Condições Do Paciente e Implantes

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journal of dentistry xxx (2014) xxxxxx
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.intl.elsevierhealth.com/journals/jden
1
2
3 Review
4 Tilted versus axially placed dental implants:

5 A meta-analysis
6 Q1 Bruno Ramos Chrcanovic a,*, Tomas Albrektsson a,b, Ann Wennerberg a

a
7 Department of Prosthodontics, Faculty of Odontology, Malmo University, Malmo, Sweden
b
8 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 Q2
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
Available online xxx 2014. Eligibility criteria included clinical human studies, either randomised or not, inter-
ventional 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 philoso-
phies 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.
11
# 2014 Elsevier Ltd. All rights reserved.
9
10
12
13
* 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.
Please cite this article in press as: Chrcanovic BR, et al. Tilted versus axially placed dental implants: A meta-analysis. Journal of Dentistry (2014),
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2 journal of dentistry xxx (2014) xxxxxx
14 2.2. Search strategies 67

1. Introduction
An electronic search without time restrictions was undertak- 68
15 The loss of posterior teeth, particularly at an early age, leads to en (and last checked) in July 2014 in the following databases: 69
16 the loss of alveolar bone with a relative surfacing of the PubMed, Web of Science, and the Cochrane Oral Health Group 70
17 inferior alveolar nerve in the mandible, thus often prohibiting Trials Register. The following terms were used in the search 71
18 placement of implants in the posterior regions.1 Bone grafting strategy on PubMed: 72
73
19 and the use of short implants have been proposed to overcome
20 these anatomic limitations. An alternative could be the (((dental implant) OR oral implant)) AND ((((tilted) OR 74
21 inferior alveolar nerve lateral transposition2 or the use of angulated) OR axial) OR upright) [all fields] 75
22 tilted implants, which allows for maximum use of the existing 76
23 bone and placement of posterior fixed teeth with minimum The following terms were used in the search strategy on 77
24 cantilevers, in a region where bone height and nerve proximity Web of Science, in all databases: 78
79
25 does not allow for the placement of axial implants.1
26 Concerning the upper jaw, implant anchorage in the totally (((dental implant) OR oral implant)) AND ((((tilted) OR 80
27 edentulous maxilla is often restricted owing to bone resorp- angulated) OR axial) OR upright) [topic]) 81
28 tion, which is especially frequent in the posterior region of the 82
29 maxillary arch, where bone grafting is often indicated.3 There The following terms were used in the search strategy on the 83
30 is also the problem of the pneumatisation, an inferior Cochrane Oral Health Group Trials Register: 84
85
31 expansion of the maxillary sinus in relation to fixed anatomic
32 landmarks which develops with time after the extraction of (dental implant OR oral implant AND (tilted OR angulated 86
33 the posterior maxillary teeth. Pterygomaxillary and zygomatic OR axial OR upright)) 87
34 implants could be used, but these techniques present 88
35 considerable surgical complexity.46 The use of tilted implants A manual search of dental implants-related journals was 89
36 in the anterior or posterior maxillary sinus walls may be used also performed. The reference list of the identified studies and 90
37 instead of maxillary sinus elevation or bone grafts, resulting in the relevant reviews on the subject were also scanned for 91
38 a simpler and less time-consuming treatment, in significantly possible additional studies. Moreover, online databases 92
39 less morbidity, in decreased financial costs associated with providing information about clinical trials in progress were 93
40 those procedures, and in a more comfortable postsurgical checked (clinicaltrials.gov; www.centerwatch.com/clinical- 94
41 period for the patients.7,8 trials; www.clinicalconnection.com). 95
42 Researchers have been trying to evaluate whether the
43 insertion of tilted implants may influence the survival of 2.3. Inclusion and exclusion criteria 96
44 dental implants. However, some studies may lack statistical
45 power, given the small number of patients per group in the Eligibility criteria included clinical human studies, either 97
46 clinical trials comparing the techniques. The ability to randomised or not, interventional or observational, compar- 98
47 anticipate outcomes is an essential part of risk management ing implant failure rates in any group of patients receiving 99
48 in an implant practice. Recognising conditions that place the tilted or axially placed dental implants. Zygomatic implants 100
49 patient at a higher risk of failure will allow the surgeon to were not considered. For this review, implant failure repre- 101
50 make informed decisions and refine the treatment plan to sents the complete loss of the implant. Exclusion criteria were 102
51 optimise the outcomes.9 The use of implant therapy in special case reports, technical reports, animal studies, in vitro studies, 103
52 populations requires consideration of potential benefits to be biomechanical studies, finite element analysis (FEA) studies, 104
53 gained from the therapy. To better appreciate this potential, and reviews papers. 105
54 we conducted a systematic review and meta-analysis to
55 compare the survival rate of dental implants, postoperative 2.4. Study selection 106
56 infection, and marginal bone loss of tilted and axially placed
57 dental implants. The titles and abstracts of all reports identified through the 107
electronic searches were read independently by the three 108
58 authors. For studies appearing to meet the inclusion criteria, or 109
2. Materials and methods for which there were insufficient data in the title and abstract to 110
make a clear decision, the full report was obtained. Disagree- 111
59 This study followed the PRISMA Statement guidelines.10 A ments were resolved by discussion between the authors. 112
60 review protocol does not exist.
2.5. Quality assessment 113
61 2.1. Objective
Quality assessment of the studies was executed according to the 114
62 The purpose of the present review was to test the null Newcastle-Ottawa scale (NOS).11 The NOS calculates the study 115
63 hypothesis of no difference in the implant failure rate, quality on the basis of 3 major components: selection, 116
64 marginal bone loss, and postoperative infection for patients comparability, and outcome for cohort studies. It assigns a 117
65 being rehabilitated by tilted or by axially placed dental maximum of 4 stars for selection, a maximum of 2 stars for 118
66 implants, against the alternative hypothesis of a difference. comparability, and a maximum of 3 stars for outcome. 119
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journal of dentistry xxx (2014) xxxxxx 3
120 According to that quality scale, a maximum of 9 stars/points can articles were cited in more than one research of terms 174
121 be given to a study, and this score represents the highest quality, (duplicates). The three reviewers independently screened the 175
122 where six or more points were considered high quality. abstracts for those articles related to the focus question. Of the 176
resulted 912 studies, 847 were excluded for not being related to 177
123 2.6. Data extraction and meta-analysis the topic, resulting in 65 entries. Additional hand-searching of 178
the reference lists of selected studies yielded 6 additional 179
124 From the studies included in the final analysis, the following papers. The full-text reports of the remaining 71 articles led to 180
125 data was extracted (when available): year of publication, study the exclusion of 27 because they did not meet the inclusion 181
126 design, unicenter or multicenter study, number of patients, criteria (11 publications did not inform of the number of 182
127 patients age, follow-up, days of antibiotic prophylaxis, rinse, implants per group, 4 evaluating tilted implants only, 4 not 183
128 implant healing period, failed and placed implants, postoper- evaluating implant failures, 2 were same study published in 184
129 ative infection, marginal bone loss, implant surface modifica- another journal, 2 reviews, 2 FEA studies, 1 biomechanical 185
130 tion, type of prosthetic rehabilitation, jaws receiving implants study, 1 used cephalometric parameters to evaluate the 186
131 (maxilla and/or mandible). Contact with authors for possible angulation of the implants). Thus, a total of 44 publications 187
132 missing data was performed. were included in the review. 188
133 Implant failure and postoperative infection were the
134 dichotomous outcomes measures evaluated. Weighted mean 3.2. Description of the studies 189
