CLINICAL RESEARCH

Correlation between implant angulation and crestal bone ]]

]]]]]]
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changes: A 5-year retrospective study

Donghyun Kim, DMD,a Kihyun Kim, DDS, MS,b Joo-Young Ohe, DMD, PhD,c Seung Jun Song, DMD, MS,d and
Janghyun Paek, DMD, PhDe

ABSTRACT
Statement of problem. The effects of nonaxial forces on peri-implant bone loss have been investigated, mostly in reference to buccal
mesiodistal implant angulations as potential risk indicators. However, when implant angulations are multidirectional, including the
buccolingual aspect, evaluations of peri-implant bone loss based solely on mesiodistal measurements may skew the correlation.
Purpose. The purpose of this retrospective study was to evaluate the correlation between the magnitudes of multidirectional implant
angulations and peri-implant crestal bone loss.
Material and methods. Data were retrospectively collected and analyzed from clinical records, periapical radiographic images, and
computer-aided design (CAD) files of custom abutments. The study included 288 patients with 506 dental implants, and the mean follow-up
duration after the placement of definitive prostheses was 5.1 years. Patients with uncontrolled systemic disease were excluded. Variables
such as age, sex, type of unit (single-unit or multi-unit), location (maxillary or mandibular and anterior, premolar, or molar), and antagonist
(natural tooth, implant-supported prosthesis, or removable prosthesis) were evaluated. The angulation of the implant (mesiodistal and
buccolingual) and status of attrition (normal, localized, or generalized) were assessed using the CAD file. The angulation of the implant was
then derived from the mesiodistal and buccolingual angle measurements by using a mathematical formula. Peri-implant bone loss was
measured from periapical radiographs. A comparison of peri-implant bone loss between axial and nonaxial implants was performed using
the Student t test (α=.05). Additional comparative evaluations were performed according to the type of unit, location, antagonist, and status
of attrition in reference to the angulation categories.
Results. The mean ±standard deviation peri-implant bone loss over 5 years was 0.10 ±0.39 mm in the axial implants and 0.22 ±0.48 mm in
the nonaxial implants. Statistical analysis showed that nonaxial implants had a significantly greater bone loss (P<.05), which was more
pronounced when the antagonists were implant-supported prostheses (P<.05) and when the implants were located in the mandible (P<.05).
Conclusions. A significant correlation was observed between implant angulation and peri-implant bone loss. Nonaxially positioned
implants exhibited greater bone loss compared with axially positioned implants. Additionally, the location of the implant and the type of
antagonist were found to influence the extent of bone loss. These findings suggest that careful consideration of implant angulation, as well
as the position and type of antagonist, is crucial in minimizing peri-implant bone loss. (J Prosthet Dent 2025;133:162.e1-e7)

To minimize biomechanical complications and peri-im­ sites and are associated with bone resorption after tooth
plant marginal bone loss, implants should be placed in a extraction.2–4 The residual ridge after tooth extraction
prosthetically driven position to apply axial occlusal forces takes different forms depending on the severity of in­
to the implant and implant-supported restoration.1 flammation before tooth extraction, the quality and
However, ridge deformities are common in edentulous thickness of the bone around the socket, and the damage

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
a
Graduate student, Department of Dentistry, Graduate School, Kyung Hee University, Seoul, Republic of Korea.
b
Resident, Section of Orthodontics, School of Dentistry, University of California, Los Angeles (UCLA), Los Angeles, CA.
c
Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea.
d
Assistant Professor, College of Dental Medicine, Columbia University, New York, NY.
e
Associate Professor, Department of Prosthodontics, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea.

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attrition status in reference to the angulations were

