Decision making for rehabilitation of the atrophic maxillary arch with tilted implants through TTPHIL:ALL TILT® Protocol: A proposed classification of various situations

Purpose Majority of classifications for implant placement is based on the morphology of the available bone. The entry and exit points of implant in all forms of atrophy are not emphasized. The purpose of this article is to classify the entry points, angulations and exit points for 6 tilted maxillary implants in anterior-posterior distribution for prompt decision making, the ease of surgery and to capitalize on the available bone width. Methods Retrospective radiographic analysis was done for 150 maxillary arch edentulous patients restored with fixed prosthesis supported by six tilted implants between April 2021 to April 2023. Post operative Orthopantomograph (OPG) tracings were done for maxillary sinus borders to classify the sinus pneumatization and the entry and exit points of implants were noted with respect to the prosthetic teeth, basal anchoring bone and implant angulations. Results Of the arches treated, 63 were SP1, 34 were SP2, 16 were SP3 in the maxilla. Many combination arches were encountered as well including 32 cases of SP1 + SP2 and 5 of SP2 + SP3 combinations. The common preferred entry points were canine, second premolar and second molar areas. Conclusions A functional surgical classification aids in placing all-6 tilted bicortcal implants for immediate function while being versatile enough to be used in delayed cases as well. The knowledge of this classification helps to visualise the entry/fixation points minimising unpredictable and morbid grafting surgical procedures. It also aids in efficiently delivering patient-centric minimally invasive, predictably stable, biomechanically sound, fixed implant treatments without cantilever in complete edentulism.