CLINICAL REVIEW

M. Menini*, A. Signori, T. Tealdo,

M. Bevilacqua, F. Pera, G. Ravera,
Tilted Implants in the Immediate
and P. Pera Loading Rehabilitation of the
University of Genoa, L. Rosanna Benzi 10, Genova, 16132,
Italy; *corresponding author, maria.menini@unige.it
Maxilla: A Systematic Review
J Dent Res 91(9):821-827, 2012

Abstract
Tilted implants have been proposed as an alterna-
tive to traditional protocols in the rehabilitation of
edentulous maxillae. The aim of this meta-analysis
was to evaluate the outcomes of upright and tilted
implants supporting full-arch fixed dentures for
the immediate rehabilitation of edentulous maxil-
lae, after at least 1 year of function. An electronic
search of databases and a hand search of relevant
Introduction
journals in oral implantology were performed
according to PRISMA guidelines through August,
2011. The literature search yielded 1,069 articles.
I n recent years, numerous articles have focused on the treatment of edentulous
maxillae with immediately loaded implant-supported prostheses (Degidi
et al., 2005; Ibañez et al., 2005; Collaert et al., 2008; Bergkvist et al., 2009).
Eleven articles were available for analysis. A total However, the presence of the maxillary sinus usually precludes the inser-
of 1,623 implants (778 tilted, 845 upright) were tion of long implants into the distal areas of resorbed maxillae. Short implants
inserted into the maxillae of 324 patients. (< 10 mm) have been proposed (Degidi et al., 2007; Telleman et al., 2011;
Seventeen tilted (2.19%) and 16 upright implants Annibali et al., 2012), but it is the authors’ opinion that these may inhibit high
(1.89%) failed during the first year. No significant levels of initial primary stability, considered one of the most important factors
difference in failure rate was found between tilted for successful osseointegration of dental implants in immediate loading pro-
and upright implants (p value = 0.52). Marginal tocols (Nedir et al., 2004).
bone level results were obtained from 6 studies. A Bone-grafting procedures to increase bone volume may be a viable treat-
non-significant mean difference between tilted and ment option, but they often imply demanding surgical procedures and can be
upright implants was found with regard to bone associated with complications, morbidity, and high costs. Moreover, they usu-
loss. Tilted implants demonstrated a favorable ally preclude the attainment of sufficient primary stability, and delayed load-
short-term prognosis in full-arch immediate load- ing protocols are needed.
ing rehabilitations of the maxillae. Randomized To overcome such limitations, implants could be placed in specific ana-
long-term trials are needed to better elucidate tomical areas, such as the pterygoid region, the tuber, or the zygoma (Bahat,
long-term success of tilted vs. upright-positioned 1992; Balshi et al., 1999; Brånemark et al., 2004). Any of these procedures
implants. has considerable surgical risks and possible sinus complications. Moreover,
implant emergence is usually unfavorable from the prosthetic point of view,
since it is too palatal.
KEY WORDS: dental implants, immediate dental
implant loading, implant-supported dental prosthesis, Tilting of the implants parallel to the anterior maxillary sinus wall may
dental implantation, endosseous, meta-analysis. represent a feasible treatment option (Krekmanov, 2000; Krekmanov et al.,
2000; Aparicio et al., 2001; Fortin et al., 2002; Malò et al., 2005; Koutouzis
and Wennström, 2007). Long tilted implants (≥ 13 mm) placed in residual
bone have been advocated to obtain high levels of initial primary stability,
avoiding bone-grafting procedures. Improved implant anchorage can be
achieved by benefiting from the cortical bone of the anterior wall of the sinus
and the nasal fossa. Additionally, tilting implants can optimize the anterior-
DOI: 10.1177/0022034512455802 posterior spread of the implants to provide satisfactory molar support for a
full fixed prosthesis (FFP) of 12 masticatory units (Krekmanov et al., 2000;
Received March 14, 2012; Last revision July 2, 2012;
Accepted July 3, 2012 Bevilacqua et al., 2011). This FFP design also eliminates or reduces the num-
ber of cantilever extensions generally seen with vertical implants to obtain the
A supplemental appendix to this article is published elec- same number of masticatory units.
tronically only at http://jdr.sagepub.com/supplemental.
The purpose of the present systematic review was to evaluate the progno-
© International & American Associations for Dental Research sis of immediately loaded full-arch prostheses supported by both upright and

821
822  Menini et al. J Dent Res 91(9) 2012

tilted implants in the maxillae, after at least 1 yr of function. Data Extraction

