Bone Level vs. Tissue Level Implant?

every implant is bone level implant,no implant is placed over the bone level ( unless you are grafting and trying to gain in height)in the other hand, restoration technique may be bone level or tissue level.

I think the simplest way to go is to ask your surgeon this question.

This is my personal experience: theoretically, soft- tissue level implants are less prone to bone loss, as the gap is placed above the bone level. However they are much more difficult to place in the ideal position (height and angulation)and the shorter abutment they are restored with makes it even more difficult for compensating their angulation. The straumann soft tissue level isn't even tapered, for historic reasons I guess, causing more fenestration and thus more need for grafting in the anterior maxilla. Here they also need to be placed more palatally to prevent their collar from protruding buccally resulting in gingival recession. All of this makes them far more demanding for 'occasional' implantologists (and restorative dentists). I admire the excellent aesthetic results the ITI- members have published in their books, but frankly, it could (and should) be much easier than that. And even they must recognise this, what other reason is there for their recent switch to their 'new' bone level implant? Therefore I now use the soft tissue level implants only for mandibular overdentures, molar replacement and in older patients, and stick to the bone level in more esthetic indications. I think this is what most straumann customers do nowadays.

Strauman has a tapered implant with the tissue level head. It is the Tapered Effect implant. It has the same thread design as the Bone Level.

See Platform Switching: Evidence for this Protocol? Topic and thread

that depends upon the implant system you use ,if your implant has a polished collar and sufficient keratinized tissue height and clearance in the opposite arch ,you can place 2mm above the bone level

the main purpose of soft tissue level implant is to be able to do screw retained bridges without using one long screw going all the way from the crown to the implant, instead they use multi unit abutment first piece to be connected to the implant (by screw) and projects till the margins of the soft tissue and the final bridge will be retained over this first abutment which has itself a hole for screw to be inserted. this can be compensated by using cemented bridges ( the abutment will be directly at implant level) but the problem with them is less flexibility in inserting because they can't tolerate angulation errors in long spam bridges. it is big topic needs more illustrations to be get the idea.

the main purpose of soft tissue level implant is to be able to do screw retained bridges without using one long screw going all the way from the crown to the implant, instead they use multi unit abutment first piece to be connected to the implant (by screw) and projects till the margins of the soft tissue and the final bridge will be retained over this first abutment which has itself a hole for screw to be inserted. this can be compensated by using cemented bridges ( the abutment will be directly at implant level) but the problem with them is less flexibility in inserting because they can't tolerate angulation errors in long spam bridges. it is big topic needs more illustrations to get the idea.

Dr Khalil Bone level implants are more restrictive as the internal connections are at 7 degress to 15degrees. That means that if your off, then the passivity is hooped unless you do custome abutments which raise the cost. The multi abutments are morew flexible as the bride components are more than the 154 degrees. The purpose of the bone levels is to shift the prosthetic cost to the restorative doctor and the complexity of the soft tissue conditioning to the next phase and also to shift the margin responsibility. The companies are reaping a windfall over this.

It is essential to have a healthy attached gingiva around an implant,so it is necessary to put implants at the bone levels and cover them with 2-4 milimetere healing abutments(in one stage surgery).it is obvious that after a time we should prepare to have about 1-2 milimeter resorption of gingival tissue so if we had put our implant at tissue level the thread of the implant will expose and this is a negative situation that we can never solve ,so i prefer to put all of my implant at bone level,the exception is in posterior area with a limited lenght of implant like 7 mm ,in these situation i have never choice to put it at tissue level. Dr.Hajiheshmati implantologist

To Dr.Hajiheshmati, Implantologist Once for all, there is NO attached gingiva around an implant. There is NO gingiva either. There is a peri-implant mucosa which can be keratinized or not. This drives me nuts every time I read that. Sorry about the rant. Dr Fabe Periodontist

I am still a neophyte when it comes to placing implants but I believe the answer to your question is as follows: All implants should have their threads buried to the crest of bone. Those implants that have a shiny collar of polished metal above the threads and protrude above are the tissue level implants. Those implants that have threads that stop at the top of the implant and no shiny metal collar are the bone level ones and I use those more for the anterior/esthetic zone. 90% of my implants that I've placed so far are in the bicuspid, molar area and are tissue level. In the posterior there is more forgiveness when it comes to esthetics as you can't always see that metal collar. In the anterior , this is not the case. It's hard to treatment plan for only one type of implant unless you stick to the back teeth. I hope this was helpful.

one of the important factores in planning implant leveling with bone is gingiva biotype,in case of thin gingiva it is better to put the implant more flushed with bone for two reasons,first expected marginal bone loss,seconed avoidence of wound fenestration.In case of thick gingiva,we leave part of flushed surface above bone for elimination of pocket formation,no risk of fenestration &also allowing for biological width.

Dr.Hajiheshmati Not all collors are polished since some are machined and act differantly from each other. Bone grows to machined but the microgap must be stable. You need to know which one you are working with. And also, what is the microgap distance and stability under bruxing forces that exceed 200 ums force. The key is Diagnostics Distance of gap from Bone Stability of Microgap 3D placement. Gingival biotype Smile line. Choice of abutment(screwed and cemented) Technical support from lab and Manufacturer. 5 kinds of abutments are available from some manufacturers but not all.