135 differences were used to construct forest plots of marginal bone
136 loss, a continuous outcome. The statistical unit for implant Detailed data of the forty-four included studies are listed in 190
137 failure and marginal bone loss was the implant, and for Tables 1 and 2. Twenty-five prospective studies8,1336 and 191
138 postoperative infection was the patient. Whenever outcomes nineteen retrospective analyses1,3,7,3752 were included in the 192
139 of interest were not clearly stated, the data were not used for meta-analysis. Five studies15,18,20,27,44 were multicenter. 193
140 analysis. The I2 statistic was used to express the percentage of Four studies24,31,39,40 had a relatively short follow-up time 194
141 the total variation across studies due to heterogeneity, with 25% (up to 12 months). All studies but two16,52 provided informa- 195
142 corresponding to low heterogeneity, 50% to moderate and 75% tion of the patients age, and none of them included non- 196
143 to high. The inverse variance method was used for random- adults patients. Some patients in thirty-three studies 197
144 effects or fixed-effects model. Where statistically significant 1,3,7,8,14,15,17,18,2025,2730,3234,36,4042,4449,51,52 198
145 (P < .10) heterogeneity is detected, a random-effects model was were smokers. Five studies16,42,44,46,49 reported the presence of 199
146 used to assess the significance of treatment effects. Where no bruxers among the patients, and six studies1,28,42,46,48,49 the 200
147 statistically significant heterogeneity is found, analysis was presence of diabetic patients. In twelve studies17 201
148 performed using a fixed-effects model.12 The estimates of 19,21,22,27,32,34,36,39,42,46
some implants were inserted in fresh 202
149 relative effect for dichotomous outcomes were expressed in risk extraction sockets, in two others28,50 all implants were 203
150 ratio (RR) and in mean difference (MD) in millimetres for inserted in fresh extraction sockets. In twenty-three studies 204
151 continuous outcomes, both with a 95% confidence interval (CI). 1,3,8,16,18,21,22,2428,30,31,35,39,42,45,46,4850,52 the 205
152 Only if there were studies with similar comparisons reporting patients were exclusively rehabilitated with fixed full-arch 206
153 the same outcome measures was meta-analysis to be prostheses receiving 2 distal tilted implants and 2 mesial 207
154 attempted. In the case where no events (or all events) are axially placed implants. Patients were submitted to grafting 208
155 observed in both groups the study provides no information procedures at the implant site in only two studies.40,43 In three 209
156 about relative probability of the event and is automatically studies14,29,38 the implants were inserted in the posterior 210
157 omitted from the meta-analysis. In this (these) case(s), the term segments of the jaws only. In two studies33,51 the tilted 211
158 not estimable is shown under the column of RR of the forest implants had intrasinus insertion. Seventeen studies 212
159 plot table. The software used here automatically checks for 3,7,14,17,19,20,23,29,32,33,36,37,39,45,47,49,51 exclusively 213
160 problematic zero counts, and adds a fixed value of 0.5 to all cells evaluated implants inserted in maxillae, and exclusively 214
161 of study results tables where the problems occur. evaluated implants inserted in mandibles in eleven studies 215
162 A funnel plot (plot of effect size versus standard error) will .1,18,21,28,30,31,42,44,46,48,50 Implants were not immediately loaded 216
163 be drawn. Asymmetry of the funnel plot may indicate in eight studies7,13,37,38,43,47,48,51 In one study36 some implants 217
164 publication bias and other biases related to sample size, were immediately or delayed loaded, and another study41 did 218
165 although the asymmetry may also represent a true relation- not provide information about the healing/loading time. 219
166 ship between trial size and effect size. Twenty-three studies8,13,1517,20,21,23,25,26,31,33,37,38,4143,4547,50 220
52
167 The data were analysed using the statistical software did not provide information about the opposing dentition 221
168 Review Manager (version 5.3.3, The Nordic Cochrane Centre, to the implants being evaluated. Information about the 222
169 The Cochrane Collaboration, Copenhagen, Denmark, 2014). implant inclination in degrees was not provided in eight 223
studies.13,19,25,36,37,39,47,52 224
170 Of the forty-four studies comparing the procedures, a total 225
3. Results of 5029 dental implants were tilted, with 82 failures (1.63%), 226
171 and 5732 implants were axially placed, with 104 failures 227
3.1. Literature search (1.81%). No study informed whether there was a statistically 228
significant difference or not between the implant failure rates 229
172 The study selection process is summarised in Fig. 1. The between the procedures. There were no implant failures in 230
173 search strategy resulted in 1336 papers. A number of 424 twelve studies.17,18,21,27,28,30,33,35,41,45,48,50 Implants from the 231
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Fig. 1 Study screening process.
232 Nobel Biocare AB (Goteborg, Sweden) were the most com- 3.4. Meta-analysis 254
233 monly 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
234 most of them with an oxidised In this study, a fixed-effects model was used to evaluate the 255
235 surface. Four studies25,36,38,51 did not inform what kind of implant failure in the comparison between the procedures, 256
236 implants was used. Thirty studies1,3,8,1422,24,26,2833,35,37 since statistically heterogeneity was not found (I2 = 0%; 257
40,44,45,4951
237 provided information about the use of prophylactic P = 0.90). The insertion of dental implants in a tilted position 258
238 antibiotics. Twenty studies14,1719,21,22,2426,2834,38,44,45,50 pro- did not statistically affect the implant failure rates (RR 1.14, 259
239 vided information about the use of chlorhexidine mouth rinse 95% CI 0.841.56, P = 0.40; Fig. 2). There were no apparent 260
240 by the patients. significant effects of tilted dental implants on the occurrence 261
241 Nine studies3,21,25,32,40,4446,51 provided information about of marginal bone loss (MD 0.03, 95% CI 0.03 to 0.08; P = 0.32; 262
242 postoperative infection. However, in five studies3,25,40,45,51 heterogeneity: random-effects model, I2 = 88%; P < 0.00001, 263
243 with ten of the thirteen occurrences, there was no information Fig. 3) in comparison with axially placed implants. Due to lack 264
244 about which groups these patients belonged to. Eight of satisfactory information, meta-analysis for the outcomes 265
245 studies1,25,38,4245,52 did not provide information about the postoperative infection was not performed. 266
246 marginal bone loss. Of the thirty-six studies providing this Sensitivity analyses were also performed for the outcome 267
247 information, twenty-five7,8,14,15,1721,23,24,2630,3235,41,4749,51 in- implant failure. The RR was examined for the groups of 268
248 formed of the marginal bone loss of tilted and axially placed studies evaluating the implants inserted in different jaws. 269
249 implants separately; one of these studies26 did not report how When studies evaluating implants inserted in maxillae only 270
250 many implants were evaluated in each group. were pooled, a RR of 1.70 resulted (95% CI 1.052.74; P = 0.03; 271
heterogeneity: fixed-effects model, I2 = 0%, P = 0.83; Fig. 4), 272
251 3.3. Quality assessment whereas when the studies evaluating implants inserted in 273
mandible only were pooled, a RR of 0.77 was observed (95% CI 274
252 Thirty-six studies were of high quality, and eight of moderate 0.391.52; P = 0.45; heterogeneity: fixed-effects model, I2 = 0%, 275
253 quality. The scores are summarised in Table 3. P = 0.95; Fig. 5). 276
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Table 1 Detailed data of the included studies Part 1.
Authors Published Study Patients Patients age Follow-up Antibiotics/ Healing Failed/ Implant P value Postoperative
design (n) range visits (or range) mouth rinse period/ placed failure (for infection
(average) (days) loading implants rate (%) failure
(years) (n) rate)
Mattsson et al.37 1999 RA (unicenter) 15a 4475 (59) Mean 45 months NP/NM 6 months 1/30 (G1) 3.33 (G1) NM NM
(range 3654) 0/56 (G2) 0 (G2)
Krekmanov et al.38 2000 RA (unicenter) 47a 3580 (62) 3560 months 5/7 1 day-3 weeks 1/40 (G1) 2.5 (G1) NM NM
6/98 (G2) 6.12 (G2)
Aparicio et al.7 2001 RA (unicenter) 25a NM (49, Mean 37 months NM Mean 29 weeks 0/42 (G1) 0 (G1) NM NM
females, (range 2187) (range 68 2/59 (G2) 3.39 (G2)
59, males) months)
Karoussis et al.13 2004 PS (CCT)c 89a 1978 (49.3) 4 months-12 years NM 46 months 1/18 (G1) 5.56 (G1) NM NM
(unicenter) 12/161 (G2) 7.45 (G2)
Calandriello and 2005 PS (unicenter) 18a 5176 (64) 14 years 3/pospoperatively Immediate/ 1/27 (G1) 3.70 (G1) NM NM