Implant cumulative survival rate (CSR) and peri-implant bone
resorption were investigated. Data were extracted independently by two reviewers using a
data extraction form.
Information was extracted from each included trial on: (1)
Materials & Methods characteristics of trial participants (including age, gender, smok-
This review is reported in accordance with the guidelines of ing habit, parafunctions, type of antagonist, cause of tooth loss);
Transparent Reporting of Systematic Reviews and Meta- (2) clinical procedures (number of implants, timing of extrac-
analyses (PRISMA statement: Liberati et al., 2009; Moher et al., tion, use of a surgical template, timing of prosthetic loading,
2009). prosthesis material, prosthesis design); and (3) outcomes
(implant survival rate, peri-implant bone resorption, prosthesis
survival rate, adverse events, complications, patient satisfaction,
Search Strategy length of follow-up, number of drop-outs).
Three Internet sources were used to search for English- or Disagreement regarding data extraction was resolved by
Italian-language papers that satisfied the study purpose. These consensus. One author was contacted for further information.
included the National Library of Medicine (MEDLINE - The author responded and provided numerical data that were not
PubMed), the Cochrane Central Register of Controlled Trials present in the published paper (Tealdo et al., 2011).
(CENTRAL), and EMBASE (Excerpta Medical Database by
Elsevier). The last search was done on August 11, 2011. Statistical Analysis
The search was complemented by manual searches of the
reference lists of all full-text articles selected. In addition, we Differences between tilted and upright implants were assessed
hand-searched contents pages of the most relevant journals in on survival and on bone loss at 1 yr by means of meta-analysis.
the field. Mean and standard deviation (SD) of differences at 1 yr
We used the following search terms to search all databases: compared with baseline for bone loss and number of implants
tilted implants, angled implants, inclined implants, off-angle failed at 1 yr for survival outcome and sample sizes were
implants, angulated implants, non-axial implants, oblique extracted for each type (tilted and upright) of implant for each
implants, and offset implants. Neither publication date nor pub- trial.
lication status restrictions were imposed. The estimates of effects of angulation were expressed as
The search was limited to studies involving human partici- Risk-Ratio (RR) for survival outcome and as Mean Difference
pants. Participants of any age receiving an immediate loading (MD) for bone loss. RR values more than 1 indicated that the
rehabilitation of the edentulous maxilla supported by both tilted group failed more than the upright group, while for MD,
upright and tilted implants were considered. values more than 0 indicated higher bone loss in tilted compared
The additional inclusion criteria for study selection were: with upright implants.
The presence of heterogeneity among studies was assessed
•• minimum of 10 patients treated by means of H and I2 coefficients (Higgins and Thompson,
•• minimum of one-year follow-up 2002), and p values associated with the heterogeneity Q test
•• loading applied within 48 hrs after surgery were also shown.
•• survival rate and/or peri-implant bone resorption for tilted I2 represents the percentage of variability in point estimates
and upright implants clearly indicated or calculable from due to heterogeneity rather than to sampling error.
data provided For I2 values more than 50%, a considerable heterogeneity
among studies could be present (Higgins and Thompson, 2002).
Publications that did not meet the above inclusion criteria and
When high values of heterogeneity were found, a random-
those that were not dealing with original clinical cases (e.g.,
effects model was preferred to combine all studies in a pooled
reviews, technical reports) were excluded. Multiple publications
effect; otherwise the most conservative model was used.
from the same pool of patients (redundant publications) were also
R software (v.2.13, R core team, Vienna, Austria) was used
excluded. Exclusion criteria were: studies dealing with orthodon-
to summarize the effects and construct the forest plots for over-
tic implants, mini-implants, zygomatic implants or pterygoid
all analysis.
implants, partial rehabilitation, removable prosthesis, rehabilita-
tion of the lower jaw, delayed loading, and early loading.
Results
Screening and Selection
Search and Selection Results
Titles and abstracts of the searches were screened by two inde-
pendent reviewers for possible inclusion. The full texts of all The search initially yielded 1,069 titles, from which 26 full-text
studies of possible relevance were then obtained for indepen- articles were obtained and assessed for eligibility.
dent assessment by the reviewers. Disagreements between After examining the full texts of the 26 articles, we excluded
reviewers were resolved by discussion between the two review 15 of them from the review (Fig. 1). Finally, 11 studies were
authors; if no agreement could be reached, a third author considered for the meta-analysis. No relevant unpublished stud-
decided. ies were obtained.
J Dent Res 91(9) 2012 Tilted Implants in Immediate Loading Rehabilitation of the Upper Jaw   823

No RCTs were found. Of the 11 remaining articles, 3 were

retrospective studies, 7 were prospective single-cohort studies,
and 1 was a prospective controlled study (Appendix 1).
The year of publication for included studies ranged from
2005 to 2011.
As per the inclusion criteria, all the studies reported the
1-year follow-up results. Seven studies had a 1-year follow-up
(Malò et al., 2005, 2006, 2007; Agliardi et al., 2008, 2010;
Hinze et al., 2010; Pomares, 2010), two studies had a 3-year
follow-up (Degidi et al., 2010a; Tealdo et al., 2010), another
study had a 40-month follow-up (Capelli et al., 2007), and
another study reported a 22- to 40-month follow-up (Francetti
et al., 2010).
The geographic origins of the included studies were: Italy
(Capelli et al., 2007; Agliardi et al., 2008, 2010; Degidi et al.,
2010a; Francetti et al., 2010; Tealdo et al., 2011), Portugal
(Malò et al., 2005, 2006, 2007), Germany (Hinze et al., 2010),
and Spain (Pomares, 2010).

