3.5 S Astra Implant : peripheral native bone - Courtesy ROOTS
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From: Terry Pannkuk
Sent: Wednesday, July 29, 2009 5:37 AM
Subject: [roots] Patience is a biologic virtue
I retreated these two lower anteriors a decade ago and one was suspected
to be vertically fractured after obturation when the sealer spread along
what appears to be a fracture plane radiographically. Since my ego is
healthy and I'm not insecure, I never blame myself and assume the root
was destined to crack due to previous spreader loading and previous
weakening from the other clinician's procedure as I applied
reasonable compaction force. :)
The perio didnt' blow out until 2007 but when it did the entire lingual
plate was compromised and I was worried about a knife edge contour profile
complicating esthetic implant placement. I graft as infrequently as I can
get away with because native bone is gold and graft isn't as good or as
predictable. I extracted the tooth, placed graft only down to the defect
level, leaving a normal clot apically, then covered with Biomend, sutured,
then cut off the crown from the extracted tooth and ad libbed a Maryland
bridge type temp bonded to the adjacent teeth.
She stayed this way for 1 1/2 years, until I had the temp removed a couple
weeks ago, made sure she had a thorough dental cleaning, then placed the
implant last week. (3.5 S Astra..... I don't like tapered implants
and rarely place them). The bone was solid and the BioOss integrated
solidly into the peripheral native bone.
I thought I'd show this because it demonstrates a "poor man's CT" technique.
I placed the radiograph sensor externally against the left jaw to get the
saggital section angle showing that the implant is properly placed
within the labial bone and in ideal parallel alignment - Terry
Excellent as usual! - Dr Sanjay Jamdade
Nicely managed terry. You should go into the implant business!
nice documentation. And of course I always enjoy when you anti foo foo
dust guys are forced to come over to the dark side - gary
I'd call it the gray side, not the dark side. Ironically the dark side
is when the entire socket is white. :):):) - Terry
Terry, why do you not like the tapered implants? My surgeon does not
either and his only answer is they integrate as predictably. Donít get
why not but it is on his dime. What is your reason? - Guy
We went through this argument before, but most of the studies are with
parallel sided implants going back to Branemark. Tapered drilling creates
less stability than a normal parallel drill; in fact most of the time
those clinician's placing tapered implants do not utilize the apical half
of drilled bone to actually thread intimately with the screwed implant
and the primary stability is all at the cervical collar creating a greater
risk for loosening and movement via fulcruming if disrupted.
The geometry just doesn't theoretically satisfy any elegant logic and there
is minimal evidence to suggest using them. Tapered implants are just simply
easier to place "sloppily" and slide into a fresh extraction socket giving
the clinican the the idea that it's easier and better. Easier is not
better. :)- Terry
Tapered implants are better, but the implant bed in bone must be prepared
with cylindrical shape and conical implant has to be with large threads
and of course self tapping. This makes things quite different from the
situation when one is preparing conical shaped bone bed to insert a
conical shaped implant with small threads - Valeri Stefanov
Now how can you make that statement with absolutely no logic or
evidence. :):):) - Terry
I can make it, because of the dental implant sytem I myself developed back
in 1990 based on these principles. (see attached case - single stage,self
tapping ,conical shape, one piece implants with SLA rough surface after
13 years of loading ) There are a number of Italian implant systems, too
based on same principles. These have been developed back in 1980ies and
are used with success till today. There was dental implantology long before
Branemark has given the world the "great news" that Titanium made orthopaedic
fixing screw replica osseointegrates - fact orthopaedic surgeons have known
since 1959 !!! Branemark's clever marketing has played a decisive role for
delaying the implant dentistry development for years. Remember when they
were pretending that the machine surface is the best and even tried to
patent it :-))). Now even NB uses rough surface on their implants - Valeri
P.S. I was the first who applied SLA surface on dental implants clinically
back in 1993 ( results reported during ICOI World Congress in Istanbul 1993
- then all others were using as machined, blasted with AlO, TPS or HA surfaces
only including Straumann )
Can't help weighing in on this...........unfortunate that TulsA HAS elected to be
so non-supportive in the online community world re; ANKYLOS.
I started with the GROOVY and REPLACE SELECT and Astra Tech stuff..........but the
reality is they lacked a progressive thread design with apical primary stability..
