Impact of tilted implants for implant-supported fixed partial dentures A systematic review with meta-analysis

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SYSTEMATIC REVIEW
Supported by
aGraduate stu
bPostgraduat
cPostgraduat
dPostgraduat
eProfessor, D
fProfessor, D
gProfessor, D
890
Impact of tilted implants for implant-supported fixed partial
dentures: A systematic review with meta-analysis
Rhaslla Gonçalves Batista, DDS,a Daniele Sorgatto Faé, DDS,b Victor Augusto Alves Bento, DDS, MSc,c
Cléber Davi Del Rey Daltro Rosa, DDS, MSc,d Victor Eduardo de Souza Batista, DDS, MSc, PhD,e
Eduardo Piza Pellizzer, DDS, MSc, PhD,f and Cleidiel Aparecido Araujo Lemos, DDS, MSc, PhDg
ABSTRACT
Statement of problem. The use of tilted implants has been considered a suitable option for
completely edentulous patients. However, consensus on their clinical performance is lacking,
specifically for partial rehabilitation.
Purpose. The purpose of this systematic review and meta-analysis was to evaluate the marginal
bone loss and implant survival rate of tilted implants compared with those of axial implants for
implant-supported fixed partial dentures (ISFPDs).
Material and methods. A systematic search of the MEDLINE/PubMed, Web of Science, Embase,
Cochrane, and ProQuest databases and reference lists for articles published until May 2022 was
performed by 2 independent reviewers without language or publication date restrictions. A
meta-analysis was performed using the RevMan version 5.4 program. Quality assessments were
performed using the NewcastleeOttawa scale.
Results. Nine studies were included, totaling 258 participants and 604 implants (269 tilted implants
and 335 axial implants). No significant differences were found between the tilted and axial implants
for the implant survival rate (P=.81; risk ratio: 1.14). However, higher marginal bone loss values were
observed for tilted implants (P=.001; mean difference: 0.12 mm). No significant heterogeneity was
observed in either analysis.
Conclusions. No significant relationship was found between tilted and axial implants for ISFPD
rehabilitation. However, tilted implants presented greater risks of marginal bone loss than axial
implants. (J Prosthet Dent 2024;132:890-7)
Oral rehabilitation with
osseointegrated implants is
considered one of the main
options for completely or
partially edentulous patients,
with good peri-implant bone
stability and high survival rates
for both removable and fixed
prostheses.1-3 However,
different factors may affect the
increase in marginal bone loss
and/or the survival of dental
implants,4,5 including the
positioning of dental im-
plants.6-8
Axial positioning of dental
implants has been recom-
mended because occlusal
forces are dissipated along
the implant’s long axis,
reducing stress in the bone,
implants, and prosthetic components.9,10 However,
the positioning of dental implant is often affected by
anatomic limitations, including decreased bone vol-
ume, height, or thickness, especially in the posterior
regions,8,11 limitations that may be addressed by bone
scholarship scientific initiation volunteer of Federal University of Juiz de F
dent, Department of Dentistry, Federal University of Juiz de Fora/Campus
e student, Program in Applied Health Sciences (PPGCAS), Federal Univer
e student, Department of Dental Materials and Prosthodontics, Araçatuba
e student, Department of Dental Materials and Prosthodontics, Araçatuba
epartment Prosthodontics, Presidente Prudente Dental School, University
epartment of Dental Materials and Prosthodontics, Araçatuba Dental Scho
epartment of Dentistry, Federal University of Juiz de Fora/Campus GV (UF
grafting11,12 or lateralization of the inferior alveolar
nerve.13 However, these techniques are associated
with an increase in postoperative morbidity, risk of
complications, higher costs, and longer treatment
periods.12
ora (UFJF) e PROPESQ (Id. 48491), Brazil.
GV (UFJF/GV), Governador Valadares, MG, Brazil.
sity of Juiz de Fora/Campus GV (UFJF/GV), Governador Valadares, MG, Brazil.
Dental School, São Paulo State Univeristy (UNESP), Araçatuba, SP, Brazil.
Dental School, São Paulo State Univeristy (UNESP), Araçatuba, SP, Brazil.
of Western São Paulo (UNOESTE), Presidente Prudente, SP, Brazil.
ol, São Paulo State Univeristy (UNESP), Araçatuba, SP, Brazil.
