Free excerpt - SAC Classification in Implant Dentistry

5 PRACTICAL APPLICATION OF THE SAC ASSESSMENT TOOL

Fig 5. Overall treatment classification: Surgical classification = complex; Prosthodontic classification = straight­ forward.

of periodontitis should be informed that they are at higher risk of peri-implant disease and may need further therapy to limit the nature and extent of biologic complications over time (Roccuzzo et al, 2012; Roccuzzo et al, 2014). Based on these considerations, two therapeutic options were presented to the patient: 1. E xtraction of tooth 47, guided bone regeneration (GBR), and placement of two implants.

One Tissue Level Implant (Standard Plus, Ø 4.8 mm wide neck, SLActive 10mm, Straumann) was positioned at site 46 according to the International Team for Implantology (ITI) principles: “The apicocoronal positioning of the implant shoulder follows the philosophy as shallow as possible; as deep as necessary” (Buser et al, 2004). This meant a place- ment of 1 mm below the cementoenamel junction (CEJ) of the adjacent teeth. Ideal positioning created a dehis- cence-type bone defect on the buccal and distal aspects of the implant. After placement of the implant, amelogenin (Emdogain, Straumann) was applied on the previously dried surface of the root (Figure 7). Autogenous bone was placed in contact with the implant surface, followed by a thick lay- er of deproteinized bovine bone mineral (DBBM; Bio-Oss, Geistlich) to completely fill the defects and rebuild an ideal crest profile (Figure 8). A resorbable collagen membrane (Bio-Gide, Geistlich) was trimmed, punched with a Ø 5.0 mm biopsy punch, and adapted around the collar of the implant to stabilize the graft (Figure 9). A 2-mm healing cap was used to stabilize the membrane and to facilitate the close adaptation of the flap in the inter- proximal area (Figure 10). Modified vertical mattress Vicryl (Johnson & Johnson) su- tures were used to seal the flap around the implant for nonsubmerged healing and were kept in place for 2 weeks (Figure 11). Six weeks after surgery, the patient was instructed to re- sume regular and normal plaque control (Figure 12). Three months after surgery, the mucosa appeared healthy and free from inflammation, around both the implant and the adjacent teeth (Figure 13). The radiograph demonstrated complete bone fill (Figure 14), and a solid abutment was in-

Treatment surgical risk = Advanced

2. Implant placement in site 46 in combination with guided tissue regeneration (GTR) on 47.

Treatment surgical risk = Complex (Figure 5)

The patient was therefore informed about the pros and the cons of both procedures and gave his informed consent for the second treatment. Surgery was performed after the assurance of good motiva- tion and compliance from the patient (full-mouth plaque score < 20%; full-mouth bleeding score < 20%). The clinical procedure for periodontal and peri-implant bone regenera- tion was based on following: (1) increase in flap/wound sta- bility, (2) improvement of primary closure of the wound, and (3) minimization of intraoperative and postoperative patient morbidity. After flap elevation, the granulation tissue was removed from the defect using curettes followed by ultrasonic instru- mentation. The root surface was thoroughly scaled and con- ditioned with 24% ethylenediaminetetraacetic acid (EDTA) gel (PrefGel, Straumann) for 2minutes to remove any smear layer. The site was then copiously rinsed with sterile saline solution (Figure 6).

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The SAC Classification in Implant Dentistry