BASIC INFORMATION ON THE SURGICAL PROCEDURES. Straumann Dental Implant System

Transcription

1 BASIC INFORMATION ON THE SURGICAL PROCEDURES Straumann Dental Imlant System

2 Straumann is industrial artner of the ITI (International Team for Imlantology) in the areas of research, develoment and education.

3 CONTENTS About this guide 2 1. The Straumann Dental Imlant System Overview Imlant lines Straumann Standard Imlant Straumann Standard Plus Imlant Straumann Taered Effect Imlant Straumann Bone Level Imlant Imlant-abutment connections Straumann synocta Morse taer connection Straumann Narrow Neck Connection Straumann Bone Level CrossFit Connection Surfaces Straumann SLActive Straumann SLA 9 2. Indications and Contraindications Indications Secific indications for small diameter (Ø 3,3 mm) imlants Secific indications for Straumann imlants with a length of 6 mm Contraindications Relative contraindications Local contraindications Imlant secific indications Preoerative Planning Imlant osition Mesiodistal imlant osition Examles for single tooth gas Examles of multile tooth gas Orofacial imlant osition Coronoaical imlant osition Planning aids Mesiodistal and orofacial sace requirements Diagnostic T for Straumann Standard, Standard Plus, and Taered Effect imlants Straumann Imlant Distance Indicator Determining the vertical bone availability X-ray reference shere X-ray temlates Surgical drill temlate Vacuum-formed drill temlate Thermolastic drill temlate Surgical Procedures Imlant bed rearation Basic imlant bed rearation Fine imlant bed rearation Examles for fine imlant bed rearation Oening the imlant ackage Placing the imlant Soft tissue management Submucosal healing Transmucosal healing Healing Phase Healing hase duration Straumann SLActive and SLA in comarison Additional Information on Instruments Surgical instruments Deth marks on Straumann instruments Single-atient ilot and twist drills Straumann Drill Sto Straumann Surgical Cassette Ratchet Holding key SCS screwdrivers Osteotomes Instrument set for bone condensation Instrument set for transalveolar sinus floor elevation Deth stos for osteotomes Cleaning and care of instruments Aendix Labeling and color coding of the Straumann Dental Imlant System Related documentation Imortant notes Index 73

4 ABOUT THIS GUIDE Basic Information on the Surgical Procedures for the Straumann Dental Imlant System rovides dental ractitioners and related secialists with the essential stes regarding surgical treatment, lanning, and rocedure. The manual is divided into the following main arts: The Straumann Dental Imlant System Indications and Contraindications Preoerative Planning Surgical Procedures Healing Phase Additional Information on Instruments Aendix Index For further information regarding the Straumann Dental Imlant System, visit our comrehensive website at 2

5 1. THE STRAUMANN DENTAL IMPLANT SYSTEM 1.1 Overview The Straumann Dental Imlant System offers four imlant lines with diverse body and neck designs, ranging from the classic soft tissue level to the bone level imlant. All imlants can be laced with one surgical kit while using very similar surgical rocedures. Straumann imlants have been extensively researched. Their otimized design, called Bone Control Design, is based on the five key biological rinciles in imlant dentistry: osseoconductivity of the imlant surface, control of the microga, biomechanical imlant design, biological distance, and the location of the surface margin. With the Bone Control Design, Straumann imlants hel to achieve otimal reservation of crestal bone and soft tissue stability. S SP TE BL 2,8 mm 1,8 mm Straumann Standard Imlant (S) Straumann Standard Plus Imlant (SP) Straumann Taered Effect Imlant (TE) Straumann Bone Level Imlant (BL) The classic soft tissue level imlant The imlant for flexible lacement The imlant for immediate lacement Straumann exertise alied at bone level Straumann dental imlants are available in three endosteal diameters: Ø 3,3 mm, Ø 4,1 mm, and Ø 4,8 mm. A unified color code simlifies identification of instruments and imlants. Color coding yellow red green Endosteal imlant diameter 3,3 mm Endosteal imlant diameter 4,1 mm Endosteal imlant diameter 4,8 mm 1. The Straumann Dental Imlant System 1.1 Overview 3

6 Imlant overview Neck diameter Straumann Standard Imlant Straumann Standard Plu S Ø 3.3 RN S Ø 4.1 RN S Ø 4.8 RN S Ø 4.8 WN SP Ø 3.3 NN SP Ø 3.3 RN SP Ø 4.1 RN Ø 4,8 mm Ø 4,8 mm Ø 4,8 mm Ø 6,5 mm Ø 3,5 mm Ø 4,8 mm Ø 4,8 mm 2,8 mm Endosteal diameter Ø 3,3 mm Ø 4,1 mm Ø 4,8 mm Ø 4,8 mm Ø 3,3 mm Ø 3,3 mm Ø 4,1 mm 6 mm S S S S SLA SLActive 8 mm S S S S S S S 10 mm S S S S S S S 12 mm S S S S S S S 14 mm S S S S S S 16 mm S S 6 mm S S S S 8 mm S S S S S S S 10 mm S S S S S S S 12 mm S S S S S S S 14 mm S S S S S S 16 mm S S Connection RN RN RN WN NN RN RN Prosthetic restoration comonents RN synocta RN Solid Abutment RN synocta RN Solid Abutment Retentive Anchor RN synocta RN Solid Abutment Retentive Anchor WN synocta WN Solid Abutment NN RN synocta RN Solid Abutment RN synocta RN Solid Abutment Retentive Anchor steco steco steco Titanmagnetics Titanmagnetics Titanmagnetics LOCATOR LOCATOR LOCATOR 4 1. The Straumann Dental Imlant System 1.1 Overview

