The SAC Classification in Implant Dentistry
SECOND EDITION
SECOND EDITION
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ISBN 978-1-78698-110-3
The materials offered in The SAC Classification in Implant Dentistry are for educational purposes only and intended as a step-by-step guide to the treatment of a particular case and patient situation. These recommendations are in line with the ITI treatment philosophy. These recommendations, nevertheless, represent the opinions of the authors. Neither the ITI nor the authors, editors, or publishers make any representation or warranty for the completeness or accuracy of the published materials and as a consequence do not accept any liability for damages (including, without limitation, direct, indirect, special, consequential, or incidental damages or loss of profits) caused by the use of the information contained in The SAC Classification in Implant Dentistry. The information contained in The SAC Classification in Implant Dentistry cannot replace an individual assessment by a clinician and its use for the treatment of patients is therefore the sole responsibility of the clinician.
The inclusion of or reference to a particular product, method, technique or material relating to such products, methods, or techniques in The SAC Classification in Implant Dentistry does not represent a recommendation or an endorsement of the values, features, or claims made by its respective manufacturers.
All rights reserved. In particular, the materials published in The SAC Classification in Implant Dentistry are protected by copyright. Any reproduction, whether in whole or in part, without the publisher’s prior written consent is prohibited. The information contained in the published materials can itself be protected by other intellectual property rights. Such information may not be used without the prior written consent of the respective intellectual property right owner.
Some of the manufacturer and product names referred to in this publication may be registered trademarks or proprietary names, even though specific reference to this fact is not made. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.
The tooth identification system used in The SAC Classification in Implant Dentistry is that of the FDI World Dental Federation.
Almost 20 years ago, the International Team for Implantology – ITI – formalized the SAC classification to categorize oral implant treatment procedures into three levels of difficulty: Straightforward, Advanced, and Complex. The SAC Classification in Implant Dentistry was published in 2009, and it immediately became clear that this approach to classifying treatment risk when planning patient treatment was a tool many dentists had been waiting for. Applying the SAC approach to the evaluation of patient-related risk factors and treatment modifiers has since become a standard procedure for many practitioners, contributing to a higher degree of predictability in the execution and outcome of proposed treatment. The SAC classification has been recognized by dental professionals as an objective, evidence-based framework, also making it an invaluable educational tool for both predoctoral and postgraduate training programs.
As dental materials, technology, and clinical techniques have evolved in the intervening years, the ITI decided to review the SAC classification and present it to clinicians in an updated form: a digital book that can be accessed from any device or computer as needed. With its mission to promote and disseminate knowledge covering all aspects of implant dentistry and related tissue regeneration, the ITI recommends this SAC Assessment Tool to all professionals in the field.
It may be trite, but it is true: projects such as this do not succeed without the commitment and hard work of a large team of people. Consequently, we would like to acknowledge the following people and groups.
The ITI Board of Directors trusted us to update one of the ITI’s crown jewels – the SAC Classification. This is a heady responsibility, as we know that the SAC Classification is widely used and respected by clinicians in implant dentistry. We thank the Board for their trust and support.
The staff at the ITI Headquarters have supported us throughout the project. From the events team that organized our meetings, to the Communications and Education teams for providing material, all have worked cheerfully and willingly to help us. Of special note: many thanks to Kati Benthaus and Katalina Cano, our project managers, who have guided us through the process.
Thanks must go to Stefan Keller and his fellow IT wizards at FERN who have turned our dreams of what we would like to do with the online tool into reality.
Thanks also to Änne Kappeler and the team at Quint-essence. Their professionalism and patience have allowed us to produce something that we can all be truly proud of.
Of course, we could not have done anything without the support of our colleagues on the Consensus Group who met in Zurich and Berlin and who toiled tirelessly to develop the framework for the new tool. Thanks also to the members of the ITI Education Committee and all the others who acted as our beta testers, and to those who have contributed material to this book. The quality of the group-achieved outcome is much, much more than the sum of the contributing parts.
And finally, but most importantly, we must thank our wives, children and families for their understanding and support. We could not have done this without you.
