Dental Implant System Design and the

Potential Impact on Long-Term Aesthetics:

A Review of the 3i T3™ Tapered Implant
Richard J. Lazzara†, DMD, MScD

Published by
 Dental Implant System Design and the
Potential Impact on Long-Term Aesthetics:
A Review of the 3i T3™* Tapered Implant
Richard J. Lazzara†, DMD, MScD

There is a growing appreciation of the importance of establishing and sustaining the aesthetics of implant
restorations. Four important factors for achieving this goal are implant primary stability, implant surface, implant-
abutment junction geometry, and implant-abutment connection. This article reviews each of these factors as
they relate to the design of the 3i T3 Tapered Implant System* and discusses the potential impact these factors
can have on long-term aesthetics.

Introduction Implant Primary Stability

It has been 30 years since Per-Ingvar Brånemark first The foundation for aesthetics starts by choosing the
introduced North American dental researchers to his correct implant design. When the clinical situation
work with endosseous dental implants. During this allows, the right implant system can be utilized to begin
time, surgical and prosthetic components, as well as aesthetically-oriented treatment as early as the day of
the treatment protocols required for implant therapy, implant surgery. For example, one can perform a
have continued to evolve. At the same time, an single-stage technique by placing a BIOMET 3i
evolution in the way clinicians think has also occurred. BellaTek™ Encode® Healing Abutment, thereby
Clinicians whose initial goal was simply to restore influencing soft-tissue healing immediately. This single-
function to edentulous patients soon began working stage technique minimizes trauma, helps contour and
towards making their restorations ever more aesthetic. potentially preserves soft tissues. Another aesthetic
Attention also shifted to expediting and simplifying option offered by select implant systems is the ability to
treatment. provisionalize on the day of surgery. This technique
provides tissue sculpting benefits along with the
More recently, the realization has been growing that it additional reward of an instantaneous aesthetic
is not enough to simply place an implant, wait for it to outcome.
osseointegrate and then deliver an aesthetic definitive
crown. Complex biological processes can sabotage A critical factor in the success of these early contouring
even the most beautiful results over time. Strategies techniques is the primary stability of the implant
for establishing and ultimately sustaining the aesthetics system. Excessive micromotion during the early
of implant restorations throughout the course of years healing process has been well-documented to impede
and even decades have thus assumed paramount or prevent osseointegration; it may be the most
importance. common cause of implant failure. The implant’s primary
stability must be sufficient for it to resist micromotion
Many factors contribute to the achievement of until secondary (biologic) stability has been
aesthetic restorations and that is also true of ensuring established.1
that those results are sustainable over time. This article
will discuss four important factors in the establishment A number of factors enhance the likelihood of
and sustainability of aesthetic implant restorations. achieving primary stability with a given implant system.
These factors include: For example, the 3i T3 Tapered Implant System utilizes
• Implant primary stability depth and diameter-specific drills to create
• Implant surface osteotomies that fit the shape (i.e. minor diameter) of
• Implant-abutment junction (IAJ) geometry the implants being placed. Implants placed so that
• Implant-abutment connection their entire surface intimately contacts the full length of

*Not yet available for sale in the United States

1
the osteotomy have been described as having high such as titanium plasma spraying and titanium oxide
Initial Bone-to-Implant Contact (IBIC).2 Such contact blasting.
enhances primary stability.3 Furthermore, the 3i T3™
Tapered Implant design incorporates additional While these initial techniques were effective at
macrogeometric elements to enhance primary stability, improving aspects of osseointegration, they often
including tall, thin threads that penetrate laterally into contributed to unforeseen problems. Mucosal and
the bone for secure long-term engagement. other peri-implant complications were reported for
dental implants featuring titanium plasma spray (TPS)
In clinical practice, primary stability is quantified through and other relatively rough surfaces that extended into
indirect measures such as insertion-torque or the coronal aspects (Fig. 1).9
Resonance Frequency Analysis (RFA). Generally,
insertion-torque measurements above 35Ncm or RFA
readings with an initial stability quotient (ISQ) greater
than 65 indicate the implant’s primary stability is
sufficient for loading.4-6