7 s Imlant Straumann Taered Effect Imlant Straumann Bone Level Imlant SP Ø 4.8 RN SP Ø 4.8 WN TE Ø 3.3 RN TE Ø 4.1 RN TE Ø 4.8 WN BL Ø 3.3 NC BL Ø 4.1 RC BL Ø 4.8 RC Ø 4,8 mm Ø 6,5 mm Ø 4,8 mm Ø 4,8 mm Ø 6,5 mm Ø 3,3 mm Ø 4,1 mm Ø 4,8 mm 1,8 mm 1,8 mm Ø 4,8 mm Ø 4,8 mm Ø 3,3 mm Ø 4,1 mm Ø 4,8 mm Ø 3,3 mm Ø 4,1 mm Ø 4,8 mm S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S RN WN RN RN WN NC RC RC RN synocta WN synocta RN synocta RN synocta WN synocta NC CrossFit RC CrossFit RC CrossFit RN Solid Abutment WN Solid Abutment RN Solid Abutment RN Solid Abutment WN Solid Abutment Retentive Anchor Retentive Anchor Retentive Anchor steco steco steco Titanmagnetics Titanmagnetics Titanmagnetics LOCATOR LOCATOR LOCATOR 1. The Straumann Dental Imlant System 1.1 Overview 5

8 1.2 Imlant lines Straumann Standard Imlant The classic soft tissue level imlant Straumann Standard imlants have a smooth neck section of 2,8 mm and are esecially suitable for classic singlestage rocedures, where the imlant is laced at soft tissue level and not covered with soft tissue during the healing hase. The Standard Imlant uses the Straumann synocta connection together with its corresonding rosthetic comonents, the Straumann synocta ortfolio and the Straumann Solid Abutment. The thread itch on the Standard imlants measures 1 mm for the Ø 3,3 mm imlants, and 1,25 mm for all other diameters Straumann Taered Effect Imlant The imlant for immediate lacement Straumann Taered Effect imlants have a secial anatomical design, which combines a cylindrical shae in its aical region and a conical shae in the coronal region, making this imlant articularly suitable for immediate or early imlantation following extraction or loss of natural teeth. With the smooth neck section of 1,8 mm, healing can occur trans- or subgingivally. Taered Effect imlants have a Straumann synocta connection. Hence, the rosthetic comonents of the Straumann synocta ortfolio and the Straumann Solid Abutment can be used. The thread itch of 0,8 mm rovides excellent rimary stability Straumann Standard Plus Imlant The imlant for flexible lacement Straumann Standard Plus imlants have a shorter smooth neck section of 1,8 mm that allows flexible coronoaical imlant lacement in combination with trans- or subgingival healing. This offers the dental surgeon additional otions that are articularly useful in the anterior tooth region of the maxilla, where esthetic demands are high. Similar to Straumann Standard imlants, this imlant tye uses the Straumann synocta connection together with its corresonding rosthetic comonents, the Straumann synocta ortfolio and the Straumann Solid Abutment. The thread itch on the Standard Plus imlants measures 1 mm for the Ø 3,3 mm imlants, and 1,25 mm for all other diameters Straumann Bone Level Imlant Straumann exertise alied at bone level Straumann Bone Level imlants are suitable for bone level treatments in combination with trans- or subgingival healing. The imlant s rough surface extends to the to of the imlant and the connection is shifted inwards. The Bone Level Imlant uses a conical-cylindrical connection, the CrossFit Connection, together with its corresonding rosthetic CrossFit comonents from the Bone Level roduct ortfolio. A cylindrical outer contour and a thread itch of 0,8 mm, that taers off in the coronal art of the imlant, rovide excellent rimary stability. The Straumann Standard Plus Narrow Neck imlants can be used as an alternative for narrow interdental saces. They are very flexible for indications where esthetic demands are high. This one-iece design imlant has an external connection with a shoulder diameter of 3,5 mm, an endosteal diameter of 3,3 mm, and a smooth neck section of 1,8 mm. Narrow neck imlants use their rorietary narrow neck (NN) rosthetic comonents. The imlant has a thread itch of 1 mm The Straumann Dental Imlant System 1.2 Imlant lines

9 1.3 Imlant-abutment connections Straumann synocta Morse taer connection The Straumann synocta Morse taer connection was introduced as a design rincile for the Straumann Dental Imlant System in The mechanically locking friction fit of the Straumann synocta internal connection, with an 8 cone and an octagon for the reositioning of rosthetic arts, shows imroved erformance over traditional external connections. Abutment loosening, even in screwretained situations, has virtually been eliminated. The Straumann synocta connection is available for all Straumann Standard, Standard Plus, and Taered Effect imlants with the Regular Neck (RN) and Wide Neck (WN) latform Straumann Narrow Neck connection Straumann Standard Plus Narrow Neck imlants have an external connection based on an octagon. Its design is secifically otimized for strength and makes the Straumann Narrow Neck Imlant one of the most stable small diameter imlants on the market. The Narrow Neck connection can be used only with rorietary narrow neck (NN) rosthetic comonents. The Narrow Neck connection is available for Straumann Standard Plus Narrow Neck imlants only. 1. The Straumann Dental Imlant System 1.3 Imlant-abutment connections 7

10 1.3.3 Straumann Bone Level CrossFit Connection The CrossFit Connection of Straumann Bone Level imlants alies the know-how and benefits from the Straumann synocta Morse taer connection to the connection requirements at bone level. Similar to the Straumann synocta connection, the mechanically locking friction fit of the 15 conicalcylindrical CrossFit Connection with four internal grooves has excellent long-term stability under all loading conditions and virtually eliminates screw loosening. The CrossFit Connection is available for Straumann Bone Level imlants only. NC RC Straumann Bone Level Ø 4,1 mm and Ø 4,8 mm imlants have the same connection, the regular CrossFit Connection (RC), and share the same secondary comonents. Straumann Bone Level Ø 3,3 mm imlants feature the narrow CrossFit Connection (NC). The corresonding secondary comonents are colorcoded: yellow = NC connection magenta = RC connection Ø 3,3 mm Ø 4,1 mm Ø 4,8 mm 8 1. The Straumann Dental Imlant System 1.3 Imlant-abutment connections