Outcome Results
In total, 1,623 implants were inserted into the maxillae of 324
patients. Of these implants, 778 (47.9%) were tilted and 845
(52.1%) were upright.
Eight of the included studies (Malò et al., 2005, 2006, 2007;
Agliardi et al., 2008; Francetti et al., 2010; Hinze et al., 2010;
Pomares, 2010; Tealdo et al., 2011) reported no drop-out Figure 1.  Flow chart representing search and selection results. Reasons
patients. One author (Capelli et al., 2007) reported one drop-out for exclusion were: no distinction between tilted and upright implants
patient. A female patient who was rehabilitated in the maxilla (Meloni et al., 2010; Degidi et al., 2010b; Franchini et al., 2011;
died 4 mos after surgery because of a car accident and was there- Alves et al., 2010), case report (Bedrossian et al., 2008), one patient
fore omitted from the study. The remaining two included studies only with edentulous upper jaw (Kawasaki et al., 2011), redundant
publication (Tealdo et al., 2008; Testori et al., 2008; Agliardi et al.,
(Appendix 1) did not report the number of drop-out patients. 2009; Corbella et al., 2011), delayed loading (Mattsson et al., 1999;
Implant CSR was available for all 11 trials. In the first year, Krekmanov et al., 2000; Aparicio et al., 2002; Pomares 2009), and
a total of 17 tilted and 16 upright implants failed. The global early loading (Calandriello and Tomatis, 2005).
implant CSR was of 1,590 implants out of 1,623 (97.97%), with
an overall weighted CSR of 98.62% (Fig. 2).
Four (Malò et al., 2006, 2007; Agliardi et al., 2010; Hinze No authors reported a correlation between smoking and
et al., 2010) of the 11 included papers reported that all of the implant failure. However, two authors excluded heavy smokers
failed implants were successfully replaced by new implants. In from the study (Degidi et al., 2010a; Pomares, 2010).
total, 22 implants of the 33 failed implants were replaced. No Marginal bone level results were obtained from 6 studies
author reported an impairment of prosthetic function because of (Capelli et al., 2007; Agliardi et al., 2008, 2010; Degidi et al.,
an implant failure. 2010a; Francetti et al., 2010; Tealdo et al., 2011) that showed
In Fig. 3, a forest plot of meta-analysis for the comparison results separated for tilted (n = 536) and upright (n = 539)
between tilted and upright implants with implant survival as implants in the maxilla.
outcome is presented. In one study (Degidi et al., 2010a), the SD for bone loss at 1
A non-significant difference between tilted and upright yr was not directly obtained but was calculated from the SD of
implants was found [Pooled RR = 1.23 (95% CI: 0.66-2.30); bone loss from baseline to 6 mos and from 6 mos to 12 mos.
p value = 0.52], and no heterogeneity among studies is high- A non-significant mean difference (Fig. 5) between tilted and
lighted (I2 = 0%). upright implants (MD = 0.02; 95% CI, -0.05-0.09; p value =
For the same outcome, but considered on a patient basis (Fig. 0.58) was found.
4), non-significant differences were shown between tilted and Some amount of heterogeneity between studies (I2 = 34.2%)
upright implants (RR = 1.06; 95% CI, 0.57 – 1.96; p value = was shown, but no differences between results from fixed or
0.86). random-effects models were found.
Five studies reported reasons for implant failure: bruxism (5 Fracture of the temporary acrylic prosthesis (Malò et al.,
implants in five patients; Malò et al., 2005, 2006, 2007), insuf- 2005, 2007; Agliardi et al., 2010; Francetti et al., 2010; Hinze
ficient primary stability due to soft bone (2 implants in two et al., 2010; Pomares, 2010) and prosthetic screw-loosening
patients; Malò et al., 2005, 2007), and “mobility” (11 implants; (Malò et al., 2006, 2007; Hinze et al., 2010) were the most com-
Agliardi et al., 2010; Hinze et al., 2010). mon complications described. Some authors observed that these
824  Menini et al. J Dent Res 91(9) 2012

