Dr. Moritz Xaver Kneer
• He serves as the clinical chef at the Swiss Biohealth Clinic in Switzerland. In 2018, he attained his degree in dentistry, focusing on oral and maxillofacial medicine, from the University of Ulm, Germany.
• In 2019 as part of his doctoral thesis at the University of Bonn, he analyzed over 500 studies on the entire spectrum of biological (dental) medicine as part of his literature research and was thus able to intensively expand his knowledge in both the dental and general medical fields.
• As a specialist in biological dentistry and ceramic implants, his expertise lies in large all-in-one operations with immediate implant placement.
Prof. Etyene Schnurr, Dr. Ulrich Volz
introduction
introduction
Digital transformation and ceramic implants have emerged as key advancements in contemporary dentistry. Computer-guided surgery has gained popularity because of its ability to predict treatment outcomes. These shifts mirror the rising patient demand for expedited implant-to-prosthesis procedures, emphasising comfort and aesthetics. A reduced treatment duration also yields economic advantages, especially for active patients. Dentists benefit from efficiency, both concerning time and financially.
Immediate implantation protocols provide various advantages beyond time and cost efficiency, including improved occlusal function, elimination of temporary removable prostheses, avoidance of secondary surgeries and preservation of the residual alveolar ridges [1,2]. However, the success of immediate approaches depends heavily on factors such as patient selection, presurgical planning, surgical expertise and prosthetic quality. In routine practice, addressing potential risk factors such as periodontal disease or smoking is crucial for promoting bone healing and achieving successful osseointegration after immediate implantation [3,4].
Fully digital dental implant placement improves osseointegration by enabling precise planning using techniques such as CBCT and intraoral scanners. Virtual implant placement ensures detailed preoperative planning, whereas customised surgical guides reduce surgical errors. Minimally invasive techniques preserve surrounding tissues, promoting faster healing, and real-time feedback allows for adjustments to optimise implant stability. Improved patient communication through digital visualisation enhances confidence and satisfaction, ultimately contributing to the long-term success of dental implants by optimising osseointegration conditions [5].
Swiss Dental Solutions (SDS) offers zirconia implants designed for the tissue level, featuring integrated posts suitable for anterior, canine and premolar regions or cemented posts for posterior regions. This system enables implant drilling and insertion without compressing the cortical or crestal bone, ensuring optimal implant length for precise crown placement [6,7]. It emphasises marginal bone sensitivity and prioritises primary stability using tulip-shaped implants and meticulously engineered threads. The biological drilling protocol emphasises the creation of sufficient space between the implant and the bone to accommodate platelet-rich fibrin (PRF) matrices, promote bone regeneration and improve aesthetic outcomes [8].
“Minimally invasive techniques preserve surrounding tissues, promoting faster healing, and real-time feedback allows for adjustments to optimise implant stability.”
the case
the case
A 38-year-old man presented at the Swiss Biohealth Clinic in Switzerland with numerous missing teeth and chewing difficulties. Two patient conditions posed challenges in this case: the patient was a heavy smoker (>10 cigarettes per day) and had an unfavourable initial condition of the alveolar bone in the maxilla (QR Code on Fig. 1). These conditions were exacerbated by his using a poorly adapted removable prosthesis for 4 years, accompanied by fistulas associated with periapical lesions and chronic sinusitis. During anamnesis, the patient reported that he preferred to remain edentulous rather than continue using a removable prosthesis. A fixed solution would provide the patient with an improved quality of life and a return to social and professional activities.