Clinical Implications evaluated. The null hypothesis was that no correlation
Implants with a large angle to the axis of occlusal would be found between implant angulation and peri-
force can exhibit progressively greater peri-implant implant bone loss.
bone loss. Furthermore, during the surgical
placement of implants, care should be exercised to
MATERIAL AND METHODS
avoid excessive tilting, especially if the antagonists
are implant-supported prostheses or if the implants This retrospective study was approved by the regional
are placed in the mandible. ethics board and abided by the World Medical
Association Declaration of Helsinki. The records of 288
patients who had received restorations supported by 506
to the bone caused by the extraction.5,6 Because of these implants between 2013 and 2021 were collected and
various factors, the relationship between the residual al­ reviewed. The mean follow-up duration was 5.1 years.
veolar ridge and the opposing teeth in the buccolingual The data were collected from the patient records of
direction is sometimes not ideal for implant placement in clinical examination, treatment notes, and CAD files of
the extraction site.5,6 Therefore, in patients with these custom abutments. Patients who had received fixed
anatomic limitations, the implant may need to be in­ partial implant-supported prostheses fabricated by the
tentionally tilted. In addition, during implant placement, computer-aided design and computer-aided manu­
the implant may sometimes be placed at an angle dif­ facturing (CAD-CAM) method and with a follow-up
ferent from the one planned. Concerning the compro­ period of at least 2 years were included. All custom
mised implant angulation, it has been established that the abutments created using CAD-CAM were designed and
force vector increases in the buccal direction, even with manufactured by a single manufacturer (RabbitBio Co,
the same amount of force.7 For example, if an occlusal Ltd) and were connected to the implants following the
force of 100 N is applied to an implant, dividing the force guidelines provided by the manufacturer. All abutments
by vector direction shows that the force on the buccal were custom titanium with a screw channel that fol­
vector increases to 25.9 N at a 15-degree tilt and 50 N at a lowed the axis of the implant, and all prostheses were
30-degree tilt, leading to possible damaging stress to the cement-retained. To minimize the influence of other
implant and surrounding bone. factors affecting peri-implant bone loss, patients with
The relationship between these nonaxial forces on active periodontal disease, poor oral hygiene, un­
implants and peri-implant bone loss has been in­ controlled systemic disease, or the absence of a radio­
vestigated.8,9 The common feature of prior studies has graph immediately after prosthesis delivery were
been the use of mesiodistal angulation values observed excluded.10–12 The periodontal status was monitored
from the buccal radiographic view as the main indicator during the follow-up period.
of nonaxial force. Nevertheless, as the implants possess The angulation of the implant was assessed by using
multidirectional angles in reference to the positions, the a measurement software program (MY-D; RabbitBio Co,
magnitudes of buccolingual angulation should not be Ltd) applied to the CAD file. The mesiodistal and buc­
underemphasized when the nonaxial force is evaluated colingual angles were determined relative to the occlusal
for the potential link to improve its possible role in the planes (Fig. 1). Furthermore, the angulation of the im­
correlation. Therefore, in the present study, both mesio­ plant in 3-dimensional coordinates was derived through
distal and buccolingual angles were considered by uti­ the formula (Fig. 2):
lizing the computer-aided design (CAD) files used in the Angulation of implant( )
design of the implant custom abutments and prostheses. 1
= tan tan (mesiodistal angle)2 + tan (buccolingual angle).2
Implant angles were measured in each direction—me­
siodistal and buccolingual—and these measurements The status of attrition was classified as normal
were calculated as a 3-dimensional angle between the (Fig. 3A), localized (adjacent teeth of the implant pros­
implant and the occlusal plane to analyze their correlation thesis showing attrition) (Fig. 3B), or generalized (entire
with peri-implant bone loss. dentition showing attrition) (Fig. 3C).13 A single pros­
The aim of the present study was to assess the cor­ thodontist (D.K.) conducted the measurement and
relation between the multidirectional implant angula­ classification procedures. The variables extracted from
tion and peri-implant bone loss associated with the the clinical records are presented in Table 1; Table 2
implants restored with fixed dental prostheses (FDP) in shows the distribution of implants according to these
partially edentulous patients. Moreover, the potential variables.
risk factors associated with bone loss in the parameters Periapical radiographs of all implant sites were made
of the type of unit, location, type of antagonist, and at the time of fixed dental prosthesis (FDP) delivery and

Kim et al THE JOURNAL OF PROSTHETIC DENTISTRY

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at periodic 6-month recall appointments using the

standardized parallel long-cone technique.8,9 Bone loss
around each implant was quantified by measuring the
difference in bone levels between the radiographs made
at FDP placement and the final recall visit. This mea­
surement involved determining the distance from the
implant platform to the nearby osseous crest on both the
mesial and distal sides for each implant. To account for
radiographic distortion, the true bone level was calcu­
lated by using a proportional equation based on the
actual implant length.14 The mean value of bone re­
sorption on the mesial and distal sides was categorized
as peri-implant bone loss and derived from the fol­
A
lowing formula (Fig. 4):

M+D AL
Peri implant bone loss = × .
2 RL

Statistical analyses were conducted using statistical

software programs (R, version 3.0.2; R Foundation for
Statistical Computing, SAS, version 9.4; SAS Institute). The
comparisons of peri-implant bone loss were performed
between the groups of axially and nonaxially positioned
implants using the Student t test (α=.05). Further com­
parative evaluations were performed using the Student t test
according to the type of unit, location of the implant, an­
tagonist, and attrition status in reference to the groups.
B
Figure 1. Implant angulation. A, Mesiodistal. B, Buccolingual.

Figure 2. Angulation of implant in 3-dimensional coordinates.

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A B C
Figure 3. Analysis of attrition status. A, Normal attrition. B, Localized attrition. C, Generalized attrition.

