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The SAC Classification in Implant Dentistry
SECOND EDITION
The SAC Classification in Implant Dentistry
SECOND EDITION
A. DAWSON, W. MARTIN, W. D. POLIDO
German National Library CIP Data
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© 2022 Quintessenz Verlags-GmbH
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| Illustrations: | Ute Drewes, Basel (CH), www.drewes.ch |
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ISBN 978-1-78698-110-3
The materials offered in The SAC Classification in Implant Dentistry are for educational purposes only and intended as a step-by-step guide to the treatment of a particular case and patient situation. These recommendations are in line with the ITI treatment philosophy. These recommendations, nevertheless, represent the opinions of the authors. Neither the ITI nor the authors, editors, or publishers make any representation or warranty for the completeness or accuracy of the published materials and as a consequence do not accept any liability for damages (including, without limitation, direct, indirect, special, consequential, or incidental damages or loss of profits) caused by the use of the information contained in The SAC Classification in Implant Dentistry. The information contained in The SAC Classification in Implant Dentistry cannot replace an individual assessment by a clinician and its use for the treatment of patients is therefore the sole responsibility of the clinician.
The inclusion of or reference to a particular product, method, technique or material relating to such products, methods, or techniques in The SAC Classification in Implant Dentistry does not represent a recommendation or an endorsement of the values, features, or claims made by its respective manufacturers.
All rights reserved. In particular, the materials published in The SAC Classification in Implant Dentistry are protected by copyright. Any reproduction, whether in whole or in part, without the publisher’s prior written consent is prohibited. The information contained in the published materials can itself be protected by other intellectual property rights. Such information may not be used without the prior written consent of the respective intellectual property right owner.
Some of the manufacturer and product names referred to in this publication may be registered trademarks or proprietary names, even though specific reference to this fact is not made. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.
The tooth identification system used in The SAC Classification in Implant Dentistry is that of the FDI World Dental Federation.
Foreword
The SAC Classification in Implant Dentistry
Almost 20 years ago, the International Team for Implantology – ITI – formalized the SAC classification to categorize oral implant treatment procedures into three levels of difficulty: Straightforward, Advanced, and Complex. The SAC Classification in Implant Dentistry was published in 2009, and it immediately became clear that this approach to classifying treatment risk when planning patient treatment was a tool many dentists had been waiting for. Applying the SAC approach to the evaluation of patient-related risk factors and treatment modifiers has since become a standard procedure for many practitioners, contributing to a higher degree of predictability in the execution and outcome of proposed treatment. The SAC classification has been recognized by dental professionals as an objective, evidence-based framework, also making it an invaluable educational tool for both predoctoral and postgraduate training programs.
As dental materials, technology, and clinical techniques have evolved in the intervening years, the ITI decided to review the SAC classification and present it to clinicians in an updated form: a digital book that can be accessed from any device or computer as needed. With its mission to promote and disseminate knowledge covering all aspects of implant dentistry and related tissue regeneration, the ITI recommends this SAC Assessment Tool to all professionals in the field.
Acknowledgments
It may be trite, but it is true: projects such as this do not succeed without the commitment and hard work of a large team of people. Consequently, we would like to acknowledge the following people and groups.
The ITI Board of Directors trusted us to update one of the ITI’s crown jewels – the SAC Classification. This is a heady responsibility, as we know that the SAC Classification is widely used and respected by clinicians in implant dentistry. We thank the Board for their trust and support.
The staff at the ITI Headquarters have supported us throughout the project. From the events team that organized our meetings, to the Communications and Education teams for providing material, all have worked cheerfully and willingly to help us. Of special note: many thanks to Kati Benthaus and Katalina Cano, our project managers, who have guided us through the process.
Thanks must go to Stefan Keller and his fellow IT wizards at FERN who have turned our dreams of what we would like to do with the online tool into reality.
Thanks also to Änne Kappeler and the team at Quint-essence. Their professionalism and patience have allowed us to produce something that we can all be truly proud of.
Of course, we could not have done anything without the support of our colleagues on the Consensus Group who met in Zurich and Berlin and who toiled tirelessly to develop the framework for the new tool. Thanks also to the members of the ITI Education Committee and all the others who acted as our beta testers, and to those who have contributed material to this book. The quality of the group-achieved outcome is much, much more than the sum of the contributing parts.