JF/GV), Governador Valadares, MG, Brazil.
THE JOURNAL OF PROSTHETIC DENTISTRY
http://crossmark.crossref.org/dialog/?doi=10.1016/j.prosdent.2022.11.015&domain=pdf
Clinical Implications
ISFPDs with tilted implants are considered suitable
for the rehabilitation of partially edentulous
patients. However, different risk factors for bone
loss should be considered during treatment
planning, as tilted implants may increase the risk of
marginal bone loss.
November 2024 891
The placement of tilted implants has been advocated
to overcome these limitations.7,14-26 Although biome-
chanical studies have determined that tilted implants
have worse biomechanical properties in terms of stress
dissipation,9,10 systematic reviews have shown that
tilted implants may be a suitable alternative to axial im-
plants.6-8 However, most studies included in these sys-
tematic reviews considered the use of tilted implants in
fixed complete dentures, including the all-on-4 technique
for cantilever reduction.6-8 A consensus regarding tilted
implants, specifically for evaluating implant-supported
fixed partial dentures (ISFPDs), is lacking.
Therefore, this systematic review with meta-analysis
evaluated the influence of tilted and axial implants on
marginal bone loss and implant survival rate. The null
hypothesis was that tilted implants would show marginal
bone loss and implant survival rates similar to those of
axial implants.
MATERIAL AND METHODS
This systematic review was performed according to the
Cochrane Handbook of Systematic Reviews of In-
terventions,27 and the protocol was registered in the In-
ternational Prospective Register of Systematic Reviews
(PROSPERO) under number CRD42022299121. The
systematic review followed the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA)
2020 statement.28
The following question considering participants,
intervention, comparison, and outcomes (PICO) was
proposed: “Does the use of tilted implants in ISFPDs
cause marginal bone loss and survival rates similar to
those of axially positioned implants?” The population
included participants who had a clinical indication for
rehabilitation with ISFPDs in which the intervention
involved implants placed in a tilted position as opposed
to implants placed axially. The primary outcome was
marginal bone loss, and implant survival rate was a
secondary outcome.
The eligibility criteria were interventional or obser-
vational clinical studies that evaluated tilted implants
compared with axial implants for ISFPDs, with a mini-
mum of 10 participants and 10 implants for each evalu-
ated group, without language or publication date
Batista et al
restrictions. The exclusion criteria were studies that
evaluated tilted implants with fixed complete dentures
(all-on-4 technique or others), studies that evaluated
participants with a follow-up period of less than 12
months, studies that evaluated zygomatic implants,
in vitro studies, case reports, reviews, in silico studies,
studies that did not consider the evaluated outcomes,
and studies that evaluated only tilted implants without
comparison with a control group.
An electronic search was performed by 2 independent
reviewers (R.B., D.S.F.) following the eligibility criteria in
the electronic databases MEDLINE/PubMed, Web of
Science, Embase, and Cochrane Library for articles
published until May 2022. A search of the nonpeer-
reviewed literature in the ProQuest database was con-
ducted to determine relevant articles (Supplemental
Table 1, available online). The reference lists of the
eligible studies were searched manually.
A reference manager software program (Rayyan QCRI)
was used to remove duplicate studies and select articles
based on the eligibility criteria.29 The initial selection pro-
cess included reading after removing duplicates, which
involved the evaluation of articles throughtitles and ab-
stracts that met the eligibility criteria. In cases where it was
not possible to establish a judgment based on reading the
title and abstract, the decision was made based on a com-
plete reading of the article. In situations where consensus
was not reached by the 2 reviewers, a third reviewer
(C.A.A.L.) was consulted to resolve disagreements.
After selecting the studies, the data collection process
was performed by a reviewer (R.B.) through a stan-
dardized form defined before study selection. Each
eligible article was summarized and categorized to pre-
sent the following data: author, year of publication, study
design, number of participants, sex, mean age, number of
implants, implant system and dimensions, prosthesis
type (single or partial), loading protocol, marginal bone
loss, complications, implant survival rate, and follow-up
period. A second reviewer (D.S.F.) was responsible for
checking the data extracted for typographic errors, and
disagreements between the 2 reviewers were resolved by
a third reviewer (C.A.A.L.)
