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

39 Two tyes of Straumann tas are available: tas for ratchet and tas for adater. The tas for ratchet are directly couled to the ratchet, and are for taing with ratchet only. The tas for adater can be couled either to a handiece or a ratchet adater and allow both, taing with the handiece or with the ratchet. Taing with handiece Connect the ta for adater to the handiece via the handiece adater. Do not exceed 15 rm. Taing with ratchet For taing with the ratchet use the ta for ratchet or connect a ratchet adater to the ta for adater. After inserting the ta into the cavity, the ratchet is laced on its couling and the thread is taed with a slow rotating movement. The holding key is used as a stabilizer to maintain the direction of taing during the rocedure. Handiece Handiece adater Ratchet Holding key Ratchet adater Ta for ratchet Ta for adater Ta for adater 4. Surgical rocedures 4.1 Imlant bed rearation 37

40 4.1.3 Examles for fine imlant bed rearation Straumann Standard and Standard Plus imlants rm max. Ste 1 Standard Plus rofile drill Shae the coronal art of the imlant bed with the Standard Plus rofile drill. Insert the Standard Plus rofile drill u to the lanned imlant shoulder level (see age 35). Note For Standard imlants, rofile drilling is not required rm max. Ste 2 Taing the thread in dense bone Pre-ta the imlant bed with the S/SP ta according to the bone class and the endosteal diameter (see table on age 36). Straumann Taered Effect imlants rm max. Ste 1 TE rofile drill Shae the coronal art of the imlant bed with the TE rofile drill. Insert the TE rofile drill u to the lanned imlant shoulder level (see age 35) Surgical rocedures 4.1 Imlant bed rearation

41 2 15 rm max. Ste 2 Taing the thread in dense bone Pre-ta the entire length of the imlant bed according to the bone class and the endosteal diameter (see table on age 36) with the BL/TE ta. Straumann Bone Level imlants The following examle shows fine imlant bed rearation for a Ø 4,1 mm Bone Level Imlant of 12 mm of length laced in bone class 1 or 2, making re-taing necessary (see table on age 36). These stes follow the basic imlant bed rearation (see ages 32 and 33) rm max. Ste 1 Bone Level rofile drill Preare the imlant bed with the Straumann Bone Level rofile drill. Insert the rofile drill u to the lanned imlant shoulder level (see age 35) rm max. Ste 2 Taing the thread in dense bone Pre-ta the entire length of the imlant bed with the BL/TE ta. 4. Surgical rocedures 4.1 Imlant bed rearation 39

42 The following table summarizes the use of rofile drills and tas for the fine imlant bed rearation for all Straumann imlants. All rofile drills are available in a short and a long version. S/SP tas are available for ratchet and for adater. The table lists the short rofile drills, and the tas for adater only. Instrumentation for fine imlant bed rearation Straumann Standard Imlant Art. No. Product Max. rm Thread itch S Ø 3.3 RN S Ø 4.1 RN S Ø 4.8 RN SP Profile drill, short, Ø 2,8 mm, RN SP Profile drill, short, Ø 3,5 mm, RN SP Profile drill, short, Ø 4,2 mm, WN S/SP Ta, Ø 3,3 mm, for adater S/SP Ta, Ø 4,1 mm, for adater 15 1, S/SP Ta, Ø 4,8 mm, for adater 1, TE Profile drill, short, Ø 2,8 mm RN TE Profile drill, short, Ø 3,5 mm RN TE Profile drill, short, Ø 4,2 mm WN BL Profile drill, Ø 3,3 mm, short BL Profile drill, Ø 4,1 mm, short BL Profile drill, Ø 4,8 mm, short BL/TE Ta, Ø 3,3 mm, for adater 0, BL/TE Ta, Ø 4,1 mm, for adater 15 0, BL/TE Ta, Ø 4,8 mm, for adater 0, Surgical rocedures 4.1 Imlant bed rearation

43 Required ste * Required in dense bone only 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. Straumann Standard Plus Imlant Straumann Taered Effect Imlant Straumann Bone Level Imlant S Ø 4.8 WN SP Ø 3.3 NN SP Ø 3.3 RN SP Ø 4.1 RN 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 * * 4. Surgical rocedures 4.1 Imlant bed rearation 41

44 4.2 Oening the imlant ackage Straumann SLActive 1 Ste 1 Oen the blister and remove the vial Note The blister ensures the sterility of the imlant. Do not oen the blister until immediately rior to imlant lacement. 2 Ste 2 Oen the vial Turn the lid in counterclockwise direction. Kee the vial uright to revent the liquid from flowing out. Note If the imlant carrier is not firmly attached to the lid, screw in the lid once again. 3 Ste 3 Detach the imlant carrier Detach the imlant carrier from the lid by ulling it off manually. Note After removing the imlant from the solution, the chemical activity of SLActive is ensured for 15 minutes Surgical rocedures 4.2 Oening the imlant ackage

45 Straumann SLA 1 Ste 1 Oen the safety ca Oen the safety ca of the sterile amoule. Note For SLA imlants the vial ensures the sterility of the imlant, unlike SLActive which utilizes a blister ackage for sterility. 2 Ste 2 Remove the imlant from the carrier Simultaneously, ull down the imlant carrier and lift the imlant out of the imlant carrier (while suorting your arms). 4. Surgical rocedures 4.2 Oening the imlant ackage 43