Table 1. Anamnestic and clinical variables

Anamnestic Variables Age, Sex, Periodontal and General Health
Clinical variables Number of implants, type of unit (single-unit or multiunit), jaw (maxilla or mandible), position of implants (anterior, premolar, or
molar tooth), attrition (normal, localized, or generalized), type of antagonist (natural tooth, implant FDP, or removable denture),
angulation of implant (mesiodistal and buccolingual), and amount of peri-implant bone loss
FDP, fixed dental prosthesis.

Table 2. Distribution of implants according to risk factors (N=506) RESULTS

Variables Characteristics Number of Implants
(Percentage, %) For data description, the implants were categorized
Age 10−30 y 31 (6%) based on their angle values so that those in the lowest
30−50 y 91 (18%)
50−70 y 282 (56%)
and highest quartiles of the angle distribution were
70−90 y 102 (20%) classified as axially positioned and nonaxially positioned
Sex Male 221 (44%)
Female 285 (56%)
implants, respectively. Figure 5 illustrates the frequency
Type of Single-unit 218 (43%) distribution of implant angulation relative to the occlusal
prosthesis Multiunit 288 (57%)
Jaw Maxilla 271 (54%)
plane. The tail quartiles, identified as axially positioned
Mandible 235 (46%) implants, had a mean angulation of 3.4 degrees (range 0
Position Anterior 55 (11%)
Premolar 132 (26%)
to 5.9 degrees). Conversely, nonaxially positioned im­
Molar 319 (63%) plants had a mean angulation of 22.3 degrees (range
Attrition Normal 162 (32%)
Localized 192 (38%)
14.9 to 47.0 degrees. Degrees of discrepancies were
Generalized 152 (30%) found in the distribution of variables that were more
Antagonist Natural tooth 339 (67%)
Implant FDP 146 (29%)
pronounced in the number of nonaxially positioned
Removable denture 21 (4%) implants and axially positioned implants in reference to
FDP, fixed dental prosthesis; y, year.
150
A B
Top of implant
Number of implants (n)

D M
100

50

0
0 10 20 30 40 50
Implant angle (degree)
RL
Figure 5. Distribution of implants according to angulation of implants.
Figure 4. Definition of peri-implant bone loss. Distance from implant A: Axially positioned implants, B: Nonaxially positioned implants. Two
top to marginal bone contact level on radiograph. AL: Actual length of tail quartiles selected to represent axially positioned implants and
implant; D: distal; M: mesial; RL: Radiographic length of implant. nonaxially positioned implants.

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Table 3. Characteristics of axial and nonaxial positioned implants

Axially Positioned Implants Nonaxially Positioned Implants
Number of implants 126 126
Mean implant angulation 3.4 degrees 22.3 degrees
Jaw (Percentage, %) Maxilla 62 (49%) 85 (67%)
Mandible 64 (51%) 41 (33%)
Position (Percentage, %) Anterior 6 (5%) 38 (30%)
Premolar 31 (25%) 36 (29%)
Molar 89 (70%) 52 (41%)

* *
2 0.9

1.5
0.6

Bone loss (mm)

Bone loss (mm)

1
0.3
0.5

0
0

–0.5 –0.3
Axial-positioned Non-axial-positioned Axial-positioned Non-axial-positioned
Figure 6. Peri-implant bone loss of axially and nonaxially positioned Natural tooth Implant-supported prosthesis
implants. Removable denture

Figure 7. Peri-implant bone loss of axially and nonaxially positioned

the location and position of the implants, respectively implants according to antagonist.
(Table 3).
The mean follow-up period for 506 implants was 5.1 anterior, premolar, and molar regions, no significant
years (range 4.8 to 5.4 years). Following the implant- differences were observed within the group of nonaxial
supported prosthesis delivery, the mean ±standard de­ implants (P>.05). The variables of attrition status and
viation peri-implant bone loss was 0.10 ±0.39 mm for patient demographic factors such as age and sex did not
the axially positioned implants and 0.22 ±0.48 mm for significantly affect the level of bone loss within the
the nonaxially positioned implants, respectively (Fig. 6). nonaxially positioned implant group (P>.05).
Statistical analysis showed that nonaxially positioned
implants had significantly greater bone loss than axially
DISCUSSION
positioned implants (P<.05).
The peri-implant bone loss appeared significantly The present study aimed to assess and address the po­
more pronounced (P<.05) for the implants that had the tential impact of nonaxially positioned implant loading on
implant-supported antagonists rather than natural teeth crestal peri-implant bone loss following the delivery of
or removable dentures when the implants were non­ implant-supported prostheses. The results showed that
axially positioned (Fig. 7). When categorized by location implant angulation had a significant effect on the peri-
of the implant, implants in the maxilla showed greater implant bone level during 5 years of functional loading of
peri-implant bone loss than those in the mandible, but prostheses in patients who were under regular period­
the difference was not statistically significant (P>.05). ontal maintenance (P<.05). Therefore, the null hypothesis
However, among the mandibular implants, there was that no correlation would be found between implant
significantly more bone loss with the group of nonaxially angulation and peri-implant bone loss was rejected.
positioned implants compared with their axially posi­ The level of biofilm control through regular period­
tioned counterparts. (P<.05) (Fig. 8). ontal maintenance is important to maintain the health of
Type of unit refers to the classification based on peri-implant tissues for favorable long-term prognosis.
whether the prosthesis was a single unit or part of a Prior studies have reported relationships between un­
multiple unit. When the implant was placed nonaxially, treated periodontal disease or previous history of peri­
bone loss did not significantly increase, depending on odontitis and peri-implantitis.10–12 Therefore, in the
the type of unit (P>.05). Additionally, when the level of present study, only participants who had demonstrated
bone loss was evaluated by the implant locations of low plaque scores (5%) were included to minimize the

