LETTER TO THE EDITOR

Response to Editorial "Oral Implants - Quo Vadis?"
By Georg Watzek, Associate Editor,
JOMI 2006; 21:6:831-831

Dr. Watzek asks the question “Quo Vadis”? Vadis means “you go" and Quo, like all prepositions in Latin, implies dynamism or movement. It means "where" but implies not only the final destination, but also the route by which to get there. His answer seems to be “Status Quo” which translates as “the state in which things remain as they are now”.

To know where the dental implant industry is going, it is helpful to know its true evolution. Contrary to the first sentence of Dr. Watzek’s Editorial, “the advent of oral implants” was not, “initiated by Branemark about 40 years ago.” In 1969 Branemark filed a patent on “A device for mounting a prosthesis on skeletal tissue.” It was rejected in the United States based on the published reports by Chercheve using two-piece submerged implants in France. Branemark’s 1977 Book on his 10 Year Study credits Leventhal (1) an orthopedist, as the first to report bone attaching to titanium. Branemark deserves credit for documenting the long-term predictability of this interface phenomenon, which he called osseointegration, but not for initiating “the advent of oral implants.”

Dr. Watzek’s editorial sees only “two alternatives” as to the future direction of dental implants: 1. “more innovations, generating more growth price-wise or failing this, 2. more low-cost, me-too implants.”

There is no significant correlation between the costs of product development/research and the prices many implant companies charge for their products today. Examination of the financial reports of two publicly traded implant companies, Nobel BioCare and Straumann, provide an understanding of the relationship of cost of goods, profits and research expenses for these major implant companies. Their 2005 Year End Financial Statements show profits in excess of 30% with cost of goods of 16.5% for Nobel Biocare and 19% for Straumann. They also report research expenses of only 3.5% for Nobel Biocare and 5% for Straumann. Much of these expenses are incurred long after the new products have been released to the market, with the main purpose being to create marketing support materials for their “innovations”. Projections of annual profits for 2006, based on 3rd Quarter Financial Reports project $225M year-end profit for Nobel Biocare and $150M for Straumann. These huge profits could easily provide adequate resources to fund additional research and product development without necessitating price increases. Both companies allocate about 40% of their expenses for sales and marketing that is about 10X more than they spend on research. One should ask why, given such high profits, the major implant companies do not price compete, other than one-on-one negotiations with high volume customers to retain or convert their business. Dr. Watzek’s Editorial concludes that “further major innovations of the implants themselves are nowhere in sight. … There is little scope for further improvements.” Dr. Watzek may be right about “further major innovations” from a biological standpoint, based on the high success rates reported with many implant systems. He may also be right that “Implant healing is another area with very little scope for future major improvements of clinical relevance.” In fact, four of the five largest implant companies claim faster healing with their “improved surfaces” and justify these claims by comparing their new surfaces to their old surfaces in animal studies. None conduct clinical comparison studies or even animal studies comparing their surfaces to other companies’ surfaces for fear that such studies would reveal no differences. If implants can be successfully placed in function immediately upon insertion, based on achieving a threshold level of initial stability, then claims of faster healing allowing loading in 4 weeks or 6 weeks becomes moot. The FDA is allowing claims of immediate non-functional loading for new implants if the Instructions for Use provide a requirement of achieving of adequate initial stability, generally accepted to be 35Ncm torque on insertion. The concept of inserting a tapered implant into an undersized receptor site to increase initial stability was reported in 2000 (Niznick 2) using the Tapered Screw-Vent implant with straight, step-drills. A 2006 study (Shalabi 3) concluded that placing a tapered implant into an undersized socket “not only has a decisive effect on implant fixation, both at the time of insertion and after a healed period as determined by torque values, but also a significant effect on the final implant-bone response as measured by histomorphometric analysis.” Additional clinical research is needed to quantify the relative advantages of changes in surgical protocol verses surface textures or additives like fluoride or BMP.

Dr. Watzek does indicate, “Improvements in the prosthodontic work associated with implant dentistry are a more realistic prospect.” Implant manufactures can provide more versatile, cost-effective prosthetic components without adding to the cost of the products. One ways to accomplish this is with all-in-one packaging of implant and abutment for specific clinical applications. Another is with one-piece implants but some implant companies set the price for one-piece implants equal to the price of buying a two-piece implant plus the abutment, so as to not cannibalize their own sales. Dr. Watzek mentions other areas where he sees the need for improvements including esthetic edentulous restorations, occlusion, virtual planning and tissue engineering/augmentation. None of these areas of needed innovation should be related to the cost of the components from implant manufacturers.

I believe the answer to Dr Watzek’s question, Quo Vadis, is that competition in the dental implant industry will ultimately result in new and improved products at lower prices. Furthermore, low cost, “me-to” implants will suffer the same obsolescence as the outdated implants they clone. When will this second implant revolution in implant dentistry occur depends on the time needed to reach a critical mass of discerning dentists able to differentiate true product advantages and value from marketing rhetoric. New Internet based business strategies will accelerate this educational process. Manufactures capable of developing innovative products offering real clinical advantages, will be able to price compete globally without the expenses of a large sales force, big booths at tradeshows and a cadre of paid opinion leaders. The dental practitioner and patients will benefit from better products at lower prices, and the companies able to provide this will re-write the market share charts, as they exist today.

Gerald Niznick DMD MSD
President, Implant Direct Company
Calabasas California
Email : drniznick@aol.com

1 : Titanium, a Metal for Surgery: Leventhal G.S. J. Bone Joint Surg. Am. 33:473-474, 1951.
2 : 2 : Achieving Osseointegration in Soft Bone: Canadian Journal of Oral Health Aug. 2000.
3 : The effects of implant surface roughness and surgical technique on implant fixation in an in vitro model:
Shalabi M., Wolk J., Jansen J., Clin. Oral Impl. Res. 17,2006: 172-178