46 4.3 Placing the imlant A Straumann imlant can be laced either manually with the ratchet or with the aid of the handiece. A maximum seed of 15 rm is recommended. The following ste-by-ste shows how a Straumann Standard Plus Imlant is laced with the handiece (left column on the following ages) and how a Straumann Bone Level Imlant is laced with the ratchet (right column). Note Straumann Bone Level imlants must be rotationally oriented for both, handiece and ratchet insertion (see Ste 5 on age 47). Aart from this excetion, all Straumann imlants are laced in the same way. Placement with the handiece Placement with the ratchet Examle: Straumann Standard Plus Imlant Examle: Straumann Bone Level Imlant 1 1 click Ste 1 Attach the handiece adater Gras the closed art of the imlant carrier. Attach the handiece adater to the imlant. A click is heard when the handiece adater is attached correctly. Ste 1 Attach the ratchet adater Hold the imlant carrier at the closed end and ush the ratchet adater onto the transfer art until you hear a click Surgical rocedures 4.3 Placing the imlant

47 2 2 Ste 2 Remove the imlant from the carrier Simultaneously, ull down the imlant carrier and lift the imlant out of the imlant carrier (while suorting your arms). Ste 2 Remove the imlant from the carrier Pull the imlant carrier slightly downward to remove the imlant from the imlant carrier. At the same time, lift the imlant from the carrier with a slight twisting movement (ro your hands while doing this). 3 3 Ste 3 Place the imlant Place the imlant with the handiece into the imlant bed. Ste 3 Place the imlant Place the imlant manually into the imlant bed with the aid of the adater. 4. Surgical rocedures 4.3 Placing the imlant 45

48 4 4 4 mm Ste 4 Insert the imlant with the handiece Move the imlant into final osition with a maximum of 15 rm, turning it clockwise. Note When the floor of the bone cavity is reached, there is a alable increase in resistance. Ste 4 Insert the imlant with the ratchet Attach the ratchet and the ivot of the holding key which is used for stabilizing. The clockwise arrow on the rotary knob signals the direction of insertion (see insert). Bring the imlant into its final osition at bone level with slow movements of the ratchet. The to 4 mm cylindrical art of the transfer art for Straumann Bone Level imlants can be used as a deth indicator (e.g. relative to the rosective gingival margin). It facilitates coronoaical imlant ositioning in the anterior area. Caution Insertion torque should not exceed 35 Ncm. To revent bone comression, check for correct imlant bed rearation when reaching 35 Ncm before the imlant is in its final osition. To avoid bone damage (bone necrosis or bone slitting) in the event of incorrect use (e.g. excessive tightening resistance with an inadequate drilling deth), the transfer art is rovided with a breaking oint. If the transfer art breaks during the tightening rocess, art of the transfer screw remains in the adater and the other art in the imlant. The art in the imlant can be easily unscrewed with the aid of a forces. For this eventuality, it is advisable to kee a used sterile transfer art in stock Surgical rocedures 4.3 Placing the imlant

49 5 Ste 5 Not needed for S/SP/TE S, SP, and TE imlants don t need to be rotationally oriented. If you are lacing a Bone Level Imlant with the handiece, choose the correct osition as shown in Ste 5 in the right column. Ste 5 Correct imlant orientation While aroaching the final imlant osition, make sure that one of the four white marks on the blue transfer art is exactly oriented orofacially. This ositions the four rotrusions of the internal connection for ideal rosthetic abutment orientation. A quarter turn to the next white mark corresonds to a vertical dislacement of 0,2 mm. Caution Avoid vertical osition corrections using reverse rotations (counterclockwise). This can cause loosening of the transfer art and may lead to a decrease in rimary stability. 4. Surgical rocedures 4.3 Placing the imlant 47

50 6 6 Ste 6 Loosen the transfer art Before removing the transfer art, set the motor on the handiece to reverse. During the first few turns, hold the imlant with the holding key which is used for stabilizing (countering) the hexagon. Ste 6 Loosen the transfer art Change the direction of the ratchet. The arrow on the rotary knob now oints counterclockwise (see insert). Use the holding key to counter the octagon and loosen the transfer art counterclockwise using the ratchet (for details of the holding key see age 64). Remove the transfer art (for details of the holding key see age 64) Surgical rocedures 4.3 Placing the imlant

51 7 7 Ste 7 Remove the instruments Remove the holding key and then comletely remove the transfer art with the adater from the imlant. Ste 7 Remove the instruments Remove the holding key, then the ratchet, while holding the adater at the bottom. Finally, remove the transfer art from the imlant with the adater still mounted comletely. 4. Surgical rocedures 4.3 Placing the imlant 49

52 4.4 Soft tissue management After imlantation, the imlant is closed hand-tightened with an SCS closure screw, healing ca or healing abutment to rotect the imlant (for SCS screwdrivers see age 64). The surgeon can choose between submucosal and transmucosal healing and has all otions available for soft tissue management made ossible through a set of secondary healing comonents. The non-eithelialized side of the fla should be aroximated to the imlant neck (soft tissue aroximation). If necessary, this ste must be combined with a gingivectomy. The wound margins are closed with atraumatic suture material, and the sutures must not be tied too tightly. One relieving suture is laced on either side of the closure screw or healing ca so that the wound margins are aroximated without tension. Use of non-absorbable suture material is recommended (e.g. Polyamide or Teflon). The sutures are removed after 7 10 days. A ostoerative X-ray is recommended Submucosal healing For submucosal healing (healing under closed mucoeriosteal fla) the use of a closure screw, shorter healing ca or healing abutment is recommended. Submucosal healing is suggested in esthetic indications and for imlantations with simultaneous guided bone restoration (GBR) or membrane technique. A second surgical rocedure is required for uncovering the imlant and insertion of the desired secondary comonent. 1 Ste 1 Inserting the closure screw after 1st surgery Ensure that the internal configuration of the imlant is clean and bloodless. Pick u the closure screw with the SCS screwdriver. The friction fit will secure the closure screw to the instrument during insertion and will allow safe handling. Hand-tighten the closure screw. The design will rovide a tight connection between the two comonents. Note Bone Level closure screws are delivered sterile and ready to use. All other Straumann closure screws are delivered non-sterile and must be sterilized rior to use. Subsequent loosening is made easier by alying chlorhexidine gel or sterile Vaseline to the closure screw before it is screwed into the imlant Surgical rocedures 4.4 Soft tissue management

