Clin Oral Impl Res 2000: 11 (Suppl.

): 8–21 Copyright C Munksgaard 2000

Printed in Denmark ¡ All rights reserved

ISSN 0905-7161

Chapter 1

The development of the ITIA DENTAL

IMPLANT SYSTEM
Part 1: A review of the literature

Scacchi M. The development of the ITIA DENTAL IMPLANT Marcel Scacchi

SYSTEM. Part 1: A Review of the literature.
Clin Oral Impl Res 2000: 11 (Suppl.): 8–21. C Munksgaard 2000. Institut Straumann AG, Waldenburg,
Switzerland

Key words: history of oral implantology –

In a short trip through more than twenty years, the development of the development of the ITIA DENTAL
ITIA DENTAL IMPLANT SYSTEM is described. The systematic un- IMPLANT SYSTEM – milestones – non-
folding and continuous advancement of the system, permanently sup- submerged approach – rough
ported and accompanied by scientific work in clinical and general practice, endosseous implant surface – morse
is outlined in short paragraphs. Some major milestones are emphasized taper connection – ITI: International
Team for Oral Implantology – Institut
and characterized.
Straumann AG

Marcel Scacchi, Vice President, Institut

Straumann AG, Hauptstrasse 26d,
CH-4437 Waldenburg BL, Switzerland
Tel.: π41 61 965 11 11
Fax: π41 61 965 11 06
e-mail: office/straumann.com

In the early 1970s, a collaboration was established niques, and the options for suprastructure design
between André Schroeder, Chairman of the De- were the predominant aspects to be inquired into.
partment of Operative Dentistry, University of The research projects were geared to the develop-
Bern, Switzerland, and the private research insti- ment of a simple, versatile system which would of-
tute Straumann (Waldenburg, Switzerland) in or- fer a maximum of predictable success.
der to study requirements and problems related to As time went on, other clinics and practitioners
oral implantology. interested in oral implantology joined the initially
The Institut Straumann AG offered its expertise small group. In 1980, this led to the inauguration
in technology, biomaterials, and engineering. Cli- of the International Team for Oral Implantology
nicians contributed a variety of experiments and (ITI).
examination methods, including histological in-
vestigations and clinical trials.
In the beginning, basic aspects of materials were 1974
scrutinized. Different materials and surfaces were The various requirements for oral implants, such
tested in biological experiments. The group later as mechanical strength and biocompatibility of the
moved on to specific problems of design and bio- material, led to the preliminary choice of a hollow
mechanics. On the clinical side, the definition of implant body as a basic design concept. Other el-
indications, the applicability of surgical tech- ementary considerations in similar type designs

8
 ITIA Dental Implant System
were described by Greenfield (1913) and Benaim
(1959). Greenfield reported satisfactory results Type C implant
with his patented iridio-platinum lattice implant – Minor modifications of these first trial implants
probably the first clinically applicable endosteal led to the standard implant, designated as Type
implant system. C (Fig. 1.1), which was subsequently inserted and
tested in patients. It is important to acknowledge
that ITI dental implants have been titanium
Requirements for oral implant design plasma-sprayed in their bone-anchoring portion
Other considerations at that time included: from the very beginning. This procedure, although
O maximum surface area for attachment and pri- not new to other disciplines, was inaugurated in
mary stability; oral implantology with the introduction of the ITI
O anchoring effect with minor surface irregular- implant. The purpose of titanium plasma spray-
ities; coating (TPS) is the creation of a rough surface
O minimum bone loss on implant site preparation; promoting an excellent ankylotic anchoring to the
O minimum implant body volume. bone (Schroeder et al. 1976; Schroeder et al. 1978).
The hollow body oral implant, designed by Franz
Sutter, was first and foremost thought to be suit-
able for animal experiments in monkeys (Macaca Titanium plasma-coating
speciosa). Transverse openings in the side walls and The industrial process of titanium plasma-coating
oblique holes at the shoulder were characteristic is used for both metals and ceramics. It creates a
of the early hollow cylinder implants. Under the rough, continuous – even though highly porous –
presumption that bone would grow over the surface, characterized by round forms. It increases
shoulder, the neck of the implant was designed to the surface area approximately 6–10 times. The
be narrower than strength requirements would per- layer is typically 20–30 mm thick, with a roughness
mit in the area where it emerges from tissue. of about 15 mm (Steinemann 1988).
This implant type was first used in a patient From a clinical standpoint, the titanium plasma-
more by accident than intentionally, simply be- coating offers three advantages over a finely or
cause implantation of a Herskovits implant had smoothly structured titanium surface (Schroeder et
failed. Despite the fact that the implantation of al. 1981):
the hollow cylinder was premature (if for no other O accelerated apposition of bone in the early heal-
reason than the lack of adequate instruments), this ing phase;
implant was still in place in 1998. Apart from this O increased surface contact area between implant
unplanned use of a ‘pioneer hollow cylinder’, clin- and bone;
ical tests were started only after satisfactory results O improved implant anchorage.
in animals had been achieved and instrumentation As a strong verification, clinical experience has
had become sufficiently advanced to justify im- clearly indicated that ITI implants shorter than the
plantation in humans. Careful documentation of standard (standard lengths of ITI implants are 8–
experiments prior to clinical trials was a corner- 12 mm) may normally be used, their dependable
stone of the entire research program. osseointegration being brought about due to their
rough surfaces.
Other implant surface characteristics were thor-
oughly investigated in order to evaluate the influ-
ence of different surface morphology on osseoin-
tegration. The results indicated that further im-
provements in that area of oral implant design
were to be expected (Buser et al. 1991a).