Tomatis14 early 1/33 (G2) 3.03 (G2)
Malo et al.39 2005 RA (unicenter) 32b NM (55.1) 6 and 12 months 7/NM Immediate 3/64 (G1) 4.69 (G1) NM NM
0/64 (G2) 0 (G2)
Malo et al.40 2006 RA (unicenter) 46a 3278 (55.2) 10 days-1 year 6/NM Immediate 2/96 (G1) 2.08 (G1) NM In 3 implants,
0/93 (G2) 0 (G2) but distinction
between groups
was not made
Capelli et al.15 2007 PS (multicenter) 65a 2883 (59.2) Up to 52 months 1/NM Immediate 2/130 (G1) 1.54 (G1) NM NM
3/212 (G2) 1.42 (G2)
Koutouzis and 2007 RA (unicenter) 38a NM (59.5) 5 years NM NM 0/33 (G1) 0 (G1) No NM
Wennstrom41 0/36 (G2) 0 (G2) failures
Malo et al.16 2007 PS (unicenter) 23b NM Mean 13 months 6/NM Immediate 1/46 (G1) 2.17 (G1) Equal NM
(range 621) 1/46 (G2) 2.17 (G2) failure
Agliardi et al.17 2008 PS (unicenter) 21a 4468 (58) Mean 20 months 1/3 Immediate 0/84 (G1) 0 (G1) No NM
(range 435) 0/42 (G2) 0 (G2) failures
Francetti et al.18 2008 PS (multicenter) 62b 3577 (56) Mean 22.4 months 1/10 Immediate 0/124 (G1) 0 (G1) No NM
Tealdo et al.19 2008 PS (unicenter) 21a NM (58) Mean 20 months 6/10 Immediate 5/42 (G1) 11.90 (G1) NM NM
3/69 (G2) 4.35 (G2)
Testori et al.20 2008 PS (multicenter) 40a 3884 (59.2) Mean 22.1 months 1/NM Immediate 2/80 (G1) 2.5 (G1) NM NM
(range 342) 3/160 (G2) 1.87 (G2)
Agliardi et al.21 2010 PS (unicenter) 24b 4073 (60) Mean 32.7 months 7/9 Immediate 0/48 (G1) 0 (G1) No 0 (G1)
(range 1947) 0/48 (G2) 0 (G2) failures 0 (G2)
Agliardi et al.22 2010 PS (unicenter) 173b 4274 (57.3) 1259 months 1/10 Immediate 1/346 (G1) 0.29 (G1) NM NM
4/346 (G2) 1.16 (G2)
Degidi et al.23 2010 PS (unicenter) 30a NM (58.1) 6, 12, 24, and NM Immediate 0/120 (G1) 0 (G1) NM NM
36 months 1/90 (G2) 1.11 (G2)
Hinze et al.24 2010 PS (unicenter) 37b 3984 (64.6) 6 and 12 months 5/14 Immediate 4/74 (G1) 5.41 (G1) NM NM
3/74 (G2) 4.05 (G2)
Butura et al.42 2011 RA (unicenter) 219b NM (60.9) 3 years NM Immediate 1/428 (G1) 0.23 (G1) NM NM
2/429 (G2) 0.47 (G2)
5
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285
284
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281
288
287
286
285
284
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279
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277
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Table 1 (Continued )
Authors Published Study Patients Patients age Follow-up Antibiotics/ Healing Failed/ Implant P value Postoperative
design (n) range visits (or range) mouth rinse period/ placed failure (for infection
(average) (days) loading implants rate (%) failure
(years) (n) rate)
Corbella et al.25 2011 PS (unicenter) 61b NM (54.2) Mean 18.3 months NM/6 Immediate 0/122 (G1) 0 (G1) NM In 3 implants,
(range 660) 3/122 (G2) 2.46 (G2) but distinction
between groups
was not made
De Vico et al.26 2011 PS (unicenter) 35b 3877 (54) Mean 25 months 7/9 Immediate 0/70 (G1) 0 (G1) No NM
0/70 (G2) 0 (G2) failures
Kawasaki et al.43 2011 RA (unicenter) 15a 3177 (53) Mean 31.5 months NM 111 months 1/48 (G1) 2.08 (G1) NM NM
(range 2446) 1/17 (G2) 5.88 (G2)
Malo et al.1 2011 RA (unicenter) 245b 2385 (59) Up to 10 years 7/NM Immediate 9/490 (G1) 1.84 (G1) NM NM
12/490 (G2) 2.45 (G2)

Acocella et al.44 2012 RA (multicenter) 45a NM (56.7) Twice a year for 7/13 Immediate 1/90 (G1) 1.11 (G1) NM 0 (G1)
4 years 1/135 (G2) 0.74 (G2) 0 (G2)
Cavalli et al.45 2012 RA (unicenter) 34b 4484 (58.7) Mean 38.8 months 6/7 Immediate 0/68 (G1) 0 (G1) No In 2 implants,
(range 1273) 0/68 (G2) 0 (G2) failures but distinction
between groups
was not made
Crespi et al.8 2012 PS (CCT)d 36b 4181 (54.6) 3, 6, 12, 24, and 7/NM Immediate 3/88 (G1) 3.41 (G1) NM NM
(unicenter) 36 months 0/88 (G2) 0 (G2)
Francetti et al.27 2012 PS (multicenter) 47b 4463 (53) 6, 12, 18, 24, 36, NM Immediate 0/98 (G1) 0 (G1) No NM
48 and 60 months 0/98 (G2) 0 (G2) failures
Galindo and 2012 RA (unicenter) 183b 2489 (60.3) >1 year of function NM Immediate 0/366 (G1) 0 (G1) NM 0 (G1)
Butura46 1/366 (G2) 0.27 (G2) 1 (G2)
Grandi et al.28 2012 PS (unicenter) 47b 5278 (62.3) 6, 12, and 18 months 6/10 Immediate 0/94 (G1) 0 (G1) No NM
Malo et al.3 2012 RA (unicenter) 242b 2587 (55.4) Every 6 months until 6/NM Immediate 12/484 (G1) 2.48 (G1) NM In 1 implant,
5 years 7/484 (G2) 1.45 (G2) but distinction
between groups
was not made
Penarrocha et al.47 2012 RA (unicenter) 18a 3569 (NM) Mean 39.2 months NM 12 weeks 1/30 (G1) 3.33 (G1) NM NM
(range 17 years) 6/77 (G2) 7.79 (G2)
Pozzi et al.29 2012 PS (unicenter) 27a 3877 (54.2) Mean 43.3 months prescribed Immediate 2/42 (G1) 4.76 (G1) NM NM
(range 3654) postoperatively 1/39 (G2) 2.56 (G2)
Weinstein et al.30 2012 PS (unicenter) 20b 4477 (60.8) Mean 30.1 7/10 Immediate 0/40 (G1) 0 (G1) No NM
Krennmair et al.48 2013 RA (unicenter) 38b NM (67.1) Mean 66.5 months NM 23 months 0/76 (G1) 0 (G1) No NM
(range 57 years) 0/76 (G2) 0 (G2) failures
Landazuri-Del 2013 PS (unicenter) 16b 4973 (59) 3, 6, and 12 months 7/14 Immediate 3/32 (G1) 9.38 (G1) NM NM
Barrio et al.31 3/32 (G2) 9.38 (G2)
Malo et al.49 2013 RA (unicenter) 70b 3581 (54) 10 days, 2, 4, and 7/NM Immediate 4/140 (G1) 2.86 (G1) NM NM
6 months, 1/140 (G2) 0.71 (G2)
1, 2, and 3 years
Mozzati et al.50 2013 RA (unicenter) 50b 4565 (54.3) 1, 2,3, 6, 12, 18 and 7/10 Immediate 0/100 (G1) 0 (G1) No NM
24 months 0/100 (G2) 0 (G2) failures
304
303
302
301
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299
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Testori et al.51 2013 RA (unicenter) 35a NM (59.2) Mean 4.9 years 1/NM 6 months 0/52 (G1) 0 (G1) NM In 1 implant,
3/144 (G2)e 2.08 (G2) but distinction

