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Review
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abstract
Article history:
Objectives: The purpose of the present review was to test the null hypothesis of no difference
in the implant failure rate, marginal bone loss, and postoperative infection for patients being
rehabilitated by tilted or by axially placed dental implants, against the alternative hypothe-
30 August 2014
sis of a difference.
Methods: An electronic search without time or language restrictions was undertaken in July
2014. Eligibility criteria included clinical human studies, either randomised or not, interventional or observational. The estimates of an intervention were expressed in risk ratio (RR)
Keywords:
Dental implants
Results: The search strategy resulted in 44 publications. A total of 5029 dental implants were
Tilted implant
tilted (82 failures; 1.63%), and 5732 implants were axially placed (104 failures; 1.81%). The
Axial implant
difference between the procedures did not significantly affect the implant failure rates
(P = 0.40), with a RR of 1.14 (95% CI 0.841.56). A statistically significant difference was found
for implant failures when studies evaluating implants inserted in maxillae only were pooled
Meta-analysis
(RR 1.70, 95% CI 1.052.74; P = 0.03), the same not happening for the mandible (RR 0.77, 95% CI
0.391.52; P = 0.45). There were no apparent significant effects of tilted dental implants on
the occurrence of marginal bone loss (MD 0.03, 95% CI
satisfactory information, meta-analysis for the outcome postoperative infection was not
performed.
Conclusions: It is suggested that the differences in angulation of dental implants might not
affect the implant survival or the marginal bone loss. The reliability and validity of the data
collected and the potential for biases and confounding factors are some of the shortcomings
of the present study.
Clinical significance: The question whether tilted implants are more at risk for failure than
axially placed implants has received increasing attention in the last years. As the philosophies of treatment alter over time, a periodic review of the different concepts is necessary to
refine techniques and eliminate unnecessary procedures. This would form a basis for
optimum treatment.
# 2014 Elsevier Ltd. All rights reserved.
* Corresponding author at: Department of Prosthodontics, Faculty of Odontology, Malmo University, Carl Gustafs vag 34, SE-205 06 Malmo,
Sweden. Tel.: +46 725 541 545; fax: +46 40 6658503.
E-mail addresses: bruno.chrcanovic@mah.se, brunochrcanovic@hotmail.com (B.R. Chrcanovic).
http://dx.doi.org/10.1016/j.jdent.2014.09.002
0300-5712/# 2014 Elsevier Ltd. All rights reserved.
150
1.
Introduction
2.
2.2.
An electronic search without time restrictions was undertaken (and last checked) in July 2014 in the following databases:
PubMed, Web of Science, and the Cochrane Oral Health Group
Trials Register. The following terms were used in the search
strategy on PubMed:
(((dental implant) OR oral implant)) AND ((((tilted) OR
angulated) OR axial) OR upright) [all fields]
The following terms were used in the search strategy on
Web of Science, in all databases:
(((dental implant) OR oral implant)) AND ((((tilted) OR
angulated) OR axial) OR upright) [topic])
The following terms were used in the search strategy on the
Cochrane Oral Health Group Trials Register:
(dental implant OR oral implant AND (tilted OR angulated
OR axial OR upright))
A manual search of dental implants-related journals was
also performed. The reference list of the identified studies and
the relevant reviews on the subject were also scanned for
possible additional studies. Moreover, online databases
providing information about clinical trials in progress were
checked (clinicaltrials.gov; www.centerwatch.com/clinicaltrials; www.clinicalconnection.com).
2.3.
Eligibility criteria included clinical human studies, either randomised or not, interventional or observational, comparing
implant failure rates in any group of patients receiving tilted or
axially placed dental implants. Zygomatic implants were not
considered. For this review, implant failure represents the
complete loss of the implant. Exclusion criteria were case reports,
technical reports, animal studies, in vitro studies, biomechanical
studies, finite element analysis (FEA) studies, and reviews papers.
2.4.
Study selection
2.5.
2.1.
Search strategies
Quality assessment
Objective
2.6.
3.
Results
3.1.
Literature search
151
3.2.
152
Nobel Biocare AB (Goteborg, Sweden) were the most commonly used, in twenty-seven studies,1,3,7,14,1618,21,22,26,27,29
33,35,37,39,40,42,43,4547,50,52
most of them with an oxidised
surface. Four studies25,36,38,51 did not inform what kind of
implants was used. Thirty studies1,3,8,1422,24,26,2833,35,37
40,44,45,4951
provided information about the use of prophylactic
antibiotics. Twenty studies14,1719,21,22,2426,2834,38,44,45,50 provided information about the use of chlorhexidine mouth rinse
by the patients.
Nine studies3,21,25,32,40,4446,51 provided information about
postoperative infection. However, in five studies3,25,40,45,51
with ten of the thirteen occurrences, there was no information
about which groups these patients belonged to. Eight
studies1,25,38,4245,52 did not provide information about the
marginal bone loss. Of the thirty-six studies providing this
information, twenty-five7,8,14,15,1721,23,24,2630,3235,41,4749,51 informed of the marginal bone loss of tilted and axially placed
implants separately; one of these studies26 did not report how
many implants were evaluated in each group.
3.3.
Quality assessment
3.4.
