Implante Angulate Ejoi - 2014 - 02 - Sup0171

CLINICAL ARTICLE S171
Massimo Del Fabbro, Valentina Ceresoli
The fate of marginal bone around axial vs.

tilted implants: A systematic review
Massimo Del Fabbro,

Key words dental implants, mandible, marginal bone loss, maxilla, systematic review, tilted implants BSc, PhD
Academic Researcher,
Department of Biomedical,
Aims: The use of tilted implants has recently gained popularity as a feasible option for the treatment Surgical and Dental
Sciences, Center of Research
of edentulous jaws by means of implant-supported rehabilitations without recurring to grafting pro- for Oral Health,
cedures. The aim of this review was to compare the crestal bone level change around axially placed Università degli Studi di
Milano, Milan, Italy;
vs. tilted implants supporting fixed prosthetic reconstructions for the rehabilitation of partially and IRCCS Istituto Ortopedico
Galeazzi, Milan, Italy
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 rele- Valentina Ceresoli,
BSc
vant journals up to January 2014 was performed. The articles were selected using specific inclusion PhD Student, Department
criteria, independent of the study design. Data on marginal bone loss and implant survival were of Biomedical, Surgical and
Dental Sciences,
extracted from included articles and statistically analysed to investigate the effect of implant tilting, Università degli Studi di
location, prosthesis type, loading mode and study design. The difference in crestal bone level change Milano, Milan, Italy
around axial vs. tilted implants was analysed using meta-analysis. Correspondence to:
Results: The literature search yielded 758 articles. A first screening based on titles and abstracts identi- Massimo Del Fabbro
IRCCS Istituto Ortopedico
fied 62 eligible studies. After a full-text review, 19 articles (14 prospective and five retrospective studies) Galeazzi Università degli
Studi di Milano,
were selected for analysis. A total of 670 patients have been rehabilitated with 716 prostheses (415 in Via Riccardo Galeazzi,
the maxilla, 301 in the mandible), supported by a total of 1494 axial and 1338 tilted implants. Peri- 4 20161 – Milano Italy
Tel: +39 02 50319950
implant crestal bone loss after 1 year of function ranged from 0.43 to 1.13 mm for axial implants and Fax: +39 02 50319960
from 0.34 to 1.14 mm for tilted implants. In spite of a trend for a lower bone loss around axial implants Email: massimo.delfabbro@
unimi.it
with respect to tilted ones at 12 months, as well as after 3 or more years of function, no significant
difference could be found (P = 0.09 and P = 0.30, respectively). The location (maxilla vs. mandible),
the loading mode (immediate vs. delayed), the restoration type (full vs. partial prosthesis) and the
study design (prospective vs. retrospective) had no significant effect on marginal bone loss. Forty-six
implants (18 axial and 28 tilted) failed in 38 patients within the first year of function. All failures except
five occurred in the maxilla. After 12 months of loading, the survival rate of implants placed in the
maxilla (97.4%) was significantly lower as compared to the mandible (99.6%). No prosthesis failure
was reported.
Conclusions: Tilting of the implants does not induce significant alteration in crestal bone level
change as compared to conventional axial placement after 1 year of function. The trend seems to
be unchanged over time even though the amount of long-term data is still scarce. The use of tilted
implants to support fixed partial and full-arch prostheses for the rehabilitation of edentulous jaws can
be considered a predictable technique, with an excellent prognosis in the short and mid-term. Further
long-term trials, possibly randomised, are needed to determine the efficacy of this surgical approach
and the remodelling pattern of marginal bone in the long term.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Eur J Oral Implantol 2014;7(Suppl2):S171–S189

S172 Del Fabbro / Ceresoli Bone loss around tilted implants
Introduction osteomyelitis7-11. Grafting procedures are generally

demanding for both clinicians and patients and are
After tooth loss the alveolar ridge undergoes pro- often associated with increased surgical risks and
gressive atrophy, which may become severe over financial cost as well. Another therapeutic option in
time, especially for totally edentulous jaws. A num- case of limited available bone is represented by the
ber of prosthetic treatment alternatives are available use of implants of reduced length12-13. However, in
to address this situation, such as complete dentures, the posterior maxilla, a minimum ridge height of 6
implant-retained removable reconstructions, fixed to 7 mm should be present for a safe placement of
implant-supported prostheses1. The latter represent implants shorter than 8 mm. On the other hand, in
today a common and well-accepted treatment for the case of extremely atrophic posterior mandible,
the rehabilitation of partial and completely eden- the use of short implants is to be carefully considered
tulous jaws. They offer an established long-term because of the risk of violating the alveolar nerve.
predictability as well as a higher level of satisfac- The combined use of axially placed and tilted
tion for the patient in terms of aesthetics, phonetics implants represents another possible alternative for
and functionality, as compared to removable pros- the treatment of edentulous jaws, which has been
theses2-4. extensively documented in the recent years14-19.
Most patients wearing complete dentures com- Implant inclination may be carefully planned by
plain about progressive loss of stability during phon- the surgeon in order to avoid damage to important
etics and mastication, and request a fixed rehabilita- anatomical structures. At the same time, the adop-
tion. However, the rehabilitation of severely atrophic tion of longer implants and a proper insertion axis
jaws using implant-supported prosthesis is often may allow engagement of as much cortical bone
challenging because of the poor quality and quantity as possible, favouring the achievement of adequate
of residual jawbone, especially in patients with long primary stability of the implants20. This may allow
term edentulism. for immediate rehabilitation in many cases. Fur-
For example, progressive bone loss in the pos- thermore, increasing the inter-implant distance and
terior mandible may lead to superficialisation of the reducing cantilever length, an optimal load distribu-
alveolar nerve, which may cause pain to denture tion may be achieved. Several computational stud-
wearers during mastication. Bone augmentation ies suggested possible biomechanical advantages of
procedures might represent a solution for facilitating implant tilting in full-arch restorations21-23. On the
implant placement in the posterior mandible, but other hand, unfavourable loading direction could in
these types of intervention are poorly accepted by theory induce greater bone resorption around tilted
patients. With regard to the maxilla, its rehabilita- implants as compared to axially placed ones, as sug-
tion with osseointegrated implants is often associ- gested by other in vitro studies that reported accen-
ated with several problems. In many cases, sufficient tuated stresses around non-axially placed implant
alveolar crest volume is found in the anterior region, necks24-25.
while in the premolar and molar region, severe bone Excellent clinical results of rehabilitations sup-
resorption can occur as a consequence of tooth loss. ported by a combination of axial and tilted implants
The presence of the maxillary sinus and a limited have been reported, with high implant survival and
ridge dimension must also be considered when plac- prosthesis success rates, and a high level of satis-
ing implants in this region5-6. During past decades, faction for the patients, in spite of a relatively high
various alternative surgical procedures have been incidence of biomechanical complications (from
adopted to place implants in the posterior atrophic 15.6%26 to 27%15 of cases). The latter could be
maxilla; one of them is the maxillary sinus augmen- generally managed at chairside16-19.
tation procedure, with either lateral or transcrestal What still remains to be studied is the stability of
approach. In spite of the excellent outcomes of the peri-implant hard and soft tissues around tilted
this procedure, it is associated with several possible and axially placed implants over time. According
complications like morbidity at the donor site, sinus- to previous systematic reviews, while excellent im-
itis, fistulae, loss of the graft or the implants, and plant survival rates were always emphasised by most