1975–1976
Types E, K, and H
In order to meet the less-than-ideal jaw conditions
that are frequently encountered, especially in the
posterior regions of the mandible, various other
types of implants were developed (Fig. 1.2). These
so-called extension implants (Types E, K, and H)
Fig. 1.1. First generation of hollow body implants. had certain advantages over the Type C, especially

9
Scacchi

outer diameter of 3.5 mm and the assortment of

five different lengths of 9, 11, 13, 15, and 17 mm.
Combinations of Type F implants used between
the mental foramen in the edentulous mandible
were found to be especially suited for retaining
overdentures. In these cases, Type F implants
proved to be of great help to patients who could
not, for whatever reason, adapt to conventional
total dentures. In this particular region of the man-
dible, the implants impinge neither on the man-
dibular canal nor on the mental nerve if proper
planning and technical procedures have been care-
fully followed. Even in severely atrophied cases,
sufficient bone is usually available to use this ap-
Fig. 1.2. Various designs of hollow body and extension im- proach (Sutter et al. 1981).
plants.

in uni- or bilateral free-end situations with ex-

tremely narrow ridges in the mandible. Extending the indications
The Type E implant was a double hollow body This implant type was also used as a single-tooth
cylinder implant, whereas Type H and K implants replacement due to its compactness and ease of
consisted of a central post, the lower end of which use. Some improvements were eventually intro-
was a hollow cylinder with two fenestrated hollow duced, such as lengthwise grooves in order to in-
cylinders on the mesial and distal sides, respec- crease the surface area of the implant by 50%. An-
tively. These implant types conformed to all design other aim was a more even distribution of non-
principles for ITI hollow cylinder implants. The axial loads to the surrounding bone. Modifications
two added hollow cylinders on either side of the in the shoulder, neck, and abutment region of the
central post acted as stabilizers and assisted in load Type F implant were further investigated with the
transmission and dispersion under functional aim of improving the attachment of the tooth re-
loading. placement with respect to its axis, the junction of
The E, K, and H implants also contained con- the soft tissue, and esthetics (Ledermann et al.
siderable disadvantages, such as the rather de- 1982; Sutter et al. 1983).
manding surgical technique or the problematic re-
moval of such an implant – especially if the apical
portion was still firmly ankylosed to the bone,
therefore leading to a much larger bony defect on
removal than a rotationally symmetrical implant
would have left after explantation.
Extension implants of Types E, K, and H are no
longer in use even though their success rates were
82–85% over a period of about 10 years (Krekeler
et al. 1985). The use of such implants diminished
over time, and finally they were completely re-
placed by the end of the 1980s when the new gener-
ation of rotationally symmetrical one- and two-
part ITI implants were introduced.

1977
In 1977, two developments were added to the im-
plant range which had a major impact on the fu-
ture implant concept of the ITI system: the Type F
implant and the Swiss Screw.

