Nobel Biocare NEWS

Nobel Biocare NEWS
Information for the Osseointegration Specialist
Issue 1/2012
Designing
for Life
By Richard Laube, CEO
Living the Endless Summer
Nobel Biocare implant-based solutions provide longevity and exceptional quality of life.
Implants from Nobel Biocare
provide the foundation for a
third dentition that can last
to the end of life.
By Frederic Love
F
or the past  years, dentists all
over the world have made a
strong case for the importance
of keeping one’s teeth. They have
successfully argued this case in both
the popular media and the dental
office alike.
Maintaining good, healthy teeth
is certainly a worthy goal, but given
current demographic trends, keeping
them for a lifetime is not always possible, despite the impressive achievements of preventative dentistry and
the best efforts of the patient.
Trauma, systemic disease and even
normal wear are just a few of the reasons a tooth may begin to fail.
Conscientious brushing, flossing
and regular checkups may delay the
advent of serious problems, but there
is likely to come a day—well before
the tooth falls out of the mouth on its
own—when replacement with a
bone-anchored solution from Nobel
Biocare will prove to be a prudent,
positively life-changing decision for
the patient.
After half a century of gradual discovery, the many benefits of osseointegrated implants are now wellknown. Implants solve real,
widespread problems.
Not only do they provide stable,
secure solutions that allow patients
to eat virtually anything they want,
they preserve the patient’s facial appearance and prevent bone loss,
which provides enormous social and
emotional benefits in addition to the
purely physiological ones.
nate lifetime solution—dentures for
instance—should be taken into account when considering implant
costs.
“While it’s true that implant-based
therapy generally represents a greater initial investment in treatment
time and money than traditional
prosthetic solutions,” he said recently, “traditional solutions such as dentures and bridges have recurring
costs in terms of maintenance and
the often-times deleterious effect
they have on the adjoining dentition
and bone.”
When asked about the deeper
value of longevity, he added simply,
“From the earliest days, back in the
sixties, life-long solutions were always what we aimed for—and time
has shown that life-long solutions are
also what we achieved.”
Of all the companies active in the
field of implant-based prosthetic
dentistry, none has more experience
or a longer patient follow-up data set
than Nobel Biocare.
Because the company understands
that an implant doesn’t just serve as
the foundation of a prosthetic solution—it also serves to restore or
maintain the patient’s self-esteem—
you can count on Nobel Biocare for
promising life-long solutions. <
Longevity just makes sense
What is less well-known is that implants usually make great comparative economic sense as well, partly
because remaining healthy teeth do
not need to be compromised, but
even more so because of the characteristic longevity of implants from
Nobel Biocare.
According to Professor Tomas Albrektsson of the University of Gothenburg in Sweden, the maintenance
and replacement costs for an alter-
In this Issue
At Nobel Biocare, we are committed
to improving the quality of life of
every patient treated with our innovative products.
Our customers—and their patients—can be confident that the
solutions we promote for the restoration of lost teeth have been designed with the objective of providing fully functional, natural-looking
results to last a lifetime.
“Designing for Life” is an ambition that covers much more than
product design and treatment innovation, however.
It is a concise expression of the
principle upon which we have established our business. It permeates
everything we do, from scientific
discovery and clinical trials to product information and customer relations.
We have assisted our customers in
the treatment of millions of patients.
This experience has shown that a
better smile, better speech, better
oral health—not to mention the
ability to eat normally again—dramatically improve a person’s life.
Providing this level of care enhances both the quality of life of the
patient and the professional reputation of the clinician. For Nobel Biocare, such improvements represent a
long-term commitment to both our
customer and the patient.
Our dedication to improving patients’ quality of life grows from unparalleled experience. Building on
the past  years of pioneering scientific research and innovation in
the field of implant-based restorative dentistry, Nobel Biocare will
continue designing for life.
Moving forward together
2
Brånemark’s 2nd patient.
His implants are still
working 45 years later.
8
TiUnite® Quite simply
the gold standard.
7
Gunshot victim made
whole with custom care.
10 Statistical presentations
can be misleading.
Reading critically helps.
On the pages to follow, you’ll find
thought-provoking reading on recent scientific findings, practical
techniques to facilitate treatment,
and the living history of osseointegration. Join us as we move the noble
practice of implant dentistry forward
together, one patient at a time. <
2
From the Editor
Nobel Biocare NEWS
Issue 1/2012
A 44-year Success Story
Sven Johansson has had oral implants longer than anyone else on Earth.
Nicolas Weidmann
Senior VP Global Communications
In the most recent issue of Nobel Biocare News, I wrote that we want this
publication to be your newsletter as
well as ours. From the enormous
outpouring of good wishes and substantive ideas for new content that
the editors have received since then,
you are obviously of the same mind.
Thank you for your kind words and
encouraging suggestions!
The third dentition
When long-term, predictably positive prognoses are paramount, there
is really no substitute for extensive,
well-documented experience, which
applies to suppliers, as well as the
surgical and prosthetic teams.
At Nobel Biocare, we’re prepared
to share our experience to support
your team at every stage of treatment. When you speak to your patient about a new set of tissue-integrated teeth, you can speak with
authority, confident in the knowledge that Nobel Biocare stands behind you.
Our wide range of TiUnite surface
implants remain at the outer edge of
the envelope for highest initial stability and enduring strength.
Our company is a lot like that
too—pioneering, stable and reliable—a partner you can trust. <
Nobel Biocare NEWS
Published regularly by
Nobel Biocare Services AG
Vol. 14, No. 1, 2012
Editor-in-chief Nicolas Weidmann
Managing Editor Frederic Love
Assistant Editor Jim Mack
Editorial offices
Nobel Biocare News
Herdevägen 11
702 17 Örebro, Sweden
Telephone: +46 19-330680
Telefax: +46 19-330681
email: [email protected]
web: nobelbiocare.com/newsletter
The contents of contributors’ articles do
not necessarily express the opinions
of Nobel Biocare.
© Nobel Biocare Services AG, 2012.
All rights reserved.
Longevity comes from careful
planning, quality products
and treatment, and conscientious follow-up.
By Dr. Christer Dagnelid
G
östa Larsson of Gothenburg,
Sweden, was the first patient
to be treated with implants by
Professor Per-Ingvar Brånemark. That
was in . When Larsson passed
away in , he had had his implants—still in place and fully functioning—for more than forty years.