Del Fabbro / Ceresoli Bone loss around tilted implants S173
studies, the crestal bone level change around tilted Inclusion criteria
implants has not been systematically reported16-18.
The primary aim of this systematic review was to The search was limited to clinical studies involving
evaluate the fate of marginal bone around tilted ver- human subjects. Restrictions were not placed regard-
sus axial implants supporting partial and complete ing the language. Both prospective and retrospective
rehabilitations, after at least 1 year of function. Fur- studies were included. Further inclusion criteria were:
ther aims were to investigate if a relationship exists a minimum of 10 partially edentulous or completely
between marginal bone change and the survival rate edentulous patients rehabilitated with partial or
of axial and tilted implants over time and if factors complete fixed prosthesis supported by both axially
like the arch (maxilla vs. mandible) the type of pros- placed and tilted implants; a minimum follow-up
thesis (partial vs. complete) or the loading timing duration of 1 year; bone loss around tilted and axial
(immediate vs. delayed) could affect marginal bone implants clearly reported; survival rate for tilted and
changes. axial implants clearly indicated or calculable from
data provided; and implants placed in a pristine jaw-
bone without additional grafting.
Materials and methods Publications that did not meet the above inclu-
sion criteria and those that were not dealing with
Search methods original clinical cases (e.g. reviews, technical reports)
were excluded. Multiple publications of the same
An electronic search was performed on the following pool of patients were also excluded from the data-
databases: MEDLINE; Embase; and the Cochrane base. When papers from the same group of authors,
Central Register of Controlled Trials (CENTRAL). with very similar databases of patients, materials,
The last search was performed on 15 January, 2014. methods and outcomes were identified, the authors
The search terms used were: ‘dental implant*’; were contacted for clarifying if the pool of patients
‘oral implant*’; ‘tilted implant*’; ‘angled implant*’; was indeed the same. In case of multiple publications
‘angulated implant*’; ‘offset implant*’; ‘upright im- relative to consecutive phases of the same study,
plant*’; ‘straight implant*’; ‘axial implant*’; ‘eden- only the most recent data (those with the longer
tulous patient*’; ‘edentulous mandible’; ‘edentulous follow-up) were considered.
maxilla’; ‘All-on-four’; ‘All-on-4’, ‘All-on-six’; and
‘All-on-6’. They were used alone or in combination
Selection of the studies
using Boolean operators OR and AND. Furthermore,
a hand search of issues from 2000 up to the last Two reviewers (MDF and VC) independently
issue available on 15 January, 2014, including the screened the titles and the abstracts of the articles
‘Early view’ (or equivalent) section was undertaken initially retrieved through the electronic search. The
on the following journals: Clinical Implant Den- reviewers were previously calibrated by assessing
tistry and Related Research; Clinical Oral Implants a sample of 20 articles. The concordance between
Research; Implant Dentistry; European Journal of reviewers was assessed by means of the Cohen’s
Oral Implantology; International Journal of Oral Kappa coefficient. In case of disagreement, a joint
and Maxillofacial Surgery; International Journal decision was taken by discussion. The full texts of
of Prosthodontics; Journal of Implantology; Jour- all studies of possible relevance were independently
nal of Oral and Maxillofacial Surgery; Journal of assessed by the same two reviewers to check if they
Periodontology; Journal of Prosthetic Dentistry; met all inclusion criteria. For articles excluded at this
The International Journal of Oral and Maxillofacial stage, the reason for exclusion was noted.
Implants; and The International Journal of Perio-
dontics and Restorative Dentistry. The reference list
Data extraction
of the retrieved reviews and of the included stud-
ies was also searched for possible additional eligible Data were extracted by two reviewers independently
studies not identified by the electronic search. (MDF and VC). Cases of disagreement were subject

to joint evaluation until an agreement was reached. were imported in the software RevMan (Review
The following variables were extracted from each Manager [RevMan] Version 5.2, 2012; The Nor-
included study: study design; sample size; patient dic Cochrane Center, The Cochrane Collaboration,
gender and age; proportion of smokers; total num- Copenhagen, Denmark) for meta-analysis. For mar-
ber of implants; number, type and location of the ginal bone loss evaluation the mean value and standard
prostheses; follow-up duration; number of tilted and deviation of crestal bone level change and the number
upright implants; degree of tilting; number of failed of tilted and axial implants available for analysis in each
implants and details (time after loading, location; study were used. A random effect model was chosen.
reason for failure); number of patients experienc- The estimates of the bone level change around axial
ing implant failure; prosthesis success rate; mar- and tilted implants were expressed as mean difference
ginal bone level change around tilted and upright (mm) together with 95% confidence intervals (CI).
implants; occurrence and type of complications. The statistical evaluation was conducted considering
The following methodological parameters were the implant as the analysis unit. The contribution of
also recorded: for randomised studies (if any), the each article to the primary outcome was weighted
random sequence generation method and alloca- based on the sample size and standard deviation.
tion concealment; for all studies: clear definition of Subgroup analysis was performed taking into account
inclusion and exclusion criteria; clear definition of location (maxilla or mandible), angulation (tilted or
outcomes assessment and success criteria; number axial), loading timing (immediate or delayed), study
of surgeons involved; completeness of the outcome design (prospective or retrospective) and restoration
data reported; recall rate (it was assumed ade- type (partial or complete prosthesis).
quate if dropout <20%); explanation for dropouts/ Regarding implant survival, the estimates of the
withdrawal (when applicable); sample size (it was effects of an intervention were expressed as odds
assumed adequate if >20 patients were treated); and ratio (OR) together with 95% confidence intervals.
length of follow-up period (it was assumed ade- The statistical evaluation was conducted considering
quate if the mean duration was ≥3 years). Details on both the implant and the patient as the analysis unit.
the methods adopted for crestal bone level change Comparison among studies was performed by meta-
evaluation were also noted, such as: type of radio- analysis. ORs were combined using a fixed-effects
graphs and standardisation (periapical radiographs model (Mantel-Haenszel method). Pearson’s chi-
(PA) with an individual holder; PA without individual square analysis was used to investigate the effect of
holder, panoramic radiographs); blinding or inde- implant location, angulation, loading timing, study
pendency of evaluators. The methodological quality design and restoration type on implant survival at
of the selected studies was evaluated independently 1-year follow-up. P = 0.05 was considered as the
and in duplicate by two reviewers (MDF and VC) significance level.
according to the above methodological parameters.
All the criteria were assessed as adequate, unclear, or
inadequate. The authors of the included studies were Results
contacted for providing clarifications or missing in-
formation as needed. Studies were considered at low The flowchart summarising the screening process is
risk of bias if more than 2/3 of the nine parameters presented in Fig 1. The last electronic search was per-
were judged as adequate. formed on 15 January, 2014. The electronic search
yielded a total of 758 articles. No additional article was
found by the hand search. After a first screening of the
Statistical analysis
titles and abstracts, 62 articles were selected, which
In order to make comparisons between studies with reported results of clinical studies in which edentulous
different follow-up duration, the statistics were made patients have been rehabilitated using prostheses sup-
considering the 1-year data for all studies. Studies ported by axial and tilted implants14,15,20,26-84. The
reporting longer follow-ups were considered sep- Cohen’s kappa coefficient was 0.92, indicating excel-
arately. The data extracted from each included study lent agreement between reviewers.

Table 1 Excluded studies and reasons for exclusion.