Type F implant
The Type F hollow cylinder implant was basically
comparable to the Type C except for the reduced Fig. 1.3. Type F and "Swiss Screw" TPS implant.

10
 ITIA Dental Implant System

primary stability due to their design character-

TPS implant or ‘‘Swiss Screw’’ istics. Ideally, the apex of the screw engages the
The second product was the TPS (titanium inferior mandibular cortex without perforation of
plasma-sprayed screw) or Swiss Screw implant the inferior border. Therefore, the final restora-
(Fig. 1.3). This solid screw type implant concept tion of the case with suprastructure and pros-
was based on experience in the field of orthopedic thesis can be carried out almost immediately.
surgery and other related research. Ganz et al. Normally, four TPS implants are connected by
(1975) studied sheep to determine bone reaction to means of a mesostructure composed of four pre-
rigidly fixed screws vs screws with relative motion fabricated gold copings soldered to a Dolder bar.
under weight-bearing. It was found that the stable This creates a stable construction that is then se-
screws were surrounded by bone, while bone cured into position with titanium occlusal screws.
around mobile screws had been resorbed and re- Soon after incorporation of the bar clips into the
placed with fibrous tissue and cartilage. These re- relined or new denture, patients are provided with
sults were also applied to the basic concept of the their prostheses and never have to spend any time
ITIA DENTAL IMPLANT SYSTEM as listed be- without prostheses.
low (Pohler 1986):
O trauma-minimizing surgical technique to avoid
primary bone damage; 1978–1984
O postoperative implant stability to avoid relative In the course of time, specific implants were
motion and bone resorption; further improved and others added in order to
O optimum primary bone contact to promote os- cover a maximum of indications. The Type F im-
seointegration; plant range (Figs 1.4, 1.5) was then available with
O micro and macro anchorage for permanent sta- external diameters of 3.5 mm and 4.0 mm. As
bility; mentioned earlier, the head and neck of the Type
O biocompatibility of implant material to pro- F as well as the surface finish were retained from
mote osseointegration. the Type C implants. Size and layout of the fen-
The standard ITI screw implant had a core diam- estrations in the cylindrical sections were altered in
eter of 3.2 mm and an outer diameter of 4.0 mm. such a way that the implant body was less stiff and
The available lengths of 11, 14, 17, and 20 mm hence closer to the biomechanical properties of the
resulted in different heights of the threaded por- mandible. Type F implants were relatively simple
tions. The abutment portion had four retention to place due to the color-coded surgical instrumen-
grooves to prevent rotation of the prefabricated tation designed for multiple use (Schroeder & Sutt-
copings suitable for a Dolder bar reconstruction. er 1996).
The 2.8 mm long neck portion was followed by a Although some experiments with two-part im-
cylindrical shoulder, which was 0.2 mm high (Kre- plants had already been carried out in the mid-
keler et al. 1990). 1970s, in the beginning of the 1980s an implant
prototype version with a removable abutment was
used in some cases. This allowed improved han-
Roots in orthopedics dling of the temporary restoration during the heal-
Geometrically, the TPS implant resembles an asym-
metric, orthopedic cortex screw. Since bone tissue is
structured in such a way that it can withstand com-
pression, one thread angle is almost perpendicular
to the bone to create compression, but no shearing
forces. The asymmetric thread design of the cortex
screw was turned upside down, because in internal
fixation the screws have to resist tearing forces,
whereas the dental implant is mainly loaded under
compression. The tip of the screw has three self-tap-
ping flutes. The screws are manufactured from ti-
tanium and have the ITI-specific rough titanium
plasma spray-coating (TPS) up to the shoulder.

Splinting of implants and immediate loading

According to findings of Ledermann (1981) and
Babbush (1986), these implants offer excellent Fig. 1.4. Increased endosseous surface area for narrow ridges.

