Bevilacqua M, Pera F, Ravera G, et al. Tilted implants in the immediate loading rehabilitation of the maxilla: A systematic review. J Dent Res 2012;91:821-7.
17Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. J Clin Epidemiol 2009;62:e1-34.
18Salameh JP, Bossuyt PM, McGrath TA, Thombs BD, Hyde CJ, Macaskill P, et al. Preferred reporting items for systematic review and meta-analysis of diagnostic test accuracy studies (PRISMA-DTA): Explanation, elaboration, and checklist. BMJ 2020;370:m2632.
19Kennedy CE, Fonner VA, Armstrong KA, Denison JA, Yeh PT, O'Reilly KR, et al. The Evidence Project risk of bias tool: Assessing study rigor for both randomized and non-randomized intervention studies. Syst Rev 2019;8:3.
20Capelli M, Zuffetti F, Del Fabbro M, Testori T. Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: A multicenter clinical study. Int J Oral Maxillofac Implants 2007;22:639-44.
21Agliardi E, Panigatti S, Clericò M, Villa C, Malò P. Immediate rehabilitation of the edentulous jaws with full fixed prostheses supported by four implants: Interim results of a single cohort prospective study. Clin Oral Implants Res 2010;21:459-65.
22Francetti L, Romeo D, Corbella S, Taschieri S, Del Fabbro M. Bone level changes around axial and tilted implants in full-arch fixed immediate restorations. Interim results of a prospective study. Clin Implant Dent Relat Res 2012;14:646-54.
23Agnini A, Agnini AM, Romeo D, Chiesi M, Pariente L, Stappert CF. Clinical investigation on axial versus tilted implants for immediate fixed rehabilitation of edentulous arches: Preliminary results of a single cohort study. Clin Implant Dent Relat Res 2014;16:527-39.
24Cavalli N, Barbaro B, Spasari D, Azzola F, Ciatti A, Francetti L. Tilted implants for full-arch rehabilitations in completely edentulous maxilla: A retrospective study. Int J Dent 2012;2012:180379.
25Crespi R, Vinci R, Capparé P, Romanos GE, Gherlone E. A clinical study of edentulous patients rehabilitated according to the “all on four” immediate function protocol. Int J Oral Maxillofac Implants 2012;27:428-34.
26Maló P, Nobre Md, Lopes A. Immediate loading of 'All-on-4' maxillary prostheses using trans-sinus tilted implants without sinus bone grafting: A retrospective study reporting the 3-year outcome. Eur J Oral Implantol 2013;6:273-83.
27Lopes A, Maló P, de Araújo Nobre M, Sanchez-Fernández E. The NobelGuide® All-on-4® treatment concept for rehabilitation of edentulous jaws: A prospective report on medium- and long-term outcomes. Clin Implant Dent Relat Res 2015;17 Suppl 2:e406-16.
28Agliardi EL, Pozzi A, Stappert CF, Benzi R, Romeo D, Gherlone E. Immediate fixed rehabilitation of the edentulous maxilla: A prospective clinical and radiological study after 3 years of loading. Clin Implant Dent Relat Res 2014;16:292-302.
29Browaeys H, Dierens M, Ruyffelaert C, Matthijs C, De Bruyn H, Vandeweghe S. Ongoing crestal bone loss around implants subjected to computer-guided flapless surgery and immediate loading using the All-on-4® concept. Clin Implant Dent Relat Res 2015;17:831-43.
30Wentaschek S, Hartmann S, Walter C, Wagner W. Six-implant-supported immediate fixed rehabilitation of atrophic edentulous maxillae with tilted distal implants. Int J Implant Dent 2017;3:35.
31Lekholm U, Zarb GA. Patient selection and preparation. In: Branemark PI, Zarb GA, Albrektsson T, editors. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago: Quintessence Publishing; 1985. p. 199-209.
32Shackleton JL, Carr L, Slabbert JC, Becker PJ. Survival of fixed implant-supported prostheses related to cantilever lengths. J Prosthet Dent 1994;71:23-6.
33Peñarrocha-Oltra D, Candel-Martí E, Ata-Ali J, Peñarrocha-Diago M. Rehabilitation of the atrophic maxilla with tilted implants: Review of the literature. J Oral Implantol 2013;39:625-32.
34Del Fabbro M, Testori T, Francetti L, Weinstein R. Systematic review of survival rates for implants placed in the grafted maxillary sinus. Int J Periodontics Restorative Dent 2004;24:565-77.
35Widmark G, Andersson B, Carlsson GE, Lindvall AM, Ivanoff CJ. Rehabilitation of patients with severely resorbed maxillae by means of implants with or without bone grafts: A 3- to 5-year follow-up clinical report. Int J Oral Maxillofac Implants 2001;16:73-9.