758 articles identified
Titles and abstracts Excluded studies Reason for exclusion
Balshi et al, 201328 No details on marginal bone loss
696 articles excluded Francetti et al, 201330 No details on marginal bone loss
Tabrizi et al, 201333 No axial implants, only tilted ones
62 articles identified Testori et al, 201334 No details on marginal bone loss; grafting
Full text
Agnini et al, 201235 No details on bone loss; inadequate report of
failures
43 articles excluded Cavalli et al, 201236 Inadequate report of bone loss
Galindo et al, 201239 Inadequate report of bone loss
19 articles included data Malò et al, 201241 Inadequate report of bone loss
extraction and analysis
Acocella et al, 201145 Inadequate report of bone loss
Butura et al, 201146 Inadequate report of bone loss
Fig 1 Flowchart of the study selection process.
Butura et al, 201147 No details on marginal bone loss
Butura et al, 201148 Redundant publication (Butura et al, 201147)
After examining the full text of the 62 articles, 43 De Vico et al, 201150 Redundant publication (Pozzi et al, 201243)
of them were excluded from the review (Table 1). Of Franchini et al, 201151 Too few tilted implants (not in all patients)
the 19 remaining articles, 14 reported the results of Graves et al, 201152 Technical article; no details on marginal bone loss
prospective studies27,29,37,38,40,43,44,56,59,60,63,69,71,76 Graves et al, 201153 Redundant publication (Graves et al, 201152)
and five of retrospective studies20,31,32,42,72. No ran- Kawasaki et al, 201154 Inadequate report of failures and bone loss
domised clinical study was identified. Table 2 reports Parel et al, 201155 Inadequate report of failures and bone loss
the most relevant characteristics of the included stud- Agliardi et al, 201026 Redundant publication (Agliardi et al, 201056)
ies. The main outcomes of these studies are described Alves et al, 201057 No details on marginal bone loss
in Table 3. Of the 19 included studies, 11 have been Balleri et al, 201058 Peculiar clinical procedure; no details on marginal
performed in Italy37,38,40,43,44,56,59,63,69,71,76, two Corbella et al, 201149 No details of implants and failures, no bone loss
in Spain20,42, and one each in Austria31, Belgium27, report
China29, Germany60, Portugal32, and Sweden72. All Peñarrocha et al, 201061 Redundant publication (Peñarrocha et al, 201242)
studies were conducted at universities or specialist Pomares et al, 201062 Inadequate report of bone loss
dental clinics. Fortin et al, 200964 No bone loss report
A total number of 2993 implants, of which Pancko et al, 200965 No axial implants, no bone loss report
112 (3.74%) had a machined surface, were origi- Agliardi et al, 200866 Redundant publication
nally inserted in 670 patients rehabilitated with 91 Bilhan et al, 200867 Case report (1 patient)
partial and 625 complete fixed prostheses (415 in Francetti et al, 200868 Redundant publication (Francetti et al, 201238)
the maxilla, 301 in the mandible). Of the placed Testori et al, 200870 Redundant publication (Capelli, 200771)
implants, 1494 were axial and 1338 tilted. These Malò et al, 200773 Inadequate report of bone loss
2832 implants were submitted to statistical analysis Rosén and Gynther, 200774 Inadequate report of bone loss
regarding implant survival. Other implants were not Malò et al, 200678 Inadequate report of bone loss
considered because they were inserted in unusual Krennmair et al, 200577 Inadequate report of bone loss
regions and/or could not be regarded as axial nor Malò et al, 200578 Inadequate report, few hollow cylinder tilted
implants
as tilted (e.g. in the study by Peñarrocha et al42 in
Karoussis et al, 200479 Inadequate report of bone loss
the same patients in which axial and tilted implants
Malò et al, 200315 Inadequate report on patients & bone loss
were placed, 55 implants were pterigomaxillary
or zygomatic or placed in the frontomaxillary re- Aparicio et al, 200280 Inadequate report of bone loss
gion, and in the study by Malò et al32 there were Fortin et al, 200281 Inadequate report of bone loss
83 trans-sinus implants). A total of 1576 maxil- Krekmanov et al, 200014 Inadequate report of bone loss
lary (904 axial, 742 tilted) and 1171 mandibular Krekmanov et al, 200082 Inadequate report and partially redundant
(Krekmanov et al, 200014)
implants (590 axial, 581 tilted) was considered for
Mattsson et al, 200083 Inadequate report of bone loss
the analysis on marginal bone level change.

Table 2 Characteristics of the included studies.
S176
Articles Study Setting No. of % Men/ Mean age Smokers Total No. maxillary No. mandiblu- Type of res- Follow-up dura-
Type patients women (range) No. of prostheses lar prostheses toration tion, months
implants (implants) (implants) (range)
Browaeys et al, 201427 P University 20 30% / 70% 55 (35–74) NR 80 9 (36) 11 (44) Full-arch 36
Di et al, 201329 P University 69 54% / 46% 56.7 (37–74) NR 344 38 (152) 48 (192) Full-arch 33.7 (12–56)
Krennmair et al, R University 38 39% / 61% 67.1 (NR) 18% 152 - 38 (152) Full-arch 66.5 (5–7 yrs)
201331
Malò et al, 201332 R Private Centre 70 41% / 59% 54 (35–81) 27% 280 70 (280) - Full-arch 36
Crespi et al, 201237 P University 36 39% / 61% 54.6 (41–81) 39% 176 24 (96) 20 (80) Full-arch 36
Francetti et al, 201238 P University 47 53% / 47% 53 (44–63) 32% 196 16 (64) 33 (132) Full-arch 36 max. 60 mand.
Grandi et al, 201240 P 1 Private 2 47 47% / 53% 62 (52–78) 23% 188 - 47 (188) Full-arch 18
Univ. centres
Del Fabbro / Ceresoli
Peñarrocha et al, R University 18 33% / 67% NR (35–69) 39% 117 18 (62)* - Full-arch 39.2 (12–84)
201242
Pozzi et al, 201243 P University 27 56% / 44% 54 (38–77) NR 81 37(81) - FPD 43.3 (36–54)
Weinstein et al, P University 20 40% / 60% 60.8 (44–77) 20% 80 - 20 (80) Full-arch 30.1 (20–48)
201244
Agliardi et al, 201056 P Private Centre 24 42% / 58% 56.4 (42–73) 25% 96 - 24 (96) Full-arch 26.8 (14–42)

Degidi et al, 201059 P Private Centre 30 53% / 47% 58.1 (NR) NR 210 30 (210) - Full-arch** 36
Bone loss around tilted implants
Hinze et al, 201060 P Private Centre 37 49% / 51% 64.6 (39–84) 30% 148 19 (76) 18 (72) Full-arch 12
Agliardi et al, 200963 P University 20 55% / 45% 57 (44–68) 35% 120 20 (120) - Full-arch 27.2 (18–42)
Tealdo et al, 200869 P University 21 52% / 48% 58 (NR) NR 111 21 (111) - Full-arch 20 (13–28)
Capelli et al, 200771 P University 65 34% / 66% 59.2 (28–83) 15% 342 41 (246) 24 (96) Full-arch 55 (33–82)
Koutouzis and R University 38 53% / 47% 59.5 (NR) 26% 111 24 (40) 18 (39) FPD 60
Wennstrom, 200772
Calandriello and P Private Centre 18 39% / 61% 64 (51–76) heavy 60 19 (60) - 12 FPD 7 12
Tomatis, 200576 smokers full-arch
excluded
Aparicio et al, 200120 R University 25 40% / 60% 59 (M) 49 (F) 24% 101 29 (101) - 29 FPD 37 (21–87)
P = prospective; R = retrospective; NR = not reported; * only tilted (n = 30) and conventionally placed axial implants (n = 32) were considered; **the implants were all splinted by a
welded bar.
Table 3 Main outcomes of the included studies.
Articles Inserted implants PSR Location of 12 m bone loss, mm (no. of >12 m bone loss, mm (no. of Complications reported
(failures) failed implants implants) implants)
axial tilted axial tilted axial tilted
Browaeys et 40 40 100% – 1.13 ± 0.71 1.14 ± 1.,14 1.55 ± 0.73 1.67 ± 1.22
al, 201427 (n = 32) (n = 32) (n = 32) (n = 32)
Di et al, 172 172 100% 11 maxilla 0.7 ± 0.2 0.8 ± 0.4 3 abutment screw loosened, 5 artificial teeth
201329 (1 ax, 10 tilt), (n = 148) (n = 148) separated from the acrylic resin base. Fracture
2 mandible near the implant metal coping in 3 provisional
(1 ax 1 tilted) restorations.
Krennmair et 76 76 100% – – – 1.17 ± 0.26 1.24 ± 0.32 256 in total (described in details in a table).
al, 201331 (n = 76) (n = 76)
Malò et al, 140(1) 57(1)* 100% Maxilla 0.62 ± 0.35 0.89 ± 0.54 1.15 ± 0.51 1.06±0.71 Mechanical complications in 36 patients
201332 (n = 114/135) (n = 47/55) (n = 88/123) (n = 40/50) (28 prosthetic screw loosening, 8 prosthe-
sis fracture); Biological complications in 26
patients/30 implants: bone resorption and BoP
(11), fistulae (2), excessive bone loss (2).
Crespi et al, 88 88 (3) 100% 1 maxilla Maxilla: Maxilla: Maxilla: Maxilla: 1 case of mucositis around 1 axial implant.
201237 2 mandible 1.02 ± 0.35 1.05 ± 0.29 1.08 ± 0.4 1.07 ± 0.46
(n = 48) (n = 47) (n = 48; 24m) (n = 47; 24 m)
1.10 ± 0.45 1.11 ± 0.32
(n = 48; 36m) (n = 47; 36 m)
Mandible: Mandible: Mandible: Mandible:
1.04 ± 0.30 1.05 ± 0.32 1.04 ± 0.35 1.09 ± 0.29