The BIOMET 3i Tapered Implant design has been

shown to regularly meet these primary stability
requirements. In a prospective immediate loading study
by Östman et al, the investigators placed 139
BIOMET 3i Tapered Implants in mostly healed sites and
reported a mean insertion torque of 53.1Ncm, a mean
ISQ of 73.3 and a survival rate of 99.2%.4 Placing the Figure 1. Patient case demonstrating peri-implantitis around
Tapered Implant into fresh molar extraction sockets, Titanium Plasma Sprayed (TPS) Implants.
Block reported mean ISQ values of 77 in the mandible,
73 in the maxillae and a survival rate of 97.2%.7 These In response to these concerns, BIOMET 3i refined the
results show the high primary stability of the implant-roughening process with the introduction of the
BIOMET 3i Tapered Implant design in these dual acid-etched (DAE) OSSEOTITE® Surface (Fig. 2).
clinical cases. This surface has a topography that includes 1-3 micron
pitting superimposed on a minimally rough surface (Sa,
An implant system that routinely enables achievement Absolute Mean Roughness < 1.0 µm).10 To further
of high primary stability provides the flexibility needed reduce the risk of mucosal complications, the
to address patient needs. When accelerated treatment OSSEOTITE Implant was made available in a hybrid
is not applicable, (e.g. when bone quality is poor) good configuration that includes the historically proven
primary stability minimizes micromotion and reduces turned surface on the first 2-3.0mm of the coronal
the risk of non-integration. When clinical conditions are
good, primary stability can provide additional benefits,
permitting early or immediate provisionalization and/or
tissue sculpting to better meet aesthetic demands.

Implant Surface
One of the earliest strategies for enhancing
osseointegration was to roughen the implant surface.
When compared to the relatively smooth surface of
turned titanium, a roughened surface was found to
increase bone-to-implant contact and improve the
strength of the bone-implant interface.8 In the 1980’s,
implant manufacturers developed various techniques
for roughening implant surfaces, including processes Figure 2. OSSEOTITE Surface at 20,000x magnification

2
aspect and the dual acid-etched surface on the • From the base of the collar to the apical tip, the
remainder of the implant body. 3i T3 Implant has increased coarse roughness
resulting in a tri-level surface. The tri-level surface
Subsequent prospective, multicenter clinical studies of consists of sub-micron features superimposed on
OSSEOTITE® Implants have reported cumulative 1-3 micron pitting, overlaid on a moderately rough
survival rates ranging up to 99.3% and meta-analyses surface topography (Sa = 1.0 - 2.0 µm).10
of published data showed no decrease in performance
under high-risk conditions.11-17 Human histologic and Regarding the coronal topography, Zetterqvist and
histomorphometric evaluations have also Baldi have provided evidence regarding the fully etched
demonstrated significantly greater bone-to-implant surface’s potential impact on peri-implantitis mitigation
contact at the OSSEOTITE Surface, as compared to and crestal bone preservation.22,23
turned surfaces.18-20
The apical surface is designed to enhance
In 2010, a prospective five-year multicenter, osseointegration. As such, the included surface
randomized-controlled study was published that features have been researched to assess their potential
compared OSSEOTITE hybrid and fully etched implant impacts on de-novo bone formation and the strength
configurations for peri-implantitis incidence.21 Peri- of the resulting bone-implant interface.
implantitis is a serious long-term complication,
generally characterized by chronic soft-tissue In-vitro studies have evaluated the surface topography
inflammation and irreversible loss of supporting bone.21 effects on bone formation through osteoconduction,
The prevalence of peri-implantitis has been reported including the steps of protein absorption, fibrin clot
to be in excess of 12%.22 In this study, Zetterqvist et al retention and platelet interaction.10,24-27 For example,
demonstrated that the fully etched surface did not Davies et al reported that enhanced surface
increase the incidence of peri-implantitis as compared topographies, such as blasted and acid etched,
to the hybrid design, while providing additional
evidence that the fully etched surface reduced crestal Sub-Micron Topography
bone loss (0.6mm versus 1.0mm, p<.0001). This DCD Discrete
Crystalline Deposition
result was consistent with the 2009 one-year results of Calcium Phosphate
of Baldi et al who also found a statistically significant Nanoparticles
reduction in bone loss for fully etched implants versus
hybrid implants (0.6mm versus 1.5mm, p<.02).23

Throughout the years, the clinical successes of Fine-Micron

OSSEOTITE encouraged continued research into Topography
Dual Acid-Etched
implant surface and its impact on osseointegration, (DAE)
crestal bone preservation, and peri-implantitis
mitigation. These research efforts have culminated in
BIOMET 3i’s newest surface enhancement: 3i T3™ –
Targeted Topography Technology™.
Coarse-Micron
Topography
In the spirit of the OSSEOTITE Surface, the 3i T3 Media Blast
Implant surface is more than just another roughened
surface. In two distinct regions of the implant, it targets
different needs.
• The coronal aspect of the implant has a
microtopography similar to the fully etched
OSSEOTITE Implant, consisting of sub-micron
features superimposed on 1-3 micron pitting,
overlaid on a minimally rough surface topography
(Sa < 1.0 µm).10
Figure 3. 3i T3 Tapered Implant Topography.
3
 Tissue Levels
At Placement Biologic Width Established

