# Introduction ral health plays important role to uphold proper mastication, digestion, phonation, aesthetic, and emotional well-being. The loss of permanent teeth can occur for a variety of reasons, ranging anywhere from hereditary factor, congenital absence, diseases of the dentition (e.g., caries or periodontal disease) and trauma. 1 An edentulous condition existing in the posterior maxilla poses a challenge to all the clinicians. The reasons behind this are the anatomic factors like bone quality (type III or IV) according to Lekholm and Zarb 2 , quantity, location of the maxillary sinus, and poor accessibility in the posterior region 3,4 . The pterygoid implants was introduced by Tulasne JF (1992). The advantage of a pterygoid implant is that it allows anchorage, eliminates posterior cantilever and improved axial loading in the posterior atrophic maxilla. 5 It eradicates the need for O lesser and implant placement in zygoma 9 . Placement of implants in the pterygoid region provides posterior bone support, bypass sinus augmentation, or bone grafts. Because of inadequate accessibility, placement of pterygoid implants is more technically demanding than placing short implants anterior to the maxillary antrum. However, there are no risks associated with implant placement in pterygoid area 3 . The TTPHIL-ALL TILT ® -(Tall Tilted Pin Hole Immediate Loading) concept has evolved from various ideologies in implantology: basal, pterygoid and angulated/tilted implants under immediate loading. To maximize the success of rehabilitation, the TTPHIL technique utilizes the use of long tilted bicortical implants by engaging the pterygoid region. Pterygoid implants were intended to pass through maxillary tuberosity, the pyramidal process of palatine bone and the pterygoid process of the sphenoid bone. 3,10,11 In the literature, success rates of pterygoid implants for maxillary rehabilitation have been more than 94 to 99%. Thus, the TTPHIL-ALL TILT ® technique is a novel approach for the placement of implants; it was derived from established schools of thought in implantology. 12 In this article, following cases are examples of patients indicated for pterygoid implants using TTPHIL-ALL TILT ® in partially edentulous and completely edentulous maxilla. # II. # Case Report # Case 1: Partially Edentulous Maxillary Arch (Immediate Implantation) A 42-year-old male patient reported with a chief complaint of loose teeth in the upper left back region of the jaw. Clinical examination revealed Grade II mobility about tooth 27, gingival recession, missing 26, and poor oral hygiene status. (Fig: 1 a, b) The patient was willing to go ahead with a fixed prosthesis for the same region. TTPHIL-ALL TILT ® technique was planned for the same; a thorough radiographic evaluation was suggested to the patient. These studies included panoramic films, CBCT, and stereolithography models. The mouth other techniques like sinus lifts or bone grafts 6,7 , increased implant diameters or short implant of 8mm or a. b. # Discussion Treatment of edentulous patients has always been a challenging task for the dentists. In the modern era, implant dentistry gained popularity and considered as the best alternative, irrespective of resorbed bone, reduced bone density in the maxillary posterior regions and systemic conditions. Krump et al and Barnett et In the literature, several articles have assigned many labels for implant placement in the posterior maxillary region. Implants placed in the posterior maxilla have been discussed as pterygoid plate implants 11 , tuberosity implants [15][16] , and pterygomaxillary implants 17 . The structures that offer support for implant placement are the tuberosity of the maxillary bone, the pyramidal process of the palatine bone, and the pterygoid process of the sphenoid bone 18 . Conventionally, because of the anatomic factors and biomechanical factors 19 , the success rates for implants placed in the atrophic posterior maxilla was lower than that for other locations. In literature, few studies were carried out