Anthony Dawson, BDS, MDS, FRACDS
Associate Professor in Prosthodontics
School of Dentistry and Medical Sciences
Charles Sturt University
346 Leeds Parade
Orange, New South Wales 2800
Australia
Email: tdawson@csu.edu.au
William C. Martin, DMD, MS, FACP
Clinical Professor and Director
Center for Implant Dentistry
Department of Oral and Maxillofacial Surgery
College of Dentistry
University of Florida
1395 Center Drive, Rm D7-6
Gainesville, Florida 32610
United States of America
Email: wmartin@dental.ufl.edu
Waldemar D. Polido, DDS, MS, PhD
Clinical Professor, Department of Oral and
Maxillofacial Surgery and Hospital Dentistry
Co-Director, Center for Implant, Esthetic and
Innovative Dentistry
Indiana University School of Dentistry
1121 W Michigan St, DS 109C
Indianapolis, Indiana 46202
United States of America
Email: wdpolido@iu.edu
Daniel Buser, DMD, Dr med dent
Professor Emeritus
University of Bern
Buser & Frei Center for Implantology
Werkgasse 2
3018 Bern
Switzerland
Email: danbuser@mac.com
Paolo Casentini, DDS, DMD
Private practice
Studio Dr Paolo Casentini
(Implantology, Oral Surgery, Periodontology, Esthetic Dentistry)
Via Anco Marzio 2
20123 Milano MI
Italy
Email: paolocasentini@fastwebnet.it
Vivianne Chappuis, PhD, DMD
Professor
Department of Oral Surgery and Stomatology
School of Dental Medicine
University of Bern
Freiburgstrasse 7
3010 Bern
Switzerland
Email: vivianne.chappuis@zmk.unibe.ch
Stephen Chen, MDSc, PhD
Faculty of Medicine, Dentistry and Health Sciences
Melbourne Dental School
The University of Melbourne
720 Swanston Street
Carlton, Victoria 3053
Australia
Email: schen@periomelbourne.com.au
Matteo Chiapasco, MD
Professor Unit of Oral Surgery
Department of Biomedical, Surgical, and Dental Sciences
University of Milan
Via della Commenda 10
20122 Milano MI
Italy
Email: matteo.chiapasco@unimi.it
Anthony J. Dickinson, OAM, BDSc, MSD, FRACDS
1564 Malvern Road
Glen Iris, Victoria 3146
Australia
Email: ajd1@i-pros.com.au
Luiz H. Gonzaga, DDS, MS
Clinical Associate Professor
Center for Implant Dentistry
Department of Oral and Maxillofacial Surgery
College of Dentistry
University of Florida
1395 Center Drive, Rm D7-6
Gainesville, Florida 32610-0434
United States of America
Email: lgonzaga@dental.ufl.edu
Stefan Keller Babotai, Dr sc nat
FERN Media Solutions GmbH
Weiherallee 11B
8610 Uster
Switzerland
Email: stefan.keller@fern.ch
Johannes Kleinheinz, MD, DDS Professor
Department of Cranio-Maxillofacial Surgery
University Hospital Münster
Albert-Schweitzer-Campus 1
48149 Münster
Germany
Email: johannes.kleinheinz@ukmuenster.de
Wei-Shao Lin, DDS, FACP, PhD
Associate Professor
Interim Chair, Department of Prosthodontics
Program Director, Advanced Education Program in Prosthodontics
Indiana University School of Dentistry
1121 W Michigan St, DS-S406
Indianapolis, Indiana 46202
United States of America
Email: weislin@iu.edu
Dean Morton, BDS, MS, FACP
Professor Department of Prosthodontics
Director, Center for Implant, Esthetic, and Innovative Dentistry
Indiana University School of Dentistry
1121 W Michigan St
Indianapolis, Indiana 46202
United States of America
Email: deamorto@iu.edu
Ali Murat Kökat, DDS, PhD
Prosthodontist
Private Practice
Valikonaǧı St 159/5
Nisantasi 34363 Sisli
Istanbul
Turkey
Email: alimurat@outlook.com
Mario Roccuzzo, DMD
Lecturer in Periodontology
Division of Maxillofacial Surgery
University of Turin
Corso Bramante 88
10126 Torino
Italy
and
Adjunct Clinical Assistant Professor
Department of Periodontics and Oral Medicine
