tmpAA62 TMP

journal of dentistry 43 (2015) 149170
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.intl.elsevierhealth.com/journals/jden
Review
Tilted versus axially placed dental implants:

A meta-analysis
Bruno Ramos Chrcanovic a,*, Tomas Albrektsson a,b, Ann Wennerberg a
a
b
Department of Prosthodontics, Faculty of Odontology, Malmo University, Malmo, Sweden

Department of Biomaterials, Goteborg University, Goteborg, Sweden
article info
abstract
Article history:
Objectives: The purpose of the present review was to test the null hypothesis of no difference
Received 24 July 2014
in the implant failure rate, marginal bone loss, and postoperative infection for patients being
Received in revised form
rehabilitated by tilted or by axially placed dental implants, against the alternative hypothe-
30 August 2014
sis of a difference.
Accepted 3 September 2014
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:
and mean difference (MD) in millimetres.
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
Implant failure rate
(P = 0.40), with a RR of 1.14 (95% CI 0.841.56). A statistically significant difference was found
Marginal bone loss
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
0.03 to 0.08; P = 0.32). Due to lack of
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
The loss of posterior teeth, particularly at an early age, leads to

the loss of alveolar bone with a relative surfacing of the
inferior alveolar nerve in the mandible, thus often prohibiting
placement of implants in the posterior regions.1 Bone grafting
and the use of short implants have been proposed to overcome
these anatomic limitations. An alternative could be the
inferior alveolar nerve lateral transposition2 or the use of
tilted implants, which allows for maximum use of the existing
bone and placement of posterior fixed teeth with minimum
cantilevers, in a region where bone height and nerve proximity
does not allow for the placement of axial implants.1
Concerning the upper jaw, implant anchorage in the totally
edentulous maxilla is often restricted owing to bone resorption, which is especially frequent in the posterior region of the
maxillary arch, where bone grafting is often indicated.3 There
is also the problem of the pneumatisation, an inferior
expansion of the maxillary sinus in relation to fixed anatomic
landmarks which develops with time after the extraction of
the posterior maxillary teeth. Pterygomaxillary and zygomatic
implants could be used, but these techniques present
considerable surgical complexity.46 The use of tilted implants
in the anterior or posterior maxillary sinus walls may be used
instead of maxillary sinus elevation or bone grafts, resulting in
a simpler and less time-consuming treatment, in significantly
less morbidity, in decreased financial costs associated with
those procedures, and in a more comfortable postsurgical
period for the patients.7,8
Researchers have been trying to evaluate whether the
insertion of tilted implants may influence the survival of
dental implants. However, some studies may lack statistical
power, given the small number of patients per group in the
clinical trials comparing the techniques. The ability to
anticipate outcomes is an essential part of risk management
in an implant practice. Recognising conditions that place the
patient at a higher risk of failure will allow the surgeon to
make informed decisions and refine the treatment plan to
optimise the outcomes.9 The use of implant therapy in special
populations requires consideration of potential benefits to be
gained from the therapy. To better appreciate this potential,
we conducted a systematic review and meta-analysis to
compare the survival rate of dental implants, postoperative
infection, and marginal bone loss of tilted and axially placed
dental implants.
2.
Materials and methods
This study followed the PRISMA Statement guidelines.10 A

review protocol does not exist.
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.
Inclusion and exclusion criteria
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
The titles and abstracts of all reports identified through the

electronic searches were read independently by the three
authors. For studies appearing to meet the inclusion criteria, or
for which there were insufficient data in the title and abstract to
make a clear decision, the full report was obtained. Disagreements were resolved by discussion between the authors.
2.5.
2.1.
Search strategies
Quality assessment
Objective
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 hypothesis of a difference.
Quality assessment of the studies was executed according to

the Newcastle-Ottawa scale (NOS).11 The NOS calculates the
study quality on the basis of 3 major components: selection,
comparability, and outcome for cohort studies. It assigns a
maximum of 4 stars for selection, a maximum of 2 stars for
comparability, and a maximum of 3 stars for outcome.
According to that quality scale, a maximum of 9 stars/points

can be given to a study, and this score represents the highest
quality, where six or more points were considered high quality.
2.6.
Data extraction and meta-analysis
From the studies included in the final analysis, the following