53 2 Ste 2 Wound closure Adat the mucoeriosteal flas carefully and suture together with interruted sutures. Make sure a tight seal is formed over the imlant. 3 Ste 3 Reoening and removal: 2nd surgery Locate the imlant. Make a small crestal incision down to the closure screw. Sread the fla slightly and remove the closure screw with the SCS screwdriver. 4. Surgical rocedures 4.4 Soft tissue management 51

54 4 Ste 4 Insertion and wound closure Rinse the exosed internal connection of the imlant thoroughly with sterile saline solution. Insert a suitable secondary comonent. Adat the soft tissue and suture it back tightly without tension around the secondary comonent Surgical rocedures 4.4 Soft tissue management

55 4.4.2 Transmucosal healing A versatile ortfolio of healing cas and healing abutments is available for all Straumann imlants enabling softtissue sculturing during transmucosal healing. They are recommended for intermediate use. After the soft-tissue healing hase they are relaced with the aroriate temorary or final restoration. 1 Ste 1 Insertion Ensure that the internal configuration of the imlant is clean and bloodless. Insert the healing ca or healing abutment with the SCS screwdriver. The friction fit secures the comonents to the instrument during insertion and ensures safe handling. Hand-tighten the healing ca or healing abutment. The design will rovide a tight connection between the two comonents. Note Healing cas and abutments are delivered non-sterile in blisters and must be sterilized rior to use. Subsequent loosening is made easier by alying chlorhexidine gel or sterile Vaseline to the healing ca or healing abutment before they are screwed into the imlant. 2 Ste 2 Wound closure Adat the soft tissue and suture it back tightly around the abutment. 4. Surgical rocedures 4.4 Soft tissue management 53

56 Overview of closure screws and healing cas for Straumann Standard, Standard Plus, and Taered Effect imlants Indication Connection Article Art. No. Submucosal healing If submucosal healing is desired, use of a closure screw or shorter healing ca is recommended. NN Closure screw with hex socket, height 1,8 mm, Ti RN Closure screw, small, Ti V4 RN Closure screw, large, height 1,5 mm, Ti V4 WN Closure screw, Ti Transmucosal healing By using a taller healing ca, transmucosal healing can be obtained even when the imlant shoulder is in a subgingival osition. NN NN Protective ca with integral occlusal screw, Ø 4 mm, height 3,4 mm, olymer/ti Healing ca with integral occlusal screw, Ø 4 mm, height 3,4 mm, Ti RN Closure screw, large, height 1,5 mm, Ti V4 RN Healing ca, height 2 mm, Ti RN Healing ca, height 3 mm, Ti RN Healing ca, height 4,5 mm, Ti WN Healing ca, height 2 mm, Ti WN Healing ca, height 3 mm, Ti WN Healing ca, height 4,5 mm, Ti Esthetic region The labial bevel facilitates exact aroximation of the soft tissue over the healing ca. Ensure that there is no tension on the vestibular wound margin, as otherwise mucosal necrosis can occur. To otimise the gingival contour, it is advisable after exosure of the imlant (4 6 weeks after imlantation) to exchange the beveled healing ca for a longer healing ca without bevel (selected according to mucosal thickness and temorary restoration). NN RN RN WN Healing ca with integral occlusal screw, Ø 4 mm, height 3,4 mm, Ti Healing ca with labial bevel, short, height 2 mm, Ti Healing ca with labial bevel, long, height 3,5 mm, Ti Healing ca with labial bevel, height 2 mm, Ti Surgical rocedures 4.4 Soft tissue management

57 Overview of closure screws and healing abutments for Straumann Bone Level imlants Indication Connection Article Art. No. Submucosal healing For submucosal healing a closure screw or a short healing abutment should be used. Use of the H 0,5 mm closure screw is recommended for deely laced imlants if bone overgrowth is resent. NC NC Closure Screw, height 0 mm, Ti * NC NC Closure Screw, height 0,5 mm, Ti * NC NC Healing Abutment, conical, diameter 3,6 mm, height 2 mm, Ti RC RC Closure Screw, height 0 mm, Ti * RC RC Closure Screw, height 0,5 mm, Ti * RC RC Healing Abutment, conical, diameter 4,5 mm, height 2 mm, Ti Transmucosal healing The set of healing abutments, which have rofiles matched to secondary comonents, allows for simle and reliable soft tissue management. NC NC NC NC Healing Abutment, conical, diameter 3,6 mm, height 2 mm, Ti NC Healing Abutment, conical, diameter 3,6 mm, height 3,5 mm, Ti NC Healing Abutment, conical, diameter 3,6 mm, height 5 mm, Ti NC NC Healing Abutment, conical, diameter 4,8 mm, height 2 mm, Ti NC NC Healing Abutment, conical, diameter 4,8 mm, height 3,5 mm, Ti NC NC Healing Abutment, conical, diameter 4,8 mm, height 5 mm, Ti RC RC Healing Abutment, conical, diameter 4,5 mm, height 2 mm, Ti RC RC Healing Abutment, conical, diameter 4,5 mm, height 4 mm, Ti RC RC Healing Abutment, conical, diameter 4,5 mm, height 6 mm, Ti RC RC Healing Abutment, conical, diameter 6 mm, height 2 mm, Ti RC RC Healing Abutment, conical, diameter 6 mm, height 4 mm, Ti RC RC Healing Abutment, conical, diameter 6 mm, height 6 mm, Ti * Sterile ack of 4 cont. 4. Surgical rocedures 4.4 Soft tissue management 55