1.0mm Sulcus
1.0mm Epithelial Attachment
1.0mm Connective Tissue Attachment

Figure 4. Schematic showing typical bone remodeling on a standard implant following formation of the biologic width.

display significantly greater fibrin retention forces than In addition to the sub-micron and micron features, the
machined surfaces (p=.02).26 Kikuchi et al have coarse roughness level has also been explored.
documented that micro-topographic surfaces, defined Coarse roughness is typically defined by
as one which exhibits features in the scale range of measurements such as Sa (absolute mean roughness).
platelets (e.g. ≤ 3 microns), display greater platelet As eluded to earlier, Svanborg et al have defined
activation than smoother surfaces.24 categories of roughness, including minimally rough (Sa
< 1.0 micron), moderately rough (1.0 < Sa < 2.0
In addition to osteoconduction research, in-vivo micron) and rough (Sa > 2.0 micron).10,36 Cordioli et al
studies also provide information on the individual reported no benefit of increasing coarse surface
elements of the 3i T3™ Implant Surface design. The roughness at five weeks in a rabbit reverse torque
sub-micron topography level has been well researched. (RTQ) model, specifically demonstrating that a dual
Nishimura et al have reported a statistically significant acid-etched surface (minimally rough) had significantly
increase in 14-day rat push-in force when adding sub- higher RTQ values than grit blasted (moderately rough)
micron features to a micro-scale topography (p<.05).28 and plasma sprayed (rough).37 Klokkevold et al one
Mendes et al published consistent results month rabbit reverse torque results were consistent
demonstrating a significant increase in 9-day rat tensile with Cordioli when comparing dual acid-etched and a
strength (p<.05).29 Similar early healing outcomes have rough surface.35 However, Klokkevold study included
been demonstrated in several other publications.30-32 additional time points. The researchers subsequently
discovered that the group with additional coarse
The microtopography component (e.g. 1-3 micron roughness had significantly higher RTQ results at the
pitting) of the 3i T3 Implant has also been well studied, two and three month time points (p<.01, p<.002).
including push in, pull-out, and reverse torque Klokkevold attributed this difference to the rough
testing.33-35 Overall, these studies demonstrated surfaces increased depth of topography and
increases in the force required to liberate implants with subsequent void volume, which permitted additional
micron versus turned topographies. For example, bone in-growth for mechanical inter-locking.
Baker et al reported statistical differences in rabbit pull-
out strengths starting at three weeks and continuing For dental implants, the surface is critical to
through the remainder of the study interval (up to eight establishing and sustaining aesthetic outcomes. To
weeks).33 this end, the 3i T3 Implant Surface represents a

4
 Certain® PREVAIL® Implant significantly less marginal bone loss around
platform-switched implants, as compared to platform-
“Medial matched ones.40
Factor”
Amount Of 4.1mm There are many hypotheses on how the platform-switch
Lateralization ~13˚
0.45mm Angle design impacts the biologic width and subsequent
bone level. The primary hypothesis is that the platform
5.0mm switched implant/abutment geometry forms the tissue
inward and away from the bone, better sealing off the
bone from oral contaminants during normal usage and
Figure 5. Schematic of a Certain PREVAIL Implant. The particularly during component swapping.41 A related
implant abutment junction (IAJ) is medialized or shifted inward. hypothesis is that the biologic width is not strictly a
vertical measure but is controlled by the relative surface
significant step forward, with multiple topography distance made available by the implant/abutment
levels and features along the implant body designed to combination. A platform-switched implant/abutment
influence osseointegration, crestal bone level, and lower combination provides additional surface distance
the risk of peri-implantitis. through its vertical and horizontal dimensions to
establish the required biologic width prior to the bone
Implant-Abutment Junction Geometry level being affected.42 A third hypothesis is that the
A third crucial factor for long-term maintenance of platform switching geometry influences the
aesthetic restorations is the influence of the implant- biomechanical stress distributions on the residual bone,
abutment junction (IAJ) geometry on the biologic width. leading to preservation.43 A final hypothesis involves the
The biologic width is the natural seal that develops shift of the IAJ inward, mitigating bone inflammation
around any object protruding from the bone and caused by microbial contamination from a poorly sealed
through the soft tissue into the oral environment. It IAJ.44 Ultimately, the reason why platform switching is
consists of approximately 1.0mm of connective tissue effective is most likely the result of one or more of these
and 1.0mm of epithelium, forming a barrier that hypotheses.
protects the bone from bacteria contained in the oral
environment (Fig. 4).38 When implants are placed and The 3i T3™ Tapered Implant incorporates integrated
connected to transmucosal abutments, the body reacts platform switching into its design, which has been
by re-creating the required biologic width between the correlated to the preservation of crestal bone.40,42 By
oral environment and bone. If the soft tissues are eliminating or reducing bone resorption at the top of the
insufficient, the bone may resorb until an adequate implant, the papillae and facial gingival marginal tissue
biologic width is re-established.39 remain supported. Tissue support is critical to the
establishment and sustainability of functional and
A discovery that occurred in the early 1990s first raised aesthetic outcomes.45
the possibility that implant design could impact biologic
width. This discovery occurred when standard 4.0mm Implant-Abutment Connection
diameter abutments were routinely used to restore A fourth factor that influences immediate and long-term
5.0mm and 6.0mm diameter implant designs. aesthetic outcomes is the implant system connection
Radiographic follow-up of these “platform-switched” design. A well-engineered connection will meet user
implants yielded the surprising finding of greater requirements for:
preservation of the crestal bone.39 This led to the • Ease of use
development of an implant system that incorporated • Versatility
platform switching into its design (PREVAIL Implant), • Strength
which enabled extensive study of the mechanisms at • Stability
work (Fig. 5). • Fit
• Accuracy
A recent systematic review and meta-analysis of ten
clinical studies including 1,238 implants found