Meta-analysis
Published
Study
design
1999
RA (unicenter)
15a
4475 (59)
Krekmanov et al.38
2000
RA (unicenter)
47a
3580 (62)
Aparicio et al.7
2001
RA (unicenter)
25a
Karoussis et al.13
2004
Calandriello and
Tomatis14
Malo et al.39
2005
PS (CCT)c
(unicenter)
PS (unicenter)
2005
Malo et al.40
Antibiotics/
mouth rinse
(days)
Healing
period/
loading
Mean 45 months
(range 3654)
3560 months
NP/NM
6 months
5/7
1 day-3 weeks
NM (49,
females,
59, males)
Mean 37 months
(range 2187)
NM
89a
1978 (49.3)
4 months-12 years
NM
Mean 29
weeks
(range 68
months)
46 months
18a
5176 (64)
14 years
3/pospoperatively
RA (unicenter)
32b
NM (55.1)
6 and 12 months
7/NM
Immediate/
early
Immediate
2006
RA (unicenter)
46a
3278 (55.2)
10 days-1 year
6/NM
Immediate
Capelli et al.15
2007
PS (multicenter)
65a
2883 (59.2)
Up to 52 months
1/NM
Immediate
Koutouzis and
Wennstrom41
Malo et al.16
2007
RA (unicenter)
38a
NM (59.5)
5 years
NM
NM
2007
PS (unicenter)
23b
NM
6/NM
Immediate
Agliardi et al.17
2008
PS (unicenter)
21a
4468 (58)
1/3
Immediate
Francetti et al.18
2008
PS (multicenter)
62b
3577 (56)
1/10
Immediate
Tealdo et al.19
2008
PS (unicenter)
21a
NM (58)
Mean 13 months
(range 621)
Mean 20 months
(range 435)
Mean 22.4 months
(range 643)
Mean 20 months
6/10
Immediate
Testori et al.20
2008
PS (multicenter)
40a
3884 (59.2)
1/NM
Immediate
Agliardi et al.21
2010
PS (unicenter)
24b
4073 (60)
7/9
Immediate
Agliardi et al.22
2010
PS (unicenter)
173b
1/10
Immediate
Degidi et al.23
2010
PS (unicenter)
30a
NM (58.1)
NM
Immediate
Hinze et al.24
2010
PS (unicenter)
37b
3984 (64.6)
5/14
Immediate
Butura et al.42
2011
RA (unicenter)
219b
NM (60.9)
3 years
NM
Immediate
4274 (57.3)
1/30
0/56
1/40
6/98
0/42
2/59
3.33 (G1)
0 (G2)
2.5 (G1)
6.12 (G2)
0 (G1)
3.39 (G2)
NM
NM
NM
NM
NM
NM
1/18 (G1)
12/161 (G2)
1/27 (G1)
1/33 (G2)
3/64 (G1)
0/64 (G2)
2/96 (G1)
0/93 (G2)
5.56 (G1)
7.45 (G2)
3.70 (G1)
3.03 (G2)
4.69 (G1)
0 (G2)
2.08 (G1)
0 (G2)
NM
NM
NM
NM
NM
NM
NM
2/130 (G1)
3/212 (G2)
0/33 (G1)
0/36 (G2)
1/46 (G1)
1/46 (G2)
0/84 (G1)
0/42 (G2)
0/124 (G1)
0/124 (G2)
5/42 (G1)
3/69 (G2)
2/80 (G1)
3/160 (G2)
0/48 (G1)
0/48 (G2)
1/346 (G1)
4/346 (G2)
0/120 (G1)
1/90 (G2)
4/74 (G1)
3/74 (G2)
1/428 (G1)
2/429 (G2)
1.54 (G1)
1.42 (G2)
0 (G1)
0 (G2)
2.17 (G1)
2.17 (G2)
0 (G1)
0 (G2)
0 (G1)
0 (G2)
11.90 (G1)
4.35 (G2)
2.5 (G1)
1.87 (G2)
0 (G1)
0 (G2)
0.29 (G1)
1.16 (G2)
0 (G1)
1.11 (G2)
5.41 (G1)
4.05 (G2)
0.23 (G1)
0.47 (G2)
NM
In 3 implants, but
distinction
between groups
was not made
NM
No
failures
Equal
failure
No
failures
No failures
NM
NM
NM
NM
NM
No
failures
NM
0 (G1)
0 (G2)
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
153
Implant
failure
rate (%)
(G1)
(G2)
(G1)
(G2)
(G1)
(G2)
P value
(for
failure
rate)
Postoperative
infection
Failed/
placed
implants
(n)
Mattsson et al.37
Follow-up
visits (or range)
154
Table 1 (Continued )
Authors
Published
Study
design
Follow-up
visits (or range)
Antibiotics/
mouth rinse
(days)
Healing
period/
loading
Failed/
placed
implants
(n)
Implant
failure
rate (%)
P value
(for
failure
rate)
PS (unicenter)
61b
NM (54.2)
NM/6
Immediate
0/122 (G1)
3/122 (G2)
0 (G1)
2.46 (G2)
NM
De Vico et al.26
2011
PS (unicenter)
35b
3877 (54)
Mean 25 months
7/9
Immediate
Kawasaki et al.43
2011
RA (unicenter)
15a
3177 (53)
NM
111 months
2011
RA (unicenter)
245b
2385 (59)
7/NM
Immediate
Acocella et al.44
2012
RA (multicenter)
45a