11
Scacchi

Fig. 1.5. Hollow screw implants in one- Fig. 1.6. Submerged vs non-submerged de- Fig. 1.7. Clean environment for abutment
part and two-part designs. sign. connection with non-submerged design.

ing phase and offered wider prosthetic choices in under clean conditions with good visibility (Fig.
cases with difficult interocclusal space conditions 1.7);
and/or misaligned implants. O the gingival seal is formed during the primary
This period was additionally characterized by healing phase and is hence not disturbed by the
systematic evaluation of clinical data in order to placement of an abutment in a second surgical
make clear statements about the significant clinical step;
parameters and possible extension of indications. O from an engineering standpoint, the non-sub-
merged method allows better mechanical joint
adaptation between the two parts (Morse
1985 Taper) and more favorable lever arm conditions
Observations and histologic findings over more (Fig. 1.8) compared to connection at the bone
than a decade, all with single-stage, non-sub- level (the submerged method).
merged procedures, clearly demonstrated that the
achievement of an ankylotic bond between bone
and implant was not purely the domain of the two- One- and two-part implants
stage, submerged procedure. A good example was Until 1985, most ITI implants consisted of a one-
presented in cases with multiple so-called one-part part design, i.e. the endosseous portion of the ITI
implants placed in edentulous mandibles for sub- implant and the part bearing the suprastructure
sequent prosthesis retention. There are basically (abutment) could not be separated (Fig. 1.9). Due
two implant design options: submerged and non- to new requirements and different indications, it
submerged (Fig. 1.6). was found that – especially for single-tooth re-
placements – an implant should ideally leave some
prosthetic options open and should allow sufficient
Rationale behind the non-submerged method flexibility for temporary restoration design during
The ITI system utilizes the non-submerged method the healing phase.
for the following reasons: Two-part implants (Fig. 1.10) were initially con-
O the microgap between two mating parts, a po- sidered for single-tooth replacement, particularly
tential site for plaque retention, is clearly out- in the anterior region of the maxilla. To improve
side the tissues; performance in this indication, the implant body
O the non-submerged method does not require widens from the core diameter in a trumpet shape
second surgery in order to recover the implants up to 5.0 mm diameter in the shoulder. This is
for attachment connection; similar to an average cervical preparation of a
O insertion of an abutment can be carried out natural tooth for the placement of a full-porcelain

12
 ITIA Dental Implant System

Fig. 1.8. Lever arm conditions. Fig. 1.9. One-part hollow cylinder im- Fig. 1.10. Two-part hollow cylinder im-
plant. plant.

or veneered (metal-ceramic) crown. Then, the mar-

ginal finishing border had a labially beveled cham- Instrumentation
fer profile to comply with esthetic necessities (Fig. The basic instrumentation (Fig. 1.13) includes
1.11). round burs and predrills, the latter in two different
lengths. Trephine drills are used in the final prep-
aration for hollow cylinder implants; they have
15æ angled hollow cylinder implants depth markings for easy determination of the im-
For situations offering a slight maxillary alveolar plant site depth. Trephine drills are available in two
protrusion, a variation of the hollow cylinder im- versions, with and without an internal cooling sys-
plant with a 15æ shoulder angle and a more favor- tem (Fig. 1.14). In-house investigations have
able inclination for prosthetic purposes (Fig. 1.12) shown that thermal damage to bone can endanger
was made available – certainly a unique approach osseointegration. Its extent depends on the nature
in oral implantology. Its use and recommended in- and quality of the cutting instruments, their speed
dications were presented by ten Bruggenkate et al. of rotation, and the preparation technique. By
(1992). using an intermittent drilling technique and a suit-

Fig. 1.11. Two-part hollow cylinder implant in the anterior Fig. 1.12:. 15æ angled hollow cylinder implant as a unique ap-
maxilla. proach.

