Analysis Of The Shortcomings Of Simply Iconic® Implant And DIRECTARCH™ MUAs

Controversial issues that affect the dental implant dentistry

Analysis Of The Shortcomings Of Simply Iconic® Implant And DIRECTARCH™ MUAs

March 22, 2023
Gerald Niznick

THE EVOLUTION OF IMPLANT DIRECT’S “ICONIC®” IMPLANT SYSTEM

Gerald Niznick DMD, MSD, a prosthodontist, started his career as an implant manufacturer in 1982 with the launch of the Core-Vent Implant System. In 1986, Core-Vent introduced the Screw-Vent implant with an internal hex and 45deg. lead-in bevel, the first conical connection (Niznick U.S. Pat. #4,960,381). In 1999, Dr. Niznick’s company, then called Paragon, launched the Tapered Screw-Vent (TSV) with the same conical connection. This implant became the cornerstone for most modern day implant designs. In 2001, Dr. Niznick sold his company and patents to what became Zimmer Dental and eventually ZimVie. Through 2022, the TSV was ZimVie’s flagship product. In 2004 Dr. Niznick formed Implant Direct (“ID”) and in 2007, shortly following the expiration of the conical connection patent in October 2007, ID launched the Legacy implant with the TSV’s 45deg. lead-in bevel and NobelBiocare introduced the NobelActive with its 78deg. conical connection. The 45deg. lead-in bevel internal hex connection has been copied by so many companies that it is often called the “Standard” connection. The first version of the Legacy implant differed from the TSV in that it included micro-threads on the neck (Niznick U.S. Patent #7,677,891). Legacy 2, 3 and 4 were added with progressively deeper threads and with different packaging options. The Legacy 4 is supplied on a carrier that also serves as a transfer and straight abutment (Niznick Pat. 9,697, 748). To offer a cost effective, prosthetically compatible alternative to the NobelActive, Dr. Niznick developed the InterActive with a NobelActive compatible 78deg. conical connection and launched it in 2013. The InterActive has the body of the Legacy 2 & 4 implants with micro-grooves added above the micro-threads (Niznick U.S. Patent #7,677,891). Dr. Niznick sold 75% of Implant Direct to Sybron, a division of Danaher, at the end of 2010 and remained president through 2013 when Sybron bought his remaining 25%. Danaher acquired NobelBiocare the end of 2014. Danaher spun off all its dental divisions around 2020 under the name Envista, and today, Implant Direct is operated as a division of NobelBiocare, sharing management, shipping facilities, sales meetings and symposiums. A decade after Dr. Niznick retired as president, Implant Direct launched what it calls the “Iconic”TM Implant with the NobelActive 78 degree lead-in bevel, claiming that connection is now the “industry standard.” Rather than “Iconic,” this implant could be called the “Ironic” implant. The mismatch between the Legacy implant diameters ranging from 3.2mmD to 5.7mmD and NobelActive 3.0mmD and 3.4mmD conical connections creates limitations in strength with its smaller diameter implants and compromises in emergence profile with its larger diameter implants. Implant Direct’s US list price for the Iconic implant is $220 including a cover-screw and healing collar in contrast to the NobelActive at $538 plus $66 for Cover Screw and $76 for a Healing Collar ($538 + $66 +$76 = $680 — $220 = $460, a 68% savings). NobelBiocare customers should ask the question posted on Implant Direct’s Website: “WHY ARE YOU STILL OVERPAYING FOR IMPLANTS?”

There is nothing simple or iconic about the Simply Iconic Implant from Implant Direct:

CLAIM: “designed for optimal primary stability and aesthetics.”
FACT: Implant Direct acknowledges that the body of the Iconic implant is the same as the Legacy2 & 4 implants so they offer no unique advantage for primary stability vs Legacy.
CLAIM: “designed for…. aesthetics”
FACT: Iconic combines the Legacy body with the InterActive/NobelActive connection and offers no unique advantage for aesthetics over the Legacy, InterActive or NobelActive implants.
CLAIM: “Treat most cases with just one platform.”
FACT: The Implant system includes a 3.0mmD and 3.4mmD platform options. The 4.7mmD implant if offered with both platform options creates a compromised emergence profile for the 4.7mmD, 5.2mmD and 5.7mmD implants with the 3.4mmD platform.
CLAIM: “4.7/3.4mm with access to wider emergence profiles when needed.”
FACT: The Iconic abutments do come in two diameters but the profile from the implant to the abutment creates a deep undercut regardless of the diameter of the abutment.

