INTRODUCTION

The prevalence of the elderly population, as well as life expectancy, increased in the final

decades of the 20th century, as described in the World Health Organization 2004 Annual

Report.¹ The edentulous condition therefore has a negative impact on the oral health–related

quality of life. Patients wearing complete dentures for many years in fact, and especially in

the mandible, are often unsatisfied because of the instability of the prosthesis during speaking

and eating.

To date, dental implant treatment is well documented as a predictable treatment for partial or

complete edentulism.²˒³ Dental implants are widely used for replacing missing teeth. The

placement of standard-length dental implants in axial position requires an adequate amount of

bone to be present. In certain conditions when remaining bone volume is less or the proximity

of vital structures (inferior alveolar nerve, mental nerve, and the maxillary sinus) is there,

advanced surgical procedures are required to allow the placement of axial implants.⁴

Such procedures are usually associated with increased morbidity, higher cost, and longer

treatment duration. The alternative treatment in such cases is to intentionally tilt the implant.⁵

In the severely atrophic maxilla, alveolar ridge resorption, maxillary sinus pneumatization,

presence of nasal cavities, and type 3 or 4 bone quality, according to Lekholm and Zarb

classification, encumber or disable conventional dental implant placement.⁶ According to the

original Brånemark System concept implants should be placed fairly upright.²

With such implant position it was often necessary to fabricate a bilateral cantilever that was

up to 20 mm in length so as to provide the patient with good chewing capacity in molar

regions, increasing the risk of implant failure.⁷

In the case of a partially edentulous maxilla in the posterior region, the implants have to be

placed in a more lineal arrangement, which may increase the risk for bending overload.
Moreover, bone with less volume and worse quality is often found in these regions, which

frequently complicates implant placement and may compromise the prognosis of the clinical

results.⁸

Consequently, in a completely edentulous atrophic maxilla, long distal cantilevers would be

necessary to provide the patient with acceptable chewing capacity in the molar regions;

however, cantilevers longer than 15 mm have been associated with increased implant failure

rates. Several treatment options have been proposed to solve this situation, including bone

grafting techniques (block bone grafts and sinus lifting via crestal or lateral approach) and

nongrafting techniques, which are modifications of the conventional implant procedure, such

as placement in the zygomatic bone, the pterygoid process or the maxillary tuberosity, and

use of short or tilted implants.⁵

One attractive approach when treating the posterior maxilla is to use tilted implants to engage

as much cortical bone as possible. It leads to an improved position of support and allows for

placement of longer implants or improved anchorage in dense bone. Biomechanical

measurements show that the tilting does not have a negative effect on the load distribution

when it is a part of prosthetic support.⁷

From a theoretic point of view, the use of tilted implants in the residual crestal bone permits:

Placement of longer implants, which increases the degree of implant-to-bone contact area and

also the implant primary stability.

A longer distance between implants, allowing for the elimination of cantilevers in the

prosthesis, which results in a better load distribution situation.

Placement of implants in residual bone, avoiding more complex techniques, such as sinus

lifting or bone grafting procedures.⁵

Tilted placement, especially of posterior implants, may complicate the prosthetic treatment

with respect to axially placed implants; however, the use of angulated abutments allows

compensation for the implant angulation. Nevertheless, some studies suggest that for tilted

implants, bending moments are greater at the level of the angled abutment. However, the

rigidity of the prosthesis and increased prosthetic support may keep stress to the implants and

the adjacent bone within acceptable levels.⁷˒⁵

References
1. WHO. World Health Organization Annual Report 2004. Geneva: World Health
Organization; 2004.
2. Brånemark PI, Hansson BO, Adell R, Breine U, Lindström J, Hallén O, et al.
Osseointegrated implants in the treatment of the edentulous jaw. Scand J Plast
Reconstr Surg Suppl. 1980;16:1–132.
3. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of
currently used dental implants: A review and proposed criteria of success. Int J Oral
Maxillofac Implants. 1986;1(1):11–25.
4. Jaffin RA, Berman CL. The excessive loss of Branemark fixtures in type IV bone: A
5-year analysis. J Periodontol. 1991;62(1):2–4.
5. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus
grafting: A clinical, radiologic, and periotest study. Clin Implant Dent Relat Res.
2001;3(1):39–49.
6. Lekholm U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA,
Albrektsson T, editors. Tissue-integrated prostheses: Osseointegration in clinical
dentistry. Chicago: Quintessence; 1985. p. 199–209.
7. Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior mandibular and
maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants.
2000;15(3):405–14.
8. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to
failures of osseointegrated oral implants. I. Success criteria and epidemiology. Eur J
Oral Sci. 1998;106(1):527–51.
REVIEW OF LITERATURE
1. Arpad Laszlo Szab, Adam Laszlo Nagy, Csaba, Bencsik Krisztina Karpati and