13
Scacchi

sity cancellous bone. The objective of achieving ex-

cellent adherence of the bone to the implant sur-
face and also of retaining it under physiological
stress was fulfilled by means of a specific thread
geometry (Fig. 1.15) combined with the porous
microstructure of the implant’s anchoring surface.
Usually, a tap is used for the final preparation
of the implant site. This tap is slightly smaller in
diameter than the corresponding screw-type im-
plant profile. This thread configuration was deter-
mined after in-depth experiments and comparative
measurements. It was established inter alia that the
maximum holding strength could be increased by
20% compared to thread flank geometry at right
Fig. 1.13. Overview of surgical instruments for specific implant angles to the axis due to the 15æ inclination angle
types. of the thread flank. Another consideration was the
lower mechanical strength of bone compared to ti-
tanium. Therefore, the proportion of bone should
able cooling medium, the thermal damage can be predominate when juxtaposed with the metal sur-
additionally reduced. The high quality of the ma- face in the longitudinal section of the screw thread.
terial from which instruments are manufactured These considerations were fully implemented in a
allows multiple use, at least twelve times, without design of a thread depth of 0.35 mm and a thread
loss of cutting efficiency (Sutter et al. 1992; Watan- pitch of 1.25 mm, with the load-bearing thread
abe et al. 1992). Today, ITI surgical instruments surfaces at an inclination of about 15æ to the axis.
can easily be stored and sterilized in a sophisti-
cated cassette (patent pending) with a stand-up
mechanism – thus avoiding damage to the delicate Morse Taper design
tips of cutting instruments. For the connection between the implant and the
abutment, a ‘Morse Taper’ design (Fig. 1.16) was
evaluated and finally introduced to the system.
Implant thread design This remarkable configuration ensures high pre-
Hollow and solid screw-type implants were de- cision and increased protection against loosening
veloped for improved primary stability in low-den- due to the specific surface area and an angle of 8æ.

Fig. 1.14. Internal cooling for trephine Fig. 1.15. ITI implant thread design. Fig. 1.16. Morse Taper concept.
drills.

14
 ITIA Dental Implant System

Fig. 1.17. Different designs to evaluate the Fig. 1.18. The BONEFIT concept. Fig. 1.19. Components for bone grafting
tightening torque. procedures.

It basically creates a friction lock similar to the O standardized and interchangeable range of abut-
Morse Taper used in mechanical engineering and ments for all two-part implants;
related industries. Any mated conical metallic sur- O coverage of a wide range of indications due to
faces of less than 8æ in angle create a mechanically the system’s relative ease of use (Levine et al.
locking friction fit. This concept is supported by 1994; Schroeder et al. 1991; Schroeder & Sutter
the fact that the loosening torque of the cone-to- 1996).
screw interface is 7–24% higher than its tightening
torque at the first placement, compared to a screw
design alone in which the loosening momentum is Manufacturing of an ITI implant
approximately 10% lower than the tightening mo- ITI implants are produced from full profiles to
mentum (Sutter et al. 1993). their final form; they are neither cast nor sintered.
Other recent investigations have confirmed the The reason for using this rather demanding pro-
superiority of this design (Fig. 1.17) compared to cedure is that the starting material is free of defects
butt joint interfaces (Norton 1997). ITI abutments and has reproducible, constant properties, which
are inserted into ITI implants by means of the are relatively difficult to achieve with other produc-
ratchet, using the torque-control device for precise tion techniques. The most important stages in im-
application of 35 Ncm. plant manufacturing are:
O cold working of the material (grade 4 titanium)
to the desired strength in the shape of bars for
The ‘‘BONEFIT’’ concept easier implant production;
All of the aforementioned features were introduced O manufacturing of the implants with an ex-
into the ITI concept as an integrated system, the tremely high precision, always using the state-
‘BONEFIT’ concept (Fig. 1.18) (Sutter et al. 1988; of-the-art technology available in order to
Buser et al. 1988), offering various advantages achieve interchangeability of different compo-
such as: nents and constant, high quality.
O wide choice of implants (hollow cylinder, hollow Since 1994, ITI implants have been sterilely packed
screw, and solid screw implants) depending on in a ‘no-touch’ packaging system in order to im-
clinical situations and personal preferences; prove efficacy of the ITI system. For quality assur-
O a standardized set of instruments which can be ance purposes, all necessary information is clearly
used in the preparation for the various implant indicated. It is highly recommended to always
types; transfer this information to the individual patient
O standardized and uniform abutment design and file.
accessories for all one-part implants; Institut Straumann AG comply with the highest