NM (56.7)
7/13
Immediate
Cavalli et al.45
2012
RA (unicenter)
34b
4484 (58.7)
6/7
Immediate
0 (G1)
0 (G2)
2.08 (G1)
5.88 (G2)
1.84 (G1)
2.45 (G2)
1.11 (G1)
0.74 (G2)
0 (G1)
0 (G2)
No
failures
NM
Malo et al.1
0/70 (G1)
0/70 (G2)
1/48 (G1)
1/17 (G2)
9/490 (G1)
12/490 (G2)
1/90 (G1)
1/135 (G2)
0/68 (G1)
0/68 (G2)
Crespi et al.8
2012
36b
4181 (54.6)
Immediate
47b
4463 (53)
NM
Immediate
Galindo and
Butura46
Grandi et al.28
2012
RA (unicenter)
183b
2489 (60.3)
NM
Immediate
2012
PS (unicenter)
47b
5278 (62.3)
6/10
Immediate
Malo et al.3
2012
RA (unicenter)
242b
2587 (55.4)
6, 12, and 18
months
Every 6 months
until 5 years
6/NM
Immediate
3/88 (G1)
0/88 (G2)
0/98 (G1)
0/98 (G2)
0/366 (G1)
1/366 (G2)
0/94 (G1)
0/94 (G2)
12/484 (G1)
7/484 (G2)
3.41 (G1)
0 (G2)
0 (G1)
0 (G2)
0 (G1)
0.27 (G2)
0 (G1)
0 (G2)
2.48 (G1)
1.45 (G2)
NM
2012
7/NM
Francetti et al.27
PS (CCT)d
(unicenter)
PS (multicenter)
Penarrocha et al.47
2012
RA (unicenter)
18a
3569 (NM)
NM
12 weeks
Pozzi et al.29
2012
PS (unicenter)
27a
3877 (54.2)
2012
PS (unicenter)
20b
4477 (60.8)
prescribed
postoperatively
7/10
Immediate
Weinstein et al.30
Krennmair et al.48
2013
RA (unicenter)
38b
NM (67.1)
NM
23 months
Landazuri-Del
Barrio et al.31
Malo et al.49
2013
PS (unicenter)
16b
4973 (59)
7/14
Immediate
2013
RA (unicenter)
70b
3581 (54)
7/NM
Immediate
3.33 (G1)
7.79 (G2)
4.76 (G1)
2.56 (G2)
0 (G1)
0 (G2)
0 (G1)
0 (G2)
9.38 (G1)
9.38 (G2)
2.86 (G1)
0.71 (G2)
Mozzati et al.50
2013
RA (unicenter)
50b
4565 (54.3)
10 days, 2, 4, and 6
months, 1, 2, and 3
years
1, 2,3, 6, 12, 18 and
24 months
1/30 (G1)
6/77 (G2)
2/42 (G1)
1/39 (G2)
0/40 (G1)
0/40 (G2)
0/76 (G1)
0/76 (G2)
3/32 (G1)
3/32 (G2)
4/140 (G1)
1/140 (G2)
7/10
Immediate
0/100 (G1)
0/100 (G2)
0 (G1)
0 (G2)
Publication bias
Immediate
In 3 implants, but
distinction
between groups
was not made
NM
NM
NM
NM
NM
0 (G1)
0 (G2)
In 2 implants, but
distinction
between groups
was not made
NM
No
failures
No
failures
NM
No
failures
NM
NM
0 (G1)
1 (G2)
NM
NM
In 1 implant, but
distinction
between groups
was not made
NM
NM
NM
No
failures
No
failures
NM
NM
NM
NM
NM
No
failures
NM
NM
2011
3.5.
Corbella et al.25
Postoperative
infection
2013
RA (unicenter)
35a
NM (59.2)
1/NM
6 months
0/52 (G1)
3/144 (G2)e
0 (G1)
2.08 (G2)
NM
Agliardi et al.32
2014
PS (unicenter)
32a
4468 (58)
1/10
Immediate
2014
PS (unicenter)
10a
5570 (60.4)
1/3
Immediate
Agnini et al.34
2014
PS (unicenter)
30a
NM (64.4)
NM/10
Immediate
Balshi et al.52
2014
RA (unicenter)
152b
NM
NM
Immediate
Browaeys et al.35
2014
PS (unicenter)
20b
3574 (55)
3 years
10/NM
Immediate
Tealdo et al.36
2014
PS (unicenter)
49a
NM (58.2)
NM
Immediate
(34 patients),
mean 8.75
months (15
patients)
2/128 (G1)
0/64 (G2)
0/10 (G1)
0/10 (G2)
0/37 (G1)
4/165 (G2)
11/400 (G1)
11/400 (G2)
0/40 (G1)
0/40 (G2)
6/68 (G1)
8/192 (G2)e
1.56 (G1)
0 (G2)
0 (G1)
0 (G2)
0 (G1)
2.42 (G2)
2.75 (G1)
2.75 (G2)
0 (G1)
0 (G2)
8.82 (G1)
4.17 (G2)
NM
Agliardi et al.33
Mean 55 months
(range 3678)
Mean 50 months
(range 4257)
Mean 44 months
(range 1867)
6 years
No
failures
NM
Equal
failure
No
failures
NM
In 1 implant, but
distinction
between groups
was not made
2 (G1)
0 (G2)
NM
NM
NM
NM
NM
NM not mentioned; NP not performed; PS prospective study; CCT controlled clinical trial; RA retrospective analysis; G1 group tilted implants; G2 group axially placed implants; TPS
titanium-plasma sprayed.
