Nanotite
Posted in Dental Implant Systems Surface Coating
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Subscribe to this PostDr. L. asks:
Some of the dental implant manufacturers have started using a new surface coating called NanoTite. This is supposed to stimulate a more rapid osseointegration. Has anybody started using Nanotite coated dental implants? Is there truly an additional benefit from this new surface? Have you attempted early or immediate loading with these? Any other thoughts? Thanks.
Editor´s Note: NanoTite involves the creation of a more complex surface topography and by encorporating calcium phosphates into the surface structure.
What “innovation” are you talking about. Straumann has no study, even after spending $18M, that shows any clinically significant advantage to using its SLActive surface vs its SLA surface. They will earn their entire research budget back just on the $50 difference they charge between the two surfaces, based on a few animal studies that show an earlier shift of about 1.5 weeks in the lowest point of torque removal. With implants being loaded immediately if 35Ncm of torque can be achieved at insertion, which is very achievable in Type 1 and Type 2 bone, shortening the healing time from 6-8 weeks to 3-4 weeks would be of absolutely no significance because overloading would become apparent within a week of immediate loading. What is significant is using an implant design (evenly tapered) in combination with a surgical protocol (undersized socket) to create an increase of insertion torque in soft bone so that more implants can be immediately loaded. That was my innovation with the development of the Tapered Screw-Vent inserted with straight step-drills. A recent article (April 2006 COIR Shalabi) confirmed that compressing soft bone at insertion increased initial stability, torque removal and bone contact. If Straumann wants to prove its SLActive surface is worth the $50 more, let it do a simple animal study comparing that surface with TiUnite, Osseospeed, SBM and HA, all on their implant body, and then repeat the study comparing SLActive on their body and surgical protocol to SBM and HA on the Tapered Screw-Vent from Zimmer or the Tapered ScrewPlant from Implant Direct using the soft bone protocol with straight step drills used with both of these implants. Companies Like Straumann control the studies so that the results of studies they fund are designed to yield positive results – that is why they do not fund comparative studies with competitor’s products.
Getting back to “Nanotite”.. I heard last week that Biomet/3i lost its court case with Bicon over use of the nanotite name. That is, Bicon will keep the Nanotite name and 3i won’t be able to use it.
Does anyone here know anything about this?
Response to MS,
Who cares about a name and which sides win the court battle. This site is meant to help clinicians with real problems and questions. Their technology is totaly different, so what is your point. I doubt Bicon or 3i is going to claim a victory either way, its just a name.
Response to Jerry: Its time to make a difference JERRY. You keep mentioning how all these companies are afraid to put their surfaces up against each other becuase of the results that might occurr. Well, here is your chance Jerry. Take the bull by the horns and make a mockery of these companies. Put together a blind study with the major competitors and oops, include yoru own. Then publish the results, this will eliminate any more scuttlebut. You keep making this point that they will not do it, so YOU DO IT. You have the money and i am sure you have the competetive desire to complete this task. After all you spend hours upon hours beating your chest on this web site asking for someone to do it. Agaain, Jerry….if they are afraid then go get them. Just imagine the satisfaciton of actually proving your claims.
HAHA…BTW that laugh was from me thinking about how you will respond to this message, and the transparency you emit.
Response to Nimnitz,
you quote this study but as i see it, its basically states something that alot of clinicians who have been placing tapered implants have been applying for a long time. Undersize in soft bone to increase BIC. This relates to tapered implants,
alabi MM, Wolke JGC, Jansen JA. The effects of implant surface roughness and surgical technique on implant fixation in an in vitro model.
Clin. Oral Impl. Res.
doi: 10.1111/j.1600-0501.2005.01202.x
Abstract
Objectives: The aim of the present study was to determine the relationship between implant surface parameters, surgical approach and initial implant fixation.
Material and methods: Sixty tapered, conical, screw-shaped implants with machined or etched surface topography were implanted into the explanted femoral condyle of goats. The implant sites were prepared either by a conventional technique, by undersized preparation, or by the osteotome technique. Peak insertion & removal torque, bone-to-implant contacts (BIC) and morphological bone appearance were assessed by scanning electron microscope (SEM) and micro-computer tomography. (micro-CT).
Results: Insertion and removal torque values were significantly higher for etched implants inserted with the undersized technique (115.2±31.1, 102.9±36.4 N cm) respectively. Also, the average BIC value was higher for the etched implants placed with the undersized technique (87.5±5.6), which was statistically significant compared with machined and etched implants inserted by conventional technique.
