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Surface Topography for Implants: Where is this Trend Headed?

posted in Active Posts, Surface Coating

« Educating Patients About Dental Implants | All On 4 Technique »

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Anon. asks:

I have been placing and restoring dental implants for twenty years. I have tried most of the major dental implant companies. They all seem to work about the same, at least in my hands. I am wondering if the critical factor here in osseointegration is the surface topography?

We have HA, SLA, plasma spray, TiUnite, Osseotite, Nanotite and so on. Each manufacturer claims his surface topography creates the most rapid and most complete osseointegration. Who to believe? There is so much contradictory research. Have any of you found one particular surface coating to be the best? Where are we headed down this road? What is the driving rationale behind this technology? Comments would be appreciated. Thanks.

46 Responses to “ Surface Topography for Implants: Where is this Trend Headed? ”

• Anonymous October 30th, 2006

  
  

  The International Journal of Oral & Maxillofacial Implants Vol. 13 Number 5 from 1998 has an article titled ” Removal Torque Values of Titanium Implants in the Maxilla of Miniature Pigs.” By Daniel Buser DDS etal. The study compares an 8mm SLA implant to a 10mm Osseotite. Torque removals for SLA which has both a Macro and Micro Morphology to its roughened surface required substantially more torque to remove them implant from bone at all time points. Despite having 2mm less of roughed surface.

  Journal of Biomed Mater Res. 1995 Mar;29(3):389-401. SLA compared to other rough surface methods and the Old Straumann TPS surface

  Clinical Oral Implants Res. 2005 Dec; 16(6): 657-66 Sand blasted (Macro) + Acid Etching (Micro) “…showed significantly enhanced rates of cell spreading in comparison with the others.”

  A Macro roughened surface that is enhanced by a micro topography appears to have the best bone to implant contact and torque removal values in the literature. The time line for osseointegration is improved allowing for patients to be restored at ealier time points when compared to Implant surfaces that do not have this dual characteristic. Hopefully their will be no further off topic discussion about immediate load which is a function of primary stability not the rate at which the body can shift from primary to secondary stability.

  You can go to Pubmed to find articles about the morphology of dental implants and the effect on osseointegration.

  You will hear 3i say that sand blasting is bad and Lifecore will say that acid etching may leave a residue of dangerous acid. But independent research is much better than marketing claims in my view.

• Anonymous October 31st, 2006

  
  

  has anyone compared to these two surfaces to Astra Tech flouride modified surface

• Dr. Tenax October 31st, 2006

  
  

  In a methodical review of promotional material of some 80 implant manufacturers and of the dental research literature, Jokstad et al found no clear evidence of biologic advantages of any particular implant system over another regardless of the type of surface. (Jokstad A, Braegger U, Brunski JB, Carr AB, Naert I, Wennerberg A. Quality of dental implants. Int Dent J. 2003;53(6 Suppl 2):409-43.)

  That being the case, practical considerations become uppermost. We can disregard implant surface types.

  There are no major differences in the surgical phase of various systems. In the prosthetic phase, however, the differences are marked. For instance, screw retention — a legacy of the research origins of many of today’s implants, is common among the established implant designs. The literature has over a hundred papers dealing with screw retention in implantology and the associated problems of screw loosening and screw fracture. Manufacturers of the newer, simpler systems use designs which approximate conventional crown and bridge work including cement retention of abutments and prostheses. To date, there are no papers in the literature on the subject of cement failure in implantology.

  We can disregard marketing department claims of surface superiority. We simply need to look for systems which approximate conventional prostheitcs and have few steps and few parts.

• Anonymous November 1st, 2006

  
  

  Yes, because the roughtness of a surface is not enough to bring a material an ability to be biologically linked to a bony structure.
  Depending on the type of coating some surfaces are more prone to enhance bone growth than others.
  It is important to distinguish two concepts:
  1- biological link between any material and bone cells
  2- bone enhancement inside some porous material with a somewhat link that could be very weak.
  There is not a straightforward link between a porous surface and its ability to make a strong biological link with tissues.
  Depending on the ability for a material to share some “bridges” with a bony structure the results may differ a lot whatever the kind of coating the material had been subdued to…

• M.Sridhar Reddy November 1st, 2006

  
  

  Nice to hear many coments on the surface. As a student in the Implant dentistry I was taught by many teachers (Dr.Linkow, Dr.Hilttatum,e.t.c.) That the surface roughness of an implant and osseointegration are directly related but there is a limiting value of roughness after which the osseointegration does not change.

• Anonymous November 1st, 2006

  
  

  Surface technology should not be dismissed. The 2003 study measured outcomes. Meaning most companies report a survival rate of between 93-99 percent for the approved treatment protocols. Although it should be noted that the quality of bone is a key factor and few companies stretch their product offering to see what kind of result they get in class III and IV bone. In addition, the various articles reveiwed have different restorative time points, so a positive outcome at 6 months from one company is viewed as equivalent to a similar case restored at 8 weeks. 4 months of time seems to be a pretty big benefit to a patient in a flipper. Just as an immediate temporary would be a benefit if it doesn’t compromise the stability of the implant.

• RS November 1st, 2006

  
  

  The discussion should not revolve around surface coatings, but more appropriately, Surface topography as not all surfaces are coatings. Some are raw titanium without any additives and some are subtractive. 

• Anonymous November 18th, 2006

  
  

  ”We can disregards marketing department claims.”

  How does one spin surface topography into a discussion on cemented abutments and is an implant system that has the worst surface topograhy?

  You are selling/marketing a porous coated surface implant-Tenax.

  Few steps fewest parts is part of you website! I did a google search. The hypocracy is at an time high.

  By the way, Tenax looks to be a limited sytem. No custome abutments, No screw retained prostheses as you can only cement abutments.

• T Giorno August 21st, 2007

  
  

  An Imaplant system should be considered as a triad: an implant mascroscopic design, (not all screws are equal), a prosthetic connection (huge differences from one to another), and finally the surface.
  Looking at only one element of the equation is being nearsighted….and you miss the whole picture.

  Who is the best is another question….