University of Michigan
1011 N University Avenue
Ann Arbor, Michigan 48109-1078
United States of America
and
Private Practice Limited to Periodontology
Corso Tassoni 14
10143 Torino
Italy
Email: mroccuzzo@icloud.com
Charlotte Stilwell, DDS
Specialist Dental Services
94 Harley Street
London W1G 7HX
United Kingdom
Email: charlotte.stilwell@iti.org
Alejandro Treviño Santos, DDS, MSc
Postdoctoral and Research Division
Faculty of Dentistry
Department of Prosthodontics and Implantology
National Autonomous University of Mexico
Prolongación Reforma 1190
05349, Santa Fe
Ciudad de México
Mexico
Email: aletresan@hotmail.com
Daniel Wismeijer, PhD, DMD
Private Practice
Zutphensestraatweg 26
6955 AH Ellecom
Netherlands
Email: Danwismeijer@gmail.com
Chapter 1:
Introduction to the Updated SAC Classification
A. DAWSON, W. MARTIN, W. D. POLIDO
1.1 Introduction
1.2 Historical Background
1.3 The Review Team
1.4 Potential Roles for the SAC Classification
1.5 Using this Book
Chapter 2:
The Rationale Behind the Updated SAC Classification
A. DAWSON, C. STILWELL
2.1 Definitions
2.2 Assumptions
2.3 Is the Clinician a Risk Factor?
2.3.1 Factors impacting the clinician as a risk factor
2.3.1.1 Experience
2.3.1.2 Training
2.3.1.3 Self-assessment of ability
2.3.1.4 Shared learning
2.3.1.5 Short training courses
2.3.1.6 Structured education and training
2.3.2 Reducing clinician-related risk
2.3.2.1 Recognizing “human factor” risks
2.3.2.2 Stress as a risk factor
2.3.2.3 Mitigating the human factor issues
2.3.2.4 Clinician risk factor in relation to other sources of risks
2.4 Classification Rationale
Chapter 3:
Risks in Implant Dentistry
A. DAWSON, W. MARTIN, W. D. POLIDO
3.1 Principles of Risk Management
3.2 The SAC Classification as a Risk Management Tool
3.3 General Risks
A. DAWSON, J. KLEINHEINZ, A. MURAT KÖKAT, D. WISMEIJER
3.3.1 Patient medical factors
3.3.1.1 Medical fitness
3.3.1.2 Medications
3.3.1.3 Radiation
3.3.1.4 Growth status
3.3.2 Patient attitudes/behaviors
3.3.2.1 Smoking habit
3.3.2.2 Compliance
3.3.2.3 Oral hygiene
3.3.2.4 Patient expectations
3.3.3 Site-related factors
3.3.3.1 Periodontal status
3.3.3.2 Access
3.3.3.3 Previous surgeries in the planned implant site
3.3.3.4 Nearby pathology
3.4 Esthetic Risk
W. MARTIN, V. CHAPPUIS, D. MORTON, D. BUSER
3.4.1 Medical status and smoking habit
3.4.2 Gingival display at full smile
3.4.3 Width of the edentulous space
3.4.4 Shapes of tooth crowns
3.4.5 Restorative status of adjacent teeth
3.4.6 Gingival phenotype
3.4.7 Volume of surrounding tissues
3.4.8 Patient’s esthetic expectations
3.5 Edentulous Esthetic Risk Assessment (EERA)
L. GONZAGA, W. MARTIN, D. MORTON
3.5.1 Facial support
3.5.2 Labial support
3.5.3 Upper lip length
3.5.4 Buccal corridor
3.5.5 Smile line
3.5.6 Maxillomandibular relationship
3.6 Surgical Risks
W. D. POLIDO
3.6.1 Anatomy
3.6.1.1 Bone volume – Horizontal
3.6.1.2 Bone volume – Vertical
3.6.1.3 Presence of keratinized tissue
3.6.1.4 Quality of soft tissues
3.6.1.5 Proximity to vital anatomical structures
3.6.2 Adjacent teeth
3.6.2.1 Papilla
3.6.2.2 Recession
3.6.2.3 Interproximal attachment
3.6.3 Extractions
3.6.3.1 Radicular morphology / interradicular bone
3.6.3.2 Alveolar and basal bone morphology
3.6.3.3 Socket walls
3.6.3.4 Thickness of facial wall
3.6.3.5 Anticipated residual defect after implant placement
3.6.3.6 Quality and quantity of soft tissues
3.6.4 Surgical complexity
3.6.4.1 Timing of placement
3.6.4.2 Grafting procedures
3.6.4.3 Number of implants
3.7 Prosthetic Risks