All of the studies included both eden-

tulous patients and patients with hope-
less dentition (except for Degidi et al.,
2010a, where completely edentulous
patients were included, and Capelli et al.,
2007, where teeth were extracted 2 mos
before implant placement). Therefore,
post-extraction implants were inserted.
But no studies reported on survival rates
and peri-implant bone resorption of
implants placed in healed bone vs. post-
extraction sites.
Three of the selected studies anec-
dotically reported high degrees of patient
satisfaction as related to the applied clin-
Figure 2.  Forest plot of proportion of total implants failed. High heterogeneity among studies ical procedure (Malò et al., 2006;
was observed, and a random-effects model was used for meta-analysis of all studies. Agliardi et al., 2010; Pomares, 2010).
Proportions of implants failed and corresponding 95% confidence intervals (CI) were reported Patient satisfaction was measured in
both for each study and for pooled estimation. At the bottom, a heterogeneity estimation with
opportune indices and associated statistical tests were also reported.
two studies only (Capelli et al., 2007;
Agliardi et al., 2008) by means of ques-
tionnaires, with good results.
Some authors reported that, at request
of the patients, their provisional prosthe-
ses were not replaced (Malò et al., 2006,
2007), demonstrating a high level of
patient satisfaction in terms of esthetics
and function.
Some heterogeneities were found in
the surgical and prosthetic protocols
applied in different studies, including:
number of implants used, prosthesis
material, prosthesis design, whether a
surgical template was used, and whether
flapless surgery was used.
The majority of the studies used 4
Figure 3.  Forest plot for comparison between tilted and upright implants regarding the risk of implants per maxilla (2 anterior upright
failure. Total numbers of implants and failed implants are shown separately for tilted and implants, 2 distal tilted implants). But
upright implants. Risk ratio (RR) for proportion of failed tilted compared with upright implants some studies used a greater number of
and its corresponding 95% confidence interval (CI) are shown. Pooled estimation of RR (95% upright implants with 2 distal tilted
CI) performed with fixed-effects model is reported, and weights [W (Fixed)] of each study for
implants (Malò et al., 2006, 2007;
the pooled estimation are also shown. No statistical heterogeneity among studies is
highlighted.
Capelli et al., 2007; Tealdo et al., 2011).
One study (Agliardi et al., 2008) applied
the so-called V-II-V technique, with 4
complications were more common in bruxers (with opposing tilted implants and 2 upright anterior implants per maxilla. As
dentition presenting wear patterns; Malò et al., 2005, 2006, compared with other procedures, such as the Columbus Bridge
2007) and in patients who did not follow instructions regarding Protocol™ (Tealdo et al., 2008, 2011) and the All-on-4 tech-
the soft food diet in the first few mos (Malò et al., 2007; nique (Malò et al., 2005), providing for the insertion of 4
Pomares, 2010). implants, in the V-II-V technique, the prosthesis is supported by
Two authors (Agliardi et al., 2010; Hinze et al., 2010) 2 additional distal tilted implants parallel to the posterior wall of
reported that these complications were easily adjusted by the the maxillary sinus. Similarly, Degidi and co-workers (2010a)
clinician without sending the prostheses back to the laboratory. inserted 3 anterior upright implants and 4 distal tilted implants.
Two other authors (Francetti et al., 2010; Pomares, 2010), Three authors (Capelli et al., 2007; Degidi et al., 2010a;
despite reporting fractures of the acrylic provisional prostheses, Tealdo et al., 2011) used a full-arch provisional prosthesis pro-
did not consider these cases as prosthetic failures. vided with a metal framework and an acrylic resin veneering
Severe parafunctions such as bruxism and clenching habits material, while the other authors used all-acrylic prostheses.
were considered an exclusion criterion in 6 studies (Capelli Seven of the 11 included papers (Malò et al., 2006, 2007;
et al., 2007; Agliardi et al., 2008, 2010; Degidi et al., 2010a; Agliardi et al., 2008, 2010; Degidi et al., 2010a; Hinze et al.,
Francetti et al., 2010; Hinze et al., 2010). 2010; Tealdo et al., 2011) reported the use of screw-retained
J Dent Res 91(9) 2012 Tilted Implants in Immediate Loading Rehabilitation of the Upper Jaw   825