between groups
was not made
Agliardi et al.32 2014 PS (unicenter) 32a 4468 (58) Mean 55 months 1/10 Immediate 2/128 (G1) 1.56 (G1) NM 2 (G1)
(range 3678) 0/64 (G2) 0 (G2) 0 (G2)
Agliardi et al.33 2014 PS (unicenter) 10a 5570 (60.4) Mean 50 months 1/3 Immediate 0/10 (G1) 0 (G1) No NM
Agnini et al.34 2014 PS (unicenter) 30a NM (64.4) Mean 44 months NM/10 Immediate 0/37 (G1) 0 (G1) NM NM
(range 1867) 4/165 (G2) 2.42 (G2)
Balshi et al.52 2014 RA (unicenter) 152b NM 6 years NM Immediate 11/400 (G1) 2.75 (G1) Equal NM
11/400 (G2) 2.75 (G2) failure
Browaeys et al.35 2014 PS (unicenter) 20b 3574 (55) 3 years 10/NM Immediate 0/40 (G1) 0 (G1) No NM
Tealdo et al.36 2014 PS (unicenter) 49a NM (58.2) Mean 75.2 months NM Immediate 6/68 (G1) 8.82 (G1) NM NM
(range 7290) (34 patients), 8/192 (G2)e 4.17 (G2)

mean 8.75
months
(15 patients)
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.
7
294
293
292
291
290
289
288
287
286
285
284
JJOD 2356 122
277 Q5 Table 2 Detailed data of the included studies Part 2. 333