C. STILWELL, W. MARTIN
3.7.1 Restorative site factors
3.7.1.1 Prosthetic volume
3.7.1.2 Interocclusal space
3.7.1.3 Volume and characteristics of the edentulous ridge
3.7.2 Occlusal factors
3.7.2.1 Occlusal scheme
3.7.2.2 Involvement in occlusion
3.7.2.3 Occlusal parafunction
3.7.3 Complexity of process
3.7.3.1 Access
3.7.3.2 Interim prosthesis
3.7.3.3 Implant-supported provisional restoration
3.7.3.4 Number and location of implants
3.7.3.5 Loading protocols
3.7.4 Complicating factors
3.7.4.1 Biologic
3.7.4.2 Mechanical and technical
3.7.4.3 Maintenance
Chapter 4:
How Does the SAC Assessment Tool Derive a Classification?
A. DAWSON, S. KELLER
4.1 Introduction
4.2 Definitions
4.3 Workflow
4.3.1 General risk assessment (GRA)
4.3.2 Esthetic risk assessment (ERA)
4.3.2.1 ERA
4.3.2.2 EERA
4.3.3 Surgical risk assessment (SRA) and surgical classification
4.3.4 Prosthodontic risk assessment (PRA) and prosthodontic classification
4.4 Calculating a Classification
4.4.1 Calculation mechanism
4.5 Testing the Algorithm
4.6 Presenting the Results
Chapter 5:
Practical Application of the SAC Assessment Tool
W. MARTIN, A. DAWSON, W. D. POLIDO
5.1 Introduction
5.2 Implants for Restoration of Single-Tooth Spaces: Areas of Low Esthetic Risk
5.2.1 Mandibular molar
M. ROCCUZZO
5.2.2 Mandibular molar
L. GONZAGA
5.3 Implants for Restoration of Single-Tooth Spaces: Areas of High Esthetic Risk
5.3.1 Maxillary central incisor
L. GONZAGA, W. MARTIN
5.3.2 Maxillary lateral incisor
A. TREVIÑO SANTOS
5.4 Implants in Extraction Sockets: Single-Rooted Teeth
5.4.1 Maxillary central incisor
W. MARTIN, L. GONZAGA
5.4.2 Maxillary premolar
L. GONZAGA
5.5 Implants in Extraction Sockets: Multirooted Teeth
5.5.1 Maxillary first molar
P. CASENTINI
5.6 Implants for Restoration of Short Edentulous Spaces: Areas of Low Esthetic Risk
5.6.1 Adjacent maxillary premolars
S. CHEN, A. DICKINSON
5.7 Implants for Restoration of Short Edentulous Spaces: Areas of High Esthetic Risk
5.7.1 Adjacent maxillary incisors
P. CASENTINI, M. CHIAPASCO
5.8 Implants for Restoration of Long Edentulous Spaces: Areas of High Esthetic Risk
5.8.1 Maxillary lateral and central incisors
A. TREVIÑO SANTOS
5.9 Implants for Restoration of Long Edentulous Spaces: Removable Prostheses
5.9.1 Maxilla
C. STILWELL
5.10 Implants for Restoration of the Full Arch: Removable
5.10.1 Edentulous maxilla: Bar-supported overdenture:
WS. LIN, D. MORTON
5.10.2 Edentulous maxilla: Zygomatic implant bar-supported overdenture
W. D. POLIDO, WS. LIN
5.11 Implants for Restoration of the Full Arch: Fixed
5.11.1 Edentulous mandible: Fixed dental prosthesis
P. CASENTINI
5.11.2 Edentulous maxilla and mandible: Implant-supported all-ceramic fixed complete dentures
D. MORTON, WS. LIN, W. D. POLIDO
Chapter 6:
Conclusion
A. DAWSON, W. MARTIN, W. D. POLIDO
Chapter 7:
References
Implant dentistry is an integral part of modern dental practice, providing a strong evidence-based option for the rehabilitation of partially and completely edentulous patients. Clinical and technologic advancements in this field have increased the level of confidence that clinicians have in this form of therapy and have also led to a broader base of incorporation into daily practice. What was once the domain of specialist practice is now a common treatment modality in many, if not most, general practices. This has increased the need for all clinicians involved with the field of implant dentistry, irrespective of specialty, to be able to provide therapy at an appropriate level of care.