data was extracted (when available): year of publication, study
design, unicenter or multicenter study, number of patients,
patients age, follow-up, days of antibiotic prophylaxis, rinse,
implant healing period, failed and placed implants, postoperative infection, marginal bone loss, implant surface modification, type of prosthetic rehabilitation, jaws receiving implants
(maxilla and/or mandible). Contact with authors for possible
missing data was performed.
Implant failure and postoperative infection were the
dichotomous outcomes measures evaluated. Weighted mean
differences were used to construct forest plots of marginal
bone loss, a continuous outcome. The statistical unit for
implant failure and marginal bone loss was the implant, and
for postoperative infection was the patient. Whenever
outcomes of interest were not clearly stated, the data were
not used for analysis. The I2 statistic was used to express the
percentage of the total variation across studies due to
heterogeneity, with 25% corresponding to low heterogeneity,
50% to moderate and 75% to high. The inverse variance
method was used for random-effects or fixed-effects model.
Where statistically significant (P < .10) heterogeneity is
detected, a random-effects model was used to assess the
significance of treatment effects. Where no statistically
significant heterogeneity is found, analysis was performed
using a fixed-effects model.12 The estimates of relative effect
for dichotomous outcomes were expressed in risk ratio (RR)
and in mean difference (MD) in millimetres for continuous
outcomes, both with a 95% confidence interval (CI). Only if
there were studies with similar comparisons reporting the
same outcome measures was meta-analysis to be attempted.
In the case where no events (or all events) are observed in both
groups the study provides no information about relative
probability of the event and is automatically omitted from the
meta-analysis. In this (these) case(s), the term not estimable
is shown under the column of RR of the forest plot table. The
software used here automatically checks for problematic zero
counts, and adds a fixed value of 0.5 to all cells of study results
tables where the problems occur.
A funnel plot (plot of effect size versus standard error) will
be drawn. Asymmetry of the funnel plot may indicate
publication bias and other biases related to sample size,
although the asymmetry may also represent a true relationship between trial size and effect size.
The data were analysed using the statistical software
Review Manager (version 5.3.3, The Nordic Cochrane Centre,
The Cochrane Collaboration, Copenhagen, Denmark, 2014).
3.
Results
3.1.
Literature search
The study selection process is summarised in Fig. 1. The

search strategy resulted in 1336 papers. A number of 424
151
articles were cited in more than one research of terms

(duplicates). The three reviewers independently screened
the abstracts for those articles related to the focus
question. Of the resulted 912 studies, 847 were excluded
for not being related to the topic, resulting in 65 entries.
Additional hand-searching of the reference lists of selected
studies yielded 6 additional papers. The full-text reports of
the remaining 71 articles led to the exclusion of 27 because
they did not meet the inclusion criteria (11 publications did
not inform of the number of implants per group, 4
evaluating tilted implants only, 4 not evaluating implant
failures, 2 were same study published in another journal, 2
reviews, 2 FEA studies, 1 biomechanical study, 1 used
cephalometric parameters to evaluate the angulation of the
implants). Thus, a total of 44 publications were included in
the review.
3.2.
Description of the studies
Detailed data of the forty-four included studies are listed in