Conclusion: In conclusion, this study shows that the surgical technique has a decisive effect on implant fixation (represented in this study by installation torque value/removal torque value and histomorphometric evaluation) in trabecular bone. Nevertheless, additional in vivo studies have to be done to prove the importance of surgical protocol for the final implant–bone response.
nanotite vs RBM or SBM what would be the difference? Packaging? Provider?
NIZNICK RESPONSE: There are measuring bars on SEM pictures. Using these bars, you can determine that the Osseotite pits are 1-2u. I think the company acknowledges that. Using these same bars on a machined surface,you can determine that the grooves are 10u appart and with blasted surfaces the pit crators are 20u across. You do not need a study to do the math, although there have been a number of studies done by Albrekkson and Weenerberg measuring surface roughness. We can debate whether a 30u layer of HA will stimulate more bone response than a 2u layer especially if both are susceptible to resorption.
ANSWER
I respect and appreciate very much your experience and comments.
Nevertheless, i must say that you are unaccurate if you rely only on SEM images to describe topography. You say there are no maths… in fact there are so many maths involved that, up to date, no 3D technique is entirely reliable to compare surfaces, if you are not measuring both at the same time with the same setup. (from SEM you get just a 2D screening, unless you have stereo sem)
Usual and reliable parameters to describe pits, grooves, porosity, interconnexion and more features are Ra, Rq and Rt.
It is well known that a wide range of topographical features from the nm to the mm range are crucial: from implant geometry (macroscale) to the lateral and vertical dimensions in the range of 1 to 100 microns which influence bone formation, cell polarity, adhesion, orientation, and morphology (Int J Oral Maxillofac Implants, 1988, 3, 247-259, Implant Dent, 1998, 7, 305-314, J Biomed Mater Res, 1997, 34, 279-290, Eur Cell Mater, 2005, 9, 50-7; discussion 57). However, lateral and vertical dimensions
However, lateral and vertical dimensions under a micron also have a strong influence on focal contacts and cytoskeletal arrangement, affecting cell adhesion, morphology and orientation of cells (Int J Oral Maxillofac Implants, 1988, 3, 231-246, J Vacuum Sci & Tech B, 16, 6,1998, 3132-3136).
Neither Mechanical Stylus Profilometry nor non-contact Laser Profilometry are able to determine small topographical features in the range less than 1 micron. To measure surface topography usually both techniques are combined with Interference Microscopy, stereoSEM or Atomic Force Microscopy, to be able to extract all the relevant information.
As for surfaces, I have funded animal and/or clinical studies in the past comparing machined, TPS, HA and SBM, as well as comparing baskets, screws and cylinders. The results are on my web site. I could easily fund a study comparing TiUnite, SLActive, OsseoSpeed, Osseotite and SBM but what is the point. I am not the one claiming SBM is superior.
In my opinion, people do not buy a system based on the surface anymore, now that we know that all rough surfaces work just fine. There are far more critical differentiating issues and they do not require studies to prove – packaging, prosthetic versitility, ease of use, precision manufacturing and product credibility. Unfortunately implant dentistry seems to be a team sport to some clinicians, and they want to be part of the Nobel or Straumann team. No amount of scientific studies would convince a guy to switch from Nobel TiUnite to SLActive or SBM if they like being a Nobel groupy and are willing to pay the price.
Meng Tejero comment: However, lateral and vertical dimensions under a micron also have a strong influence on focal contacts and cytoskeletal arrangement, affecting cell adhesion, morphology and orientation of cells (Int J Oral Maxillofac Implants, 1988, 3, 231-246, J Vacuum Sci & Tech B, 16, 6,1998, 3132-3136).
Neither Mechanical Stylus Profilometry nor non-contact Laser Profilometry are able to determine small topographical features in the range less than 1 micron. To measure surface topography usually both techniques are combined with Interference Microscopy, stereoSEM or Atomic Force Microscopy, to be able to extract all the relevant information.
T GIORNO answer:
An implant design must be validated at every level of magnification:
from macroscopic level to the micro, nano and why not atomic level, analyzing interferences with surroundings in terms of physico-chemical interactions, as well as mechanical interactions.
Do the elderly colleagues remember the “marketing hypes” around “bullet shape” implants over 15 years ago. That design was doomed to fail from a macroscopic perspective. (shear stress and no compression.)
The industry invented the word “biointegration” trying to make us believe that this “superior” surface would take care of everything….
How many of us have been burned on those false promises?…
RESPONSE TO “Do the elderly colleagues remember the “marketing hypes” around “bullet shape” implants over 15 years ago. That design was doomed to fail from a macroscopic perspective. (shear stress and no compression.”
