Tilted Implants as an Alternative to Maxillary Sinus Grafting: A Clinical, Radiologic, and Periotest Study Carlos Aparicio, MD, DDS, MS;*" Pilar Perales, MD, DDS;* Bo Rangert, Mech Eng, PhD* ABSTRACT Background: Owing to mechanical and anatomic difficulties, implant treatment in the atrophic maxilla represents a challenge. The maxillary sinus floor augmentation procedure is still not universally accepted because of its complexity and its unpredictability. Purpose: In this study, a combination of tilted and axial implants was used in patients with severely resorbed posterior maxillae as an alternative to sinus grafting. Materials and Methods: Twenty-five patients were rehabilitated with 29 fixed partial prostheses supported by 101 Brinemark System” implants. Fifty-nine implants were installed in an axial and 42 in a tilted direction. The average follow-up period was 37 months (range: 21-87 mo post lo Results: After 5 years, the implant cumulative success rate was 95.2% (survival: rate 100%) for the tilted implants and 91.3% (survival rate: 96.5%) for the axial implants, and the prosthesis survival rate was 100%, At the fifth year, the aver- age marginal bone loss was 1.21 mm for the tilted implants and 0.92 mm for the axial ones. The mean Periotest” values (PTV) at loading time were ~2.62 and -3.57, and after 5 years the PTVs were ~4.73 and -5.00 for the tilted and the axial implants, respectively. During the follow-up, all prostheses but two were mechanically stable, retightening of 18 abut- ‘ment screws and of 5 gold screws in 14 prostheses was done, and fracture of two abutment screws and two occlusal sur- faces was experienced. Conclusions: Results indicate that the use of tilted implants is an effective and safe alternative to maxillary sinus floor augmentation procedures. KEY WORDS: dental implants, maxillary sinus, partial fixed prostheses, Periotest®, posterior maxillary segment, screw loosening, tilted implants SS 'n the case of total edentulousness in the maxilla, a clinical results? The presence of the maxillary sinus and full-arch bridge supported by multiple implants dis- _Jimited vertical space are two other obstacles encoun- tributes the masticatory loads primarily in axial direc- tered when placing implants in this region.*9 As a con- tion along the maxillary arch.' In the case of a partially sequence, the implants placed in the premolar or molar edentulous maxilla in the posterior region, the implants __ areas are shorter than the ones located in the incisive or have to be placed in a more lineal arrangement, which canine areas. It is known that shorter implants have a ‘may increase the risk for bending overload.? Moreover, higher failure rate than longer ones.*® Thus, the place- bone with less volume and worse quality is often found —_ment of dental implants in the posterior atrophic max- in these regions, which frequently complicates implant lla usually results in a compromised biomechanical sit- placement and may compromise the prognosis of the uation with a combination of short implants placed on 4 straight line in poor quality bone in an area exposed to : aera high loading forces." “Department of Biomaterials and Handicap Research University of ; ee Cree Sedees trees pacientnaoaien Ppa eas During the past decades, various alternative clinical Biocare AB, Goteborg Sweden procedures have been proposed to place implants in the eprint requests: Cals Aparicio, MD, DDS, MS, General Mitre 99 Posterior atrophic maxilla; one of them is the maxillary 3B, 08021 Barcelona, Spain; e-mail cpob@arrakises sinus floor augmentation or the sinus graft procedure. 3940° Clinical Implant Dentistry and Related Research, Volume 3, Number 1, 2001 Numerous grafting materials, including autologous bone taken from different areas, such as the hip, the calvaria, or the chin, have been used.""!? The clinical results of these techniques are related to the amount of the residual crestal bone. Possible complications are morbidity of the donor site and those related to sinus surgery, such as sinusitis, fistulae, loss of the graft or the implants, and osteomyelitis.!® Most of the published sinus graft studies are retrospective. In those studies, clinical and biotechnologic treatment concepts are mixed in such a way that the reader can get easily con- fused. At the present time, the maxillary sinus grafting procedure is still not universally accepted.!*!5 One attractive approach when treating the posterior maxilla is to use tilted implants to engage as much cortical bone as possible.'® From a theoretic point of view, the use of tilted implants in the residual crestal bone permits 1. Placement of longer implants, which increases the degree of implant-to-bone contact area and also the implant primary stability. 