Tables 1 and 2. Twenty-five prospective studies8,1336 and
nineteen retrospective analyses1,3,7,3752 were included in the
meta-analysis. Five studies15,18,20,27,44 were multicenter.
Four studies24,31,39,40 had a relatively short follow-up time
(up to 12 months). All studies but two16,52 provided information of the patients age, and none of them included
non-adults patients. Some patients in thirty-three studies1,3,7,8,14,15,17,18,2025,2730,3234,36,4042,4449,51,52 were smokers.
Five studies16,42,44,46,49 reported the presence of bruxers among
the patients, and six studies1,28,42,46,48,49 the presence of
diabetic patients. In twelve studies1719,21,22,27,32,34,36,39,42,46
some implants were inserted in fresh extraction sockets, in
two others28,50 all implants were inserted in fresh extraction
In
twenty-three
studies1,3,8,16,18,21,22,24
sockets.
28,30,31,35,39,42,45,46,4850,52
the patients were exclusively rehabilitated with fixed full-arch prostheses receiving 2 distal tilted
implants and 2 mesial axially placed implants. Patients were
submitted to grafting procedures at the implant site in only
two studies.40,43 In three studies14,29,38 the implants were
inserted in the posterior segments of the jaws only. In two
studies33,51 the tilted implants had intrasinus insertion.
Seventeen studies3,7,14,17,19,20,23,29,32,33,36,37,39,45,47,49,51 exclusively evaluated implants inserted in maxillae, and exclusively evaluated implants inserted in mandibles in eleven
studies.1,18,21,28,30,31,42,44,46,48,50 Implants were not immediately
loaded in eight studies7,13,37,38,43,47,48,51 In one study36 some
implants were immediately or delayed loaded, and another
study41 did not provide information about the healing/loading
time. Twenty-three studies8,13,1517,20,21,23,25,26,31,33,37,38,4143,45
47,5052
did not provide information about the opposing
dentition to the implants being evaluated. Information about
the implant inclination in degrees was not provided in eight
studies.13,19,25,36,37,39,47,52
Of the forty-four studies comparing the procedures, a total
of 5029 dental implants were tilted, with 82 failures (1.63%),
and 5732 implants were axially placed, with 104 failures
(1.81%). No study informed whether there was a statistically
significant difference or not between the implant failure rates
between the procedures. There were no implant failures in
twelve studies.17,18,21,27,28,30,33,35,41,45,48,50 Implants from the
152
Fig. 1 Study screening process.
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
Thirty-six studies were of high quality, and eight of moderate

quality. The scores are summarised in Table 3.
3.4.
Meta-analysis
In this study, a fixed-effects model was used to evaluate the

implant failure in the comparison between the procedures,
since statistically heterogeneity was not found (I2 = 0%;
P = 0.90). The insertion of dental implants in a tilted position
did not statistically affect the implant failure rates (RR 1.14,
95% CI 0.841.56, P = 0.40; Fig. 2). There were no apparent
significant effects of tilted dental implants on the occurrence
of marginal bone loss (MD 0.03, 95% CI 0.03 to 0.08; P = 0.32;
heterogeneity: random-effects model, I2 = 88%; P < 0.00001,
Fig. 3) in comparison with axially placed implants. Due to lack
of satisfactory information, meta-analysis for the outcomes
postoperative infection was not performed.
Sensitivity analyses were also performed for the outcome
implant failure. The RR was examined for the groups of
studies evaluating the implants inserted in different jaws.
When studies evaluating implants inserted in maxillae only
were pooled, a RR of 1.70 resulted (95% CI 1.052.74; P = 0.03;
heterogeneity: fixed-effects model, I2 = 0%, P = 0.83; Fig. 4),
whereas when the studies evaluating implants inserted in
mandible only were pooled, a RR of 0.77 was observed (95% CI
0.391.52; P = 0.45; heterogeneity: fixed-effects model, I2 = 0%,
P = 0.95; Fig. 5).
Table 1 Detailed data of the included studies Part 1.

Authors
Published
Study
design
Patients Patients age

(n)
range
(average)
(years)
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
Mean 22.1 months

(range 342)
Mean 32.7 months
(range 1947)
1259 months
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)
6, 12, 24, and 36

months
6 and 12 months
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
Patients Patients age

(n)
range
(average)
(years)
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)
Mean 18.3 months

(range 660)
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)
Twice a year for 4

years
Mean 38.8 months
(range 1273)
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
Mean 31.5 months

(range 2446)
Up to 10 years
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
3, 6, 12, 24, and 36

months
6, 12, 18, 24, 36, 48
and 60 months
>1 year of function
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)
Mean 39.2 months

(range 17 years)
Mean 43.3 months
(range 3654)
Mean 30.1 (range
2048)
Mean 66.5 months
(range 57 years)
3, 6, and 12 months
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)
Mean 4.9 years
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)
Mean 75.2 months

(range 7290)
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
Table 2 Detailed data of the included studies Part 2.

