Bone Level vs Tissue Level
One of the huge privileges of being an ITI fellow is having an invitation to attend a fellows meeting once a year, where issues around implant dentistry are discussed within a closed group.
At the ITI fellows meeting this year in Crawley for the UK and Ireland section, there was a discussion around the use of bone level vs tissue level implants. This was provided by Steve Barter and Shakeel Shadad and was based loosely on a study club they jointly provided.
This is a debate that has raged for years, ever since I became involved with the ITI dental implant system in 1998. The debate generally goes along these lines:
“Bone Level Guy” – you can’t place tissue level implants because the silver collar shows and they are not an aesthetic restoration.
“Tissue Level Guy” – bone level guy doesn’t know how to place tissue level implants.
“Sales Guys” – bone level implants are by far the best implant to use because they are much more aesthetically pleasing.
I had no understanding of this principle when I started using the Straumann dental implant system but I tried to follow the principles that I had read about associated with the system and in general terms in achieved some pretty good results. I had more than my fair share of tissue level implants where the tissue level collar was visible in aesthetic cases but on retrospection now and looking at the photographs of these cases… the implants were in the wrong place!!
I have recently been introduced to a new principle from Colin Burns and Shakeel Shadad and this is the principle of collared and collarless implants instead of bone level vs tissue level.
If you describe an implant as a bone level implant, this encourages people to place the implant at the level of the bone. This is in the wrong place!!
If you do provide a restoratively driven solution and place a dental implant in the appropriate restorative position then the outcomes are excellent regardless of whether the implant has a collar or not. What most people forget is that there is a restorative space above a “bone level” implant of approximately 2mm where the abutment must sit. This is effectively the collar on an implant.
This principle was presented clearly and beautifully by the 2 speakers at the fellows meeting, but more importantly than this, Shakeel Shadad, who was formally an Astra user showed historical data going back 6 years which has convinced him never to use a “bone level” implant in the aesthetic region.
The quality of his cases was absolutely fabulous and the data is backed up by cross sectional CBCT scans showing the position of the bone around collared and collarless implants following that time. It just might be that another change in implant dentistry is coming, when people see the huge advantage of placing collared implants in the anterior maxilla.