(n = 40) (n = 38) (n = 40; 24 m) (n = 38; 24 m)
1.06 ± 0.41 1.12 ± 0.35
(n = 40; 36 m) (n = 38; 36 m)
Francetti et 98 98 100% – Maxilla: Maxilla: Maxilla: Maxilla: Light hypoaesthesia on the left side of the
al, 201238 0.40 ± 0.27 0.32 ± 0.28 0.44 ± 0.37 0.63 ± 0.38 lower lip after surgery, resolved after 6
(n = 32) (n = 32) (n = 32; 24 m) (n = 32; 24 m) months (1 patient); fracture of the acrylic
0.85 ± 0.74 0.85 ± 0.34 prosthesis (7 patients); 3 axial implants
(n = 14; 36 m) (n = 14; 36 m) showed peri-implantitis after 3 y (3 mm bone
loss).
Mandible: Mandible: Mandible: Mandible:
0.57 ± 0.42 0.48 ± 0.23 0.90 ± 0.49 0.67 ± 0.38
(n = 66) (n = 66) (n = 64; 24 m) (n = 64; 24 m)
0.92 ± 0.43 0.69 ± 0.52

(n = 54; 36 m) (n = 54; 36 m)
0.51 ± 0.17 0.39 ± 0.18
(n = 24; 60 m) (n = 24; 60 m)
Grandi et al, 94 94 100% – 0.57 ± 0.13 0.60 ± 0.16 0.68 ± 0.14 0.68 ± 0.14 Three patients had a fracture of the provi-
201240 (n = 94) (n = 94) (n = 94; 18 m) (n = 94; 18 m) sional restoration, but all of the definitive
prostheses remained stable throughout the
study period without any complications.
Peñarrocha 32 (2) 30 (1) 100% 3 maxilla 0,52 ± 0,10 0,76 ± 0.06 – – NR
et al, 201242 (n = 32) (n = 30)
S177
Table 3 (cont.) Main outcomes of the included studies.
S178
Articles Inserted implants PSR Location of 12 m bone loss, mm (no. of >12 m bone loss, mm (no. of Complications reported
(failures) failed implants implants) implants)
axial tilted axial tilted axial tilted
Pozzi et al, 39 (1) 42 (2) 100% 3 maxilla 0.48 ± 0.3 Ant: 0.6 ± 0.5 ± 0.3 Ant: 0.7 ± 0.38 No biological or mechanical complications
201243 (1 patient) (n = 38) 0.38 (n = 38. 36m) (n = 14; 36 m) occurred during the entire follow-up period.
(n = 14) Post: 0.7 ± 0.2
Post: 0.62 ± (n = 26; 36 m)
0.37
(n = 26)
Weinstein et 40 40 100% – 0.6 ± 0.3 0.7± 0.4 – – NR
al, 201244 (n = 36) (n = 36)
Agliardi et al, 48 48 100% – 0.9 ± 0.4 0.8 ± 0.5 – – No complication during surgical and prosthetic
201056 (n = 42) (n = 42) procedures.
Degidi et al, 90 (1) 120 100% maxilla 0.60 ± 0.11 0.63 ± 0.24 0.92 ± 0.89 1.03 ± 0.87 Three implants had serious biologic complica-
201059 (n = 89) (n = 120) (n = 89; 36 m) (n = 120; 36 m) tion (peri-implantitis).
Hinze et al, 74 (3) 74 (4) 100% Tilted: 0.82 ± 0.31 0.76 ± 0.49 – – 4 fractures of provisional prostheses. One
201060 3 maxilla (n = 71) (n = 70) fracture of definitive prosthesis. Loss of the
1 mandible screw access hole restoration in 9.5% of the
cases. Occlusal screw loosening in 6% of
Axial:
cases. Extensive bruising in 2 patients.
3 maxilla
Agliardi et al, 40 80 100% – 0.8 ± 0.4 0.9 ± 0.5 – – No complications occurred during surgical and
200963 (n = 30) (n = 60) prosthetic procedures.

Tealdo et al, 64 (3) 47 (5) 100% maxilla Mesial: 0.62 Mesial 0.92 – – No loose abutment screws nor reported frac-
200869 (n = 61); (n = 42); tures of prosthesis frameworks.
Distal 0.86 Distal 1.04
(n = 61) (n = 42)
Capelli et al, 189 (2) 117 (1) 100% maxilla Maxilla: Maxilla: – – Two more implants failures (1 axial and 1
200771 0.95 ± 0.44 0.88 ± 0.59 tilted in maxilla) were recorded during the
(n = 84); (n = 42); second year of function.
Mandible: Mandible:
0.82 ± 0.64 0.75 ± 0.55
(n = 32) (n = 32)
Kout- 36 33 100% – – – 0.4 ± 0.94 0.5 ± 0.95 Three implant fractures, three cases with
ouzis and (n = 36; 60 m) (n = 33; 60 m) crown-screw loosening and three cases with
Wennstrom, minor porcelain fractures.
200772
Calandriello 33 (1) 27 (1) 100% maxilla 0.82 ± 0.86 0.34 ± 0.76 – – One fracture of the acrylic bridge that prob-
and Tomatis, (n = 32) (n = 26) ably lead to implant failure.
200576
Aparicio et 59 (2) 42 100% maxilla 0.43 ± 0.45 0.57 ± 0.50 0.92 ± 0.55 1.21 ± 0.68 28 mechanical incidents in 16 prostheses
al, 200120 (n = 53) (n = 40) (n = 12; 60 m) (n = 12; 60 m) (55.2%). 18 retightening of the abutment
screw in 14 prostheses, gold screw retighten-
ing in five prostheses. Fracture of the abut-
ment screws and of the occlusal material was
in two prostheses.
* in adjunct, 83 trans-sinus tilted implants were placed; NR = not reported.