• Dr. Mehdi Jafari August 22nd, 2007

  
  

  The biochemical properties of the microstructure are highly determinant in the process of osseointegration, and the implant shape (e.g., radius of curvature, geometrical discontinuities, smoothness etc.) and its relation to the load situation and specific morphology of the jaw determine the stress distribution . It is now believed that a larger surface area of the implant may not necessarily improve the biomechanical outcome. Surface roughness is categrized into three groups: amplitude, spatial, and hybrid parameters. The surface of the material is different from the bulk material and it is reactive/bioactive. Bioactivity has been associated with materials allowing the formation of carbonate hydroxyapatite on their surfaces when immersed in simulated body fluid. Bioactive biomaterials develop direct, adherent, and strong bonding with the bone tissue. This means that surface properties of materials are truly decisive for the tissue response that they receive.
  The contact between implant material surfaces and biological components, such as proteins and cells, and the outcome of this contact (protein adsorption, cascade reactions, and cell behavior) are highly dependent on the properties of the material surface. The correlation between material surface properties, including chemical composition, structure, roughness, wettability, electro-optics and mechanics, has a keyrole for desired biological reactions. Steigenga et al.[ (2003) Dental implant design and its relationship to long-term implant success. Implant Dentistry 12: 306–317] suggested that ‘there is no “optimal” design criterion’ and that ‘implants can be engineered to maximize strength, interfacial stability, and load transfer by using different materials, surfaces, and thread designs’. In addition to design and material, the configuration of the implants in situ (i.e., the interimplant distances) and the suprastructures (i.e., abutments and bar connection) also have an impact on the stress distribution within the surrounding tissue and jaw bone [Iplikcioglu, H. & Akca, K. (2002) Comparative evaluation of the effect of diameter, length and number of implants supporting three-unit fixed partial prostheses on stress distribution in the bone. Journal of Dentistry 30: 41–46] as well as the angulation of implants. The shape of implants is one of the essential criteria for the resulting biomechanical properties and for osseointegration [Joos, U., Vollmer, D. & Kleinheinz, J. (2000) Effect of implant geometry on strain distribution in peri-implant bone. Mund Kiefer Gesichtschir 4: 143–147] . Peri-implant stress distribution is of course not solely determined by the design of the implants themselves. The selection of the implants should always take the specific morphology of the patient’s bone into consideration. Although in many cases an increase of the implant diameter allows achieving a more favourable mechanical situation, nevertheless, the largest implant or a maximum diameter does not necessarily yield the optimum clinical outcome.

• Robert J. Miller August 22nd, 2007

  
  

  Dr Jafari has very eloquently delineated most of the components that comprise successful implant surfaces. But I will add one more paradigm to the mix. Regardless of the means that is employed to make an implant rough and to create the ideal Ra value for wettability and cell adhesion, we have completely ignored the implants interaction with bone. As the implant roughness increases, whether by subtraction (etch) or addition (coatings), as an implant is being turned through bone, it has an osteoreductive effect. This microfracturing of bone leaves a significant smear layer in the interface between implant body and undamaged osteocytes. This layer goes through a catabolic phase and results in a weakened interface two weeks after implant placement. This may account for the decreasing implant survival rate as implant roughness increases arithmetically. There is a new concept emerging; that of idealizing nanostructure technology that changes the genetic expression of bone cells without super roughness. This has not only been borne out in our invitro testing, but has an additional advantage. It helps to keep the macrostructure of the implant topogpraphy intact. This will decrease trauma to the bone interface and idealize ISQ values as compared to other earlier systems. This new surface is available on Intra-Lock implants. Add to that a calcium phosphate impregnation (rather than appositional coating), and you have a surface that is far more ideal than anything currently available.

• Gerald Niznick August 22nd, 2007

  
  

  I of course could put any surface I wanted on my implants. I started with blasting followed by etching in 1982. Because “too rough” was used by Nobel to market against me, and surface analysis of implants blasted with AlO shows some “contamination” albeit with a biocompatible oxide, I switched to Acid etching with Hydrofloric acid in 1986 as did Steri-oss. Etching is a chemical polishing process of taking down the 10u grooves to 2u pits. With the outcome of the VA study which included etched and rougher HA coated implants, the results in soft bone were significantly (20%) different so in 1993 I stopped Acid Etching and started blasting with soluable blast media (SBM) of HA crystals and have not seen any evidence to pursuade me to change in almost 15 years. Zimmer, Lifecore, BioHorizons all use the same surface and none of us make BS claims about our surfaces like TiUnite, OsseoSpeed, SLActive and Nanotite. When you blast with HA you get 20-30u pits but you also get the full range of pit sizes below this, with pits within pits. Nobel and Branemark claimed in the 1980’s to have a patent on micropits below a micron… This patent was declared invalid by fraud and Nobel paid 3i $15M. I had taken a license just to stop the legal expenses. If a company needs to differentiate its products by claiming surface advantages, usually only over their prior surface, then they probably do not have other features and benefits to talk about.
  HERE IS WHAT I THINK DIFFERENTIATES IMPLANTS FROM AN OSSEOINTEGRATION STANDPOINT IN SOFT BONE:
  An article by Shalabi COIR (posted on my web site at implantdirect.com) showed that when you put a tapered implant into an udersized socket in soft bone, you not only get increased initial torque important for early loading, you also get increased percentage of bone contact and increased torque removal after osseointegration. I wrote an article on this procedure in 2000 (also on my web site) and incorporated this principal into the tapered Screw-Vent by inserting it into soft bone using a straight intermediate drill, and in dense bone using a step drill that was wide enough that a bone tap is never needed. When I developed my new system for Implant Direct, I used the dimensions and taper of the Tapered Screw-Vent. I am now developing a set of drills to accomplish the same thing for the Nobel RePlace and Implant Direct’s RePlant implant which is tapered only in the lower half of the implant.

• Gerald Niznick August 22nd, 2007

  
  

  To add one more thing, I think the best surface is a dense layer (30+u) of high crystaline HA. It gives you the exact same roughness as SBM (HA blasting), is hydrophilic and bioactive. For marketing perposes I keep it 3mm away from the top, but in reality exposed HA is not a problem now that it is high cystalinity.

• Robert J. Miller August 22nd, 2007

  
  

  Jerry, you completely missed the point. Appositional HA coatings do have an advantage. They help to change the genetic expression of bone cells by increasing the synthesis of type I human collagen. These collagen fragments are inducers of osteoblastic activity. This is why ceramic coatings heal more quickly and with greater bone to implant contact. But the major problems associated with these 40-60u plasma sprayed coatings are that they destroy the implant architecture (creating more microfractures) and, when infected, they leave a seam the size of the grand canyon for invasion of pathogenic bacteria and epithelialization down the implant body. This is why, around the world, the percentage of HA coated implants is a fraction of the total number of implants manufactured. The one way to get the benefits of ceramics without the attendant problems is to IMPREGNATE the body rather than plasma spray. This ultra thin layer has the initial desired cellular effect, then completely resorbs so that integration is to the implant body, not a coating. The implant architecture is then unaffected, reducing microfracture and, as a result, reducing the catabolic phase of bone. Time is passing you by, as has the market.