And finally, but most importantly, we must thank our wives, children and families for their understanding and support. We could not have done this without you.
Editors / Authors
Anthony Dawson, BDS, MDS, FRACDS
Associate Professor in Prosthodontics
School of Dentistry and Medical Sciences
Charles Sturt University
346 Leeds Parade
Orange, New South Wales 2800
Australia
Email: tdawson@csu.edu.au
William C. Martin, DMD, MS, FACP
Clinical Professor and Director
Center for Implant Dentistry
Department of Oral and Maxillofacial Surgery
College of Dentistry
University of Florida
1395 Center Drive, Rm D7-6
Gainesville, Florida 32610
United States of America
Email: wmartin@dental.ufl.edu
Waldemar D. Polido, DDS, MS, PhD
Clinical Professor, Department of Oral and
Maxillofacial Surgery and Hospital Dentistry
Co-Director, Center for Implant, Esthetic and
Innovative Dentistry
Indiana University School of Dentistry
1121 W Michigan St, DS 109C
Indianapolis, Indiana 46202
United States of America
Email: wdpolido@iu.edu
Contributors
Daniel Buser, DMD, Dr med dent
Professor Emeritus
University of Bern
Buser & Frei Center for Implantology
Werkgasse 2
3018 Bern
Switzerland
Email: danbuser@mac.com
Paolo Casentini, DDS, DMD
Private practice
Studio Dr Paolo Casentini
(Implantology, Oral Surgery, Periodontology, Esthetic Dentistry)
Via Anco Marzio 2
20123 Milano MI
Italy
Email: paolocasentini@fastwebnet.it
Vivianne Chappuis, PhD, DMD
Professor
Department of Oral Surgery and Stomatology
School of Dental Medicine
University of Bern
Freiburgstrasse 7
3010 Bern
Switzerland
Email: vivianne.chappuis@zmk.unibe.ch
Stephen Chen, MDSc, PhD
Faculty of Medicine, Dentistry and Health Sciences
Melbourne Dental School
The University of Melbourne
720 Swanston Street
Carlton, Victoria 3053
Australia
Email: schen@periomelbourne.com.au
Matteo Chiapasco, MD
Professor Unit of Oral Surgery
Department of Biomedical, Surgical, and Dental Sciences
University of Milan
Via della Commenda 10
20122 Milano MI
Italy
Email: matteo.chiapasco@unimi.it
Anthony J. Dickinson, OAM, BDSc, MSD, FRACDS
1564 Malvern Road
Glen Iris, Victoria 3146
Australia
Email: ajd1@i-pros.com.au
Luiz H. Gonzaga, DDS, MS
Clinical Associate Professor
Center for Implant Dentistry
Department of Oral and Maxillofacial Surgery
College of Dentistry
University of Florida
1395 Center Drive, Rm D7-6
Gainesville, Florida 32610-0434
United States of America
Email: lgonzaga@dental.ufl.edu
Stefan Keller Babotai, Dr sc nat
FERN Media Solutions GmbH
Weiherallee 11B
8610 Uster
Switzerland
Email: stefan.keller@fern.ch
Johannes Kleinheinz, MD, DDS Professor
Department of Cranio-Maxillofacial Surgery
University Hospital Münster
Albert-Schweitzer-Campus 1
48149 Münster
Germany
Email: johannes.kleinheinz@ukmuenster.de
Wei-Shao Lin, DDS, FACP, PhD
Associate Professor
Interim Chair, Department of Prosthodontics
Program Director, Advanced Education Program in Prosthodontics
Indiana University School of Dentistry
1121 W Michigan St, DS-S406
Indianapolis, Indiana 46202
United States of America
Email: weislin@iu.edu
Dean Morton, BDS, MS, FACP
Professor Department of Prosthodontics
Director, Center for Implant, Esthetic, and Innovative Dentistry
Indiana University School of Dentistry
1121 W Michigan St
Indianapolis, Indiana 46202
United States of America
Email: deamorto@iu.edu
Ali Murat Kökat, DDS, PhD