11 1.4 Surfaces Straumann imlants are manufactured from biocomatible ure Grade 4 titanium. All dental imlants are rovided with the SLActive or the SLA surfaces Straumann SLActive The SLActive surface features the scientifically roven SLA surface toograhy. Additionally, it exhibits fundamentally imroved surface roerties such as hydrohilicity and chemical activity which significantly accelerate the entire osseointegration rocess. Hydrohilicity The hydrohilic roerties of SLActive enable a larger accessible surface area for increased blood contact and bone cell attachment. Straumann SLActive surface innovation Proven SLA surface toograhy Hydrohilicity for a larger accessible surface area Chemical activity romoting faster osseointegration Chemical activity The chemical activity of SLActive rovides ideal conditions for direct rotein adsortion, stimulating immediate new bone formation Straumann SLA The SLA surface is roduced using a large-grit sandblasting technique that generates a macro-roughness on the titanium surface. This is followed by acid-etching that sueroses a micro-roughness. The resulting toograhy offers the ideal structure for cell attachment and is also the basis for the further develoed SLActive surface. 1. The Straumann Dental Imlant System 1.4 Surfaces 9

12 2. INDICATIONS AND CONTRAINDICATIONS 2.1 Indications Straumann dental imlants are suitable for the treatment of oral endosteal imlantation in the uer and lower jaw and for the functional and esthetic oral rehabilitation of edentulous and artially dentate atients (unless secific indications and limitations are resent, as stated below). Straumann dental imlants can also be used for immediate or early imlantation following extraction or loss of natural teeth. Straumann imlants are aroved, within the scoe of indications, for immediate restoration in single tooth gas and in an edentulous or artially dentate jaw. Good rimary stability and an aroriate occlusal load are essential. Two or more adjacent imlants should be rosthetically connected together if restored immediately. In the case of immediately restored edentulous indications, at least 4 imlants must be connected together. Healing hase duration for delayed restorations is given on age 57. The rosthetic restorations used are single crowns, bridges and artial or full dentures, which are connected to the imlants by the corresonding elements (abutments). On age 11, ff. you find imlant secific details about indications, the necessary bone volume and the sacing between imlants and the distance from adjacent teeth Secific indications for small diameter (Ø 3,3 mm) imlants As a general rule, always use the largest ossible imlant diameter. Because of their reduced mechanical stability, small diameter imlants are used only in cases with a low mechanical load. Placement in the molar region is not recommendable. For further restrictions see age 11, ff. 2.2 Contraindications Serious internal medical roblems, bone metabolism disturbances, uncontrolled bleeding disorders, inadequate wound healing caacity, oor oral hygiene, maxillary and mandibular growth not comleted, oor general state of health, uncooerative, unmotivated atient, drug or alcohol abuse, sychoses, rolonged theray-resistant functional disorders, xerostomia, weakened immune system, illnesses requiring eriodic use of steroids, titanium allergy, uncontrollable endocrine disorders Relative contraindications Previously irradiated bone, diabetes mellitus, anticoagulation drugs/hemorrhagic diatheses, bruxism, arafunctional habits, unfavorable anatomic bone conditions, tobacco abuse, uncontrolled eriodontitis, temoromandibular joint disorders, treatable athologic diseases of the jaw and changes in the oral mucosa, regnancy, inadequate oral hygiene Local contraindications Inadequate bone volume and/or quality, local root remnants. Attention should be aid to the secific indications of the small diameter imlants and the imlants with a length of 6 mm as secified above Secific indications for Straumann imlants with a length of 6 mm Because of the reduced surface area for anchorage in the bone, these imlants are to be used solely for the following indications: As an additional imlant together with longer imlants to suort imlant-borne reconstructions. As an auxiliary imlant for imlant-borne bar constructions suorting full dentures in a seriously atrohied mandible Indications and Contraindications 2.1 Indications 2.2 Contraindications

13 2.3 Imlant secific indications Secific indications for Straumann Standard and Standard Plus imlants Imlant tye Indications and distinctive features Minimal ridge width* Minimal ga width** SP Ø 3.3 mm NN Small diameter imlant for narrow interdental saces and ridges 5,5 mm 5,5 mm Caution Placement in the molar region is not recommended S Ø 3.3 mm RN SP Ø 3.3 mm RN An alternative in the case of a restricted ridge width In view of their lower mechanical strength comared to the Ø 4,1 mm imlants, these imlants should be used exclusively for the following indications: Edentulous jaw: 4 imlants S/SP Ø 3,3 RN in conjunction with a bar construction Partially edentulous jaw: In the case of fixed reconstruction, combined with Ø 4,1 mm imlants and slinted with a suerstructure 5,5 mm 7 mm S Ø 4.1 mm RN For oral endosteal imlant indications in the maxilla and 6 mm 7 mm mandible, for functional and esthetic rehabilitation of edentulous and artially edentulous atients SP Ø 4.1 mm RN S = S tandard SP = S tandard P lus NN = N arrow N eck Ø 3,5 mm RN = R egular N eck Ø 4,8 mm cont. * Minimal ridge width: Minimal orofacial ridge width, rounded off to 0,5 mm ** Minimal ga width: Minimal mesial-distal ga width for a single tooth restoration, between adjacent teeth, rounded off to 0,5 mm 2. Indications and Contraindications 2.3 Imlant secific indications 11

14 Secific indications for Straumann Standard and Standard Plus imlants, cont. Imlant tye Indications and distinctive features Minimal ridge width* Minimal ga width** S Ø 4.8 mm RN SP Ø 4.8 mm RN For oral endosteal imlant indications in the maxilla and mandible, for functional and esthetic rehabilitation of edentulous and artially edentulous atients The S/SP Ø 4,8 mm imlants are esecially suited for wider interdental saces and ridges 7 mm 7 mm S Ø 4.8 mm WN SP Ø 4.8 mm WN For oral endosteal imlant indications in the maxilla and mandible, for functional and esthetic rehabilitation of edentulous and artially edentulous atients The S/SP Ø 4,8 mm imlants are esecially suited for wider interdental saces and ridges S/SP imlants with a WN latform are designed for the reconstruction of teeth with a greater neck diameter 7 mm 8,5 mm S = S tandard SP = S tandard P lus RN = R egular N eck Ø 4,8 mm WN = W ide N eck Ø 6,5 mm * Minimal ridge width: Minimal orofacial ridge width, rounded off to 0,5 mm ** Minimal ga width: Minimal mesial-distal ga width for a single tooth restoration, between adjacent teeth, rounded off to 0,5 mm Indications and Contraindications 2.3 Imlant secific indications