The NewcastleeOttawa Scale (NOS), which is based
on 3 main components of cohort studiesdselection,
comparability, and resultsdwas used for observational
studies (cohort and case-control). According to this
quality scale, a maximum of 9 stars may be assigned for
each study, with a score of 9 representing the highest
quality. Five or fewer stars represent a high risk of bias,
whereas 6 or more stars indicate a low risk of bias.30
A meta-analysis was performed on continuous and
dichotomous outcomes. Marginal bone loss values were
calculated using an inverse variance method based on the
mean difference (MD) of the marginal bone loss values in
millimeters (mm) reported by previous studies. The
THE JOURNAL OF PROSTHETIC DENTISTRY
In
cl
ud
ed
El
ig
ib
ili
ty
Sc
re
en
in
g
Id
en
tifi
ca
tio
n
Records identified through
database searching
(MEDLINE/PubMed; scopus;
web of science; cochrane;
ProQuest)
(n=1320)
Records after duplicates
removed
(n=823)
Full-text articles evaluated
for eligibility
(n=17)
Records screened
(n=823)
Records excluded
(n=806)
Full text articles
excluded (n=8)
Included complete
fixed denture (3)
Not evaluated
outcomes (2)
Without comparative
group (2)
Included zygomatic
implants (1)
Additional records
identified through
other sources
(n=0)
Studies
included in
qualitative
synthesis
(n=9)
Studies
included in
quantitative
synthesis
(n=9)
Figure 1. Flowchart of search strategy.
892 Volume 132 Issue 5
survival rates were calculated with the odds ratio (OR)
based on the implant unit taken into consideration
(a=.05). In case of significant heterogeneity (Pet al THE JOURNAL OF PROSTHETIC DENTISTRY
Table 1. (Continued) Characteristics of included studies
Author/
Year
Study
Design
Patient,
n Sex
Mean
Age, y
Implants,
n
Implant System/
Diameter/Length
Retention System/
Span/Material
Arch/Region/
Loading
Protocol
Mean (SD)
MBL
Complications,
n
Survival
Rates of
Implants, n
(%)
Follow-up,
mo
Koutouzis
and
Wennström
200725
RS 38
18 Fe
20 Ma
59.5 69
Axial: 36
Tilted: 33
Astra Techs Dental
Implant System;
Astra Tech AB/3.5
mm/8 mm-19 mm
Screw-retained/2-3
implants*/NR
Maxilla Mandible/
Posterior/
Conventional
Axial: 0.4
(±0.97)
Tilted: 0.5
(±0.95)
NR based on
evaluated
groups
Axial: 36
(100%)
Tilted 33
(100%)
60 mo
Aparicio
et al
200126
RS 25
10 Fe
15 Ma
49 Fe
59 Ma
101
Axial: 59
Tilted: 42
Standard Brånemark
System@ implants
(Nobel Biocare AB)/
3.75 mm-5 mm/8.5
mm-20 mm
Screw retained/2-5
implants*/MC and
acrylic resin
Maxilla/Anterior
and Posterior/
Conventional
Axial: 0.92
(±0.33)
Tilted: 1.21
(±0.40)
NR based on
evaluated
groups
Axial: 57
(96.6%)
Tilted 42
(100%)
37
mo (range:
21-87 mo)
CS, case series; Fe, female; ISFPD, implant-supported fixed partial dentures; Ma, male; MBL, marginal bone loss; MC, metal-ceramic; NR, not reported; POS, prospective observational study;
RS, retrospective study; SD, standard deviation; Ti, titanium framework; ZR, zirconia framework. *Authors reported only number of implants for each ISFPD.
10 10010.10.01
Favors [Axial]Favors [Tilted]
Aparicio et al.
Koutozis and Wennstrom
Balleri et al.
Pozzi et al.
Peñarrocha Diago et al.
Agliardi et al.
Barnea et al.
Queridinha et al.
Ferrini et al.
