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For the benefit of the patient

by: Professor Alessandro Pozzi

An assessment of three years of extensive clinical experience with the NobelReplace® Conical Connection

Professor Alessandro Pozzi reports from his state-of-the-art private practice in Rome, where he has accumulated several years of experience using NobelReplace Conical Connection implants.

One might begin by saying, “Peri-implant tissues are not an issue with the NobelReplace Conical Connection (CC),” but that indeed is just the beginning of all that ought to be said!   

I have been working with NobelReplace CC since late 2010, yet at the start I was a bit hesitant to introduce a new implant system into my implant practice. “Why,” I asked myself, “should I disturb my team’s well-established implant workflow by using a new fixture so far from the traditional and well-proven Brånemark design?”

Fortunately, a desire to constantly improve patient care—along with my innate “researcher mentality”— helped me to overcome this initial ambivalence and provided me with the impetus to move forward.

Today, the NobelReplace CC has become my implant of choice. I think it provides the perfect implant body and neck configuration to imitate the natural tooth and establish a natural connection at the peri-implant interface. It certainly contributes to the long-lasting success of my restorations.

Great natural outcomes are the result of biological synergy between the TiUnite surface, the tight prosthetic connection—which incorporates built-in platform shifting—and a minimally invasive operating approach that considers the implant surgery, to quote Per-Ingvar Brånemark, “a gentle handling of Mother Nature’s gifts.”

The NobelReplace CC is a new implant concept that merges the biomechanical and prosthetic features of a meticulously engineered third-generation internal connection within a strong implant body with the biological advantages of the platform shifting concept. From all the experience I have gathered to date, the NobelReplace CC is a versatile, easy-to-use implant, which performs well in soft and hard bone alike, in both partial and totally edentulous clinical scenarios, and with axial and tilted insertion.

Widely used new restorative designs for the treatment of total edentulism (based as they are on a reduced number of implants and by immediate loading protocols) require stronger implant-prosthetic connections in order to withstand the higher insertion torque and the lateral loading stress, as well as to minimize forces on the retaining screw and prosthetic components.

Without compromise

Up until now, internal connections (as a consequence of the designs themselves) have exacerbated this stress, due to the weakness of implant walls and deficient load distribution to the bone. The wall thickness of the implant in the critical stress zones has to be able to resist material fatigue and breakage under prolonged use, while neither sacrificing “osseointegratable” threads at the neck nor reducing the diameter of the connecting screw.

In the design of the NobelReplace CC implant, the depth of the connection has been optimized to obtain all the biomechanical and clinical benefits associated with an internal connection without substantially weakening the implant body by reducing the thickness of its walls.

The anti-rotational design of the conical connection minimizes torsion forces and allows the application of high insertion torque on the implant without incurring distortion. In my practice, I have personally determined that the mean bone loss (MBL) and soft-tissue parameters—from implant insertion to nearly three years of function—have evidenced an overall stability of the peri-implant hard and soft tissues.

This applies in both post-extraction and healed sites, regardless of the loading protocol.

Platform shifting

In my experience, NobelReplace CC is effective in preserving the periimplant bone and maximizing the soft tissue volume. Although the mechanisms have yet to be definitively established, it has been suggested that the biological process resulting in the loss of marginal bone may be limited when the outer edge of the implant–abutment interface is horizontally repositioned inwardly, away from the outer edge of the implant platform.

This prosthetic concept is generally defined as “platform shifting” (i.e. the use of a smaller diameter abutment on a wider diameter implant platform) and it has been integrated into the NobelReplace CC design. The reduction of marginal bone loss that I have observed may be the result of how platform shifting encourages soft tissue healing away from the crestal bone.

The concept is as simple as it is ingenious: Platform shifting moves the initial inflammatory area that exists at the implant-abutment interface away from the crestal bone, resulting in less bone resorption and highly satisfactory esthetics. This approach minimizes microbial colonization of the prosthetic interface and internal cavity, as well as the spread of bacterial endotoxins into the surrounding tissue, which might otherwise result in peri-implant inflammation and marginal bone loss.

Preserving marginal bone

Whenever a microgap exists at the implant-abutment interface, there is a concomitant risk of bacterial colonization of the implant sulcus, consequently leading to peri-implant inflammatory reactions and bone resorption.

The unwelcome presence of a microgap also results in micromovements occurring at the implantabutment interface, which can affect the stress distribution in the surrounding bone, thus increasing crestal bone resorption. The conical connection—as engineered by Nobel Biocare—decreases the micromovements at the implant-abutment prosthetic interface, reducing the stress and strain on the alveolar crest.

The tight, precision-manufactured conical connection preserves the marginal bone not only by minimizing micromovements, but also by preventing microleakage and the subsequent bacterial contamination of the implant–abutment complex. As an advantageous consequence, these CC stability features also lead to enhanced pink esthetics.

Versatility in use

In addition to all these outstanding features, I would also like to highlight the surgical flexibility of the NobelReplace CC. Its use ensures the safe placement of the implant platform up to 3 mm below the bone crest, for example, and without unusual bone resorption.

The tight conical connection with built-in platform shifting makes the deep placement of the implant possible as a rescue solution in clinical scenarios where we need to increase the running room in order to meet the biomechanical demands for a long-lasting restoration.

Meeting needs and demands

The NobelReplace CC makes the kind of implant dentistry that I want to practice possible. It facilitates the minimally invasive surgical approach I prefer. It serves as the benchmark for highly biocompatible prosthetic accuracy. And perhaps most important of all, working with NobelReplace CC makes it possible for me and my team to concentrate on my patients’ needs and comfort, every single step of the way.

I’ve written this before, but it deserves to be repeated: NobelReplace CC is an implant system that meets the demands and requirements of both clinician and patient alike. I recommend it confidently to colleagues, not only because it is a pleasure to work with, but also because it is the product of an evidence-based R&D culture that I admire.

I have never been as productive as I am today, and NobelReplace CC can take at least part of the credit. This well-conceived, well-engineered design is an implant I can hardly imagine working without!

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