Straumann Implants: Bone Level vs. Tissue Level?

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Dr. P asks:
I am seeking advice from Straumann Implant users. With the past 5 patients that I sent to periodontists and oral surgeons for placement of Straumann implants in the maxillary anterior region, some placed bone level implants while others used tissue level Standard Plus implants. It appears as though the more experienced periodontists and oral surgeons favored the tissue level implants for the maxillary anterior region. The bone level implant requires the additional step of making a temporary crown to shape and condition the gingival to develop an aesthetic emergence profile. My question is what factors determine the better choice for selecting a bone or tissue level implant in the maxillary anterior region? What are the advantages and disadvantages of each design?

17 Comments on Straumann Implants: Bone Level vs. Tissue Level?

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Mark P. Miller, DDS, FICO
8/24/2010
Good question...glad you asked. I lectured for Straumann for 10 years. My wife was a rep for the company for six years. One of the reasons for leaving the company was that we knew a bone level implant was better suited in the anterior than a tissue level implant in most cases. Other companies had a bone level and Straumann did not. I felt we were doing patients a disservice using a tissue level implant in the anterior when bone level implants were better for a variety of reasons. We didn't know a lot about what is now called 'platform switching' which is a proprietary name used by one of the companies. Straumann realized that there was no bone die back with bone level implants so they changed their tune and developed their own bone level implant. The good news is both their bone and tissue level implants work wonderfully. Both can be used as single stage implants or the bone level can be buried and heal without exposure to the oral environment. There are cases when I don't want anything exposed to the oral cavity. One example we all can think of is when membranes need to be used. Then we're after primary closure and no chance of micromovement. If you have an esthetic case in the anterior, by all means use a bone level implant. With the advent of CAD CAM abutments, we don't have to use stock round abutments anymore and can shape them more like teeth. This helps tremendously to cut down on those horrible gaps mesially and distally where food traps around implant crowns. And don't sweat using temporary crowns. In fact, be glad to do it. You get to try out a prototype crown for a month or so to see what tissue response will be. That way there are no abutments showing following crown placement. Make a screw retained temporary crown, send the patient on their way, have them back in a month or so (some will respond 4-6 months, but let's get real), take a final impression of implant AND sculpted new tissue, and have a great result and happy patient. Your comment about more experienced periodontists and oral surgeons favoring tissue level implants in the anterior region tells me that just maybe those 'seasoned' practitioners either haven't kept up with technology or have inventory they need to use up. Don't, as a restorative doctor, get conned into using an implant that will not give you excellent restorative and esthetic results. You tell THEM what to place, not the other way around. Whatever they place will integrate and they get paid. Whatever esthetic compromise ends up will be your fault in the patient's mind. You're the quaterback, you control the case...period.
Carlos Boudet, DDS
8/24/2010
Good comments! I have used both, and both work well. I will add that sometimes those "experienced periodontists and oral surgeons" as you say, still place the tissue level implants in the anterior region because they are so used to the system that they don't want to change. The bone level implants, especially those with the platform switching design are a better option in the cosmetic zones. You wanted advantages and disadvantages. The ability to use a custom abutment and modify the angulation and emergence profile is a great advantage of bone level fixtures. Here is a previous thread about the topic: http://www.osseonews.com/bone-level-vs-tissue-level-implant/ Good luck!
Steven J. Rosenstein
8/24/2010
Doctor Miller, I have worked with Straumann implants almost from their initial entry into North America. I think that your comments to this question are right to point and wonderfully expressed. I would add emphasis to your comment about screw retained temporaries. I know the tissue sculpting can be done with a temporary custom abutment and cemented crown, but not as elegantly as with a screw retained one piece approach. It is also much easier to modify your emergence contours with the one piece approach and without dealing with cement. With respect to the older surgeon comments, I think that another explanation is realistic. Many people resist change and if something is working why expend the time, energy, and investment to do something differently...we did quite well esthetically with the tissue level implant, but it puts a much higher demand on the skill of the surgeon and his/her understanding of the restorative demands. Finally, yes! the restorative dentist needs to be the quarterback. So he needs to educate himself fully in order to assume that role. Dr. Miller, thanks again for your great comments
Laz S
8/25/2010
Great comments above. Hard to add anything. I would say, given what we know, it is insane to use anything other bone level in the anterior. If you have a thin tissue type the tissue will always settle below the polished collar in the long-termwhich creates an esthetic hazard. With thick tissue types the tissue level can be almost preferable as it ends up with a more hygenic long-term result. The implant abutment junction is not buried so deep (if for example you have 5mm thick tissue).