• Gerald Niznick August 23rd, 2007

  
  

  The problems with HA Coatings you describe relate to Calcitek in the late 1980’s when they coated to the top and used a porous HA. The VA study using 1600 HA coated implants side by side with Titanium Alloy and CP titanium screws and baskets proved the value of HA. Even then I did not coat to the top, and I left the apical 3mm uncoated so that the HA would not compromise the ability of the implant to self-tap. With tapered implants,and the use of hard bone and soft bone surgical protocols, the self-tapping feature is far less significant. With 3mm of a blasted surface between the top of the implant and the start of the HA, and two mm of micro-threads inbetween, if the HA gets exposed we have bigger problems going on than worrying about the HA. It sounds like you are a proponent of Nanotite. This surface makes the worse of a bad situation. Acid etching makes it too smooth, and having a few crystals of CaPhosphate in the 2u pits is just window-dressing. Sure it may improve Osseotite, but how difficult is that when the VA resarch proved that etched surfaces are too smooth. Nanotite starts out with an uneven coating (scattered deposits) no thicker than 3-4u. This will probably resorb the first time blood hits it. As for the market passing me by, you apparently have not read any of the articles by ML, Barrons Magazine, DeucheBank, and many other analysts who think I am right on with the pulse of this market from a product, pricing and internet ordering strategy.

• periodoc August 23rd, 2007

  
  

  re: articles by ML, Barrons, et al. You think those guys are concerned about patients, or with the bottom line? Sadly, not a word from you about patient welfare…only self congratulations about your financial acumen.

• Robert J. Miller August 24th, 2007

  
  

  No Jerry, I do not use nanotite, nor do I use any of the 3i product line. I do, however, have 14 different implant systems in my practice, the tapered screwvent being one of them. But being a serious student of the discipline, I am tired of implant technology that is 10-35 years old. The last thing I, or any other serious clinician needs, is more of the same. While your contributions to implant dentistry are well codified, clones of already existing technology is not what is needed. There will always be a market for lower cost. I could write a thesis on what I require in a new implant system. Your marketing strategy does not touch on any of those requirements. With all due respect to market analysts, the forcasts are as much related to past performance as they are with potential future trends. They know little of what true implantologists are looking for and even less of what the current research will bring to market. I stand by my statement that the market will be heading in new directions. RJM

• Gerald Niznick August 24th, 2007

  
  

  Robert:
  My comment that ML, Barrons Magazine, DeucheBank, and many other analysts think I am right on with the pulse of this market from a product, pricing and internet ordering strategy, was prompted by your comment that “Time is passing you buy as has the market.” When you couldn’t refute my response regarding HA, you then attacked me for citing the articles I referenced to refute your personal attack on me by stating: “Sadly, not a word from you about patient welfare…only self congratulations about your financial acumen.” Since you brought up patient welfare, in the last 25 years I think that my efforts have contributed significantly to the welfare of patients, starting with the first published case of two free-standing implants to stabilize a denture, now considered the standard of care by the ACP to my invention of the Internal Connection in 1986, considered by many as the cornerstone of modern implant design. Lets also not forget my funding of the VA Study, the largest ever undertaken in dentistry. As for your reference to “Time is passing you by as has the market,” my new company, Implant Direct, with about 140 employees, is gaining wide professional acceptance and recognition based on what many consider the broadest, best product line and value on the market. Time will tell if the market is passing me by or whether I have again passed the market by.

• Gerald Niznick August 24th, 2007

  
  

  Thank you for using Screw-Vents. Now you can get the updated version (Generation II Screw-no-vent or as I call it ScrewPlant), with mini-threads, an external bevel, a longer self-tapping groove, blasted to the top, with all-in-one packaging that includes a transfer, healing collar and a straight abutment with a snap-on comfort cap. Now maybe you are right and I am wrong… and this is not what “true implantologists are looking for”, but at $150, 70% of the competition, it will do just fine until some company makes you that “new direction” implant of your dreams. Like the song say…”looking for love in all the wrong places.” You may be looking for innovation in all the wrong places. Forget surfaces…. we now how to get implants to osseointegrate and by using a tapered implant in an undersized socket, you can get enough initial stability to immediate load most implants. How about a one-piece implant with a screw-receiving abutment head, a comfort cap, snap-on transfer and 2mm extender… also all for $150 in all-in-one packaging? That’s innovation and the power of having an efficient manufacturing facility and a business strategy that takes advantage of the internet to lower operational costs and pass on the savings. With immediate load becoming a reality, what exactly are you true implantologists looking for? I must have missed it.

• Dr T.Vmanabhan.Pad August 24th, 2007

  
  

  The claim about different configuration of surface and its influence is never ending.However the miniature surface roughness with titanium alloy elevations look good on pictures before implantation.I have done a study where I have studied the SEM picture aftr the implantation in living human individuals and noticed that none of the said or claimed surface do exist after torque forcing the implant in to the bone at45N
  Attached are the photograghs of pre and post SEM pictures of X company implants
  This may open a little thought ,are we really bothered about the surface as long as you get a good osseointegration
  I am not able to paste the picture

• Don Callan August 24th, 2007

  
  

  Look at the data, all implants work for a period of time. The problem is not the short time period, but it is how it reacts in the oral environment. Research has shown the # 1 cause of implant failure is infections from periodontal pathogens, given the established associations between periodontitis and systemic health, it is possible that infection in and around the implant components may impart risks to systemic health. And, where do these pathogens hide–THE MICRO-GAP.
  Although most manufacturers have focused their implant design modifications on the compatibility of the surface texture or composition to osseointegration with bone, future evaluations might well consider the risks involved in placing open micro-gap implants that permit periodontal pathogens to flourish unaffected by hygienic efforts (the implant/abutment).

• Dr. JB August 24th, 2007

  
  

  Dr. Callan has hit the nail on the head! More and more research is showing the mouth and periodontal pathogens are one of the major contributors to systemic diseases. All implants do osseointegrate!!! Now specific design might have a small factor in which implant is more stable, however it is not an extreme factor in the success of an implant. The implant companies need to find another way to market their product, which the big ones spend a lot of money and do a good job…because people are buying into the hype! Be smart….do your own research…

  Dr. Callan has a great article in “Dentistry Today”…He talks all about the micro-gap and the current implant system he is using today to combat this issue. I looked into the implant system he is using and it looks like a very valuable system (PerioSeal). PerioSeal, based on the information I have seen and researched, has an attachment which they call the “Ferrule” attachment…it shows to seal the micro-gap up inside the crown with cement. Now based on this concept, I see a huge advantage that PerioSeal doesn’t mention in their literature…probably because the name is supposed to speak for itself…the concept of a ferrule attachment in other industries is to bring two components together to act as one. Now wouldn’t this system eliminate the need for special threading design??? From my knowledge and research, I can see how the “Ferrule” attachment would eliminate both the micro-gap and micro-movement. Other systems would need stronger stability because they are trying to make two components work together instead of trying to combine them to act as one when in occlusion.

