Nanotite

This is 3"lies" newest technology. I have not seen their research on new surface. (and we probably never will because it doesn't exist)Sorry for the negative post but after you have been burned time and time again... (especially with the NT) This just happens. They are a marketing machine. Failure is not an option.

From what I know of nanotite, it is just plasma spraying the surface with a thin layer of HA or tri-calcium phospate. I supported research at LSU in the early 1990's with this kind of surface and it showed no advantage in animal studies. I think that the roughness from thicker coating of HA contributed to its improved results over acid etched, smoother surfaces... that was one of the findings of the 3000 implant study conducted by the VA.

Both wrong! Nanotite has nothing to do with 3i or plasma spraying as suggested above. It is another innovation from Bicon and involves an ion beam assisted deposition of Calcium Phosphate see ....bicon.com/product_info/pi_new.html Whether this Nanotite surface brings any real life improvement is another question..

The Nanotite should provide a rougher surface than they had before... but I see this as merely bringing them to a level of roughness comparable to that which many other companies already have- not leapfrogging them to another level. I read their promotional material on it, and it basically says they will have better results in every challenging bone type than they did with the acid-etched surface. That makes sense, because it is rougher. I havent seen any comparative studies to what else is currently out there such as RBM (which uses CaP as a blasting material) or SLA...

Tiunite may be to Nobel as Nanotite is to 3I. It is not about a rougher surface. Most implants today are moderately roughened. They have a 2um pit size or RA or SA value. The bone seems to favor this level of roughness. This is at the 10-6 size. Nano technology is at the 10-9 level. Not about rougher for sure! It has more to do with an intermolecular reaction with the ecf and anion and cation reations to so to speak start up a "faster connectivity" with the bone. I think its like anodixed as is the Tiunite? It may well be termined "bioactive" but the FDA has a hypersensitivity to that word w/o proper 5/10K issues resolved. This may entail rather costly research and time. But it might be bioactive nano technology? Do you remember when the FDA did not like the term biointergration?

COMMENT: Both wrong! Nanotite has nothing to do with 3i or plasma spraying as suggested above. It is another innovation from Bicon and involves an ion beam assisted deposition of Calcium Phosphate see ….bicon.com/product_info/pi_new.html NIZNICK: Bicon and 3i may be fighting over who gets to use the name "Nanotite." That is because the only thing new here is the name. If 3i's Nanotite is no rougher than Osseotite, it will fall short of the benefits of HA, SLA, TiUnite, SBM, Osseospeed

Jerry: How rough is rough enough?

There is a published study on 3i's Nanotite implant in February's J Perio. They are still using the Osseotite surface and in now way does it say that it is plasma sprayed or anything of the sort. The roughness is the same with the dual acid etching. The implant is put in a solution where nano sized crystals self assemble onto the implant and onto the osseotite surface. It is not a coating like the SLA or other "plasma sprayed" implants. This article is very interesting in that the histology compares the enhanced Nano surface to the original Osseotite surface. I found it quite intriguing because there are many studies on the success of Osseotite. The result for the initial stability were outstanding. Seems like 3i's Nanotite could be a huge leap for compromised sites.

Thats the problem I related above... it compares the prior 3i surface with the new 3i surface. And it is not a human study, correct? You say it is a huge leap for compromised sites? How? In what way? For 3i customers only?

it has been very well documented that the results of the Osseotite surface is excellent as are many other surfaces(sla, cell-plus etc) The discrete deposition of Ca-P crystals at the Nano scale enables true bone bonding, Jed Davies has done extensive reseach on this. Ganted we are not doing as much human histo as before, but the research is sound. This should give the advantages of HA without the negative problems seen before. Time will tell the true results. I have used roughly 10 fixtures so far as part of there pilot study and the early results with the Ostel are extremely favorable. Granted we were all burned by the NT(myself included) but this one seems good. The decesion of when to load is still up to the clinician. I still won't load my sinus cases earlier just because of Nanotite. But i will use them in these cases.

I still can't figure out why we are expected to use these fixtures based on such small scale studies.I always thought the premium I paid for using brand name, high priced screws that are worth about $20 was because I was paying for first rate research to back up my clinical decisions.

The Osseotite surface topography has been prooved beneficial compared with previous machined ones. CP titanium however, although it developes osseointegration, it is still not osteophilic material. On the other hand, other material such as HA, Tricalcium phosphate and Ca-P are more osteophilic. So the concept of Nanotite is simple: They keep using the documented beneficial osseotite topography covered by Ca-P which is more osteopfylic material. The layer is in a nano level of the thickness in order to avoid the previous well known disadvantages of HA thick layers on implant surface. Yes, we still wait for animal or human research but I think that soon we will see it.

COMMENT ON NANOTITE: "it has been very well documented that the results of the Osseotite surface is excellent as are many other surfaces(sla, cell-plus etc) The discrete deposition of Ca-P crystals at the Nano scale enables true bone bonding, Jed Davies has done extensive reseach on this. Ganted we are not doing as much human histo as before, but the research is sound. This should give the advantages of HA without the negative problems seen before." NIZNICK'S COMMENTS: 3I built its Osseotite reputation quoting studies of Davis that when you read them revealed that they were blasted, not etched. I documented 3i's very misleading claims and references to studies in 1999. If someone wants the benefits of HA, then buy HA coated implants and you will also get the benefits of its medium rough surface. The VA study and others documented no negative problems with modern high crystalin HA coatings. There were some problems pre 1990 with low crystalin HA. To answer the question how rough is rough enough, the answer is contained in articles by Albrektsson and Wennerberg. It falls between being too smooth, like acid etched (Osseotite) and too rough (TPS).

About 2mu cubed? Does it matter how high are the peaks and how low are the depressions? Is there a certain effective density of pores per unit area?

Animal histology is not an either or thing compared to human trials and the follow-up histomorphometric studies. This relates to the above comments. It has value, but low level.

holy bias batman! I love taking out old Crappitek implants that fail and my patients really enjoy the grafting needed. I gues that is why we see so many HA coated implants today. Jerry, We all know how you feel toward diferent implant comapnys but try to limit your bias;it really does work against your very high credibility.

Jerry, i have been a big user of 3i for many years and had great success with their implant surface. I have seen countless studies showing the success of Osseotite, are you in diagreement of this? Why do you reference the VA study all the time. Your earlier post about NANOTITE shows you have disdain for new technologies. Current day HA coated implants usually have the HA coating only on half of the implant in case it becomes exposed. Did you read the recent article in the Journal Perio regarding Nanotite? Show me articles disproving how ineffective Osseotite is, because I can list several that demonstrates its effectiveness. Which implant company came up with the first roughned surface? Oh, one more thing Jerry...can you respond to every one of these points instead of picking and choosing which ones you want to respond to. Should be easy for a pioneer like yourself.