Authors
Mattsson et al.37
Krekmanov et al.38
Marginal bone loss

(mean SD) (mm)
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
0.57 0.50 (G1, n = 42)

0.43 0.45 (G2, n = 57)
(1 year)
>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
1.0 1.0, mesial, n = 99

0.9 1.1, distal, n = 98
NM
Malo et al.40
1.2 0.8, mesial

1.1 0.9, distal
45, maxilla
30, mandible
Oxidised
(TiUnite,
NobelSpeedy,
MkIII, MkIV,
Nobel Biocare
AB, Goteborg,
Sweden)
Capelli et al.15
0.88 0.59 (G1, n = 42)

0.95 0.44 (G2, n = 84)
(1 year)
3035, maxilla
2535, mandible
Acid-etched
(Osseotite, NT,
Biomet 3i, Palm
Beach Gardens,
USA)
prostheses/opposing
dentition: implantsupported prostheses
(n = 15), natural teeth
(n = 11), a combination
of both (n = 6)
full-arch prostheses/
opposing dentition:
implant-supported
natural teeth (n = 13), a
combination of both
(n = 5), removable
prostheses (n = 1)
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
Authors
Marginal bone loss

(mean SD) (mm)
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)
partial prostheses,
supported by 2 or 3
implants/opposing
dentition: NM
10 smokers,
periodontally
compromised
treated patients
only
Flapless surgery
with surgical
template, 6
bruxers
prostheses/opposing
dentition: NM
8 smokers, fresh
extraction
sockets
(40 implants)
Mandible/fixed full-arch
prostheses/opposing
dentition: removable
natural teeth (n = 8),
natural teeth and fixed
prostheses on natural
teeth (n = 8), fixed
teeth (n = 3),
implant-supported
bridges (n = 9), natural
teeth and two
implant-supported
bridges (n = 4)
prostheses/opposing
or fixed or removable
prostheses
25 smokers, fresh
extraction
sockets
(40 implants)
prostheses/opposing
dentition: NM
12 smokers
prostheses/opposing
dentition: NM
4 smokers, some
implants were
inserted in fresh
extraction
sockets, but the
precise number
was not
informed
Koutouzis and
Wennstrom41
0.5 0.95 (G1)

0.4 0.97 (G2)
(5 years)
1130
Malo et al.16
between tilted and
axial implants
30
Agliardi et al.17
0.9 0.5 (G1, n = 56)

0.8 0.4 (G2, n = 28)
(1 year)
3045
Francetti et al.18
0.7 0.5 (G1, n = 120)

0.7 0.4 (G2, n = 120)
(1 year)
30
Tealdo et al.19
0.92 0.35 (G1, mesial,

n = 42)
1.04 0.37 (G1, distal,
n = 42)
0.62 0.30 (G2, mesial,
n = 61)
0.86 0.26 (G2, distal,
n = 61)
(1 year)
0.8 0.5 (G1, n = 80)
0.9 0.4 (G2, n = 160)
(1 year)
NM
Acid-etched
(Osseotite, NT,
Biomet 3i, Palm
Beach Gardens,
USA)
3035
0.8 0.5 (G1, n = 42)

0.9 0.4 (G2, n = 42)
(1 year)
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
Authors
Marginal bone loss

(mean SD) (mm)
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Agliardi et al.22
0.9 0.7, maxilla,

n = 204
1.2 0.9, mandible,
n = 292
3045, maxilla
30, mandible
Oxidised
(TiUnite,
Branemark,
MkIV, n = 92,
NobelSpeedy
Groovy, n = 600,
Nobel Biocare
AB, Goteborg,
Sweden)
Degidi et al.23
1.03 0.69 (G1, n = 120)

0.92 0.75 (G2, n = 90)
3045
Sandblasted and
acid-etched
(XiVE Plus,
Dentsply
Friadent,
Mannheim,
Germany)
Hinze et al.24
0.76 0.49 (G1, n = 74)

0.82 0.31 (G2, n = 74)
(1 year)
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
0.77 0.42 (G1, n = NM)

0.66 0.14 (G2, n = NM)
(1 year)
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
opposing dentition:
removable prostheses
(n = 50, maxilla; n = 22,
mandible), natural teeth
(n = 15, maxilla; n = 9,
and fixed prostheses on
natural teeth (n = 12,
maxilla), fixed
teeth (n = 3, maxilla;
n = 5, mandible),
implant-supported
bridges/prostheses
(n = 9, maxilla; n = 25,
and two implantsupported bridges (n = 4,
maxilla)
prostheses/opposing
dentition: NM
48 smokers,
some implants
were inserted in
fresh extraction
sockets, but the
precise number
was not
informed
opposing dentition:
tooth-supported FPDs
(n = 11), implantsupported FPDs (n = 14),
full-arch implantsupported prostheses
(n = 5)
prostheses/opposing
dentition: NM
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
Authors
Marginal bone loss