prostheses, while the other papers did not

specify the retention mechanism.
Three authors (Degidi et al., 2010a;
Hinze et al., 2010; Tealdo et al., 2011)
reported that provisional fixed prosthe-
ses were manufactured without distal
cantilevers, while the other authors did
not specify whether distal cantilevers
were present.
All of the papers except 4 (Capelli
et al., 2007; Agliardi et al., 2010; Degidi
et al., 2010a; Hinze et al., 2010) reported
the use of a surgical template during
implant insertion and angulated abut-
ment positioning. However, the surgical
templates used by the different authors Figure 4. Forest plot for patient-based comparison between tilted and upright implants
regarding risk of failure. Total number of failed implants and number of patients involved are
included in this review varied greatly in
shown separated for tilted and upright implants. Risk ratio (RR) for proportion of failed tilted
both design and purpose. Therefore, a compared with upright implants and corresponding 95% confidence intervals (CI) are shown.
comparison between papers using and Pooled estimation of RR (95% CI) performed with a fixed-effects model is reported, and
those not using a surgical template was weights [W (Fixed)] of each study for the pooled estimation are also shown. No statistical
not performed. heterogeneity among studies is highlighted.
Two of the 11 studies used computer-
guided flapless surgery and reported
favorable results (Malò et al., 2007;
Pomares, 2010). These papers reported
that patients with insufficient mouth-
opening to accommodate surgical instru-
ments (minimum, 40-50 mm) were
excluded from the study.
All authors suggested achieving an
insertion torque of at least 30 Ncm to
allow for immediate rehabilitation.
Figure 5.  Forest plot for comparison between tilted and upright implants regarding mean bone
loss. Total number of tilted and upright implants considered and mean bone loss with standard
Discussion deviation (SD) for each group of implants are reported. Mean difference (MD) for each study
The present systematic review focused and pooled with corresponding 95% CI are also plotted. A random-effects model was used
for pooling.
on the immediate loading rehabilitation
of the edentulous maxilla using upright
and tilted implants. Studies dealing with
orthodontic implants, mini-implants, zygomatic implants or limited number of studies reporting the 3-year follow-up results,
pterygoid implants, partial rehabilitation, removable prostheses, only the 1-year follow-up data were considered for meta-analysis.
rehabilitation of the lower jaw, delayed loading, and early load- Survival rates and incidence of biological and technical com-
ing were excluded. plications over a long term are needed before definitive conclu-
Investigating the available literature on this topic, we found sions can be drawn (Papaspyridakos et al., 2012).
no RCTs. There is a need for additional studies that ideally ran- Given these limitations, the preliminary results indicate that
domize assignment to alternative treatments. such a technique may lead to an excellent prognosis, at least in
Only one paper (Tealdo et al., 2011) reported a controlled the short term. In fact, a global CSR of 97.97%, with a mean
study. That paper had a prospective case-control design but peri-implant bone resorption of 0.75 mm (tilted, 0.77 mm;
lacked randomization and evaluated two unmatched groups. upright, 0.73 mm), was found at 1 yr of function. These data do not
Additionally, long-term clinical data about this treatment seem to be affected by an excessive number of drop-out patients.
modality are still lacking. In fact, immediate loading of maxillary In fact, 8 of the included studies reported no drop-out patients; one
full-arch prostheses supported by tilted implants is a recent tech- author (Capelli et al., 2007) reported one drop-out patient, and
nique. To the authors’ knowledge, the first patients treated accord- only 2 of the included studies did not report the number of drop-
ing to this kind of protocol date back to 2000. Some of the out patients.
included studies (Capelli et al., 2007; Degidi et al., 2010a; Fracture of the temporary acrylic prosthesis was the most
Francetti et al., 2010; Tealdo et al., 2011) reported a follow-up common complication described. Only three authors (Capelli
greater than 1 yr (up to 36 or 40 mos). However, because of the et al., 2007; Degidi et al., 2010a; Tealdo et al., 2011) used a
826  Menini et al. J Dent Res 91(9) 2012