Study or subgroup axial tilted Mean difference Mean difference Fig 2 Forest plot of
Mean SD Total Mean SD Total Weight IV, Random, 95% Year IV, Random, 95% CI (mm) the mean differences
(mm) (mm) (mm) (mm) CI (mm)
Aparicio et al, 200120 0.43 0.45 57 0.57 0.5 42 5.0% -0.14 [-0.33, 0.05] 2001 in marginal bone level
Calandriello et al, 200576 0.82 0.86 35 0.34 0.76 26 2.0% 0.48 [0.07, 0.89] 2005 change between axial
Capelli et al, 2007 71 0.91 0.58 116 0.81 0.57 74 5.5% 0.10 [-0.07, 0.27] 2007
69
and tilted implants in
Tealdo et al, 2008 0.74 0.5 61 0.98 0.5 42 4.8% -0.24 [-0.44, -0.04] 2008
Agliardi et al, 2009 63 0.8 0.4 30 0.9 0.5 60 5.0% -0.10 [-0.29, 0.09] 2009
the included studies at
Hinze et al, 201060 0.82 0.31 71 0.76 0.49 70 6.3% 0.06 [-0.08, 0.20] 2010 12-months follow-up.
Degidi et al, 201059 0.6 0.11 89 0.63 0.24 120 8.3% -0.03 [-0.08, 0.02] 2010
Agliardi et al, 201056 0.9 0.4 42 0.8 0.5 42 4.9% 0.10 [-0.09, 0.29] 2010
Pozzi et al, 201243 0.48 0.3 38 0.61 0.38 40 5.9% -0.13 [-0.28, 0.02] 2012
Crespi et al, 2012 37 1.03 0.33 88 1.05 0.31 85 7.3% -0.02 [-0.12, 0.08] 2012
Grandi et al, 201240 0.57 0.13 94 0.6 0.16 94 8.4% -0.03 [-0.07, 0.01] 2012
Weinstein et al, 201244 0.6 0.3 36 0.7 0.4 36 5.6% -0.10 [-0.26, 0.06] 2012
Peñarrocha et al, 201242 0.52 0.1 32 0.76 0.06 30 8.4% -0.24 [-0.28, -0.20] 2012
Francetti et al, 201238 0.51 0.37 98 0.43 0.25 98 7.5% 0.08 [-0.01, 0.17] 2012
Di et al, 201329 0.7 0.2 148 0.8 0.4148 7.9% -0.10 [-0.17, -0.03] 2013
Malo et al, 2013 32 0.62 0.35 114 0.89 0.54 47 5.5% -0.27 [-0.44, -0.10] 2013
Browaeys et al, 201427 1.13 0.71 32 1.14 1.14 32 1.6% -0.01 [-0.48, 0.46] 2014
Total (95% CI) 1181 1086 100.0% -0.06 [-0.12, 0.01]
Heterogeneity: Tau² = 0.01; Chi² = 110.31, df = 16 (P < 0.00001); I² = 85%
Test for overall effect: Z = 1.72 (P = 0.09)
–1 –0.5 0 0.5 1
Favours axial Favours tilted
Study or subgroup axial tilted Mean difference Mean difference Fig 3 Forest plot of
Mean SD Total Mean SD Total Weight IV, Random, 95% Year IV, Random, 95% CI (mm) the mean differences
(mm) (mm) (mm) (mm) CI (mm)
Aparicio et al, 200120 0.92 0.55 13 1.21 0.68 12 3.5% -0.29 [-0.78, 0.20] 2001 in marginal bone level
Koutouzis & Wennstrom, 200772 0.4 0.94 36 0.5 0.95 33 4.0% -0.10 [-0.55, 0.35] 2007 change between axial
Degidi et al, 2010 59 0.92 0.89 89 1.03 0.87 120 9.6% -0.11 [-0.35, 0.13] 2010 and tilted implants in
Crespi et al, 201237 1.08 0.43 88 1.115 0.33 85 17.5% -0.03 [-0.15, 0.08] 2012
Pozzi et al, 201243 0.5 0.3 94 0.7 0.3 94 19.5% -0.20 [-0.29, -0.11] 2012
the six included studies
Francetti et al, 201238 0.91 0.49 68 0.72 0.48 68 14.0% 0.19 [0.03, 0.35] 2012 reporting data of at
Malo et al, 201332 1.15 0.51 88 1.06 0.71 40 9.5% 0.09 [-0.15, 0.33] 2013 least 36-months follow-
Krennmair et al, 2013 31 1.17 0.26 76 1.24 0.32 76 19.0% -0.07 [-0.16, 0.02] 2013
Browaeys et al, 2014 27 1.55 0.73 32 1.67 1.22 32 3.4% -0.12 [-0.61, 0.37] 2014
up.
Total (95% CI) 1181 1086 100.0% -0.06 [-0.12, 0.01]
Heterogeneity: Tau² = 0.01; Chi² = 21.36, df = 8 (P < 0.006); I² = 63%
Test for overall effect: Z = 1.04 (P = 0.30) –1 –0.5 0 0.5 1
Crestal bone level change At least 36-months follow-up (nine

studies)
One-year follow-up (seventeen studies) Nine studies evaluated marginal bone level change
The results of the random effects meta-analysis for around axial and tilted implants after at least 36
marginal bone level change around axial vs. tilted months of loading20,27,31,32,37,38,43,59,72. The meta-
implants at 12 months are presented in Fig 2. Two analysis relative to these studies is shown in Fig 3.
studies provided results at 5 years only31,72, there- Again, a trend for lower marginal bone level change
fore they were not included in this meta-analysis. in favour of the axial implants was found (-0.05 mm,
The comparison between axial and tilted implants 95% C.I.: -0.15, 0.05) but did not achieve signifi-
across the 17 studies (Fig 2) showed considerable cance (P = 0.30).
statistical heterogeneity (I2 = 0.85%, P < 0.001).
No significant difference was found (P = 0.09), with
Prosthesis type (sixteen studies)
a slight discrepancy in favour of the axially placed
implants (mean difference in bone loss -0.06 mm When separating the data according to the prosthe-
(95% C.I.: -0.12, 0.01)). Only one study reported sis type, a significant difference in marginal bone loss
significantly lower bone loss for tilted implants as in favour of axial implants was found for fixed par-
compared to axial ones76. A sensitivity analysis was tial prostheses (P = 0.03, mean difference -0.13 mm,
also performed by excluding such a study, but the 95% C.I.: -0.25, -0.02) but not for full-arch fixed
result did not substantially change, though slight prostheses (P = 0.09, mean difference -0.06 mm,
significance was achieved (P = 0.04, mean differ- 95% C.I.: -0.13, 0.01). The study by Calandriello
ence in bone loss -0.07 mm (95% C.I.: -0.13, 0.00)), and Tomatis76 was not considered because the
confirming the robustness of the analysis. bone loss data for full-arch and partial prostheses

Fig 4 Forest plot of Study or subgroup axial tilted Odds Ratio Odds Ratio
the differences in im- Events Total Events Total Weight M-H, Fixed, 95% CI Year M-H, Fixed, 95% CI
plant survival between Aparicio et al, 200120 2 57 0 42 1.8% 3.83 [0.18, 81.87] 2001
axial and tilted implants Calandriello et al, 200576 1 25 1 16 3.8% 0.63 [0.04, 10.76] 2005
Koutouzis & Wennstrom, 200772 0 36 0 33 Not estimable 2007
in the included studies
Capelli et al, 200771 2 162 1 103 3.9% 1.27 [0.11, 14.24] 2007
at 12-months follow-up.
Tealdo et al, 200869 3 61 5 42 18.3% 0.38 [0.09, 1.70] 2008
Agliardi et al, 200963 0 40 0 80 Not estimable 2009
Hinze et al, 201060 3 71 4 70 12.5% 0.73 [0.16, 3.38] 2010
Degidi et al, 201059 1 88 0 119 1.4% 4.10 [0.16, 101.77] 2010
Agliardi et al, 201056 0 24 0 24 Not estimable 2010
Pozzi et al, 201243 1 38 2 40 6.2% 0.51 [0.04, 5.91] 2012
Crespi et al, 201237 0 88 3 85 11.5% 0.13 [0.01, 2.62] 2012
Francetti et al, 201238 0 98 0 98 Not estimable 2012
Peñarrocha et al, 201242 2 30 1 29 3.1% 2.00 [0.17, 23.34] 2012
Grandi et al, 201240 0 94 0 94 Not estimable 2012
Weinstein et al, 201244 0 40 0 40 Not estimable 2012
Malo et al, 201332 1 135 0 55 2.3% 1.24 [0.05, 30.85] 2013
Di et al, 201329 2 172 11 172 35.3% 0.17 [0.04, 0.79] 2013
Krennmair et al, 201331 0 76 0 76 Not estimable 2013
Browaeys et al, 201427 0 40 0 40 Not estimable 2014
Total (95% CI) 1375 1258 100.0% 0.56 [0.31, 1.00]
Total events 18 28
Total (95% CI) 1181 100.0% -0.06 [-0.12, 0.01]
Heterogeneity: Chi² = 8.28, df = 10 (P = 0.60); I² = 0%
Test for overall effect: Z = 1.97 (P = 0.05)
0.002 0.1 0 500
were not reported separately. The study by Krenn- loss around axial and tilted implants was found
mair et al31 and Koutouzis et al72 provided bone at 12-months follow-up in 14 prospective stud-
loss data on fixed partial dentures relative only to ies27,29,37,38,40,43,44,56,59,60,63,69,71,76
5-year follow-up, so they were excluded from this (P = 0.32, mean difference -0.02 mm, 95% C.I.:
subgroup analysis. -0.07, 0.02), while significant difference in favour of
axial implants was found in three retrospective stud-
ies20,32,42 (P <0.001, mean difference -0.24 mm,
Implant location (fifteen studies)
95% C.I.: -0.28, -0.20). Again, the retrospective
When considering the data from the maxilla and studies by Krennmair et al31 and Koutouzis et al72
from the mandible separately, no significant dif- were not considered because they only reported
ference was found in marginal bone loss between 5-year data.
axial and tilted implants at 12-months follow-up in
both jaws. For maxillary implants the mean differ-
Loading timing (eighteen studies)
ence in bone loss was -0.08 mm, 95% C.I.: -0.17,
0.01 (P = 0.09) and for the mandibular implants it A similar result was found when considering the
was 0.00 mm, 95% C.I.: -0.06, 0.05 (P = 0.96). The studies separately according to loading timing. In
studies by Hinze et al60, Di et al29 and Browaeys et fact, 14 of the 15 immediate loading studies were
al27 were not considered because the bone loss data the same prospective studies considered above.
of axial and tilted implants relative to maxilla and Only one study adopting immediate loading pro-
mandible were not reported separately. Conversely, tocol had a retrospective design32. Two studies in
the study by Koutouzis et al72 reported separately which conventional delayed loading procedure was
the bone loss data for maxilla and mandible, but only adopted20,42 showed significant difference in bone
5-year data were provided. loss in favour of axial implants (P <0.001, mean
difference -0.24 mm, 95% C.I.: -0.28, -0.19). The
overall sample size of implants rehabilitated accord-
Study design (eighteen studies)
ing to a delayed loading protocol was consistently
When separating the studies according to the lower than immediately loaded implants (n = 161
study design, no significant difference in bone and 2106, respectively).