ACTUALLY, bullet implants showed the highest success rate of any of the other designs used in the VA study of 3000 implants including screws (Screw-Vent CP, Alloy and HA), baskets (core-vent) and ledge implants (micro-vent), primarily because it had an HA coated surface and was easy to put in. Bullets (cylinders lost popularity with the advent of one-stage healing and immediate loading that demanded greater initial stability. Saying that you must consider the surface at all levels of magnification, doown to the micron and nanometer level.. and even the sub-atomic level is to confuse the issue. Everything has pits below a micron and whether you modify the surface at the nanometer level is not nearly as important as creating roughness at the 20-30u level for increased stability.
Jerry,
We agree that the bullet shape success was due: first to its surface, and second to the ease of placement.
Why not use a good surface on a better macroscopic design?
If we could follow up on those bullet implant cases 10 years later, what results should we look at?
About:”Everything has pits below a micron and whether you modify the surface at the nanometer level is not nearly as important as creating roughness at the 20-30u level for increased stability.”
The point is to create a fractal surface, with pattern at the 20-30 microns level for osteoblast ingrowth, as well as a finer profile in the 2-3 microns level to allow for platelets to get on it, and even a finer profile at the nanolevel to increase the fibrin adhesion on the surface.
Large bibliography on those topics in the biomat world….
RESPONSE TO COMMENT: “The point is to create a fractal surface, with pattern at the 20-30 microns level for osteoblast ingrowth, as well as a finer profile in the 2-3 microns level to allow for platelets to get on it, and even a finer profile at the nanolevel to increase the fibrin adhesion on the surface.”
NIZNICK: I agree and that is exactly what blasting with SBM (soluable blast media) RBM (resorbable blast media) or MTX (Zimmer). They are all the same – blasting with HA soluable particles. At lower resolution SEMs you see the 20-30u pits and as you enlarge the view, you see the full range of smaller pits.
I am not amazed but extremely appalled by the ignorant level of this discussion. When we first read and intellectually dissected the Adell study, 18 years of data and precise science was viewed skeptically. Now an extension of an existing product and idea with some animal science gets a product to market, into our patient’s jaws and lead to the my father can beat up your father discussion. This ladies and gentlemen magnifies the worst of our profession the one with the 90 second crown prep and the $25,000 a day production. Shame on us. This is why those of us placing implants (I’d like to think that as a board certified periodontist I do it “right” but who hasn’t had failures and issues) have to hear and see patient’s horror stories.
Let’s start with the science, after all isn’t that what we are as healthcare providers? The “current and mainstream” implants are out there with data and clinical experience. What is wrong with using those systems? NOTHING. What advantages do we see with the “new and improved” and what improvement are we really looking for? Considering that nothing is 100% how much better can we reasonably get?
Issue two is what qualifications does one have to surgically place implants? Remember when Nobel Pharma (the original Branemark and their predecessor before they lowered their bar to become $terri Oss) would only train and allow oral surgeons and later periodontists to place their holy fixtures? Now they sell anything to anybody and are making a strong push to the non-surgical specialists to drill into the same bone that we did with such trepidation. Clearly there are many non-surgical specialist capable of placing implants and surgical specialist that are clueless.
Judging by the level of these questions, statements and the problems that are and have been discussed is frightening. The big loser will be the public, first. Implants are here to stay and arguably the best service we as a profession can offer. Rather than debate a subject without the requisite science, those people who need these answers should use the proven and documented systems and should spend the time to see the leaders of the science (not company shills) and oh yes, read the referred science.
Statement: Rather than debate a subject without the requisite science, those people who need these answers should use the proven and documented systems and should spend the time to see the leaders of the science (not company shills) and oh yes, read the referred science.
Question: who are the leaders of the science? every oppinion leader I ever met was getting paid off by one company or the other. As for Albrektsson, there is the biggest paid in the industry. He wrote an article in 1982 showing an SEM that was a fibroblast from skin around an ear implant and the next eyar the same SEM was in an article wht Branemark but now it was a fibroblast from an upper jaw implant. That SEM became famous when Nobel colorized it and still uses it today to represent osseointegration. At least the company shills as you call us, let you know where we are comming from whereas the paid oppinon leaders hid behind scientific objectivity while pushing the lates surface, connection or color coding of a company.
If you think all implants are the same, just because you are getting high success rates, there are many new users who would like to avoid the learning curve with simplier, more predictable systems. The costs, the prosthetic components, the packaging and the ordering all effect the success of a case that that varies from company to company as does quality and product availability.. oh lets not forget product options. Do you want to get your one-piece implant from one company, your two stage implant from another and the one-stage one from a third?
Tell me what system you are using and I will tell you how you can improve what you are doing for your practise and your patients. That would even apply to some of the implants I sell in certain applications.