full-arch provisional prosthesis provided with a metal frame- support immediately loaded fixed prostheses for the rehabilita-
work, instead of an all-acrylic prosthesis. According to Tealdo tion of edentulous jaws was considered a predictable technique,
et al. (2011), the metal framework may be particularly important and no significant differences in failure rates were found
to improve the stiffness and rigidity of the structure splinting the between tilted and upright implants.
implants, which may affect the favorable outcome of predictable As underlined by Del Fabbro and co-workers (2010), one limi-
osseointegration. tation to the widespread use of this technique could be the relative
Many of the failures and technical complications were attrib- difficulty in inserting posterior tilted implants. Pomares (2010)
uted to bruxism or failure to follow dietary recommendations in suggested that this technique could be sensitive to the experience of
the first few mos (Malò et al., 2005, 2006, 2007). Moreover, five the surgeon, and that a learning curve is required. Capelli et al.
authors (Capelli et al., 2007; Agliardi et al., 2008, 2010; Degidi (2007) recommended that this technique be adopted by expert clini-
et al., 2010a; Francetti et al., 2010; Hinze et al., 2010) consid- cians. In 5 included studies (Capelli et al., 2007; Agliardi et al.,
ered severe parafunctions as exclusion criteria for patient selec- 2010; Degidi et al., 2010a; Francetti et al., 2010; Hinze et al.,
tion. Analysis of these data underlines the importance of 2010), the operator was reported to be expert.
overloading as a risk factor in implant prosthodontics. In par- Del Fabbro et al. (2010) maintained that, with computer-
ticular, overloading can potentially jeopardize the attainment guided implant planning and the use of a surgical template, the
and maintenance of osseointegration. placement of tilted implants became easier in recent years.
In the present review, distal tilted vs. mesial upright implant However, difficulties could be found in patients with limited
outcomes were evaluated. However, the minimum angulation mouth-opening.
required to define an implant as tilted has not yet been estab- No randomized controlled trials were present, and only
lished (Del Fabbro et al., 2010). Seven of the 11 included papers short-term (1-year) outcomes could be evaluated. Definitive
(Malò et al., 2006; Capelli et al., 2007; Agliardi et al., 2008, conclusions cannot be drawn because there are too few reliable
2010; Degidi et al., 2010; Francetti et al., 2010; Hinze et al., studies.
2010) reported the degree of angulation that constituted tilting, More high-level evidence-based studies are needed to demon-
which was approximately 30 to 45°. The author of another paper strate the merits of this protocol compared with other procedures.
(Tealdo et al., 2011) was contacted for further information on A next step for future trials would be the comparison of this
this topic and reported that tilted implants were considered those protocol with an immediate loading protocol using upright
having an angulation greater than 30°. However, as reported by implants to see whether the use of distal tilted implants deter-
Hinze and co-workers (2010), the 2 anterior implants may mines different outcomes compared with distal upright implants.
incline marginally mesiodistally as well as buccally, but usually
never approach the degree of tilting of the posterior implants.
In 2010, a meta-analysis of the outcomes of tilted implants in
Acknowledgments
immediate loading rehabilitations was published (Del Fabbro The authors received no financial support and declare no poten-
et al., 2010). tial conflicts of interest with respect to the authorship and/or
Del Fabbro’s review included studies published up to March publication of this article.
2009. The present review included 6 studies that were already
present in the pre-existing review (Malò et al., 2005, 2006,
2007; Capelli et al., 2007; Agliardi et al., 2008, 2010), plus 5 References
more recent studies (Degidi et al., 2010a; Francetti et al., 2010; Agliardi EL, Francetti L, Romeo S, Taschieri S, Del Fabbro M (2008).
Hinze et al., 2010; Pomares, 2010; Tealdo et al., 2011; number Immediate loading in the fully edentulous maxilla without bone graft-
of implants in the 5 new papers: 641). ing: the V-II-V technique. Minerva Stomatol 57:251-263.
Agliardi E, Francetti L, Romeo S, Taschieri S, Del Fabbro M (2009).
One of the main differences between the two systematic
Immediate rehabilitation of the edentulous maxilla: preliminary results
reviews is that the present review focused on maxillary reha- of a single cohort study. Int J Oral Maxillofac Implants 24:887-895.
bilitations only, while the review by Del Fabbro and co-workers Agliardi E, Panigatti S, Clericò M, Villa C, Malò P (2010). Immediate reha-
(2010) included both maxillary and mandibular rehabilitations. bilitation of the edentulous jaw with full fixed prostheses supported by
This explains the majority of the differences between the papers four implants: interim results of a single cohort prospective study. Clin
Oral Implants Res 21:459-465.
included in the two reviews. A study by Calandriello and
Alves CC, Correia AR, Neves M (2010). Immediate implants and immediate
Tomatis (2005) was included by Del Fabbro but excluded in the loading in periodontally compromised patients – a 3-year prospective
present review. In fact, in that paper, an early loading protocol clinical study. Int J Periodontics Restorative Dent 30:447-455.
instead of an immediate loading protocol was applied in the Annibali S, Cristalli MP, Dell’Aquila D, Bignozzi I, La Monaca G, Pilloni
upper jaw. A (2012). Short dental implants: a systematic review. J Dent Res 91:25-
32.
Moreover, Del Fabbro et al. performed a meta-analysis for Aparicio C, Perales P, Rangert B (2001). Tilted implants as an alternative to
1-year implant survival, but a meta-analysis for 1-year peri-implant maxillary sinus grafting: a clinical, radiologic, and periotest study. Clin
bone loss, as performed in the present review, was lacking. Implant Dent Relat Res 3:39-49.
In addition, Del Fabbro did not report a quality and bias Aparicio C, Arévalo X, Ouazzani W, Granados C (2002). A retrospective
assessment of included studies, as we did in the present review clinical and radiographic evaluation of tilted implants used in the treat-
ment of the severely resorbed edentulous maxilla. Appl Osseoint Res
(see Appendices 1, 2). 1:17-21.
That being said, the present meta-analysis confirms the con- Bahat O (1992). Osseointegrated implants in the maxillary tuberosity: report
clusions of Del Fabbro et al., since the use of tilted implants to on 45 consecutive patients. Int J Oral Maxillofac Implants 7:459-467.
J Dent Res 91(9) 2012 Tilted Implants in Immediate Loading Rehabilitation of the Upper Jaw   827