Authors Marginal bone loss Implant Implant sur- Region/prosthetic Observations 334
278 (mean SD) (mm) inclination face modifica- rehabilitation/oppos- 335
279 (G1, degrees) tion (brand) ing dentition 336
280 Mattsson et al.37 No major bone NM Turned Maxilla/fixed full-arch 337
resorption (1 mm) (Branemark, prostheses/opposing 338
281 was observed on the Nobel Biocare dentition: NM 339
radiographs 1 and 3 AB, Goteborg, 340
years after implant Sweden) 341
installation
282 342
Krekmanov et al.38 NM 3035, maxilla NM Maxilla, mandible/fixed Only in posterior
283 2535, mandible partial and full-arch regions
343
284 prostheses/opposing 344
285 dentition: NM 345
286 Aparicio et al.7 0.57 0.50 (G1, n = 42) >15 Turned Maxilla/fixed partial 6 smokers 346
287 0.43 0.45 (G2, n = 57) (Branemark, prostheses/opposing 347
(1 year) Nobel Biocare dentition: natural
288 348
AB, Goteborg, dentition or a fixed
289 349
Sweden) implant-supported
290 prostheses up to the 350
291 third molar (n = 6), up to 351
292 the second molar 352
293 (n = 14), up to the first 353
294 molar (n = 2), up to the 354
second premolar (n = 3)
295 355
Karoussis et al.13 Information provided, NM TPS (ITI, Maxilla, mandible/single
296 356
but with no distinction Straumann, crowns, fixed partial
297 between tilted and Waldenburg, prostheses/opposing 357
298 axial implants Switzerland) dentition: NM 358
299 Calandriello and 0.34 0.76 (G1, n = 36) 1745 Turned (n = 11), Maxilla/fixed partial Only in the 359
300 Tomatis14 0.82 0.86 (G2, n = 32) acid etched (n = 12) and fixed full- atrophic 360
301 (1 year) (n = 3), oxidised arch prostheses (n = 7)/ posterior 361
(n = 46) opposing dentition: maxilla, flapless
302 362
(Branemark, natural teeth or surgery (5
303 MkIV, n = 39, implant-supported patients), light
363
304 Replace Select prostheses (n = 18), smokers were 364
305 Tapered, n = 21, removable dentures also included, 365
306 Nobel Biocare (n = 2) but the precise 366
307 AB, Goteborg, number was not 367
Sweden) informed
308 368
Malo et al.39 1.0 1.0, mesial, n = 99 NM Oxidised Maxilla/fixed full-arch Some implants
309 369
0.9 1.1, distal, n = 98 (TiUnite, MKIII, prostheses/opposing were inserted in
310 MkIV, Nobel dentition: implant- fresh extraction 370
311 Biocare AB, supported prostheses sockets, but the 371
312 Goteborg, (n = 15), natural teeth precise number 372
313 Sweden) (n = 11), a combination was not 373
314 of both (n = 6) informed 374
Malo et al.40 1.2 0.8, mesial 45, maxilla Oxidised Maxilla, mandible/fixed Graft in 4
315 375
1.1 0.9, distal 30, mandible (TiUnite, full-arch prostheses/ patients (iliac
316 376
NobelSpeedy, opposing dentition: crest, 6 months
317 MkIII, MkIV, implant-supported before implants), 377
318 Nobel Biocare prostheses (n = 27), 16 smokers 378
319 AB, Goteborg, natural teeth (n = 13), a 379
320 Sweden) combination of both 380
321 (n = 5), removable 381
prostheses (n = 1)
322 382
Capelli et al.15 0.88 0.59 (G1, n = 42) 3035, maxilla Acid-etched Maxilla, mandible/fixed 10 smokers
323 0.95 0.44 (G2, n = 84) 2535, mandible (Osseotite, NT, full-arch prostheses/
383
324 (1 year) Biomet 3i, Palm opposing dentition: NM 384
325 Beach Gardens, 385
326 USA) 386
327 Koutouzis and 0.5 0.95 (G1) 1130 Fluoride- Maxilla, mandible/fixed 10 smokers, 387
Wennstrom41 0.4 0.97 (G2) modified partial prostheses, periodontally
328 388
(5 years) nanostructure supported by 2 or 3 compromised
329 389
(Astra Tech implants/opposing treated patients
330 Dental, Molndal, dentition: NM only 390
331 Sweden) 391
332 392
JJOD 2356 122
Authors Marginal bone loss Implant Implant sur- Region/prosthetic Observations
(mean SD) (mm) inclination face modifica- rehabilitation/oppos-
(G1, degrees) tion (brand) ing dentition
Malo et al.16 Information provided, 30 Oxidised Maxilla, mandible/fixed Flapless surgery
but with no distinction (TiUnite, full-arch prostheses/ with surgical
between tilted and NobelSpeedy, opposing dentition: NM template, 6
axial implants Nobel Biocare bruxers
AB, Goteborg,
Sweden)
Agliardi et al.17 0.9 0.5 (G1, n = 56) 3045 Oxidised Maxilla/fixed full-arch 8 smokers, fresh
0.8 0.4 (G2, n = 28) (TiUnite, prostheses/opposing extraction
(1 year) Branemark, dentition: NM sockets (40
MkIV, n = 30, implants)
NobelSpeedy
Groovy, n = 96,
Nobel Biocare
AB, Goteborg,
Sweden)
Francetti et al.18 0.7 0.5 (G1, n = 120) 30 Oxidised Mandible/fixed full-arch 25 smokers, fresh
(1 year) Branemark, dentition: removable sockets (40
MkIV, n = 116, prostheses (n = 27), implants)
NobelSpeedy natural teeth (n = 8),
Groovy, n = 132, natural teeth and fixed
Nobel Biocare prostheses on natural
AB, Goteborg, teeth (n = 8), fixed
Sweden) prostheses on natural
teeth (n = 3), implant-
supported bridges
(n = 9), natural teeth and
two implant-supported
bridges (n = 4)
Tealdo et al.19 0.92 0.35 (G1, mesial, NM Acid-etched Maxilla/fixed full-arch Fresh extraction
n = 42) (Osseotite, NT, prostheses/opposing sockets (47
1.04 0.37 (G1, distal, Biomet 3i, Palm dentition: natural teeth implants)
n = 42) Beach Gardens, or fixed or removable
0.62 0.30 (G2, mesial, USA) prostheses
n = 61)
0.86 0.26 (G2, distal,
n = 61)
(1 year)
Testori et al.20 0.8 0.5 (G1, n = 80) 3035 Acid-etched Maxilla/fixed full-arch 12 smokers
0.9 0.4 (G2, n = 160) (Osseotite, NT, prostheses/opposing
(1 year) Biomet 3i, Palm dentition: NM
Beach Gardens,
USA)
Agliardi et al.21 0.8 0.5 (G1, n = 42) 30 Oxidised Mandible/fixed full-arch 4 smokers, some
0.9 0.4 (G2, n = 42) (TiUnite, prostheses/opposing implants were
(1 year) Branemark, dentition: NM inserted in fresh
MkIV, n = 16, extraction
NobelSpeedy sockets, but the
Groovy, n = 80, precise number
Nobel Biocare was not
AB, Goteborg, informed
Sweden)
JJOD 2356 122
Agliardi et al.22 0.9 0.7, maxilla, 3045, maxilla Oxidised Maxilla, mandible/fixed 48 smokers,
n = 204 30, mandible (TiUnite, full-arch prostheses/ some implants
1.2 0.9, mandible, Branemark, opposing dentition: were inserted in
n = 292 MkIV, n = 92, removable prostheses fresh extraction
NobelSpeedy (n = 50, maxilla; n = 22, sockets, but the
Groovy, n = 600, mandible), natural teeth precise number
Nobel Biocare (n = 15, maxilla; n = 9, was not
AB, Goteborg, mandible), natural teeth informed
Sweden) 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 implant-
supported bridges (n = 4,
maxilla)
Degidi et al.23 1.03 0.69 (G1, n = 120) 3045 Sandblasted and Maxilla/fixed full-arch Patients smoking
0.92 0.75 (G2, n = 90) acid-etched prostheses/opposing less than 10
(XiVE Plus, dentition: NM cigarettes per
Dentsply day were also
Friadent, included, but the
Mannheim, precise number
Germany) was not
informed, no
grafting
Hinze et al.24 0.76 0.49 (G1, n = 74) 30 Acid-etched Maxilla, mandible/fixed 11 smokers
0.82 0.31 (G2, n = 74) (Osseotite, full-arch prostheses/
(1 year) NanoTite opposing dentition:
Tapered, Biomet natural teeth (n = 7),
3i, Palm Beach tooth-supported FPDs
Gardens, USA) (n = 11), implant-
supported FPDs (n = 14),
full-arch implant-
supported prostheses
(n = 5)
Butura et al.42 NM 30 Oxidised Mandible/fixed full-arch 64 smokers, 45
(TiUnite, prostheses/opposing bruxers, 20
NobelSpeedy dentition: NM diabetic patients,
Groovy, Nobel some implants
Biocare AB, were inserted in
Goteborg, fresh extraction
Sweden) sockets, but the
precise number
was not
informed
Corbella et al.25 NM NM NM Maxilla, mandible/fixed 30 smokers
full-arch prostheses/
opposing dentition: NM
De Vico et al.26 0.77 0.42 (G1, n = ?) 30 Oxidised Maxilla, mandible/fixed -
0.66 0.14 (G2, n = ?) (TiUnite, full-arch prostheses/
(1 year) NobelActive, opposing dentition: NM
277 Nobel Biocare
281
AB, Goteborg,
Sweden)
278
Kawasaki et al.43 NM > 17 ? (Nobel Biocare Maxilla, mandible/fixed Bone graft in 1
279 AB, Goteborg, partial and full-arch implant site
282
280 Sweden) prostheses/opposing 283
dentition: NM 284
285
JJOD 2356 122
Malo et al.1 NM 3045 Oxidised Mandible/fixed full-arch 61 smokers, 5
(TiUnite, prostheses/opposing diabetic patients,
Branemark, dentition: implant- 4 patients taking
MkIV, n = 930, supported fixed biphosphonates
NobelSpeedy, prosthesis (n = 100),
n = 50, Nobel natural teeth (n = 31),
Biocare AB, fixed prosthetics over
Goteborg, natural teeth (n = 21),
Sweden) combination of natural
teeth and implant-
supported fixed
prosthetics (n = 30),
removable prostheses
(n = 63)
Acocella et al.44 NM 2030 Fluoride- Mandible/fixed full-arch 10 smokers, 2
modified prostheses/opposing bruxers
nanostructure dentition: natural teeth
(Osseospeed, (n = 6), fixed partial
Astra Tech denture (n = 19),
Dental, Molndal, complete removable
Sweden) denture (n = 20)
Cavalli et al.45 NM 30 Oxidised Maxilla/fixed full-arch 19 smokers
(TiUnite, prostheses/opposing
Branemark, dentition: NM
MkIV,
NobelSpeedy
Groovy, Nobel
Biocare AB,
Goteborg,
Sweden)
Crespi et al.8 1.11 0.32, maxilla, 3035 ? (Sweden & Maxilla, mandible/fixed Patients smoking
n = 48 Martina, Due full-arch prostheses/ less than 15
1.12 0.35, mandible, Carrare, Italy) opposing dentition: NM cigarettes per
n = 40 day were also
(3 years) (G1) included, but the
1.10 0.45, maxilla, precise number
n = 48 was not
1.06 0.41, mandible, informed
n = 40
(3 years) (G2)
Francetti et al.27 0.47 0.22 (G1) 30 Oxidised Maxilla, mandible/fixed 15 smokers, fresh
0.52 0.22 (G2) (TiUnite, full-arch prostheses/ extraction
(6 months; n = 132) Branemark, opposing dentition: sockets (14
0.39 0.18 (G1) MkIV, n = 92, removable prostheses implants)
0.51 0.17 (G2) NobelSpeedy (n = 23), natural teeth
