The Journal of Contemporary Dental Practice

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 20 , ISSUE 6 ( June, 2019 ) > List of Articles


Treatment of the Complete Edentulous Atrophic Maxilla: The Tall Tilted Pin Hole Placement Immediate Loading (TTPHIL)-ALL TILT™ Implant Option

P Venkat Ratna Nag, Vasantha Dhara, Sarika Puppala, Tejashree Bhagwatkar

Keywords : Atrophic edentulous maxilla, Bicortical engagement, Immediate loading, Tilted implants

Citation Information : Nag PV, Dhara V, Puppala S, Bhagwatkar T. Treatment of the Complete Edentulous Atrophic Maxilla: The Tall Tilted Pin Hole Placement Immediate Loading (TTPHIL)-ALL TILT™ Implant Option. J Contemp Dent Pract 2019; 20 (6):754-763.

DOI: 10.5005/jp-journals-10024-2592

License: CC BY-NC 4.0

Published Online: 01-07-2019

Copyright Statement:  Copyright © 2019; The Author(s).


Aim: A severely atrophied maxilla presents serious limitations for conventional implant placement and the reconstruction of which requires extensive surgical treatments. This original article presents an overview of this evidence-based technique used for maxillary rehabilitation. Background: Growing patients’ needs to regain proper oral function with limited surgical effort presents a challenge to the surgeon for implant placement in harmony with the planned prosthesis. Different techniques and protocols have been put forward through the ages to improve implant survival, osseointegration, and quality of life. A new technique—Tall Tilted Pin Hole Immediate Loading (TTPHIL-ALL TILT™ technique)—utilizes angulated long bicortical tapered implants placed in a flapless way in immediate loading with screw-retained prosthetic solutions. Technique: TTPHIL-ALL TILT™ technique involves flapless subcrestal bicortical placement of a total of six tall threaded tilted implants engaging the nasal cortex and the pterygoid pillars, rigidly splinted maintaining adequate anteroposterior spread, achieving proper primary stability, fit for immediate loading. Screw-retained prosthetic solutions are provided with the elimination of distal cantilever. Conclusion: The TTPHIL-ALL TILT™ technique can facilitate surgical rehabilitation of patients with maxillary resorption, as an alternative to other graft less and grafting procedures. Clinical significance: TTPHIL-ALL TILT™ technique provides a graftless solution for the challenging resorbed maxillary edentulous ridges. By following this protocol, primary stability is achieved which gives way for immediate loading satisfying the patient's functional and aesthetic needs.