on pterygoid implants for the survival of implant and prosthesis. Bahat 15 performed a study on 45 patients, 72 implants were engaged in the tuberosity region, and they noted 93% survival rate over an average loading time of 1.7 years. Balshi 16 reported satisfactory 3-year results for 51 implants placed in the pterygoid area supported fixed prostheses in partially edentulous patients. Khayat et al 20 reported on cases of implants placed in the pterygoid region with four years of follow up. Graves 11 described forty-three implants in the pterygoid plate area. The subcrestal implant placement decreases the stress in the crestal cortical bone around dental implants. Flapless guided implant placement helps in mucointegration, good aesthetics, reduces the time of treatment, and improves patient satisfaction. Nowadays, practice-driven implantology has been evolved the dimensions (lengths 15-25mm) of implants. 28 Multi-unit abutments, and their components help dentists to correct the angulations caused by the tilted implant. 29 This aids in immediate loading of the fixed prosthesis. 30 IV. # Conclusion Based on the outcomes of the case reports, Immediate/Delayed implant placement with immediate loading is considered as a feasible treatment option for the patients with the severely atrophic maxilla. The TTPHIL-ALL TILT ® technique considered as a graftless solution which is characterized by Tall, tilted implant with bicortical engagement, minimal invasiveness (flapless approach), screw-retained prosthetic solutions with rigid cross arch stabilization with no cantileverage can be delivered in 2-5 days. However, this technique is highly sensitive and requires experts in implant dentistry for its execution. Careful selection of patients, thorough radiographic evaluation, proper treatment planning, and adequate follow-up of surgical and prosthetic protocols are the keys to success. TTPHIL-ALL TILT ® (Tall Tilted Pin Hole Immediate Loading) technique [21][22][23][24][25] was evolved after studying and analyzing all the advantages and shortcomings of other traditional and advanced techniques. Using this concept two tall tilted implants engaged the pterygoid region (junction of the palatine process of maxilla, the pyramidal process of palatine bone and pterygoid process of the sphenoid bone), thus eliminating distal cantilever, avoiding sinus encroachment and other augmentation procedures in the posterior maxilla. Tilting of implants avoids anatomical structures like the maxillary sinus. In literature, many studies were carried out on tilted implants, the success rates were found to be 95.7 to 100% 26 , which have been improved by bicortical engagement. Tall implants with bicortical engagement offer primary stability which improves implant success. 27 1![Fig. 1 a and b: Intra-oral view showing gingival recession with 27, missing 26](image-2.png "Fig. 1 a") 2![Fig. 2 a: Clinical photograph showing two implant placements (26, 28) in left maxillary region](image-3.png "Fig. 2 a") 2![Fig. 2 c: Final Metal-ceramic prosthesis was given](image-4.png "Fig. 2 c") 3![Fig. 3 a: Intra-oral view shows missing posterior maxillary teeth and badly decayed upper front teeth](image-5.png "Fig. 3 a") 5![Fig. 5 c: Pre-operative OPG showing severe bone loss and inadequate bone in maxillary sinus region](image-6.png "Fig. 5 c") © 2019 Global Journals * Immediate dental implant placement with immediate loading following extraction of natural teeth MSingh LKumar MAnwar PChand Natl J Maxillofac Surg 6 2015 * Albrektsson al reported higher success rates for immediate implant placement ULekholm GZarb Bra°nemark PI, Zarb G 13 14 1985 Patient selection and preparation * Tissue-integrated protheses Osseointegration in clinical dentistry Quintessence, Chicago * Analysis of 356 pterygomaxillary implants in edentulous arches for fixed prosthesis anchorage T JBalshi G JWolfinger S FBalshi Ii Int J Oral Maxillofac Implants 14 1999 * The excessive loss of Branemark fixtures in type IV bone: a 5-year analysis R AJaffin CBerman J Periodontol 