Shortcomings of Iconic Implant and DIRECTarch MUAs

To validate its Iconic System, Implant Direct claims “we’re experts in all things implantology. Almost 20 years ago we set a new standard for quality care with clinically proven implant systems made right here in the U. S.” While this may be true, it has nothing to do with the current product development and engineering team at Implant Direct today. All the “clinically proven implant systems” sold by Implant Direct prior to 2023 were developed by Dr. Gerald Niznick and were covered by 10 patents issued to him, as shown below. Even Implant Direct’s Toll Free phone number 888.649.6425 spells out Dr. Niznick’s name. Dr. Niznick started Paragon Implant Co. April 2022 in his Calabasas factory that he rented to Zimmer Dental from 2001-2004 and to Implant Direct from 2004-2014. Since Paragon Implant Company about 28 employees left Implant Direct to join Paragon, confident that Dr. Niznick’s ability to innovate new products and his commitment to both quality and value, assured the success of his new company.

• 24. Filed 2003: 7,014,464 Multi-part abutment and transfer cap for use with an endosseous dental implant with noncircular, beveled implant/abutment interface

• 25. Filed 2003:7,108,510 Endosseous dental implant

• 26. Filed 2005: 7,785,107 Multi-functional fixture mount

• 27. Filed 2005: 7,677,891 Tapered endosseous dental implants with external multiple lead threads

• 28. Filed 2005: 7,699,613 One-piece, screw-receiving, externally threaded endosseous dental implants and related transfer components, comfort caps and abutments

• 29. Filed 2005: 7,396,231 Flared implant extender for endosseous dental implants

• 30. Filed 2010: 8,118,596 One-piece, screw-receiving, externally threaded endosseous dental implants and related transfer components, comfort caps and abutments

• 31. Filed 2010: 9,452,028 External microthreaded and micro-grooved, endosseous dental implants

• 32. Filed 2010: 9,456,881Dental attachment assembly

• 33. Filed 2012: 9,697,748 Two-piece fixture mount assembly

The Legacy 2, 3 & 4 systems offer 4 platforms for 7 implant diameters and color code the implant platforms and the prosthetic components for simplicity. Reducing the number of platforms does simplify inventory control. Deep undercuts created by using a single narrow implant platform on wide implants compromise esthetics and oral hygiene. The 3.2mmD, 3.7mmD, 4.2mmD, and 4.7mmD Iconic implants have the same 3.0mmD NobelActive/InterActive connection in contrast to the Legacy System with 3 platforms (3.2, 3.5 and 4.5mmD) for these 4 diameters. The NobelActive System includes 3 platform diameters, 3.0, 3.4, and 5.0mmD but Iconic only uses the 3.0mmD and 3.4mmD NobelActive platforms. The 4.7mmD Iconic implant is provided with both the 3.0mmD and 3.4mmD platforms. This allows all 4 of the smaller diameter implants to have the same 3.0mmD platform. In all likelihood, these 4 diameters provide a great enough range to meet the needs of full arch restorations with the same multi-unit abutment under the misconception that the emergence profile discrepancy created by using the same abutment for a 3.2mmD implant as a 4.7mmD implant would be acceptable when using multi-unit abutments for a screwretained full arch restoration. Offering the same 4.7mmD Iconic implant with the 3.4mmD platform recognizes that while this may not be significant with MUAs or OverDenture abutments, it compromises the emergence profile for cemented and screw-retained crowns, thereby affecting both hygiene and esthetics.