tom s.
8/25/2010
looks, like you are all sales reps from Straumann. Its funny that Straumann claims there new bone level implant (bli) as an innovation. I am wondering, which implants you have used in the anterior area before having Straumann. I have stopped with the BLI, after having 10 breaks with the srew, the connection is not good. last week there CEO has admitted that their super modern SLactive surface makes only one third of their sold implants. And their new guided system (IVS) is also not working at all!! sorry guys, but for me the parallel implant in soft bone is not working at all.
Dr. Ben C. Ng
8/25/2010
I totally agreed with Dr. Miller. I've been using Straumann Implants since 1996; using the Tissue-level SP implants in both situations with great success. With introduction of Bone level implants, I found it to be more flexible, especially in the anterior region. It gives the added advantage of 'platform- switching'. Esthetic is much better with BL, but if done properly with tissue level implants, one can get equally good esthetic result. But don't totally chuck off the tissue level implants as they have some good use, especially in the posterior regions and over-denture case. On the whole, this BL open up a whole new world of exciting implant dentistry. Dr. Ben
Geoffrey Poon
8/26/2010
Thankyou for your responses. They have been very helpful. Currently I have a narrow crossfit bone level implant in site 22. It came with a 3.3 mm wide healing abutment. Now I wish to sculpt the gingival tissues to create a nice emergence profile for the final crown. I intend to use the temp meso abutment and keep adding to the abutment until it is flared enough. I want to avoid the ridge lap in the final crown. My question is : Can I safely go from the 3.3mm to a 6.5 mm diameter anatomical root without the gingival tissues retracting apically?? Thanks again. Geoffrey
Richard Hughes, DDS, FAAI
8/26/2010
Dr. Poon: You may be able to. I would trtract the tissue and make a mesial and distal releasing incision. Place the abutment and do not suture but hold the gingiva for five minutes or so with finger pressure. I have done this many times with success. I hope I understood your question.
G Poon
8/27/2010
Dr Hughes. Thanks for the tip . How deep do I make this incision and does it extend all the way to the adjacent teeth??
Richard Hughes, DDS, FAAI
8/27/2010
J Poon: Yes the incision does extend to the adjacient tooth. It's no big deal and will heal nicely. Let me know how it works out.
Mark P. Miller, DDS, MAGD
8/31/2010
Dr. Richard Hughes, I want to thank you publicly for all your great comments. You always add positive comments to these sites. I agree with everything you say about releasing incisions to seat abutments and crowns. For some reason, GP's seem to be fearful of picking up a scalpel. It is far easier than most things we do. As a side issue, I have used a laser often with these procedures...and rarely do so now. Why? I had one experience trying to find a buried cover screw on an implant I had placed. By the time I got through finding it and uncovering it, I had left a fairly large hole in the gingiva that took months to recover. A scalpel is an easy way to expose cover screws in order to place a healing abutment. And no tissue is lost. In fact, by placing the incision slightly to the lingual, the buccal flap can be bunched against the healing abutment to create more keratinized tissue. One responder noted that parallel implants were not working in his hands. Good that he understood his limitations, but realize that "if it's being done, it's probably possible." Thousands upon thousands of parallel imlplants have been placed. Because it doesn't work in your hands only means it doesn't work in your hands. It works for others just fine. The same could be said with my experience with lasers. I now prefer the scalpel to the laser. It just works better in my hands. Again, kudos Dr. Hughes. Keep up the good work.