(5 years; n = 48) Replace, n = 104, (n = 11), natural teeth
277 Nobel Biocare and fixed prostheses on 289
AB, Goteborg, natural teeth (n = 9), 290
278 Sweden) implant-supported 291
279 bridges (n = 2), natural 292
teeth and two implant-
280 293
supported bridges (n = 2)
294
Galindo and No visual evidence of 30 Oxidised Mandible/fixed full-arch 55 smokers, 43
281 Butura46 bone loss greater than (TiUnite, prostheses/opposing bruxers, 14 295
1 mm on any of the NobelSpeedy dentition: NM diabetic patients, 296
implants Groovy, n = 672, some implants 297
282 NobelActive, were inserted in 298
283 n = 60, Nobel fresh extraction 299
Biocare AB, sockets, but the
284 300
Goteborg, precise number
285 Sweden) was not
301
286 informed 302
287 303
288 304
JJOD 2356 122
Grandi et al.28 0.68 0.14 (G1, n = 94) 30 Acid-etched Mandible/fixed full-arch All implants
0.77 0.14 (G2, n = 94) (JDEvolution, prostheses/opposing inserted in fresh
(18 months) JDentalCare, dentition: complete extraction
Modena, Italy) denture (n = 8) fixed sockets, 11
rehabilitation and smokers, 2
natural teeth (n = 27) diabetic patients
removable prosthesis
and natural teeth (n = 12)
Malo et al.3 1.52 0.31 (3 years, 45 Oxidised (TiUnite Maxilla/fixed full-arch Smokers were
n = 621) NobelSpeedy prostheses/opposing included, but the
1.95 0.44 (5 years, Replace, Nobel dentition: implant- precise number
n = 106) Biocare AB, supported prostheses was not
Goteborg, (n = 107), natural teeth informed
Sweden) (n = 68), a combination
of both (n = 60),
removable prosthesis
(n = 7)
Penarrocha et al.47 0.76 0.06 (G1, n = 30) NM ? (Nobel Biocare Maxilla/fixed full-arch Patients smoking
0.52 0.10 (G2- AB, Goteborg, prostheses (n = 16), less than 10
conventional, n = 32) Sweden) ovendentures (n = 2)/ cigarettes per
0.58 0.06 (G2-palatal, opposing dentition: NM day were also
n = 35) included, but the
0.68 0.02 (G2- precise number
pterygomaxil, n=.10) was not
informed
Pozzi et al.29 0.6 0.38 (G1-ASW, Mean 2535 Oxidised Maxilla/3- to 5-unit fixed Only in severely
n = 14) (TiUnite, partial prostheses/ atrophied
0.62 0.37 (G1-PSW, NobelSpeedy opposing dentition: posterior
n = 26) Replace, n = 57, natural dentition or a maxilla, patients
0.48 0.3 (G2, n = 38) NobelSpeedy fixed implant-supported smoking less
(1 year) Groovy, n = 24, prosthesis than 10
0.7 0.38 (G1-ASW, Nobel Biocare cigarettes per
n = 14) AB, Goteborg, day were also
0.7 0.2 (G1-PSW, Sweden) included, but the
n = 26) precise number
0.5 0.3 (G2, n = 38) was not
(3 years) informed
Weinstein et al.30 0.7 0.4 (G1, n = 36) 30 Oxidised Mandible/fixed full-arch 4 smokers
0.6 0.3 (G2, n = 36) (TiUnite, MkIV, prostheses/opposing
n = 12, dentition: removable
NobelSpeedy prostheses (n = 11),
Groovy, n = 68, natural teeth and fixed
AB, Goteborg, teeth (n = 4), implant-
Sweden) supported prostheses
(n = 5)
Krennmair et al.48 1.24 0.32 (G1, n = 76) 6690 (calculated Sandblasted and Mandible/fixed full-arch 7 smokers, 2
1.17 0.26 (G2, n = 76) from the acid-etched prostheses/opposing diabetic patients
relationship of (Screw-Line dentition: natural
the implant axis Promote, Camlog dentition (n = 4), fixed
to the denture Biotechnologies, partial dentures (n = 6),
occlusal plane) Basel, complete dentures
Switzerland) (n = 13), anterior natural
277 dentition with posterior 281
removable partial
278 dentures (n = 5),
279 implant-supported fixed 282
280 prostheses (n = 16), 283
implant-supported
284
281 (n = 2)
285
286
287
282 288
JJOD 2356 122
Landazuri-Del 0.83 0.14 (1 year) 3045 Oxidised (TiUnite Mandible/fixed full-arch Only completely
Barrio et al.31 NobelSpeedy prostheses/opposing edentulous
Replace, Nobel dentition: NM patients,
Biocare AB, flapless-guided
Goteborg, surgery, no
Sweden) smokers
Malo et al.49 0.96 0.62 (G1, trans- <45 Oxidised Maxilla/fixed full-arch 83 trans-sinus
sinus, n = 59) (NobelSpeedy prostheses/opposing implants, 19
0.89 0.54 (G1, Speedy, Nobel dentition: implant- smokers, 22
conventional, n = 47) Biocare AB, supported prostheses bruxers, 3
0.62 0.35 (G2, n = 57) Goteborg, (n = 28), natural teeth diabetic patients
(1 year) Sweden) (n = 16), a combination
1.14 0.74 (G1, trans- of both (n = 25),
sinus, n = 50) removable prosthesis
1.06 0.71 (G1, (n = 1)
conventional, n = 40)
1.15 0.51 (G2, n = 44)
(3 years)
Mozzati et al.50 1.48 0.39 (2 years, 30 Oxidised (TiUnite Mandible/fixed full-arch All implants in
n = 200) Branemark MkIII, prostheses/opposing fresh extraction
n = 180, dentition: NM sockets
NobelSpeedy
Groovy, n = 20,
Nobel Biocare
AB, Goteborg,
Sweden)
Testori et al.51 0.8 0.5 (G1, n = 52) < 30 NM Maxilla/partial (3-unit 11 smokers,
0.9 0.4 (G2, n = 144) fixed bridge; 3 patients) some implants
or fixed full-arch with intrasinus
prostheses (32 patients)/ insertion
opposing dentition: NM
Agliardi et al.32 0.88 0.16 (G1, n = 128) 3045 Oxidised Maxilla/fixed full-arch 11 smokers, fresh
(1 year) Branemark, dentition: removable sockets (44
1.46 0.19 (G1, n = 128) MkIV, n = 30, prostheses (n = 6), implants)
1.55 0.31 (G2, n = 64) NobelSpeedy natural teeth (n = 7),
(3 years) Groovy, n = 162, natural teeth and fixed
AB, Goteborg, teeth (n = 8), fixed
Sweden) prostheses on natural
teeth (n = 6), natural
teeth and two implant-
supported partial
prostheses (n = 5)
Agliardi et al.33 0.9 0.5 (G1, n = 10) 30 Oxidised Maxilla/3-unit fixed Some implants
1.0 0.4 (G2, n = 10) (TiUnite, partial prostheses/ with intrasinus
(1 year) NobelSpeedy opposing dentition: NM insertion, 4
Groovy, Nobel smokers
Biocare AB,
277 Goteborg, 286
Sweden)
287
278 288
279 289
280 290
291
281 292
293
294
282 295
283 296
284 297
285 298
JJOD 2356 122
Agnini et al.34 1.42 0.14 (G1, 2040 Sandblasted and Maxilla, mandible/fixed 7 smokers, fresh
maxilla, n = 21) acid-etched, and full-arch prostheses/ extraction
1.35 0.12 (G1, hydroxyapatite- opposing dentition: sockets (76
mandible, n = 16) coated (Spline, natural teeth (n = 7), implants)
1.37 0.14 (G2, n = 84, Tapered natural teeth and fixed
maxilla, n = 97) Screw-Vent, implant prostheses
1.3 0.11 (G2, n = 188, Zimmer (n = 3), natural teeth and
mandible, n = 68) Dental Inc., removable prostheses
(1 year) Carlsbad, USA) (n = 2), fixed prostheses
on natural teeth (n = 5),
(n = 4), implant-
supported fixed-dental
prostheses (n = 9)
Balshi et al.52 NM NM ? (Nobel Biocare Maxilla, mandible/fixed 132 implants in
AB, Goteborg, full-arch prostheses/ smokers
Sweden) opposing dentition: NM
Browaeys et al.35 1.14 1.14 (G1, n = 32) 2040 Oxidised Maxilla, mandible/fixed Computer-
1.13 0.71 (G2, n = 32) (TiUnite, MkIII full-arch prostheses/ guided flapless
(1 year) Groovy, n = 44, opposing dentition: surgery, no grafts
1.67 1.22 (G1, n = 32) NobelSpeedy natural teeth, an
1.55 0.73 (G2, n = 32) Groovy, n = 36, implant-borne fixed
(3 years) Nobel Biocare restoration, or a
AB, Goteborg, removable prosthesis
Sweden) with a corresponding
number of teeth
Tealdo et al.36 Information provided, NM NM Maxilla/fixed full-arch Fresh extraction
but with no distinction prostheses/opposing sockets (163
between tilted and dentition: natural teeth, implants),
axial implants fixed or removable patients smoking
prostheses 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.
277
3.5. Publication bias axially oriented implants can provide a predictable foundation 293
for implant-supported full-arch prostheses.8 An FEA study 294
278 The funnel plot did not show asymmetry when the studies concluded that there is a biomechanical advantage in using 295
279 reporting the outcome implant failure were analysed (Fig. 6), splinted tilted distal implants rather than axial implants 296
280 indicating possible absence of publication bias. supporting a higher number of cantilever teeth.53 Tilting of the 297
implants may allow using longer implants that may engage 298
281 greater quantity of residual bone, which may be beneficial to 299
4. Discussion implant stability.26 Moreover, a more even distribution of 300
stress around implants is achieved when implants with longer 301
282 According to the results of the present study, the insertion of lengths are used.54 302
283 dental implants in a tilted position did not statistically affect It is also important to make some consideration about the 303
284 the implant failure rates in relation to axially placed implants. splinting of the implants. It has been suggested that it is not 304
285 This suggests that tilted implants may achieve the same the immediate loading per se that is critical for osseointegra- 305
286 outcome as implants placed in a straight manner. This result tion, but rather the absence of excessive micromotion at the 306
287 is associated with biomechanical advantages in the case of interface. Micromotion consists of relative movement be- 307
288 fixed full-arch prostheses with splinted implants, the most tween the implant surface and surrounding bone during 308
289 common rehabilitation observed in the studies here included, functional loading and above a certain threshold excessive 309
290 since in this protocol implants are placed in strategic positions interfacial micromotion early after the implantation interferes 310
291 from a load-sharing point of view. Placement of two or more with local bone healing, predisposes to a fibrous tissue 311
292 well-anchored posterior tilted implants together with anterior interface, and may prevent the fibrin clot from adhering to 312
328
327
326
325
324
323
322
321
320
319
318
317
316
315
314
313
JJOD 2356 122