It has long been recognized that clinical situations present with different levels of difficulty and with different degrees of risk for esthetic, restorative, and surgical complications. Despite the advances in knowledge and improved techniques, implant dentistry is not free from risks of complications or suboptimal outcomes. Over the last decade, research in this field has increasingly provided information regarding the risks associated with this treatment option. The successful osseointegration of an implant is no longer the primary focus of treatment. Rather, the range of potential problems with implants and their related prostheses has come into sharper focus. It is in this environment that the SAC classification has evolved to assist practitioners in recognizing risk factors and providing appropriate levels of care.
The concept of assessing risk factors in implant dentistry has attracted considerable attention since the early 1990s, when the number of clinicians placing and restoring implants increased significantly. With this increase in use, the number of associated complications also increased.
Renouard and Rangert (1999) published a classification system that addressed the risk factors involved with the surgical and restorative phases of implant rehabilitation. At that time, they affirmed that some risk factors are relative, while others are absolute. The distinction between the two is not as clear as it might appear. However, several relative contraindications or one absolute contraindication should lead to a reevaluation of the original treatment plan. Although they were using terms like “OK,” “Caution,” and “Danger,” and using the green, yellow, and red colors associated with increased risk factors, an integrated decision tree was not present.
The term SAC, with the associated risk factor classification and color scheme, was first used by its two creators, Sailer and Pajarola (1999), in an atlas of oral surgery, with the intent to classify risk factors for general dentists practicing dentoalveolar surgery. The authors described in detail various clinical situations for procedures in oral surgery, such as the removal of third molars, and proposed the classification S = Simple, A = Advanced, and C = Complex. This concept was then adopted in 1999 by the Swiss Society of Oral Implantology (SSOI) during a 1-week congress on quality guidelines in dentistry. The working group of the SSOI developed this SAC classification from a surgical and prosthetic point of view for various clinical situations in implant dentistry. This SAC classification was then adopted by the International Team for Implantology (ITI) in 2003 during the ITI Consensus Conference in Gstaad, Switzerland. The surgical SAC classification was presented in the proceedings of this conference (Buser et al, 2004). The ITI Education Core Group decided in 2006 to slightly modify the original classification by changing the term Simple to Straightforward.
Fig 1. The participants of the SAC Consensus Conference held by the ITI in Palma de Mallorca in March 2007. (Source: The SAC Classification in Implant Dentistry, 2009).
In March 2007, the ITI held a consensus conference in Palma de Mallorca in Mallorca, Spain aimed at improving on the SAC classification (Figure 1). In its initial form, the SAC classification tended to be subjective, as it related the perceived difficulty of the treatment to the individual practitioner. The Mallorca meeting sought to develop a classification scheme that was more structured and objective. The results of this conference were published in an adjunct to the ITI Treatment Guide series in 2009 (Dawson & Chen, 2009). Later in 2009, the ITI developed an SAC Assessment Tool that clinicians could use to determine the normative classification for a case type that they were treating and identify any additional modifying factors that might apply to their own patient’s clinical situation.