Brånemark’s second patient, Sven
Johansson, also of Gothenburg, received his implants in . This year
will mark the th anniversary of his
treatment, which makes him a part
of living history in the field of osseointegration. Sven’s missing dentition
was restored with two full-arch gold/
acrylic bridges supported by a total
of  Brånemark System implants in
the upper and lower jaw. Further developed by Nobel Biocare, this signature system is still widely used and
much appreciated today.
All too common story
Like so many other members of his
generation, Sven had had problems
with his teeth from an early age.
Born in , by the time he was in
his s, he was completely edentulous. The usual prosthetic solution at
that time—the s—was treatment with full dentures.
Dentures didn’t suit Sven well,
however, and he experienced major
problems in his relationships to
other people as a result. As with so
many other denture wearers, he had
difficulty eating and he felt insecure
in many common social situations.
At the time, Sven was a cab owner
and driver in Mölndal, a small town
on the outskirts of Gothenburg. One
day he received a call to drive a patient to the Brånemark Clinic, which
was located there, and the passenger
turned out to be none other than
Gösta Larsson—Patient No. —who
had not only been the first to be
treated with Brånemark System implants, but had also been treated in
both jaws.
Gösta Larsson spoke highly of the
professionalism of the people he had
met at the clinic, the care he had
received there, and the dramatic
change he had seen in his life because of the results. His driver, Sven
Johansson, decided immediately to
book a consultation. After careful
X-ray examinations, a thorough
evaluation of the amount of remaining jawbone and a psychological
exam, Sven was deemed suitable for
treatment.
A bold decision paid off
Sven, by nature, is a brave soul. When
he decided to subject himself to implant surgery, it had only been carried out once before, after all. When I
asked him at a routine check-up this
December if he hadn’t been anxious
about submitting to the procedure,
he simply shook his head and replied,
“Not at all!” As it turned out, he had
no reason to worry, of course. Always
a man of few words, he explained
succinctly, “The surgeries went very
well. I had no problems.”
Before  came to an end, Sven
felt secure once again in social situations that he had tried to avoid ever
since becoming edentulous.
His diet improved too. Sven had
dreamed for years of once again
being able to take a bite out of a large
green apple, and that dream came
true before the new year as well.
In Sven’s own words, “Everything
worked perfectly from the first moment.”
In , I took over Professor
Brånemark’s dental practice in
Mölndal, and thus inherited Sven Johansson as a patient. A good patient,
Sven has rarely missed a regularly
scheduled dental check-up throughout the + years his implants have
been in place. He has practiced good
oral hygiene and problems such as
peri-implantitis have never been a
concern.
Sven Johansson of Gothenburg, Sweden, was the second patient to
ever receive Brånemark System implants. They have been serving him
well since 1967.
patient in an individualized recall
program. In as much as the implant
treatment amounts to a major investment for the patient, our objective is
uncompromising: “Life-long service.”
Over the last  years, I have participated in and performed thousands of Brånemark System dental
implant cases. High-quality products,
skilled clinicians, good teamwork
and an individualized recall system
have led to great success and implant
longevity for me, my colleagues and—
most importantly—for our patients.
The experience we have gained
since Gösta Larsson and Sven Jo-
hansson were first treated by Professor Brånemark has taught us that
good implant-related dental care
must be based on a long-standing relationship between the patient and
dentist, where the number and frequency of return visits are tailored
to the different stages of life.
I take my hat off to Sven Johansson, who is rapidly approaching ,
and Professor Per-Ingvar Brånemark.
Through a combination of boldness
and insight they have helped millions
of orally handicapped people return
to a life of dignity over the last half-acentury. <
Prerequisites for longevity
From our side, as dentists, it is essential to create the conditions for good
oral hygiene through the proper design of bone-anchored prosthetic reconstructions. Well-designed occlusion and articulation are also
important prerequisites for optimal
loading of the implants and essential
for implant longevity.
Sven, and thousands of other patients since Sven was first treated,
have received instructions in good
oral hygiene practices by my wife,
Dental Hygienist Eva Dagnelid.
From the moment he first received
his Brånemark System implants,
Sven has never missed a booked recall visit and he has conscientiously
followed the oral hygiene advice that
we’ve given him.
To ensure longevity, it is also a
good idea to follow up every implant
These eleven implants were placed by Professor Per-Ingvar Brånemark
himself and are still fully functional for Sven Johansson.
Issue 1/2012
3
Nobel Biocare NEWS
In Brief
Landmark Science
Nobel Biocare has the longest, most extensive follow-up data set.
There’s an app for that
A free app, not surprisingly called “Nobel Biocare News” now makes
it possible for you to stay up-to-date with the latest edition of this
newsletter on your iPad, iPhone or iPod Touch.
Without two pioneering
studies from 1981 and 1990,
implant dentistry might still
be in its infancy today.
By Frederic Love
M
Just visit the App Store on your Apple mobile device and search for
“Nobel Biocare News” to download the most appropriate app for
your device. Naturally, it’s free of charge.
Prefer to read
Nobel Biocare News online?
If you would rather catch up on Nobel Biocare News on your office
computer or a laptop—of any brand and with any browser—there
are several options open to you.
You can read individual articles on our newsletter home page,
nobelbiocare.com/newsletter, which also serves as a digital hub.
Here you can do word searches or browse subject categories to find
any studies have been carried
out on the procedures and consequences of osseointegration since
Per-Ingvar Brånemark treated his
first implant patient, Gösta Larsson,
 years ago in . Perhaps none
has been more widely read than “A year study of osseointegrated implants in the treatment of the edentulous jaw” by Ragnar Adell et al, which
was published in the International
Journal of Oral Surgery in .
In this groundbreaking work, and
the follow-up study published in
, Adell and his colleagues meticulously documented the high success
rates generated by implant treatment
ad modum Brånemark and produced
an impressive yardstick against which
all subsequent studies would be measured.
Dr. Adell, formerly head of the Department of Oral and Maxillofacial
Surgery at the Örebro University
Hospital in Sweden, recently commented, “When we started our work
in the s, the possibility of the
body permanently retaining a titanium fixture was not widely accepted.
By the time our second report on this
study was published in , the process of osseointegration had become
accepted science.”