a
The patients received tilted and axially placed implants.
b
The patients received two implants from each group in each rehabilitated arch: 2 distal implants tilted and 2 mesial implants axially placed.
c
The study was controlled for the implant design (hollow screw, hollow cylinder, angulated hollow cylinder).
d
The study was controlled for definitive acrylic resin prostheses (with or without a cast metal framework).
e
Unpublished information was obtained by personal communication with one of the authors.
Testori et al.51
155
156
Mattsson et al.37
Krekmanov et al.38
No major bone
res or pti on ( 1 m m)
was observed on the
radiographs 1 and 3
years after implant
installation
NM
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Observations
NM
Turned
(Branemark,
Nobel Biocare
AB, Goteborg,
Sweden)
Maxilla/fixed full-arch
prostheses/opposing
dentition: NM
3035, maxilla
2535, mandible
NM
Maxilla, mandible/fixed
partial and full-arch
prostheses/opposing
dentition: NM
Maxilla/fixed partial
prostheses/opposing
dentition: natural
dentition or a fixed
implant-supported
prostheses up to the
third molar (n = 6), up to
the second molar
(n = 14), up to the first
molar (n = 2), up to the
second premolar (n = 3)
Maxilla, mandible/single
crowns, fixed partial
prostheses/opposing
dentition: NM
Maxilla/fixed partial
(n = 12) and fixed
full-arch prostheses
(n = 7)/opposing
dentition: natural teeth
or implant-supported
prostheses (n = 18),
removable dentures
(n = 2)
Only in posterior
regions
Aparicio et al.7
>15
Turned
(Branemark,
Nobel Biocare
AB, Goteborg,
Sweden)
Karoussis et al.13
Information provided,
but with no distinction
between tilted and
axial implants
0.34 0.76 (G1, n = 36)
0.82 0.86 (G2, n = 32)
(1 year)
NM
TPS (ITI,
Straumann,
Waldenburg,
Switzerland)
Turned (n = 11),
acid etched
(n = 3), oxidised
(n = 46)
(Branemark,
MkIV, n = 39,
Replace Select
Tapered, n = 21,
Nobel Biocare
AB, Goteborg,
Sweden)
Oxidised
(TiUnite, MKIII,
MkIV, Nobel
Biocare AB,
Goteborg,
Sweden)
Calandriello and
Tomatis14
Region/prosthetic
rehabilitation/
opposing dentition
1745
Malo et al.39
NM
Malo et al.40
45, maxilla
30, mandible
Oxidised
(TiUnite,
NobelSpeedy,
MkIII, MkIV,
Nobel Biocare
AB, Goteborg,
Sweden)
Capelli et al.15
3035, maxilla
2535, mandible
Acid-etched
(Osseotite, NT,
Biomet 3i, Palm
Beach Gardens,
USA)
Maxilla/fixed full-arch
prostheses/opposing
dentition: implantsupported prostheses
(n = 15), natural teeth
(n = 11), a combination
of both (n = 6)
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition:
implant-supported
prostheses (n = 27),
natural teeth (n = 13), a
combination of both
(n = 5), removable
prostheses (n = 1)
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition: NM
6 smokers
Only in the
atrophic
posterior
maxilla, flapless
surgery (5
patients), light
smokers were
also included,
but the precise
number was not
informed
Some implants
were inserted in
fresh extraction
sockets, but the
precise number
was not
informed
Graft in 4
patients (iliac
crest, 6 months
before implants),
16 smokers
10 smokers
157
Table 2 (Continued )
Authors
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Region/prosthetic
rehabilitation/
opposing dentition
Observations
Fluoridemodified
nanostructure
(Astra Tech
Dental, Molndal,
Sweden)
Oxidised
(TiUnite,
NobelSpeedy,
Nobel Biocare
AB, Goteborg,
Sweden)
Oxidised
(TiUnite,
Branemark,
MkIV, n = 30,
NobelSpeedy
Groovy, n = 96,
Nobel Biocare
AB, Goteborg,
Sweden)
Oxidised
(TiUnite,
Branemark,
MkIV, n = 116,
NobelSpeedy
Groovy, n = 132,
Nobel Biocare
AB, Goteborg,
Sweden)
Maxilla, mandible/fixed
partial prostheses,
supported by 2 or 3
implants/opposing
dentition: NM
10 smokers,
periodontally
compromised
treated patients
only
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition: NM
Flapless surgery
with surgical
template, 6
bruxers
Maxilla/fixed full-arch
prostheses/opposing
dentition: NM
8 smokers, fresh
extraction
sockets
(40 implants)
Mandible/fixed full-arch
prostheses/opposing
dentition: removable
prostheses (n = 27),
natural teeth (n = 8),
natural teeth and fixed
prostheses on natural
teeth (n = 8), fixed
prostheses on natural
teeth (n = 3),
implant-supported
bridges (n = 9), natural
teeth and two
implant-supported
bridges (n = 4)
Maxilla/fixed full-arch
prostheses/opposing
dentition: natural teeth
or fixed or removable
prostheses