0
0
0
2
2
0
2
0
0
6
Heterogeneity: χ2 =1.63, df=4 (P=.80); I2=0%
Test for overall effect: Z=0.24 (P=.81)
6
2
0
0
1
0
0
2
1
0
42
33
20
42
39
10
29
30
24
Total (95% CI)
Total events
269
59
36
20
39
28
10
29
90
24
2001
2007
2009
2012
2013
2014
2016
2016
2018
0.27 [0.01, 5.78]
Not estimable
Not estimable
1.90 [0.17, 21.82]
3.80 [0.18, 82.28]
Not estimable
1.00 [0.13, 7.62]
0.98 [0.04, 24.65]
Not estimable
1.14 [0.39, 3.35]335
33.2%
15.9%
8.8%
30.0%
12.1%
100.0%
Odds Ratio
M-H, Fixed, 95% CI
Odds Ratio
M-H, Fixed, 95% CI YearEvents Total
AxialTilted
Events Total WeightStudy or Subgroup
Figure 2. Forest plot of implant survival event. CI, confidence interval.
0.5 10–0.5–1
Favors [Axial]Favors [Tilted]
Aparicio et al.
Koutozis and Wennstrom
Pozzi et al.
Peñarrocha Diago et al.
Agliardi et al.
Barnea et al.
Queridinha et al.
Ferrini et al.
1.21
0.5
0.65
0.59
0.9
1.18
1.92
1.03
0.4
0.95
0.33
0.26
0.5
0.69
0.48
0.65
0.92
0.4
0.49
0.49
1
1.18
2.01
1.09
42
33
40
37
10
29
30
24
Heterogeneity: χ2 =12.02, df=7 (P=.10); I2=42%
Test for overall effect: Z=3.25 (P=.001)
Total (95% CI) 245
57
36
38
28
10
29
89
29
316
24.1%
2.6%
27.1%
22.2%
3.4%
3.7%
11.9%
5.1%
2001
2007
2012
2013
2014
2016
2016
2018
0.29 [0.14, 0.44]
0.10 [–0.35, 0.55]
0.16 [0.02, 0.30]
0.10 [–0.05, 0.25]
–0.10 [–0.50, 0.30]
0.00 [–0.38, 0.38]
–0.09 [–0.30, 0.12]
–0.06 [–0.38, 0.26]
100.0% 0.12 [0.05, 0.19]
0.33
0.97
0.3
0.35
0.4
0.77
0.59
0.52
Mean Difference
IV, Fixed, 95% CI
Mean Difference
IV, Fixed, 95% CI YearTotal Total
AxialTilted
Mean MeanSD SD WeightStudy or Subgroup
Figure 3. Forest plot of marginal bone loss event. CI, confidence interval; SD, standard deviation.
894 Volume 132 Issue 5
In contrast, the quantitative analysis showed that
tilted implants presented higher marginal bone loss than
implants placed axially (P=.001), with an MD of 0.12
mm (CI: 0.05 to 0.19 mm). No significant heterogeneity
was observed in the marginal bone loss analysis (P=.10)
(Fig. 3). The funnel plot of each outcome evaluated
shows the symmetry of included studies for implant
THE JOURNAL OF PROSTHETIC DENTISTRY
survival and marginal bone loss, indicating the possible
absence of publication bias (Fig. 4).
Based on the NOS, most studies were of moderate
and high quality. Four studies18,19,23,25 scored 8 stars, 3
studies22,24,26 scored 7 stars, and 2 studies20,21 scored 6
stars. No included study scored 9 stars. The absence of
stars was related to the exposition of the cohort,
Batista et al
SE
(M
D
)
MD
A
–1
0.5
0.4
0.3
0.2
0.1
0
–0.5 0 0.5 1
SE
(lo
g[
O
R]
)
OR
B
2
1
1.5
0.5
0.01
0
0.1 1 10 100
Figure 4. Funnel plots. A, Implant survival. B, Marginal bone loss.
November 2024 895
comparability of the main or additional factors, and,
chiefly, the lack of adequate follow-up (Supplemental
Table 2, available online).
DISCUSSION
The null hypothesis was rejected because higher mar-
ginal bone loss was observed for the tilted implants, re-
sults that contradict the findings of previously published
systematic reviews on this topic.6-8 This difference may
be explained by the previous reviews including studies
that evaluated completely edentulous patients with an
atrophic maxilla or mandible by using fixed complete
Batista et al
denture rehabilitation with tilting of the distal implants to
compensate for the cantilever generated, and, conse-
quently, improving the biomechanical behavior of the
rehabilitation.