COMMENT ON NANOTITE from JERRY NIZNICK: From what I know of nanotite, it is just plasma spraying the surface with a thin layer of HA or tri-calcium phospate. N. COLEMAN: Completely wrong, its a discrete Deposistion of Calcium Phosphate crystals that assemble on half of the osseotite surface. Traditional HA coated implant had 20,000 micrograms of HA versus NANOTITE which has less than 20 micrograms...Huge difference, not a layer or coating.

To answer Dr. Alan Snyder, Bicon was the first company to used a roughened surface on its Titanodont implant back in 1981. This was mechanically roughened and acid etched. In 1985 Bicon were then the first to market grit-blasted, acid treated passivated implants in a sterile package. I know 3i likes to claim lots of things as their own invention ("platform switching" anyone?), but back in 1974 the precursor complany to Bicon was the first to use wide-bodied implants and pre-angled abutments. Nanotite is a Bicon invention too and involves the deposition of an extremely thin layer of CaP using an ion beam. I remember hearing about this at a talk in London 3 or 4 years ago in London.

MS, 3i states that it accidentaly discovered Platform switching, have you really looked into their claims. Nanotite from 3i is completely different than Bicon's, please read the above posts before discussing. One more thing, BICON. Are you kidding me, do you really want to go there. There is a reason why their market share is so NANO, the system is a nightmare to work with. Unless you are a GP and are to lazy to learn how good systems operate. Bicon is a joke to the whole Specialist community, so pleace spare us.

Mr. Snyder, (Or is that Mr. Snyde judging by some of your previous comments which are arrogant and bitchy?) The joke's on you. You are obviously an ignoramus who knows nothing more than he's told by his Rep - or perhaps you are a Rep, for 3i I would guess..Just what is this 'Specialist Community' that you claim to represent? Whatever it is, I hope that I am not a member! Platform switching is not a 3i discovery. The concept has been in use for years by other manufacturers. 3i just saw a gap in the patents. Bicon is a fantastic system with a market share comparable to 3i. In fact in many markets they sell more than 3i. Granted, it has some quirks (as do many systems) but these are accessible to any surgeon with a basic skill level. Perhaps you ought to try it if you think you have the necessary skills? The system is easy to work with (bet you haven't even tried it) If it's so difficult to use why do you foolishly and arrogantly suggest that only GP's can use it? Fool. Think before you write. I use implants from a number of different manufacturers and recognise that no one product is suitable for every patient. 3i, good for some, Bicon, good for others. Jerry Niznick's company seems to cover lots of options, but I guess you would find the choice confusing!

Well said MS! Snyde's either a Rep or has an abutment torqued-up where the sun don't shine. Seriously though, he sounds as though he has a big Bicon chip on his sloping shoulders :-O

Yes, I work for Biomet 3i and proud of it. To clear up some issues, at least from one biased persons perspective. There are two currently marketed products which unfortunately are carrying the NanoTite brand name. They are very different technologies however. I encourage readers to better understand the differences and seek the evidenced based research that might be available from both companies. We are confident that in terms of pre-clinical and clinical data (with histology), that the Biomet 3i NanoTite product has more research at time of launch than any implant surface we are aware had at time of initial introduction. Dr. Davies had done some initial work on several different surfaces, but the overwhelming majority of his work has been done on the Osseotite surface which is comparable on our commercially available product. Concerning Platform Switching, there have been similar clinical uses of the concept. I do think we have done much to show it's use clinically and to fund research to determine any significant difference in outcomes. Our goal has been to help the industry to better understand the role the micro gap, micro gap location, stages of surgery, abutment attachment/removal, bone loading surfaces, etc. play in crestal bone remodeling. We regard this as a scientific approach and not marketing, although we do this as part of being in the business of selling implants. I encourage you to please consider our NanoTite product - but challenge your 3i rep for the facts and answers to any questions you have - I trust they will be more accurate than some answers posted here, though they maybe well intentioned.

Sorry 3i Biomet... I think the challenge would be for the 3i reps to actually have any scientific documents because your company has not produced any true research... 3i is a marketing machine. Nanotite is Calcium Phosphate being applied to a hydro-chloric acid-etched surface, so what is the bond to the implant? Will their be a risk of debonding? Is it brought to the top? How do they know exposure to the oral cavity won't have perioimplantitis issues not unlike HA and TPS. Without 5+ year data you wont. HA and TPS had outstanding data until year 6 and 7. After the recent NT problems, what data is available?

Dr. CA, What is "perioimplantitis"? As stated above.

Dr CA, 3i has released a lot of data/studies with the release of NANOTITE. Please name a company that releases data with 5+ years to support their product release. Sounds great but its not reality in the world we live in today. Give credit where credit is due, there is more data released with this surface than any other companny that has come to market with a new surface.

Alpha-bio (alpha-bio.net) have more than 5 years research on their surface and this was done before it was released on to the market. So you are WRONG again. Why does 3i and its lick-spittles persist in making claims for the complany that are just plain rubbish? And before you slag it off Dr. Snyder, they are the market leaders in Israel and Poland, 2 countries where more implants are placed per capita than anywhere else in the world.

I have read the study in JPerio, which was interesting. I noticed it has an 8 week healing period for the implants placed in the posterior maxilla. However, I haven't been able to get information from 3i on a definite healing period (I know most companies have a "published" healing time like 3-4 weeks, 6-8 weeks, etc). Does anyone know anything? Appreciate it!

I think all of you need to take a deep breath and relax. You are accomplishing nothing by ripping each other. I have been placing Zimmer (Paragon) and Biohorizon implants for over ten years. HA surface has been a agreat surface. We all know the key to implant survival is adequate bone and adequate number of implants. They all work, when stress on the implants is accounted for in the fabricatiion of the prosthesis. The only implants that seem to fail over time that I have encountered is the calitek HA cylinder implants. Probably more to do with the threadless (cylinder) design of the implant than anything. All companies have come a long way in surface coating of their implants since the design of the calcitek bullet. If you like 3i, great, use it. If you like NTI, great use it. Leave the egos at the office.

Amen Dr. D!

Dr. Snyder, Why the visceral response regarding Bicon? I have successfully used the product for more than 15 years and I am a specialist. It is a superior product in my opinion yet not the only one on the market that allows dentists to restore dentition. Is another specialist in your area using Bicon which has caused you to lose referrals? Your reaction must be related to money. Either you have lost money as a result of Bicon or you are a paid spokesman of another company (3i?). You obviously have not read the note of the Osseonews editors asking that the ad hominem and promotional comments be avoided on this site. LB

Leave the Bicon cheerleading to the Bicon website. Let's get back top the topic here: Nanotite. Clearly, what the original question had in mind was the 3i Nanotite surface. I'd be interested in an answer to the above question regarding the definate healing period for 3i's Nanotite? (most companies have a “published” healing time like 3-4 weeks, 6-8 weeks, etc). Any thoughts? Thanks.