58 Overview of closure screws and healing abutments for Straumann Bone Level imlants, cont. Indication Connection Article Art. No. Esthetic region Bottle-shaed healing abutments reshae the soft tissue by allowing for a slight excess of mucosa during healing. The insertion of the final restoration ushes the formed tissue outward, suorting the creation of a naturally shaed eri-imlant soft tissue. Make sure that there is no tension on the wound margin. Otherwise mucosal necrosis can occur. NC NC RC RC NC Healing Abutment, bottle shae, diameter 3,3 mm, height 3,5 mm, Ti NC Healing Abutment, bottle shae, diameter 3,3 mm, height 5 mm, Ti RC Healing Abutment, bottle shae, diameter 4,4 mm, height 4 mm, Ti RC Healing Abutment bottle shae, diameter 4,7 mm, height 6 mm, Ti The customizable Healing Abutment allows NC NC Healing Abutment, for individual soft tissue management. customizable, diameter 5 mm, olymer Note Do not use customizable healing abutments for longer than 6 months. RC RC Healing Abutment, customizable, diameter 7 mm, olymer Surgical rocedures 4.4 Soft tissue management

59 5. HEALING PHASE 5.1 Healing hase duration Situation Healing hase SLActive SLA Good bone quality and adequate bone quantity Imlants with a diameter of 4,1 mm or 4,8 mm and a Straumann SLActive/SLA surface length of 8 mm At least 3 4 weeks At least 6 weeks Cancellous bone quality Imlants with a diameter of 3,3 mm Imlants with a Straumann SLActive/SLA surface length of 6 mm At least 8 weeks At least 12 weeks Straumann SLActive/SLA surface is not comletely in contact with the bone Bone augmentation measures* are necessary Healing hase corresonding to the situation SLActive = S and-blasted, L arge grit, A cid-etched, chemically active and hydrohilic, SLA = S and-blasted, L arge grit, A cid-etched * This technique should be emloyed only by dentists who have adequate exerience in the use of augmentation rocedures. 5.2 Straumann SLActive and SLA in comarison The bone formation rocess is initiated at an earlier stage with Straumann SLActive, resulting in significantly earlier secondary stability and thus risk reduction during the critical healing eriod. Total stability with SLA Total stability with SLActive Total stability Total stability Stability Primary stability (old bone) Stability di SLA Secondary stability (new bone) S. Raghavendra, M. Wood, T.D. Taylor (2005) Stability Primary stability (old bone) SLActive SLA Secondary stability (new bone) SLActive (blue line), SLA (dotted blue line) Time (weeks) Time (weeks) 5. Healing hase 5.1 Healing hase duration 5.2 Straumann SLActive and SLA in comarison 57

60 6. ADDITIONAL INFORMATION ON INSTRUMENTS 6.1 Surgical instruments Instruments must be checked for comleteness and function. An adequate stock of imlants and sare sterile instruments should always be available. The instruments must be disassembled for sterilization. Well maintained instruments revent infections from develoing that could endanger atients as well as the ractice team. To avoid contamination of the oeration field, all of the instruments and material emloyed must be sterile. To revent contamination of the sterile instruments, they should be removed from the surgical cassette with a sterile forces and ut into the handle or ratchet. The forces (Art. No ) was develoed and shaed secially to allow round instruments to be gried securely. Forces All stes related to the maintenance of Straumann surgical instruments are art of a dental ractice hygiene lan (see also Care and maintenance of surgical and rosthetic instruments (Art. No ) Deth marks on Straumann instruments Straumann instruments have deth marks in 2 mm intervals that corresond to the available imlant lengths. The marks on twist drills are continuous between 10 mm and 12 mm. The lower edge of the mark corresonds to 10 mm and the uer edge to 12 mm. When inserting a Straumann Standard Plus or Taered Effect Imlant u to the imlant shoulder level (see Preoerative Planning on age 21), the rearation deth must be 2 mm more than the indicated imlant length. Examle: The rearation deth for a 10 mm SP imlant inserted u to shoulder level must be 12 mm. 12 mm 10 mm 8 mm 6 mm Pilot drill 1, Ø 2,2 mm 2. Alignment in, Ø 2,2 mm 3. Pilot drill 2, Ø 2,8 mm 4. Twist drill, Ø 3,5 mm 5. Twist drill PRO, Ø 4,2 mm 6. Straumann Standard Plus Imlant, Ø 4,1 RN, length 10 mm 7. Straumann Bone Level Imlant, Ø 4,1 RC, length 10 mm 12 mm 10 mm Due to the function and design of the drills, the drill ti is 0,4 mm longer than the insertion deth of the imlant (see also age 26 on X-ray temlates). Additional length of the drill ti max. 0.4 mm Additional information on instruments 6.1 Surgical Instruments

