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.
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