Table 3 Quality assessment of the studies by the Newcastle-Ottawa scale.
Study Selection Comparability Outcome Total (9/9)
Representativeness Selection Ascertainment Outcome Comparability of co- Assessment Follow-up Adequacy

of the exposed of external of exposure of interest horts of outcome long enougha of follow-up
cohort control not present
at start
Main Additional
factor factor
Mattsson et al.37 0 $ $ $ $ $ $ $ 0 7/9
Krekmanov et al.38 0 $ $ $ $ $ $ $ 0 7/9
Aparicio et al.7 0 $ $ $ $ $ $ $ 0 7/9
Karoussis et al.13 $ $ $ $ $ $ $ $ 0 8/9
Calandriello and 0 $ $ $ $ 0 $ 0 0 5/9
Tomatis14

Malo et al.39 0 $ $ $ $ 0 $ 0 $ 6/9
Malo et al.40 0 $ $ $ $ 0 $ 0 $ 6/9
Capelli et al.15 0 $ $ $ $ 0 $ 0 0 5/9
Koutouzis and 0 $ $ $ $ 0 $ $ 0 6/9
Wennstrom41
Malo et al.16 0 $ $ $ $ $ $ 0 0 6/9
Agliardi et al.17 0 $ $ $ $ 0 $ 0 0 5/9
Francetti et al.18 0 $ $ $ $ $ $ 0 0 6/9
Tealdo et al.19 0 $ $ $ $ $ $ 0 $ 7/9
Testori et al.20 0 $ $ $ $ 0 $ 0 0 5/9
Agliardi et al.21 0 $ $ $ $ 0 $ 0 0 5/9
Agliardi et al.22 0 $ $ $ $ $ $ 0 0 6/9
Degidi et al.23 0 $ $ $ $ 0 $ $ 0 6/9
Hinze et al.24 0 $ $ $ $ 0 $ 0 $ 6/9
Butura et al.42 0 $ $ $ $ $ $ $ 0 7/9
Corbella et al.25 0 $ $ $ $ 0 $ 0 0 5/9
De Vico et al.26 0 $ $ $ $ 0 $ 0 0 5/9
Kawasaki et al.43 0 $ $ $ $ $ $ 0 0 6/9
Malo et al.1 0 $ $ $ $ $ $ $ 0 7/9
Acocella et al.44 0 $ $ $ $ 0 $ $ $ 7/9
Cavalli et al.45 0 $ $ $ $ 0 $ $ 0 6/9
Crespi et al.8 0 $ $ $ $ 0 $ $ $ 7/9
Francetti et al.27 0 $ $ $ $ 0 $ $ 0 6/9
Galindo and Butura46 0 $ $ $ $ $ $ 0 0 6/9
Grandi et al.28 0 $ $ $ $ 0 $ 0 $ 6/9
Malo et al.3 0 $ $ $ $ $ $ $ 0 7/9
Penarrocha et al.47 0 $ $ $ $ $ $ $ $ 8/9
Pozzi et al.29 0 $ $ $ $ $ $ $ $ 8/9
Weinstein et al.30 0 $ $ $ $ 0 $ 0 0 5/9
Krennmair et al.48 0 $ $ $ $ 0 $ $ $ 7/9
Landazuri-Del 0 $ $ $ $ $ $ 0 $ 7/9
Barrio et al.31
Malo et al.49 0 $ $ $ $ $ $ $ $ 8/9
15
344
343
342
341
340
339
338
337
336
335
334
333
332
331
330
329
JJOD 2356 122
313 Total (9/9) the implant surface during healing.55 Splinting of the implants
314 in the case of the immediate-loaded fixed full-arch prostheses
6/9
6/9
8/9
7/9
7/9
7/9
8/9
8/9
315 might have protected these implants from micromotion.56
316 Splinting allows a more even distribution of the occlusal
317 forces, thereby reducing stresses at the bone-implant inter-
of follow-up
face.57 It was also suggested that the reason for the high
Adequacy
318
319 survival of tilted implants may be the increased contact
$
$
$
$
$
0
0
0
320 between cortical bone and tilted implants, increasing the
321 initial stability,52 which may be true for the maxilla, but not
322 necessarily for the mandible. However, when a sensitivity
long enougha
323 analysis was performed pooling the studies evaluating

Follow-up
Outcome
324 implants inserted in maxillae only, a statistically significant

difference was observed, favouring axially placed implants.
$
$
$
$
$
$
$
325
0
326 This might be associated with the lower bone density

327 encountered at the posterior regions of the edentulous
328 maxilla, where the tilted implants were inserted.
Assessment
of outcome
329 Concerning marginal bone loss, it was suggested by finite

330 element analysis (FEA) studies which reported accentuated
$
$
$
$
$
$
$
$
331 stresses around non-axially placed implant necks5860 that

332 unfavourable loading direction could in theory induce greater
333 bone resorption around tilted implants as compared to axially
Additional
Comparability of co-
334 placed implants. Tilted implants may be also subjected to

factor
$
$
$
$
Comparability
335 bending, possibly increasing marginal bone stress.61 On the

0
0
336 other side, it was shown in FEA studies for full-arch prosthesis
horts
337 that the reduction of the cantilever length achieved by tilting

338 of the distal implants allows for a more widespread distribu-
$
$
$
$
$
$
$
$
factor
Main
339 tion of the occlusal forces under loading, and consequently for
340 a reduction of the stresses at the implant neck.53,62,63 It is
341 interesting to note that photoelastic and FEA studies that
analysed single angulated implants5860 showed increase of
not present
342
of interest
Outcome
at start
343 stress in the surrounding bone, whereas FEA studies53,62,63

Three years of follow-up was chosen to be enough for the outcome implant failure to occur.
$
$
$
$
$
$
$
$
344 analysing tilted implants in splinted full-arch prostheses

345 observed more favourable results for tilted implants concern-
346 ing marginal bone loss, due to the splinting effect. The
Ascertainment
347 cantilever length of the prosthesis also has some influence, as

of exposure
348 shorter cantilevers have been correlated to a reduced peri-

349 implant bone loss.64 The present meta-analysis did not find an
$
$
$
$
$
$
$
$
350 apparent significant effect of tilted dental implants on the

351 occurrence of greater marginal bone loss in comparison with
Selection
352 axially placed implants. The fact that fixed full-arch prosthe-
353 ses with splinted implants were the most common rehabilita-
of external
Selection
control
354 tion observed in the studies here included might have