Thanks in large part to the pioneering work of Adell and his colleagues,
the viability of the routine placement
of endosseous implants became wellknown among readers of dental literature in the s and s—and the
rest, as they say, is history. <
Dr. Ragnar Adell established a
tradition for conscientious
follow-up study that lives on today
at Nobel Biocare.
More to explore:
Adell R, Eriksson B, Lekholm U,
Brånemark PI, and Jemt T, “Longterm follow-up study of
osseointegrated implants in the
treatment of totally edentulous
jaws.” Int J Oral Maxillofac
Implants, 1990. 5(4): p. 347–359.
Maintenance of Marginal Bone
Ask questions of the expert panel – in person or in advance.
individual articles on specific topics. Via links located at this site,
you can also download entire issues as PDF files, view the current
edition in PageFlip format, and/or sign-up for email delivery of our
e-newsletters.
Later in the year, every issue of Nobelpharma News and Nobel
Biocare Global Forum—our current newsletter’s direct antecedents—
will be available as PDF files going all the way back (14 volumes!)
to the very first edition in 1987.
Impressive snapshots
Dr. Scott MacLean of Halifax, Nova Scotia, Canada, recently wrote to
the editors about a NobelActive case and sent the following images.
Last September, Nobel
Biocare brought together a
group of internationally
acknowledged experts to
reach agreement on the
subject of marginal bone
management. Held at
Karolinska Institutet in
Stockholm, it has became
known as the “Consensus
Meeting.” On June 8, they
will be reconvening at
Europerio 7 to publically
discuss their findings.
O
Dr. Scott MacLean: “The molar was placed 5 years ago (one of the
first placed in Canada during the initial pre-launch study). The premolar was immediately placed during study club in Feb 2011. Look at
the bone between the implants ... This implant rocks!”
n June , , Nobel Biocare
will be hosting a public forum
at Europerio  in Vienna, Austria, on
the subject of “Maintenance of Marginal Bone around Implants”.
The panel will be made up of such
well-known authorities as Drs.
Marco Esposito, Björn Klinge, Jörg
Meyle, Andrea Mombelli, Eric
Rompen, Tom Van Dyke, Hom-Lay
Wang, Arie-Jan van Winkelhoff, and
Moderator, Daniel van Steenberghe.
These experts were invited by
Nobel Biocare on the basis of their
interest in the subject and publication record. Since tens of millions of
Before restoration and more than a decade later. Eleven years
separate these two radiographs of an implant with a TiUnite surface from
Nobel Biocare. Images courtesy of Dr. Giovanni Polizzi.
patients now have oral implants,
there is an increasing awareness of
the need to ensure their longevity by
maintaining stable marginal bone. A
hot subject today, this issue is much
discussed in the world of dental implants.
After circulating their review papers among themselves, and then
meeting for two days of candid exchanges at Karolinska Institutet in
Stockholm last fall, the group formulated a set of consensus guidelines,
both preventive and therapeutic.
They updated their manuscripts and
the papers have now been published
as a special supplement to the European Journal of Oral Implantology.
This Europerio  will allow you to
hear what the working group has to
say about the key clinical issues.
Questions will be entertained from
the audience as well as via online
submission. <
More to explore
Read the special supplement to
the March issue of the European
Journal of Oral Implantology.
To pose advance questions to the
Europerio 7 panel, please go to
nobelbiocare.com/europerio2012
4
Nobel Biocare NEWS
Issue 1/2012
Managing Soft Tissues by Design
Longevity has many aspects. Good management of the soft tissue/implant interface is one of them.
Creating an effective and
stable soft tissue barrier
around the abutment is
essential for the esthetic
and functional longevity of
implant-supported restorations.
By Hans Geiselhöringer
I
mplant treatment has proven to be
a highly predictable and extremely
reliable option for today’s patients.
With sixty years of continuous
research, innovation and clinical follow-up behind its implants and related components, Nobel Biocare
continues today to provide optimal
solutions for the patient, both in
terms of functional and esthetically
pleasing outcomes.
Nobel Biocare designs products for
solutions in harmony with the adjacent dentition—and ideally invisible
to the human eye.
Never complacent
Despite the extremely high success
rates that have resulted from treatment optimization over the years,
Nobel Biocare continues to actively
pursue scientific research with probable clinical consequences.
The maintenance and stability of
the peri-implant tissue architecture
is currently a key area of enquiry.
While pathways and cellular responses during the osseointegration
of an implant have been described in
detail, questions related to soft tissue
stability and ideal treatment protocols are also being explored [Cairo
et al, ].
Clinicians naturally want to create
an effective barrier protecting the
underlying bone from intraoral microorganisms and their by-products
[Rompen et al, ]. In this context,
it is generally accepted that the tight
and stable soft tissue integration of
an implant-based restoration means
a great deal for long-term success.
Although clinical protocols have
been developed to maintain or improve soft tissue quality and quantity
at implant recipient sites [Thoma et
al., ], it is important to understand that the interaction and interdependencies of the tissue surrounding restorative components play as
vital a role as the general anatomic
situation at the implant site.
Nobel Biocare has been among the
first manufacturers to take this critical interface between the oral cavity
and the body seriously in every as-
pect of product development. To ensure safe, reliable and long-lasting
implant outcomes, Nobel Biocare
emphasizes four product characteristics that complement patient-related
factors and the selection of appropriate treatment protocols in the quest
for such outcomes. These are:
r UIF EFTJHO BOE DPOUPVS PG UIF
implant-abutment interface
r UIFGJUPGNBUJOHDPNQPOFOUTBOE
quality of the screw joint
r UIF BCVUNFOU NPSQIPMPHZ BOE
choice of materials and
r FBTZBEBQUBUJPOUPBOZHJWFODMJOJcal situation (e.g. via tactile feedback).
Meeting clinical needs and
personal preferences
Every patient is unique, as is every
clinical situation. In terms of personal confidence and professional preferences for protocols and components, every dentist is also unique.
Recognizing diverse needs and
preferences, Nobel Biocare provides
a wide variety of implant platform
configurations. With recent NobelReplace line extensions featuring
conical connection and platform
shifting interfaces, Nobel Biocare has
once again proven its commitment
to meeting every clinician’s needs.
Nobel Biocare incorporated new
connections into the world’s most
versatile and widely used implant
system in order to facilitate the use of
a variety of established and highly
predictable treatment protocols.
