Straumann® SNOW Ceramic Implant System

"Thanks to its bone level design, the new SNOW is suitable for all surgical indications"

An interview with Ralf Lüttmann

Ceramic implants have been a standard alternative to titanium implants in your practice for two decades. Where did this very early interest in the then exotic material variant come from?

About Ralf Lüttmann

Dr. Ralf Lüttmann

Dr. med. dent/PhD

Degree in dentistry from the University of Hamburg, Germany. Inventor and pioneer in ceramic implantology. Partner at L Dental Clinic with focus on ceramic-based esthetic dentistry, periodontology and CMD. Lecturer and author on international level on ceramic implantology and clinic business (growth, marketing and management).

Ceramic implants have been a standard alternative to titanium implants in your practice for two decades. Where did this very early interest in the then exotic material variant come from?

At the beginning of the 1990s, I got to know and love the excellent tissue-friendliness and esthetic advantages of this material through the ceramics then already available for prosthetic applications. Therefore, it was only a logical step to look for ceramic solutions in implantology as well.

What sacrifices did one have to make about 10 to 15 years ago with the ceramic implants available at that time compared to the contemporary titanium implants?

On the one hand, the ceramic surfaces of the time were significantly smoother than those of titanium implants, which could make fast and reliable osseointegration more difficult due to a reduced BIC (bone-to-implant contact). On the other hand, for reasons of mechanical stability, the implants were predominantly one-piece. A rather smooth surface in combination with the one-piece design could transform the critical early osseointegration phase into a challenging situation, and simultaneous augmentation and sinus lift procedures were not an option. In addition, the one-piece design often forced compromises in implant positioning due to prosthetic limitations.

“In the past, the one-piece design of ceramic implants often forced compromises in implant positioning.”

Why should even those dentists who are not holistically oriented today also deal with the subject of ceramic implants?

Ceramic implants, like ceramic materials in prosthetics, are high-tech products, but for a long time they had to lead a shadowy existence in the niche of holistic dentistry. But when we see the excellent mucosal behavior around ceramics and, at the same time, given the importance of the mucosal cuff for the long-term preservation of implants, this material cannot simply be ignored. When, in medicine, we are forced to replace body parts, we should consider the use of materials that most closely match the body's own substances. Ultimately, our bone is nothing more than a calcium-based bioceramic - so what could be more natural than replacing hard substances in the body with high-performance ceramics such as zirconium dioxide? No study has investigated the risks posed by ceramics to the human body, and any dentist who wants to provide their patients with materials that are as biocompatible as possible should look into this issue.

In cases where esthetics are the decisive factor, is a ceramic abutment, or a titanium implant with a ceramic shoulder in the transgingival region, not sufficient?

If it is only about esthetics, this can be worth considering. However, ceramic implants are not just about esthetics. A dental implant is initially a fixed anchor, set in place to accommodate a crown or multi-unit construction - but the long-term success depends on secure osseointegration and stable integration in the soft tissues. In my opinion, ceramic implants have decisive advantages in this latter scenario of periointegration. The gingival cuff is clearly more stable than with titanium implants, and plaque formation is clearly reduced, and both are certainly positive factors for long-term stability. Ceramic abutments in titanium implants, on the other hand, pose the risk of damage to the titanium-ceramic connection under the influence of chewing movements due to the superior stability of the ceramic part. In the long term, titanium particles may be released and abutment loosening can occur. A mere ceramic shoulder on a titanium implant seems unfavorable to me because of the potentially unstable bond between the ceramic coating and the underlying, much softer, titanium.

“Ceramic implants are not just about esthetics. The gingival cuff is very stable and plaque formation is reduced.”

Why are ceramic implants only available in the high-price segment, in contrast to the broad existing range of titanium implants?

Well-developed ceramic implants are high-tech products whose manufacture involves a large number of complex steps. This starts with the production of the high-purity ceramic powder and continues through the whole subsequent processing phase. More than 20 time-consuming and costly production steps are necessary from the original zirconium dioxide powder to the final product. A high-quality ceramic implant cannot be produced at low cost today.

How do patients interested in ceramic implants react when the expected treatment costs are discussed?

Implants are generally not a low-budget solution. Patients who are concerned with implants know that this type of tooth replacement is more expensive and are willing to invest in the best possible quality of life. Implant patients for whom quality of life means not only good function but also a highly esthetic solution, and one that is as compatible as possible with their body, often explicitly demand ceramics. The costs of such a treatment then only compete with other elements of their individual lifestyle, such as holidays, a car or leisure activities. It is therefore less a question of price than of the patient's attitude, and of course the dentist can also promote acceptance by providing objective information.

“Many patients are willing to invest in the best possible quality of life. Dentists can promote acceptance of added-value solutions by providing objective information.”

Can one say that all ceramic implant systems on the market are equally well-engineered, or do significant differences exist?

All ceramic implant systems today are based on zirconium dioxide (ZrO2). However, the systems differ significantly in terms of macro design, secure osseointegration and long-term stability. Many systems are one-piece designs and mostly tissue-level concepts. There is only one true bone level system that provides all the advantages of this design, such as simultaneous augmentation or sinus lift procedures even in difficult bone qualities, and thus ensures load-free healing. Among the two-piece ceramic implants available on the market, there are also serious differences in the abutment-to-implant connection. Studies by Zipprich and others show that conical connections are very stable and greatly reduce the risk of abutment loosening or pumping effects known from hex connections. This promotes the long-term success of the prosthetics and the preservation of the crestal bone. However, the production of a conical connection in ceramic requires extremely high manufacturing precision - this is why most ceramic implant brands do not currently offer this type of two-piece connection.

What about the ceramic material - is the zirconium dioxide used identical for all brands?