Using the NobelActive 3.4mmD connection with a 4.7mmD Legacy body leaves a 0.65mm wide ledge compared to using the Legacy 4.5mmD connection with a 4.7mmD body which leaves only a 0.1mm ledge. The Iconic catalog claims that the system offers “a selection of emergence profiles within each interface…for… aesthetics and biomechanics.” Attaching an abutment with a wider profile to an implant with a narrow connection provides neither optimal emergence

The claims about the “ Iconic” are:

1. “Proven implant body with aggressive threading.”
FACT: True….I designed the implant body with progressively deeper threads and micro-threads in 2009 for the Legacy implant. (Niznick 2010 Patent on Micro-Threads).

2. The Iconic implant offers a “modern conical connection for enhanced clinical outcomes”.
The conical connection was developed in 1986 with a 45 degree lead-in bevel. The patent covered any degree of lead-in bevel, including the original Screw-Vent 45deg. and the NobelActive 78 Degrees was introduced in 2008, 22 years later. Neither the NobelActive nor Legacy implants were launched until after the Niznick internal conical connection patent expired in October 2007. Today there is a wide range of implants with different degrees of lead-in bevels. The secret to the stability of any conical connection is making the mating angle of the abutment 1 degree less, as measured from the vertical, than the lead-in bevel of the implant. This assures engagement primarily at the opening to the internal shaft. A study entitled Abutment Connections: Evaluation of 3-Year Postloading Outcomes showed “no significant difference between-group differences in RMBL [P = .74], gingival bleeding on probing.

3. Iconic’s connection is called “SimplePlatform(tm)” by Implant Direct
The Iconic claims simplicity by using the NobelActive 3.0mmD platform, with its 78 degree lead-in bevel, on the 3.2, 3.7, 4.2 and 4.7mmD Legacy bodies, claiming that these implants with the same platform can be used for most cases. This is in contrast to the 3.2mmD Legacy implant which uses a 2mmD internal hex connection and the 3.7mmD Legacy uses a 2.5mmD connection. Using these narrower connections makes the relatively narrow Iconic implants more prone to fracture than Legacy implants of the same diameter.

The Nobelization of Implant Direct
Danaher completed the purchase of Implant Direct from Dr. Gerald Niznick in January 2014 and December of the same year bought NobelBiocare (“Nobel”). In 2019, Danaher’s dental-related companies were spun off as a separate public company under the name Envista. While NobelBiocare and Implant Direct have different presidents, the two implant companies coordinate their operations with Implant Direct shipping its products out of Nobel’s Yorba Linda facility and the two companies share trade show booths, symposiums, and national sales meetings. Implant Direct salespeople are discouraged from trying to convert Nobel customers even though Implant Direct’s RePlant Tri-lobe implant as well as InterActive and Iconic implants offer compatible prosthetic platforms with Nobel implants. Nobel customers should pay attention to Implant Direct’s marketing slogan “SAVVY CLINICIANS ARE CHOOSING IMPLANT DIRECT…WHY ARE YOU STILL OVERPAYING FOR IMPLANTS?”

Considering that Implant Direct’s implants with All-in-1 packaging are about 65-70% less expensive than Nobel’s implants plus the added components provided free with Implant Direct’s implants, it sounds like Implant Direct is saying Nobel customers are not “SAVVY”. To close the price gap between the two companies’ products, Implant Direct introduced “DIRECTarch” MUAs that mimics Nobel’s abutments, effectively at a price increase of about 50% when you consider the components provided free with the Legacy and InterActive abutments. These Nobel MUAs use a fixation screw for the prosthesis that is 1.4mmD vs the Legacy/InterActive at 1.72mmD. The result is that strength and stability of the narrow screw is reduced, with only 15Ncm. vs 30Ncm. recommended. In order to sell “new” abutments, Implant Direct makes a number of unsubstantiated claims. Truly savvy clinicians will not be fooled and will stick with Legacy.

Questionable claims in the DIRECTarch brochure

CLAIM 1: “Control the complexity of parts and pieces”
FACT: Changing the MUA platform to match the NobelActive abutments and eliminating the snap-on transfer and comfort cap that is included with the Legacy and InterActive MUAs, increases “the complexity of parts and pieces.”

CLAIM 2: “Universal multi-unit abutment (MUA) prosthesis connection enables easy use with any workflow.”
FACT: Since both types of straight MUAs have retentive grooves but only the Legacy and InterActive angled MUAs have retentive grooves on them, the workflow does not become easier.