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* The implant location (anterior, premolar, or molar)

0.3 was not found to be a significant risk factor for pro­
nounced peri-implant bone loss within the nonaxially
placed implant group (P>.05), consistent with Lin et al.28
Bone loss (mm)

However, others have reported contradictory findings.

0.2
Jemt et al29 reported significantly greater bone loss in
the mandibular posterior region, and Carr30 and Noda
et al31 reported that implant placement in the maxillary
0.1 posterior region was associated with a greater risk of
peri-implant bone loss. In the present study, bone loss
around the anterior implants of the axially positioned
0 group was higher (P<.05). Given these conflicting find­
ings, further research is needed to better establish the
–0.05 link between implant position and peri-implant bone
Mandible Maxilla
loss. Age and sex were not found to be significantly
Axial-positioned Non-axial-positioned
associated with peri-implant bone loss (P>.05), con­
Figure 8. Peri-implant bone loss of axially and nonaxially positioned sistent with previous studies.31–34
implants according to implant position. Categorizing the analysis according to the conditions
of attrition was based on the speculation that paraf­
possible effect of bacterial plaque accumulation on peri- unctional habits such as bruxism and clenching would
implant bone loss. exert greater occlusal forces on the implants. However,
The effect of excessive nonaxial loading on peri-im­ no significant relationship was found between attrition
plant marginal bone was investigated by Koutouziset and peri-implant bone loss, even when implants were
and Wennstrom.8 Their 5-year retrospective study re­ nonaxially positioned (P>.05). This similarity was con­
ported that nonaxial implant loading did not increase sistent with the results of previous studies35–37 and was
the risk of peri-implant bone loss. However, only the likely associated with the occlusal adjustment of the
mesiodistal implant angulation was measured and implant prosthesis, which eliminates premature contacts
considered in their study, omitting the buccolingual during central occlusion and lateral movements.
angulation. Lee et al9 also reported that nonaxial loading Limitations of the present study included that only
did not increase the risk of peri-implant bone loss. the mesial and distal peri-implant bone loss was as­
However, the authors specified that the nonaxial loading sessed on 2-dimensional radiographs. The inclusion of
was evaluated by measuring the mesiodistal length ratio cone beam computed tomography (CBCT) scans
of the widths of the crown and implant. Other previous would have provided buccolingual peri-implant bone
studies also reported weak correlation between off-axial level data and may have established a correlation
loading and bone loss.15–17 between nonaxial occlusal forces and peri-implant
In the present study, attempts were made to overcome bone loss. Additionally, the subgingival profile of the
the potential shortcomings of prior studies that confined prostheses may have a contributing role in the
the measurements of implant angulation to the mesio­ maintenance of the peri-implant bone level. Several
distal aspects on the 2-dimensional radiographs by using preclinical and clinical studies have investigated and
a CAD and angle measurement software program (MY- reported the correlation of the subgingival profile with
D; RabbitBio Co, Ltd) to measure multidirectional im­ subsequent peri-implant bone loss.38–43 A wide sub­
plant angles, including the buccolingual values. gingival profile has been associated with increased
Because of the different biomechanical properties in­ peri-implant bone loss, whereas a narrower profile
volved, the functional mechanisms of occlusion on dental was observed to maintain the bone level in a more
implants are different from those of occlusion in natural stable state.38–43 However, in the present study, the
dentition with a periodontal ligament.18–20 This difference subgingival morphology was not considered. In
may explain the finding that peri-implant bone loss was forthcoming studies, a combination of 3-dimensional
greater when the antagonist was an implant-supported radiographic and supragingival and subgingival sur­
restoration than when it was a natural tooth. face data may lead to additional correlations.
No significant difference was found in peri-implant
bone loss between the maxilla and mandible in the
present study (P>.05), in contrast with previous stu­
CONCLUSIONS
dies.21–27 This lack of significance may be due to the
level of maintenance of the patients included in the Based on the findings of this retrospective clinical study,
study along with the limited sample sizes. the following conclusions were drawn:

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162.e7 Volume 133 Issue 1

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