Respectfully, Sf, the subject at hand is NanoTite. Apparently Bicon has something quite different, also called NanoTite. From what I read on their website it is an ion-beam assisted depostition of calcium phosphate to their Intergra-Ti surface. From what I know, ion-beam assisted depostition is an important innovation in nanotechnology. It is being adopted in many industries for thin film coatings. There are also some articles on this technology at PubMedInt J Oral Maxillofac Implants. 2001 Nov-Dec;16(6):809-18. Int J Oral Maxillofac Implants. 2005 Jan-Feb;20(1):31

I wholeheartedly agree with Dr. D. The only way we can all learn is to put aside our prejudices and preconceptions and listen carefully to the experiences of others with an open mind. Every system works. Every system has its quirks. Every system has areas where they shine. Ad hominem attacks do not belong here.

Don't want to add to the negativity, but I'm a little confused by the "most studies at time of launch" claim. According to the "References" section on the 3i website, there are 15 articles listed, 10 of which relate to Osseotite. Only five relate to calcium phosphate nanocrystals and they appear to be pre-clinical. Am I missing something? I recall that the Straumann SLActive was launched with 15 studies relating specifically to SLActive. Plus there were actual ongoing clinical trials. So what (and who) am I to believe? The 3i rep who posted above encourages us to ask for the evidence. So where's the evidence to support their marketing claim that they have more studies at time of launch than other surface? And where are the clinical trials? I am not compensated by any company for these opinions.

So no healing time then other than the one from the study? (8 weeks posterior maxilla) thanks!

It seems everyone has a problem with their current implant companies. We are all looking for the perfect company and implant. The most important aspect is everyone working as a team-the surgeon,the general dentist,rep and lab. And working with a company you can rely on and believe in. Then their will be a good outcome and a happy patient. The buzz on the street now is about the current company called NEOSS that has only 94 parts for surgery and restorations. As a general dentist it is a simple system and not alot of inventory. Keeping the ovehead down. And yes they have long term studies. Check it out for youself.

Response to Dr Alan Snyder February 26th, 2007 Posting addressed to Jerry Niznick COMMENT: i have been a big user of 3i for many years and had great success with their implant surface. I have seen countless studies showing the success of Osseotite, are you in diagreement of this? ANSWER: I have a well based general distrust for any claims by 3i. When Osseotite was first introduced, 3i’s referenced studies supporting this surface were so false and misleading, I produced booklet exposing this. My accusations went unchallenged by 3i because they could not be refuted. This booklet can still be read on the Controversies section of my website. COMMENT: Why do you reference the VA study all the time. ANSWER: Because it was the largest, most controlled study ever conducted on dental implants and the most expensive study ever conducted in dentistry. It resulted in special issues of the JOMFS and JPerio. The study was prospective, double blind, and monitored by both internal and external peer review committees. This clinical study, involving 3000 implants in 1000 patients compared 2 and 3 different types of implants side-by-side in the same jaw under the same load conditions. COMMENT: Your earlier post about NANOTITE shows you have disdain for new technologies. ANSWER: What I consider in evaluating new technology is “what problem is it solving”. All the marketing hype about TiUnite, Osseospeed, CellPlus, SLActive and now Nanotite doesn’t amount to any clinically relevant benefits since all medium rough (which excudes Osseotite and maybe Nanotite) work equally as well given the high success rates of dental implants. One study evaluated 123 studies and found no proof that any one was any better. A recent study by Shalabi in April 2006 COIR Journal evaluated the benefits of placing a tapered implant into an undersized socket. They found a significant advantage to this surgical technic, both in initial stability, removal torque following osseointegration and increase in % of bone contact. The only implants on the market today that take advantage of this soft-bone surgical protocol are the Tapered Screw-Vent (Niznick 1999) and the Implant Direct Spectra-System implants (Niznick 2006.) COMMENT: Current day HA coated implants usually have the HA coating only on half of the implant in case it becomes exposed. ANSWER: The VA study showed no increased soft tissue complications if HA became exposed but I still keep a 3mm blasted collar between the top of the implant and the HA coating available on only 1 of my 8 implants. COMMENT: Did you read the recent article in the Journal Perio regarding Nanotite? Show me articles disproving how ineffective Osseotite is, because I can list several that demonstrates its effectiveness. ANSWER: Don’t believe everything you read. The best answer as to what nanotite from 3i can accomplis is stated in their ads... COMMENT: Which implant company came up with the first roughned surface? ANSWER: I don’t know but the Core-Vent implant in 1982 had a surface that was blasted with aluminous oxide followed by acid passivation.

Thomas Driskell's Titanodont had a mechanically textured and acid etched surface back in 1981.

ANSWER: Don’t believe everything you read. The best answer as to what nanotite from 3i can accomplish is stated in their ads… "Potentially Improved Bone Fixation.... May Improve Predictability.."

At the AO meeting there was significant data on the new 3i surface. Dr. Davies (great speaker) showed a substantial body of work that showed the new surface to be far superior to their existing Osseotite surface which is already an excellent surface. Human data was also shown and presented fromt he main podium. I think they are being very resonsible to not say a product works 100% of the time, we all know this is reality. Not all manufacturers take this approach these days.

Nobel claimed for a decade that its machined smooth surface was the best, with the mot research. When they changed to a rougher surface they made similar claims and the results in soft bone certainly proved that their TiUnite rougher surface was better. Osseotite is much smoother than any other surface from the major and even minor companies and Nanotite, while being rougher than Osseotite, falls far short of the roughness of its competitors. Interesting that the surface BioHorizons, Lifecore, Core-Vent/Paragon, Zimmer and now Implant Direct used is the same since 1994... no need to change if you already have a good clean rough surface. Improved results in soft bone can be accomplished by compressing soft bone with a tapered implant going into an undersized socket prepared with a straight drill (Implant Direct, Screw-Vent from Zimmer)

Congratulations to all of you on this post!!!!!! I am a patient who recently recieved an implant consultation from my dentist. Based upon that I decided to reseach this because I want to be comforatable with anything that will be put into my body. I am also a marketing director for a software company in the bay area, and after reading 42 responses to a concept that clearly has not reached a non- biased consensus of its efficacy, I have to take my hat off to this 3i company and their marketing team. It seems that they have created a marketing buzz that has more to do with their campaign/strategy than the actual merit of the product they are releasing. And the evidence is the fact that so many of you have invested your time debating it- this is what I strive for with my marketing and brand teams. Subsequently, for my sake, which implant/surface is considered the gold standard with the most history of success- in people?

I think that you said it best Mr. Sanderson, these postings are an excellent example of the 'Research' behind the 3i products. It is nothing more than a smoke and mirrors show that uses patients like you as the testing grounds. I think it is a shame that more and more companies are relying on their marketing departments to sell their implants rather than the science and research. The only companies that I trust anymore are Nobel and Straumann. They at least still focus on the science.

I just wonder why some of you consider 3i a marketing machine??? I've visited their website and found there enough information about their newest surface. In my opinion 3i is the most science based company among all the companies. And real marketing generator is Nobel...