PDF Share
  1. Elham E, Raphael FS, et al. The Impact of Edentulism on Oral and General Health. Int J Dent 2013;2013:498305. DOI: 10.1155/2013/498305.
  2. Lalit, K. Biomechanics and clinical implications of complete edentulous state. J Clin Gerontol Geriatr 2014;5(4):101–104. DOI: 10.1016/j.jcgg.2014.03.001.
  3. Hong DGK, Oh JH. Recent advances in dental implants. Maxillofac Plast Reconstr Surg 2017;39:33. DOI: 10.1186/s40902-017-0132-2.
  4. Lars C, Tord R, et al. Osseointegration of titanium implants, Acta Orthopaedica Scandinavica 1986;57:285–289. DOI: 10.3109/17453678- 608994393.
  5. Ozan O, Orhan K, et al. The Effect of Removable Partial Dentures on Alveolar Bone Resorption: A Retrospective Study with Cone-Beam Computed Tomography. J Prosthodontics 2012;22:42–48. DOI: 10.1111/j.1532-849x.2012.00877.x.
  6. Sharan A, Madjar D. Maxillary sinus pneumatization following extractions: a radiographic study. Int J Oral Maxillofac Implants 2008;23:48–56.
  7. Hyun SC, Ji WK, et al. Frequency of bone graft in implant surgery. Maxillofac Plast Reconstr Surg 2016;38:19. DOI: 10.1186/s40902-016- 0064-2.
  8. Cha HS, Kim A, et al. Simultaneous sinus lift and implant installation: prospective study of consecutive two hundred seventeen sinus lift and four hundred sixty-two implants. Clin Implant Dent Relat Res 2014;16:337–347. DOI: 10.1111/cid.12012.
  9. Jong HK, Young KK, et al. Retrospective clinical study on sinus bone graft and tapered-body implant placement. J Korean Assoc Oral Maxillofac Surg 2013;39:77–84. DOI: 10.5125/jkaoms.2013.39.2.77.
  10. Gonzalez S, Tuan MC, et al. Crestal approach for maxillary sinus augmentation in patients with
  11. Zeeshan S, Corneliu S, et al. Bone Replacement Materials and Techniques Used for Achieving Vertical Alveolar Bone Augmentation. Materials 2015;8:2953–2993. DOI: 10.3390/ma8062953.
  12. Schwartz AD, Herzberg R, et al. The Prevalence of Surgical Complications of the Sinus Graft Procedure and Their Impact on Implant Survival. J Periodontol 2004;75:511–516. DOI: 10.1902/jop.2004.75.4.511.
  13. Silva FM, Cortez AL, et al. Complications of Intraoral Donor Site for Bone Grafting Prior to Implant Placement. Implant Dent 2006;15:420–
  14. DOI: 10.1097/
  15. Li J, Wang HL. Common Implant-Related Advanced Bone Grafting Complications: Classification, Etiology, and Management. Implant Dent 2008;17:389–401. DOI: 10.1097/id.0b013e31818c4992.
  16. Guillaume O, Carl EM, et al. Fixed Rehabilitation of Severely Atrophic Jaws Using Immediately Loaded Basal Disk Implants After In Situ Bone Activation. J Oral Implantol 2012;38:611–616. DOI: 10.1563/aaid-joi-d-10-00163.
  17. Cucchi A, Vignudelli E, et al. Minimally Invasive Approach Based on Pterygoid and Short Implants for Rehabilitation of an Extremely Atrophic Maxilla: Case Report. Implant Dent 2017;26:639–644. DOI: 10.1097/id.0000000000000603.
  18. Babbush CA, Kutsko GT, et al. The All-on-Four Immediate Function Treatment Concept With Nobel Active Implants: A Retrospective Study. J Oral Implantol 2011;37:431–445. DOI: 10.1563/aaid-joi-d-10-00133.
  19. Preshaw P. Summary of: Implant surface characteristics and their effect on osseointegration. Br Dent J 2015;218:292–293. DOI: 10.1038/sj.bdj.2015.169.
  20. Fugazzotto P, Melnick PR, et al. Complications When Augmenting the Posterior Maxilla. Dent Clin North Am 2015;59:97–130. DOI: 10.1016/j. cden.2014.09.005.
  21. Stefan I. Comparison of Basal and Crestal Implants and Their Modus of Application. Smile Dent J 2009;4:36–46.
  22. Ritesh G, Neha M, et al. Implant Survival between Endoosseous Dental Implants in Immediate Loading, Delayed Loading, and Basal Immediate Loading Dental Implants a 3 Year Followup. Ann Maxillofac Surg 2017;7:237–244. DOI: 10.4103/ams.ams_87_17.
  23. Stefan I, Antonina AI, et al. New Systematic Terminology of Cortical Bone Areas for Osseo-Fixated Implants in Strategic Oral Implantology. J J Anatomy 2016;1:007.