15
Scacchi
quality assurance standards, such as EN ISO 9001, other abutments used in this system. This enlarge-
EN 46001, and 94/42/EWG. ment of the ITI system’s indications has been in
clinical use since 1988 (Asikainen & Sutter 1990;
Weingart et al. 1990; Sutter et al. 1994).
1986–1993
Further clinical experience with the new ITI
BONEFIT concept clearly demonstrated that the Implants for specific indications
major objectives of this development had been Special implants are understood to be implants
realized (Buser et al. 1990a, 1991b). Specifically, ‘‘it having limited indications only. In narrow type
should be mentioned that the single-stage ap- ridges, the use of standard diameter implants of
proach with ITI implants achieves a complication- 4.1 mm is not always appropriate. Accordingly, 3.3
free tissue integration with a high predictability if mm diameter-reduced two-part solid screw im-
the clinical protocol is followed carefully’’ (Schro- plants (Figs 1.21, 1.22) have been made available
eder et al. 1991). Buser et al. (1991b) stated: ‘‘At (Krekeler et al. 1993). Since their core diameter is
the end of the 3-year observation period, the suc- 2.8 mm, all existing instruments can be used for
cess rate was 96.3%. This confirms results of long- preparing the implant site. Their neck portions
term studies with screw-type titanium implants in
which the authors concluded that the long-term
prognosis of dental implants depends to a signifi-
cant degree on tissue integration in the first year
following placement.’’

ITI implants combined with bone-grafting techniques

In cases with extremely atrophied alveolar ridges,
augmentation with bone grafts is often necessary
(Fig. 1.19). The simultaneous augmentation is
mostly carried out with bone grafts, which are fix-
ed rigidly by means of endosseous implants and
thereby integrated into the biodynamics of the jaw.
As a prerequisite, maximum wound closure during
healing is necessary. Accordingly, implants in this
indication are normally placed submerged, and
later on, at second-stage surgery, a transmucosal
extension unit is mounted into the ITI implant.
Thus, the implant is elongated and the peri-im-
plant mucosa adapts to the neck portion of the
implant (Fig. 1.20). Any tertiary components of
the BONEFIT concept are compatible with all the Fig. 1.21. 3.3 mm diameter solid screw implant.

Fig. 1.20. Submerged healing. Fig. 1.22. Overview of 3.3 mm diameter solid screw implants.

16
 ITIA Dental Implant System
also correspond to all available abutments within for connecting mandibular overdentures has be-
the system. However, biomechanical measurements come a clinical routine procedure, and some in-
have shown that this type of implant should only vestigations have demonstrated that these situ-
be used in indications without excessive occlusal ations can be maintained healthy and stable over a
forces or bending momentum, and the implant long period of time (Mericske-Stern & Zarb 1993;
should be splinted to other implants whenever Wismeijer et al. 1995). Magnets offer another
possible. alternative as a single anchor (Wirz et al. 1993a, b,
Another category of special implants are solid/ c).
hollow screw-type implants with a 6.0 mm an-
choring length for both mandible and maxilla situ-
ations with extremely limited bone height. Despite Conical abutments
the reduced endosseous surface, osseointegration Single-crown and bridgework abutments proved to
and adequate functional stress tolerance are made be especially versatile since they offer both the
possible by the macroshape and the micromorpho- cementation of a suprastructure by using zinc-
logical surface characteristics. Their indications phosphate luting cement and the removable fix-
are limited to: ation by titanium screws (M2).
O bar-supported prosthesis with four implants in Abutments are available in different heights and
the anterior mandible; with various angles, such as 6æ, 8æ and 15æ (Figs
O combination with longer ‘‘standard’’ implants – 1.23, 1.24). The major advantage of this system is
supporting implant-borne fixed restorations in its simplicity of use due to the roots in conven-
the posterior region of the maxilla or mandible. tional crown and bridgework procedures and the

Prosthetics
Originally, the ITI system offered three types of
abutments in four different versions (‘‘BONEFIT’’
concept):
O retentive anchor (Mericske-Stern 1988, 1990);
O bar abutment (Mericske-Stern 1988, 1990;
Wirz & Jäger 1991);
O single-crown and bridge abutments (Brägger et
al. 1990a; Flury et al. 1991; ten Bruggenkate et
al. 1991).

Bar restorations
O Prefabricated gold alloy copings for the stan-
dard technique;
O burn-out copings for titanium casting; Fig. 1.23. Overview of conical abutment system.
O prefabricated titanium copings and bars for
laser-welding according to the monometal prin-
ciple (all in titanium) (Wirz 1994).

Retentive anchor
The retentive anchor is assigned to the class of
single spherical stud attachments. These retentive
units permit rotational movements of the pros-
thesis in one or several directions and/or vertical
translation movements. This mobility shortens the
lever arm of the tilting forces. Usually, two im-
plants are placed at an angle of 90æ to the occlusal
plane to ensure their axial loading. Matrices are
offered in two versions: a gold alloy for adjustable
retention after Dalla-Bona, or titanium for prede-
termined retentive forces.
Nowadays, the placement of only two implants Fig. 1.24. Extension sleeve for conical abutments.