15 Secific indications for Straumann Taered Effect imlants Imlant tye Indications and distinctive features Minimal ridge width* Minimal ga width** TE Ø 3.3 mm RN For oral endosteal imlant indications in the maxilla and mandible, for functional and esthetic rehabilitation of edentulous and artially edentulous atients Alternative in dental gas where the roots of adjacent teeth are close together, where imlants with a greater endosteal diameter are contraindicated 7 mm 7 mm TE Ø 4.1 mm RN For oral endosteal imlant indications in the maxilla and mandible, 7 mm 7 mm for functional and esthetic rehabilitation of edentulous and artially edentulous atients TE Ø 4.8 mm WN For oral endosteal imlant indications in the maxilla and mandible, for functional and esthetic rehabilitation of edentulous and artially edentulous atients The TE Ø 4,8 mm imlants are esecially suited for wider interdental saces and ridges 8,5 mm 8,5 mm TE = T aered E ffect RN = R egular N eck Ø 4,8 mm WN = W ide N eck Ø 6,5 mm * Minimal ridge width: Minimal orofacial ridge width between adjacent teeth, rounded off to 0,5 mm ** Minimal ga width: Minimal mesial-distal ga width for a single tooth restoration, between adjacent teeth, rounded off to 0,5 mm 2. Indications and Contraindications 2.3 Imlant secific indications 13

16 Secific indications for Straumann Bone Level imlants Imlant tye Indications and distinctive features Minimal ridge width* Minimal ga width** BL Ø 3.3 mm NC Small diameter imlant for narrow interdental saces and 5,5 mm 5,5 mm ridges Caution Placement in the molar region is not recommended BL Ø 4.1 mm RC For oral endosteal imlant indications in the maxilla and mandible, 6 mm 6 mm for functional and esthetic rehabilitation of edentulous and artially edentulous atients BL Ø 4.8 mm RC For oral endosteal imlant indications in the maxilla and mandible, for functional and esthetic rehabilitation of edentulous and artially edentulous atients The BL Ø 4,8 mm imlants are esecially suited for wider interdental saces and ridges 7 mm 7 mm BL = B one L evel NC = N arrow C rossfit RC = R egular C rossfit * Minimal ridge width: Minimal orofacial ridge width, rounded off to 0,5 mm ** Minimal ga width: Minimal mesial-distal ga width for a single tooth restoration, between adjacent teeth, rounded off to 0,5 mm Indications and Contraindications 2.3 Imlant secific indications

17 3. PREOPERATIVE PLANNING 3.1 Imlant osition The imlant is the focal oint of the restoration. It rovides the basis for lanning the surgical rocedure. Close communication between the atient, dentist, surgeon and dental technician is imerative for achieving the desired rosthetic result. To establish the toograhical situation, the axial orientation and the choice of imlants, we recommend the following: Make a wax-u/set-u on the reviously reared study cast. Define the tye of suerstructure. The wax-u/set-u can later be used as the basis for a custom-made X-ray or drill temlate and for a temorary restoration. The imlant diameter, imlant tye, osition and number of imlants should be selected individually, taking the anatomy and satial circumstances (e.g. malositioned or inclined teeth) into account. The measurements given here should be regarded as minimum guidelines. Only when the minimum distances are observed is it ossible to design the restoration so that the necessary oral hygiene measures can be carried out. The final hard and soft tissue resonse is influenced by the osition between the imlant and the roosed restoration. Therefore, it should be based on the osition of the imlantabutment connection. The imlant osition can be viewed in three dimensions: Mesiodistal Orofacial Coronoaical Note The imlant abutments should always be loaded axially. Ideally, the long axis of the imlant is aligned with the cuss of the oosing tooth. Extreme cus formation should be avoided. It can lead to unhysiological loading. 3. Preoerative Planning 3.1 Imlant osition 15

18 3.1.1 Mesiodistal imlant osition The mesiodistal bone availability is an imortant factor for choosing the imlant tye and diameter as well as the interimlant distances in the case of multile imlants. The oint of reference on the imlant for measuring mesiodistal distances is always the shoulder, being the most voluminous art of the imlant. Note that all distances given in this chater are rounded off to 0,5 mm. The following basic rules must be alied: Rule 1 Distance to adjacent tooth at bone level: A minimal distance of 1,5 mm from the imlant shoulder to the adjacent tooth at bone level (mesial and distal) is required. S/SP imlants TE imlants BL imlants 1,5 mm 1,5 mm 1,5 mm Rule 2 Distance to adjacent imlants at bone level: A minimal distance of 3 mm between two adjacent imlant shoulders (mesiodistal) is required. S/SP imlants TE imlants BL imlants 3 mm 3 mm 3 mm Preoerative Planning 3.1 Imlant osition

19 Examles for single tooth gas For single tooth restoration, the imlant is laced centered within the single tooth ga. The following examles show how rule 1 is imlemented. Straumann Standard, Standard Plus, and Taered Effect imlants For Straumann soft tissue level imlants, the ga size has to be considered for the selection of the shoulder diameter (NN, RN, WN). In order to make use of the ga width in conjunction with rule 1, the following aroximation can be used. Distance between adjacent teeth at bone level 0,5 mm Ga width 0,5 mm The distance between adjacent teeth at bone level is aroximately 1 mm (2 x 0,5 mm) more than the ga width. Hence, alying rule 1, the ga width must be 2 mm wider than the imlant shoulder. 3. Preoerative Planning 3.1 Imlant osition 17

20 S/SP/TE imlants Shoulder diameter D (mm) Ga width a min (mm) Distance between adjacent teeth at bone level b min (mm) b Ø 3,5 (NN) 5,5 6,5 a D Ø 4,8 (RN) 7 8 Ø 6,5 (WN) 8,5 9,5 Rule D + 2 mm D + 3 mm* 1,5 mm 1,5 mm *Rule 1 alied on both imlant sides The Diagnostic T (see age 23), alied in the atient s mouth or on the cast, can be used to obtain an initial measurement of the ga width for the choice of the imlant shoulder diameter and rosthetic reconstruction. Straumann Bone Level imlants For Straumann Bone Level imlants, the distance between adjacent teeth at bone level determines the imlant diameter. BL imlants Imlant diameter D (mm) Ga width a min (mm) Distance between adjacent teeth at bone level b min (mm) b BL Ø 3,3 5,5 6,5 a D BL Ø 4,1 6 7 BL Ø 4,8 7 8 Rule D + 2 mm D + 3 mm* 1,5 mm 1,5 mm *Rule 1 alied on both imlant sides Preoerative Planning 3.1 Imlant osition