Yes, the patient has spoken! They are always in the dark and have to rely on the reputation of their doctor. The companies are always worrying how much is going in their pockets and what percent will they grow that year. With all the new products on the market it is confusing to general dentists and our staff members. We ask ourselves the question- do these products work? If the patient goes home happy because the implant integrated then they have a good dental outcome. I am happy! That is what we want! Then our practices will grow because of happy patients. Research longer than two years is what we need. HA took years before it failed. Do we want this all over again?

In case anyone is wondering, Biomet/3i actually put out a press release concerning Nanotite, earlier this month. This is what the company said: "The NanoTite Implant builds upon the benefits of Biomet 3i’s OSSEOTITE Implant by adding deposits of nano-scale calcium phosphate crystals to approximately 50% of the surface. According to pre-clinical studies, these nano-scale deposits create a complex surface on the implant that appears to play a key role in how the implant bonds with the bone. Human bone recognizes calcium phosphate as biologically natural, allowing the bone and implant to bond during healing." Steven F. Schiess, President of Biomet 3i, commented, "The new NanoTite Implant represents a notable advancement in dental implant technology and we are pleased to announce its introduction to the market today."

Greetings to all. I have not taken the time to read every entery posted related to nanotite, but I might suggest that if one were interested in getting the facts, they consult the 3i website or contact a 3i representative.I have seen the data published by 3i and I find it both substantial and significant.

Nanotite research compares the new surface to the Osseotite surface, not to any blasted surfaces like RBM, MTX or SBM (all same.. created by blasting with HA), SLA or SLActive (Straumann) , OsseoSpeed (Astra), TiUnite (Nobel) and especially not to any HA coated surface. While 3i claims that it doubles the roughness, it is still 10 times smoother than any of the above surfaces. They claim less resorption with HA but start out with a layer of 4u going down to about 1u compared to HA coating which they claim are 30u going down to 15u. What they overlook is that if HA is so worthwhile, which it probably is, it makes more sense to have a thicker coating that even if half disolves you have more than a nanolayer of material. Osseotite and Nanotite are smoother than a machined surface and even Branemark/Nobel had to let that dog die a quiet death.

. Sanderson Says: March 19th, 2007 at 11:50 pm C which implant/surface is considered the gold standard with the most history of success- in people? I can tell you that the surfaces on Zimmer's and Paragon's), Lifecore's and BioHorizons implants have not changed in 15 years.... because no study has shown that any of the newer surfaces are any better. That is why Implant Direct went back to medium rough, clean surface. All the other companies compare their new surfaces to their old ones... there was a reason they thought they needed to improve their old surfaces but SBM, RBM, MTX, all created by blasting with soluable HA, does not need improving.

Comment : Jerry Niznick While 3i claims that it doubles the roughness, it is still 10 times smoother than any of the above surfaces. Response: Nanotite is 10 times smoother then the surfaces you state? Can you help by showing me the studies that suggest that. If you are going to make a claim then please back it up.

Comment Jerry Niznick What they overlook is that if HA is so worthwhile, which it probably is, it makes more sense to have a thicker coating that even if half disolves you have more than a nanolayer of material. Osseotite and Nanotite are smoother than a machined surface Response: Nanotite is not a coating, cystals are dposited on the surface. This is a benefit because legacy HA implants had issues for many reasons, one being the coating delaminating or fracturing. Where did you get your clinical information that Nanotite is smoother than a machined surface?

Snyder's Comment: Nanotite is not a coating, Crystals are deposited on the surface. Response: There are only two ways that an implant surface is created, by addition or by subtraction. For example, HA would be added on top of the titanium (addition) and Acid etching takes away from the surface of the titanium (subtraction). So when you say that they are deposited on the surface, you should really be saying that they are added to the surface. Hence Niznick's comment about a coating. He is correct in saying that because it is added to the titanium.

EAD, Wrong my friend. A coating implies a confluent layer, the crystals are not a confluent layer. They occupy only 50% of the surface of the implant. Imagine snow flakes on only 50% of your front lawn. These crystals are 20-100 nanometers in length, to fully comprehed this you must be able to visualize what a nanometer is. Let me help you in lament terms. If the Earth represents a Meter a Soccer ball next to EARTH represents a nanometer. Here endth the lesson!!

The opinion that the rougher the surface the better is plain wrong and with little support. However, surface complexity (a very different concept) is the issue. The HA crystals are what they say creates the very complex surface of Nanotite and this makes sense. The HA crystals in addition to creating the surface complexity, might also be triggering a chemical/biologic early healing reaction. I think the idea is sound. Why would one think that more HA is better? As clinicians, I think we know HA helps with early healing. I don’t think anyone knows what amount it takes to trigger the benefits. And if we can get the benefits with less, then why not? Some of you are trying to beat up on a company that has some good initial data and it is up to us to at least read it before jumping into these otherwise stimulating discussions.

Osseotite itself produces 1-2u pits. A machined surface creates 10u grooves. Adding HA crystals to Osseotite that cover have the surface and dissolve down to 1u thickness, can not be increasing the roughness anywhere a machined and especially any where near as rough as the 20-25u created from blasting with SBM. The question to ask is "What problem is Nanotite solving." If it is to double the roughness of Osseotite, why didn't they do that in the last 10 years and more importantly why don't they do it by blasting like everyone else,to increase the roughness 10-20 fold to match the roughness of SLA, SBM, RBM, HA and Osseospeed. The answer is that they must have read the marketing book "Differentiate or Die" and determined that it is better to be different than to even be as good as the well documented blasted surfaces with 15 years of clinical history.

A question to Jerry Niznick: Why don't you like 3i? Have you ever tried it?

I do not need to place an implant to know what I do not like about it. In my oppinion, the 3i implant has the worse surface and internal connection in the industry and here is why I say that: Surface; From 1982 through 1986,I was blasting my implants with Aluminum Oxide and cleaning them with a mild acid that did not remove any material from the surface. In 1986, I did away with blasting and etched the surface with HFl acid. When the research results of the VA study showed a significantly lower success rate in soft bone with etched implants vs the rougher HA, I went back to blasing the surface but this time used HA crystals in a process that was called Resorbable Blast Media (RBM). I called it SBM for Soluable Blast Media. Zimmer, BioHorizons and Lifecore use the same roughening process and there is no need to change. 3i is the only company using acid etching, a chemically smoothing process for the last 10 years and now is trying to roughen their surface with HA crystals deposited on the surface in a layer tha is less than 5u, claiming it doubles the surface roughness. That still leaves it about 10 times smoother than RBM, SBM or HA. The 3i internal connection, now licensed by Zimmer on the patent I sold them, falls far short of my objectives in developing such a connection in 1986. The 3i Certain implant uses a 2.5mmD double hex below a 3.0mmD hex claiming that the 12 sides allows for adjustments every 30 degrees (12 positions), but if they just indexed the contour and angle of their abutments to the flat of the hex, the dentist would just need to position the flat at time of implant placement to control the direction of the angled head to allow 360 different positions. Because 3i chases the double hex myth for increased adjustability, they need to use a larger upper hex (3.0mm) and that means that they can not make a 3.7mmD implant.. the narrowest with the double hex is 4.2 (I think) with thin walls. And don't get me started about their clicking abutment to know that it is fully seated. Why wouldn't an abutment fully seat as it has no where else to go if it is an internal hex.