In terms of a tissue level implant resulting in bone loss and subsequent tissue loss, I recommend looking further into Astra Tech and the Straumann bone level. Astra has somewhere around 40 published studies documenting .3mm of bone loss over 5 years as all of their implants are bone level. Why are we accepting 1-2mm of bone loss around implants?! Restoratively speaking, I couldn't be happier. Straumann cloned a few of Astra's features but no long-terms research yet as I am aware.

Bone level - the titanium is roughened all the way to the top and the implant is placed level with the bone. Tissue level - the implant has polished titanium, usually about 2mm, at the top. The implant is placed level with the tissue. I basically only place bone level implants because: 1. There is less crestal bone loss if a platform switching abutment (medialized abutment eg. astra) is used 2. There is more room to develop an emergence profile making the tooth look more natural. 3. I don't have to worry about recession exposing the metal on the implant. You CAN keep is simple and place only bone level implants. My favorite is the Blue Sky Bio Trilobe.

This is a concept that has been around for some time. I remember Tatum describing this in the implant program at Howard in 1992. Linkow's early root forms had the same concept, with the polished collar. They have their place in dentistry.

To answer the question: Bone level implants are implants that are placed flush with the crest of the alveolar bone or even slightly below and this was a classical surgical feature of the traditional Branemark implants (countersinking was necessary then to sink the slightly wider implant head within the bone and have the cover-screw placed without protruding through the mucosa after flap closure. The literature ususlly refers to these implants as 2-piece implants as a transmucosal part (abutment) will then be connected to the implant to protrude through the mucosa to carry the restoration. The tissue level implants represented by the original ITI/Straumann implants are not placed at the crest of the bone but few mm above and in some cases where esthetics is not critical will be even at the level of the mucosa. These implants are referred to as one-piece implants. The main controversy between the two types aside from what was mentioned by other colleagues is related to the presence or absence of a microgap at the implant-abutment interface. With the 2-piece implants (ie bone level implants) a gap exists between the implant and the abutment close the crest of the bone such as in the Branemark implants and their alikes, while with the one-piece implants (ie tissue level implants) the gap is shifted more coronally above the bone level such as in the Straumann implants. The significance of this microgap is said to be related to the amount of bone loss expected around these implants (see D. Cochran publications comparing the one-piece and 2-piece implants) and now becoming even more controversial with the emerging platform switching concept. I think if you are working in the esthetic zone, you will have more control over the restoration with bone level implants, because you have wider range of options in abutment selection and to correct implant mal-angulation. If working in less critical areas or when overdentures are the planned restorations either type would do.

All of the previous posts have very well described the differentiation between bone level and tissue level implants and also have addressed the rational for the two designs. I do believe there is a place for both bone level and tissue level implants and in my clinic, I inventory both types and utilize one or the other on a case by case basis.

JUST TO BE CLEAR THE ORGIGNAL BRANEMARK IMPLANT WAS PLACED TO THE BONE BUT EXPERIENCED BONE LOSS DUE TO microgap INSTABILITY and tolorance issues. ITI Straumann raised the MIcrogap to 1.8mm due to David Cochrans work on the Biological width issues with a POLISHED oollor. Astra added along with Dentsply and others the microgap SIDE SHIFT. Platform shifted implants that preserved the bone thru a change in position laterally and also micron size of bacteria infiltration to around 10 ums. There are others that have designed the implant with an original machined collor that can be used as bone level or tissue level and that is the differance. The stability and tollorance is taken into consideration to achieve this Question the stability and tolorance and collor surface?

i think robert 56 is right at the Tissue level the implant the implant is placed level with the tissue.

It is amazing to me that this is our profession and how little each individual actual knows about implants and there performance. Research each design, learn what the design concept is completely about and what the clinical results are achieved through the research that can be provided. Conus interfaces have proved to be a better biomechanical connection and by design have to move the interface away from the bone. Platform shifting, switching... are two flat to flat wrong parts being pieced together that MAY preserve crestal bone.

Nice thought David There arehundreds of companies with similer designs b ut some designs imoprove and some dodge patents. Hard to believe everyone since some studies are paid for and skewed and some are ligit. But, we all must spend time and pay attention to the engineering design and maximise it. Also we need to use multiple systems as some are out of their indications. BTW The indications are in the packages and to get at them, you must buy the product or ask you rep to bring in a copy and help intrepret it. Many break the rules daily.

R

Robert 56: Right On!

Bone level implants are only now starting to be understood. With a tapered connection and a platform switch they both show very significant differences in bone and tissue recession. It is not yet confirmed but they may be able to be placed closer together than 3mms without the unzipping of the bone between them and they also can probably can be put closer to natural teeth than 2mms. When you are placing an anterior implant you are always placing the implant subcrestal to some reference such as the interproximal bone. The question is do you want to use an implant system that predictably can maintain the bone or dont you. This is why astra and ankylos are growing so quickly and why straumann and others are getting into this design. There are many reasons for why these implants behave differently - it is probably not just one reason - it is probably a series of design features that create a different biology around the implant and abutment.