Prosthodontist
Private Practice
Valikonaǧı St 159/5
Nisantasi 34363 Sisli
Istanbul
Turkey
Email: alimurat@outlook.com
Mario Roccuzzo, DMD
Lecturer in Periodontology
Division of Maxillofacial Surgery
University of Turin
Corso Bramante 88
10126 Torino
Italy
and
Adjunct Clinical Assistant Professor
Department of Periodontics and Oral Medicine
University of Michigan
1011 N University Avenue
Ann Arbor, Michigan 48109-1078
United States of America
and
Private Practice Limited to Periodontology
Corso Tassoni 14
10143 Torino
Italy
Email: mroccuzzo@icloud.com
Charlotte Stilwell, DDS
Specialist Dental Services
94 Harley Street
London W1G 7HX
United Kingdom
Email: charlotte.stilwell@iti.org
Alejandro Treviño Santos, DDS, MSc
Postdoctoral and Research Division
Faculty of Dentistry
Department of Prosthodontics and Implantology
National Autonomous University of Mexico
Prolongación Reforma 1190
05349, Santa Fe
Ciudad de México
Mexico
Email: aletresan@hotmail.com
Daniel Wismeijer, PhD, DMD
Private Practice
Zutphensestraatweg 26
6955 AH Ellecom
Netherlands
Email: Danwismeijer@gmail.com
Table of Contents
Chapter 1: Introduction to the Updated SAC Classification
A. DAWSON, W. MARTIN, W. D. POLIDO
1.1 Introduction
1.2 Historical Background
1.3 The Review Team
1.4 Potential Roles for the SAC Classification
1.5 Using this Book
Chapter 2: The Rationale Behind the Updated SAC Classification
A. DAWSON, C. STILWELL
2.1 Definitions
2.2 Assumptions
2.3 Is the Clinician a Risk Factor?
2.3.1 Factors impacting the clinician as a risk factor
2.3.1.1 Experience
2.3.1.2 Training
2.3.1.3 Self-assessment of ability
2.3.1.4 Shared learning
2.3.1.5 Short training courses
2.3.1.6 Structured education and training
2.3.2 Reducing clinician-related risk
2.3.2.1 Recognizing “human factor” risks
2.3.2.2 Stress as a risk factor
2.3.2.3 Mitigating the human factor issues
2.3.2.4 Clinician risk factor in relation to other sources of risks
2.4 Classification Rationale
Chapter 3: Risks in Implant Dentistry
A. DAWSON, W. MARTIN, W. D. POLIDO
3.1 Principles of Risk Management
3.2 The SAC Classification as a Risk Management Tool
3.3 General Risks
A. DAWSON, J. KLEINHEINZ, A. MURAT KÖKAT, D. WISMEIJER
3.3.1 Patient medical factors
3.3.1.1 Medical fitness
3.3.1.2 Medications
3.3.1.3 Radiation
3.3.1.4 Growth status
3.3.2 Patient attitudes/behaviors
3.3.2.1 Smoking habit
3.3.2.2 Compliance
3.3.2.3 Oral hygiene
3.3.2.4 Patient expectations
3.3.3 Site-related factors
3.3.3.1 Periodontal status
3.3.3.2 Access
3.3.3.3 Previous surgeries in the planned implant site
3.3.3.4 Nearby pathology
3.4 Esthetic Risk
W. MARTIN, V. CHAPPUIS, D. MORTON, D. BUSER
3.4.1 Medical status and smoking habit
3.4.2 Gingival display at full smile
3.4.3 Width of the edentulous space
3.4.4 Shapes of tooth crowns
3.4.5 Restorative status of adjacent teeth
3.4.6 Gingival phenotype
3.4.7 Volume of surrounding tissues
3.4.8 Patient’s esthetic expectations
3.5 Edentulous Esthetic Risk Assessment (EERA)
L. GONZAGA, W. MARTIN, D. MORTON
3.5.1 Facial support
3.5.2 Labial support
3.5.3 Upper lip length
3.5.4 Buccal corridor
3.5.5 Smile line
3.5.6 Maxillomandibular relationship
3.6 Surgical Risks
W. D. POLIDO
3.6.1 Anatomy
3.6.1.1 Bone volume – Horizontal
3.6.1.2 Bone volume – Vertical
3.6.1.3 Presence of keratinized tissue
3.6.1.4 Quality of soft tissues