To put it another way, Nobel Biocare developed and launched implants with conical connection and
platform shifting in order to provide
new tools for soft tissue management
erned by an apparent paradox: On
the one hand, precision is paramount, on the other, acceptable tolerances make the seating of prosthetic
components possible. In defining acceptable tolerances, Nobel Biocare
has specified figures that facilitate
passive fit yet remain well below the
critical threshold limits that would
lead to micromotion and ultimately
to loosening of the implant-abutment
joint. (Read more about micromotion in Professor John Brunski’s article on page .)
An inconspicuous hero:
the TorqTite™ screw
The NobelActive conical connection is exceptionally strong, making
for a tight seal achieved by the use of a special grade of commercially pure
titanium and the radial design of the connection, which distributes the
forces deep within the robust core of the implant.
and the preservation of the crestal
bone.
Platform shifting provides a narrower diameter prosthetic component
on a wider diameter implant platform
(see figure  on the next page and the
accompanying case study by Dr.
David Lustbader). This creates an exposed ridge on the implant platform
where the soft tissue can develop.
Implants with platform shifting increase the interface between biological width and retention and may act
as a “stop” preventing tissue recession. Literature shows that utilizing
platform shifting results in both significantly less radiographically detectable bone loss in humans and better soft tissue support and
maintenance in the esthetic zone
[Atieh MA et al, ; Canullo et al,
; López-Mari et al, ].
Decisive design features
The back-tapered collar of the
NobelActive regular platform implant has been designed to maximize
the volume of bone at the alveolar
crest and to improve soft tissue support. Tissue management is further
supported by the built-in platform
shift and the internal conical connection.
The expanding tapered NobelActive implant body with doublelead thread is designed to condense
bone gradually to provide high initial stability and support for immediate loading.
The results of a multi-center
study—encompassing  partially or
fully edentulous patients receiving
 NobelActive implants in  centers—show that the marginal bone
level as well as the soft tissue level is
stable two years after implant insertion. The study demonstrates that
NobelActive can be placed under demanding immediate loading conditions as it provides stable bone and
soft tissue levels after two years of
function [Martinez-de Fuentes et al,
].
The perfect balance
NobelReplace
Tapered
NobelReplace
Platform Shift
NobelReplace
Conical Connection
The newly launched NobelReplace Platform Shift and NobelReplace
Conical Connection demonstrate strength values in the same range
as NobelReplace Tapered Groovy when evaluated mechanically using ISO
tests.
While the implant platform-abutment interface design plays a significant role in a stable and lasting connection, other design considerations
have also been taken to reduce detrimental effects on the peri-implant
tissues. Bona fide precision fit and
the ingenious design of the Nobel
Biocare abutment screw minimize
micromotion, for example.
The achievement of proper fit between mating components is gov-
In the early days of implant dentistry,
one of the most commonly reported
maintenance needs for implant restorations was retightening or changing
the abutment screws [Goodacre et al,
]. Nobel Biocare’s engineers
solved the problem by developing a
screw with features outclassing any
other retaining screw.
Other implant systems have tried
to introduce similar screws, but the
features of Nobel Biocare’s TorqTite
screws remain unique. To keep the
implant and abutment interface connected and to prevent any rotational
movement upon load application,
special features have been integrated
into its design.
For one thing, the screw is manufactured from a specific titanium
alloy and coated with a carbon layer
that reduces friction between the internal screw-threads of the implant
and the threads of the retaining
screw.
A reduction of friction is namely
needed to reach the pre-torque values
required to create pre-tension in the
screw shank. (See the Tips and Techniques article by Dr. Chandur Wadhwani on page .) Nobel Biocare’s
TorqTite screws have been designed
and tested to occupy the center of
the proper torque zone.
If screw threads ran all the way up
to the head of the screw—as they do
in many other implant systems—the
shaft could not act as the pre-load
spring necessary to ensure the longevity of the screw-joint. <
There’s more to this story!
For a longer version of this article,
including a discussion of optimal
material choices and the full list of
references, please continue reading
in our enhanced digital edition at:
nobelbiocare.com/newsletter
Issue 1/2012
Popular, Well-proven Concept
Experience NobelReplace® Platform Shift from the clinical point of view.
Platform shifting, or platform
switching, is a concept that
has come into the mainstream as it has become an
integral feature of some of
Nobel Biocare’s most popular
implants.
O
2012
IDEM Singapore
20–22 April
Singapore
Dental Salon Moscow
23–26 April
Moscow, Russia
Fig. 1. Platform shifting has been
designed to maximize soft tissue
volume.
overcoming any negative tissue influences from a large maxillary frenum. The tooth was atraumatically
removed and a surgical guide was
fabricated to assist with depth placement of the implant.
The osteotomy was started with
twist drills, but finished with osteotomes to preserve the buccal plate. A
 x  mm NobelReplace Platform
Shift implant was placed using the
. mm implant driver, placing the
implant to just below the facial height
Scandefa
26–28 April
Copenhagen, Denmark
ODA Spring Meeting
10–12 May
Toronto, Canada
Fig. 2. NobelReplace Platform
Shift. The ease of use of the
internal tri-channel connection
combined with built-in platform
shifting.
Fig. 3. NobelReplace Conical
Connection. The original tapered
implant body combined with the
tight conical connection and built-in
platform shifting.
of the crestal bone to take full advantage of the platform shift.
A  x  mm healing abutment, .
series was placed on the implant (fig-
ure ), and the patient was then seen
by his restorative dentist for immediate temporization (figure ).
The patient functioned on the immediate temporary for  weeks, at
which time the final impression was
taken (figure ). Note that at all times
the integrity of the marginal bone was
preserved.
A CAD/CAM custom abutment
was fabricated using the NobelProcera Scanner and Software (figure ).
The final crown was inserted at 
weeks (figure ). As can be seen in
the final restoration (figure ), tissue
level integrity is preserved.
Our practice has acquired a great
deal of experience with NobelReplace
Platform Shift and Conical Connection implants over the past year. We
have seen superior esthetic results
with excellent preservation of soft tissue and crestal bone. Although the follow-up period is relatively short, preliminary results are very encouraging.
This is an excellent addition to the
Nobel family of implant products. <
Fig. 4–5. Pre-op clinical and radiographic views.
Fig. 6–7. Extraction site and implant with healing abutment.
Temporary and final crowns
courtesy of Dr. Craig M. Allen.