Zoltan Barath (2022):This study examined the use of distally tilted implants in the

All-on-Four prosthetic concept, assessing clinical success and bone loss rates. Thirty-

six patients received full-arch fixed bridge supported by two axial and two distal tilted

implants each in the maxilla and mandible. Peri-implant bone-level changes were

evaluated using OPT images at 1.5, 2.5-, and 3.5-years post-restoration. All implants

exhibited 100% survival rate, but bone loss increased significantly over time,

particularly around tilted distal implants. Smoking and underlying conditions

correlated with higher bone resorption levels on individual implant-level analysis. The

study suggests a potential for increased bone loss, especially around tilted implants

and vertically positioned implants after long-term use.

2. Qi Wang, Zhen Zhen Zhang, shi- zu Bai, shao- feng Zang (2022):The study aimed

to compare stress distribution in an All-on-4 system with different tilted distal

implantsand cantilever lengths. Three All-on-4 implant models were created using

CAD and RP, with distally implants at 0, 15, and 45 degrees. The models were

subjected to a vertical load at different cantilever lengths and stress distribution was

captured and analysed. Results showed that the CAD and RP method was effective in

creating accurate models with controllable stress distribution. Single tilted implants

had higher stress compared to distal implants with the same inclination. The 0-degree

distal implant had the highest stress, while the 45-degree implant had the lowest.

Overall, the study concluded that tilted implants with reduced cantilever lengths did

not significantly increase stress levels compared to vertical implants.

3. Ozge OzdalZincir and AtesParlar (2021): This research evaluates stress and tension

in dental implant systems used in the All-on-four procedure. Two groups of models
 were analysed, featuring multiunit abutment-implant connection systems (group A)

and monoblock dental implants (group B). Results indicate significantly higher stress

in bone, prosthesis screws, and implants in group A models compared to group B

under axial and oblique forces. Monoblock implant systems show lower stress

accumulation, suggesting potential advantages in clinical application

4. Adam Hamilton, Faris Z. Jamjoom, Muhsen Alnasser, Jacqueline R. Starr,

Bernard Friedland, German O. Gallucci (2021):This study investigated the

effectiveness of using distally angulated implants to avoid the maxillary sinus and

bone augmentation while enhancing anterior-posterior (A-P) implant distribution in

edentulous maxilla. Involving 115 patients, virtual implant planning was conducted

using cone-beam computed tomography to position 8 mm axial and 12 mm tilted

implants at 30-degree and 45-degree angles. Results showed that 20.4% of sites

lacked sufficient bone for either implant type. Axial implants were placed more

distally than the tilted implants in 24% and 42% of sites, respectively. The average

change in A-P spread at the implant level was minimal for 30-degree tilted implants

(−0.25 mm) but showed a notable increase with 45-degree tilted implants (1.9 mm).

When measured from the multi-unit abutment center, the A-P distances increased by

0.97 mm for 30-degree and 1.74 mm for 45-degree tilted implants.

5. M. Wafa Richi,SevcanKurtulmus-Yilmaz and Oguz Ozan (2020): In this study

three maxillary master models were created, each with six implants positioned in

various orientations: Model 1 had parallel implants, while Models 2 and 3 featured

anterior implants inclined buccally and posterior implants inclined distally at 10 and

20 degrees, respectively. The study tested three types of impression copings (hexed,

non-hexed, multi-unit) and two impression techniques (splinting and non-splinting),

resulting in 180 impressions made with mono-phase vinyl polysiloxane. A 5-axis

 laboratory scanner was used to scan both the master models and duplicate casts, with

data analysed for coronal and angular deviations. Results indicated that the splinted

non-hex coping group showed the lowest deviation values for angulated models. The

study concluded that implant angulation, impression coping type, and the use of

splinting significantly affect impression accuracy.

6. Vaishnavi Rajaraman,ThiyaneswaranNesappan, Subhabrata Maiti, Subhashree

Rohinikumar (2019): This study presents a technique for transferring intermaxillary

and occlusal relationships from a complete denture to an implant-supported 3D-

printed hybrid prosthesis using a digital workflow. The method involves determining

mandibular position before immediate loading procedures and potentially using

interim removable prostheses for occlusal testing. A prosthetic stent is utilized to scan

the edentulous mandibular arch and record intermaxillary relations. The delivery of

hybrid implant-supported prostheses demonstrated minimal occlusal adjustments and

high patient satisfaction at the 1- year follow-up. This approach reliably maintains

prosthetic information, ensuring the final implant-supported restoration aligns with

the tested occlusal relationship from provisional diagnostic dentures.