• Dr. Kfc August 24th, 2007

  
  

  Coming back to the issue first discussed, which is where surface topography of implants are headed. The autoclaved machine-finished-surface titanium screw dental implants placed by Branemark 40 years ago was laid to rest with his first patient …..still osseointegrated.

  The basic principles of successful osseointegration remains the same, plain and simple, i.e. sterile titanium surface, atraumatic placement, undisturbed healing.

  The surface topography of dental implants are headed towards absurd levels of hyperbole. The discovery that osseointegration is improved qualitatively and speeded up marginally if you roughened the implant surface by blasting and etching is a wonderful discovery and should be incorporated into implant design. I suspect though that the improvement is not as significant as it is hyped up to be. The significance pales in comparison to the basic principles of osseointegration because you can ignore blasting and etching and coating and impregnation etc. and the implant will still osseointegrate, but you cannot ignore sterility, titanium surface, atraumatic placement and reasonably undisturbed healing. Branemark’s first patient graphically adnecdotes it after 40 years.

  The implant makers have to uniquefy their product in order to gain that competive business advantage. The other points they try to score are in the type of threads, connections, abutments and ease of use. As professionals we understand and humor them, but we never forget the basic principles of osseointegration.

• Gerald Niznick August 25th, 2007

  
  

  READ MY LIPS….THERE IS NO MICROGAP PROBLEM WITH ANY OF THE SUCCESSFUL IMPLANT SYSTEMS. Claims of solving the “micro-gap problem” is just a form of marketing by creating concern that there is a problem that even needs fixing. As long as the connection is stable, which all internal connection implants can provide, the joint will stay sealed. Yes the Ferrule interface contributes to stability, and it has been incorporated into the ScrewPlant implant (external bevel overlapped with internal connection) but I do not claim that this can be correlated to less bone loss or long term success. It is just a good design. There are many additional features that are as important to long term success in an implant abutment system. And lets not forget other important aspects, like prosthetic options, packaging, simplicity body and thread design, surfaces and price.

• Robert J. Miller August 25th, 2007

  
  

  Maybe that odor that is present when I remove a tapered screwvent healing abutment is in my imagination? I am reading your lips, Jerry, and it’s the same stuff you have been selling for years. Of course there is a micro gap and it does contribute to soft/hard tissue changes. Now the bad news: I have stopped using the tapered screwvent. The fastest growing segment of my implant practice is extraction/immediate placement. And the TS is a terrible choice. It has no tracking ability. The implant tends to shift in the osteotomy defect from an area of dense bone into the defect area. This results in an off axis implant position and often adversely affects the facial plate. So you see, Jerry, even the next generation TS does not fulfill my needs. All you have done is to mimic the Nobel Biocare model of the “implant du jour”. When companies move from an “engineering” based implant design to a “biologically” based design, we will be on our way to the next logical evolution of implant design. My comment about the market passing you by has nothing to do with sales. It is about implant design and the effect on living tissue. Clones no longer fit our paradigm. Good luck and leave the science to us.

• Dr. Mehdi Jafari August 25th, 2007

  
  

  • When the issue of micro-gap is regarded, one cannot overlook the study by Hermann J et al. (Biologic Width around one- and two-piece titanium implants. A histometric evaluation of unloaded non-submerged and submerged implants in the canine mandible
  Clinical Oral Implants Research 12 (6), 559–571). The results of their study indicated that the dimensions of the peri-implant soft tissues as evaluated by histometric measurements are significantly influenced by the presence/absence of a micro-gap between the implant and the abutment, and the location of this micro-gap in relation to the crest of the bone. Furthermore, there was no difference in the soft tissue dimensions comparing two-piece implants that had been placed utilizing a submerged or a non-submerged technique. In addition, the tip of the gingival margin was significantly located more coronal for one-piece compared to two-piece titanium implants. Thus, the significant factor that influences soft tissue dimensions is the presence/absence of a micro-gap between components and not the surgical technique used (submerged vs. non-submerged). A significant alteration of the soft tissues occurs when a clinically relevant sized micro-gap of about 50 μm is introduced according to several in vitro reports which have shown that micro-gap sizes of implant/abutment combinations currently used vary from around 100 μm to about 50 μm or even below 10 μm. These findings, furthermore, suggest that the influence of the micro-gap is greater than the effect of the rough/smooth border as it relates to the first bone-to-implant contact on the implant. Consequently, these histological findings also reinforce the radiological findings around these implants and the similar conclusion that the micro-gap (interface) has a significant influence on crestal bone levels around two-piece implant systems. These findings indicate that the apical placement of a micro-gap in order to achieve a harmonious emergence profile in areas of esthetic concern has the most significant influence on the hard and soft tissues with the largest Biologic Width dimension, the most apical location of the crestal bone, small connective tissue contact area, very long epithelial attachment, and the most apical location of the gingival margin. These conclusions have been confirmed by further investigations. ( Nowzari H et al. Clinical Implant Dentistry and Related Research 8:1, 1–10) and (Berglundh T et al. Clinical Oral Implants Research 18:1, 1–8)are worthy to be mentioned.

• Dr. Mehdi Jafari August 26th, 2007

  
  

  Any scrutiny on topographical microstructure, or so called micro-features of an implant, may redirect our attention towards the macrostructure of the implants. This role, if not more, is as important as the role of microstructure. The shape or macro-features of an implant determines the surface area available for stress transfer and manages the initial stability of the implant in the jawbone. Finite element analysis studies of implants indicate that the severity of the stress distributions in bone vary with implant macro-features. Surface features such as threads are incorporated into the design to transform the shear loads to more resistible forces. The significance in increased implant length or its ability to achieve osseointegration is not found at the crestal bone interface, but rather in initial stability and the overall amount of bone/implant interface. The increased length can provide resistance to torque or shear forces when abutments are screwed into place. However, the increased length has a tiny role in decreasing the stress that occurs at the crestal region or can do better to achieve osseointegration. An analytical study has revealed that implants longer than 12 mm will not significantly reduce force transfer proportionately to the increased length. Wider implants have a greater area of bone contact than narrow implants of similar height and design resulting from their increased circumferential bone contact areas. Some investigators believe that only %70 of this contact area is the maximum that could be integrated to bone. Width appears to be more important than height of the implant once a minimum or optimal height has been obtained for initial fixation and resistance to torque. Ironically, the longest implants are usually inserted into the anterior regions of the mouth, where forces of less extent and a better bone quality normally exist. Some clinicians are now in doubt that the best way to decrease the risk factors in such regions, is to increase implant surface area primarily by focusing on diameter only, and are not convinced that such an increase in surface area could merely decrease the stresses to the crestal bone regions and reduce crestal bone loss.