The participants in the first SAC Conference were as follows: Urs Belser (Switzerland), Daniel Botticelli (Italy), Daniel Buser (Switzerland), Stephen Chen (Australia), Luca Cordaro (Italy), Anthony Dawson (Australia), Anthony Dickinson (Australia), Javier G. Fabrega (Spain), Andreas Feloutzis (Greece), Kerstin Fischer (Sweden), Christoph Hämmerle (Switzerland), Timothy Head (Canada), Frank Higginbottom (USA), Haldun Iplikcioglu (Turkey), Alessandro Januario (Brazil), Simon Jensen (Denmark), Hideaki Katsuyama (Japan), Christian Krenkel (Austria), Richard Leesungbok (South Korea), Will Martin (USA), Lisa Heitz-Mayfield (Australia), Dean Morton (USA), Helena Rebelo (Portugal), Paul Rousseau (France), Bruno Schmid (Switzerland), Hendrik Terheyden (Germany), Adrian Watkinson (UK), and Daniel Wismeijer (Netherlands).
The 2009 version of the SAC classification scheme has received widespread acceptance in the dental profession and in the realm of dental education (Mattheos et al, 2014), where it has formed the basis of implant dentistry teaching in many predoctoral and postgraduate dental programs.
From its initial release in 2009, clinical techniques, materials, and technology have continued to evolve and, in early 2017, the ITI recognized that there was a need to review the SAC classification to ensure that it was still consistent with contemporary implant practice. A review group met in Zurich in October 2018, and again in Berlin in April 2019, to develop an updated SAC classification scheme. The primary aim of this review was to develop an updated SAC Assessment Tool, as this had been found to be clinicians’ favored way of determining the classification of their patients’ treatment needs. The publication of this book satisfies the secondary goal of the review: to document the rationale for this SAC Assessment Tool and the evolution of the SAC classification.
This text documents the proceedings of consensus meetings held by the ITI in 2018 and 2019. The following individuals contributed to the findings of this conference and the content of this publication (Figure 2):
Fig 2. Review team members.
Paolo Casentini |
Italy |
David Cochran |
USA |
Anthony Dawson |
Australia |
Luiz Gonzaga |
USA |
Stefan Keller |
Switzerland |
Thomas Kiss |
Switzerland |
Johannes Kleinheinz |
Germany |
Ali Kökat |
Turkey |
William Martin |
USA |
Dean Morton |
USA |
Waldemar Polido |
USA |
Lira Rahman |
Switzerland |
Mario Roccuzzo |
Italy |
Irena Sailer |
Switzerland |
Charlotte Stilwell |
UK |
Mauro Tosta |
Brazil |
Alejandro Treviño Santos |
Mexico |
Daniel Wismeijer |
Netherlands |
On its surface, the SAC classification provides an assessment of the potential difficulty and risk of an implant-related treatment for a given clinical situation and serves as a guide for clinicians in both patient selection and treatment planning. In addition, it can also fulfill several additional roles.
Primarily, the classification scheme is aimed at providing clinicians with an objective and evidence-based framework against which they can assess clinical cases regarding the complexity of the planned treatment. This can then be used to assist them in deciding if they possess the necessary skills and knowledge to complete the treatment themselves, or whether referral to a more experienced clinician is indicated. With this capacity, they can build their experience in implant dentistry incrementally and minimize potential risk to their patients. Recently, the current SAC Assessment Tool validity was tested in regard to the agreement level between users, confirming its role as a clinical decision-making tool, as well as a valuable tool for the education of less experienced clinicians (Correia et al, 2020).
The SAC classification can also act as a checklist for more experienced clinicians to help them ensure that all relevant risks have been considered in the patient assessment and treatment planning phases of care.
Communication is a vital part of any step of patient management. In this regard, the SAC classification can aid in communication between clinicians as well as between them and their patients. The classification facilitates communication between colleagues by providing a known framework to exchange information: a shorthand that all involved clinicians are familiar with. When dealing with patients, clinicians can use the SAC classification of their situation to illustrate to patients the complexity and risks associated with their care. As such, it becomes an important tool not only in treatment planning but in the informed consent process as well.
Finally, the SAC classification can aid educators in developing training programs that gradually introduce increasingly more complex cases to their students, allowing an incremental development of knowledge and skill.