61 6.1.2 Single-atient ilot and twist drills Like multi-use drills, single-atient drills are indicated for the rearation of the imlant bed for Straumann Dental Imlants. They are sulied sterile and are to be used for one oeration only and for one atient only. Singleatient drills can minimize the risk of infection for the atient. They are color-coded for easy identification of the diameter width. Collar for drill sto mounting Due to the function and design of the drills, the drill ti is 0,4 mm longer than the insertion deth of the imlant. New generation single-atient drills are drill sto comatible. They can be ordered using searate article numbers. Single atient drill, drill sto comatible (with collar for drill sto mounting) Straumann Drill Sto Precise deth control The Straumann Drill Sto rovides recise control over drilling deth during imlant bed rearation for the lacement of Straumann dental imlants. Delivered in sterile sets the drill stos are ready to use. The Straumann Drill Sto is designed for single-atient use only and must be used in conjunction with the single-atient drills secifically designed for them. Each Straumann Drill Sto Set includes drill stos with the following diameters: Ø 2,2 mm (blue), Ø 2,8 mm (yellow), Ø 3,5 mm (red), Ø 4,2 mm (green). These diameters corresond to the diameters of the Straumann drills. Ø 2,2 mm Ø 2,8 mm Ø 3,5 mm Ø 4,2 mm Drill Sto Set for one deth 6. Additional information on instruments 6.1 Surgical Instruments 59

62 Straumann Drill Sto reference chart Short drill Long drill Imlant bed deth Drill sto tye Drill sto tye 16 mm 14 mm 12 mm 10 mm 8 mm 6 mm A B C D A B C D Note Straumann drill stos are not indicated for: Extraction sites, where bone cavity is often wider than the diameter necessary to hold the drill sto. Use with drill temlates, due to the interference from or with the temlate. For more information of the Straumann Drill Sto lease refer to the brochure Straumann Drill Sto: Precise deth control (Art. No ) Additional information on instruments 6.1 Surgical Instruments

63 6.1.4 Straumann Surgical Cassette The surgical cassette is used for the secure storage and sterilisation of the surgical instruments and auxiliary instruments of the Straumann Dental Imlant System. The cassette is made of a highly shock-roof thermolastic, which has been roven for years in the medical area and is suitable for frequent sterilisation in the autoclave. Autoclaving at a temerature of u to 134 C (273 F) is recommended. Screw container Color coding: Green = Endosteal imlant diameter 4,8 mm Red = Endosteal imlant diameter 4,1 mm Yellow = Endosteal imlant diameter 3,3 mm The easy-to-read user guide ensures a reliable working sequence through color-coded arrows and silicon sleeves. Clear illustrations and drill length stos allow the arranged instruments, screws and healing cas to be checked at a glance for correctness and comleteness. The instruments are ositioned securely in the silicone sleeves for sterilisation and storage. The cassette can be acked according to the working rocedure (using the handiece or manually with the ratchet). The surgical cassette also houses a searate screw container in which the required Straumann synocta and Narrow Neck closure screws and healing cas are arranged, thus roviding ease of access to them. CrossFit healing abutments for the Straumann Bone Level Imlant are stored searately. 6. Additional information on instruments 6.1 Surgical Instruments 61

64 Guidelines for the sterilisation of the surgical cassette Method Temerature Exosure Time Dry Time Steam Sterilization Prevacuum Cycle 134 C/273 F min min min* Steam Sterilization Gravity Cycle 134 C/273 F min. 40 min min* No dry heat sterilization! * Instruments that are not thoroughly dried may corrode. Before sterilisation, the cassette is acked (e.g. sealed in foil or wraed in towels) in order to kee it sterile. Imortant Chemical sterilisation is not recommended! Do not use dry heat sterilisation Ensure that the individual sterilisation arameters comly with the current regulations of the resective country. In order to avoid damaging the surgical cassette during autoclaving, it must be laced correctly in the autoclave (see fig.). See also DVD Straumann Dental Imlant System Surgical, Art. No , Surgical cassette Additional information on instruments 6.1 Surgical Instruments

65 6.1.5 Ratchet Ratchet Service instrument Ratchet disassembled The ratchet of the Straumann Dental Imlant System is a two-art lever arm instrument with a rotary knob for changing the direction of force. The ratchet is sulied with a service instrument, which is used to loosen the headed screw. After loosening, the ratchet bolt can be removed from the body of the ratchet. It must be disassembled for cleaning and sterilisation. The ratchet is required for the following oerations: manual thread taing manual lacement of imlants into their final osition in the imlant bed 6. Additional information on instruments 6.1 Surgical Instruments 63

66 6.1.6 Holding key The holding key is used for stabilizing the ratchet. countering the transfer art. Holding key Stabilizing the ratchet Use the ivot of the holding key to stabilize the ratchet during imlant insertion or during taing. Stabilizing the ratchet Countering the transfer art Use the holding key for countering when loosening the transfer art from the imlant. The transfer art should be loosened only with the ratchet or handiece (counterclockwise). The shae of the holding key is secially designed for different oral situations Forked end: when saces are normal, the forked end is attached directly to the hexagon. Closed end: when the interdental sace is limited, the closed end must be laced on the hexagon over the transfer art. To do this, the ratchet and adater or handiece must be removed. Forked end Closed end SCS screwdrivers SCS screwdriver for manual use Article: extrashort, short, long Lengths: 15 mm, 21 mm, 27 mm Material: stainless steel SCS screwdriver for mechanical use in the handiece Article: extrashort, short, long Lengths: 20 mm, 26 mm, 32 mm Material: stainless steel Additional information on instruments 6.1 Surgical Instruments