• Gerald Niznick August 27th, 2007

  
  

  Response to Miller’s Comments:
  “Maybe that odor that is present when I remove a tapered screwvent healing abutment is in my imagination? I am reading your lips, Jerry, and it’s the same stuff you have been selling for years. Of course there is a micro gap and it does contribute to soft/hard tissue changes.”

  Niznick: So you are torquing your healing abutments down to 30Ncm as recommended for a final abutment to seal the margins of the 45 degree lead-in bevel? - I doubt it.

  Miller: Now the bad news: I have stopped using the tapered screwvent.

  Niznick: So have a lot of their customers… they are switching to the Generation II updated version which I call ScrewPlant. Let me know when you smell one of those?

  Miller: The fastest growing segment of my implant practice is extraction/immediate placement. And the TS is a terrible choice. It has no tracking ability. The implant tends to shift in the osteotomy defect from an area of dense bone into the defect area. This results in an off axis implant position and often adversely affects the facial plate.

  Niznick: You must be talking about immediate placement in molar sites and/or maxillary anterior sites. As for the molars, I question the wisdom of replacing these teeth immediately. As for the maxillary anterior teeth, it is true that the drill could slide off the lingual plate and defect towards the buccal, but that is a drilling problem, not an implant insertion problem. If you can re-direct the osteotomy more to the lingual, and start the implant into the hole created by your drill, the self tapping narrow end of the Screw-Vent will track on the socket you prepared. If you are havng problems controling the angulation of the drills, buy new drills.

  Miller: So you see, Jerry, even the next generation TS does not fulfill my needs.

  Niznick: You do not know that until you try it.. without an apical thread and with the cutting groove extending half way up the implant, your extrapolation of a limitation with Screw-Vent to my new implants is neither valid nor intellectually honest.

  Miller: All you have done is to mimic the Nobel Biocare model of the “implant du jour”.

  Niznick: It is true that I incorporated features in my new implants that have become popular because they have proven successful over a decade, Like the Screw-Vent connection, and the taper and drills for the Screw-Vent. I then incorporated other proven features, like micro-threads, blasting to the top and an external bevel.

  Miller: When companies move from an “engineering” based implant design to a “biologically” based design, we will be on our way to the next logical evolution of implant design.

  Niznick: Again you are talking about some imaginary implant that is going to do what…get us from 98% to 99%? And at what cost in prosthetic compromise?

  Miller: My comment about the market passing you by has nothing to do with sales. It is about implant design and the effect on living tissue. Clones no longer fit our paradigm. Good luck and leave the science to us.

  Niznick: OK you can have the science and I will just make parts and pieces based on 3 decades of making and selling several million implants with a demonstrated history of clinical success.

• Gerald Niznick August 27th, 2007

  
  

  CORRECTION
  Niznick: You do not know that until you try it.. without an apical “VENT” …. I had put apical thread by mistake.

• Robert J. Miller August 28th, 2007

  
  

  Response to Niznick’s comments:

  Niznick: You must be talking about immediate placement in molar sites and/or maxillary anterior sites. As for the molars, I question the wisdom of replacing these teeth immediately. As for the maxillary anterior teeth, it is true that the drill could slide off the lingual plate and defect towards the buccal, but that is a drilling problem, not an implant insertion problem.

  Miller: I am giving you my clinical experience after placement of several thousand implants and 14 different systems. I do not have to “invent” any of my experiences and can assure the readers of this website that I am quite intellectually honest. BOTH your drills and your tapered screwvent design are fine in healed bone but have terrible tracking problems when placed in extraction site defects. The lack of tracking of the implant body is the very reason I have stopped using the TS. I will also relate my experience using the CAMLOG system. This conclusion was also reached independently by one of the finest oral surgeons in the world, Dr. Charles Babbush. When Axel Kirsch developed an all tapered implant to compete with the TS as a replacment for the root line (bullet shaped) implants, both Charles and my failure rates went UP. We both went back to using the previous root line as a result. The torque and compressive values of all tapered implants go up dramatically when seated. In more dense bone, this may lead to pressure necrosis and failure of the implant after downward epithelialization. In softer bone, at final seating, a too agressive seating torque results in stripping of the bone. I have had the same results using the TS and have made a conscious decision to move away from all tapered implants.

  Niznick: OK you can have the science and I will just make parts and pieces based on 3 decades of making and selling several million implants with a demonstrated history of clinical success.

  Miller: I will use the analogy of the American auto industry. Detroit for decades lead the world in automobile production. But then they decided that they knew better about what the consumer wanted than we did. Now our competitors are eating us for breakfast. Any questions?
  P.S. When was the last time YOU placed an implant? Being intellectually honest starts at home. RJM

• Gerald Niznick August 29th, 2007

  
  

  Miller: When was the last time YOU placed an implant? Being intellectually honest starts at home.

  Niznick: So now the issue of good implant design is dependent on when I placed my last implant. When was the last time you designed an implant, commanded a team of 120 design and test engineers plus machinists and QA people. I designed the Screw-Vent in 1986 and its connection became the industry standard. I designed the Tapered Screw-Vent, and Zimmer now sells about $100M worth of this product in the US alone. I was the first with sterile packaging, fixture-mount packaging and responsible for 25 other patents in the field, but I guess if I haven’t drilled a hole in bone, I am not qualified to debate implant design in your book. The combinaton of a gentle even Taper along with straight drills to overcome both lack of stability in soft bone and elimination of both need for a bone tap and overcompression in dense bone is what made the Tapered Screw-Vent so commercially and clinically successful. I was placing dental implants when you were still in highschool and to my knowledge, the bone has not changed since then, or the principles of good surgery. Try this tip…. drill the hole in the direction you want using a drill that only is end-cutting, like those of the Screw-Vent and my new system which uses the same drills. Then insert the self-tapping implant (my new implants have a longer self-tapping groove) into that hole without changing direction, following the direction of the hole. If you do this, you will not have to worry about implant tacking.

• Robert J. Miller August 30th, 2007

  
  

  Niznick: When was the last time you designed an implant, commanded a team of 120 design and test engineers plus machinists and QA people.

  Miller: You just proved my point better than I could. These designs are engineering rather than biologicvally driven. If you told me you had 120 biologists designing your implant systems, I would have an entirely different view.