25 smokers, fresh
extraction
sockets
(40 implants)
Maxilla/fixed full-arch
prostheses/opposing
dentition: NM
12 smokers
Mandible/fixed full-arch
prostheses/opposing
dentition: NM
4 smokers, some
implants were
inserted in fresh
extraction
sockets, but the
precise number
was not
informed
Koutouzis and
Wennstrom41
1130
Malo et al.16
Information provided,
but with no distinction
between tilted and
axial implants
30
Agliardi et al.17
3045
Francetti et al.18
30
Tealdo et al.19
NM
Acid-etched
(Osseotite, NT,
Biomet 3i, Palm
Beach Gardens,
USA)
3035
30
Acid-etched
(Osseotite, NT,
Biomet 3i, Palm
Beach Gardens,
USA)
Oxidised
(TiUnite,
Branemark,
MkIV, n = 16,
NobelSpeedy
Groovy, n = 80,
Nobel Biocare
AB, Goteborg,
Sweden)
Testori et al.20
Agliardi et al.21
Fresh extraction
sockets
(47 implants)
158
Table 2 (Continued )
Authors
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Agliardi et al.22
3045, maxilla
30, mandible
Oxidised
(TiUnite,
Branemark,
MkIV, n = 92,
NobelSpeedy
Groovy, n = 600,
Nobel Biocare
AB, Goteborg,
Sweden)
Degidi et al.23
3045
Sandblasted and
acid-etched
(XiVE Plus,
Dentsply
Friadent,
Mannheim,
Germany)
Hinze et al.24
30
Acid-etched
(Osseotite,
NanoTite
Tapered, Biomet
3i, Palm Beach
Gardens, USA)
Butura et al.42
NM
30
Oxidised
(TiUnite,
NobelSpeedy
Groovy, Nobel
Biocare AB,
Goteborg,
Sweden)
Corbella et al.25
NM
NM
NM
De Vico et al.26
30
Kawasaki et al.43
NM
> 17
Oxidised
(TiUnite,
NobelActive,
Nobel Biocare
AB, Goteborg,
Sweden)
NM (Nobel
Biocare AB,
Goteborg,
Sweden)
Region/prosthetic
rehabilitation/
opposing dentition
Observations
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition:
removable prostheses
(n = 50, maxilla; n = 22,
mandible), natural teeth
(n = 15, maxilla; n = 9,
mandible), natural teeth
and fixed prostheses on
natural teeth (n = 12,
maxilla), fixed
prostheses on natural
teeth (n = 3, maxilla;
n = 5, mandible),
implant-supported
bridges/prostheses
(n = 9, maxilla; n = 25,
mandible), natural teeth
and two implantsupported bridges (n = 4,
maxilla)
Maxilla/fixed full-arch
prostheses/opposing
dentition: NM
48 smokers,
some implants
were inserted in
fresh extraction
sockets, but the
precise number
was not
informed
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition:
natural teeth (n = 7),
tooth-supported FPDs
(n = 11), implantsupported FPDs (n = 14),
full-arch implantsupported prostheses
(n = 5)
Mandible/fixed full-arch
prostheses/opposing
dentition: NM
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition: NM
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition: NM
Maxilla, mandible/fixed
partial and full-arch
prostheses/opposing
dentition: NM
Patients smoking
less than 10
cigarettes per
day were also
included, but the
precise number
was not
informed,
no grafting
11 smokers
64 smokers, 45
bruxers, 20
diabetic patients,
some implants
were inserted in
fresh extraction
sockets, but the
precise number
was not
informed
30 smokers
Bone graft in 1
implant site
159
Table 2 (Continued )
Authors
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Malo et al.1
NM
3045
Oxidised
(TiUnite,
Branemark,
MkIV, n = 930,
NobelSpeedy,
n = 50, Nobel
Biocare AB,
Goteborg,
Sweden)
Acocella et al.44
NM
2030
Cavalli et al.45
NM
30
Crespi et al.8
3035
Fluoridemodified
nanostructure
(Osseospeed,
Astra Tech
Dental, Molndal,
Sweden)
Oxidised
(TiUnite,
Branemark,
MkIV,
NobelSpeedy
Groovy, Nobel
Biocare AB,
Goteborg,
Sweden)
NM (Sweden &
Martina, Due
Carrare, Italy)
Francetti et al.27
No visual evidence of
bone loss greater than
1 mm on any of the
implants
30
Oxidised
(TiUnite,
Branemark,
MkIV, n = 92,
NobelSpeedy
Replace, n = 104,
Nobel Biocare
AB, Goteborg,
Sweden)
30
Oxidised
(TiUnite,
NobelSpeedy
Groovy, n = 672,
NobelActive,
n = 60, Nobel
Biocare AB,
Goteborg,
Sweden)
Region/prosthetic
rehabilitation/
opposing dentition
Observations
Mandible/fixed full-arch
prostheses/opposing
dentition: implant-supported fixed prosthesis
(n = 100), natural teeth
(n = 31), fixed prosthetics
over natural teeth
(n = 21), combination of
natural teeth and implant-supported fixed
prosthetics (n = 30),
removable prostheses
(n = 63)
Mandible/fixed full-arch
prostheses/opposing
dentition: natural teeth
(n = 6), fixed partial
denture (n = 19),
complete removable
denture (n = 20)
Maxilla/fixed full-arch
prostheses/opposing
dentition: NM
61 smokers, 5
diabetic patients,