Fig. 8. Temporary crown at six
weeks post-op.
Fig. 9. Impression appointment
12 weeks post-op.
EAED Spring Meeting
24–26 May
Izmir, Turkey
62. Kongress der Deutschen Gesellschaft
für Mund-, Kiefer- und Gesichtschirurgie
31 May – 2 June
Freiburg, Germany
Nobel Biocare Symposium
1–2 June
Avignon, France
Europerio 7
6–9 June
Vienna, Austria
Nobel Biocare Symposium
9–11 June
Odessa, Ukraine
Sino Dental
9–12 June
Bejing, China
Nobel Biocare Symposium
15–16 June
Hamburg, Germany
IADR General Session
20–23 June
Iguaçú Falls, Brazil
FDI Annual World Dental Conference
29 August – 1 September
Hong Kong, China
AAOMS Annual Meeting
10–15 September
San Diego, USA
EACMFS Congress
11–15 September
Dubrovnik, Croatia
ICOI World Congress
20–22 September
Orlando, USA
AAP Annual Meeting
29 September – 2 October
Los Angeles, USA
Platform shifting in practice
The case illustrated in this page is of a
-year-old man who had a vertical
and horizontal fracture through tooth
# (FDI ), evident clinically and on
the pre-op film (figures  and ). The
treatment plan was to remove # and
to immediately place a NobelReplace
Platform Shift with immediate load.
This implant was chosen to maximize soft tissue volume in hopes of
Upcoming
Events
Visit Nobel Biocare at events
around the world. They provide a
great opportunity for observing
the latest innovations and
scientific research.
By Dr. David Lustbader
riginally described by Dr.
Lazzara, platform shifting is
a concept that involves an
inward horizontal repositioning of
the implant-abutment interface (figure ). This connection shifts the
perimeter of the implant-abutment
junction towards the center of the
implant, creating a horizontal component for the total linear distance
between the abutment and crestal
bone required for biologic width.
This allows for higher tissue volume and vascularization, ultimately
leading to more stable crestal bone
heights and interdental papilla.
Most studies show that a horizontal component of about . mm results in significantly less radiographically detectable crestal bone loss and
better soft tissue support in the esthetic zone. Platform shifting can be
accomplished with the NobelReplace
Platform Shift tri-channel (figure )
or NobelReplace Conical Connection (figure ), which is identical to
the NobelActive configuration.
I have had the good fortune to be
able to place both the NobelReplace
Platform Shift and Conical Connection implants during the pre-launch
and evaluation stages. To date, our
practice has placed over one hundred of these implants and have
found the marginal bone levels and
soft tissue esthetics to be excellent.
The surgical placement and instrumentation is virtually identical
to the standard NobelReplace system, making it ideal from a staff
training and surgical armamentarium standpoint. A simple case illustration will demonstrate the ease of
use and predictability.
5
Nobel Biocare NEWS
Nobel Biocare Symposium
19–20 October
Rimini, Italy
Nobel Biocare Symposium
19–20 October
Toronto, Canada
Fig. 10. CAD/CAM abutment
fabrication using NobelProcera
Software.
Fig. 11. Final crown insertion at 14
weeks. Note continued excellent
bone level preservation.
Fig. 12. The final restoration from
the clinician’s perspective.
To find out more, visit
nobelbiocare.com/events
|
6
Nobel Biocare NEWS
Issue 1/2012
Meeting One-of-a-kind Patient Needs
Custom-made devices from Nobel Biocare can make a decisive difference when no one else has a solution to offer.
For over 20 years, Nobel
Biocare has been offering a
unique service to its
worldwide customer base
that you may not be aware of.
A special custom-made
device service exists in
Sweden that makes it
possible to create a one-time
solution for a one-time
patient need.
By Jim Mack
N
o matter how far technology
may advance your favorite
products, you will always be left
wanting more. But when it comes
to a special patient need, or even an
emergency, you may not be able to
find your “dream product” in the
marketplace.
With Nobel Biocare’s custommade device service, all you have to
do is ask. Your custom-made device
can be created in a matter of weeks—
or even less in cases of extreme medical emergency.
Not your normal solution
Custom-made solutions are tailored
to fit a unique and one-time patient
need. These special solutions extend
beyond the typical esthetic circumstances and can also be used to assist
trauma victims, including those recovering from such serious injuries
as gunshot wounds. (See article on
the facing page.)
One caveat may be in order: This
service is not meant to provide indi-
“restorative auxiliary”, “surgery components” and “miscellaneous” (which
includes maxillofacial surgical components).
Attention to detail
The production process typically
takes around five weeks, unless an-
“I have used the custom device workshop at Nobel
Biocare for many years to provide me and
my patients with bespoke parts to solve large and
small problems alike.”
— Dr. Andrew Dawood, London, United Kingdom
tions, Nobel Biocare takes the responsibility of its heritage very seriously.
The experience and production
capability reflected in Dahlmo’s
department put the company in a
unique position to support clinicians
worldwide in their efforts to improve
their patients’ quality of life.
In addition to simply recreating
discontinued products, Nobel Biocare can further cater to needs beyond its core assortment.
In many circumstances, clinical
indications may be so complex that
only sophisticated custom-made solutions are the right answer. <
There’s more to this story!
For a longer version of this article,
vidually designed products for doctors to have in stock for similar indications. There are no catalogs, nor
are there any product lists.
While each item is reviewed by the
Nobel Biocare regulatory department,
custom devices are not CE marked as
they are intended for specific patients
and not for a general market release.
For regulatory reasons, an order is
based on a prescription filled out for a
named patient only.
Each device is classified into one
of  product categories, under the
headings of “abutment components”,
other timeline is decided upon. Each
case that comes in requires great attention to detail and must be assessed individually according to
Karin Dahlmo, who manages the
Custom Devices and Replacement
Parts department at Nobel Biocare in
Gothenburg, Sweden. “We must look
closely at all the circumstances of
each case. Decisions are made based
upon medical, legal and regulatory
requirements.”
As the founder of modern implant
dentistry, with more than  years at
the forefront of implant-based restora-
please continue the story in our
enhanced digital edition at:
nobelbiocare.com/newsletter
Is a custom-made
device the right
solution for your
patient?