5
Most of these needs correlate with aesthetics. The treatment that requires less-than-optimal surgical
3i T3™ Tapered Implant was designed with the placement by using stock pre-angled components.
Certain® Internal Connection to meet these
requirements. In addition to being easy to use, the implant connection
must work synergistically with the overall implant,
The Certain Connection incorporates several features abutment, and screw designs to provide the strength
to enhance its ease of use (Fig. 6). These include a non- required for long-term aesthetic performance. To
mounted design to eliminate steps during surgical assess system strength, dental implant manufacturers
placement, color coding of the implant connection and typically test their systems using the standardized test
associated restorative components for easy selection, method described in ISO14801, Dynamic Fatigue Test
and a patented audible “click” feature confirming for Endosseous Dental Implants.46 The standardization
component seating. Additionally this connection offers of this test permits the comparison of results provided
compatibility with the BellaTek™ Encode® Impression by various manufacturers. Table I displays the fatigue
System, which eliminates the need for impression strength of the BIOMET 3i Certain Implant System
copings and implant-level impressions. relative to three other competitive implants.

The connection design also includes a 12-position Looking beyond strength, the stability and tightness of
double hex. This serves two related purposes. First, the the implant/abutment connection may also affect
12 positions allow the surgeon to place the implant aesthetics. A stable, tight implant/abutment interface
optimally in the prepared osteotomy without indexing minimizes abutment micromotion and reduces potential
the connection (over rotating or under rotating to match microleakage. Improved performance in these areas
a connection point to a buccal landmark). This makes has been theorized to reduce the inflammatory
surgical placement easier, as well as allows the implant processes associated with bone or tissue loss.
to be placed with the highest amount of Initial Bone-to-
Implant Contact (IBIC), and subsequent primary In a recently presented study, Suttin et al assessed the
stability. Second, the 12-position connection provides strength and seal robustness of four commercially
the restoring clinician with maximum aesthetic available implant systems including Thommen Medical
versatility. They can more easily compensate for (flat on flat connection), Straumann® (conical
connection), Astra Tech™ (conical connection) and
BIOMET 3i (flat on flat connection).49 The results of the
study demonstrated the potential advantages of the
BIOMET 3i Certain Implant connection in terms of
BellaTek Encode microleakage resistance under dynamic load
Abutment
conditions. Figure 7 demonstrates the final failure loads
at which each of the samples (n=5 per manufacturer)
leaked, fractured, or exhibited a combination of both.
PREVAIL® Implant
Certain
The Certain Internal Connection microleakage results
Gold-Tite®
Screw Internal run counter to the assertions of manufacturers of
Connection implants with conical connections. But not all flat-on-flat
implant systems are created equal. The Certain System
has been designed with exacting interface tolerances
for precise abutment mating and Gold-Tite Abutment
Screw technology to maximize clamping forces.50
3i T3 Tapered
Implant The Gold-Tite Abutment Screw is coated with a
minimum of 40 microinches of 99.9% pure gold. This
coating acts as a dry lubricant, reducing the friction
between the screw and the implant threads. The dry
Figure 6. Schematic of a 3i T3 Tapered PREVAIL Implant. lubrication permits the screw to stretch, rotating the