Well...Mr. Niznick, I do really respect your studies and researches, but please make sure you know what you are talking about. 3i Osseotite surface is the most documented and the most studied surface nowadays! HA on the Nanotite surface is aimed at increasing and improving initial osseintegration (not at increasing it's surface). And remember that it is a dyscrete deposition (not layer that is made through plasma blasting). I really advise you to try 3i. It has a lot of advantages on other systems. Good luck

Blah Blah Blah.....but you never answer the question you just give your canned responses and hope somebody forgets about the questions raised. Let's start today's lesson by answering my last two questions, for times sake I posted it again. Thanks bud! BTW increasing surface area is different than surface roughness...just checkin. You would think that you would find out all the infomation about this before stickin your foot in mouth. If you persist I will cut and paste stmts you made earlier. Stick to answering the questions and I will save you that embarrassment. Agreed? Alan Snyder Says: March 26th, 2007 at 2:18 pm Comment : Jerry Niznick While 3i claims that it doubles the roughness, it is still 10 times smoother than any of the above surfaces. Response:Nanotite is 10 times smoother then the surfaces you state? Can you help by showing me the studies that suggest that. If you are going to make a claim then please back it up.

You have to trust me that I am not the biggest Jerry N. fan, as his responses usually serve his ends and his means; however, he often makes sense. I was caught holding the bag with the 3i Tapered NT implants and their failure. I was even told that it was my fault because I didn't understand BIC "bone implant contact" with tapred implants. Subsequently, my other system that I have been placing for years was tapered and I had no "BIC" problems with failures. Lets just agree that based upon the 3i NT, Freilet II, Calcitek HA, Replace Select 3.5 fractures, and Astra's true "clinical bone loss" rates, that there are issues with all systems and that we should not be vehemently defending them like we are dependant share holders, or their sales reps. In fact, until you have several years and several hundred of these placed and loaded in your own private practice- without being incentivised by the company, please then forward your insight to the rest of us. Until then please refrain from regurgitating what is on the company web site, or what the rep left at your office and consider your experience for what it is-anecdotal.

Comment : Jerry Niznick While 3i claims that it doubles the roughness, it is still 10 times smoother than any of the above surfaces. Response:Nanotite is 10 times smoother then the surfaces you state? Can you help by showing me the studies that suggest that.If you are going to make a claim then please back it up. 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.

It's nice to see such a diversity of brand loyalties. Company reps are doing a fine job of establishing rapport with their customers. Of course the relavent thing is that all medium roughened surface have high success rates approaching 97% when there is good bone. Even the lesser rough surfaces have pretty good success. Probably the "special surfaces" will prove out to also have good success. Maybe they will get up to 97.5% success or better, or maybe not. As for me, I quite like the idea of Dr. Niznik's option to choose a high quality implant at half price. I think patients will like it also.

I hate to have to say this and ruin a perfectly good debate, but all of the rough surface inplant systems will work if the surgical and restorative people know what they are doing, have examined their patients well and know how each of the systems work. All the systems have little quirks and tricks that you need to be familiar with. (And it is NOT to say that just because you know the tricks of the system that you really know what you are doing.) All the systems use fairly similar tooling and techniques for their insertion and restoration. There are various factors involved that lend themselves to personal preference, and some manufacturers have clearly better surgical instruments for placing their implants, but once they have been inserted, they will all osseointegrate and be maintained. I won't even get into the restorative option arguments. This thread sounds like a bunch of guys arguing over whether BMW, Audi or M-B makes the better car, all citing a statistic here and there trying to make their points.

Tom Wilson from Dallas presented at the 2006 AO meeting on 300 Straumann ITI implants with SLA (old surface) placed in immediate extraction sockets and immediately loaded. He got 98% success. I asked him from the audience whether he thought he would get 99% success if he used thier new surface SLActive which cost $50 more per implant. He had no answer because the question is retorhic. You could not devise a study that could differentiate between 98% and 99% with so many other variables at play other than the surface. All the claims about Osseospeed, TiUnite, SLActive, Nanotite is just marketing BS and shows that these companies do not have much else to claim as a differentiating feature of their products. I have used the same medium rough surface for 15 years... HA blasted. So has Zimmer, BioHorizons and Lifecore. Studies at LSU university in the 1990's showed no difference in %bone contact or torque removal after one month between this surface and HA but the HA had a stronger bond after two months which may not be clinically significant once osseointegration has been achieved. An article by Shalabi in COIR April 2006 showed that inserting a tapered implant into an undersized socket in soft bone increased not only initial stability but also torque removal and %bone in contact.

If that is true, than any tapered implant put into soft bone while undersizing the socket would work, correct? Just trying to understand your point on a granular level.

COMMENT JERRY: Tom Wilson from Dallas presented at the 2006 AO meeting on 300 Straumann ITI implants with SLA (old surface) placed in immediate extraction sockets and immediately loaded Question: When you say immediately loaded, are you referring to a restoration placed that day and put into occlussion. Or are you referring to a healing abutment placed and you say immediate because there has to be some measurable load on it/ Or are you saying that temporized the implant and left the crown out of occlussion?

That was not the point you were trying to make but its so frustrating when people in the field just throw these terms out with out defining them....BTW what is your point....buy your implant and save money. You treat an implant like a comoditiy, so you are trying to win the hearts by the mighty dollar. Jerry, I bet you have never seen the inside of a WalMart, Target or Marshall's. You are simply trying to make more money buy selling a cheaper product and making other dentist feel like they are being ripped off it they use a large implant company. You also simply ignore advancements in the field, you simply dismiss them as trivial and non material as you go on and on about the 90 VA study and your implant.

NIZNICK RESPONSE TO Dr Les Ratner'S COMMENT: If that is true, than any tapered implant put into soft bone while undersizing the socket would work, correct? ANSER; Implants with the taper all at the bottom, like Nobel Replace and 3i's Certain implant would result in greater compression near the crest if they were inserted into an undersized socket because all the expansion of the opening has to occur in a very short distance. This is in contrast to the evenly Tapered Screw-Vent and new Spectra-System implants from Implant Direct which taper from top to bottom allowing it to act like an osteotome. Another critical factor is that only these two implants are inserted into sockets prepared with straight step drills. Inserting a tapered implant into a straight socket (smaller diameter socket at the bottom because of the step-in of the drill)has additional advantages such as backing the implant out a little does not reduce its stability and inserting it a little further down the straight socket does not increase the compression.

NIZNICK RESPONSE TO MIKE SELLERS QUESTION ABOUT IMMEDIATE LOAD: I don't know how he loaded the implant at the time of implant placement but I would assume that he provided a temporary crown for esthetics, not function. To get 98% success with immediate load in extraction sockets, he had to be doing a lot of things right.