Table 4 Results of the comparisons of implant survival at 12-months follow-up for

SE(log[OR])
0 axial and tilted implants according to loading time and location.
P value Tilted vs. axial

0.5
(chi square)
Tilted Axial Tilted Axial
ISR% ISR% N. N.
1
Total 0.481 97.9% 98.8% 1338 1494
1.5
Delayed 0.849 99.4% 98.1% 181 213
Immediate 0.225 97.7% 98.9% 1157 1281

OR
2 Maxilla total 0.545 96.8% 98.1% 742 904
0.002 0.1 1 10 500
Maxilla delayed 0.860 98.9% 96.5% 90 113

Fig 5 Funnel plot of the studies reporting implant survival
for axial and tilted implants at 12-months follow-up, show- Maxilla immediate 0.266 96.5% 98.4% 652 791
ing homogeneity among studies.
Mandible total 0.763 99.3% 99.8% 581 590
Mandible delayed 1.000 100.0% 100.0% 91 100

Implant survival
Mandible immediate 0.771 99.2% 99.8% 490 490
A total number of 46 implants (1.54%) failed in 38
P value Maxilla vs. mandible
patients (6.58%) during the first year of function. (chi square)
Maxilla Mandible Maxilla Mandible
The reasons for failure were: mobility/lack of osseo- ISR% ISR% total total
integration (n = 31); mobility and pain (n = 2); pain
Total <0.001* 97.4% 99.6% 1576 1171
(n = 3); while for 10 implants (22%) no reason was
reported. Two maxillary implants (one axial and one Tilted 0.037* 96.8% 99.3% 742 581
tilted) failed in two patients later than 1 year, after Axial 0.003* 98.1% 99.8% 904 590
15 and 18 months of function71 and another maxil-
* = significant difference.
lary tilted implant failed after 23 months in another
patient32. Of the implants that failed within 12
months, 18 were axial and 28 tilted and all but five Table 4 reports the results of the comparisons of
implants (one axial and four tilted) were placed in implant survival between axial and tilted implants
the maxilla. Two of the failed implants (one axial and according to the arch and the loading mode, as well
one tilted, both in maxilla) had a machined surface76. as comparisons between survival rates of maxil-
One-year implant survival was 97.4% and 99.6% lary and mandibular implants. Implants placed in
for the maxilla and the mandible, respectively. No the mandible (independent of the inclination) dis-
prosthesis failure was reported in any of the evalu- played a significantly better survival rate after 12
ated studies. Consequently, no further analysis was months as compared to maxillary ones (P <0.001).
performed at prosthesis level. This trend was confirmed when the analysis was
The results of the fixed effects meta-analysis for performed separately for tilted (P = 0.037) and
implant survival at 1 year is presented in Fig 4. Con- axial implants (P = 0.003). When performing the
sidering the outcome of tilted versus axial implants in analysis at patient level, no significant difference
both jaws, slightly statistically significant difference in implant survival rate was found according to the
in favour of axial implants (OR = 0.56, 95% CI: 0.31, loading mode (P = 1.00), while a significant differ-
1.00, P = 0.05) and no heterogeneity was found ence was found according to the arch, with patients
(Fig 5). In this analysis, a single recent study had a rehabilitated in the mandible experiencing signifi-
consistent influence on such result, as its weight was cantly fewer implant failures than patients treated
more than one-third (35.3%) of the overall stud- with maxillary prostheses (P = 0.01).
ies29. Sensitivity analysis performed excluding this As most of the failed implants were located in
study showed no significant difference in implant the maxilla, a further meta-analysis was conducted
survival between axial and tilted implants (P = 0.43). on 14 studies that reported 1-year treatment out-

supported by 4 implants according to the all-on-four
Blinding of outcome assessment (detection bias)

concept (total n. implants = 704) or supported by 5
to 7 implants (n = 777 implants), respectively. The
Incomplete outcome data (attrition bias)

difference was not significant (P = 0.96).
Definition of outcome assessment

Definition of selection criteria
Complications
RX examination method
The most common complications described in the
included studies were fracture of the temporary
Follow-up length
No. of surgeons
acrylic prosthesis and screw loosening (Table 3).

Study design
Sample size
No significant relationship with the arch was found
for such mechanical complications. A few authors
reported wear patterns in the opposing dentition41.
Agliardi et al, 2009 + + + + + + + + – L
Most of patients that experienced fracture of the
prosthetic reconstruction orloosening of the pros-
Agliardi et al, 2010 + + + + – ? + + – H
thetic screw displayed parafunctions like bruxism41,43
Aparicio et al, 2001 – – + + – ? + + + H or had a short face morphotype with powerful mas-
Browaeys et al. 2014 + + + + – + + + + L tication muscles46,48.
Calandriello et al, 2005 + – + + + + + – – H
Capelli et al, 2007 + – + – + + – + + H

Other outcome variables
Crespi et al, 2012 + ? + + – – + + + H In studies that assessed parameters related to oral

hygiene level, plaque and bleeding scores pro-
Degidi et al, 2010 + + + + + ? + + + L
gressively decreased over the first year of func-
Di et al, 2013 + – + + – ? + + – H tion38,44,56,59,60,63. Two studies with longer follow-
Francetti et al, 2012 + – + + + + + + + L up reported substantial maintenance of plaque and
bleeding scores up to 5 years31,38. Finally, all studies
Grandi et al, 2012 + – + + + + + + L
that evaluated patient satisfaction by means of ques-
Hinze et al, 2010 + – + + – ? + + H tionnaires or interviews reported extremely positive
Koutouzis et al, 2007 – – + + + + + + + L feedback of patients regarding function, phonetics
– + + – + + +
and aesthetics after 1 year of loading32,38,44,56,63.
Krennmair 2013 ? ? H
Malo et al, 2013 – ? + + ? – + + + H