7. Ernesto Bruschi, Paolo Francesco Manicone, Paolo De Angelis et al (2018):This

study used CBCT images to examine how implant inclination affects peri-implant

marginal bone loss after 18 to 24 months of functional loading in 25 patients with

edentulous or partially edentulous maxilla or mandible. The analysis included tilted or

axial implants supporting various prostheses. Significant differences were found in

buccal bone loss between axial and tilted implants, but no significant differences were

observed in other aspects of bone loss or prosthesis type. Both tilted and axial

implants exhibited a 100% success rate with no complications. While tilted implants

showed greater buccal bone loss, overall, both types of implants were successful and
 reliable for fixed partial or total rehabilitation, offering advantages to patients and

operators.

8. Joseph A. Toljanic, Karl Ekstrand,Russell A. Baer, Andreas Thor (2018):The

study aimed to compare the long-term outcomes of immediately loaded tilted and

axial implants in the posterior region of the edentulous maxillary arch. Data from a 5-

year prospective study on implants with screw-retained fixed restorations were

reviewed. Tilted implants were used when there was insufficient bone for axial

placement. Out of 102 implants, 12 failed. There was no significant difference in

survival rates or marginal bone loss between tilted and axial implants after 5 years.

9. Manuel Menéndez-Collar, Maria-Angeles Serrera-Figallo, Pilar Hita-Iglesias,

Raquel Castillo-Oyagüe (2018):The study followed 32 patients who received

maxillary full-arch fixed dental prostheses supported by a mix of tilted and axially-

placed implants over 2 years. A total of 187 implants were used, with 36% tilted and

64% axially placed. Some implants were immediately loaded with provisional

restorations, while others underwent delayed loading. The definitive restorations were

checked regularly for two years for function and aesthetics, with peri-implant bone

levels assessed. Results showed a 2-year implant survival rate of 100% for axially

placed implants and 98.5% for tilted implants, with no significant differences between

the groups. Marginal bone loss was measured at 2 years and was found to be

statistically significant when comparing immediate and delayed-loaded

[Link] Gabriela Mocan, Laurentiu Iulian

10. Florica, Cristina Teodora Preoteasa, Mihaela Daniela Meghea, Elena Preotease

(2020): The study evaluated peri-implant bone resorption in tilted implants in SKY

fast & fixed restorations. Thirty tilted implants were analyzed in patients with
 implant-prosthetic rehabilitation in one or both jaws. It was found that bone resorption

and bone apposition were observed after the follow-up period, with more pronounced

resorption in the mandible. Factors such as tooth loss due to periodontal disease,

implant length less than 16 mm, and absence of bone addition materials and

membranes at the extraction socket were associated with greater resorption. The SKY

fast & fixed technique, involving a small number of implants and a fixed

prosthesis, was shown to be a beneficial and cost-effective method for maintaining

optimal bone support without the need for complex surgical interventions.

11. Wei-Shao Lin, Steven E. Eckert (2018): This review aimed to assess the clinical

performance of intentionally tilted dental implants compared to implants placed along

the long axis of the residual alveolar ridge. A systematic review was conducted using

a predefined PICO question and search strategy, examining five electronic databases.

The review process identified 811 articles, with 42 ultimately included for analysis,

which consisted of two level I and 20 level II studies, along with additional lower-

level studies and [Link] to heterogeneity in the data, a quantitative analysis was

not possible, and only descriptive data were reviewed. The results showed no

significant differences between tilted and axially placed implants in terms of implant

survival, marginal bone loss, prosthesis survival, or patient-reported outcomes

(PROMs).The conclusion from the descriptive data suggests that there is no

significant difference in clinical performance between axial and tilted implants in

edentulous jaws.

12. Stefan Krennmair, Michael Weinl€ander,Michael MalekThomas Forstner,

Gerald Krennmair, Michael Stimmelmayr(2016): This study examined the

outcomes of 4-implant-supported fixed mandibular prostheses with distally placed

implants in either an axial or tilted direction. Forty-one edentulous patients were

 divided into two groups based on implant placement. Over three years, annual

examinations showed no implant or prosthetic loss, with consistent survival rates.

Peri-implant marginal bone resorption and pocket depth showed a significant

reduction over time, regardless of implant direction. Plaque and calculus indices were

higher for anterior implants compared to posterior implants in both groups. The

posterior implant region had higher plaque and calculus indices in the axial group

compared to the tilted group. Overall, there were no significant differences in

biological or mechanical complications between the two [Link] conclusion, the

study found no significant differences in clinical outcomes between distally

cantilevered 4-implant-supported fixed mandibular prostheses with implants placed in

a tilted or axial direction.