21 Examles of multile tooth gas The following examles show how rules 1 and 2 are imlemented in multile tooth gas. The measurement is made at bone level from the adjacent tooth to the center of the imlant and between imlant centers. The minimal distance of 3 mm between two adjacent imlant shoulders (rule 2) is imortant to facilitate fla adatation, avoid roximity of secondary comonents and rovide adequate sace for maintenance and home-care. Straumann Standard, Standard Plus, and Taered Effect imlants S/SP/TE imlants Shoulder diameter D 1 (mm) Shoulder diameter D 2 (mm) a min (mm) b min (mm) c min (mm) L min (mm) L Ø 3,5 (NN) Ø 3,5 (NN) 3 6,5 3 12,5 a b c Ø 3,5 (NN) Ø 4,8 (RN) D 1 D 2 3 mm Ø 3,5 (NN) Ø 6,5 (WN) Ø 4,8 (RN) Ø 4,8 (RN) Ø 4,8 (RN) Ø 6,5 (WN) 4 8,5 5 17,5 1,5 mm 1,5 mm Ø 6,5 (WN) Ø 6,5 (WN) 5 9,5 5 19,5 Straumann Bone Level imlants BL imlants Imlant diameter D 1 (mm) Imlant diameter D 2 (mm) a min (mm) b min (mm) c min (mm) L min (mm) L BL Ø 3,3 BL Ø 3,3 3 6,5 3 12,5 a b c BL Ø 3,3 BL Ø 4, ,5 13,5 D 1 D 2 BL Ø 3,3 BL Ø 4, BL Ø 4,1 BL Ø 4,1 3,5 7 3,5 14 BL Ø 4,1 BL Ø 4,8 3,5 7, ,5 mm 3 mm 1,5 mm BL Ø 4,8 BL Ø 4,8 4 7,5 4 15,5 3. Preoerative Planning 3.1 Imlant osition 19

22 3.1.2 Orofacial imlant osition The facial and alatal bone layer must be at least 1 mm thick in order to ensure stable hard and soft tissue conditions. The minimal orofacial ridge widths for individual imlant tyes are given in the indication tables on age 11, ff. Within this limitation, a restoration-driven orofacial imlant osition and axis should be chosen such that screw retained restorations are ossible. Caution An augmentation rocedure is indicated, where the orofacial bone wall is less than 1 mm or a layer of bone is missing on one or more sides. This technique should be emloyed only by dentists who have adequate exerience in the use of augmentation rocedures. 1 mm Bone layer at least 1 mm in thickness 1 mm Choose the orofacial imlant osition and axis so that the screw channel of the screwretained restoration is located behind the incisial edge Preoerative Planning 3.1 Imlant osition

23 3.1.3 Coronoaical imlant osition Straumann dental imlants allow for flexible coronoaical imlant ositioning, deending on individual anatomy, imlant site, the tye of restoration lanned and reference. In the anterior area, a deeer coronoaical imlant osition is better for esthetic reasons. In this situation, the use of Straumann Standard Plus, Taered Effect or Bone Level imlants is recommended. The following illustration shows the coronoaical imlant osition for these imlants. 2,8 mm 1,8 mm Standard Standard Plus Taered Effect Bone Level Straumann Standard imlants Straumann Standard imlants with a smooth neck section of 2,8 mm are submerged in the bone as far as the margin of the SLA /SLActive surface. Straumann Standard Plus and Taered Effect imlants Straumann Standard Plus and Taered Effect imlants with a smooth neck section of 1,8 mm are submerged in the bone as far as the margin of the Straumann SLA/SLActive surface. Otionally they can be laced slightly deeer if necessary. Ideally, in the esthetic region, the imlant shoulder should be ositioned about 1 mm aical to the cemento-enamel junction (CEJ) of the contralateral tooth or 2 mm subgingival of the rosective gingival margin (see also references on age 22). Caution If a Straumann Standard Plus or a Taered Effect imlant is inserted deeer as the margin of the Straumann SLA/SLActive surface, the rearation deth must be increased accordingly (see also age 58). 3. Preoerative Planning 3.1 Imlant osition 21

24 Straumann Bone Level imlants Straumann Bone Level imlants are best set with the outer rim of the small 45 sloing edge (chamfer) at bone level. Ideally, in the esthetic region, the imlant shoulder should be ositioned about 3 4 mm subgingival of the rosective gingival margin (see also use of Bone Level transfer art on age 46). In a scalloed situation, lace the mesial/distal oint of the outer rim of the imlant to bone level. The lingual/alatinal wall will then extend slightly over the to line of the imlant. The buccal wall is located somewhat below the imlant edge. For further information regarding surgical rocedures in cases ertaining to esthetics, lease refer to the following scientific ublications: ITI Consensus Paer ITI Treatment Guide Buser D./ Martin W./ Belser U.: Otimizing esthetics for imlant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Imlants, 2004; 19 Sul: Buser D./ Martin W, Belser U.: Surgical considerations for single-tooth relacements in the esthetic zone: standard rocedure in sites without bone deficiencies. ITI Treatment Guide. Imlant Theray in the Esthetic Zone. Single- Tooth Relacements. 2007, Vol. 1; Quintessence Publishing Co. Ltd, Berlin Preoerative Planning 3.1 Imlant osition

25 3.2 Planning aids Mesiodistal and orofacial sace requirements Diagnostic T for Straumann Standard, Standard Plus, and Taered Effect imlants By using the Diagnostic T in the atient s mouth or on the cast, an initial imression of the satial relations for the choice of the imlant shoulder diameter and rosthetic reconstruction can be obtained. The ictograms on the instruments show which arm is used for which measurement. The use of additional lanning methods, such as the use of a drill temlate (see age 28), is recommended. Note Currently, a Diagnostic T for Straumann Bone Level imlants is not available. X = Minimum occlusal sace requirement (for the lowest rosthetic restoration otion) Y = Interroximal distance (ga width) Z = Imlant center to adjacent tooth ( 1 / 2 the ga width) Determining the imlant shoulder diameter in a single tooth ga Imlant shoulders: NN = Narrow Neck (Ø 3,5 mm) RN = Regular Neck (Ø 4,8 mm) WN = Wide Neck (Ø 6,5 mm) Determining the minimal distance between imlant axis and adjacent teeth Minimum vertical sace requirement for access with surgical instruments 3. Preoerative Planning 3.2 Planning aids 23

