After the position of the implant has been identified, the direction of the implant in

the jaw (bucco-lingual and mesio-distal) must be determined.

If possible the implant should be placed in tooth position. This means that in a
normal case the long axis of the implant should be directed through the occlusal
surface of the final restoration. Regarding the bucco-lingual dimension, the long axis
of mandibular implant will be mainly be directed toward the limbus part of the
incisors or the palatal cusps of the teeth in the maxilla, the corresponding
inclination should be toward the incisal edge of the frontal teeth or the buccal cusps
of the premolars and molars of the mandible .if the starting point of the implant
sites in the maxilla is located close to the top of the crest, and if a concavity on the
buccal side of the ridge is present, there is a risk that the surgeon leans the long
axis of the implant too far buccally .the equivalent for the mandible is an implant
directed too far lingually owing the presence of lingual concavities . Such adverse
directions can impair the esthetics and function of the future restoration, even
though angulated abutments may to some extent compensate for such a surgical
shortcoming.
In addition ,inclination of the implant to be inserted will depend on the
existing jaw relation .in the case of angle class I jaw relation ,the implants should be
placed rather vertically in both jaws .in angle class II ,the implants should often be
placed vertically in the maxilla and slightly buccally in the mandible .in angle class
III relations ,the implant are inclined buccally in the maxilla and more lingually in the
mandible .if the relation between the jaws is markedly adverse ,orthognatic surgery
may be considered to correct the abnormal jaw relation .
For the mesio-distal orientation of the implant, the rule is that the implant
closest to the last tooth is placed parallel with the long axis of the root of this tooth.
The further distally the site is located into the molar region; on the other hand the
more inclined are the positions of the implants. In the mandible, for example, it is
recommended that the most distal implants be placed in a slightly mesial direction
to facilitate the connection of the abutments with the fixed bridge restoration.
In extremely resorbed mandibles, the most distal implant that is placed
immediately in front of the mental foramen can be tilted distally in order to achieve
optimal spreading of the supporting units. Correspondingly , in the resorbed
maxilla ,the canal prepared for the most distal implant (lateral to the canine )can
be directed slightly distally and follow the mesial wall of the maxillary sinus ,thereby
allowing a longer implant to be placed .an alternative to this procedure would be the
use of sinus elevation and grafting techniques .