CLAIM 3. “SimplePlatform™ for simpler inventory management of restorative components matching implant diameter”
FACT: Both the Iconic and InterActive implants have the same two NobelActive compatible platforms. Iconic offers the 3.0mmD small platform on 4 implant diameters, compromising the emergence profile. NobelActive includes a 5mmD platform for wider implants.

CLAIM 4: “Final cylinder with angulated screw channel (ASC) unlocks surgical and restorative flexibility”
FACT: This is a good idea and could easily be done with the Legacy and InterActive MUAs.

CLAIM 5: Iconic implant includes “All-in-one packaging with matching cover screw and healing collar.”
FACT: Legacy4 and InterActive All-in-one packaging include cover screw, healing collar, transfer, and straight final abutment.

Dr. Mehrdad Favagehi is quoted in this advertisement touting the advantages of Implant Direct’s IconicTM Implant. The same marketing piece is featured on Implant Direct’s Website. Dr. Favagehi has years of experience and success with Implant Direct’s Legacy System. After he has experience with the Iconic system, he will realize that a more appropriate name would be the “Ironic” System.

“Sometimes, the bone and the surgical site dictate which implant diameter size should be used. But with traditional implants, a wider implant diameter automatically requires larger components that may not be indicated for the ideal restoration,” said Dr. Mehrdad Favagehi, an implant surgeon in Falls Church, VA. He went on to explain: “For example, in a case involving immediate implant placement in an extraction socket, I must choose an implant diameter that is wide enough to engage or go beyond the walls of the extraction socket to give me primary stability. But I still want my restorative colleague to choose the best restorative components for the ideal restoration. That’s where the Iconic Implant system comes in.”

FACT: The diameter of a crown on a tooth flares out from the CEJ in what is a smooth emergence profile. If teeth drift to reduce the width of the space, the diameter of the implant, the abutment and the crown will also have to be reduced in diameter. There is no reason not to maintain a smooth emergence profile for both esthetic and hygienic reasons. The Iconic implants from 3.2mm to 4.7mm all have the same 3.0mmD platform. The 4.7mmD implant also has an option of a 3.4mmD platform in an effort to improve the emergence profile, but the difference is only 0.2mm on each side, about twice the thickness of a human hair. The greater problem exists with the 4.7mmD, 5.2mmD and 5.7mmD Iconic implants with its 3.4mmD platform, compared to Legacy for the same diameter implants of 4.5mmD and 5.7mmD platforms.

“The Simply Iconic implant is unique because it allows me to separate restorative platform choices from implant surgical options. I can choose a wider implant diameter based on surgical reasons without limiting the restorative dentist to using only wider implant restorative components,” said Dr. Favagehi.

This shows an unacceptable emergence profile with 5.7mmD Iconic with its 3.4mmD connection, regardless if the 4.7mmD or 5.7mmD Abutment is used.

FACT: Just like natural teeth, the diameter of the abutment (and crown) will increase proportionately with the diameter of the implant. Choosing a narrow abutment with a wide implant is the definition of a poor emergence profile. Iconic straight abutments come in two diameter options BUT since the base on the wider implants is only 3.4mmD, an undercut is created regardless of which diameter abutment is used. Legacy System only offers 1 diameter of straight, contoured abutment for each implant platform diameter with each abutment flaring slightly wider than the platform to create an ideal emergence profile and to provide material for the dentist to prepare the margins on the abutment. Having only one abutment option adds to the simplicity of the restorative dentist.

“This means that restorative components can be an industry-standard 3.4-mm conical connection, allowing for the ideal implant emergence profile and esthetics, even for wider body 4.7-or 5.7-mm diameter implants. “This makes Simply Iconic perfect for immediate implant placement,” he added.”

FACT: NobelBiocare’s 3.4mmD conical connection with its 78-degree lead in the bevel is not “industry standard”. More implant companies use the Screw-Vent’s/Legacy’s 45-degree conical connection first introduced in 1986, 22 years before NobelActive was launched. This claim that the NobelActive connection is “the industry standard” is probably the reason behind the launch of the Iconic by Implant Direct, operating as a division of NobelBiocare. In 2021, Straumann introduced its Neodent Nuvo implant system and the connection it chose was the 45deg. Internal hex Screw-Vent connection.

