Healing cap exposure 1 week post implant surgery: recommendations?

Keep it clean and let it heal. Nothing to gain switching out a healing head while it is osteo integrating. This is a transmucosal implant, designed that way and the tissue should adapt.

Ditto CRS

I agree with CRS. Keep it clean and let it integrate. Tell the patient not to eat on that side.

i appreciate your comments. this was my 3rd case using a TL straumann implant. i have been using 3i implants previously. i am not sure if this is just me but i found that the thread design of this particular implant is not as aggresive as some of that of BL implant, finding harder to get a high torque primary stability with RN 4.1 implants. i initially attempted to place 4.1 wide RN implant, but during the placement, it spinned hence the placement of WN implant. Yesterday, i placed another RN TL implant on maxillary 1st molar site and the primary stability was just over 15Ncm. i followed the surgical protols as shown in the manuel eg.use of 800rpm,600rpm and 400 RPM for cortical drill. Do you guys use the cortical drill routinly for the placement of RN TL implants? and do you guys use bone tap routinly for the placement of WN implants? thanks in advance

I find Straumann implants the most technically demanding implants to place due to the thread pattern and fixture mount.. The standard plus is a beautiful implant in the molar regions due to the emergence profile. The bone level thread design is a bit easier to place. Have the rep attend the surgery to give technical advice, that's what I did to help the learning curve. This a big head and the soft tissue will not cover it. The top of the osteotomy is prepared with the profile drill, I rarely tap these. The tapered effect is another option but I think they look like aircraft carriers on the film! Good luck.

thanks for your comment CRS. So, Do you routinly use profile drill to place TL implants? i appreciate your help. cheers William choi

The term TL threw me, there are three tissue level types but the protocol for standard plus and tapered effect have profile drills to allow the implant to seat at the top. The bone needs to be nearly perfect to get the standard plus to work, the osteotomy can't be oval and I drill these really slow depending on the bone type. The benefit is the lovely restorative platform and the soft tissue result. A spinner won't integrate since it is exposed to the oral cavity. The bone level is much kinder to work with and placing a short healing head can prevent having a second surgery but you don't have the same restorative platform. I wish they would change the thread pattern and the drills can eat up bone pretty quick. The blunt SP bottom is also unforgiving. Technically challenging to place, great to restore. I usually have a backup sized implant at surgery in case of a surprise.

This implant was designed to be at the tissue level and when slightly buried, exposure is not uncommon as the bevelled head of the implant sheds tissue; not a flaw in design but appropriate for the location you have selected. Leave it as is unless inflammation develops; if it does, place a longer healing abutment.

Straumann TL is one of the better option for molar sites. As for your second question 15ncm torque is acceptable for straumann but not ideal. like astra strauamnn is low torque as well. In particular if u r used to 3i which is a high torque system u not going to like strauamnn surgical placement. In mandile strauamnn gives u high torque in most of the cases. Maxilla is challenging and for plus implant i dont drop the profile drill to recommended length. keep it 1 mm short. also i keep bluesky or implant direct 5.6 or 5.4 diameter as backup if 4.8 spins.i dont use bone tap in maxilla. Only use it in type 1 bone.

Great comments. May u ask your incision design? I do not place an incision over the implant but to the lingual. I bevel the edge of the flap on the lingual so there isn't a butt primary closure. Iits more of a KT surface to surface design. From Sclars book. If thin bio type, I release the buccal periosteum for primary closure. If the healing contraction exposes the lingual of the surgical screw, I leave it alone. It is usually always fine. Then when I uncover it later, I use a biopsy punch sized for the implant and it gives a perfectly clean exposure of the platform. Just my thoughts.

Agree with most of the commentators above. You should'nt be tinkering with the implant in the critical 2-4 weeks window. The term TL threw me also. Straumann tissue level though surgically challenging, gives you fantastic restorative results. As someone pointed out, this can be successful in low torque situations, you just bury it under the tissue. I think your protocol of periodic review and oral hygiene maintenance is the best way to go. A wider and longer healing abutment can come later after proper integration. You will not routinely need tapping in the maxilla. I dont use the profile in the maxilla if its soft bone. Sometimes, what i do in maxilla is condense the bone with expanders, even if there is adequate width. Or reverse the drill and go in very very slow - the drill slowly condenses the bone. This tissue level design is a little technique sensitive, could rotate easily. In a bone level, you could manage by going a little deeper, not the case here. The error is that sometimes we tend to be too over conservative, not raising adequate flap, and go some-what blind ( almost flapless). While it may work for bone level, I would recommend never lose your view while torqueing the implant in. And take radiographs - sometimes we may get over-confident and complacent. And as someone said, always have a spare implant handy. Best regards Dr B

i really appreciate all the comments above. The above comments have answered most of my questions that i had in mind. i have some more questions for you guys. 1) dear dr bill woods i do normally place the crestal incision lingually too. You mentione about the bevelled margin. How would bevel the margin? i normally place the scapel perpendicular to the crestal bone. would you angle scapel lingually in order to make the bevelled margin?! 2) Dr B You metioned about the drill in reverse to condense the bone. Would you be able to elaborate the drill sequence little more? eg. for TL SP 4.1 diameter placement - i would think to use 800rpm for 2.2mm full depth. for 2.8mm pilot use 600rpm set in reverse. for 3.5mm pilot drill set 500rpm in reverse. is this sound about right? 3) Any of you guys have used expander drills to place straumann implants?? i thought this was not possible due to non-self-tapping micro design of the thread (both TL and BL).

it is not matter of concern at all because i place healing abutment routinely in practice.but patient should maintain hygiene.

Dr B thanks for your comments! i appreciate your time. the expansion kit you have mentioned refers to the bone condensation osteotome with convex tips right? regards William

Dr Will, Going in and out is something u would do during the drilling if u encounter too much resistance. It would technically make the osteotomy larger if you arent steady, but u are placing an implant thats 6 mm wider than the last drill, so u have a little margin for error. Moreover, in this reverse drilling, u are compacting and condensing the bone within, hence it is better if done twice. Did i mention it should be done without irrigation..? And as in any expansion, place something like the parallelling pin inside the osteotomy site in the 'in-between' times.. Occasionally , when torqueing the implant in after expansing like this, you would encounter too much resistance, what i do in situations like this is to go in again with the same last drill in conventional direction, very slow like 50 RPM. Hope this helps. Yes, the bone condensation osteotomes is what i am talking abt , with convex ends. The concave heads are for sinus elevation ( summers). Best regards