Prof. Etyene Schnurr
DMD, PhD
• Associate Professor Health Institute, Federal Fluminense University, Rio de Janeiro, Brazil since 2008
• Scientific Advisor, Ceramic and Biological Dentistry Foundation, Switzerland since 2022
• Guest Researcher at the University of Zurich, Switzerland (2017-2019)
• Post-doctoral in Infectious Diseases at the University of California, USA (2012-2014)
• MSc and Doctor in Pharmacology and Medicinal Chemistry, Federal University of Rio de Janeiro, Brazil (2000- 2006)
• Dental Degree, University Gama Filho, Rio de Janeiro Brazil (1991-1995)
Dr. Ulrich Volz, Dr. Moritz Xaver Kneer
introduction
introduction
The evolution in implantology includes integrating digital technology and using ceramic implants.
Digital implantology enables healthcare professionals to manage complex cases involving medically compromised patients and demanding dental restorations. Success depends on refined diagnostics, comprehensive treatment planning, and dedication to surgical precision, culminating in restoration-focused outcomes.
This report highlights the feasibility of creating customised emergence profiles in the tulip area using Swiss Dental Solutions (SDS) ceramic implants. This approach involves a preparation process using diamond drills that allows for adjusting the position of the crown margin relative to the gum by up to 0.5 mm. Moreover, it allows for a maximum of 3 mm horizontal and 5 mm vertical reduction at a 30° drill angulation, conforming to DIN ISO 14801 standards [1] (Fig. 1).
While several studies have reported deviations between the digitally planned and actual implant positions, including crestal, apical, and angular deviations [2], clinical data on the differences in deviations with one- and two-piece implants are notably lacking. Several studies performed implantations under controlled laboratory conditions using models or anatomical preparations, making their comparison difficult. Moreover, findings from such studies have limited applicability to clinical research [3].
Given the challenges associated with accurate implant placement despite advancements in implant technology and careful selection of implant systems, this case report aimed to verify the placement precision of one- and two-piece tissue-level ceramic implants in the posterior region using the same sleeveless 3D drill guide.
clinical case
clinical case
A 62-year-old man presented to the Swiss Biohealth Clinic in Switzerland with chronic fatigue and joint pain symptoms.
Clinical and radiological examinations revealed multiple teeth with periapical lesions that indicated failure of endodontic treatment and ill-fitting crowns and bridges (Fig. 2A-D).
Hematological investigations included evaluation of inflammatory cytokine levels and tests of mitochondrial performance and telomere length to compare biological and chronological age.
The objective was to explore the correlation between dental issues and chronic inflammation, which might have compromised physiological functions and led to chronic fatigue syndrome (Table 1).
Based on the cone-beam computed tomography (CBCT; CBCT Orthophos, Sirona) findings, teeth 16, 17, 12, 11, 47, 45, and 32, associated with either periapical lesions or deep cavities, were extracted.
Since the study objective was to compare placement accuracy with sleeveless 3D drill guides between digitally planned one- and two-piece ceramic implants, the following description outlines the procedures for late implantation in teeth regions 46, 36, and 37.
Digital data acquisition included facial scans using Face Hunter (Zirkonzahn GmbH, Germany), intraoral scans using IOS Primescan (Dentsply Sirona, Germany), and digital recordings of jaw movements using JMA (Zebris Medical GmbH, Germany). Considering aesthetic parameters and proportions, a 3D virtual wax-up and smile design were created using Exocad (Exocad GmbH, Germany; Fig. 3A, B).
By integrating these digital datasets, we achieved a precise 3D virtual smile design that aligned with the segmentation of intraoral scans and CBCT data using SMOP (Swissmeda AG, Switzerland). Using digital imaging and communication in medicine (DICOM) and stereolithography (STL) segmentation, the planning software provided a visual representation of tooth extraction and alveolar analysis, significantly enhancing the accuracy of surgical procedures. We then proceeded with implantation planning (Fig. 4A-E).
“The planning software provided a visual representation of tooth extraction and alveolar analysis, significantly enhancing the accuracy of the surgical procedures.”
Three implants for the lower arch were digitally planned in an aesthetically and functionally oriented position, guided by the 3D-designed virtual smile. The SDS-surgical configuration, as designated by the manufacturer, included a resin surgical guide (Fig. 5), a metal-free temporary prosthesis crafted from high-strength resin (PMMA) for cementation (using Durelon, 3M Espe), and surgical handpiece guides.
These handpiece guides encompassed an initial drill, a pilot drill, specific drills for the intended implant lengths of 11 and 14 mm, and the guide for implant insertion. The remaining natural teeth were used as supports for the lower guide.
Surgical procedures in the lower jaw were performed using the highly precise and stable 3D-printed guides (Table 2; QR Code). As planned, the implants achieved initial stability with a torque of 35 Ncm and were immediately loaded using cemented high-precision passive-fit provisional crowns/prostheses (Fig. 6).
SDS zirconia implants were placed to replace missing teeth 46 (one-piece), 36 (two-piece), and 37 (two-piece). In addition, augmentation with a collagen membrane (Biocollagen; Biotech, Italy) was performed in tooth region 37. A/i-platelet rich-fibrin was used in all implant beds. All implants were tested for stability using the AnyCheck tool (Neo Biotech, Republic of Korea). Implant Stability Test (IST) scale scores >65 were considered optimal (Table 2).