62 1991 * Implant Rehabilitation For Atrophic Maxilla: A Review S AAli SKarthigeyan MDeivanai AKumar J Indian Prosthodont Soc 14 3 2014 * The applicability of osseointegrated oral implants in the rehabilitation of partial edentulism: a prospective multicenter study on 558 fixtures DVan Steenberghe ULekholm CBolender Int J Oral Maxillofac Implants 5 1990 * Implants and sinus-inlay bone grafts in a one-stage procedure on severely atrophied maxillae: surgical aspects of a 3-year follow-up study BJohansson KWannfors JEkenba¨ck J ISmedberg JHirsch Int J Oral Maxillofac Implants 14 1999 * Prospective study of treatment of severely resorbed maxillae with narrow nonsubmerged implants: results after one year of loading MHallmann Int Oral Maxillofac Implants 16 2001 * Implants in anatomical buttresses of the upper jaw MSorn?´ JGuarinos MPen?arrocha Med Oral Patol Oral Cir Bucal 10 2005 * Implants in the Pterygoid Region: A Systematic Review of the Literature ASBidra BGHuynh Int J Oral Maxillofac Surg 40 2011 * The Pterygoid Plate Implant: A Solution for Restoring the Posterior Maxilla SLGraves Int J Periodont Rest Dent 14 1994 * Treatment of the Complete Edentulous Atrophic Maxilla: The Tall Tilted Pin Hole Placement Immediate Loading (TTPHIL)-ALL TILT? Implant Option PvrNag VDhara J Contemp Dent Pract 20 6 2019 * The immediate implant: A treatment alternative J LKrump BBarnett Int J Oral Maxillofac Implants 6 1991 * Immediate dental implant placement with immediate loading following extraction of natural teeth MSingh LKumar MAnwar PChand Natl J Maxillofac Surg 6 2015 * Osseointegrated implants in the maxillary tuberosity: report on 45 consecutive cases OBahat Int J Oral Maxillofac Implants 7 1992 * Single tuberosity osseointegrated implant support for a tissue integrated prosthesis TBalshi Int J Periodont Restor Dent 12 1992 * The use of pterygomaxillary implants in the partially edentulous patient T JBalshi HyLHernandez R Int J Oral Maxillofac Implants 10 1995 * An atlas of anatomy JcbGrant 1956 Williams & Wilkins 541 Baltimore * Pterygomaxillary Implants: A Graftless Solution to Deficient Maxillary Bone G NAnandakrishna GRao J Indian Prosthodont Soc 12 3 2012 * The use of osseointegrated implants in the maxillary tuberosity PKhayat NNader Pract Periodontics Aesthet Dent 6 1994 * Venkat Ratna Nag P. Immediate Implant Placement and Loading with Tall and Tilted Pinhole Immediate Loading (TTPHIL) Technique Guident Sep 2017 * TTPHIL-ALL TILT TM Concept -An Innovative Technique in Immediate Functional Loading Implant Placement in Maxilla VenkatNag PSarika PPavankumar A Scholars Journal of Dental Sciences 4 9 2017 * Tall and tilted pin hole immediately loaded implants (TTPHIL) technique for maxillary arch rehabilitation VenkatNag PSarika PKhan RBhagwatkar T International Journal of Research and Review 5 2018 * Immediate implantation and loading in just two days with TTPHIL technique using CAD/CAM Prosthesis VenkatNag PSarika PKhan RBhagwatkar T International Journal of Applied Dental Sciences 4 3 2018 * Tilted Implant Placement for Rehabilitation of Severe Atrophic Maxilla Supported by Finite Element Analysis Venkat Ratna Nag PSarika TBhagwatkar VDhara The Journal of Implant & Advanced Clinical Dentistry 11 1 2019 * Rehabilitation of the Atrophic Maxilla with Tilted Implants: Review of the Literature O DPenarrocha M ECandel A JAta Journal of Oral Implantology 38 5 2013 * Comparison of initial implant stability of implants placed using bicortical fixation, Indirect sinus elevation, and unicortical fixation. Int J of Oral Max Implants HAndrea SWook-Jin WRyan 2016 31 * Biomechanical evaluation of subcrestal dental implants with different bone anchorages BrunoSalles S M CamilaDe Andrade L PlinioMendes S Braz Oral Res 28 1 2014 * Tilted Implant Concept for Full Mouth Immediate Loading Restoration A VSingh SSingh Int J Oral Implantol Clin Res 5 1 2014 * Pterygoid Implant: Option for Rehabilitation of the Atrophic Posterior Maxilla PvrNag PSarika TBhagwatkar VDhara ID: 011218 Int J Contemp Dent Med Rev 2019 2019