67 6.2 Osteotomes Instrument set for bone condensation Indicated in cases with cancellous bone (bone class 3 and 4). Reinforces bone radially to give imroved rimary stability to the imlant. Note The instruments with diameters of 2,2 mm, 2,8 mm, 3,5 mm and 4,2 mm match the imlant diameters of the Straumann Dental Imlant System. They are available as a straight or angled model, which facilitates access in the osterior region. Osteotomes for bone condensation Instrument set for transalveolar sinus floor elevation Indicated in cases with inadequate vertical bone. By taing on the osteotomes with a mallet, the sinus floor can be fractured and elevated. Note The instruments with diameters of 2,2 mm, 2,8 mm, 3,5 mm and 4,2 mm match the imlant diameters of the Straumann Dental Imlant System. They are available as a straight or angled model, which facilitates access in the osterior region. Osteotomes for sinus floor elevation Deth stos for osteotomes All osteotomes have clear laser marks for deths of 6 mm, 8 mm, 10 mm, 12 mm and 14 mm. In addition, adjustable deth stos facilitate deth checking. Further references regarding use in the instructions for use Straumann Osteotomes (Art. Nos and ). See also DVD Straumann Dental Imlant System Surgical (Art. No ). Deth stos for osteotomes 6. Additional information on instruments 6.2 Osteotomes 65

68 6.3 Cleaning and care of instruments Careful treatment of all instruments is of the utmost imortance. Even slight damage for instance to the drill tis (e.g., when the drills are thrown into a bowl of water) imairs cutting erformance and thus the clinical result. With correct and careful care, the high quality of the material and excellent workmanshi ensure that the rotating instruments (drills*, tas etc.) can be used reeatedly (u to a maximum of ten times is recommended). The Surgery tracking sheet for Straumann cutting instruments (Art. No ) hels to give an overview of how often the individual instruments have already been used. *Excetion: Single-atient drills (see age 59). SURGERY TRACKING SHEET FOR STRAUMANN CUTTING INSTRUMENTS Article Art. No. Dimensions Number of surgical rocedures Round bur Ø 1.4mm Round bur Ø 2.3 mm Round bur Ø 3.1 mm Pilot drill Ø2.2 mm, short Pilot drill Ø2.2 mm, long Pilot drill Ø2.8 mm, short Pilot drill Ø2.8 mm, long Twist drill Ø 3.5 mm, short Twist drill Ø 3.5 mm, long Twist drill PRO Ø4.2 mm, short Twist drill PRO Ø4.2 mm, long SP Profile drill, RN Ø2.8 mm, short SP Profile drill, RN Ø2.8 mm, long SP Profile drill, RN Ø3.5 mm, short SP Profile drill, RN Ø3.5 mm, long SP Profile drill, WN Ø4.2 mm, short SP Profile drill, WN Ø4.2 mm, long TE Profile drill, RN Ø2.8 mm, short TE Profile drill, RN Ø2.8 mm, long TE Profile drill, RN Ø3.5 mm, short TE Profile drill, RN Ø3.5 mm, long TE Profile drill, WN Ø4.2 mm, short TE Profile drill, WN Ø4.2 mm, long BL Profile drill Ø 3.3 mm, short BL Profile drill Ø 3.3 mm, long BL Profile drill Ø 4.1 mm, short BL Profile drill Ø4.1 mm, long BL Profile drill Ø 4.8 mm, short BL Profile drill Ø 4.8 mm, long S/SP Ta for Ratchet Ø 3.3 mm, short S/SP Ta for Ratchet Ø 3.3 mm, long S/SP Ta for Adater Ø 3.3 mm S/SP Ta for Ratchet Ø 4.1 mm, short S/SP Ta for Ratchet Ø 4.1 mm, long S/SP Ta for Adater Ø 4.1 mm S/SP Ta for Ratchet Ø 4.8 mm, short S/SP Ta for Ratchet Ø 4.8 mm, long S/SP Ta for Adater Ø 4.8 mm BL/TE Ta for Adater Ø3.3 mm BL/TE Ta for Adater Ø4.1 mm BL/TE Ta for Adater Ø 4.8 mm Straumann roducts are CE marked 07/ /e B00907 Note Because Straumann drills and tas are recisely manufactured and made of high quality material, they can be used in u to 10 surgical rocedures. However, careful handling and cleaning techniques are essential to maintain correct function (refer to Care and maintenance of surgical and rosthetic instruments ). For additional information visit Additional information on instruments 6.3 Cleaning and care of instruments

69 Instruments with high cutting erformance are a basic requirement for successful imlantation. The following should therefore be remembered: Never allow instruments to land on their tis. Every instrument must be used only for its articular intended urose. Dirty instruments should be laced in a bowl of Ringer s solution (avoid allowing blood or tissue residue to dry on them). Residues of blood, saliva, tissue or bone must be removed from the instruments immediately after surgery. Every iece of residue that adheres to the instruments and dries on them leads to corrosion. Multi-art instruments (e.g., ratchet, internally cooled trehine drill) must be disassembled for sterilisation and storage. Used instruments must always be laced in a suitable medium for disinfection rior to cleaning. Dirty instruments must be laced only on the intended surface (cassette lid or aroriate dish). Never disinfect, clean (including ultrasonically) or sterilise instruments made of different materials together. Damaged instruments must be sorted, disinfected, cleaned searately, and discarded. Never store instruments dam or wet for rolonged eriods. You will find detailed information in the brochure Care and maintenance of surgical and rosthetic instruments Art. No Ultrasonic Cleaning Cassette The Ultrasonic Cleaning Cassette ensures otimal storage during instrument disinfection and cleaning in the ultrasonic bath. The imled silicone mat revents the cutting edges of the instruments from coming in contact, which would have a negative effect on their cutting erformance. 6. Additional information on instruments 6.3 Cleaning and care of instruments 67