3.6.1.5 Proximity to vital anatomical structures
3.6.2 Adjacent teeth
3.6.2.1 Papilla
3.6.2.2 Recession
3.6.2.3 Interproximal attachment
3.6.3 Extractions
3.6.3.1 Radicular morphology / interradicular bone
3.6.3.2 Alveolar and basal bone morphology
3.6.3.3 Socket walls
3.6.3.4 Thickness of facial wall
3.6.3.5 Anticipated residual defect after implant placement
3.6.3.6 Quality and quantity of soft tissues
3.6.4 Surgical complexity
3.6.4.1 Timing of placement
3.6.4.2 Grafting procedures
3.6.4.3 Number of implants
3.7 Prosthetic Risks
C. STILWELL, W. MARTIN
3.7.1 Restorative site factors
3.7.1.1 Prosthetic volume
3.7.1.2 Interocclusal space
3.7.1.3 Volume and characteristics of the edentulous ridge
3.7.2 Occlusal factors
3.7.2.1 Occlusal scheme
3.7.2.2 Involvement in occlusion
3.7.2.3 Occlusal parafunction
3.7.3 Complexity of process
3.7.3.1 Access
3.7.3.2 Interim prosthesis
3.7.3.3 Implant-supported provisional restoration
3.7.3.4 Number and location of implants
3.7.3.5 Loading protocols
3.7.4 Complicating factors
3.7.4.1 Biologic
3.7.4.2 Mechanical and technical
3.7.4.3 Maintenance
Chapter 4: How Does the SAC Assessment Tool Derive a Classification?
A. DAWSON, S. KELLER
4.1 Introduction
4.2 Definitions
4.3 Workflow
4.3.1 General risk assessment (GRA)
4.3.2 Esthetic risk assessment (ERA)
4.3.2.1 ERA
4.3.2.2 EERA
4.3.3 Surgical risk assessment (SRA) and surgical classification
4.3.4 Prosthodontic risk assessment (PRA) and prosthodontic classification
4.4 Calculating a Classification
4.4.1 Calculation mechanism
4.5 Testing the Algorithm
4.6 Presenting the Results
Chapter 5: Practical Application of the SAC Assessment Tool
W. MARTIN, A. DAWSON, W. D. POLIDO
5.1 Introduction
5.2 Implants for Restoration of Single-Tooth Spaces: Areas of Low Esthetic Risk
5.2.1 Mandibular molar
M. ROCCUZZO
5.2.2 Mandibular molar
L. GONZAGA
5.3 Implants for Restoration of Single-Tooth Spaces: Areas of High Esthetic Risk
5.3.1 Maxillary central incisor
L. GONZAGA, W. MARTIN
5.3.2 Maxillary lateral incisor
A. TREVIÑO SANTOS
5.4 Implants in Extraction Sockets: Single-Rooted Teeth
5.4.1 Maxillary central incisor
W. MARTIN, L. GONZAGA
5.4.2 Maxillary premolar
L. GONZAGA
5.5 Implants in Extraction Sockets: Multirooted Teeth
5.5.1 Maxillary first molar
P. CASENTINI
5.6 Implants for Restoration of Short Edentulous Spaces: Areas of Low Esthetic Risk
5.6.1 Adjacent maxillary premolars
S. CHEN, A. DICKINSON
5.7 Implants for Restoration of Short Edentulous Spaces: Areas of High Esthetic Risk
5.7.1 Adjacent maxillary incisors
P. CASENTINI, M. CHIAPASCO
5.8 Implants for Restoration of Long Edentulous Spaces: Areas of High Esthetic Risk
5.8.1 Maxillary lateral and central incisors
A. TREVIÑO SANTOS
5.9 Implants for Restoration of Long Edentulous Spaces: Removable Prostheses
5.9.1 Maxilla
C. STILWELL
5.10 Implants for Restoration of the Full Arch: Removable
5.10.1 Edentulous maxilla: Bar-supported overdenture:
WS. LIN, D. MORTON
5.10.2 Edentulous maxilla: Zygomatic implant bar-supported overdenture
W. D. POLIDO, WS. LIN
5.11 Implants for Restoration of the Full Arch: Fixed
5.11.1 Edentulous mandible: Fixed dental prosthesis
P. CASENTINI
5.11.2 Edentulous maxilla and mandible: Implant-supported all-ceramic fixed complete dentures
D. MORTON, WS. LIN, W. D. POLIDO
Chapter 6: Conclusion
A. DAWSON, W. MARTIN, W. D. POLIDO
Chapter 7: References