26 Straumann Imlant Distance Indicator Two tyes of distance indicators are available: For Straumann Standard, Standard Plus and Taered Effect imlants (Art. No ) For Straumann Bone Level imlants (Art. No ) The four discs of the imlant distance indicators dislay the shoulder diameters of Straumann imlants. The imlant distance indicators can be used to check the available sace before the start of treatment or intraoeratively to mark the desired imlant site. After fla oening and recise ositioning of the disc(s) at the lanned imlantation site, it is ossible to drill through the erforation in the disc(s) with the round bur Ø 1,4 mm (Art. No ) in order to mark the centre of the imlant bed. Intraoerative use of the distance indicator before fla oening Round bur Ø 1,4 mm Distance indicator for Straumann Standard, Standard Plus, and Taered Effect imlants Straumann Imlant Distance Indicator for Straumann Standard, Standard Plus and Taered Effect imlants (Art. No ) Leg label Disk diameter Corresonding imlants Leg 1 RN Ø 4,8 Ø 4,8 mm all Regular Neck (RN) imlants Leg 2 RN Ø 4,8 Ø 4,8 mm all Regular Neck (RN) imlants Leg 3 NN Ø 3,5 Ø 3,5 mm all Narrow Neck (NN) imlants Leg 4 WN Ø 6,5 Ø 6,5 mm all Wide Neck (WN) imlants Preoerative Planning 3.2 Planning aids

27 Distance Indicator for Straumann Bone Level imlants Straumann Imlant Distance Indicator for Straumann Bone Level imlants (Art. No ) Leg label Disk diameter Corresonding imlants Leg 1 BL Ø 4,1 Ø 4,1 mm Bone Level imlants Ø 4,1 mm Leg 2 BL Ø 4,1 Ø 4,1 mm Bone Level imlants Ø 4,1 mm Leg 3 BL Ø 3,3 Ø 3,3 mm Bone Level imlants Ø 3,3 mm Leg 4 BL Ø 4,8 Ø 4,8 mm Bone Level imlants Ø 4,8 mm Determining the vertical bone availability The vertical bone availability determines the maximal allowable length of the imlant that can be laced. To make it easier in determining the vertical bone availability, the use of an X-ray temlate with X-ray reference sheres is recommended X-ray reference shere The X-ray reference shere (Art. No V4) has a diameter of 5 mm. The image of the shere on the X-ray rovides the reference value for the magnification scale. To reare a reference shere carrying temlate, the selected imlant ositions are marked on the study cast. The X-ray reference sheres are fixed at the marked oints. The vacuum-formed temlate is then made with the sheres. The subsequent X-ray shows the vertical bone availability and mucosal thickness, from which the corresonding imlant length and tye can be derived, in consideration of the enlargement factor. 3. Preoerative Planning 3.2 Planning aids 25

28 X-ray temlates The X-ray temlates are used for measurement and comarison. They also assist the user in selecting the suitable imlant tye, diameter and length. The following X-ray temlates are available: ( V4) = Ø 5,0 mm S S Ø 3,3 mm Ø 4,1 mm RN RN S Ø 4,8 mm RN S Ø 4,8 mm WN SP Ø 3,3 mm NN SP Ø 3,3 mm RN SP Ø 4,1 mm RN SP Ø 4,8 mm RN SP Ø 4,8 mm WN For Straumann Standard and Standard Plus imlants (Art. No ) For Straumann Taered Effect imlants (Art. No ) For Straumann Bone Level imlants (Art No ) Similar to the distortions that occur in X-rays, the imlant dimensions are shown on the individual temlates with the corresonding distortion factors (1:1 to 1,7:1). Determining each magnification factor or scale is facilitated by showing the X-ray reference shere on the temlate (next to the scale reference). The first stage consists of comaring the size of the X-ray reference shere on the atient s X-ray with the size of the reference shere on the temlate. By suerimosing the two ictures, the correct scale can be found. Then, the satial relations around the imlant osition are determined and the imlant length and insertion deth are established. Examle: scale 1,1:1 = reference shere Ø 5,5 mm Taered Effect Imlant : : Taered Effect Imlant 1.1 : :1 Straumann Bone Level Imlant Straumann Bone Level Imlant S SP S Ø 3,3 mm RN = Straumann Standard imlant = Straumann Standard Plus imlant ( V4) = Ø 5,5 mm S Ø 4,1 mm RN ( V4) = Ø 5,0 mm Ø 3,3 mm Ø 4,1 mm RN RN ( V4) = Ø 5,5 mm Ø 3,3 mm Ø 4,1 mm RN RN ( V4) = Ø 5.0 mm ( V4) = Ø 5.5 mm S Ø 4,8 mm RN 0.4 mm NN = Narrow Neck (Ø 3,5 mm) RN S Ø 4,8 mm WN = Regular Neck (Ø 4,8 mm) max. 0,4 mm SP Ø 3,3 mm NN SP Ø 3,3 mm RN WN = Wide Neck SP Ø 4,1 mm RN SP Ø 4,8 mm RN ( V4) = Ø 6.0 mm Ø4.1 mm Ø4.8 mm Ø 3.3 mm Ø4.1 mm Ø4.8 mm Ø 3.3 mm ( V4) = Ø 6.5 mm (Ø 6,5 mm) X-ray temlate for Straumann Standard and Standard Plus imlants (Art. No ) Ø 4,8 mm WN Ø 4,8 mm WN Ø4.1 mm Ø4.8 mm Ø 3.3 mm Ø4.1 mm Ø4.8 mm Ø 3.3 mm Ø 3,3 mm RN Ø 3,3 mm RN RN = Regular Neck (Ø 4,8 mm) WN = Wide Neck (Ø 6,5 mm) Ø 4,1 mm RN Ø 4,1 mm RN X-ray temlate for Straumann Taered Effect imlants (Art. No ) X-ray temlate for Straumann Bone Level imlants (Art. No ) 0,4 mm Ø 4,8 mm WN Ø 4,8 mm WN SP Ø 4,8 mm WN :1 Straumann Bone Level Imlant :1 Straumann Bone Level Imlant / E / B / E Preoerative Planning 3.2 Planning aids