70 7. APPENDIX 7.1 Labeling and color coding of the Straumann Dental Imlant System Naming and labeling exlanations Color coding yellow red green Endosteal imlant diameter 3,3 mm Endosteal imlant diameter 4,1 mm Endosteal imlant diameter 4,8 mm Imlant tyes S: Standard Imlant SP: Standard Plus Imlant TE: Taered Effect Imlant BL: Bone Level Imlant Connection tyes NN: Narrow Neck Ø 3,5 mm Ø 3,5 mm RN: Regular Neck Ø 4,8 mm Ø 4,8 mm WN: Wide Neck Ø 6,5 mm Ø 6,5 mm NC: Narrow CrossFit Ø 3,3 mm Ø 3,3 mm RC: Regular CrossFit Ø 4,1 and Ø 4,8 mm Ø 4,1 mm Ø 4,8 mm Aendix 7.1 Labeling and color coding of the Straumann Dental Imlant System

71 Examle of label on imlant ackaging Connection tye Endosteal diameter Imlant tye Length of the SLA /SLActive surface Standard Plus Imlant Ø 4.1 mm RN SLA 8 mm Surface tye Article number REF S XXXXX LOT number JJJJ-MM 0510 The Green Dot 128 Barcode 940.XXX Institut Straumann AG CH-4002 Basel Switzerland Manufacturer Use before exiration date Single use only Caution: Federal law (US) restricts this roduct to sale by or on the order of a dentist or hysician Please read and follow instruction leaflet Straumann roducts are CE marked and fulfill the requirements of the Euroean Medical Devices Directive 93/42 EEC Sterilized with gamma radiation SP Ø 3.3 NN 8 SP Ø 4.1 RN SLActive 10 TE Ø 4.8 WN SLActive 12 BL Ø 4.1 RC SLActive 12 Straumann Standard Plus Imlant Endosteal diameter 3,3 mm Narrow Neck 8 mm SLA Straumann Standard Plus Imlant Endosteal diameter 4,1 mm Regular Neck 10 mm SLActive Straumann Taered Effect Imlant Endosteal diameter 4,8 mm Wide Neck 12 mm SLActive Straumann Bone Level Imlant Endosteal diameter 4,1 mm Regular CrossFit 12 mm SLActive 7. Aendix 7.1 Labeling and color coding of the Straumann Dental Imlant System 69

72 7.2 Related documentation Note Our detailed documentation will hel you in carefully lanning and erforming your imlant-based restorations: Straumann Narrow Neck, Art. No Crown and Bridge Restorations: Straumann synocta Prosthetic System, Art. No Cement-retained crowns and bridges with the solid abutment system: Straumann Solid Abutment Prosthetic System, Art. No Straumann Osteotomes, Art. No and Straumann Bone Level Imlant line: Basic information on the rosthetic rocedures, Art. No The DVD Straumann Dental Imlant System Surgical, Art. No , features the following films: Measurement and analysis rocedure for oeration lanning Imlantation of a Standard Plus imlant Imlantation of a Taered Effect imlant Surgical cassette Osteotomes Instrument care and maintenance Well maintained instruments are a basic requirement for successful treatment. You will find detailed information in the brochure Care and maintenance of surgical and rosthetic instruments Art. No The Straumann guarantee As a Swiss comany, we attach the greatest imortance to manufacturing our roducts in to the highest quality. We are firmly convinced of the scientific and clinical basis of our Straumann Dental Imlant System and draw on the fund of know-how from nearly 30 years of quality roduction. The Straumann guarantee regulates relacement of all comonents of the Straumann Dental Imlant System. You will find detailed information in the brochure The Straumann guarantee Art. No Exlantation For exlantation guidelines lease refer to the Directions for use: Exlantation rocedure for Straumann dental imlants, Art. No The comonents required for exlanation can be found in our current roduct catalogue. References The Straumann Dental Imlant System has been comrehensively clinically documented for over 25 years. You can find references to the current research literature on our website or by contacting your local Straumann reresentative. Courses and training Continuing education ensures long-term success! Please, ask your Straumann reresentative directly for information on the Straumann Dental Imlant System courses and training. Further information at Aendix 7.2 Related documentation

73 Custom-made roducts Under certain circumstances, custom-made roducts can be sulied for secial indications or cases that cannot be treated with standard roducts. A custom-made roduct is defined according to EEC directive 93/42/EEC (Article 1, section d) as being any roduct fabricated secifically for a named atient according to secific characteristics and rescribed in writing by an aroriately qualified doctor, who assumes the resonsibility. List of abbreviations SCS = Screw Carrying System HDD = Horizontal Defect Dimension SLActive = Sand-blasted, Large grit, Acid-etched, chemically active and hydrohilic SLA = Sand-blasted, Large grit, Acid-etched If you require a custom-made roduct, lease contact your customer service. Quality assurance in accordance with MDD 93/42/EEC All roduction stages carried out by Institut Straumann AG are subject to the Standards laid down in the EN ISO 9001 quality assurance system. This Euroean standard establishes in detail the criteria which a comany must fulfil regarding comrehensive quality assurance during its manufacturing rocesses in order to be recognized. Particularly high standards are rightly exected of medical roducts. They are defined in Euroean standards ISO 13485, which we also meet. This ensures that the quality of our roducts and services meets our customers exectations, and can be reroduced and traced at any time. Our roducts comly with the essential requirements defined in the Medical Devices Directive 93/42/EEC. All of our medical roducts therefore carry the CE mark. Institut Straumann AG meets the stringent requirements of Euroean directive MDD 93/42/EEC for medical devices and standards EN ISO 9001 and ISO NN = Narrow Neck (3,5 mm) RN = Regular Neck (4,8 mm) WN = Wide Neck (6,5 mm) NC = Narrow CrossFit Connection (for BL imlants) RC = Regular CrossFit Connection (for BL imlants) S = Standard SP = Standard Plus TE = Taered Effect BL = Bone Level 7. Aendix 7.2 Related documentation 71

