What are the main advantages of tissue level implants in the posterior area?

From my viewpoint I decide on whether I think the implant will heal and I prefer to close tissue over the implant to protect it. There are factors such as smoking, hygiene, adjacent teeth and occlusion. Basically I like to send the patient off without having to worry about what goes on in the interim. However a tissue level implant and I've only used Straumann, is really nice for the restoring doctor but the bone has to be great and the implant protected during healing. I trust my prostodontist to do this. I've had a multiple of doctors placing provisional over implants causing failures and patients chewing on the newly placed implants. I think that each case need be evaluated for the best individual prognosis. I like a tissue level in molar areas that are protected with adequate hard and soft tissue. The clinical anatomy will dictate this especially the crestal bone, I can graft with better results around a covered implant.

In the posterior a tissue level implant works very well, especially in good keratinized tissue. It keeps the cement line far away form the crest of bone and therefore, minimal bone loss ever happens. The downside is that if you need a larger platform to get the emergence for your restoration, you may be better off with a bone level impant. Also, if primary stability is in question, a bone level implant is safer in the long run because you can cover it with your soft tissue while it heals. I use predominantly tissue level implants in the posterior and try to place them where i will achieve the best emergence and support for the intended restoration. Chuck

The same parameters that we use to choose between a tissue level and bone level implant in the aesthetic zone apply to posterior quadrants as well. You can look at two important considerations; functional and aesthetic. First. let the biotype and parabolic nature of the tissue envelope shape your decision. In a flat architecture, where the facial bone is almost at the level of the interproximal bone, either type of implant is perfectly acceptable. You generally will not see exposure of the facial implant/abutment interface. However, the more parabolic the tissue, the greater the chance for a tissue level implant to have an interface exposure. While many patients will not care about having the metal show, the highly demanding patient may not accept this outcome. Only a bone level implant can give you the security of controlling the level of the platform. On the tissue level implant, you may cheat a bit by placing the implant more apically. But if you decide on this course, you may loose interproximal bone and sacrifice the height of the papillas. This may create a food trap and patient dissatisfaction. Also remember that the implant/abutment interface in a tissue level implant is absolutely flat; the lack of capacity to create a parabolic interface in the transmucosal zone makes reconstruction more difficult, and creates a scenario where you will likely get cement in an area deeper than desired. The possibility of a cement induced peri-implantitis is relatively high. Finally, this architecture was developed by Straumann in 1975. This 40 year old design, while a profound improvement over the competition of the day (Branemark), is really no longer acceptable to clinicians who value the best possible outcomes. Would you accept a 40 year old hip or knee replacement? If I need an implant in the future, I would choose a bone level architecture with a medialized platform. Our long term outcomes clearly indicate the superiority of this type of design. Time to put the tissue level implant on the shelf and move on. RJM