First contact your
Nobel Biocare sales
office to decide whether
a custom-made device
is required. If yes, fill in
the online prescription
form and follow the
instructions on how to
proceed at:
nobelbiocare.com/
custom
Unique service for unique circumstances. Nobel Biocare
customized devices can solve those difficult, one-time surgical and
prosthetic challenges for you and your patient.
The Freedom to Choose and an Upgrade, too
NobelClinician™ – for the Mac®, for Windows®, for you!
Think of diagnostics and
treatment planning software
and your first association is
probably “Windows!” No need
for that any longer. Nobel
Biocare gives you choices.
By Jim Mack
N
obelClinician Software is now
available for both Mac and
Windows, and for the first time in
the dental industry, clinicians can
decide which platform is best for
them. With an increasing number of
dental professionals moving towards
Apple products, that’s a very nice
choice to have.
“The look and feel of a treatment
planning software is very important
as it is often used to explain the treatment directly to the patient,” says Dr.
Pascal Kunz, who leads the guided
NobelClinician Software
version 1.5 is now available
as an upgrade for current
users or for purchase as new.
See more: Streak artifacts are gone and tooth roots are now shown in 3D.
surgery solutions team at Nobel Biocare. “A clinician using a software like
NobelClinician projects a modern
image which can help build up additional confidence with the patient
that this is the most favorable treatment for him or her.”
Making a good impression
Nothing says “cutting edge” like demonstrating a treatment plan to a patient on a sleek-looking MacBook
Pro, but it’s important to note that the
software has the same look and feel
on Windows as well. On either OS,
NobelClinician allows you to easily
and impressively move between
workspaces and display both the
thought and process behind the plan.
This provides the assurance a patient
needs in order to select a safer, more
predictable solution. <
There’s more to this story!
Please continue reading in our
enhanced digital edition at:
nobelbiocare.com/newsletter
H
ere’s some good news: opening
up for other implant systems,
NobelClinician v. includes Straumann® implants fully integrated into
the system for planning for the first
time.
What’s more, reports in the new
version contain more clinical information than ever before. The OPG
cross-sectional X-ray views are included for each implant planned. You
can create reports automatically in
just a few seconds and use them with
both free-hand and guided surgery.
One of the things users asked most
for in this version of NobelClinician
was the removal of streak artifacts in
the D model. Caused by metal fillings in remaining teeth, these artifacts are now history, leaving a clean
D bone model that makes for faster
planning, good-looking lecture pictures and easier-to-understand patient presentations.
In version ., tooth roots can now
be visualized in the D scene. This
feature makes it easier to ensure than
implants won’t collide with natural
roots.
NobelClinician now even provides
an option to simulate tooth extraction in the D scene so the extraction
socket can be visualized.
New clinical warnings have also
been added. You will now get a planning warning when an implant is
either too close to a nerve or a root,
which makes it easier to complete a
plan. Minimum distances to trigger
the warning—you’ll be glad to
know—are customizable. <
Issue 1/2012
7
Nobel Biocare NEWS
Cross-border Cooperation Solves Case
Solution for gunshot victim made possible by custom-made devices and 3D software from Nobel Biocare
Reconstruction of 3D defects
in the anterior maxilla are
challenging in terms of both
restored function and
esthetics. The Chairman of the
Department of Oral & Maxillofacial Surgery at Umeå
University in Sweden sends us
the following treatment report.
By Professor Stefan Lundgren
A
-year-old female was
wounded by a gunshot during a robbery in a store. The
 mm bullet, fired from the distance
of a few meters, resulted in a significant D-defect in the left upper lip
and maxilla. The bullet penetrated
the throat and was stopped by the
cervical vertebrae a few mm from the
spinal cord. The -year-old Estonian
female was seen in a consultation visit
in Tallin by Dr. Juha Peltola, an oral &
maxillofacial surgeon in private practice in Helsinki, who referred the patient for treatment planning—and if
possible, treatment—to the Department of Oral & Maxillofacial Surgery,
Umeå University Hospital.
The initial treatment planning was
done by Dr. Peltola together with me
and Dr. Hans Nilson, the planned restorative dentist from the Department of Prostetic Dentistry at Umeå.
The first step was a contact with
Nobel Biocare to help with the funding of travel expenses, laboratory
costs and components. Financial negotiatons were carried out with the
University Hospital and The Dental
Fig. 1. Patient with a significant defect in the left maxilla. The patient was
injured from a gun shot.
School in order for us to be able to
complete the planned treatment at no
cost to the patient, who was unable to
otherwise finance it.
Bone graft first
Under general anesthesia, a bone
graft was harvested from the anterior
left iliac crest and placed in the defect
in order to provide good bone architecture for the later placement of implants.
Three months later, a CT with a radiological guide was performed in
Helsinki and the implant placement
was virtually planned with NobelGuide treatment planning software
in collaboration with Matts Andersson and Andreas Pettersson at the
Nobel Biocare office in Gothenburg.
We placed the implants in the office of Dr. Peltola in Salora, Finland,
with help from the surgical guide derived from the preoperative NobelGuide planning. At this point, the
implants were placed in good bone,
with a nice bone architecture, yet
remote from the planned bridge!
Placement of the implants—as well
as the planned final navigation of the
anterior maxillary segment, including
the grafted bone and the three implants—was all performed in the virtual D environment. The implants
were allowed to heal for two months
before the distraction surgery was initiated. The external distraction device
was custom-designed by the Department of Early Development, Nobel
Biocare in Gothenburg.
A distraction device
Fig. 2. Predominantly cortical bone
graft was harvested from the iliac
crest, seen here in place in the
defect for a 3D reconstruction of
the bone that will later host three
implants.
Fig. 5. Segmental anterior maxillary
osteotomy with the bone block
including the three implants. A
custom-designed distraction device
acted also as a temporary bridge
during active distraction and the
consolidation period.
Fig. 3. Implants, placed with the
aid of the NobelGuide concept.
Fig. 4. Virtual computerized
planning showing the three planned
implants in correct interrelated
positions, but in a remote site.
The custom designed distraction device was divided in two parts. A small
Procera bridge connected the three
implants in order to create a system
of two rods which were parallel and
in the direction of the planned vector.
The second part of the distraction
device was incorporated in the temporary bridge, which was retained
with temporary cement, as a splint,
on the posterior dentition.