29 To calculate the effective bone availability the following formula should be used: X-ray reference shere 5 mm x bone availability (X-ray*) Reference shere diameter on the X-ray = effective bone availability * Taking into consideration all imlant-related anatomic structures (e.g. mandibular canal, sinus maxillaris, etc.) Examle for a measured bone availability and reference shere diameter on the X-ray of 13 mm and 6 mm (+ 20 % distortion), resectively. 5 mm x 13 mm 6 mm = 10,8 mm Additional length of the drill ti: max. 0.4 mm Note Due to the construction and function of the drills, the drill ti is a maximum of 0,4 mm longer than the imlant insertion deth. This additional length must be taken into consideration during the lanning hase. Additional length of the drill ti See also the section Measurement and analysis rocedure for oeration lanning in the DVD Straumann Dental Imlant System Surgical (Art. No ) 3. Preoerative Planning 3.2 Planning aids 27

30 3.2.3 Surgical drill temlate A custom-made drill temlate facilitates lanning and rearation of the imlant bed and enables recise use of the cutting instruments. The lanning basis for fabricating this temlate should be the desired rosthetic result Vacuum-formed drill temlate A conventional surgical drill temlate can be roduced with the vacuumformed temlate comonents. The 10 mm long metal in functions as the X-ray reference in. After the in is integrated into the temlate, the lanned imlant axis and osition become visible on the X-ray. The drill sleeve is then secured in a drill temlate. Note For verification, an X-ray with the drill temlate may also be taken. A Ø 2,2 mm ilot drill is then used for the subsequent drilling. For further information see Fabrication and use of an individual drill temlate (Art. No ), where two fabrication methods are shown gradually in a ste-by-ste Preoerative Planning 3.2 Planning aids

31 Thermolastic drill temlate 1. Drill a hole into the reviously determined imlant osition and in the laster anatomic cast on its axis. 2. Check the imlant osition by inserting the in into the drilled hole. 3. Heat the temlate in water until it is soft and transarent. 4. Place the temlate on the guide in and ress onto the laster teeth. After it has cooled off and has been disinfected, the thermolastic drill temlate determines exactly how the Ø 2,2 mm ilot drill is to be guided. Drill hole temlate for single tooth ga Drill hole temlate for free end saddle Note For more detailed information lease refer to the brochure The efficient aid for case lanning and imlant bed rearation: Thermolastic drill temlate (Art. No ). 3. Preoerative Planning 3.2 Planning aids 29

32 4. SURGICAL PROCEDURES 4.1 Imlant bed rearation Prearing the imlant bed is done using one surgical kit for all Straumann dental imlants and covers two main stes: Stes Influencing factors 1. Basic imlant bed rearation Ridge rearation Twist drilling Endosteal imlant diameter Basic imlant bed rearation involves ridge rearation and twist drilling. For twist drilling, the endosteal diameter of the imlant (3,3/4,1/4,8 mm), not the imlant tye or the bone class, determines the instrumentation used. 2. Fine imlant bed rearation Profile drilling Imlant tye and bone class Fine imlant bed rearation involves rofile drilling and taing. For taing, the imlant tye (S/SP/ TE/BL) and bone class determine the instrumentation used. Taing Before starting and during the surgical rocedure, the following oints must be considered: Check all instruments for comleteness and function. An adequate stock of imlants and sterile sare instruments should always be available. Do not use cutting instruments more than 10 times. The table Surgery Tracking Sheet for Straumann Cutting Instruments (Art. No ) facilitates tracking. Ensure amle cooling of drills with re-cooled (5 C, 41 F) hysiological sterile saline solution (NaCl) or Ringer s solution. Do not exceed the indicated seed for drills (see grahics and tables on age 31, ff.). Use drills in ascending order of their diameter. Use only light ressure and an intermittent drilling technique Surgical rocedures 4.1 Imlant bed rearation

33 Basic imlant bed rearation After oening the gingiva, the basic imlant bed rearation begins with rearing the alveolar ridge (Ste 1) and marking the imlantation site with a round bur (Ste 2). After that, the imlant bed rearation with ilot and twist drills follows (Ste 3 7), according to the endosteal imlant diameter chosen in the reoerative lanning (see Chater 3, age 15, ff.) rm max. Ste 1 Preare the alveolar ridge Carefully reduce and smooth a narrow taering ridge with a large round bur. This will rovide a flat bone surface and a sufficiently wide area of bone. Note When choosing the imlant length (SLActive/SLA surface), the vertical reduction of the bone has to be considered rm max. Ste 2 Mark the imlantation site Mark the imlantation site determined during the imlant osition lanning with the Ø 1,4 mm round bur. The imlant distance indicator can be used for that urose (see ages 24 and 25). Widen and correct the osition of the mark with the Ø 2,3 mm or the Ø 3,1 mm round bur, if necessary. 4. Surgical rocedures 4.1 Imlant bed rearation 31

34 3 800 rm max. Ste 3 Mark the imlant axis With the Ø 2,2 mm ilot drill, mark the imlant axis by drilling to a deth of about 6 mm. Insert the short side of the deth gauge with the distance indicator to check for correct imlant axis orientation. If necessary, correct unsatisfactory imlant axis orientation in the following ste. Note The distance indicator visualizes the shoulder diameter of 4,8 mm (RN) and enables checking of the robable osition of the imlant shoulder rm max. Ste 4 Preare the imlant bed to Ø 2,2 mm Pre-drill the imlant bed to the final rearation deth with the Ø 2,2 mm ilot drill. Use the Ø 2,2 mm alignment in to check the imlant axis and rearation deth. Caution At this oint take an X-ray, articularly with vertically reduced bone availability. The alignment in is inserted into the drilled area, which allows a comarative visualization of the drill hole in relation to the anatomical structures rm max. Ste 5 Widen the imlant bed to Ø 2,8 mm Continue with the imlant bed rearation. If necessary, correct the imlant osition with the Ø 2,8 mm ilot drill. Use the Ø 2,8 deth gauge to check the rearation deth. For an imlant with an endosteal diameter of 3,3 mm, basic rearation ends here. Continue with the fine imlant bed rearation on age Surgical rocedures 4.1 Imlant bed rearation