Dr. Akhavizadegan
8/31/2010
the tissue level implants in the cases with thin gingiva on the edntoulus ridge or thin gingival biotype in the esthetic zone may show the gray shadow of the implant collar throught the gingiva and interfer with the esthetic result. the main cause of the this ITI new bone level implant design is this not reasons listed by dear Dr.miller. be louk !
MJK
9/1/2010
Dr. Ben, I'm glad the Straumann Bone Level Implant has opened you up to a new world of Implant Dentistry. That "World" however is not new for many surgeons who have been placing implants at the bone level for years. The only thing new is Straumann's break from years of their science and representation telling us that the tissue level implant is the way to go. MJK
keith goldstein
9/2/2010
straumann's guided surgery is an east german software company that they bought and the system enables a dental lab to make the guides which is interesting. they are trying to push into the cad/cam space with acquisitions and partnerships. i am a competitor of theirs offering both offering zirconia abutments using straumann bone level titanium bases as well as a whole line of straumann tissue level implants and abutments- there are so many other more reasonably priced viable implant and abutment solutions that are out there which are compatible with straumann drills and restorative instruments that many doctors given this economy may want to consider further exploring -
don grgas
11/30/2010
I couldn't agree with Dr. Miller more, as a lab tech. I have come across numerous situations in the anterior region and also 1st, 2nd premolars where the esthetics are very important esp. with a high smile line that a bone level system should be used. That being said I had numerous discussions with the restorative dentists that send their patient to the oral surgeon for implant placement then the patient comes back after 4-6 months to face a dilema at hand, how to restore a mess at hand. Personally I thank the technology at hand that we can go ahead and cad cam design custom abts. and still have a very beautiful outcome. [ I suggest that all anteriors should be restored with circonia Implants abt. with a zirconia or lithiium disculite crowns.
Dr. bill. Messageinabottl
1/21/2011
ITI BONE LEVEL WAS AND IS SOMETHING THAT I HAVE BEEN WAITING FOR.... 1. Sometimes, it is really not that easy to get a primary closure with the big "lotus head of ITI"... bone level made it much easier to close especially with larger grafting GBR cases. 2. I have used ITI BL the first conception that were available, the abutment only has 4 positions to fit on, so do be careful and it is in my opionion to install an abutment (angled or not) onto the fixture and visualize your final position prior to suturing. It is not as forgiving as octagon. 3. You may and hopefully not see this, because BL (bone level) is buried so deep and you need to un-discover it.... I love SLA... but the bone may not grow as well as you wanted to. (we usaully don't need to un-discover ITI due to the presence of its larger lotus head and assume bone will grow to the top of rough surface.....but it sure look good on the X ray) 4. Be prepared to spend a little extra money.... some components are not compatible with tradtional ITI. 5. Tell your lab and assistants to be careful with the impression transfer and other components of BL. They go down the drain pretty fast.... they are small. " and are not sold separately" lol (laugh out load... i just learn that today after asking my assistant..) 6. The follow up at my clinic for phase one and phase two of BL are perfect, the bone " on the x ray really are beautiful" ...... love the platform switching. 7. May be I am wrong, but unless i go with a custom BL UCLA...... am I saving much trans-mucosal space comparing with traditional SP head. 8. P.S. add a "wine cap" as I call it (healing abutment for BL), after fixture placement, it will save you a lot of time searching and rescuing for the implant opening. 9. you do get a lot more soft tissue to play with especially for anterior which might make or break your case for anterior esthetic zone when using Bone level ITI. Not sure if anybody will hear this message, but i would love to hear more back about other specialists thoughts on bone level ITI; as long as it is constructive and no sales please. This may well be the essence of this forum. Sincerely Bill H.
Diego ospina DMD,DICOI
11/30/2011
Absolutely agree. In all facets of dentistry the General dentist needs to be the quarterback not the specialist