The third surgical phase was performed in Umeå under local anesthesia and I.V. sedation. The anterior
maxillary segment was osteotomized
and the bone segment, including the
three implants, was mobilized. Then
the different parts of the distraction
device were assembled, the temporary bridge was cemented to the posterior maxillary teeth, and the surgical wound was closed with sutures.
The patient went home to Tallinn
the day after surgery and the active
distraction was started ten days after
Fig. 6. Left: Before the treatment. Right: After completed bone grafting,
implant insertion and distraction osteotomy.
Fig. 7. Permanent zirconium/ceramic bridge in place.
Fig. 8. Bridge delivery followed by lip correction.
the surgical intervention. The active
distraction over ten days was assisted
by the patient’s dentist in Tallin and
was followed by two months of consolidation before the distraction device was removed, and the patient
could receive a temporary bridge in
Tallin.
Then the patient came to Umeå for
the processing of the final bridge,
which was temporarily provided.
After another few weeks, she returned again for the final adjustment
of the bridge. After delivery of the
corrected bridge we did the final surgical correction of the upper lip.
requires treatment planning performed in a virtual D environment.
The sequence of treatment provides a
number of benefits.
The distraction device, retained by
the implants, can be removed in a
noninvasive way as the device is extra-mucosally positioned. The distraction technique increases not only
bone tissue but also mucosal volume.
With the correct technique, the
width of the keratinized mucosa can
be increased both on the newly
formed alveolar process and around
the implants. <
Note on technique
Breine U, Brånemark P-I.
According to this treatment protocol,
we place the implants in the bone
graft to allow optimal placement in
the bone regardless of the final implant position. If the implants are
correctly positioned in relation to
each other, the bone segment (including the implants) can later be
transported to the final correct position for the temporary bridge. This
“Reconstruction of alveolar jaw
More to explore:
bone.” Scand J Plast Reconstr Surg
1980: 14: 23–48.
Lundgren S, Sennerby L (eds).
Bone Reformation: Contemporary
Bone Augmentation Procedures in
Oral and Maxillofacial Implant
Surgery. Quintessence, Berlin, 2008.
8
Nobel Biocare NEWS
Issue 1/2012
TiUnite – A Unique Biomaterial
®
A remarkable set of images displays the process of osseointegration as it’s never been revealed before.
Implant surface properties
are of key importance for
initial tissue interactions, the
acceleration of bone healing
and osseointegration. TiUnite
is titanium oxide rendered
into an osteoconductive
biomaterial through spark
anodization. New insights
explain how TiUnite interacts
with tissue and why it
remains the osteoconductive
surface of choice.
By Drs. Peter Schüpbach
and Roland Glauser
N
obel Biocare first introduced
TiUnite to the market in
 on its Brånemark System implants, and then applied it
to Replace Select in . Today,
TiUnite is available on all Nobel
Biocare implants, including those
with machined collars.
Unlike implants with machined
surfaces, TiUnite has clinically demonstrated the ability to increase the
predictability and speed at which
dental implants osseointegrate
through osteoconductive bone formation (Glauser et al, ).
TiUnite is formed by spark anodization in an electrolytic solution
containing phosphoric acid. This results in a thickened titanium oxide
layer (up to  microns) and a moderately rough porous surface topography (Ra .). TiUnite contains anatase and rutile, the most important
Platelet activation: Immediately following implant insertion, blood proteins and platelets are attracted by the negatively charged TiUnite surface.
The activated platelets form pseudopodia and clump together to form aggregates.
titanium oxides, and is thereby a
highly crystalline biomaterial. Studies have also shown the presence of
phosphorus in the oxide layer (Lausmaa & Hall, ; Schüpbach et al,
). Thus, TiUnite may have both
a topography-related as well as a
chemistry-related effect on osseointegration.
This article explains how TiUnite
interacts with living tissue and accelerates wound healing.
S&E
Safety and Efficacy
An inevitable chronology
Wound healing comprises a cascade
of events that the body brings into
play to resolve injury. Nature’s first
priorities are to stop bleeding, restore function and to prevent infection. Generally, the wound-healing
events are grouped into four phases:
hemostasis, inflammatory, proliferative/repair, and remodeling.
Hemostasis (0 to 10 minutes
following implant placement)
TiUnite shows its strength already at
the time of placement of an implant:
Within seconds, blood proteins and
platelets are attracted to the negatively charged TiUnite surface and
become immediately activated.
This first step is crucial for the
wound healing. Their activation is
followed by the release of growth
factors, such as platelet-derived
growth factor (PDGF) and transforming growth factor beta (TGF-b).
These factors play a crucial role in
the regulation of the wound-healing
cascade (Park JY et al, ; Marx
RE, ). During the first ten minutes, fibrin—the reaction product of
thrombin and fibrinogen—will be
released at the wound site.
The resulting stabilized blood clot
reveals improved adherence to the
moderately rough TiUnite surface
when compared to smooth surface
implants.
Day 1 to 2
The inflammatory phase
The inflammatory phase begins
minutes following the implant insertion and continues for approximately two days.
Neutrophils are the first cells attracted by chemical signals released
by the platelets, followed by macrophages. Both cell types will phagocytize small bone debris. The fibrin
will be broken down by the enzyme
plasmin and the debris will also be
removed by the leukocytes. Fibrinolysis starts already during hemostasis but is slower and thereby contributes to its regulation.
The breakdown of the fibrin clot
creates the room in the wound site
needed for the invasion of fibroblast
and thereby the forming of the provisional matrix (Schüpbach et al, in
preparation).
Day 3 to 5
The proliferative/repair phase
The proliferative phase is characterized by granulation tissue formation, angiogenesis, collagen deposition, and wound contraction. In
granulation tissue formation, fibroblasts invade the wound and form a
more on following page
Hemostasis: Blood clot formation will be accomplished by the formation of the fibrin matrix. Activated platelets (arrows) become embedded in the matrix. Eventually, the platelets start to release
granules containing full batteries of enzymes and growth factors needed for the wound healing.
Issue 1/2012
Nobel Biocare NEWS
9
Recent Findings
TiUnite® 10-year, Immediate Loading
Early wound healing: The fibrin matrix will be broken down by the enzyme plasmin and their debris will be
removed by neutrophils (green, left) and later macrophages. The healing site will be invaded by fibroblasts and the
blood clot replaced by the provisional extracellular matrix. Eventually, osteogenic cells (red arrows) stream to the
implant surface. Once they reach it, they migrate by active locomotion using their pseudopodia and the open pores
as attachment points (yellow arrow) to the front of bone formation.