  Niznick: I designed the Screw-Vent in 1986 and its connection became the industry standard.

  Miller: You want me to accept that a 20 year old design is the cutting edge in implant dentistry? Are any of your cars, jets, electronics or, for that matter, machine lathes 20 years old?

  Niznick: …to my knowledge, the bone has not changed since then, or the principles of good surgery.

  Miller: Correct, but implanted devices and their interaction with bone/soft tissue, and prosthetic function have. Can anyone spell Core-Vent?

  Over the past 20 years I have watched you skillfully obsfucate the direction of debates. I will always speak my mind and defend this discipline based on fact and good science. I would love an opportunity to debate you in an open forum. RJM

• Dr. Gerald Rudick September 5th, 2007

  
  

  OsseoNews must be complimented for inviting dentists from anywhere in the world to ask questions and seek answers from confreres who share their knowledge and expertize.

  Anon asked the simple question : ” I am wondering if the critical factor here in osseointegration is the surface topography?” and is looking for a straight forward answer.

  He did not think he would draw out some of the biggest brains in the world and each of them, while pouring out a multitude of information and statistics, would fan the flames of the other to get higher up the mountain.

  Dr. Tenax mentions that Jokstad & al. reported that there is no clear evidence of bilogic advantage of any particular implant system over another regardless of the surface.

  It is also mentioned that 40 years ago, Branemark and associates implanted steam sterilized machined titanium implants into a patient, and that patient was buried with those implants.

  Drs. Mehdi Jafari, Robert Miller, and Gerald Niznick spued a wealth of knowledge and history of all aspects of the dental implant industry in their heated debate.

  The younger dentist reading this column must realize that all of these opinions are completely valid, and is privledged to be able to read what is going on.

  Dr. Robert Miller’s comment on the odor detected when removing a healing collar or an abutment or a UCLA type crown must be noted; and this problem has not been solved by any manufacturer. Bacteria do get into the tiniest and best fitting abutment-implant connection, and produce toxins that must be a factor in the deterioration of the prognosis of a dental implant. Will a one piece implant be the solution?

  Dr. Gerald Niznick’s comments and arguments come from a terrific background not only as an outstanding clinician and teacher, but as a person who helped implant dentistry become more credible by funding scientific studies, and as a dentist- businessman who has helped build this industry……regardless if he has or has not been a wet fingered dentist in the last 5 years.

  Dr. Niznick tells us that it was he who invented the internal hex connection; however if one looks at a piece of knockdown furniture with adjustible screw legs, you can see the internal hex implant cast in brass that has been utilized longer than the Niznick patent. Dr. Niznick was the fastest runner to the patent office on that score.

  Dr. Niznick is proud to mention the vast number of highly skilled technical people he employs, and as a matter of fact….. I personally met one of these people 15 years ago, who started his own company called Medigma Technologies in Israel, and markets the exact same implants at a lower price than ImplantsDirect.

  I admire the intelligence and tenacity of Gerry, who I know personally, and our profession has to thank him for his agressive marketing strategies that force the competition to get out and come up with new ideas.

  Do not be swayed by all these coatings, and surface treatments, as the next generation of dental implants will not come from a titanium base, but from stem cells that will allow the patient to grow an anatomically correct implant and tooth which will be the biological exact replacement.

  Dr. Gerald Rudick, Montreal,Canada

• LC September 7th, 2007

  
  

  Comparing to medical practice, demending for new product with new concept/story every day for a conventional condition is a typical problem of dentistry.

  Dr Niznick, in your understanding/definition,is jaw a dense bone, soft bone, or a hybride of both? I would deeply appreciate more details about soft bone vs. dense bone, especially the connection of this biological concept to your systems.

• Gerald Niznick September 10th, 2007

  
  

  Niznick: When was the last time you designed an implant, commanded a team of 120 design and test engineers plus machinists and QA people.

  Miller: You just proved my point better than I could. These designs are engineering rather than biologicvally driven. If you told me you had 120 biologists designing your implant systems, I would have an entirely different view.

  Niznick Response: I would take one prosthodontist and one mechanical engineer over 120 biologists when it comes to desiging an implant system with 600 interrelated parts. Better yet, a prosthodontist who understands mechanical engineering. Remember, a camel was a horse designed by a committee. You keep talking about this nebulous biological implant design you hope to someday see

  Miller: You want me to accept that a 20 year old design is the cutting edge in implant dentistry? Are any of your cars, jets, electronics or, for that matter, machine lathes 20 years old?

  Niznick Response: Check out Nobel Biocare’s “implant of the future” on its website. It is exactly the same internal hex internal bevel platform that Alpha Bio, Medigma, BioHorizons and Now Nobel copied from me.

  Niznick: …to my knowledge, the bone has not changed since then, or the principles of good surgery.

  Miller: Correct, but implanted devices and their interaction with bone/soft tissue, and prosthetic function have. Can anyone spell Core-Vent?

  Niznick: You just did. Gone but not forgotten.

  Over the past 20 years I have watched you skillfully obsfucate the direction of debates. I will always speak my mind and defend this discipline based on fact and good science. I would love an opportunity to debate you in an open forum. RJM

  Niznick Response: “fact and good science” is in the eyes of the beholder. You haven’t said a single thing about any facts or science in this exchange but instead talk in the abstract so apparently you are still looking for the holy grail of implants. You miss the point that we have implants that work very successfully when proper case planning and surgical protocol are followed. The Holy Grail today (until something truly revolutionary comes along) is not at the nanometer scale of the surface but in the global scale of a well thought out, application specific, versatile, easy to place system with all-in-one packaging at reasonable prices sold over the internet using interactive ordering and 3D graphic technical support.

  Why don’t you say one thing of importance in your response that might indicate what you actually think is good science. It certainly can’t be any of Nobel’s studies, or for that matter all the studies by Astra, Straumann or 3i to create marketing support for their overpriced products.

  Jerry Niznick

• Gerald Niznick September 10th, 2007

  
  

  Dr Niznick, in your understanding/definition,is jaw a dense bone, soft bone, or a hybride of both? I would deeply appreciate more details about soft bone vs. dense bone, especially the connection of this biological concept to your systems.