Your right about WallMart, Target and Marshall's ..but I am a Cosco member for the last 10 years and I slept at a Holliday Inn last night. My financial success in the implant market is the result of providing high quality innovative products for two decades. Zimmer's success today is because they are selling products I developed that have stood the test of time, including the surface and the connection.You can learn a lot about a company by what they claim is their unique selling proposition. When you have four major companies (Nobel, Straumann, 3i and Astra all claiming faster healing with their new and improved surfaces, while not comparing their surfaces to that of any of their competitors, or to HA, you have to wonder if there is really any difference between all these surfaces. None of them try to differentiate by what is really important..simplicity, versatility and value. I do not "ignore advancements in the field." That would be bad business. I do dismiss many of hte claimed advances as "trivial and non material" but I explain why I beleive that to be the case. If I thought they were good featues, I would incorporate them into my products because they would sell implants, but in the end if they prove to be trivial and non-material as I think they are, then that would be bad for business. I guess I could come up with a surface that started with TiUnite followed by blasting and etching with HFl, springled with HA crystals and packagedm in sterile saline. I could call it "TiSpeedNanoActive."

Your repsonse speaks volumes to your motives, thanks for making my case so easy.

My motives have been clear for the last 25 years.. make the best product I could and sell it for a reasonable price so that my implant business will be successful. That is no surprise. What is not clear is what is your "case" you are trying to make and what are your motives/affilliations with various implant companies. Your last name indicates that you may sell implants "Sellers" which is OK, but it takes more than pontificating about various "innovations"... explain why you think they are advantageous using other than a company's marketing claims.

Mike Sellers. I've been following this post and have commented myself but I am baffled by your remarks. What indeed is your case? Envy? Loss of business? Are you a salesman with a competitive affiliation? Your comments make no sense to me other than they seem to be personal.

Good observation Dennis, I Googled "Mike Sellers, DDS"- got nothing. The I ran "Mike Sellers DMD"- nothing again. "Mike Sellers, dentist"- strike. Thank you for outing Mr. "Sellers" and his agenda.

Dr Niznick, I've used just about every system there is in all types of situations. I like Zimmer, BioHorizons, and Astra implants the most. What is your opinion on Astra implants be it the surface or design. I ask because they have little research behind their design but I get very good results from their implant. I think BioHorizons has the most research and is a very affordable system. Zimmer is nice but expensive. I know you have a new company selling affordable "imitation" implants but I have already read the advantages from your previous comments. If you want to donate some implants to my department I would be happy to compare them longterm to other systems. We can end this debate once and for all. I respect your opinion as many at the university I am at know and commend your past efforts and contributions.

I will try to compare and contrast the three implant systems you inquired about. SURFACE and PLATFORM: Zimmer and BioHorizons have the same surface (HA blasted) and now that Zimmer has licensed BioHorizons on the internal connection, they have the same platform. My Legacy abutments fit both systems and offer design and cost advantages. Astra's surface was blasted with TiO which left imbedded particles. They now etch with HFl, something I did from the mid 1980's as a surface cleaning process. It removes the TiO and creates smaller pits which may account for the slight improvement in bone attachment compared to their old surface. No studies exist that compare these two surfaces and there probably is no clinically significant difference between either one. Of the three implants only the Zimmer Screw-Vent (my earlier invention) is tapered and goes in with a straight drill allowing for bone expansion in soft bone. A study by Shalabi in COIR April 2006 shows that surgical protocol can be a significant factor in bone attachment and initial stability. The Astra implant offers micro-threads near the top which has been demonstrated to reduce stress near the crest, a factor that my retard bone loss so that is a plus for that design (a feature I incorporated in my new system). The platform of the Astra is internal like the other two but because it strives for a connical connection, the abutments do not cover the top of the implant which can have esthetic limitations in that its abutments have undercut just above the top of the implant. All three provide adequat lateral stability... no real advantage to Astra's connical or Zimmer's friction fit over Bio-Horizon's internal hex connection other than the fact that they do not make their own implants so precision fits may be less predictable. RESEARCH and PRICE: I think BioHorizons has the most research and is a very affordable system. Biohorizon's "research" was biomechanical with claims that different threads were needed for different qualities of bone, but that went out the window when they introduced the Prodigy implant with just one thread. Square threads in my oppinion are not desirable because they are not condusive to self-tapping other than in soft bone, and self-tapping insertion improves initial stability so important for immedate and early loading. Zimmer is nice but expensive. My new ScrewPlant implant is not an imitation or even a copy of the Screw-Vent from Zimmer. It is the next generation of design, with the taper starting at the top rather than 3mm below the top, with micro-threads and with an external bevel and no vents and a longer self-tapping groove. All this for about 1/3d the price! I will be making an implant called the Legacy which will copy the Screw-Vent platform. Think of it as Screw-Novent. What university are you with? Keep asking the right questions as it is the only way to get the right answers.Jerry Niznick

Dr. Niznick Thank you for your response. I'm at the Univ Of Michigan. We have access to most systems and typically use Zimmer and Replace. Replace is very popular amongst the GPs and Prosthodontists. The residents in perio tend to place zimmer and recently I have enjoyed astra. Biohorizons has a really nice surgical kit and comes with the abutment. I think you offer a similar combo. Anyway, I agree with the shalabi article that surgical protocol is important for primary stability. I understand the importance of animal studies but he used long bones in his study which can be misleading...plus he osteotomed to the same size as the implant, which we don't do in softer bone. I don't think there is much debate over smooth vs rough implant surface anymore. I believe 3i is getting rid of the hybrid implants soon but I'm not sure. Again, thanks for your input and if you are interested in supporting some research I can try and set something up.

does anyone know of the failure rate of the endopore system?

Well, the topic is Nanotite, not Endopore system. As for Endopore I don't think that it is very comfortable system as it is not screw-type implants and I'm not quite sure about the surface of these implants. Nonatite is really revolutionary surface, I hope you will understand it soon.

I call Dr Niznick "El Che", becouse his revolutionary point of view in the implant Market. I was involved with IMZ implants in the late 80´s; with the very beginning of 3i, with the Replace birth (Steri-Oss onthat time) and with NobelBiocare since the merge. It took more than 20 years to realize that most of what we hear from company research is just marketing bullshit!!! Of course there are many clinicians doing research work independently but what companies do is taking some of this data and using it to it´s own benefit. Now I know that what I really need is a nice implant with a versatile prosth connection, beautifully machined, with a proven surface (RBM, SLA, TioBlast), and all the extras included (straight abutment, impression coping, cover screw, comfort cap...) at an unbeatable price!! Thank you Dr Niznick for your unexpected gift, thank you for comming back into the implant bussines (ie ImplantDirect Spectra System) Dr. P.P.

Please, gentelmen! BIOMET 3i's, NanoTite is not a marketing stuff! All the revolutionary things faced a lot of opponents all over the world. But only time is going to prove what was wright and what was wrong, where was marketing and where was science. I just wonder why most of you are so conservative and prefer to use cheap, simple systems. Why you don't want to adopt innovative things in the industry. Please tell me, can you really solve all your clinical situations with Zimmer or Biohorizons? When patient has type 3 or type 4 bond? I would never believe you if you tell me yes. Don't you want to become a successfull doctor?