Balshi TJ, Wolfinger GJ, Balshi SF (1999). Analysis of 356 pterygo-maxil- titanium implants in 41 consecutive full-arch cases in the mandible and
lary implants in edentulous arches for fixed prosthesis anchorage. Int J maxilla: 6- to 74-month results. J Periodontol 76:1972-1981.
Oral Maxillofac Implants 14:398-406. Kawasaki T, Komatsu K, Tsuchiya R (2011). Tilted placement of tapered
Bedrossian E, Sullivan RM, Fortin Y, Malò P, Indresano T (2008). Fixed- implants using a modified surgical template. J Oral Maxillofac Surg
prosthetic implant restoration of the edentulous maxilla: a systematic 69:1642-1650.
pretreatment evaluation method. J Oral Maxillofac Surg 66: 112-122. Koutouzis T, Wennström JL (2007). Bone level changes at axial- and non-
Bergkvist G, Nilner K, Sahlholm S, Karlsson U, Lindh C (2009). Immediate axial-positioned implants supporting fixed partial dentures. A 5-year
loading of implants in the edentulous maxilla: use of an interim fixed retrospective longitudinal study. Clin Oral Implants Res 18:585-590.
prosthesis followed by a permanent fixed prosthesis: a 32-month pro- Krekmanov L (2000) Placement of posterio mandibular and maxillary
spective radiological and clinical study. Clin Implant Dent Relat Res implants in patients with severe bone deficiency: a clinical report of
11:1-10. procedure. Int J Oral Maxillofac Implants 15:722-730.
Bevilacqua M, Tealdo T, Menini M, Pera F, Mossolov A, Drago C, et al. Krekmanov L, Kahn M, Rangert B, Lindstrom H (2000). Tilting of posterior
(2011). The influence of cantilever length and implant inclination on mandibular and maxillary implants for improved prosthesis support. Int
stress distribution in maxillary implant-supported fixed dentures. J Oral Maxillofac Implants 15:405-414.
J Prosthet Dent 105:5-13. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al.
Brånemark PI, Gröndahl K, Ohrnell LO, Nilson P, Petruson B, Svenson B, (2009). Research methods and reporting. The PRISMA statement for
et al. (2004). Zygoma fixture in the management of advanced atrophy reporting systematic reviews and meta-analysis of studies that evaluate
of the maxilla: technique and long-term results. Scand J Plast Reconstr health-care interventions: explanation and elaboration. BMJ 339:b2700.
Surg Hand Surg 38:70-85. Maló P, Rangert B, Nobre M (2005). All-on-4 immediate-function concept
Calandriello R, Tomatis M (2005). Simplified treatment of the atrophic posterior with Brånemark System® implants for completely edentulous maxil-
maxilla via immediate/early function and tilted implants: a prospective lae: a 1-year retrospective clinical study. Clin Implant Dent Relat Res
1-year clinical study. Clin Implant Dent Relat Res 7(Suppl 1):1-12. 7(Suppl 1):88S-94S.
Capelli M, Zuffetti F, Del Fabbro M, Testori T (2007). Immediate rehabilita- Malò P, Nobre M, Petersson U, Wigren S (2006). A pilot study of complete
tion of the completely edentulous jaw with fixed prostheses supported edentulous rehabilitation with immediate function using a new implant
by either upright or tilted implants: a multicenter clinical study. Int J design: case series. Clin Implant Dent Relat Res 8:223-232.
Oral Maxillofac Implants 22:639-644. Malò P, de Araujo Nobre M, Lopes A (2007). The use of computer-guided
Collaert B, De Bruyn H (2008). Immediate functional loading of TiO blast flapless surgery and four implants placed in immediate function to sup-
dental implants in full-arch edentulous maxillae: a 3-year prospective port a fixed denture: preliminary results after a mean follow-up period
study. Clin Oral Implants Res 19:1254-1260. of thirteen months. J Prosthet Dent 97(6 Suppl):26S-34S; erratum in J
Corbella S, Del Fabbro M, Taschieri S, De Siena F, Francetti L (2011). Prosthet Dent 99:167, 2008.
Clinical evaluation of an implant maintenance protocol for the preven- Mattsson T, Köndell PA, Gynther GW, Fredholm U, Bolin A (1999). Implant
tion of peri-implant diseases in patients treated with immediately treatment without bone grafting in severely resorbed edentulous maxil-
loaded full-arch rehabilitations. Int J Dent Hygiene 9:216-222. lae. J Oral Maxillofac Surg 57:281-287.
Degidi M, Piattelli A, Felice P, Carinci F (2005). Immediate functional load- Meloni SM, De Riu G, Pisano M, Cattina G, Tullio A (2010). Implant treatment
