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23Implant Tribune United Kingdom Edition | 3/2015 TRENDS&APPLICATIONS several implant–abutment interface responsestoloadingthatareavailable on YouTube. Once the videos have been viewed, a rational decision as to which connections are more stable (rigid) under loading can be reached and this information then applied to selectinganimplantsystem. Doesthesystemofferawiderange of prosthetic, CAD/CAM and guided surgery solutions for dental implant treatment? Once a dental implant system has gained some degree of market penetration (or traction) and hasdocumentedevidencetosupport its clinical effectiveness, it is worth- while taking an unbiased view of the system.Hopefully,mostglitcheswould havebeenidentifiedandcorrectedby the early adopters, thus reducing the risksforthemorecautiousclinicians. A personal recommendation is to focus on the restorative aspects first (restoratively driven treatment). Questionstobeaskedincludewhether the system has a broad range of com- ponents for the various treatment needsinimplantdentistry,CAD/CAM- based treatment solutions and a guided surgery solution for the sur- gical placement of dental implants. If you are impressed by what you see, then place a few implants and mo- nitor them closely. If the treatment outcomesaresuccessfulandyouhave a positive impression of the system, thenthereisnoreasonthat you should not add a cost- effective solution to your dentalimplantportfolio. What impact does the macro-geometry (implant shape) and micro-geome- try (surface treatment) have in relation to long- term success? The surface treatments applied to var- ious implant systems are designed to improve the degree of osseointegration andbone–implantcontact. This is extremely impor- tant for the long-term preservation of bone around a dental implant. However, is the surface treatment that important when looking at im- mediate loading situations? In those situations, it is the primary stability ofthedentalimplant,combinedwith the closeness of fit to reduce micro- movement of frameworks, that is the key factor in determining long- term success. Any beneficial effects ofasurfacetreatmentwilloccurpost- osseointegrationandseveralmonths afterloading.So,arethemacro-geom- etry of the implant and the physical stability of the abutment connection more important than the surface treatment for long-term success or viceversa? Again, it depends on what the cli- nician is planning to do, immediate loading or conventional delayed protocols. Very little independent re- searchhaslookedintotheaccuracyof theclaimsmadebyimplantsystems, and even less work has been done di- rectlycomparingthevariousimplant designstoevaluatedifferentsystems. One group that has attempted such ananalysisistheCochraneCollabora- tionanditsreportsarepresentedlater inthearticle. Primary stability is mainly governed by the implant thread design and this directly affects the insertion torque. The implant–abutment connection stability is equallyimportant.Ifthis was not the case, then animplantinsertedwith a low insertion torque and poor component fit wouldbesubjecttopros- thetic movement under occlusal loading with loss of primary stability and implant failure long before osseointegration wouldhaveoccurred. If one is following conventional delayed loading protocols, then the surface treatment, as well as the macro-geometry and connection stability,willaffectlong-termsuccess. Do the larger prestige dental implant brands provide dental implants with themostidealthreaddesigns,bestpri- marystability,andhighesttolerances of fit of abutments and frameworks, or do the various surface treatments have a clinically significant improve- mentinlong-termsuccesswhencom- pared with a so-called budget brand? Again, no real cross-comparison re- search exists. The surface roughness of the dental implant is also of vital importance, as research has found increased peri-implantitis associated with macro-roughened surfaces. Smooth or machined surfaces clini- cally show reduced levels of osseo- integration, so the current thinking seems to be that micro-roughened surfaces provide the optimum sur- faceforosseointegration. An affordable implant solution Thelow-costsystemthatwillbeused hereforcomparisonistheICXsystem manufacturedbymedentismedicalin Germany. On the market for several yearsandwellknowninEurope,ithas recently arrived in the UK as part of the company’s global expansion. All ofitsresearchhasbeenconductedand validated by several prestigious insti- tutions, adding weight to the product, including the Fraunhofer Institute, whichconducteddurabilitytesting,as wellasuniversitiesinCologne,Aachen and Mainz, which also contributed with clinical research. The Robert MathysInstituteinBettlachinSwitzer- landperformedresearchonthemicro- gap(tolerancesoffitofabutments). TheICXsystemhasawell-developed CAD/CAM workflow for fabricating abutments, bars and frameworks for restoration with both ICX and other dental implants in addition to pre- made components. Titanium, zirco- nia and non-precious restorative componentsforICXandotherbrands areavailableandaresuppliedwiththe final prosthetic screw included. With some systems, the final screw is not includedandmustbepurchasedsep- arately. ICX also has a bespoke CBCT guidedsurgerysolutioncalledMagel- lan that is also multi-implant system based.Thedentistcaneitherpurchase the software or upload the DICOM filetotheparentcompanyserverand