This book is intended to support your use of the SAC Assessment Tool that can be found at www.iti.org. Many sections of this publication are also supported by additional online information from the ITI Academy, the ITI’s e-learning platform, including learning modules and assessments, congress lectures, clinical cases, and Consensus Conference papers.
To view this additional material in full and for free, you need to be an ITI Member and logged in at www.iti.org.
Are you an ITI Member?
Please click here to log in to the ITI Academy or scan the QR code below:
Would you like to sign up for ITI membership?
Please click here or scan the QR code below:
Would you like to create a free ITI Academy account?
Please click here or scan the QR code below. Please note that only selected items featured in this publication will be available to view on the ITI Academy free of charge.
As soon as you have logged in or have created your free ITI Academy account, and if you are reading the print version of this publication, you can scan QR codes like the one below and will be taken to the corresponding item in the ITI Academy.
If you are an ITI Member and reading the online version of the book on the ITI Academy, you can also click on the link in the text that accompanies each QR code:
|
The SAC Assessment Tool distills the content of this book in an easy-to-use process that takes you through each step necessary to identify the degree of complexity and potential risk involved in individual clinical cases. To start your assessment, scan the QR code to the left or click on the link. |
Please refer to chapter 1, section 1.5 for information on the prerequisites for accessing the additional online information from the ITI Academy via the QR-codes and links provided in this chapter.
Please note that to view this additional material in full and for free, you need to be an ITI Member and logged in at www.iti.org.
Case type A class of implant-supported prostheses that share similar defining characteristics. For example, implant-supported crowns for single-tooth replacements, or short-span implant-supported fixed dental prostheses replacing three or four teeth and supported by two implants.
Process: The implant dentistry “process” is defined as the full range of issues pertaining to assessment, planning, management of treatment, and subsequent maintenance of the implant and prosthetic reconstruction; it does not merely refer to the clinical treatment procedures that are involved.
Normative classification In this context, “normative” relates to the classification that conforms to the norm, or standard, for a given clinical situation in implant dentistry. The normative classification relates to the most likely classification of a case type. The final classification of a specific case may differ from the normative classification for the case type as a result of individual risk factors.
Timing of implant placement and loading: Loading and placement protocols have been investigated by the ITI at its last four Consensus Conferences. Hämmerle and coworkers (Hämmerle et al, 2004) defined the timing of implant placement relative to the event of tooth removal in a site, relating this to healing events rather than a specific time frame. This classification is detailed in Table 1.
Table 1 Implant placement protocols (Hämmerle et al, 2004).
Classification |
Definition |
Type 1 |
Implant placement immediately following tooth extraction and as part of the same surgical procedure |
Type 2 |
Complete soft tissue coverage of the socket (typically 4 to 8 weeks) |
Type 3 |
Substantial clinical and/or radiographic bone fill of the socket (typically 12 to 16 weeks) |
Type 4 |
Healed site (typically more than 16 weeks) |
|
Review article from the 3rd ITI Consensus Conference on the Placement of Implants in Extraction Sockets by Hämmerle and coworkers (2004). |
Implant loading protocols were also the subject of consensus conference reviews. At the Fourth ITI Consensus Conference, Weber and coworkers (Weber et al, 2009) defined the timing of implant loading relative to its placement. These descriptions are summarized in Table 2.
Table 2 Implant loading protocols (Weber et al, 2009).
Classification |
Definition |
Conventional loading |
Greater than 2 months subsequent to implant placement |
Early loading |
Between 1 week and 2 months subsequent to implant placement |
Immediate loading |
Earlier than 1 week subsequent to implant placement |
|
Review article from the 4th ITI Consensus Conference on Loading Protocols by Weber and coworkers (2009). |
Most recently, the relationships between the timing of implant placement (relative to the time that the tooth in the placement site was extracted) and the timing of loading of the implant with a provisional or definitive prosthesis in partially dentate patients were addressed by Gallucci et al (Gallucci et al, 2018). The outcomes of this review, correlating the evidence for the various combinations of placement and loading protocol, are summarized in Table 3