2. A longer distance between implants, allowing for the elimination of cantilevers in the prosthesis, which results in a better load distribution situation, 3. Placement of implants in residual bone, avoiding more complex techniques, such as sinus lifting or bone grafting procedures. In this study, the rehabilitation of the extremely resorbed posterior maxilla by means of a prosthesis sup- ported by a combination of axial and tilted implants was evaluated by clinical, radiographic, and Periotest® exam- inations with a follow-up period of 21 to 87 months. MATERIALS AND METHODS Patients ‘This retrospective study included 25 consecutive (10 male; 15 female) patients with partially edentulous maxillae (Appelgate-Kennedy Class 1, Il, and III). The mean age was 59 years for males and 49 years for females. From June 1991 to June 1998, the patients were treated with implants placed in axial and tilted directions, in relation to the occlusal plane, to support fixed prostheses without distal or mesial cantilevers. ‘The indication for the placement of tilted implants was established because the residual bone quantity was less than 8 mm under the maxillary sinus. Six patients were smokers and eight patients showed signs of wear on the occlusal surfaces. In general, the patients were healthy. One patient had epilepsy, and another had undergone angioplastic surgery owing to a coronary event and was being treated with acetylsalicylic acid. ‘The authors recognize that all placed implants are somewhat angulated to the occlusal plane, However, in this study, an implant was considered tilted when the inclination was over 15 degrees with respect to the occlusal plane. The inclination could be in the mesio- distal or distomesial direction and combined with a buccopalatal angulation, Surgery ‘The presurgical examinations of all the patients included panoramic radiograph. In most cases, the extension of the maxillary sinus and the volume and density of the remaining bone was evaluated by means of maxil- lary computed tomography. The bone quantity and quality were estimated based on the presurgical radiog- raphy and on the resistance to surgical drilling during surgery and classified according to the index described by Lekholm and Zarb.!? The data concerning bone qual- ity were 1 patient type 1, 7 patients type II, 13 patients type Ill, and 4 patients type IV. One surgeon treated all the patients in one clinic. ‘The implants were placed using a two-stage surgical approach, according to the method described by Adell etal Of 101 fixtures placed, 42 were with a tilted position in relation to the occlusal plane (Figure 1). Standard Brinemark System" implants (Nobel Biocare AB, Géte- borg, Sweden) 15 mm and 18 mm long with diameters of 3.75 mm and 4 mm were most frequently used (Table 1), Each patient received a minimum of two and a maxi- mum of five implants. One to three of these were tilted implants placed in the tuberosity or pterygoid bone or in the area just mesial to the maxillary sinus (Figure 2). All prostheses were supported by both test (tilted) and control (axial) implants. No implants shorter than 13 mm. were used in the tilted group (see Table 1). The majority of the fixtures were placed without pretapping. All implants reached a high primary stability. Table 2 pre- sents the distribution of implants according to their length and year of placement. Abutment connection was performed 6 to 8 months after implant placement (average 29 weeks). To give a better orientation to the gold screw or to obtain a better parallelism, 30-degree angulated abutments (Nobel Bio- care AB) were connected to 38 of the 42 tilted implantsFigure 1. A, Surgical placement of an axial implant following t the guide for the orientation of the tilted implant. B, Note the tlt corresponds to the tooth to be replaced. (90%), whereas Aur-Adapt® abutments (Nobel Biocare AB) were used for the remaining four implants (10%) (Table 3). In the group of the axial implants, Estheti- Cone® (Nobel Biocare AB) abutments were used in 87% Cone* (Nobel Biocare AB) in the radiograph was used to verify of the cases and Miru rest (13%). A peri the correct abutment seating PROSTHETICS ne fixed partial screw-retained prostheses sup- ported by a combination of tilted and axial implants wer delivered to the 25 patients. Eleven of the 29 prostheses ‘were supported by four or five implants, fourteen were supported by three implants (Figure 3), and four by two Tamer ko One eas Diameter Implant Rinbereeeeeee Length (mm) Implants (%) 3.75mm 4mm 5mm Tilted 100.0) -21(50) 20148) 1(2) B 4 (95) 2 1 1 (wp) 1s 12 (285) 8 E56 18 23. (55.0) 8 ase aid) Axial 59(100.0) 4068; 4(7) 85 1 Qo 1 or) 100 4 (8.0) 2 0 2 Bo 8 (130 6 0 2 (WP) 150 18 (30.0) 10 a) 180 20) 18 o WP = wide platform Tilted Implants as an Alternative to Maxillary Sinus Grafting 41 anterior wall of the maxillary sinus. The mesial axial implant will be ing of the implant. Once the implant is placed, the emergence point implants (Figures 4 and 5) (Tables 4 and 5). Rigid teeth- to-implant connections were used in four prostheses. Seven prostheses included the canine position (2 prosthe ses of 3 implants and 5 of 4 or 5 implants). The prosthe ses had neither distal nor mesial cantilevers. The opposing jaw presented a natural dentition or a fixed implant-supported prostheses up to the third molar in six patients, up to the second molar in fourteen Figure 2. Radiographic images. A, Tilted implants placed in the tuberosity or pterygoid bone and in the area just mesial to the maxillary sinus. B, A combination of axial and tilted implants, the later placed in the area just mesial to the maxillary sinus.