6
 Endurance Limit
Item Description
N
Ex-Hex Connection Implant Competitor #1, 3.75 mm diameter 18547,48

Internal Connection Implant Competitor #1, 4.3 mm diameter 28347,48

Conical Connection Implant Competitor #2, 4.1 mm diameter 30047,48

XIFNT415 BIOMET 3i Tapered, 4.0mm Diameter 37748

XIIOS4315 BIOMET 3i PREVAIL®, 4.0mm Diameter x 3.4mm Platform 45148

Table 1. Results from fatigue testing of implants based on ISO14801 test method (set-up specified as per ISO14801).

screw further into the implant, and ultimately pulling As the dental implant community transitions to digital
downward on the mated component (Fig. 8). The tight restorative technologies, new sources of error are
clamping of the implant and mating components presenting themselves. In order for this technology
maximizes the stability of the interface, while reducing transformation to be successful, it is becoming
the potential for micromotion. This output helps to increasingly critical that all participants in the workflow
explain the microleakage resistance of the Certain® minimize their contributions to the overall error. The
Implant System. 3i T3™ Implant with the Certain Connection is leading
the way in vertical restorative accuracy, and is
A final advantage of the Certain Connection is its ability subsequently well positioned to meet current and future
to minimize vertical restorative errors. Such errors may digital technology demands.
be created through the inaccurate transfer of the
seating position through the restorative process, which Clinical Relevance
can result in a definitive prosthesis experiencing Patients want and increasingly will expect, their implant-
improper occlusion, contact error, or a non-passive supported restorations to look as good over time as
fit.51,52 The constant seating position of the Certain they did on the day of delivery. This requires attention
Connection eliminates error sources that are known to to many factors. The implant design can significantly
plague conical interface connections. Dailey et al and impact the factors required to establish and sustain
Towse et al identified and quantified sources of conical aesthetics.
connection error, demonstrating the potential benefits
the Certain Connection provides.51,52 The 3i T3 Tapered Implant System has been
1000 engineered to meet these fundamental requirements

900
providing:
• The primary stability necessary for early aesthetic
800 provisionalization and/or tissue sculpting.
700 • A refined surface design to enhance
Failure Load

600 osseointegration, with no increased risk of peri-

500
implantitis as compared to hybrid implants.

400
• The system strength for long-term aesthetic
function.
300 • An implant/abutment geometry and related
200 connection features designed to preserve bone at
100
and around the implant to provide support for the
Thommen Astra Tech™ Straumann® BIOMET 3i All pairs development and maintenance of soft tissue.
Tukey -Kramer
0.05
• A highly accurate connection well positioned to
Test Groups meet current and future digital restorative needs.
Figure 7: Ramped Cyclic Loading.
7
 Screw

Implant

Figure 8. The Gold-Tite® Abutment Screw, coated with a minimum of 40 microinches of 99.99% pure gold, acts as a dry lubricant to
reduce friction between the screw and the implant threads, thus permitting the screw to stretch and applying greater clamping force.

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9
 Dr. Lazzara† received his
Certificate in Periodontics and
Master of Science in Dentistry
at Boston University. He is
formerly a Clinical Assistant
Professor at the University of
Southern California School of
Dentistry, Associate Clinical Professor at the
University of Maryland, Periodontal and
Implant Regenerative Center, and Associate
Professor at the University of Miami. He has
lectured nationally and internationally on
the surgical and prosthetic applications of
implant dentistry.

†
Dr. Richard J. Lazzara has a financial relationship with
BIOMET 3i, LLC resulting from speaking engagements,
consulting engagements and other retained services.

*While these surgeon experiences are true, the results are not necessarily typical, indicative or representative of all procedures in which the BIOMET 3i
Implant and related components are used. The BIOMET 3i components have been used successfully in patients. However as with any implant device,
there are surgical and post-operative factors, which ultimately may result in unpredictable variable outcomes. These factors include, but are not limited to,
the patient’s pre-and post-operative health conditions, bone quality, number of surgical procedures and adherence to instructions regarding the procedural
guidelines. Due to these variables, it is not possible to predict or warrant specific results, patient or clinician satisfaction.

Certain, Encode, Gold-Tite, OSSEOTITE and PREVAIL are registered trademarks

of BIOMET 3i LLC. BellaTek, NanoTite and 3i T3 are trademarks of BIOMET 3i
LLC. Astra Tech is a trademark of Astra Tech. Straumann is a registered trademark ART1193EU
of Straumann. ©2012 BIOMET 3i LLC.
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