  24. Vaibhav S, Dharti G, et al. Cold shoulder to Basal implant: It's time to acknowledge endosteal implant. Int J Oral Implantol Clin Res 2015;6:73–75.
  25. Morgano AT. Functional load in oblique bicortical implants: parasinusal implants and palatine implants. J Oral Implantol 2013;50:20–27.
  26. Charles AB, Gary TK, et al. The All-on-Four Immediate Function Treatment Concept With Nobel Active Implants: A Retrospective Study. J Oral Implantol 2011;37:431–445. DOI: 10.1563/aaid-joi-d-10-00133.
  27. Taruna M, Chittaranjan B, et al. Prosthodontic Perspective to All-On-4® Concept for Dental Implants. J Clin Diagn Res 2014;10:16–19.
  28. Bhering CL, Mesquita MF, et al. Comparison between all-on-four and all-on-six treatment concepts and framework material on stress distribution in atrophic maxilla: A prototyping guided 3D-FEA study. Mater Sci Eng C 2016;69:715–725. DOI: 10.1016/j.msec.2016.07.059.
  29. Heydecke G, Zwahlen M, et al. What is the optimal number of implants for fixed reconstructions: a systematic review. Clin Oral Implants Res 2012;23:217–228. DOI: 10.1111/j.1600-0501.2012.02548.x.
  30. Malo P, Nobre M, et al. The rehabilitation of completely edentulous maxillae with different degrees of resorption with four or more immediately loaded implants: a 5-year retrospective study and a new classification. Eur J Oral Implantol 2011;4:227–243.
  31. Chrcanovic BR, Pedrosa AR, et al. Zygomatic implants: a critical review of the surgical techniques. Oral Maxillofac Surg 2013;17:1–9. DOI: 10.1007/s10006-012-0316-y.
  32. Pedro MM, Laura BG, et al. Surgical complications in zygomatic implants: A systematic review. Med Oral Patol Oral Cir Bucal 2016;21:751–757. DOI: 10.4317/medoral.21357.
  33. Aparicio C, Perales P, et al. Tilted implants as an alternative to maxillary sinus grafting: A clinical, radiologic, and periotest study. Clin Implant Dent Related Res 2001;3:39–49. DOI: 10.1111/j.1708-8208.2001. tb00127.x.
  34. Kim KS, Kim YL, et al. Biomechanical comparison of axial and tilted implants for mandibular full-arch fixed prostheses. Int J Oral Maxillofac Implants 2011;26:976–984.
  35. Yvan F, Kenji W, et al. The Fully Edentulous Resorbed Maxilla: Surgical and Restorative Techniques to Avoid Bone Grafting. Can J Restorative Dent Prosthodontics 2010;2:20–25.
  36. Balshi TJ, Wolfinger GJ, et al. Analysis of 356 Pterygomaxillary Implants in Edentulous Arches for Fixed Prosthesis Anchorage. Int J Oral Maxillofac Implants 1999;14:398–406.
  37. Bidra AS, Huynh BG. Implants In The Pterygoid Region: A Systematic Review Of The Literature. Int J Oral Maxillofac Surg 2011;40:773–781. DOI: 10.1016/j.ijom.2011.04.007.
  38. Graves SL. The Pterygoid Plate Implant: A Solution for Restoring the Posterior Maxilla. Int J Periodont Rest Dent 1994;14:513–523.
  39. Brodala N. Flapless Surgery and Its Effect on Dental Implant Outcomes. Int J Oral Maxillofac Implants 2009;24:118–125.
  40. Laverty DP, Buglass J, et al. Flapless Dental Implant Surgery and Use Of Cone Beam Computer Tomography Guided Surgery. Br Dent J 2018;224:601–611. DOI: 10.1038/sj.bdj.2018.268.
  41. Chrcanovic BR, Albrektsson T, et al. Flapless versus Conventional Flapped Dental Implant Surgery: A Meta-Analysis. PLoS One 2014;9:e100624. DOI: 10.1371/journal.pone.0100624.
  42. Touati B, Rompen E, et al. A New Concept For Optimizing Soft Tissue Integration. Int Dent SA 2005;17:711–715.
  43. Gehrke SA, Bettach A, et al. Peri-Implant Bone Behavior after Single Drill versus Multiple Sequence for Osteotomy Drill. BioMed Res Int 2018 Article ID 9756043.
  44. Bettach R, Taschieri S, et al. Implant Survival after Preparation of the Implant Site Using a Single Bur: A Case Series. Clin Implant Dent Relat Res 2015;17:13–21. DOI: 10.1111/cid.12082.
  45. Lakha T, Kheur MG, et al. Effect of Implant Design and Thread Geometry on Stress Distribution in the Surrounding Bone—A Photoelastic Stress Analysis. J Dent Res Sci Develop 2016;3:1–6.