4 patients taking
biphosphonates
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition: NM
Patients smoking
less than 15
cigarettes per
day were also
included, but the
precise number
was not
informed
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition:
removable prostheses
(n = 23), natural teeth
(n = 11), natural teeth
and fixed prostheses on
natural teeth (n = 9),
implant-supported
bridges
(n = 2), natural teeth and
two implant-supported
bridges (n = 2)
Mandible/fixed full-arch
prostheses/opposing
dentition: NM
15 smokers, fresh
extraction sockets (14 implants)
10 smokers, 2
bruxers
19 smokers
55 smokers, 43
bruxers, 14
diabetic patients,
some implants
were inserted in
fresh extraction
sockets, but the
precise number
was not
informed
160
Table 2 (Continued )
Authors
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Region/prosthetic
rehabilitation/
opposing dentition
Observations
Mandible/fixed full-arch
prostheses/opposing
dentition: complete
denture (n = 8) fixed
rehabilitation and
natural teeth (n = 27)
removable prosthesis
and natural teeth (n = 12)
Maxilla/fixed full-arch
prostheses/opposing
dentition: implantsupported prostheses
(n = 107), natural teeth
(n = 68), a combination
of both (n = 60),
removable prosthesis
(n = 7)
Maxilla/fixed full-arch
prostheses (n = 16),
ovendentures (n = 2)/
opposing dentition: NM
All implants
inserted in fresh
extraction
sockets, 11
smokers, 2
diabetic patients
Grandi et al.28
30
Acid-etched
(JDEvolution,
JDentalCare,
Modena, Italy)
Malo et al.3
1.52 0.31
(3 years, n = 621)
1.95 0.44
(5 years, n = 106)
45
Oxidised (TiUnite
NobelSpeedy
Replace, Nobel
Biocare AB,
Goteborg,
Sweden)
Penarrocha et al.47
NM
NM (Nobel
Biocare AB,
Goteborg,
Sweden)
Mean 2535
Oxidised
(TiUnite,
NobelSpeedy
Replace, n = 57,
NobelSpeedy
Groovy, n = 24,
Nobel Biocare
AB, Goteborg,
Sweden)
30
Oxidised
(TiUnite, MkIV,
n = 12,
NobelSpeedy
Groovy, n = 68,
Nobel Biocare
AB, Goteborg,
Sweden)
6690 (calculated
from the
relationship of
the implant axis
to the denture
occlusal plane)
Sandblasted and
acid-etched
(Screw-Line
Promote, Camlog
Biotechnologies,
Basel,
Switzerland)
Mandible/fixed full-arch
prostheses/opposing
dentition: removable
prostheses (n = 11),
natural teeth and fixed
prostheses on natural
teeth (n = 4),
implant-supported
prostheses (n = 5)
Mandible/fixed full-arch
prostheses/opposing
dentition: natural
dentition (n = 4), fixed
partial dentures (n = 6),
complete dentures
(n = 13), anterior natural
dentition with posterior
removable partial
dentures (n = 5),
implant-supported fixed
prostheses (n = 16),
implant-supported
removable prostheses
(n = 2)
Pozzi et al.29
Weinstein et al.30
Krennmair et al.48
Smokers were
included, but the
precise number
was not
informed
Patients smoking
less than 10
cigarettes per
day were also
included, but the
precise number
was not
informed
Only in severely
atrophied
posterior
maxilla, patients
smoking less
than 10
cigarettes per
day were also
included, but the
precise number
was not
informed
4 smokers
7 smokers, 2
diabetic patients
161
Table 2 (Continued )
Authors
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Region/prosthetic
rehabilitation/
opposing dentition
Observations
Oxidised (TiUnite
NobelSpeedy
Replace, Nobel
Biocare AB,
Goteborg,
Sweden)
Oxidised
(NobelSpeedy
Speedy, Nobel
Biocare AB,
Goteborg,
Sweden)
Mandible/fixed full-arch
prostheses/opposing
dentition: NM
Only completely
edentulous
patients,
flapless-guided
surgery, no
smokers
83 trans-sinus
implants,
19 smokers,
22 bruxers,
3 diabetic
patients
Oxidised (TiUnite
Branemark MkIII,
n = 180,
NobelSpeedy
Groovy, n = 20,
Nobel Biocare
AB, Goteborg,
Sweden)
NM
Mandible/fixed full-arch
prostheses/opposing
dentition: NM
All implants in
fresh extraction
sockets
Maxilla/partial (3-unit
fixed bridge; 3 patients)
or fixed full-arch
prostheses (32 patients)/
opposing dentition: NM
Maxilla/fixed full-arch
prostheses/opposing
dentition: removable
prostheses (n = 6),
natural teeth (n = 7),
natural teeth and fixed
prostheses on natural
teeth (n = 8), fixed
prostheses on natural
teeth (n = 6), natural
teeth and two
implant-supported
partial prostheses (n = 5)
Maxilla/3-unit fixed
partial prostheses/
opposing dentition: NM
11 smokers,
some implants
with intrasinus
insertion
Landazuri-Del
Barrio et al.31
3045
Malo et al.49
<45
Testori et al.51
< 30
Agliardi et al.32