17
Scacchi
small inventory required for restoring a case (Bräg- Occasionally, the screw-retained fixation of a su-
ger et al. 1990b). prastructure by means of an occlusal screw jeop-
However, in some cases the design did not al- ardizes esthetic requirements or necessitates the
ways meet the requirements – limitations were re- use of an angled abutment or even of an individu-
lated to impression-taking, master-cast produc- ally cast abutment (Wiskott & Belser 1992). Fur-
tion, or the demand for prefabricated components thermore, the preference for an occlusal screw
for suprastructure design. This then led to the de- often interferes with functional occlusal and/or ar-
velopment of the OctasystemA (Sutter et al. 1993; ticulating contacts. These disadvantages may be
Belser et al. 1993). compensated by transversally placed fixation
screws. The Transversal Screw (TS) System is com-
patible with OctasystemA and offers a variety of
Prosthetic choices prosthetic options for manufacturing a single
OctasystemA was developed to offer the following crown, from full titanium blanks to prefabricated
benefits (Fig. 1.25): burn-out and non-oxidizing cast-on copings (Sutt-
O a safe and precise transfer system using the ana- er et al. 1996) (Fig. 1.30).
log technique, especially suitable in cases with
multiple, screw-retained units and/or implants 1994–1997
placed in esthetically demanding regions (Fig.
1.26); Solid abutment concept
O compatibility with all two-part ITI implants With the ITI system (Fig. 1.27) and its tight roots
using the Morse Taper connection; to conventional crown and bridge prosthetics on
O allowing simplified procedures for soft tissue natural abutments, it has always been possible to
management in esthetically exigent regions; cement suprastructures. Sometimes, it is necessary
O safeguarding against rotation (single-crown res- to optimize an abutment in order to adapt to speci-
torations); fic clinical situations, i.e.:
O sufficient options to overcome divergent implant O abutment preparation due to occlusal space
placement in order to define a common path of conditions or increasing non-rotational devices;
insertion with multiple unit restorations; O placing the crown margin slightly subgingivally
O modular system allowing rather simple exten- for esthetic purposes – preventing metal from
sions of specific technical solutions. being visible;
The system was first introduced to the U.S. market O opening of interproximal space for design and
(Wilson 1993) and added a tremendous momen- hygiene reasons if two implants are placed too
tum to the ITI system as a whole concept. closely to each other (Weigel et al. 1994).

Fig. 1.25. The basic concept of Octasy- Fig. 1.26. Screw-retained transfer with Oc- Fig. 1.27. Standard ITI implant with solid
stemA. tasystemA. abutment.

18
 ITIA Dental Implant System

Fig. 1.28. Transfer system for solid abut- Fig. 1.29. Cemented crown with solid Fig. 1.30. Transversal screw retention with
ment. abutment. OctasystemA.

Based on their investigations, Brägger et al. (1995) tenance. In recent years, dentists have started ce-
emphasize that in all these instances adequate menting cases to address esthetic concerns as well.
cooling with spray from a dental unit and use of Usually, implants are placed ‘deeper’ so that the
perfectly cutting rotary instruments are indispens- crown margins are located in the sulcus. For such
able. situations, a transfer system (patent pending) (Fig.
A cemented restoration is an excellent alterna- 1.28) was developed in order to simplify the im-
tive to the screw-retained approach. It reduces pression-taking procedure (Wirz et al. 1997; Hig-
costs significantly and normally requires less main- ginbottom 1997) (Fig. 1.29).

Fig. 1.31. External octagon design for Fig. 1.32. Tertiary components for Nar- Fig. 1.33. Wide Body Implant.
Narrow Neck Implants. row Neck Implants.