  46. de Oliveira Nicolau Mantovani AK, de Mattias Sartori IA, et al. Influence of cortical bone anchorage on the primary stability of dental implants. Oral Maxillofac Surg 2018;22(3):297–301. DOI: 10.1007/s10006-018-0705-y.
  47. Maló P, Nobre MA, et al. Preliminary Report on the Outcome of Tilted Implants with Longer Lengths (20–25 mm) in Low-Density Bone: One-Year Follow-Up of a Prospective Cohort Study. Clin Implant Dent Relat Res 17;1:134–142. DOI: 10.1111/cid.12144.
  48. Sotto-Maior BS, Lima CA, et al. Biomechanical evaluation of subcrestal dental implants with different bone anchorages. Braz Oral Res, (São Paulo) 2014;28(1):1–7. DOI: 10.1590/1807-3107bor-2014.vol28.0023.
  49. Cavalli N, Barbaro B, et al. Tilted Implants for Full-Arch Rehabilitations in Completely Edentulous Maxilla: A Retrospective Study. Int J Dent 2012;2012:180379. DOI: 10.1155/2012/180379.
  50. Wittneben JG, Joda T, et al. Screw Retained vs Cement Retained Implant-Supported Fixed Dental Prosthesis. Periodontology 2017;73:141–151. DOI: 10.1111/prd.12168.
  51. Behnaz E, Ramin M, et al. The effect of implant angulation and splinting on stress distribution in implant body and supporting bone: A finite element analysis. Eur J Dent 2015;9:311–318. DOI: 10.4103/1305-7456.163235.
  52. Chrcanovic BR, Albrektsson T, et al. Platform switch and dental implants: A meta-analysis. J Dent 2015;43(6):629–646. DOI: 10.1016/j. jdent.2014.12.013.
  53. Sorní M, Guarinos J, et al. Implants in anatomical buttresses of the upper jaw. Med Oral Patol Oral Cir Bucal 2005;10:163–168.
  54. Penarrocha OD, Candel ME, et al. Rehabilitation of the Atrophic Maxilla With Tilted Implants: Review of the Literature. J Oral Implantol 2013;38(5) 625–632. DOI: 10.1563/aaid-joi-d-11-00068.
  55. Andrea H, Wook-Jin S, et al. Comparison of initial implant stability of implants placed using bicortical fixation, Indirect sinus elevation, and unicortical fixation. Int J Oral Max Implants 2016.31;2:459–468. DOI: 10.11607/jomi.4142.
  56. Georgiopoulos B, Kalioras K, et al. The ef fects of implant length and diameter prior to and after osseointegration: a 2-D finite element analysis. J Oral Implantol 2007;31:243–256. DOI: 10.1563/1548-1336(2007)33[243:teoila];2.
  57. Kinsel RP, Liss M. Retrospective analysis of 56 edentulous dental arches restored with 344 single-stage implants using an immediate loading fixed provisional protocol: statistical predictors of implant failure. Int J Oral Maxillofac Implants 2007;22:823–830.
  58. Swanberg DF, Henry MD. Avoiding implant overload. Implant Soc 1995;6:12–14.
  59. Piattelli A, Piattelli M, et al. Light and scanning electron microscopic report of four fractured implants. Int J Oral Maxillofac Implants 1998;13:561–564.
  60. Van Steenberghe D, Jacobs R, et al. The relative impact of local and endogenous patient-related factors on implant failure up to the abutment stage. Clin Oral Implants Res 2002;13:617–622. DOI: 10.1034/j.1600-0501.2002.130607.x.
  61. Stach RM, Kohles SS. A meta-analysis examining the clinical survivability of machined-surface and osseotite implants in poor-quality bone. Implant Dent 2003;12:87–96. DOI: 10.1097/
  62. Menini M, Signori A, et al. Tilted Implants in the Immediate Loading Rehabilitation of the Maxilla: A Systematic Review. J Dent Res 2012;91(9):821–827. DOI: 10.1177/0022034512455802.
  63. Leonard K, Mikael K, et al. Tilting of Posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Max Implants 2000;15(3):405–414.
  64. Bruno Salles SM, Camila de Andrade L, et al. Biomechanical evaluation of subcrestal dental implants with different bone anchorages. Braz Oral Res, (São Paulo) 2014;28(1):1–7. DOI: 10.1590/1807-3107bor-2014. vol28.0023.
  65. Georgios ER, Bhumija G, et al. Distal Cantilevers and Implant Dentistry. Int J Oral Maxillofac Implants 2012;27(5):1131–1137.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.