A conventional CBCT method was used to compare the actual implant positions with the digitally planned positions. CBCT data in DICOM format obtained six months after implantation were overlaid with the initial scanning model in STL format and integrated into the implant planning software (Exocad; Fig. 4D, E).
The alignment and merging of these datasets involved surface matching and registration using at least three reference points: entry and apex points on the planned implant (1 and 2) and the corresponding points on the actual implant (3 and 4) [3]. Accuracy was evaluated based on three parameters: the linear distance deviations (measured in millimetres) at the entry and apex points and the angular deviation between the axes of the planned and actual implants. Table 3 shows the accuracy outcomes for the one- and two-piece implants in the 46 and 36 regions, respectively. These regions were selected because they were contralateral teeth and received identical implant fixtures (diameter = 4.6 mm, length = 14 mm) and to facilitate comparisons with previous studies.
Six months postoperatively, there was a noticeable increase in telomere length from 44% to 48%, indicating enhanced cellular health. As previously discussed, telomeres, which act as protective caps at the ends of chromosomes, shorten with each cell division, demonstrating the pace of cellular ageing. The extent of telomere shortening or lengthening approximates an individual’s age, reflecting the cumulative speed of cellular ageing. Telomere lengthening more accurately evaluates cellular age than chronological age, potentially signalling improved patient health after dental treatment.
discussion
discussion
Ceramic implants provide a compelling option for patients sensitive to titanium and those prioritising aesthetics and soft-tissue preservation [4]. Notably, our patient showed early indicators of acute inflammation, immune system activation, mitochondrial weakness, and potential metal intoxication. Extensive research has focused on ceramic implants as a biocompatible substitute for titanium-sensitive patients, aiming to prevent biocorrosion and enhance the long-term stability and performance of metal-free implants [5]. These findings emphasise the substantial advantages of digital surgery for patients with compromised health.
The complexity of pre-implantation planning is greater for one-piece implant systems. Unlike two-piece systems, they lack the option for a second intervention to compensate for implant mispositioning using appropriate abutments. Nonetheless, this challenge can be overcome with prosthetic-oriented 3D planning and guided implant placement, allowing one-piece implants to be used in more complex cases [6].
Ceramic tissue-level implants, whether one-piece with an integrated coronal part or two-piece with a separate coronal part, are consistently placed above the alveolar crest, aiding in precise digital prosthetic planning. These implants effectively support the soft tissues, preventing tissue margin collapse and ridge-related issues. The primary advantage is avoiding implant-abutment interface exposure, which prevents discolouration below the implant platform, reduces plaque aggregation, and promotes gingival health [7].
“Ceramic implants provide a compelling option for patients sensitive to titanium and cases prioritizing aesthetics and soft-tissue preservation.”
Advances in digital technology have been helpful in locating crucial anatomical structures, accurately planning implant sizes and positions, and enhancing the confidence and comfort of dental professionals. Moreover, these innovations have decreased surgical duration and costs while facilitating rapid immediate and permanent dental restorations. Together, these factors can aid in swiftly restoring the patient’s oral and systemic health, enabling them to resume their daily routine and improve their productivity.
In this study, the accuracy outcomes with both one- and two-piece implants were consistent with the existing published definitions of accuracy [8]. This study’s limitations included using data from a single patient and placing only one implant per type. Further studies with more cases are required to determine differences in the positioning of one- and two-piece ceramic implants.
Nonetheless, this study demonstrated the possibility of comparing implant accuracy between these two types of implants and the prospect of assessing the impact of metal-free dentistry and digitalisation on enhancing cellular activity and ageing.
SOURCES
(1) ISO 14801:2016 https://standards.iteh.ai/catalog/standards/sist/76926102-25bb-46ce-932cd911ba96db92/iso-14801-2016. Assessed 26.10.2023
(2) Aghaloo T, Hadaya D, Schoenbaum TR, Pratt L, Favagehi M. Guided and navigation implant surgery: A systematic review. Int J Oral Maxillofac Implants. 2023 May-June;38(suppl):7-15.
(3) Taheri Otaghsara SS, Joda T, Thieringer FM. Accuracy of dental implant placement using static versus dynamic computer-assisted implant surgery: An in vitro study. J Dent. 2023 May;132:104487.
(4) Rutkowski R, Smeets R, Neuhöffer L, Stolzer C, Strick K, Gosau M, Sehner S, Volz KU, Henningsen A. Success and patient satisfaction of immediately loaded zirconia implants with fixed restorations one year after loading. BMC Oral Health. 2022 May 23;22(1):198.
(5) Paparella ML, Domingo MG, Puia SA, Jacobi-Gresser E, Olmedo DG. Titanium dental implant-related pathologies: a retrospective histopathological study. Oral Dis. 2022;28(2):503–512.
(6) Schnutenhaus S, von Koenigsmarck V, Blender S, Ambrosius L, Luthardt RG, Rudolph H. Precision of sleeveless 3D drill guides for insertion of one-piece ceramic implants: A prospective clinical trial. Int J Comput Dent. 2018;21(2):97-105.
(7) Volz U, Schnurr E, Kneer MX. Zirconia implants: Digital workflow incorporating guided surgery and 3D-printed prostheses. DDS-Mag 2023; 2:55-61. https://digital-dentistry.org/dds-mag-2-now-online/
(8) Yi C, Li S, Wen A, Wang Y, Zhao Y, Zhang Y. Digital versus radiographic accuracy evaluation of guided implant surgery: An in vitro study. BMC Oral Health. 2022 Nov 24;22(1):540.