Unique Design
“An implant designed for biomechanical stability and optimum esthetics, Simply Iconic has an expansive range of implant diameters and two prosthetic platforms.”

FACT: The Iconic’s “expansive range of implant diameters” matches 6 of the 7 implant diameters offered with the Legacy System. By using the very narrow range of platform diameters (only 3.0mmD and 3.4mmD) from the InterActive (and NobelActive) implants, a mismatch is created that weakens the smaller diameter implants and compromises the emergence profile of the 4.7mmD, 5.2mmD, and 5.7mmD Iconic implants. Legacy includes a 7mmD implant for immediate insertion in molar extraction sockets.

“It has all the modern features of a next-generation implant, including a stable conical connection, platform switching, and a proven implant surface,” said Dr. Favagehi, adding “wider platform switch options allow for better bone level maintenance that prevents dentists from removing too much tissue around the implant to fit restorative components.”

FACT: The conical connection on the Legacy from Implant Direct and TSV/TSX from Zimvie, have a long history of providing a stable conical connection. All conical connections inherently have a platform-switching interface because the abutment emerges from the internal shaft of the implant. Research shows no clinical benefit to platform-switching interfaces. This quote, attributed to Dr. Favagehi, tries to justify the “wider platform switch” inherent in the mismatch of using Legacy implant diameters with NobelActive platform diameters. A “wider platform switch” is the definition of a poor emergence profile.

“I can’t think of a site or situation that the Simply Iconic implant is not advantageous,” he said.

FACT: I can think of a number of situations where the Iconic implant is at a disadvantage to the Legacy implant. One (see picture on Page 3) is in the unfavorable emergence profile with stock and cad milled abutments that are unavoidable using the 4.7, 5.2, and 5.7 Iconic implants with only a 3.4mmD connection. Another is the risk of fracture with the 3.2mmD Iconic implant with its 3.0mmD platform and 2mm deep, 78-degree bevel vs. Legacy’s 3.2mmD

Success Rooted in Simplicity “Unlike other implant manufacturers that offer a variety of implant systems with various surface treatments, tissue and bone levels, and hybrid implant designs, Implant Direct systems are primarily based on just 2 proven restorative connections: the internal hex and conical connection,” Dr. Favagehi said.

Fact: The internal hex connection of the Legacy implants is the original conical connection. Both the Legacy and Iconic implants have internal hexes. The differences are in the angle (45deg. vs. 78deg.) and depth (0.5mm vs. 2mm) of the lead-in bevels and the diameter of the internal shaft that receives the abutment. Implant Direct does offer a variety of implant systems with various surfaces (HA and SBM), tissue, and bone level (SwishPlant, GoDirect, and ScrewIndirect tissue level implants). As the developer of both the Legacy and InterActive implant systems, I would never have considered using the connection of one with the body dimensions of the other. The only purpose in the first place for developing the InterActive was to offer a low-priced alternative to NobelActive customers. Implant Direct is now operated as a division of NobelBiocare. The only business rationale I can figure for Implant Direct’s promotion of the Iconic implant over its flagship Legacy product line is that NobelBiocare wants Implant Direct to also be advocating its 78-degree conical connection as the “industry standard.” Of course, the introduction and promotion of the Iconic allow Implant Direct to charge an additional $50 for every Legacy1 implant and $20 for every Legacy2 implant sale it converts to the Iconic at $220.

“This simplicity is ideal for busy clinicians who must rely on their team members to order components and maintain an inventory in their clinics,” he said.

Fact: Implant Direct, under Niznick’s management (2004-2013) created the value segment in the implant industry with fair pricing and All-in-1 implant packaging that simplified ordering and inventory control.

EVOLUTION AND INNOVATION: THREE PATENTED FEATURES OF THE GEN5™ AND GEN5+™ IMPLANTS

PATENTED FEATURES OF THE 1-PIECE NIZPLANT™ IMPLANT WITH ITS DUAL-FUNCTION PLATFORM

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