0.88 0.16
1.07 0.23
(1 year)
1.46 0.19
1.55 0.31
(3 years)
3045
Oxidised
(TiUnite,
Branemark,
MkIV, n = 30,
NobelSpeedy
Groovy, n = 162,
Nobel Biocare
AB, Goteborg,
Sweden)
30
Oxidised
(TiUnite,
NobelSpeedy
Groovy, Nobel
Biocare AB,
Goteborg,
Sweden)
Mozzati et al.50
Agliardi et al.33
(G1, n = 128)
(G2, n = 64)
30
(G1, n = 128)
(G2, n = 64)
Maxilla/fixed full-arch
prostheses/opposing
dentition: implantsupported prostheses
(n = 28), natural teeth
(n = 16), a combination
of both (n = 25),
removable prosthesis
(n = 1)
11 smokers, fresh
extraction
sockets
(44 implants)
Some implants
with intrasinus
insertion, 4
smokers
162
Table 2 (Continued )
Authors
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Region/prosthetic
rehabilitation/
opposing dentition
Observations
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition:
natural teeth (n = 7),
natural
teeth and fixed implant
prostheses (n = 3),
natural teeth and
removable prostheses
(n = 2), fixed prostheses
on natural teeth (n = 5),
removable prostheses
(n = 4), implantsupported fixed-dental
prostheses (n = 9)
Maxilla, mandible/fixed
full-arch prostheses/opposing dentition: NM
7 smokers, fresh
extraction
sockets
(76 implants)
Agnini et al.34
2040
Sandblasted and
acid-etched, and
hydroxyapatitecoated (Spline,
n = 84, Tapered
Screw-Vent,
n = 188, Zimmer
Dental Inc.,
Carlsbad, USA)
Balshi et al.52
NM
NM
Browaeys et al.35
1.14 1.14
1.13 0.71
(1 year)
1.67 1.22
1.55 0.73
(3 years)
NM (Nobel
Biocare AB,
Goteborg,
Sweden)
Oxidised
(TiUnite, MkIII
Groovy, n = 44,
NobelSpeedy
Groovy, n = 36,
Nobel Biocare
AB, Goteborg,
Sweden)
Tealdo et al.36
(G1, n = 32)
(G2, n = 32)
2040
(G1, n = 32)
(G2, n = 32)
Information provided,
but with no distinction
between tilted and
axial implants
NM
NM
Maxilla, mandible/fixed
full-arch prostheses/
opposing dentition:
natural teeth, an
implant-borne fixed
restoration, or a
removable prosthesis
with a corresponding
number of teeth
Maxilla/fixed full-arch
prostheses/opposing
dentition: natural teeth,
fixed or removable
prostheses
132 implants in
smokers
Computerguided flapless
surgery, no grafts
Fresh extraction
sockets
(163 implants),
patients smoking
less than 20
cigarettes per
day were also
included, but the
precise number
was not
informed
NM not mentioned; G1 group tilted implants; G2 group axially placed implants; ASW anterior sinus wall; PSW posterior sinus wall.
The funnel plot did not show asymmetry when the studies
reporting the outcome implant failure were analysed (Fig. 6),
indicating possible absence of publication bias.
4.
Discussion
Selection
Representativeness
of the exposed
cohort
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Outcome
of interest
not present
at start
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Comparability of
cohorts
Main
factor
Additional
factor
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0
0
0
0
0
$
0
$
$
0
0
$
0
0
$
0
0
$
$
0
0
0
0
$
0
$
$
$
0
0
$
$
0
0
$
Total (9/9)
Assessment
of outcome
Follow-up
long enougha
Adequacy
of follow-up
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0
0
0
0
$
0
0
0
0
0
0
0
$
0
$
0
0
0
$
$
$
$
$
0
0
$
$
$
0
$
0
$
0
$
$
0
0
0
0
0
$
$
0
0
0
0
0
$
0
0
0
0
$
0
0
0
0
0
$
0
$
0
0
$
0
$
$
0
$
$
$
$
0
$
7/9
7/9
7/9
8/9
5/9
6/9
6/9
5/9
6/9
6/9
5/9
6/9
7/9
5/9
5/9
6/9
6/9
6/9
7/9
5/9
5/9
6/9
7/9
7/9
6/9
7/9
6/9
6/9
6/9
7/9
8/9
8/9
5/9
7/9
7/9
8/9
6/9
6/9
8/9
163
0
0
0
$
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Ascertainment
of exposure
Outcome
Mattsson et al.37
Krekmanov et al.38
Aparicio et al.7
Karoussis et al.13
Calandriello and Tomatis14
Malo et al.39
Malo et al.40
Capelli et al.15
Koutouzis and Wennstrom41
Malo et al.16
Agliardi et al.17
Francetti et al.18
Tealdo et al.19
Testori et al.20
Agliardi et al.21
Agliardi et al.22
Degidi et al.23
Hinze et al.24
Butura et al.42
Corbella et al.25
De Vico et al.26
Kawasaki et al.43
Malo et al.1
Acocella et al.44
Cavalli et al.45
Crespi et al.8
Francetti et al.27
Galindo and Butura46
Grandi et al.28
Malo et al.3
Penarrocha et al.47
Pozzi et al.29
Weinstein et al.30
Krennmair et al.48
Landazuri-Del Barrio et al.31
Malo et al.49
Mozzati et al.50
Testori et al.51
Agliardi et al.32
Selection of
external
control
Comparability
164
$
0
0
$
$
$
$
$
$
$
$
$
$
$
$
0
$
$
$
$
Three years of follow-up was chosen to be enough for the outcome implant failure to occur.