Quality assessment/risk of bias of the
Peñearrocha et al, 2012 – + + + + ? + – + H
included studies
Pozzi et al, 2012 + ? + + + + + + + L
According to the criteria established in this review,
Tealdo et al, 2008 + ? + + + + + – H
eleven studies20,29,31,32,37,42,56,60,69,71,76 were con-
Weinstein et al, 2012 + + + + – + + + – L sidered to have a high potential risk of bias and
eight27,38,40,43,44,59,63,72 having a low risk (Fig 6).
Fig 6 Risk of bias summary: review authors’ judgements about each risk of bias item
for each included study (H = high risk of bias; L = low risk of bias). Of the five retrospective studies, only the study
by Koutouzis et al72 was considered at low risk of
bias. The most critical parameter was the number
comes for the maxilla (in total 870 axial and 716 of surgeons involved, which was not declared in
tilted implants). Again, significant difference favour- five studies31,32,37,43,69 and was greater than one
ing axial implants (OR = 0.45, 95% CI: 0.24, 0.83, in another seven studies20,29,38,40,60,71,76. One of
P = 0.01) and no heterogeneity was found. them declared that surgeries have been performed
The 1-year implant survival rate was at 97.2% by a “surgical team”69. The bone loss assessment
and 97.8% for maxillary complete rehabilitations method in six studies was based on non standard-

ised periapical radiographs 20,27,31,32,40,76 , and in ies used panoramic radiographs and, when possi-
three studies it was performed using only panoramic ble, periapical films, but did not specify the relative
radiographs29,37,60. Finally, eight studies reported a proportion of both techniques44,63. Standardised
mean follow-up shorter than 3 years (see Table 2). periapical radiographs should be adopted whenever
possible because they have a better accuracy than
panoramic radiographs, estimated within a range
Discussion of 0.2 mm from actual values85. In adjunct to a low
resolution, panoramic radiographs may cause image
The aim of this review was to determine the trend of distortion rate averaging up to 25%86. However, it
marginal bone loss around axial and tilted implants has to be acknowledged that in cases of extremely
supporting partial and full-arch rehabilitations, after atrophic jaws in patients with a shallow vestibule, it
at least 1 year of function. For this reason, some might be practically very difficult to take periapical
studies with a large sample size and/or long term radiographs. Furthermore, in nine studies the radio-
follow-up that reported details on the survival/suc- graphic evaluation was reported to be performed by
cess of axial and tilted implants, but not on crestal a non-independent/not blinded evaluator or was not
bone level changes around axial and tilted implants specified20,29,31,32,37,42,56,59,60. Therefore, the non
have been excluded from the present review. A dif- systematic use of a standardised technique aiming
ferent situation was represented by the study by at obtaining a precise and reproducible bone loss
Agnini et al, which correctly reported the results of measurement poses an experimental limitation and
bone loss evaluation separately for tilted and axially suggests that the results of the present review should
placed implants for the maxilla and mandible, up to 5 be cautiously interpreted.
years of function35. However, it had to be excluded, The meta-analyses comparing axial versus tilted
because not all patients received tilted implants and implants were performed at implant level. In fact,
the bone loss data of those patients treated with since all patients received both axial and tilted
both tilted and axial implants could not be separated implants and no individual data was provided, it was
from the overall data. not feasible to present results at patient level. The
The level of evidence of the included studies was analysis took into account different factors. Consid-
rather poor because no randomised clinical trials ering the overall studies, peri-implant bone loss at 1
neither comparative prospective trials were found. year of function did not show significant difference
The included studies were mostly prospective single between axial and tilted implants, although there
cohort or multicentre studies. The study quality was a trend in favour of the axially placed implants.
assessment showed that more than half of the stud- Only the study of Calandriello and Tomatis, which
ies were at high risk of bias. Among the parameters also included partial prostheses, was discordant with
that were considered to potentially affect the reli- such a trend76. In that study, lower bone loss values
ability of the study outcomes was the procedure for for tilted implants were recorded, as compared to
radiographically evaluating the peri-implant bone axial ones. The authors suggested that this could be
loss. Since the main aim of the present review was related to the position of the implant neck relative to
to assess changes in peri-implant bone level around the bone crest: mesially, the neck was in a supracrestal
tilted and axial implants, particular emphasis was position, while distally it was positioned subcrestally,
dedicated to parameters related to such outcome. resulting in a favourable soft tissue seal76. It should
In fact, the quality of the radiographic method be considered that in the study by Calandriello and
adopted might potentially affect the accuracy of Tomatis76, partial and complete restorations were
the measurements. Of the 19 included studies only analysed together, even though a different perfor-
eight (42%) adopted a standardised paralleling tech- mance could be expected, given the biomechanical
nique based on periapical radiographs taken with differences between complete and partial prosthetic
an individual film holder, while others used non rehabilitations. However, after performing a sensitiv-
standardised periapical radiographs (five studies) or ity analysis by excluding this specific study, the result
panoramic radiographs (three studies). Two stud- did not substantially change, suggesting that the

weight of this study was negligible, and highlighting is applied vertically24. Furthermore, tensile stresses
the robustness of the meta-analysis. were shown to peak on the opposite side of the
In all the included studies, limited peri-implant inclination87, posing tilted implants in a situation
bone loss was observed over a follow-up period of nonhomogeneous stress pattern88. In vivo ani-
of 1 year, the greatest value reported averaging mal studies showed that both cortical and trabecu-
1.13 mm and 1.14 mm around axial and tilted lar bone remodelling is greater around non-axially
implants, respectively27. In the nine studies report- placed implants under loading89-90. Nevertheless the
ing peri-implant bone loss after 3 or more years present meta-analysis, like the previously published
of function, a similar trend was observed, that is ones, did not support the hypothesis of greater bone
an overall limited bone loss around axial and tilted loss around tilted implants.
implants, with the latter presenting slightly higher The use of posterior tilting of the implants pre-
(but not significant) bone loss values (Fig 3). The sents some biomechanical advantages as compared
subgroup analysis showed that such a trend was to the configuration based fairly axial position for all
unaffected by the arch and the prosthesis type, implants22-23. This could be due to several reasons.
and a significant difference was achieved in the For example, tilting of the implants may allow using
delayed loading studies but not in the immediate longer implants that may engage greater quantity
loading ones. However, one should consider that of residual bone, which is beneficial to implant sta-
the sample size of delayed loading studies is very bility. In the majority of studies on tilted implants,
small respect to the immediate loading cases, pre- length ranged from at least 10 mm up to 20 mm20.
venting any comparison. When increasing implant length, a more even dis-
The results of the present review are slightly distribution of stress around implants is achieved as
cordant with another recent meta-analysis on a simi- shown by a number of computer-simulated stud-
lar topic18. That review found that marginal bone loss ies91-94. Further important means for reducing
was lower (though not significantly) around tilted as stress around tilted implant necks are splinting
compared to axial implants at 12 months, while the into a fixed suprastructure and shortening of the
trend reversed in favour of the axial implants in stud- distal cantilever, both producing favourable bio-
ies with follow-up greater than 1 year. Our review mechanical situations21,95-96. These features were
adopted similar inclusion criteria but since we could observed in most of the prosthetic configurations
count upon a more extended database of studies, of the included studies. In all studies, tilted implants
a greater number of patients could be included. In were splinted in both partial and full-arch recon-
fact most of the recent studies report a slight dif- structions. The distalisation of the implant platform
ference in bone loss in favour of axial implants at reduces the moments of force, improving the load
12 months29,31,40,42-44. This trend is maintained in distribution22-23,78,97. Recent finite element stud-
studies with a longer follow-up, this result being ies support the hypothesis that reduction of the
similar to that found in the review by Monje et al18. cantilever length in a full-arch prosthesis, achieved
However, it must be acknowledged that, significant by tilting of the distal implants, allows for a more
or not, the order of magnitude of the mean differ- widespread distribution of the occlusal forces under
ence in marginal bone loss between axial and tilted loading and consequently for a reduction of the
implants (0.05 mm in the Monje et al review18 and stresses at the implant neck23,95-96,98. The findings
0.06 mm in the present one at 12-months follow- of such computer-simulated studies may partially
up) can be considered clinically irrelevant. explain the favourable crestal bone level changes
In theory, the stress received by tilted implants observed around tilted implants.
under functional loading is higher than axially placed One limitation to the widespread use of tilted
implants, which should result in greater marginal implants is the relative difficulty in the placement
bone loss. Studies based on finite element ana- of the fixtures that must be inserted with a pre-
lysis showed higher stress around a tilted implant cise angulation, so as to engage as much cortical
neck24,25. The compressive stress can be up to five bone as possible. The latter is essential for achiev-
times higher around tilted implants when the load ing adequate primary implant stability, which is a