13. Yvan Fortin, Richard M. Sullivan(2016): The study focused on the long-term

results of using posterior maxillary tilted implants as an alternative to sinus grafts in

supporting fixed maxillary restorations. Forty-four patients were evaluated, with most

receiving bilateral tilted implants. The results showed that 79 out of 84 tilted implants

survived for at least 10 years, with one implant lost at 10 years. Additional implants

were placed when needed, with one replacement implant surviving for at least 10

years. All patients maintained continuous fixed function throughout the follow-up

period, with some restorations needing modifications to accommodate additional

implants. The study concluded that utilizing posterior tilted implants in combination

with axial anterior implants as a sinus graft alternative is a viable option for fully

implant-supported maxillary restorations, with manageable solutions available in case

of implant loss.

14. Ajay Vikram Singh, Sunita Singh (2014):The conventional techniques for full

mouth implantation involve placing implants and allowing them toheal for 3 to 6
 months before being uncovered and restored for function. However, challenges arise

in cases with vertical ridge loss and maxillary sinus issues, leading to limitations in

implant placement. Patients with chronic sinus problems or uncontrolled diabetes may

not be suitable candidates for certain procedures. In cases where the posterior

mandible has experienced vertical resorption, implant dentists may struggle to find

sufficient bone for implant placement. Various procedures like onlay block grafting or

nerve repositioning have been proposed to address this issue, but they can be invasive,

time-consuming, and cause tissue morbidity. Treating edentulous patients with full

mouth implant-supported prosthetics can be complex and may require multiple

implants, bone augmentation, and lengthy treatment times. This can make the

procedures uncomfortable and expensive for patients. A tilted implant concept has

been developed to address these challenges, where implants are angled to optimize

placement in areas with higher bone density. This technique allows for longer

implants with greater stability and reduces the need for extensive bone augmentation

procedures. A clinical study was conducted on 80 implants using the tilted implant

concept for full arch immediate rehabilitation. The success rate was high, with no

failures in the tilted implants after 3 years of follow-up. Some implants in the anterior

positions did fail but were promptly replaced with new implants. The average bone

loss relative to the implant platforms was minimal at 1 and 3 years follow-up,

indicating positive outcomes for this technique. The tilted implant immediate function

concept proved to be effective, patient-friendly, and suitable for a range of clinical

scenarios where traditional methods might not be feasible.

15. Nicolò Cavalli, Stefano Corbella, Silvio Taschieri and Luca Francetti (2015):This

study aimed to evaluate the incidence and prevalence of peri-implant mucositis and

peri-implantitis in patients with fixed full-arch prostheses supported by two axial and
 two tilted implants. Sixty-nine patients with 336 implants across 84 restorations

participated, with follow-up visits every six months for the first two years and yearly

afterward. The mean follow-up period was 63.2 months. Peri-implantitis was found in

3 patients, with a prevalence of peri-implant mucositis ranging from 0 to 7.14% and

peri-implantitis from 0 to 4.55%. These rates are lower than those reported in most

studies, suggesting that this type of rehabilitation is a viable option if proper hygiene

protocols are followed.

16. G. De Vico, M. Bonino, D. Spinelli, R. Schiavetti, G. Sannino, A. Pozzi, L.

Ottria(2011): The World Health Organization 2004 Annual Report noted an increase

in the elderly population and life expectancy towards the end of the 20th century.

Edentulous individuals, or those without teeth, face challenges in their oral health and

quality of life, particularly with traditional dentures that may be unstable during daily

activities. Dental implant treatment has been established as a successful solution for

partial or complete edentulism. However, treating severely atrophied edentulous

arches with implants can be complicated by anatomical issues such as bone resorption

and poor bone quality. The use of tilted implants has been proposed as a conservative

approach to address these challenges. A study from 2008-2010 evaluated the long-

term outcomes of immediately loaded fixed prostheses using both axial and tilted

implants for edentulous patients with extreme bone atrophy. The results suggested that

this technique could improve patient outcomes and contribute to higher quality

standards in implantology.

17. Erika O. Almeida, Eduardo P. Rocha, Amilcar C. Freitas Júnior, Rodolfo B.

Anchieta, Ronald Poveda, Nikhil Gupta, Paulo G. Coelho (2013):This study

 investigated the biomechanical behaviour of tilted long implants versus vertical short

implants in supporting fixed prostheses in atrophic maxillae. A maxilla model was

created from patient tomographic images, and various implant configurations were

tested: four vertical anterior implants (M4S), two mesial vertical and two distal tilted

implants (M4T), and four vertical anterior plus two vertical posterior implants (M6S).