a
Additional
factor
Main
factor
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Ascertainment
of exposure
Selection of
external
control
$
$
$
$
$
0
0
0
0
0
Agliardi et al.33
Agnini et al.34
Balshi et al.52
Browaeys et al.35
Tealdo et al.36
Follow-up
long enougha
Comparability of
cohorts
Study
Table 3 (Continued )
Representativeness
of the exposed
cohort
Selection
Outcome
of interest
not present
at start
Assessment
of outcome
Outcome
Comparability
Adequacy
of follow-up
7/9
7/9
7/9
8/9
8/9
Total (9/9)
interface, and may prevent the fibrin clot from adhering to the
implant surface during healing.55 Splinting of the implants in
the case of the immediate-loaded fixed full-arch prostheses
might have protected these implants from micromotion.56
Splinting allows a more even distribution of the occlusal
forces, thereby reducing stresses at the bone-implant interface.57 It was also suggested that the reason for the high
survival of tilted implants may be the increased contact
between cortical bone and tilted implants, increasing the
initial stability,52 which may be true for the maxilla, but not
necessarily for the mandible. However, when a sensitivity
analysis was performed pooling the studies evaluating
implants inserted in maxillae only, a statistically significant
difference was observed, favouring axially placed implants.
This might be associated with the lower bone density
encountered at the posterior regions of the edentulous
maxilla, where the tilted implants were inserted.
Concerning marginal bone loss, it was suggested by finite
element analysis (FEA) studies which reported accentuated
stresses around non-axially placed implant necks5860 that
unfavourable loading direction could in theory induce greater
bone resorption around tilted implants as compared to axially
placed implants. Tilted implants may be also subjected to
bending, possibly increasing marginal bone stress.61 On the
other side, it was shown in FEA studies for full-arch prosthesis
that the reduction of the cantilever length achieved by tilting
of the distal implants allows for a more widespread distribution of the occlusal forces under loading, and consequently for
a reduction of the stresses at the implant neck.53,62,63 It is
interesting to note that photoelastic and FEA studies that
analysed single angulated implants5860 showed increase of
stress in the surrounding bone, whereas FEA studies53,62,63
analysing tilted implants in splinted full-arch prostheses
observed more favourable results for tilted implants concerning marginal bone loss, due to the splinting effect. The
cantilever length of the prosthesis also has some influence, as
shorter cantilevers have been correlated to a reduced periimplant bone loss.64 The present meta-analysis did not find an
apparent significant effect of tilted dental implants on the
occurrence of greater marginal bone loss in comparison with
axially placed implants. The fact that fixed full-arch prostheses
with splinted implants were the most common rehabilitation
observed in the studies here included might have collaborated
to these findings. However, these results should be interpreted
with caution due to the lack of use among the included studies
of a standardised technique aiming to obtain a precise and
reproducible bone loss measurement, and also due to the
variability of the follow-up period among the studies.
The studies included here have a considerable number of
confounding factors, and most of the studies, if not all, did not
inform how many implant were inserted and survived/lost in
several different conditions. The use of grafting in some
studies40,43 is a confounding risk factor, as well as the insertion
of some1719,21,22,27,32,34,36,39,42,46 or all28,50 implants in fresh
extraction sockets, the insertion of implants in different
locations, different healing periods, different prosthetic configurations, type of opposing dentition, different implant
angulation ranges, splinting of the implants, and the presence
of smokers,1,3,7,8,14,15,17,18,2025,2730,3234,36,4042,4449,51,52 bruxers,16,42,44,46,49 or diabetics patients.1,28,42,46,48,49
165
166
Fig. 4 Forest plot for the event implant failure studies evaluating implants inserted in maxillae.
167
Fig. 5 Forest plot for the event implant failure studies evaluating implants inserted in mandibles.
level of specificity, where the assessment of implant angulation as a complicating factor for dental implants was seldom
the main focus of the investigation.
5.
Conclusion
Acknowledgements
This work was supported by CNPq, Conselho Nacional de
Desenvolvimento Cientfico e Tecnologico Brazil. The
authors would like to thank Dr. Tommaso Grandi, Dr. Miguel
de Araujo Nobre, Dr. Massimo Del Fabbro, and Dr. Enrico
Agliardi for having sent us their articles, Dr. Maria Menini, and
Dr. Tiziano Testori, who provided us some missing information about their studies.
references
168
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
169
170