prerequisite in case an immediate implant loading latter more closely reflects the standard clinical out-
protocol is adopted, as in the majority of the studies comes of most clinical studies included in the review
included in the present review. However, in recent as well as the results of all the subgroup analyses. In
years, the placement of tilted implants has become fact, when considering subgroups, no effect could
easier due to the introduction of computer-guided be attributed to loading temporisation, to the arch or
implant planning and the widespread use of custom- to a combination or both. In other words, as shown
ised surgical mask. in Table 4, there was no significant difference in
The survival of tilted vs. axial implants was not failure rate between axial and tilted implants when
the primary aim of the present review. Therefore the the immediate and the delayed loading cases were
failure analysis performed on the studies included evaluated separately, though the latter was not sig-
according to the specific criteria of this review is nificantly different between implants placed in the
under-representative of the published evidence maxilla and those placed in the mandible.
regarding tilted vs. axial implant survival. Neverthe- The technical difficulty of placing angulated
less, the results of the present analysis are in line with implants in the maxilla for surgeons not accustomed
those of other recent reviews that addressed this to such a technique has been claimed by some
topic in a more comprehensive way16-19. authors as a factor contributing to implant failure29.
In this review, slight statistically significant dif- As a consequence, for achieving optimal outcomes
ference in implant survival at 12-months follow-up when dealing with tilted implants, a learning curve is
was observed, favouring axial over tilted implants recommended and guided surgery might help in the
(Fig 4), although, similar to what was discussed early approaches.
for marginal bone loss, such difference cannot be The improvement in oral hygiene parameters fre-
considered clinically relevant, being less than 1%. quently reported in some studies on tilted implants
Regarding implant survival, a fair homogeneity was might reflect the easy maintenance of this type of
found among studies, as shown by the funnel plot rehabilitations, in which there is a relatively wide
in Fig 5. Due to the absence of randomised clinical distance between fixtures. Another factor that might
studies, definitive conclusions cannot be drawn on be accounted for such a good compliance is the high
the efficacy of rehabilitations supported by a combi- level of satisfaction correlated with this treatment, as
nation of axial and tilted implants. However, based reported by patients45-46,49 in a few studies.
on the available included studies, the present review The most frequent complication reported by
suggests that the prognosis of such a therapeutic the included studies was the fracture of the acrylic
approach is excellent, as only 1.54% of the implants prosthesis. One of the reasons addressed for such
was lost during the first year of loading, and only inconvenience was the progressive shift from a soft
three failures were recorded thereafter. diet to a diet including hard food, as well as the wear
From the implant failure analysis, some trends of the resin due to repeated cycles of deglutition
can be observed. Regarding the comparison and mastication38,44,63. Furthermore, some authors
between axial and tilted implants, the meta-analysis pointed out that most fractures of the prosthesis
performed on the overall studies provided borderline occurred close to the temporary abutments of the
significance (P = 0.05, Fig 4) in favour of the axial anterior implants, which can be considered a rela-
implants. However, such meta-analysis was strongly tively weak point26,38,68. In the study by Tealdo and
affected by a single study29 in which 2 axial and co-workers, the provisional and definitive prostheses
11 tilted implants failed (that is 40% of the over- were made of cast metal (palladium-alloy) frame-
all failed tilted implants). Since the author of that works69. Metal reinforced frameworks, as suggested
study attributed most failures to the early cases in by these authors, are significantly stronger than all-
which there was scarce acquaintance with the all- acrylic resin frameworks since they provide increased
on-four technique, we repeated the meta-analysis rigidity, and could represent a solution for reducing
after excluding that study. Such sensitivity analysis the incidence of such complication.
displayed no significant difference in survival rate The current review presents some limitations,
between axial and tilted implants (P = 0.43). The which deserve to be discussed. First of all, the follow-

up duration for most studies is in the short-medium Conclusion

range (Table 2). As a matter of fact, the introduction
of tilted implants for supporting prosthetic rehabilita- This review demonstrated that the tilting of implants
tions is a relatively recent technique, which started does not induce significant alteration in crestal bone
to spread among clinicians during the past 10 years level change as compared to conventional axial
with the advent of the so-called “All-on-four” tech- placement after 1 year of function, and this trend
nique15. Studies evaluating the performance of tilted apparently maintains up to 5 years of function. Due
implants with a follow-up longer than 5 years are to the lack of evidence, no conclusion can be drawn
quite scarce30,32,38,98. Only one study on the all-on- regarding the fate of marginal bone around axial vs.
four technique with a follow-up range of 10 years tilted implants in the long term.
has been published to date but did not provide spe- In rehabilitations supported by tilted and axial
cific information about marginal bone loss around implants, there is a higher risk of implant failure in
axial and tilted implants98. Besides, different implant- the maxilla as compared to the mandible, although
supported prosthetic designs, which differ regarding no significant difference in bone loss was found
the total number of implants as well as the number around implants placed in the maxillary as com-
and angulation of tilted implants were considered pared to the mandible, independent of implant
all together, thus neglecting any possible different inclination. In the maxilla, the all-on-four concept
performance. It should also be taken into account is as successful as rehabilitations supported by five
that the minimum angulation required to define an or more implants.
implant as tilted has not yet been established. Some In order to determine the efficacy of tilted
studies arbitrarily defined a threshold of 15 degrees implants as an alternative to grafting techniques
of inclination respect to the occlusa plane20,80. In the or to the use of short implants or other treatment
included studies, the inclination of the distal fixtures options for the rehabilitation of edentulous atrophic
in the full-arch rehabilitations ranged from about 25 jaws, randomised clinical trials with large sample size
to 35 degrees for the mandible and from 25 to 45 and long-term follow-up are urgently needed. The
degrees for the maxilla, respective to the occlusal impact on the quality of life for the patients of these
plane. Only in the study by Calandriello and Tomatis two alternative techniques cannot be ignored.
was a higher inclination reported (45 to 75 degrees
relative to the occlusal plane)76. In some studies, the
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CLINICAL ARTICLE  S171

Massimo Del Fabbro, Valentina Ceresoli

The fate of marginal bone around axial vs.

Massimo Del Fabbro,

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

 Introduction osteomyelitis7-11. Grafting procedures are generally

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Table 1 Excluded studies and reasons for exclusion.

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

1.04 ± 0.30 1.05 ± 0.32 1.04 ± 0.35 1.09 ± 0.29

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

* in adjunct, 83 trans-sinus tilted implants were placed; NR = not reported.

 Crestal bone level change At least 36-months follow-up (nine

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Table 4 Results of the comparisons of implant survival at 12-months follow-up for

P value Tilted vs. axial

Immediate 0.225 97.7% 98.9% 1157 1281

Maxilla delayed 0.860 98.9% 96.5% 90 113

Mandible delayed 1.000 100.0% 100.0% 91 100

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

supported by 4 implants according to the all-on-four

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Deﬁnition of outcome assessment

acrylic prosthesis and screw loosening (Table 3).

Calandriello et al, 2005 + – + + + + + – – H

Capelli et al, 2007 + – + – + + – + + H

Crespi et al, 2012 + ? + + – – + + + H In studies that assessed parameters related to oral

Malo et al, 2013 – ? + + ? – + + + H

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

up duration for most studies is in the short-medium  Conclusion

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

Eur J Oral Implantol 2014;7(Suppl2):S171–S189

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CLINICAL ARTICLE S171

Introduction osteomyelitis7-11. Grafting procedures are generally

Crestal bone level change At least 36-months follow-up (nine

up duration for most studies is in the short-medium Conclusion