Tissue level implants provide 1 single agvantage: when healing, mucosa attaches to the neck without epitelial ingrowth right to the crest level. When restoring(removing healing abatment,placing transfers etc), this connection will not be torn apart, as implant/abatment connection is more coronal. The biology is - there must be a connective tissue connection near the implant.When restoring bone level implants, connection is torn and epitelium grows deeper, and,consequently, a new connection is formed more apically(often to the implant first threds :( ). This is where platform switch gets handy: connective tissue attachement can establish itself to the slopping shoulder of the implant(hear it stays,as we do not tear it). Basically, with emergence of systems with platform switch and conicall connection, I anticipate tissue level implants go into history. If i was forced, i would only use tissue level at the molar area and only in people who prefer function to aesthetics.

Bl implant s are making the companies more$ I believe in superior placement. Restortive Bl's cost more. TL placed properly cost less. Get it. But there is a place for Bl's i n some casework.

Bone level: implant/abutment interface is at level of crestal bone, or slightly sub-osseous. Tissue level: interface is above the crestal level, since the interface is atop a polished collar which is about 2mm in height. The bone level abutment thus has about 2mm more length which allows for easier development of a more favorable emergence profile. Hope this helps.

PerioDoc Not all collors are polished. Some are machined like the ole Branemark implant that grows to the surface with more stable connections that do not harbor bacteria like some that have gaps that are above 10 microns and unstable to boot. Some are new hybird designs that act as platform shifted implants as well as Tissue level implants. BL types do cost more for restorative parts and more for labor and most likly CAD CAM abutments that escalate the cost. As long as your good with that then both can achieve the same results.

Your surgeon is discussing the Straumann implant system. Have the Straumann rep sit down and explain the differences. All the other blogs are informational but the actual term bone level and tissue level derive from the Straumann implant designs. In short, the tissue level implant is one piece, with the finish line on the implant and this finish line is positioned by the surgeon. It is fine for posteriors where esthetics are not critical. The bone level implant is a two piece implant and requires an abutment to bring it to the crest of tissue (or beyond), The restorative dentist positions the finish line, not the surgeon. Much better implant anteriorly for esthetics.

I've restored many Straumann "tissue level" and "bone level" implants. In 2008, I submitted an idea to Rowland Herzog of Straumann regarding emergence profile as it relates to their "bone level" implant. The presentation included the pitfalls related to their temporary implant abutments, inaccurate transfer of emergence profile to labs, as well as the long chairside procedures and the various ways to solve them. I simply transfered the s-contour shape of the temporary abutment to the impression coping via a jig. The lab technician can now work with a more uniform emergence profile. Since the numerous modified impression copings are made in advance not only for Straumann parts, but also Nobel parts, I don't waist precious chairtime. This technique improves one's ability to use the "bone level" tryin kits as well. Hope this idea helps anyone using platform switching implant designs. BTW, Straumann wasn't ready to add the idea to their portfolio.

Another fanstastic advantage of the tissue level implant (I use Straumann) is the ability to use stock abutments more often. The gingival margin / emergence profile is already built in to the implant. When TL implants are placed in the posterior the lab can, more often than not, pick a stock abutment (or I have started placing solid abutments myself). With bone level type implants, the labs will often default to a custom abutment which can double the abutment costs without any real benefit to the patient. It's important to work with a specialist who puts the implants in straight too! Now I use BL implants in the anterior and TL implants in the posterior with excellent long-term hard and soft tissue results (3yrs on BL and 10+ yrs on TL). Finally, as stated above, not all BL implants are the same. I agree with the person who commented that we should no longer accept 1-2mm of crestal bone loss as with many bone level implants (eg, Nobel replace, etc).

All implants are bone level implants. The difference is where the prosthetic interface is located. Some are supragingival (Straumann) some are infragingival (most brands) and some are even subcrestal (bicon, Ankylos). Carl Misch stated a long time ago the Health/Aesthetic dilema, meaning that the deeper the more esthetic result but also the worst halthy situation. Probably one should select the system for an specific situation instead selecting patients for your system. Good luck, this is a brave new world in dentistry!

Dr. Fabe, You mentioned the piezotome intralift tips can be used with the Variosurg. I'd love to hear your experience. (718.770.7401) Michael Zidile

The main diffrence between bone level and tissue level implants aside the definition is that the tissue level implants have high polished neck 1.5-2.5 mm which should not inserted in bone(concept for biologic width) but in bone level implant all the implant length will be inserted in bone, and there more intersting advantages such as platform switching, more esthetic. In my exprience bone level implant is much better than tissue level, they have all the advatages of tissue levels and less disadvantange than them. In tissue level implant high polished neck work as force leverage outside the bone it means whatever you crown height is you must add the high polished length to it.

Dear sir, I thought that the concept of crown/root ratio does not apply to the implant supported prostheses.What do you think ?