The tilting of distal implants for cantilever reduction in
fixed complete dentures has been well established14-16
and has been highlighted by previously published re-
view papers.6-8 However, the authors are unaware of a
previous systematic review that only included studies
that used tilted implants for ISFPD rehabilitation.
The greater risks of bone loss for tilted implants may
be related to the biomechanical behavior of these im-
plants, since biomechanical studies have reported that
THE JOURNAL OF PROSTHETIC DENTISTRY
896 Volume 132 Issue 5
tilted implants in ISFPDs present greater risks of stress in
the bone tissue region than axial implants.9,10 The worse
biomechanical behavior of tilted implants for ISFPDs may
be explained by the possible transfer of masticatory load
outside the long axis of the implant (nonaxial) to struc-
tures9; this alters the fulcrum of the prosthesis and sug-
gests a greater dissipation of forces in adjacent
components and structures.10
Another possible explanation for the higher bone loss
values may be linked to the biological parameters of the
patients. Hopp et al17 reported that biological complica-
tions tended to be greater in tilted implants. The reduced
oral hygiene around tilted implants and the increased risk
complications may be risk factors leading to a higher
incidence of biological complications.4,17
Although a statistically significant difference was
observed for marginal bone loss, the difference of 0.12
mm is not likely to be considered clinically significant.
Therefore, rehabilitation with tilted implants for ISFPDs
should not be rejected given that it may provide the most
cost-effective functional option. However, clinicians
should consider the possible association between risk
factors that could increase the levels of marginal bone
loss and, consequently, risk of failure.
Tilted implants have an implant survival rate similar
to that of axial implants. In the included studies, the
implant failure rate was low (6 implants in each group),
and 4 studies18,21,24,25 did not report any type of failure
during the follow-up period. Although most included
studies were observational, the justification for the
absence of differences may be related to the short follow-
up period in some studies. A minimum period of 5 years
has been recommended for an assertive assessment of
the survival rate of dental implants.5
Limitations of the present systematic review included
the short follow-up period. The inclusion of studies with
a minimum follow-up of only 1 year was necessary, as an
inclusion criterion of a minimum follow-up of 5 years
would have limited this review to only 2 studies,19,25
which would not allow an in-depth evaluation of the
data found. However, studies that included patients
evaluated for a period of less than 1 year were excluded.
Therefore, further standardization with a longer follow-
up period is recommendedto reassess the implant sur-
vival rates.
Another limitation of the current systematic review is
the absence of patient standardization. One of these
factors could be related to the number of units of IFPDs.
Most included studies evaluated 2, 3, or 4 units in the
IFPDs. The differences in the number of units for each
group evaluated could affect the stress during masticatory
force and, consequently, the outcomes evaluated.
Another factor may be the absence of information related
to rehabilitation with tilted and axial implants in the
THE JOURNAL OF PROSTHETIC DENTISTRY
same patients or a combination of axial and tilted im-
plants in the same prosthesis. However, these data were
not provided or individualized in the included studies.
Other limitations are the inclusion of different study
designs and the low number of studies in the meta-
analysis. Although this is not the best approach, if
observational studies had not been included, this sys-
tematic review would have been limited to a small
number of studies. Unfortunately, no randomized clinical
trials on this topic were found. Therefore, these results
should be interpreted with caution, and well-designed
standardized randomized controlled studies are highly
recommended to validate the results of this study.
CONCLUSIONS
Based on the findings from this systematic review and
meta-analysis, the following conclusions were drawn:
1. No significant relationship was found between the
position of dental implants and the survival rate of
ISFPD rehabilitations.
2. Titled implants contribute to increased marginal
bone loss around dental implants in ISFPDs.
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Corresponding author:
Dr Cleidiel Aparecido Araujo Lemos
Department of Dentistry
Federal University of Juiz de Fora/Campus GV (UFJF/GV)
Governador Valadares, MG
BRAZIL
Email: cleidiel.lemos@ufjf.br
Copyright © 2022 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2022.11.015
THE JOURNAL OF PROSTHETIC DENTISTRY
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mailto:cleidiel.lemos@ufjf.br
https://doi.org/10.1016/j.prosdent.2022.11.015
	Impact of tilted implants for implant-supported fixed partial dentures: A systematic review with meta-analysis
	Material and methods
	Results
	Discussion
	Conclusions
	References