  Response: You can have a dense cortical layer in the mandible and drop into a void just below. Generally speaking the maxilla is always type 3 or 4 bone and the mandible is generally type 2 bone in the posterior and type 1 in the anterior but rather than try to put lables on the bone, judge its consistency by how your drill cuts and how much torque it takes to sea your implant. Of course how dull your drill is and how undersized you create the socket will determine both so I am not able to tell you much - you will need to learn by experience. One thing I can tell you is that if you use a system that offers a softbone and hard bone protocol with a tapered implant going into a straight socket prepared with step drills, you at least have the opportunity to increase stability in soft bone and eliminate the need for a bone tap in hard bone. The proof for this statement is that 8 years after I introduced this concept with the Tapred Screw-Vent with step drills, the New NobelActive implant being launched this fall, uses exactly the same surgical principals although its implant misses the point by only having the root of the threads taper and the neck of the implant angles in failing to seal the crest of the ridge so that it will become a race between the downgrowth of epithelium and the regrowth of bone that was cut away to accomodate the bulge in the implant about 3mm below the top.

• LC September 10th, 2007

  
  

  Dr. Niznick: Thanks a million for the directions. Is there a device to help a clinical desicion for a soft-bone procedure or hard-bone procedure?
  How about the inf. generated from a CBCT for this decision?

  The discussions are really exciting. It reminds me the approach of systems biology.

• Robert J. Miller September 11th, 2007

  
  

  Niznick Response: “fact and good science” is in the eyes of the beholder.

  Miller: Gerry, you must be kidding. If we were to apply this axiom to your statements, all you would be left with is marketing hype. “Fact” is, and you have not addressed my previous posts, completely tapered implants fail with higher frequency than modified taper implants. This has been corroborated independently by some of the best implantologists in the world. As the director of the Oral Implantology program at the Atlantic Coast Dental Research Clinic in Florida, our 30 residents have also proven this paradigm and we are moving away from this architecture. “Good Science” has always been the holy grail of implantology. When we invited you to the AO’s Clinical Innovations program in San Antonio this past year, we did so thinking you had something “innovative” to share with us. All we got was a marketing campaign for your company. The attendees were rather perturbed and let us know after the meeting.

  Niznick: The Holy Grail today (until something truly revolutionary comes along) is not at the nanometer scale of the surface but in the global scale of a well thought out, application specific, versatile, easy to place system with all-in-one packaging at reasonable prices sold over the internet using interactive ordering and 3D graphic technical support.

  Miller: So the true measure of the worth of an implant system is cost, packaging, and internet ordering? Spoken like a true marketer. “Fact” is that it is still about the biological response. Any implant can integrate, but the “issue is the soft tissue response”. When we pay more attention to crestal bone changes, papillary support, apical migration of tissue margins, bone to implant contact, speed to loading, degree of loading to deleterious bone breakdown, rate of bone turnover in the steady state, relationship to bone levels of adjacent natural teeth, then we will be addressing true biological parameters. 20 year old implant designs no longer meet my criteria. RJM

• Gerald Niznick September 12th, 2007

  
  

  Miller: “Fact” is, and you have not addressed my previous posts, completely tapered implants fail with higher frequency than modified taper implants. This has been corroborated independently by some of the best implantologists in the world. As the director of the Oral Implantology program at the Atlantic Coast Dental Research Clinic in Florida, our 30 residents have also proven this paradigm and we are moving away from this architecture.

  Niznick Responds: And this is what you call fact? The opinions of some unnamed “best implantologists in the world” and the experience of some GPs that you teach implants to? I suggest you read an article published in Int. Dent. J, 2003:53 409-443 that was important enough that it was also reprinted in Int. J. Prosthodontics 2004:17: 607-641 entitled “Quality of Dental Implants. A group of prominent academicians, including Jokstad, Brunski, and Wennerberg reviewed 123 articles on 220 implant brands from 80 manufacturers and concluded: “The scientific literature does not provide any clear directives to claims of alleged benefits of specific morphological characteristics of dental implants.” I guess they forgot to ask you!

  Miller: “Good Science” has always been the holy grail of Implantology. When we invited you to the AO’s Clinical Innovations program in San Antonio this past year, we did so thinking you had something “innovative” to share with us. All we got was a marketing campaign for your company. The attendees were rather perturbed and let us know after the meeting.

  Niznick Responds: Funny, that is what they said years ago when I introduced the internal connections. At the 12 minute talk I gave at the AO’s Innovations forum, I talked about three new one-piece implants that are part of my Spectra-System, all with the same evenly tapered body and each for different clinical applications. Only one dentist in the audience questioned the value of the innovations - probably a employee or paid oppinion leader of one of the other major companies I am making very uncomfortable with my products and prices. All three of the implants are the subject of new patents I have filed, so I think they qualify as innovations. In my opinion, with the wide acceptance of one-stage surgery and the growing evidence of success with immediate provisionalization of implants in good quality bone, the natural evolution of implant design is towards one-piece implants. They have not attained their due place in Implantology primarily because of the greed of manufacturers who add the cost of the abutment to the implant when pricing their one-piece implant in order not to cannibalize their sales. I am sure that the introduction of 3 new one-piece implants, all priced at less than the major companies charge for their abutments, has disturbed quite a few “opinion leaders” who rely on financial support from these companies. If I let these people bother me when I advocate a product or feature I believe in, you would still be using bone taps and placing external hex implants for screw-retained single tooth restorations.

  Niznick prior Comment: The Holy Grail today (until something truly revolutionary comes along) is not at the nanometer scale of the surface but in the global scale of a well thought out, application specific, versatile, easy to place system with all-in-one packaging at reasonable prices sold over the internet using interactive ordering and 3D graphic technical support.

  Miller: So the true measure of the worth of an implant system is cost, packaging, and internet ordering? Spoken like a true marketer. “Fact” is that it is still about the biological response. Any implant can integrate, but the “issue is the soft tissue response”. When we pay more attention to crestal bone changes, papillary support, apical migration of tissue margins, bone to implant contact, speed to loading, degree of loading to deleterious bone breakdown, rate of bone turnover in the steady state, relationship to bone levels of adjacent natural teeth, then we will be addressing true biological parameters.

  Niznick: Companies with 16-20% cost of goods, like Straumann, Nobel, Astra, Zimmer and 3i make a number of claims about their designs, surfaces, threads, and connections. In marketing terms this is called “Unique Selling Propositions” and is designed to distinguish their products from the competition in order to justify high prices. You may recall the NobelPerfect implant with its two speed-bumps claiming to provide “papillary support”, a factory you mention above. BioHorizons claims its square threads reduce “degree of loading to (avoid) deleterious bone breakdown.” Then you have Straumann’s SLActive, Astra’s Osseospeed, Nobel’s TiUnite and 3i’s Nanotite all claiming the best “bone to implant contact, (and faster) speed to loading.” Can they all be right? Actually they all only provide comparisons with their old surfaces, not daring to compare to HA coated implants or SBM/RBM/MTX HA blasted surfaces.