$
$
$
$
$
$
$
$
355 collaborated to these findings. However, these results should

356 be interpreted with caution due to the lack of use among the
357 included studies of a standardised technique aiming to obtain
Representativeness
358 a precise and reproducible bone loss measurement, and also

of the exposed
359 due to the variability of the follow-up period among the

360 studies.
cohort
361 The studies included here have a considerable number of

0
0
0
0
0
0
0
0
362 confounding factors, and most of the studies, if not all, did not
363 inform how many implant were inserted and survived/lost in
364 several different conditions. The use of grafting in some
365 studies40,43 is a confounding risk factor, as well as the insertion
366 of some1719,21,22,27,32,34,36,39,42,46 or all28,50 implants in fresh

Browaeys et al.35
367 extraction sockets, the insertion of implants in different

Mozzati et al.50
Agliardi et al.32
Agliardi et al.33
Testori et al.51
Tealdo et al.36
Agnini et al.34
locations, different healing periods, different prosthetic

Balshi et al.52
368
369 configurations, type of opposing dentition, different implant
370 angulation ranges, splinting of the implants, and the presence
Study
371 of smokers,1,3,7,8,14,15,17,18,2025,2730,3234,36,4042,4449,51,52 brux-

a
372 ers,16,42,44,46,49 or diabetics patients.1,28,42,46,48,49
JJOD 2356 122
Fig. 2 Forest plot for the event implant failure.
373 Moreover, it is known that the surface properties of dental are prepared and handled,6668 and it is not clear whether, in 381
374 implants such as topography and chemistry are relevant for general, one surface modification is better than another.65 382
375 the osseointegration process influencing ionic interaction, Concerning the angulation of the implants, one should 383
376 protein adsorption and cellular activity at the surface.65 The recall that in the interpretation of the results, the classification 384
377 studies here included implants of different brands and surface of tilted and axially placed implants was based on the 385
378 treatments. Titanium with different surface modifications assessment of the inclination in only the mesialdistal 386
379 shows a wide range of chemical, physical properties, and direction. Inclination in buccallingual direction might be of 387
380 surface topographies or morphologies, depending on how they equal importance but was not included because of difficulties 388
JJOD 2356 122
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.
JJOD 2356 122
Fig. 5 Forest plot for the event implant failure studies evaluating implants inserted in mandibles.
389 experienced in defining the occlusal plane in a transversal level of specificity, where the assessment of implant angula- 410
390 direction.41 tion as a complicating factor for dental implants was seldom 411
391 The results of the present study have to be interpreted with the main focus of the investigation. 412
392 caution because of its limitations. First of all, all confounding
393 factors may have affected the long-term outcomes and not 413
394 just the fact that implants were tilted or axially placed and the 5. Conclusion
395 impact of these variables on the implant survival rate,
396 postoperative infection and marginal bone loss is difficult to The results of the present review should be interpreted with 414
397 estimate if these factors are not identified separately between caution due to the presence of uncontrolled confounding 415
398 the two different procedures in order to perform a meta- factors in the included studies, none of them randomised. 416
399 regression analysis. The lack of control of the confounding Within the limitations of the existing investigations, the 417
400 factors limited the potential to draw robust conclusions. present study suggests that the differences in angulation of 418
401 Second, most of the included studies had a retrospective dental implants in relation to the mesialdistal occlusal plane 419
402 design, and the nature of a retrospective study inherently might not affect the survival of these dental implants or the 420
403 results in flaws. These problems were manifested by the gaps marginal bone loss. A statistically significant difference was 421
404 in information and incomplete records. Furthermore, all data found for implant failures when studies evaluating implants 422
405 rely on the accuracy of the original examination and inserted in maxillae only were pooled, in favour of axially 423
406 documentation. Items may have been excluded in the initial placed implants. The same was not true for implants inserted 424
407 examination or not recorded in the medical chart.6971 Third, in mandibles. 425
408 much of the research in the field is limited by small cohort 426
409 sizes. Fourth, some included studies are characterised by a low
Acknowledgements 427
This work was supported by CNPq, Conselho Nacional de 428

Desenvolvimento Cientfico e Tecnologico Brazil. The 429
authors would like to thank Dr. Tommaso Grandi, Dr. Miguel 430
de Araujo Nobre, Dr. Massimo Del Fabbro, and Dr. Enrico 431
Agliardi for having sent us their articles, Dr. Maria Menini, and 432
Dr. Tiziano Testori, who provided us some missing informa- 433
tion about their studies. 434
references 435
1. Malo P, de Araujo Nobre M, Lopes A, Moss SM, Molina GJ. A 436

longitudinal study of the survival of all-on-4 implants in the 437
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Fig. 6 Funnel plot for the studies reporting the outcome 2. Chrcanovic BR, Custodio AL. Inferior alveolar nerve lateral 440
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journal of dentistry xxx (2014) xxxxxx

Available online at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/jden

4 Tilted versus axially placed dental implants:

6 Q1 Bruno Ramos Chrcanovic a,*, Tomas Albrektsson a,b, Ann Wennerberg a

article info abstract

2 journal of dentistry xxx (2014) xxxxxx

14 2.2. Search strategies 67

journal of dentistry xxx (2014) xxxxxx 3

4 journal of dentistry xxx (2014) xxxxxx

Fig. 1 Study screening process.

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journal of dentistry xxx (2014) xxxxxx

JJOD 2356 122

journal of dentistry xxx (2014) xxxxxx

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3/144 (G2)e 2.08 (G2) but distinction

journal of dentistry xxx (2014) xxxxxx

8 journal of dentistry xxx (2014) xxxxxx

277 Q5 Table 2 Detailed data of the included studies Part 2. 333

journal of dentistry xxx (2014) xxxxxx 9

10 journal of dentistry xxx (2014) xxxxxx

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12 journal of dentistry xxx (2014) xxxxxx

journal of dentistry xxx (2014) xxxxxx 13

14 journal of dentistry xxx (2014) xxxxxx

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Study Selection Comparability Outcome Total (9/9)

Representativeness Selection Ascertainment Outcome Comparability of co- Assessment Follow-up Adequacy

journal of dentistry xxx (2014) xxxxxx

16 journal of dentistry xxx (2014) xxxxxx

323 analysis was performed pooling the studies evaluating

324 implants inserted in maxillae only, a statistically significant

326 This might be associated with the lower bone density

329 Concerning marginal bone loss, it was suggested by finite

331 stresses around non-axially placed implant necks5860 that

334 placed implants. Tilted implants may be also subjected to

335 bending, possibly increasing marginal bone stress.61 On the

337 that the reduction of the cantilever length achieved by tilting

343 stress in the surrounding bone, whereas FEA studies53,62,63

344 analysing tilted implants in splinted full-arch prostheses

347 cantilever length of the prosthesis also has some influence, as

348 shorter cantilevers have been correlated to a reduced peri-

350 apparent significant effect of tilted dental implants on the

354 tion observed in the studies here included might have

355 collaborated to these findings. However, these results should

358 a precise and reproducible bone loss measurement, and also

359 due to the variability of the follow-up period among the

361 The studies included here have a considerable number of

366 of some1719,21,22,27,32,34,36,39,42,46 or all28,50 implants in fresh

367 extraction sockets, the insertion of implants in different

locations, different healing periods, different prosthetic

371 of smokers,1,3,7,8,14,15,17,18,2025,2730,3234,36,4042,4449,51,52 brux-

372 ers,16,42,44,46,49 or diabetics patients.1,28,42,46,48,49

journal of dentistry xxx (2014) xxxxxx 17

Fig. 2 Forest plot for the event implant failure.

18 journal of dentistry xxx (2014) xxxxxx

Fig. 3 Forest plot for the event marginal bone loss.

journal of dentistry xxx (2014) xxxxxx 19

This work was supported by CNPq, Conselho Nacional de 428

1. Malo P, de Araujo Nobre M, Lopes A, Moss SM, Molina GJ. A 436

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