(mean SD) (mm)
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
1.11 0.32, maxilla,

n = 48
1.12 0.35, mandible,
n = 40
(3 years) (G1)
1.10 0.45, maxilla,
n = 48
1.06 0.41, mandible,
n = 40
(3 years) (G2)
0.47 0.22 (G1)
0.52 0.22 (G2)
(6 months; n = 132)
0.39 0.18 (G1)
0.51 0.17 (G2)
(5 years; n = 48)
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
Galindo and Butura46
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
prostheses/opposing
dentition: implant-supported fixed prosthesis
(n = 31), fixed prosthetics
over natural teeth
(n = 21), combination of
natural teeth and implant-supported fixed
prosthetics (n = 30),
(n = 63)
prostheses/opposing
(n = 6), fixed partial
denture (n = 19),
complete removable
denture (n = 20)
prostheses/opposing
dentition: NM
61 smokers, 5
diabetic patients,
4 patients taking
biphosphonates
Patients smoking
less than 15
cigarettes per
day were also
included, but the
precise number
was not
informed
opposing dentition:
and fixed prostheses on
implant-supported
bridges
(n = 2), natural teeth and
two implant-supported
bridges (n = 2)
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
Authors
Marginal bone loss

(mean SD) (mm)
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Region/prosthetic
rehabilitation/
opposing dentition
Observations
prostheses/opposing
dentition: complete
denture (n = 8) fixed
rehabilitation and
natural teeth (n = 27)
removable prosthesis
and natural teeth (n = 12)
prostheses/opposing
of both (n = 60),
(n = 7)
ovendentures (n = 2)/
All implants
inserted in fresh
extraction
sockets, 11
smokers, 2
diabetic patients
Grandi et al.28
0.68 0.14 (G1, n = 94)

0.77 0.14 (G2, n = 94)
(18 months)
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
0.76 0.06 (G1, n = 30)

0.52 0.10 (G2-conventional, n = 32)
0.58 0.06
(G2-palatal, n = 35)
0.68 0.02
(G2-pterygomaxil,
n=.10)
0.6 0.38 (G1-ASW,
n = 14)
0.62 0.37 (G1-PSW,
n = 26)
0.48 0.3 (G2, n = 38)
(1 year)
0.7 0.38 (G1-ASW,
n = 14)
0.7 0.2 (G1-PSW,
n = 26)
0.5 0.3 (G2, n = 38)
(3 years)
0.7 0.4 (G1, n = 36)
0.6 0.3 (G2, n = 36)
NM
NM (Nobel
Biocare AB,
Goteborg,
Sweden)
Mean 2535
Oxidised
(TiUnite,
NobelSpeedy
Replace, n = 57,
NobelSpeedy
Groovy, n = 24,
Nobel Biocare
AB, Goteborg,
Sweden)
Maxilla/3- to 5-unit fixed

partial prostheses/
opposing dentition:
natural dentition or a
fixed implant-supported
prosthesis
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)
prostheses/opposing
teeth (n = 4),
implant-supported
prostheses (n = 5)
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
implant-supported
(n = 2)
Pozzi et al.29
Weinstein et al.30
Krennmair et al.48
1.24 0.32 (G1, n = 76)

1.17 0.26 (G2, n = 76)
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
Authors
Marginal bone loss

(mean SD) (mm)
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)
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
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)/
prostheses/opposing
prostheses (n = 6),
teeth (n = 8), fixed
teeth (n = 6), natural
teeth and two
implant-supported
partial prostheses (n = 5)
Maxilla/3-unit fixed
partial prostheses/
11 smokers,
some implants
with intrasinus
insertion
Landazuri-Del
Barrio et al.31
0.83 0.14 (1 year)
3045
Malo et al.49
0.96 0.62 (G1, transsinus, n = 59)

0.89 0.54 (G1,
conventional, n = 47)
0.62 0.35 (G2, n = 57)
(1 year)
1.14 0.74 (G1,
trans-sinus, n = 50)
1.06 0.71 (G1,
conventional, n = 40)
1.15 0.51 (G2, n = 44)
(3 years)
1.48 0.39 (2 years,
n = 200)
<45
Testori et al.51
0.8 0.5 (G1, n = 52)