thecompanywillcarryoutthedesign process and fabricate the guide once the design has been approved by the dentist. Magellan can also be used to produce guided surgery drill guides for various dental implant systems, butatafractionofthecost. When considering an implant solu- tion,alookatthetotalsystemcostsin- volved with both surgical and restora- tive components can reduce the over- all cost to the patient. The table shows a price comparison of the ICX system againstmultipleimplantsystems,both prestige brands and cost-effective systemsbasedon2013costsintheUK. In terms of cost and product content, theICXimplantseemstoprovideacost- effectiveimplantsolutionforpatients. How does the implant fare when tested in the laboratory against the prestige systems? The Fraunhofer Institute conducted durability (ISO 14801)tests(Figs.1a&b)onseveralim- plant systems, including Straumann Bone Level implants. These tests showed that the ICX implant was more fatigue resistant than all of the implants tested (Figs. 2a & b). Thus, the implant has a durable, fatigue- resistantconnectioninterface. The implant– abutment interface Howstableistheconnectionwhen viewedintermsofclosenessoffitorthe micro-gap between the implant and theabutment?InOraleImplantologie in 2007, Berlin dentist Dr Stefan Wolf Schermer examined the micro-gap between the abutment and the de- ntal implant connection interface of several systems and showed that ICX implant–abutment micro-gap was the smallest of all of those examined (Figs.3a&b). Closeness of fit is directly related to movement of the abutment when under load. The fatigue test figures in conjunction with the smallest micro- gap figures show the ICX implant has a well-designed and rigid connection interfacethatisplatformswitched.The macro-geometry of the implant with self-tapping apical threads provides high insertion torques with excellent primary stability. These are key com- ponents in preserving crestal bone aroundanimplant.Intermsofsurface treatment, the ICX implant has an etched and blasted micro-roughened surface (Ra of 1–3 μm) with a pure titanium dioxide surface withnoadditives. The implant was previ- ously described as having ahydrophilicsurface.How- ever, this claim was suc- cessfully challenged by Straumannandisnolonger usedtodescribetheimplant. The surface is currently be- ingupdated. Asaprosthodontistworkinginpri- vatepracticemostofwhatisoutlined above is how I personally approach new implant systems. There is very little clinical research comparing the various dental implant systems directly to one another and a signifi- cant proportion of studies published cannotbedirectlycross-compared,as there is no standard clinical method for doing so. All of the variations in implantgeometry,surfacetreatment andrestorativesolutioninadditionto the operator variables (the surgeons involved, their individual skill sets and the correlation of the statistics) all make such direct comparisons between implant systems a potential minefield. Arethereanyindependentreviews of published articles that might be a source of further information? Possibly the Cochrane report, which is an ongoing study. The Cochrane Collaborationisaglobal,independent networkofresearchers,professionals, patients,carers,andpeopleinterested in health who gather and summarise the best evidence from research to help you make informed choices about treatment. It does not accept commercialorconflictedfundingand has contributors in over 120 coun- tries. Starting in 2003 with follow-up reports conducted in 2005 and 2007, the group published its latest evalua- tion last year.1 The full report can still beaccessedonline,ascantheprevious versions. It has led to intense online debate by various dental implant companies and clinicians largely be- cause of its conclusions, which are reproduced here directly from the summary of the report: “Based on the results of the included RCTs (randomised controlled trials), we found no evidence showing that any particular type of dental implant hadsuperiorlong-termsuccess.There was limited evidence showing that implants with relatively smooth (turned) surfaces were less prone to lose bone due to chronic infection (peri-implantitis)thanimplantswith much rougher surfaces (titanium- plasma-sprayed).Thesefindingswere basedonseveralRCTs,oftenathighrisk of bias, with few participants and re- lativelyshortfollow-upperiods.” In summary, use of a cost-effective dentalimplantsystem(intheauthor’s opinion) is justified in terms of eco- nomic savings to the patient and in- creasing the reach of dental implant treatment to the wider public. It is reasonable once the system has been cleared for use in general dentistry (CE mark, FDA approval) and should be considered a viable clinical option once the dentist has reviewed the available clinical data (conventional and guided surgery solutions) and restorative treatment (conventional and CAD/CAM-based) options. He or shewillthencometoaninformedde- cision,atwhichpointheorsheshould place and review a small number of implantsinvaryingclinicalsituations andmonitortheresults. Conflict of interests: Dr Tuss Tambra has not received any payments or other in- ducements of any kind from any company mentionedinthearticle. Reference 1.Esposito,M.,Ardebili,Y.&Worthington,H.V., “Interventions for Replacing Missing Teeth: Different Types of Dental Implants”, Cochrane Database of Systematic Reviews, 7 Article CD003815 (22 Jul 2014).