.........the force vector studies done in Europe for lo these 20 + years
were very dramatic and convincing.......implant need to engage apically, not cervically
The lack of saucerization and dieback is simply a reflection of the fact that force
distribution on the fixture by the abutment is along the fixture length...
NOT CERVICALLY...think of a well sized and designed post................
There are so many others who can weigh in here on the design, it's rationale.....
it's "difference" from the design of BioHorizon and Nobel and 3i et al.............
Active is similar but still not capable of the progressive thread
capability of ANKYLOS, Astra Tech created a better collar with it's microthreads,
but sizing was odd and restorative issues abound...........
BONE SUPPORTS TISSUE and the narrow one size fits all abutment doesn't create
a hygiene defect, it enables full occlusion, not passive occlusion, it enables
esthetics that are truly tissue "driven" et al. I sound like an infomercial and
I dislike it intensely.......I have supported Tulsa in the past, but have lost
interest as they persist in avoiding digital education in any format.......
you can't compete one on one in this market and as a result, the endodontist
who brings this product into his service mix is woefully unsupported and must
do his or her own marketing with literally NO RESOURCES. They have 10 designated
implant specialists who can help on ROOTS or IMPLANTS with OFF LABEL I grant
you commentary based on their demographics which cover OS's and Perios from
around the US.........
I choke everytime I hear a company say, we can't go OFF LABEL.........take 10
dentists who by the same product and the minute the box is opened, the product
is used OFF LABEL............the good done by encouraging that which is supported
and validated and verified with recognition of regulatory oversight is needed,
the bad by avoiding it.....horrific..... ....think any carrier based obturation
system........think Beruti and Cantatore, then think Joe Schmo in KOKOMO.
Ovidiu - would you be kind enough to send ONE low res image of ANKYLOS C/X -
only academic representative I know is Kurt Magnus who works with Fred at
He is invited to weigh in on this topic........simply because it can be
science based and in the absence of any marketing resources, he has no
choice but to speak logic and science.
Jose - you're running an endo/implant residency near Beantown.........
step on board........granddaughter down for her nap............adieu.
OH BY THE WAY - August 1st, 2010............www.rootssummit2010.com.....
......you have a choice....make it a resounding success and continue to
discuss your scope needs et al.......
You all have databases and address books, know people around the world...
....DTI and Dental India seem to have no problem using ROOTS resources..
.......et al.......YOU can all make it a success.......if not..........
no threats, no diatribes, it ends because it simply isn't worth the time
I'm asking for evidence or at least a logical rationale. What does
that have to do with taper versus straight implant selection?
Granted, surfaces have improved dramatically.
Ones mere invention doesn't construe validity otherwise the world
would be littered with Rube Goldberg machines and a malfunctioning
inefficient industry . :):):)
Why do you insist that being first equates to being best? Show me
the evidence that tapered is better than atraight. At best, the very
limited evidence shows that "tapered might be as good", but that's very
speculative and not established well at all. In the absence of
evidential and compelling theoretical validity, "tried and true"
rules - Terry
It's a long discussion, if we start it now here on Roots. We have had
this on Implantology list years ago back in 2001 - 2002. The advantage
of conical shaped self tapping ,large threads implants with rough surface
is "visible" in cases with so called delayed immediate insertion.
Inserting a self tapping conical implant with large threads into
a cylindrically prepared bone hole with diameter slightly less than
the body of the implant (not dia of threads ) give an exceptional primary
stability of such implants even in D5 bone / :-))) / ( means inserting
3.6 - 3.7 mm dia implant into 2 mm cylindrical bone hole )
I, for example, am not brave enough to place for example a single
piece-single stage, non self tapping , cylinder shaped implant with low
( 0.25 - 0.30 mm high ) threads into D3-D4 bone. I will surely, with
no doubt, place a conical self tapping implant with large threads into
same qulaity bone as one stage implant.
Rough surface helps both - cylinder and conical shaped implants -
there is no question about that. Macrodesign of
the implants is what gives advantages on macro level.
Here is another attached example - an SDV 1 implant developed myself
- 8 years after loading. See bone loss around teeth and bone being nicely
preserved around the conical, one piece, self tapping, single stage
implant with SLA surface.