0.9 0.4 (G2, n = 144)
< 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)
0.9 0.5 (G1, n = 10)

1.0 0.4 (G2, n = 10)
(1 year)
prostheses/opposing
of both (n = 25),
(n = 1)
11 smokers, fresh
extraction
sockets
(44 implants)
Some implants
with intrasinus
insertion, 4
smokers
162
Authors
Marginal bone loss

(mean SD) (mm)
Implant
inclination
(G1, degrees)
Implant
surface
modification
(brand)
Region/prosthetic
rehabilitation/
opposing dentition
Observations
opposing dentition:
natural
teeth and fixed implant
prostheses (n = 3),
natural teeth and
(n = 2), fixed prostheses
on natural teeth (n = 5),
(n = 4), implantsupported fixed-dental
prostheses (n = 9)
full-arch prostheses/opposing dentition: NM
7 smokers, fresh
extraction
sockets
(76 implants)
Agnini et al.34
1.42 0.14 (G1,

maxilla, n = 21)
1.35 0.12 (G1,
mandible, n = 16)
1.37 0.14 (G2,
maxilla, n = 97)
1.3 0.11 (G2,
mandible, n = 68)
(1 year)
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)
between tilted and
axial implants
NM
NM
opposing dentition:
natural teeth, an
implant-borne fixed
restoration, or a
with a corresponding
number of teeth
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
According to the results of the present study, the insertion of

dental implants in a tilted position did not statistically affect
the implant failure rates in relation to axially placed implants.
This suggests that tilted implants may achieve the same
outcome as implants placed in a straight manner. This result
is associated with biomechanical advantages in the case of
fixed full-arch prostheses with splinted implants, the most
common rehabilitation observed in the studies here included,
since in this protocol implants are placed in strategic positions
from a load-sharing point of view. Placement of two or more
well-anchored posterior tilted implants together with anterior
axially oriented implants can provide a predictable foundation for

implant-supported full-arch prostheses.8 An FEA study concluded
that there is a biomechanical advantage in using splinted tilted
distal implants rather than axial implants supporting a higher
number of cantilever teeth.53 Tilting of the implants may allow
using longer implants that may engage greater quantity of residual
bone, which may be beneficial to implant stability.26 Moreover, a
more even distribution of stress around implants is achieved when
implants with longer lengths are used.54
It is also important to make some consideration about the
splinting of the implants. It has been suggested that it is not
the immediate loading per se that is critical for osseointegration, but rather the absence of excessive micromotion at the
interface. Micromotion consists of relative movement between the implant surface and surrounding bone during
functional loading and above a certain threshold excessive
interfacial micromotion early after the implantation interferes
with local bone healing, predisposes to a fibrous tissue
Table 3 Quality assessment of the studies by the Newcastle-Ottawa scale.

Study
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
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
Fig. 2 Forest plot for the event implant failure.
Moreover, it is known that the surface properties of dental

implants such as topography and chemistry are relevant for
the osseointegration process influencing ionic interaction,
protein adsorption and cellular activity at the surface.65 The
studies here included implants of different brands and surface
treatments. Titanium with different surface modifications
shows a wide range of chemical, physical properties, and
surface topographies or morphologies, depending on how they
are prepared and handled,6668 and it is not clear whether, in

general, one surface modification is better than another.65
Concerning the angulation of the implants, one should
recall that in the interpretation of the results, the classification
of tilted and axially placed implants was based on the
assessment of the inclination in only the mesialdistal
direction. Inclination in buccallingual direction might be of
equal importance but was not included because of difficulties
166
Fig. 3 Forest plot for the event marginal bone loss.
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.
experienced in defining the occlusal plane in a transversal