  I dare you to invite me to debate you at your Atlantic Coast Dental Research Clinic (implant training center) on the subject of tapered screws verse any other design you my think is fashionable. Your students would undoubtedly reevaluate what they had been told by you although I think you are less likely to be influenced by anything I, a lowly implant manufacturer/salesman would have to say. I did help design and fund the largest implant study ever undertaken at 32 VA hospitals involving 3000 implants that was the subject of two special issues of the JP and JOMS, and I did sleep in a Holliday Inn last night so maybe even you would learn something.

• Robert J. Miller December 25th, 2007

  
  

  Your study is as dated as your reasoning. And I would much rather debate you in a national forum rather than our small research facility. RJM

• Thomas Dahl January 28th, 2008

  
  

  I have been reading the various and diverse posts on Osseonews and would like to ask a couple of questions. I am sorry if my post may seem self serving, but I do have some genuine questions.

  I own a small representation and engineering company in Germany and we have been involved in many medical device developments. I am currently trying to get a better understanding of dental implant coatings, particularly with respect to a new surface treatment that we think way have some interesting implications in dental implant applications.

  In all discussions around what a good implant coating should contain there seem to be two conclusions:

  A good rough micropitted surface seems to be essential for rapid osteointegration. The precise surface topology that is best seems to be open to interpretation and marketing spin. There are many names and methods used to get various topographies.
  A HA or Calcium Phosphate (and its various derivatives) coating seems to add some advantages and speed up the healing process, although the influence seems to be much lower than previously thought
  Thick HA coatings may have shown improvements in the process partly due the roughness they add rather than bioactive properties of the HA itself.
  Bare Titanium seem to be a perfectly sufficient long term given enough time
  The coating debate is heavily influenced by Marketing and Sales pressures rather than good science. Also the push for faster loading times seems to be the most important push of all.

  Is this a fair Birds-Eye view or have I over simplified the current industry position too much?

  Of course, implant shape, taper, thread, cutting edges, socket drilling etc etc are perhaps more important than any of these coasting issues.

  My questions center around the surface properties of Titanium itself and what can be done to improve its inherent properties.

  As the surface of Titanium oxidises rapidly what we are really talking about is the ability of Titanium Oxide mix on the implant surface to encourage the implant to embed and bond into bone. The precise condition of this oxide layer seems to have been ignored in most research that we have seen. SLActive appears to be an attempt to address the Titanium Oxide properties by (and please correct me if I am wrong) simply washing the implant surface in liquid Nitrogen after the final acid etch. This would cause some temporary adhesion of Nitrogen (Nitride?) groups to the surface of the Titanium. In its passivated state the timing for this wash would seem critical. To help keep these groups stable on the implant they need to store the implant in a buffering liquid.

  As far as I can see the only advantage that this coating has is to reduce the contact angle on the implant. They talk about reducing this to 0 degrees which is a physical impossibility. In fact we know that measuring contact angles under 10-20 degrees is extremely difficult. As the Nitrogen based groups dispel from the surface once removed from its liquid buffer rapidly they suggest placing the implant within 15 minutes. This suggests that the active groups are then completely gone.

  Adding “Hydrophilic” groups to implants as a way of increasing the hydrophilic properties is a well established process and there are many ways of doing this.

  We are in the process of seeking patent protection for a novel way of controlling Titanium Oxide layer which makes it Hydrophilic for a period of 1-20 hours when exposed briefly to UV light. We know that this Oxide layer is non Photo Catalytic (ie. does not attack cellular structures). We also know that the Oxide Layer is physically/bioactively no different that regular Titanium Oxide layers found on all implants hence there should be minimum regulatory issues. We can also add additional precursor linker molecules to enable the attachment of proteins (among others).

  So my questions to the group. Does anyone have any knowledge of the importance of Hydrophilicity to the healing process? Is there someone who has looked into this whole subject that can throw some light on this? What will the “next” generation coatings contain and what is the “holy grail” that we are looking for.

  Thomas

• Jerry Niznick February 2nd, 2008

  
  

  Here is my answer to your question regarding the importance of Hydrophilicity to the healing process. Straumann has demonstrated that preventing carbon formation on the surface by using a nitrogen environment after etching, followed by packaging in saline provides some improvement in bone cell attachment between the 3rd and 6th week. In reality, since implants with adequate stability are loaded immediately and those without are usually not loaded for 2-3 months, Straumann’s claims of increased hydrophilicity have no clinical advantage although it makes a good marketing story. What is more important is using an implant (tapered) and drill (straight)design that increases initial stability

• Paul February 10th, 2008

  
  

  Dr. Niznick,
  Just wanted to say I commend and support your efforts. I place the screwplant implant and, for me and my patients, it IS the implant I’ve been waiting for. It’s predictable AND economical. I’ve placed 4 other brands and, IMO, yours is every bit as good or better. Your efforts are making it easier for the average guy to afford dental implants. After all, what use is the “perfect” implant if only the wealthy can afford it? Thanks for keeping prices reasonable.

  Paul Maupin, DDS

• George F. May 22nd, 2008

  
  

  I ran across a recent article in The International Journal of Periodontics and Restorative Dentistry Volume 28 Number 2, 2008 “Human histologic evidence of a connective tissue attachment to a dental implant”, showing connective tissue attachment to an implant. I didnt think this was possible any thoughts?

• Robert J. Miller January 6th, 2009

  
  

  Over the past year we have been using a new implant system that utilizes a nano-impregated calcium phosphate surface (Intra-Lock,International). The Ossean surface has now been tested in comparison to the 3i Nanotite and Astra Osseospeed. At ONE WEEK, the bone bonding study (confirmed by reverse torque testing at New York University and Tufts)shows that the Ossean surface gives a 500% greater bone contact than the other implants tested. This study has been accepted for publication in one of the Biomaterials journals with implications for oral implantology and orthopedics. This new surface skips the catabolic phase of bone which, in other systems, results in a weaker bone to implant interface for the first two weeks. By going directly to the anabolic bone phase, osteoblastic deposition of type I collagen occurs immediately after implant placement. By preventing crestal bone remodeling, we are able to load our implants faster, maintain papillary support, and address virtually ALL of the BIOLOGICAL concerns I had elucidated earlier in this posting. We will be presenting this paper and other ongoing research on the Ossean surface at the AO meeting in San Diego this year. RJM

• Robert J. Miller August 4th, 2009

  
  

  You can find out more about the Ossean literature. There are both animal and human studies that prove the efficacy of this new surface (Piatelli in Italy, Coelho at NYU). A significant advantage in extraction/immediate implant cases. It also helps to preserve crestal bone by re-engineering the biology of the osteotomy. We will be presenting this at the AAID meeting in New Orleans in November 2009.

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