ing of edentulous maxilla: a 5-year retrospective study of 388 titanium software planning and guided flapless surgery with immediate provisional
implants. J Periodontol 76:1016–1024. prosthesis delivery in the fully edentulous maxilla. A retrospective analysis
Degidi M, Piattelli A, Iezzi G, Carinci F (2007). Immediately loaded short of 15 consecutively treated patients. Eur J Implantol 3:245-251.
implants: analysis of a case series of 133 implants. Quintessence Int Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009).
38:193-201. Methods of systematic reviews and meta-analysis. Preferred reporting
Degidi M, Nardi D, Piattelli A (2010a). Immediate loading of the edentulous items for systematic reviews and meta-analysis: the PRISMA state-
maxilla with a definitive restoration supported by an intraorally welded ment. J Clin Epidemiol 62:1006-1012.
titanium bar and tilted implants. Int J Oral Maxillofac Implants Nedir R, Bischof M, Szmukler-Moncler S, Bernard JP, Samson J (2004).
25:1175-1182. Predicting osseointegration by means of implant primary stability. Clin
Degidi M, Nardi D, Piattelli A (2010b). Immediate definitive rehabilitation Oral Implants Res 15:520-528.
of the edentulous patient using an intraorally welded titanium frame- Papaspyridakos P, Chen CJ, Singh M, Weber HP, Gallucci GO (2012).
work: a 3-year prospective study. Quintessence Int 41:651-659. Success criteria in implant dentistry: a systematic review. J Dent Res
Del Fabbro M, Bellini CM, Romeo D, Francetti L (2010). Tilted implants 91:242-248.
for the rehabilitation of edentulous jaws: a systematic review. Clin Pomares C (2009). A retrospective clinical study of edentulous patients
Implant Dent Relat Res [Epub ahead of print May 13, 2010] (in press). rehabilitated according to the “all-on-four” or the “all-on-six” immedi-
Fortin Y, Sullivan R, Rangert BR (2002). The Marius implant bridge: surgi- ate function concept. Eur J Oral Implantol 2:55-60.
cal and prosthetic rehabilitation of the completely edentulous upper jaw Pomares C (2010). A retrospective study of edentulous patients rehabilitated
with moderate to severe resorption: a 5-year retrospective clinical according to the “all-on-four” or the “all-on-six” immediate function
study. Clin Implant Dent Relat Res 4:69-77. concept using flapless computer-guided implant surgery. Eur J Oral
Francetti L, Romeo D, Corbella S, Taschieri S, Del Fabbro M (2010). Bone Implantol 3:155-163.
level changes around axial and tilted implants in full-arch fixed imme- Tealdo T, Bevilacqua M, Pera F, Menini M, Ravera G, Pera P (2008).
diate restorations. Interim results of a prospective study. Clin Implant Immediate function with fixed implant-supported maxillary dentures: a
Dent Relat Res [Epub ahead of print October 26, 2010] (in press). 12 month follow-up report. J Prosthet Dent 99:351-360.
Franchini I, Capelli M, Fumagalli L, Parenti A, Testori T (2011). Multicenter Tealdo T, Bevilacqua M, Menini M, Pera F, Ravera G, Drago C, et al. (2011).
retrospective analysis of 201 consecutively placed Camlog dental Immediate versus delayed loading of dental implants in edentulous maxil-
implants. Int J Periodontics Restorative Dent 31:255-263. lae: a 36 month prospective study. Int J Prosthodont 24:294-302.
Higgins JP, Thompson SG (2002). Quantifying heterogeneity in a meta- Telleman G, Raghoebar GM, Vissink A, den Hartog L, Huddleston Slater JJ,
analysis. Stat Med 21:1539-1558. Meijer HJ (2011). A systematic review of the prognosis of short (<10
Hinze M, Thalmair T, Bolz W, Wachtel H (2010). Immediate loading of mm) dental implants placed in the partially edentulous patient. J Clin
fixed provisional prostheses using four implants for the rehabilitation of Periodontol 38:667-676.
the edentulous arch: a prospective clinical study. Int J Oral Maxillofac Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL
Implants 25:1011-1018. (2008). Immediate occlusal loading and tilted implants for the rehabili-
Ibañez JC, Tahhan MJ, Zamar JA, Menendez AB, Juaneda AM, Zamar NJ, tation of the atrophic edentulous maxilla: 1-year interim results of a
et al. (2005). Immediate occlusal loading of double acid-etched surface multicentre prospective study. Clin Oral Implants Res 19:227-232.
Copyright of Journal of Dental Research is the property of Sage Publications Inc. and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.