36Galán Gil S, Peñarrocha Diago M, Balaguer Martínez J, Marti Bowen E. Rehabilitation of severely resorbed maxilla with zygomatic implants: An update. Med Oral Patol Oral Cir Bucal 2007;12:E216-20.
37Balshi TJ, Wolfinger GJ, Balshi SF 2nd. Analysis of 356 pterygomaxillary implants in edentulous arches for fixed prosthesis anchorage. Int J Oral Maxillofac Implants 1999;14:398-406.
38Renouard F, Nisand D. Impact of implant length and diameter on survival rates. Clin Oral Implants Res 2006;17 Suppl 2:35-51.
39Jensen OT, Adams MW. The maxillary M-4: A technical and biomechanical note for all-on-4 management of severe maxillary atrophy – Report of 3 cases. J Oral Maxillofac Surg 2009;67:1739-44.
40Morton D, Gallucci G, Lin WS, Pjetursson B, Polido W, Roehling S, et al. Group 2 ITI Consensus Report: Prosthodontics and implant dentistry. Clin Oral Implants Res 2018;29 Suppl 16:215-23.
41Nag PV, Bhagwatkar T. Prosthetic management of a hemimandibulectomy patient using tilted implant protocol with 3-year follow-up. J Indian Prosthodont Soc 2020;20:326-30.
42Asawa N, Bulbule N, Kakade D, Shah R. Angulated implants: An alternative to bone augmentation and sinus lift procedure: Systematic review. J Clin Diagn Res 2015;9:E10-3.
43Barnea E, Tal H, Nissan J, Tarrasch R, Peleg M, Kolerman R. The use of tilted implant for posterior atrophic maxilla. Clin Implant Dent Relat Res 2016;18:788-800.
44Pancko F, Dyer J, Weisglass S, Kraut RA. Use of tilted implants in treatment of the atrophic posterior mandible: A preliminary report of a novel approach. J Oral Maxillofac Surg 2010;68:407-13.
45Bevilacqua M, Tealdo T, Pera F, Menini M, Mossolov A, Drago C, et al. Three-dimensional finite element analysis of load transmission using different implant inclinations and cantilever lengths. Int J Prosthodont 2008;21:539-42.
46Zampelis A, Rangert B, Heijl L. Tilting of splinted implants for improved prosthodontic support: A two-dimensional finite element analysis. J Prosthet Dent 2007;97:S35-43.
47Bevilacqua M, Tealdo T, Menini M, Pera F, Mossolov A, Drago C, et al. The influence of cantilever length and implant inclination on stress distribution in maxillary implant-supported fixed dentures. J Prosthet Dent 2011;105:5-13.
48DE Vico G, Ferraris F, Arcuri L, Guzzo F, Spinelli D. A novel workflow for computer guided implant surgery matching digital dental casts and CBCT scan. Oral Implantol (Rome) 2016;9:33-48.
49Cavallaro J Jr., Greenstein G. Angled implant abutments: A practical application of available knowledge. J Am Dent Assoc 2011;142:150-8.
50Wang HL, Ormianer Z, Palti A, Perel ML, Trisi P, Sammartino G. Consensus conference on immediate loading: The single tooth and partial edentulous areas. Implant Dent 2006;15:324-33.
51De Bruyn H, Raes S, Ostman PO, Cosyn J. Immediate loading in partially and completely edentulous jaws: A review of the literature with clinical guidelines. Periodontol 2000 2014;66:153-87.
52Kushaldeep, Tandan A, Upadhyaya V, Raghuvanshi M. Comparative evaluation of the influence of immediate versus delayed loading protocols of dental implants: A radiographic and clinical study. J Indian Prosthodont Soc 2018;18:131-8.
53Del Fabbro M, Bellini CM, Romeo D, Francetti L. Tilted implants for the rehabilitation of edentulous jaws: A systematic review. Clin Implant Dent Relat Res 2012;14:612-21.
54Gaonkar SH, Aras MA, Chitre V, Mascarenhas K, Amin B, Rajagopal P. Survival rates of axial and tilted implants in the rehabilitation of edentulous jaws using the All-on-four™ concept: A systematic review. J Indian Prosthodont Soc 2021;21:3.
55Apaza Alccayhuaman KA, Soto-Peñaloza D, Nakajima Y, Papageorgiou SN, Botticelli D, Lang NP. Biological and technical complications of tilted implants in comparison with straight implants supporting fixed dental prostheses. A systematic review and meta-analysis. Clin Oral Implants Res 2018;29 Suppl 18:295-308.
56Swami V, Vijayaraghavan V, Swami V. Current trends to measure implant stability. J Indian Prosthodont Soc 2016;16:124-30.
57Satwalekar P, Nalla S, Reddy R, Chowdary SG. Clinical evaluation of osseointegration using resonance frequency analysis. J Indian Prosthodont Soc 2015;15:192-9.