35 6 500 rm max. For Ø 4,1 mm and Ø 4,8 mm imlants Ste 6 Widen the imlant bed to Ø 3,5 mm Continue with the Ø 3,5 mm twist drill and check the final rearation deth with the Ø 3,5 mm deth gauge. For an imlant with an endosteal diameter of 4,1 mm, basic rearation ends here. Continue with the fine imlant bed rearation on age rm max. For Ø 4,8 mm imlants Ste 7 Widen the imlant bed to Ø 4,2 mm Continue with the Ø 4,2 mm Straumann Twist Drill PRO and check the final rearation deth with the Ø 4,2 mm deth gauge. Continue with the fine imlant bed rearation on age 35. Note To facilitate introducing the instruments into the bone cavity, the bony margin of the drill hole can be beveled slightly using a large round bur or with an SP rofile drill corresonding to the diameter of the last twist/siral drill emloyed. The rofile drills are inserted only a fraction into the drill hole. 4. Surgical rocedures 4.1 Imlant bed rearation 33

36 The following table summarizes the use of instruments for the basic imlant bed rearation according to the endosteal imlant diameter. All drills are available in a short and a long version and as multi-use as well as single-atient drills (see also Surgical Instruments on age 58). The table lists the short multi-use drills only. Instrumentation for basic imlant bed rearation Ste Art. No. Product max. rm Endosteal Ø (mm) Ø 3.3 Ø 4.1 Ø Preare ridge Round bur, Ø 3,1 mm Mark imlant osition Round bur, Ø 1,4 mm Round bur, Ø 2,3 mm Round bur, Ø 3,1 mm 3 Mark imlant axis Pilot drill 1, short, Ø 2,2 mm Deth gauge, with distance indicator, Ø 2,2/2,8 mm 4 Preare imlant bed to Ø 2,2 mm 5 Preare imlant bed to Ø 2,8 mm 6 Preare imlant bed to Ø 3,5 mm Pilot drill 1, short, Ø 2,2 mm Alignment in, Ø 2,2 mm, straight Pilot drill 2, short, Ø 2,8 mm Deth gauge, with distance indicator, Ø 2,2/2,8 mm Twist drill, short, Ø 3,5 mm Deth gauge Ø 3,5 mm Preare imlant bed to Ø 4,2 mm Twist drill PRO, short, Ø 4,2 mm Deth gauge Ø 4,8 mm Surgical rocedures 4.1 Imlant bed rearation

37 Fine imlant bed rearation The fine imlant bed rearation encomasses rofile drilling and subsequent taing. Instrumentation deends on the imlant tye, the endosteal imlant diameter, and the bone class. Profile drilling The rofile drill reares the imlant bed for a secific Straumann imlant. Straumann Standard Plus, Taered Effect, and Bone Level imlants require rofile drilling with secific instruments. This is indeendent of the bone class. Straumann Standard imlants are inserted without rofile drilling. The rofile drills are clearly marked SP, TE, or BL. The (first) diameter indicated on the label corresonds to the diameter of the guide cylinder and, accordingly, to the diameter of the imlant bed before rofile drilling. All Straumann rofile drills are available in a short and a long version. Straumann Standard Plus Profile Drill Straumann Taered Effect Profile Drill Straumann Bone Level Profile Drill Insertion deth on SLActive/SLA surface margin level Insertion deth on imlant shoulder Insertion deth on SLActive/SLA surface margin level Insertion deth on imlant shoulder Insert the Straumann Standard Plus Profile Drill according to the lanned insertion deth of the imlant. Insert the Straumann Taered Effect Profile Drill according to the lanned insertion deth of the imlant. Insert the Straumann Bone Level Profile Drill u to the lanned imlant shoulder level. A dent on the front of the guide cylinder makes the drills better distinguishable from Taered Effect rofile drills. 400 rm max. 300 rm max. 300 rm max. Note Due to the unflared neck ortion, the Straumann Standard Plus Ø 3,3 mm NN and Standard Plus Ø 4,8 mm RN imlants are inserted without rofile drilling. Caution The rofile drills are suitable only for the corresonding imlant tye! 4. Surgical rocedures 4.1 Imlant bed rearation 35

38 Taing Taing reares the imlant bed for a secific thread tye. It is an otional ste that gives the surgeon the flexibility to adjust the surgical rotocol to the bone class to hel achieve otimal rimary stability. It is recommended in dense bone and with large diameter imlants in order to kee the insertion torque in a desirable range. The table below summarizes suggested ta usage. Taing according to bone class S, SP imlants BL, TE imlants Bone Endosteal diameter Endosteal diameter Classes* Ø 3.3 mm Ø 4.1 mm Ø 4.8 mm Ø 3.3 mm Ø 4.1 mm Ø 4.8 mm Class 1 full full full full full full Class 2 coronal coronal full full full full Class 3 full full Class 4 full full *Class 1: hardest bone/class 4: soft bone coronal = thread taing in the coronal area of the imlant bed full = thread taing over full deth of the imlant bed Straumann Standard and Standard Plus tas Straumann Bone Level and Taered Effect tas Ta for ratchet Ta for adater Couling for ratchet Ta for adater Couling for adater Deth mark Couling for adater Label for imlant tye Deth mark Cutting head S/SP tas are used in the coronal area only or over the full deth of the imlant bed, deending on imlant diameter and bone class (see table above). The S/SP tas are available for adater and for ratchet. Two lengths are offered for the ratchet version. Cutting head If a BL/TE ta is used, it should always be inserted over the full deth of the imlant bed rearation (see table above). BL/TE tas are available for adater only. Caution Straumann tas are to be used only for the corresonding imlant tye! 15 rm max. 15 rm max Surgical rocedures 4.1 Imlant bed rearation