This is all quite amusing... There is a very good chance that 3i will have to drop the 'Nanotite' name in the future as it has been in use by Bicon for some time and presumably registered. I understand negotiations are ongoing... This is no 'breakthrough' by 3i, just marketing rubbish propagated by those with a business interest in Biomet/3i. I have had just had some marketing literature through the post from 3i about their Nanotite surface and it is utter cr*p, absolute utter cr*p. In fact it's worse than that, it is an insult to those of use who choose to make decisions for our patients based on science. Just count how many times the word 'may' is used in their claims! They have taken the 'Differentiate or Die' approach to marketing too far. No doubt a Biomet/3i "Opinion leader" or "expert" will be along soon to defend their product. Just bear in mind that Biomet/3i spend at least 50% of their budget on marketing. This maeans that of the $400 you spend on your 3i implant, over $200 goes on adverts, Reps and buttering so-called Opinion leaders (free lunches, free implants, free holidays and courses etc etc).

When will Biomet/3i show us the clinical data on Nanotite? I know they have a couple of rat studies published. Oh, yeah... They do not have any. Let's see what a discrete amount of HA does in year five, six and seven!

Sorry, but the last post simply can't go unanswered and has nothing to do with the intention of this forum. The NanoTite name issue will hopefully be resolved soon. The statement made is inaccurate. It is a complicated matter, but to answer the question, no it is not a registered mark for either company at this point in time. The products are also very different in many substantial ways. There is plenty of science behind the Biomet 3i NanoTite surface and much more on the way. All that is asked is before deciding based on a ranting post(s), review the material available. There are pre-clinical, clinical and human histology results available. Using the proven Osseotite surface as the control in many of the studies the comparative results are overwhelming. They are actually far more compelling that many of the same study results done year's back comparing Osseotite to a machined surface and we all recognize the substantial impact that difference made in clinical outcomes. And before using this statement to bash Osseotite, please consider that it is a very well accepted surface serving the needs of patients and clinicians alike for over ten years. The statement on what is spent on marketing is completely absurd as to not warrant a reply.

The statement regarding marketing expenditure is fact. The fact that you might not want people to know about is is not suprising! Biomet/3i (as well as Straumann and Nobel) spend more than 50% of their income on marketing. Fact. Look at your company's financial records. When you buy a $400 3i implant, $200+ goes on marketing. I'm sure Jerry Niznick can give us some inside info here.

Well this discussion is about Nanotite, not about marketing. So who cares what anybody spends on marketing. It's the science and studies that matter. But, to clear up the marketing issue: Every medical device company spends fortunes on marketing, since these are businesses and not non-profits. Nothing wrong with it. As far as Niznick: he will also spend a fortune on marketing, mostly non-creative bashing of competitors. His only cost savings long-term will presumably be in not having as many reps, but this cost will also go up as more service is needed. People tend to forget that Niznick is in this just as much, or more, for the money than anybody else. But again, the issues here are science, not business or marketing. Keep up the thought provoking discussions!

Dear ManAlive: Please show me who is spending $400 for a Biomet 3i implant? You can't because we don't have any priced at that level. It is disingenuous to state something as fact when it is not. While Nobel and ITI do have expenses around 50% of sales, please understand this is for total expenses - not just marketing. Biomet 3i has expenses which are lower in absolute and percentage terms to our two biggest competitors. If you have financial data to show otherwise, please post.

Dear Mr. Biomet/3i In the UK your implants cost about £260 each (price for 1 fixture). This equates to about $520. Yes folks that's $520 per 3i implant in the UK. Perhaps we in the UK are subsidising your prices across the pond?

I personally do not mind paying the high price for implants as long as there is science tied behind it. ITI and ASTRA seem to be the only ones out there still doing the research. That is not my opinion either. Have you read the Merrill Lynch reports?

“All that is asked is before deciding based on a ranting post(s), review the material available. There are pre-clinical, clinical and human histology results available."- Biomet 3i Are these going to be consistant with the "pre-clinical, clinical and human histology studies" that were put out with the Tapered NT implant? Also, If I have a failure rate in the high 30% again are you going to have someone call and tell me that "I don't undestand the difference between tapered and straight implants or will it be that I do not understand the idiosyncrasies between osseotite and nanotite surfaces this time.

It would seem that Biomet/3i needs to spend way MORE than 50% on marketing etc as it appears to have quite a few p*ssed-off ex-customers. I have been to the 3i factory and there is no way those implants cost more than a few $'s to make. If the money isn't spent on marketing, then it obviously isn't being spent at all. It's pure profit!

There is a difference in placing a tapered implant. Failure to understand this will result in higher failures. Not everyone has them - I didn't. 3i makes great implants, so do some other companies. The new Nanotite surface makes sense and I will use it. I am sure all implant companies run their businesses the same, much like there are similarities in the fees we charge and the costs we have to cover. I prefer to buy American when I can - cars, TVs..and my implants.

let me respond to the 3i rep's claims of their research on osseotite and nanotite. he states: using the proven osseotite surface as the control in many of the studies the comparative results are overwhelming. comment: first you have to buy the false premise that the clinical reports on osseotite are "overwhelming" assumng he means favorable. the way these studies work is they ask 10 of their most experienced clinicians to report their results. no peer review controled, prospective studies. now of the 10, if 3 have less than their target % of success, they are not mentioned in any reports, leaving the 7 who all want to have good results so that 3i will invite them to speak at meetings and they can hold themselves out as experts. the bottom line is that the va study, which was multi-center, prospective, double blind and peer reviewed, did compare ha coated implants to acid etched implants with as much as 20% greater success in soft bone with ha (50u coating, not 4u sprinkles of ha.) the va study also compared results of experienced and inexperienced clinicians.... you do not see that with any other study. the results showed no diffference in dense bone and no difference in soft bone with ha coated implants. he states: they are actually far more compelling that many of the same study results done year’s back comparing osseotite to a machined surface and we all recognize the substantial impact that difference made in clinical outcomes. comment: so here is how the game is played. they compare osseotite to smooth machined surface and claim better results. where are there studies compariting it to sla, tiunite, sbm, ha coating or any of the surfaces that have not been obsoleted. he states: and before using this statement to bash osseotite, please consider that it is a very well accepted surface serving the needs of patients and clinicians alike for over ten years. comment: so now history repeats itself... osseotite must be good because it is better than machined... nanotite must be good because it is better than osseotite. and of course osseotite is "very well accepted" so it must be good. the argument that osseotite must have been good because it "served the needs ... for 10 years" is specious because the same thing was said about machined branemark surface which was on the market for 20 years... about 15 years longer than it took for any discerning dentist to figure out the smooth surface did not work well in soft bone. those dentists who had failures with 3i's nt implant may have avoided those failures if 3i had a rougher surface that could have helped overcome failures of initial stability that came from mismaches in the diameter of the drills and that of the implant. nobel now compares tiunite to machined while straumann compares slactive to sla. i double dare either of these companies to compare torque values after 2 months to that of ha coated implants. i have two university studies done in the 1990's that show bone attachment strength of ha increases with time whereas tps, sbm and machined surfaces stay the same... with machined being much lower than all the others. 3i wants you to beleive that spinkling a few microns of ha on etched smooth titanium is somehow better than 50 microns of an ha coating that has been tested with 1500 implants in the va study and about 800 implants in a columbus university study, all with 96% + success after 5-8 yers. 3i's markeing literature says the reason nanotite is better is because when it resorbes it goes down from 4u to 1u but ha goes from 30u to 15u (i doubt they tested commercially used high crystaline ha). if ha is so good that 3i is sprinkling it on their implant, wouldn't you think they would prefer to have 15u left instead of 1u. their marketing people just don't understand the leap of logic in this marketing position