After a cone-beam computed tomography (CBCT) examination (Orthophos, Sirona), the treatment plan defined the extraction of all remaining teeth in the upper and lower arches. A two-phase treatment was proposed for the upper arch. The first phase involved an external sinus lift and 3D correction of the bilateral bone defect, and the second phase involved implantation into regions 16, 17, 26 and 27. Immediate implantation of SDS zirconia implants was performed in regions 13, 11, 21 and 23, and late implantation was performed in regions 14 and 24. In the lower arch, 10 implants were placed, with immediate implantation in regions 44, 43, 41, 31 and 33 and late implantation in regions 46, 47, 34, 36 and 37. Additionally, augmentation with artificial bone (TCP, Dentoss DEMEDI-DENT) in the upper jaw and Allodyn (MEGAGEN CH) in the anterior region 21/11, as well as on both sides, following an external maxillary sinus lift covered with a collagen membrane (Biocollagen, Bioteck), was recommended. A-PRFs and i-PRFs were used in all the implant beds. All the implants were tested for stability using the AnyCheck tool (Neo Biotech). Values greater than 65 on the Implant Stability Test scale were considered optimal (Fig.1A-F, Video 1).
Digital data collection included facial scans (Face Hunter; Zirkonzahn GmbH), intraoral scans (IOS Primescan; Dentsply Sirona) and jaw movement recordings (Zebris Medical GmbH). A precise 3D virtual smile design, based on aesthetic parameters and proportions (Exocad GmbH), was prepared by overlaying digital data and segmenting IOS and CBCT data (SMOP, Swissmeda AG). The integration of DICOM and STL segmentation into the planning software facilitated the visualisation of tooth extraction and alveolar analysis, optimising surgical procedures. Implantation planning commenced with data uploaded (2-Ingis DigitellV4) and surgical guides printed in the SDS prosthodontic laboratory (Video 2).
The surgery proceeded smoothly with guided procedures in both the upper and lower jaws, using precise 3D-printed guides. Guide stability was achieved in the lower arch by retaining the screws in the molar region (Fig. 2A-D). Six implants were planned for the upper arch and 10 for the lower arch, aiming for stable mandibular rehabilitation in an aesthetically and functionally optimal position, guided by the 3D virtual smile design.
Although the lower arch experienced a loss of vertical dimensions and vestibularisation, the final implant positions precisely matched those in the 3D-printed model. However, obtaining a well-adapted passive-fit provisional prosthesis is challenging. As planned, the immediately loaded implants (Fig. 3A-E) attained initial stability with a torque of up to 45 Ncm, supporting the cemented provisional prostheses in both the upper (teeth 14–24) and lower arches (teeth 44–34). Special attention was paid to ensure that the temporary prosthesis did not impede soft tissue healing and to avoid overcompression of the soft tissues. Moreover, careful consideration was given to balancing the prosthesis with the antagonistic teeth to promote even loading across all implants.
The patient underwent a high-precision, passive-fit provisional procedure on the same day, following a purely digital workflow. This eliminated the need for post-insertion adjustments. The coronal shape and tissue-level insertion of the SDS implants ensured predictable soft tissue support, resulting in an elegant provisional structure that was perfectly adapted to the gingival situation. This support was expected to facilitate proper tissue healing and maintenance of the keratinised gingiva over time, thereby reducing the risk of gingival recession (Fig. 4A-D).
From an economic perspective, the immediate loading protocol proved to be more cost-effective, considering the overall improvement in quality of life. Minimally invasive backward-planned surgeries, such as those using zirconia implants, align with the principles of metal-free dentistry.
The inert properties of zirconia make it stable and resistant to corrosion in the oral cavity with low bacterial plaque affinity and minimal inflammatory infiltration, thus promoting excellent soft tissue integration [9,10].
“The inert properties of zirconia make it stable and resistant to corrosion in the oral cavity with low bacterial plaque affinity and minimal inflammatory infiltration.”
conclusion
conclusion
SDS implants, in conjunction with an open-guided surgery system, enable precise implant placement. This protocol, facilitated by digital workflows, has proven effective for both immediate and delayed implantation, even in cases of extreme bone atrophy requiring 3D reconstruction.
Digitisation with SDS implants leads to faster and more accurate procedures at a reduced cost. Patients also benefit from receiving a perfectly aligned provisional on the same day, promoting soft tissue health and facilitating osseointegration while mitigating patient-related risk factors.
NOTES
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