One thing I agree with you - in so called routine cases ( enough bone
volume, enough space between teeth, D1-D2 bone ) it will be hard to
demonstrate significant difference between cylindrical and conical
implants when placed with two stage surgery.
Advantages of conical self tapping implants with large threads where
the reason for NB to purchase Israeli Alpha Bio company adding an
implant with large threads implants to their line
( called "Nobel Active" now ). They, however were not brave enough
to offer the single piece version of Alpha Bio implant :-) !
Implants like BICON or QUANTUM with their unique design also have
certain advantages for particular cases - especially when short
implants are needed - Valeri
I repeat: Where's the research validity? You're talking products
not studies - Terry
I am talking implant's macrodesign and biomechanics and I'm talking
experience - Valeri
I've placed some tapered implants as well, but only when anatomy
dictates it (i.e. safer vital structures and when the ridge is knife edge).
I've viewed it as an occasional necessary compromise (like grafting).
Tapers are easier to self-tap and tend to fit the shape of extraction
sockets, easier for immediate placements many times.
My eyebrows raise everytime someone insists something is better with no
evidence or rationale. How in the world can someone be positive that
tapered implants are better when there are no comparison long-term results
versus straight? That's ludicrous. Straights have been used longer and
have a successful history. Tapered implants do not have the same long
history of use.
The most appropriate thing you can say is that they "seem' to be similarly
successful as straights at this point. Change should be dictated by need,
not novelty. - Terry
Placement of well designed tapered implants is definetely NOT a compromise.
Placing tapered NB implant( beside Alpha Bio aka "Nobel Active" implant )
is a compromise due to lack of real threads in half of implant's
There is a vast difference in biomechanics of tapered implants, which are
not self tapping, have low threads ( less than 0.30 mm high ) and are inserted
into tapered bone hole and tapered implants which are self tapping,
have a large threads ( over 0.5 , usually 0.7 - 1 mm high ) and are
inserted into a cylindrically shaped bone hole having a smaller diameter
than at least upper two thirds of the implant body ( not threads ).
These type of tapered implants are virtually unknown to dentists in USA
( beside Bicortical screw which was sold in US for a short while and one USA
made implant, which I do not know, if it is still on sale in USA) and most
EU countries. May be hundred of thousands of such implants have been placed
with success in Italy and Germany through last 30 - 35 years. Significant
portion of these have been immediately loaded or more often placed with
delayed immediate placement technique.
Simply said - tapered implants will work in all cases where one can use
cylindrical implants, but cylindrical implants will not work in cases where
tapered implants will perform very well. That's the logic to say tapered,
self tapping and with large threads is better than cylindrical, non self
tapping and with small height threads.- Valeri
I find this thread interesting for several reasons - one - the lessons
learned in endo in terms of deep shaping and gauging, the lessons learned
from the endodontic restorative continuum do relate to orthobiologics and
Photo-elastic stress studies may be soft science to some, but they test
cars, bullet trains and airplanes in wind tunnels for a reason.................
Please visit www.ovidiu.ca/example032 for a moment.......
as I suggested before, I won't reiterate my perspective on ANKYLOS - having
placed at least one or two of the top 5 implants in N. America, after much
due diligence I chose ANKYLOS in spite of some restorative deficiencies
such as CAD/CAM. Bone supports tissue, even on the most elemental level,
bone over the platform makes sense and saucerization does not.
IMPLANT engagement in the apical 1/3 rather than the cervical or coronal
1/3 makes infinitely more sense. and Ankyolos is a tapered and a parallet
implant you need to look carefully at the configuration and unlike Activ
with the screw threads, the threads are squared off, more surface area..........
There are many things happening with ROOTS.........not discussable, suffice
it to say the linkage to cbCT is underway........anyone practising endo or
implants without immediate access to cbCT is simply not in the 21st century.
..it's like 2D flat field graphics, 2D flat field radiographs are yesterday's
news.........and in some ways suberting standard of care.
Placing implants next to one another is always difficult unless you can keep
the bone - think Tarnow........ you really can't cantilever off a
fixture/abutment using IKEA design, that is internal hex........anon.
I am working on what I hope will be the ability to bring these kinds of text
messages into graphics and animations you will see on the link and attach them
to a mechanism for content renewal that will include cbCT avi files.....
as well......like the last 11 years on ROOTS, always a CRUCIBLE of the
non-Arthur Miller variety........