As far as research goes, I would have ot say that ITI & Nobel have the lion share. While some companies claim that the research matters to them, they clearly do not have anything to back their statements up. For example, I encourage everyone to look into the Astra website where they say that science matters, yet with less than 50 studies they are having a tough time convincing me of their scientific committment. Companies like ITI & Nobel have thousands of studies on their implants. That is where our focus should be. I've said it before. It is a shame that many of us hold marketing claims in higher regard than scientific studies. (by scientific studies I will echo Dr. Niznick...peer reviewed, independent studies)

Since Nobel and ITI are probably the two largest implant companies, it makes sense that they would have research - it is relative to some degree. 3i does produce a great deal of research and you must not be reading the same Journals as I do to not see research or articles documenting the clinical use of Osseotite. HA has it's merits. But does anyone know what amount is needed to create the chemical/biologic reaction to enhance early healing? Jerry, why do you feel more is necessarily better? Maybe, and data presented at a presentation given by Mike Block, showed the amount 3i uses does deliver the desired impact but without making the surface so rough as to hold bacteria if exposed or to delaminate. The theory and supporting research points to getting the full advantage of HA while eliminating the down side of using it as a complete coating. Jerry, please let us know where we can find research to support your new implants? Lastly, I don't think how you paint what Biomt 3i says is what was said. I think they are either number 2 or 3 in the world. That says something for Osseotite. Many of us use it day in and day out. Nothing works 100%, but it has established a track record of proven performance. To now have data to show how NanoTite compares to a proven surface when used as the control is complelling as Biomet 3i says.

Take a look at the annual reports from Nobel and Straumann. In 2006 Nobel spent 17.6m Euro on R&D or 2.9% of revenue. Straumann spent 18.7m Euro or 5.1% of revenues. Straumann invests way more. Having just returned from the ITI World Symposium in New York I can tell you which horse I'm backing. Someone half-joked that, through ITI scholarships and research grants, they spend more on research with Nobel and 3i implants than Nobel and 3i do!! (I am not paid by any company for my views)

RESPONSE TO QUESTION: Jerry, why do you feel more (HA) is necessarily better? Maybe, and data presented at a presentation given by Mike Block, showed the amount 3i uses does deliver the desired impact but without making the surface so rough as to hold bacteria if exposed or to delaminate. The theory and supporting research points to getting the full advantage of HA while eliminating the down side of using it as a complete coating. NIZNICK: 3i's brochure shows that under increasing PH, Nanotite layer decreases from 4u to 1u or less whereas HA coating is shown on their chart to decrease from 30u to 15u. WHICH MEANS THAT COATING THE SURFACE WITH 30u WILL ASSURE YOU THAT AT LEAST 15u will remain. I am a pilot and a lesson I learned the hard way was that you never have too much fuel or too much altitude because things don't always go as planned. Another important difference is that HA coating is applied to a blasted surface such that if the HA were to discolve or delaminate you still have the same surface as provided on many uncoated surfaces (Implant Direct, BioHorizons, Lifecore, Zimmer - called SBM, RBM or MTS. On the other hand, when the few crystals of HA that only partially cover the osseotite surface, are rubbed off in insertion or disolved with time (and we do not have any long-term experience to know how much time), you are left with the relatively smooth etched Osseotite surface that you were trying to improve with HA. THE EFFICACY OF NANOTITE FAILS ON SHEAR LOGIC ALONG. STATEMENT: Lastly, I don’t think how you paint what Biomt 3i says is what was said. I think they are either number 2 or 3 in the world. That says something for Osseotite. Many of us use it day in and day out. Nothing works 100%, but it has established a track record of proven performance. To now have data to show how NanoTite compares to a proven surface when used as the control is complelling as Biomet 3i says.NIZNICK; Biomet is #3 but Zimmer grew 24% last quarter and will overtake 3i if 3i's slow growth continues. The amount of sales of a product has a lot to do with its marketing and much less to do with its scientific efficacy. 3i enlisted the backing of well respected dentists like Dennis Tarnow and built a large sales force. There is nothing in its product line that I would even want to clone, although I probably will make some compatible abutments. If you start out with the premiss that all titanium screw implants work and the ones with a medium rough surface work better than a smooth surface (ethcing blasting), then you get down to what really differentiates products today, simplicity, packaging, prosthetic options and cost.

Albert OS Says: RESPONSE TO ALBER OS: Take a look at the annual reports from Nobel and Straumann. In 2006 Nobel spent 17.6m Euro on R&D or 2.9% of revenue. Straumann spent 18.7m Euro or 5.1% of revenues. Straumann invests way more. Actually the difference between $18.7 and $17.6 on "research" does not prove that Straumann spends "way more". And who is to say that what they categorize as research in their financial reports is really research...it could be payments to clinicians for lecturing and supporting their products, grants to the ITI members for backing the company etc. Most studies are done to provide marketing support as none of the companies do the comparative studies to show if their new surface or design is as good or better than any of the other surfaces or designs on the market. Why hasn't Straumann done a side-by-side animal study comparing removal torque and BIC after 1-2 months ofr its SLActive vs TiUnite, or Astra do a study comparing Osseospeed to Osseotite? My VA study in the early 1990's compared etched to HA, Alloy to Pure, Cylinder to Basket to Screw designs and it was done in a way where I, the manufacturer could not influence the results because I didn't see them until they were published. That is the perpose of peer reviewed studies Having just returned from the ITI World Symposium in New York I can tell you which horse I’m backing. Someone half-joked that, through ITI scholarships and research grants, they spend more on research with Nobel and 3i implants than Nobel and 3i do!! Staumann's marketing is dependent on the ITI group and those guys don't come cheap. First these brilliant guys broght TPS to the crest of the bone, a surface that is worse than HA if it gets exposed. Then they only made 1-stage implants with 2mm polished necks... which usually ended up sub-crestal in esthetic areas encouraging bone loss. Now finally they are coming out with a 2-stage implant, when most of the time the ITI implant was treated like a two-stage implant in the esthetic zone by placing it flush with the crest of the bone and adding a healing collar.

Again, Dr Niznick, your unbending commitment to criticizing innovations that aren't yours never fails to astonish me.

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.