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Scacchi

ESTHETIC PLUS concept

Indications for implant-borne restorations have
been expanded in recent years due to significant
progress in hard and soft tissue management. Sim-
ultaneously, esthetic demands of implant patients
and implanting clinicians have also increased.
Consequently, esthetic compromises within the vis-
ible zone are less tolerated. This has led to further
developments within the ITI system to meet speci-
fic requirements for esthetically demanding res-
torations, maintaining the single-stage principle.
When fabricating esthetic, implant-borne res-
torations, comprehensive planning according to
the principle of ‘‘restoration-driven implant place- Fig. 1.34. Overview of ITI abutment concepts.
ment’’ (Garber & Belser 1995) is crucial. In the
esthetically important zone, ITI implants are
usually placed 2 mm deeper (countersunk) than
when using the standard protocol, thus requiring
a special profile drill to transfer the ITI implant-
specific trumpet shape of the neck portion to the
bone crest and requiring use of an implant with a
TPS surface area enlarged by 1 mm coronally.
Special healing caps, which are labially beveled,
allow an improved mucoperiosteal flap adaptation
with appropriate wound closure for the so-called
‘semi-submerged’ healing. If indicated, a slightly
undercontoured vestibular gingivectomy is carried
out, after a period of approximately ten weeks.
The healing cap is replaced by a longer, transmu-
cosal healing cap, thus ensuring the contouring of
the soft tissues. After placement of the Octa abut-
Fig. 1.35. Ortho implant.
ment, slightly oversized protective caps with vari-
able emergence profiles shaped according to the
clinical situation maintain the soft tissue contours
during fabrication of the temporary or final res-
toration (Buser & Belser 1995, 1997; Belser et al.
1996; Hess et al. 1996).

Narrow neck implant

In order to complement the ESTHETIC PLUS
concept, the Narrow Neck Implant was introduced
in 1996. The central idea has been to create out-
standing conditions for the treatment of small
single-tooth gaps in the anterior upper and lower
jaws. With the so-called MonoCorps design, ITI
Narrow Neck Implants provide a solid restorative
platform despite the reduced shoulder width of 3.5
mm (Fig. 1.31). This approach can meet high es- Fig. 1.36. Indication for use with an orthodontic appliance in
thetic expectations. However, the indispensable combination with ITI implants.
basis has been the harmonization of esthetic de-
mands and biological determinants. The engineer-
ing solution: a machined implant neck, offering for single lateral incisors in the maxilla and cen-
full development possibilities for the biological tral/lateral incisors in the mandible. It is mainly in
width while preserving sufficient space for soft these areas that the interdental space is extremely
tissue conditioning. This implant type is indicated limited, and vestibulo-oral bone quantity is often

20
 ITIA Dental Implant System
restricted. Again, additional surgical instrumen- existing abutment options (Fig. 1.34) are compat-
tation is unnecessary since the core diameter of the ible with Wide Body Implants (Morse Taper).
endosseous portion is 2.8 mm and the thread di-
ameter is 3.3 mm, measurements which already
Exploring further possibilities
exist in the ITI system. Handling of Narrow Neck
Implants has been considerably simplified by Orthosystem
modification of the sterile ampoule (patent pend- In 1996, a new implant-based orthodontic system
ing) and the one-piece inserting device. Standard- was presented by Wehrbein et al. (1996a). Compli-
ized impression-taking and prefabricated pros- ance-dependent extraoral anchoring aids for or-
thetic components add even more comfort to the thodontics like unsightly headgears can be re-
Narrow Neck Implant system (Fig. 1.32). placed by Orthosystem (Fig. 1.35) and bonding of
well-aligned mandibular dentition and use with
class II elastics are rendered superfluous. The pure
Other implant options titanium implant is designed for single-stage appli-
The Wide Body Implant (Fig. 1.33), which is indi- cation. Its threaded endosseous part is self-tapping
cated with sufficient bone mass (7 mm minimum with a sand-blasted, large grit, acid-etched (SLA)
bone or crest width), offers increased surface area surface. It is available in a diameter of 3.3 mm and
for bone apposition with even higher mechanical lengths of 4.0 mm and 6.0 mm.
strength than ITI standard implants. This type of The concept is based on two fundamental ap-
implant provides major advantages in the posterior proaches: the ortho implant for temporary inser-
region, where loading forces are usually higher. tion in the median palate or in retromolar posi-
Another indication may be implant placement im- tions, and the bonding base for combinations with
mediately after extraction of a tooth. The basic regular, permanently anchored ITI implants (Fig.
prosthetic ITI concept is maintained because all 1.36) (Wehrbein et al. 1996a, 1996b).

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