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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

The German National Library has listed this publication in the German National Bibliography. Detailed bibliographical data are available at http://dnb.ddb.de.

© 2022 Quintessenz Verlags-GmbH

Ifenpfad 2–4, 12107 Berlin, Germany

www.quintessence-publishing.com

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Illustrations:	Ute Drewes, Basel (CH), www.drewes.ch
Editing:	Quintessence Publishing Co, Inc, Batavia (US)
Layout and Production:	Quintessenz Verlags-GmbH, Berlin (DE)

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