74 7.3 Imortant notes Disclaimer of liability The Straumann dental imlant is art of an overall concet and may only be used in conjunction with the associated original comonents and instruments according to Institut Straumann AG s instructions and recommendations. Use of roducts made by third arties in conjunction with the Straumann Dental Imlant System will void any warranty or other obligation, exress or imlied, of Institut Straumann AG. Instructions as to alication of our roducts take lace verbally, in writing, by electronic media or in hands-on trainings corresonding to state of the art at the time of introduction of the roduct. Exlanation of the symbols on labels and instruction leaflets Lot/batch number Article number Sterile by gamma irradiation Nonsterile The user of Straumann roducts has the duty to determine whether or not any roduct is suitable for the articular atient and circumstances. Straumann disclaims any liability, exress or imlied, and shall have no resonsibility for any direct, indirect, unitive or other damages, arising out of or in connection with any errors in rofessional judgment or ractice in the use or installation of Straumann roducts. min. max. Lower temerature limit Uer temerature limit The user is also obliged to study the latest develoments of the Straumann Dental Imlant System and their alications regularly. min. max. Temerature limit Please note The descritions contained in this document are not sufficient for immediate use of the Straumann Dental Imlant System. Knowledge of dental imlantology and instruction in the handling of the Straumann Dental Imlant System rovided by an oerator with the relevant exerience are always necessary. Caution: Federal (USA) law restricts this roduct to sale by or on the order of a dentist or hysician Do not use on atients Availability Not all roducts listed in this brochure are available in all countries. Validity Uon ublication of this brochure, all revious versions are suerseded. Caution Our roducts must be secured against asiration when used intraorally. Do not use damaged or blunt instruments. Do not reuse Refer to instructions for use Use before exiry date Units er ackage Unless stated otherwise, there is one unit in each ackage. Documentation You can obtain detailed instructions on the Straumann Dental Imlant System from your Straumann reresentative. Coyright and trademarks Straumann documents may not be rerinted or ublished, in whole or art, without the written authorization of Institut Straumann AG. Straumann and/or other roducts and logos from Straumann that are mentioned here are trademarks or registered trademarks of Straumann Holding AG and/or its affiliates. Definition SLActive Sand-blasted, Large grit, Acid-etched, chemically active and hydrohilic Definition SLA Sand-blasted, Large grit, Acid-etched XXXX Colored warning labels YELLOW = CAUTION ORANGE = WARNING Protect from exosure to strong light or heat Straumann roducts carry the CE mark and fulfill the requirements of the Medical Devices Directive 93/42 EEC Consult oerating instructions Indicates hazards or unsafe handling which might cause minor injury or damage to roerty Indicates hazards which might cause serious or fatal injury RED = DANGER Indicates hazards which might cause immediate serious or fatal injury Aendix 7.3 Imortant notes

75 8. INDEX axial orientation 15 biological rinciles 3 bone availability 25, 32 augmentation 57 class 39 condensation 65 damage 46 effective availability 27 formation rocess 57 quality 57 quantity 57 Bone Control Design 3 buccal wall 22 cemento-enamel-junction 21 color-coded 59 contraindications 10 contralateral 21 coronal 36 coronoaical 21 CrossFit Connection 8 dental ractice hygiene lan 58 deth marks 58 deth stos 65 Diagnostic T 18, 23 drill temlate custom made 28 free end situations 29 single tooth gas 29 vacuum formed 28 drilling deth 59 endosteal diameters 3 full deth taing 36 healing hase duration 57 holding key 48, 64 hydrohilic roerties 9 imlant diameter 15 distance indicator 24 insertion deth 27 orofacial 20 osition 15, 32 shoulder diameter 23 secific indications 11 Straumann Bone Level 6 Straumann Standard 6 Straumann Standard Plus 6 Straumann Taered Effect 6 indications 10 insertion deth 59 instrumentation 35 instruments 34, 58 lingual/alatinal wall 22 mesial/distal oint 22 minimum guidelines 15 Morse taer connection 7 osteotomes Index 73

76 ilot drill 32 rearation imlant bed 31 basic 31 fine 35 rearation deth 58 rofile drilling 35 ratchet 63 reconstruction rosthetic 23 reference shere diameter 26 risk of infection minimize 59 SCS screw driver 64 single tooth ga 17 single-atient drill new generation 59 sinus floor elevation 65 SLA surface 9, 57 Standard Imlant 21 Straumann Dental Imlant System 3 Straumann Drill Sto 59 Straumann Drill Sto Set 59 Straumann SLA 9, 57 Straumann SLActive 9, 57 Straumann Surgical cassette 61 suerstructure 15 surfaces 9 surgical kit 3, 30 synocta connection 7 taered effect 21 taing 36 temlate vacuum-formed 28 transfer art 46 Twist Drill PRO 33 twist drill 58 wax-u/set-u 15 X-ray distortion 26 temlates 26 X-ray reference shere Index

77 NOTES

78 NOTES

79 International Headquarters Institut Straumann AG Peter Merian-Weg 12 CH-4002 Basel, Switzerland Phone +41 (0) Fax +41 (0) Straumann roducts are CE marked 09/ /e B00907