direction.41
The results of the present study have to be interpreted with
caution because of its limitations. First of all, all confounding
factors may have affected the long-term outcomes and not
just the fact that implants were tilted or axially placed and the
impact of these variables on the implant survival rate,
postoperative infection and marginal bone loss is difficult to
estimate if these factors are not identified separately between
the two different procedures in order to perform a metaregression analysis. The lack of control of the confounding
factors limited the potential to draw robust conclusions.
Second, most of the included studies had a retrospective
design, and the nature of a retrospective study inherently
results in flaws. These problems were manifested by the gaps
in information and incomplete records. Furthermore, all data
rely on the accuracy of the original examination and
documentation. Items may have been excluded in the initial
examination or not recorded in the medical chart.6971 Third,
much of the research in the field is limited by small cohort
sizes. Fourth, some included studies are characterised by a low
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
The results of the present review should be interpreted with

caution due to the presence of uncontrolled confounding
factors in the included studies, none of them randomised.
Within the limitations of the existing investigations, the
present study suggests that the differences in angulation of
dental implants in relation to the mesialdistal occlusal plane
might not affect the survival of these dental implants or the
marginal bone loss. A statistically significant difference was
found for implant failures when studies evaluating implants
inserted in maxillae only were pooled, in favour of axially
placed implants. The same was not true for implants inserted
in mandibles.
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.
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63.
64.
169
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journal of dentistry 43 (2015) 149170

Available online at www.sciencedirect.com

Tilted versus axially placed dental implants:

Department of Prosthodontics, Faculty of Odontology, Malmo University, Malmo, Sweden

Received 24 July 2014

Received in revised form

Accepted 3 September 2014

and mean difference (MD) in millimetres.

Implant failure rate

Marginal bone loss

0.03 to 0.08; P = 0.32). Due to lack of

journal of dentistry 43 (2015) 149170

The loss of posterior teeth, particularly at an early age, leads to

Materials and methods

This study followed the PRISMA Statement guidelines.10 A

Inclusion and exclusion criteria

The titles and abstracts of all reports identified through the

The purpose of the present review was to test the null

Quality assessment of the studies was executed according to

journal of dentistry 43 (2015) 149170

According to that quality scale, a maximum of 9 stars/points

Data extraction and meta-analysis

From the studies included in the final analysis, the following

The study selection process is summarised in Fig. 1. The

articles were cited in more than one research of terms

Description of the studies

Detailed data of the forty-four included studies are listed in

journal of dentistry 43 (2015) 149170

Fig. 1 Study screening process.

Thirty-six studies were of high quality, and eight of moderate

In this study, a fixed-effects model was used to evaluate the

Table 1 Detailed data of the included studies Part 1.

Patients Patients age

Mean 22.1 months

6, 12, 24, and 36

journal of dentistry 43 (2015) 149170

Patients Patients age

Mean 18.3 months

Twice a year for 4

Mean 31.5 months

3, 6, 12, 24, and 36

Mean 39.2 months

journal of dentistry 43 (2015) 149170

Mean 4.9 years

Mean 75.2 months

journal of dentistry 43 (2015) 149170

journal of dentistry 43 (2015) 149170

Table 2 Detailed data of the included studies Part 2.

Marginal bone loss

0.57  0.50 (G1, n = 42)

1.0  1.0, mesial, n = 99

1.2  0.8, mesial

0.88  0.59 (G1, n = 42)

journal of dentistry 43 (2015) 149170

Marginal bone loss

0.5  0.95 (G1)

0.9  0.5 (G1, n = 56)

0.7  0.5 (G1, n = 120)

0.92  0.35 (G1, mesial,

0.8  0.5 (G1, n = 42)

journal of dentistry 43 (2015) 149170

Marginal bone loss

0.57 0.50 (G1, n = 42)

1.0 1.0, mesial, n = 99

1.2 0.8, mesial

0.88 0.59 (G1, n = 42)

0.5 0.95 (G1)

0.9 0.5 (G1, n = 56)

0.7 0.5 (G1, n = 120)

0.92 0.35 (G1, mesial,

0.8 0.5 (G1, n = 42)

0.9 0.7, maxilla,

1.03 0.69 (G1, n = 120)

0.76 0.49 (G1, n = 74)

0.77 0.42 (G1, n = NM)

1.11 0.32, maxilla,

0.68 0.14 (G1, n = 94)

0.76 0.06 (G1, n = 30)

1.24 0.32 (G1, n = 76)

0.83 0.14 (1 year)

0.96 0.62 (G1, transsinus, n = 59)

0.8 0.5 (G1, n = 52)

0.9 0.5 (G1, n = 10)

1.42 0.14 (G1,