The only thing that is relevant re; WORDS is the song by the BEEGEES......
believe nothing of what you read, half of what you hear and ALL YOU SEE IN
THREE D if it is time stamped and follows DICOM.....
Bone sets the tone, tissue is the issue but an implant design that factors
bone preservation into is biomechanics, that because of the fixture abutment
connection doesn't mandate a 5.0 mm fixture diameter.....now that would
Endudes doing implants is SERIOUSLY late to the dance.........y'all better
have more than words to justify a) why you should be chosen rather than a
PERIO OR OS who has been doing them for 20 years, b) how to ensure that
they appreciate your choice as being not more of the same - you do NBC,
so does Joe Schmo and he's done hundreds and thousands, and c) you better
have a team of people who walk the walk and talk the talk........otherwise,
it's a very expensive and risky gamble..............dazzle them with science,
graphics, animations........ cbCT for your endo and implants........
you need to rock their worlds................not just advise them of the
addition to your service mix - Kendo
Baumgarten presented some research on this at the AAE all day course...
don't know if you saw him. Stated that obtaining primary stability with
immediate placement was easier and greater with tapered implants - Tim Bachman
Here's a recent study that suggests the opposite (although not statistically
significant). Most of the studies I've seen by proponents of tapered implants
are very low level evidence and mostly opinion. It's clear that tapered
implants might be technically easier to place in some cases. There may even
be some cases where they may decrease the risk of buccal or lingual plate
perforation, but to say they are inherently better and more stable doesn't seem
to jive with the established evidence. I'm always happy to change my opinion
when the evidence and rationale is there, but I just don't see it being
presented on this topic - Terry
J Oral Rehabil. 2009 Apr;36(4):279-83. Epub 2009 Feb 10.
Reliability and validity of the instrumental assessment of implant
stability in dry human mandibles. Brouwers JE, Lobbezoo F, Visscher CM,
Wismeijer D, Naeije M. Department of Prosthetic Dentistry & Oral
Implantology, Academic Centre for Dentistry (ACTA) Amsterdam,
The aim of this study was to determine the intra- and interobserver
reliability and validity of the instrumental assessment of primary
dental implant stability, using resonance frequency analysis (RFA).
Sixteen tapered implants and 16 cylindrical implants were installed
in eight unfixed dry human mandibles (Cawood classification IV/V).
Implant stability quotients (ISQ; the outcome variable of RFA) and
peak removal torque were determined. Both the intra-observer
reliability and the interobserver reliability of the RFA measurements
were fair-to-good, while no significant correlations between the ISQ
values and removal torque were found. The removal torque of the
cylindrical implants was higher than that of the tapered implants.
The smallest detectable difference was almost nine ISQ units.
Within the limitations of the present dry cadaver study, it was
concluded that (i) primary dental implant stability can be assessed
reliably with RFA measurements, (ii) the concurrent validity between
RFA measurements and removal torque is poor, (iii) cylindrical
implants may be more stable than tapered ones and (iv) two subsequent
readings of RFA measurements need to differ at least nine ISQ units
before the difference between the two measurements can be considered
statistically significant. More research is needed to see whether
these conclusions can be extrapolated to the clinical situation,
including the assessment of implants during function
Do you know the literature citings? - Terru Pannkuk
I tend to agree with you, but there is little research in this arena.
one thing I do believe in, however, is I do a parallel wall osteotomy
even with a tapered fixture, allowing it to expand the osteotomy.
Very easy to overprep and strip out a tapered prep with a tapered bur.
And better primary fixation at the crest, where occlusal forces
in lateral movements are the greatest - gary
Hi Terry..I will look through my notes. I enjoyed his lecture quite a
bit. Gave a really good bit on Biotype as well. I have used only Astra
straight implants as well but after his lecture I decided to give some
tapered larger thread implants a try. I dont think they are necessarily
easier to place technically...not sure why you say that. Both
types are going to work well but I have found it easier to control
the osteotomy and get greater primary stability
in immediate sites with the tapered implants.
In an edentulous non-immediate site I would probably still prefer the
straight every time if no anatomical concerns
Baumgarten was going for insertion torques of 75-100 NCM with tapered
implants in immediate sites. 25-50 less with the straight - Tim
Tim: astra is not straight, it flares in the coronal 1/3 - Gary L Henkel