No, there are huge differences also in the manufacturing process, from the original powder form to the finished implant, which have a significant effect on the mechanical stability and ageing resistance of the implants. The base material is almost identical, and all implants are called zirconia ceramic implants. However, the manufacturing process - whether injection-molded, milled from the sintered material, or milled from a sintered and additionally compressed material - means that the strength values differ considerably.

“Most ceramic implant brands do not offer conical connections due to the required extremely high manufacturing precision.”

In your opinion, what exactly distinguishes implant manufacturers with extensive ceramic experience from their competitors who have only recently embraced this technology?

As banal as it may sound: experience, experience and once again experience in the very specialized development and manufacturing process of high-tech ceramic products. It is relatively easy to visually imitate a product. But, especially with ceramics, it is not the external design that is decisive for long-term success. The difference lies in the processing of the powder into a highly stable finished product, the surface treatment for secure osseointegration, and the precise connection between implant and abutment. Clinical reality has shown time and again that only highly focused specialists with many years of experience are capable of ensuring process-oriented, ceramic-compatible series production, in addition to the ideal product design.

In the case of ceramic implants, critical reference is often made to the still underdeveloped study situation compared to titanium implants. After placing a few thousand of these implants, what advice would you give to a colleague who is interested in starting today?

Dentistry, and implantology in particular, is an empirical discipline. If our titanium pioneers had waited for studies, we would not be where we are today. Today, ceramic implantology works just as well in clinical practice as titanium implantology. In the long term, ceramics might be even better because of the more stable periointegration. My advice to interested colleagues is clear: start as soon as possible, deal with the material and its handling, and attend specific training courses. Over the past 10 years, I have accompanied many young colleagues who started their implantology directly with ceramics and now work very successfully with it. As a dentist, ceramic implants allow you to make a relatively strong name for yourself within the oversupplied field of implantology that exists today from the patient's point of view.

“Placing ceramic implants can be very helpful for practice marketing.”

What significance does the original shape of ceramic implants, i.e. the one-piece design, still have in practice today?

Nature has designed the tooth in one piece rather than two pieces. In this respect, the one-piece design continues to play an important role in our practice for immediate implant placement and immediate restorations. What could be better for a patient than to leave the practice with fixed teeth and immediately participate in social life with a radiant smile?

You are the first user of the brand new Straumann® SNOW implant. What exactly can this innovation offer that none of the previous ceramic implants in your 20 years of practical experience has made possible?

SNOW is truly the first reversibly screw-retained all-ceramic implant system at bone level: ceramic implant, ceramic abutment and ceramic connecting screw. The special feature is the true bone level design with platform switch and excellent mucosal adaptation in the important transition area of the implant abutment.

“The new SNOW is the first screw-retained all-ceramic implant at bone level. Even the connecting screw is made from ceramic!”

What specific advantages does SNOW offer in the surgical field over other ceramic implants?

Thanks to the bone-level design, this implant is suitable for all surgical applications in implantology in all bone qualities, including immediate implant placement after extraction, simultaneous internal or external sinus lift, or extensive accompanying augmentation. The drilling instruments are available with integrated drill stops, which simplifies surgery especially for less experienced users, but also provides additional safety for experienced implantologists in critical situations.

What specific advantages does SNOW offer in the prosthetic field over other ceramic implants?

For SNOW, a large number of ceramic standard abutments are available for prosthetic restorations, enabling simple solutions for all cases. Analog impressions are possible both indirectly and directly, and the abutments are optimized for intraoral scans to allow direct scanning at abutment level as an alternative to scan bodies.

“With a large variety of ceramic standard abutments available for the new Straumann® SNOW, all prosthetic cases can be solved.”

Can SNOW also be expected to make a breakthrough in what has been up to now, for ceramic implants, the rather difficult indication of completely edentulous jaws?

The critical point in full-arch treatments was always the avoidance of macro-movements of the ceramic implants during the healing phase. Either it was possible to place six or more one-piece implants with good bone quality and to splint them by means of a fixed temporary, or there was an increased residual risk of biomechanical overload. This risk is greatly reduced with the SNOW bone-level implant and is comparable with the procedure for titanium implants. The prosthetic restoration is performed using fixed bridges, removable telescopic constructions or SNOW-Loc, a locator-based solution.

What further development steps are planned for Straumann® SNOW?

The next step is full integration into the digital workflow: from case planning and drilling templates all the way to automated manufacturing of the final restoration.

“Full-arch cases can be done with a ceramic implant for the first time without an increased biomechanical risk, thanks to the new SNOW.”

With all the advantages that SNOW already has, what do you think are the limitations that still exist compared to the full titanium systems that Straumann has been offering for decades?

It is not yet possible to fabricate individual abutments and, as with Straumann® Pro Arch, complete restorations on only four implants per jaw, some of which are tilted, are not yet possible.

How do you, personally or together with your patients, decide in each individual case whether to use a titanium implant, a classic ceramic implant or the new SNOW?

This is a very individual decision. In a standard clinical indication, the question whether to use titanium or ceramic can only be decided by the patient. We as dentists are required to inform the patient properly and professionally. The topics here are esthetics, biocompatibility, treatment procedure and costs. Based on my many years of experience with ceramic implants, I see the long-term advantages of this material in terms of stable, firm gums and esthetics after many years, and I explain this to the patient with my own corresponding image material. Whether to opt for a classic one-piece or bone-level SNOW implant will clearly depend on bone quality. In critical bone qualities, I prefer safe healing at bone level rather than multiple one-piece implants that may not all subsequently be used in prosthetics. Now that the option of a bone-level ceramic implant is available, it is not acceptable to use one-piece implants in what are fundamentally at-risk situations, like in softer bone qualities, or where no sufficient protection of the implants during the healing phase can be assured.