Numerical simulations applied bilateral 150 N loads in axial and oblique directions,

analysing bone stress (maximum and minimum principal stress) and von Mises stress

on implants. Results indicated that the M4T configuration experienced the highest

maximum stress, followed by M6S and M4S under different loading conditions. In

terms of von Mises stress, M4T also showed the highest values. The findings suggest

that the use of distal tilted or short implants leads to greater stress in the maxillary

bone compared to solely vertical implants.

[Link] Aparicio, Pilar Perales, Bo Rangert (2001):This study evaluated the use of

distally angulated implants to prevent maxillary sinus issues and bone augmentation

while improving anterior-posterior (A-P) implant distribution in edentulous maxillae.

In a sample of 115 patients, virtual planning employed cone-beam computed

tomography to place 8 mm axial and 12 mm tilted implants at 30-degree and 45-

degree angles. The findings revealed that 20.4% of sites had insufficient bone for

either implant type. Axial implants were positioned more distally than tilted implants

in 24% and 42% of sites, respectively. The A-P spread change at the implant level was

minimal for 30-degree tilted implants (−0.25 mm) but significantly increased for 45-

degree tilted implants (1.9 mm). Measurements from the center of multi-unit

abutments showed increases of 0.97 mm for 30-degree and 1.74 mm for 45-degree

tilted implants.
19. M. Menini, A. Signori, T. Tealdo, M. Bevilacqua, F. Pera, G. Ravera, and P. Pera

(2012):This meta-analysis evaluates the outcomes of using upright and tilted implants

for the immediate rehabilitation of edentulous maxillae (upper jaws without teeth)

with full-arch fixed dentures, after at least one year of function. The study followed

PRISMA guidelines and reviewed 1,069 articles, selecting 11 for analysis. It involved

1,623 implants (778 tilted and 845 upright) in 324 patients. Implant failure rates were

2.19% for tilted and 1.89% for upright implants, with no significant difference

between the two (p = 0.52). Marginal bone loss was also similar between both

[Link], tilted implants showed favorable short-term outcomes, but further

randomized, long-term trials are recommended to better assess their long-term success

compared to upright implants.

20. Antonios Zampelis, Bo Rangertand Lars Heijl(2007): This study aimed to evaluate

whether tilting splinted implants affects stress distribution in the surrounding bone

and to compare the biomechanical performance of tilted implants used as distal

abutments versus distal cantilevers. A 2-dimensional finite element model was created

using two 13-mm implants splinted by a titanium beam in simulated bone blocks.

Different scenarios were compared, including a distal cantilever and a tilted distal

implant (13 mm or 19 mm) inclined at 45 degrees. A force of 50 N was applied via

the [Link] showed that tilting the implants did not increase stress at the bone-

to-implant contact point. However, using distal cantilevers resulted in higher stress

around the marginal bone. This stress was reduced when a tilted implant supported the

distal end of the cantilever. Using a longer implant only marginally decreased stress.

The study concludes that tilting distal implants does not increase bone stress and

offers a biomechanical advantage over distal cantilevers.

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13. Fortin Y, Sullivan RM. Long-term results of posterior maxillary tilted implants as
sinus graft alternative. Int J Oral Maxillofac Implants. 2016;31(2):373–380.
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15. Cavalli N, Corbella S, Taschieri S, Francetti L. Peri-implant mucositis and peri-
implantitis in full-arch prostheses with tilted implants. Clin Oral Implants Res.
2015;26(11):1304–1310.
16. De Vico G, Bonino M, Spinelli D, Schiavetti R, Sannino G, Pozzi A, Ottria L. Use of
tilted implants in edentulous patients with extreme atrophy: Clinical outcomes. Int J
Oral Maxillofac Implants. 2011;26(6):1169–1176.
17. Almeida EO, Rocha EP, Freitas Júnior AC, Anchieta RB, Poveda R, Gupta N, Coelho
PG. Biomechanical behavior of tilted long vs vertical short implants in atrophic
maxilla. Clin Implant Dent Relat Res. 2013;15(5):707–715.
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19. Menini M, Signori A, Tealdo T, Bevilacqua M, Pera F, Ravera G, Pera P. Meta-
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20. Zampelis A, Rangert B, Heijl L. Biomechanical evaluation of tilted vs distal
cantilever implants. Clin Oral Implants Res. 2007;18(6):732–738.