Already available as an ePub ahead of publication, an
article in “Clinical Implant Dentistry and Related Research”
documents the 10-year outcome of immediately loaded
implants with the TiUnite surface.
“10-Year Follow-Up of Immediately Loaded Implants with TiUnite
Porous Anodized Surface,“ by Drs. Marco Degidi, Diego Nardi and
Adriano Piattelli reports on a prospective study the authors carried out
to assess the 10-year performance of TiUnite implants supporting
fixed prostheses placed with an immediate loading approach in both
postextractive and healed sites.
All the patients in this study received a fixed provisional restoration
supported by parallel design, self-tapping implants with a TiUnite surface, and an external hexagonal connection.
Success and survival rate for restorations and implants, changes in
marginal peri-implant bone level, probing depth measurements, biological or technical complications, and any other adverse event were
recorded at yearly follow-ups.
The implants placed in healed and post-extractive sites, respectively,
achieved a 98.05% and a 96.52% cumulative survival rate and the
authors conclude that positive results—in terms of bone maintenance
in the long-term perspective—are to be expected using immediately
Osteoconductive bone formation: Human histology six months following insertion shows bone anchored in the
TiUnite pores (left). In extraction sockets, newly formed bone crosses the gap between local bone (LB) and the
implant surface by distance osteogenesis (middle, yellow arrow). As soon as the implant surface is reached, new
bone spreads over the surface by contact osteogenesis (middle, red arrow) characterized by woven bone deposited
directly on and along the surface (right).
from the previous page
provisional extracellular matrix
(ECM) by secreting collagen and
fibronectin. In angiogenesis, new
blood vessels are formed by vascular
endothelial cells. In contraction, the
wound is made smaller by the action
of myofibroblasts, which establish a
grip on the wound edges and contract themselves.
Now the benefit of the TiUnite
topography comes into play as the
moderately rough surface diminishes the ECM retraction from the surface—when compared to smooth
surfaces—and inhibits its retraction
from the surface. This is a prerequisite for osteoconductive bone formation as osteogenic cells, again attracted by the chemical signals of the
platelets, may reach the surface only
if the ECM remains attached.
Day 5 to 7 – Osteoconductive
bone formation
Once the osteogenic cells have
reached the TiUnite surface, they migrate to the front of bone formation,
i.e. where wound edges of the local
bone of the osteotomy are in contact
with the implant surface or where
bone newly formed by distance osteogenesis already has reached the
surface. At the front of bone formation they will become differentiated
to osteoblasts. The latter will form
the bone collagenous bone matrix,
which eventually becomes mineralized, and woven bone is formed.
The strength of TiUnite in this
phase of the wound healing is obvious: the porous surface is an ideal
substrate for the migration of osteogenic cells along the surface (Schüpbach et al, ) and the surface
properties (with Ra <  μm and Rm
Conclusions
Taken together, the unique TiUnite
properties allow teamplay between
topography-related as well as chemistry-related factors to accelerate
osseointegration.
Therefore, it’s not surprising that a
variety of animal and human studies
have demonstrated enhanced osseointegration, both in terms of speed
loaded implants with a TiUnite surface in both post-extractive
and healed sites when adequate levels of oral hygiene are maintained.
www.nobelbiocare.com/tiunite-10-year-abstract
7-year TiUnite® Overdenture Study
Also available as an ePub, another study to be published in
“Clinical Implant Dentistry and Related Research” follows
up seven years of experience with the implant-supported
mandibular overdentures that have become a popular
treatment alternative for edentulous patients desiring
increased retention of complete dentures.
“Seven-year Follow-up Results of TiUnite Implants Supporting Mandib-
“The TiUnite surface has improved our results,
especially in grafted bone and in bone of low
density. It has, without question, significantly
reduced our early failure rate as well.”
— Professor Bertil Friberg, Sweden
ular Overdentures: Early versus Delayed Loading,” by Drs. Ilser Turkyilmaz, Tolga F. Tozum, Dana M. Fuhrmann and Celal Tumer, evaluates
and presents treatment outcomes of mandibular overdentures retained
by two unsplinted, early-loaded implants and compares these results
with those for delayed-loaded implants.
No implant was lost in this clinical trial, and the results show that
there is no significant difference in the clinical and radiographic
outcomes of patients treated with mandibular overdentures supported
by TiUnite implants that are either early or delayed loaded.
>  μm) are optimal for the differentiation of stem cells into osteogenic
cells (Schwartz et al, ). According to these characteristics, TiUnite is
highly osteoconductive and new bone
formation occurs rapidly and directly
on and along the implant surface.
Moreover, the osteoblasts, being
polarized cells, secrete collagen matrix only perpendicularly to the surface—and thereby directly into the
open TiUnite pores (Schüpbach et al,
). A kinetic study about early
bone formation with TiUnite showed
initial bone formation and its direct
anchorage already around day ,
thereby maintaining the primary stability (Schüpbach et al, in prep.).
and amount of bone-to-implant
contact on par with that of hydroxyapatite surfaces, which many still
consider the gold standard for osteoconductivity (Zechner et al, ).
From a clinical perspective, TiUnite has enabled the predictable application of very short implants and
implants placed in very demanding
bone conditions. Moreover, TiUnite
has both reduced the healing time
necessary before functional implant
loading can take place, and lifted immediate function solutions to a very
high and very reliable level of success
(Glauser ). <
www.nobelbiocare.com/overdenture-abstract
Over 11 million TiUnite® Implants
Sold to Date!
Scientific studies on TiUnite have demonstrated over and
over again this surface’s ability to increase the predictability and speed of dental implant osseointegration. Help
us celebrate a decade of success by reading all about it:
More to explore:
nobelbiocare.com/resources
10
Nobel Biocare NEWS
Issue 1/2012
Statistics can be Deceiving
Be forewarned: Everyone has an axe to grind, a point to prove, or a product to sell.
Tables instead of graphs?
Presentations of results and conclusions are often based on statistical
analyses. Their reliability depends
not only on the quality and the manner of presentation, but their interpretation by the reader as well. Interpretation varies depending on the
background of the reader and how
the material is presented.
It is crucial for the reader to be
critical. Many questions need to be
asked. A few examples: Is it reasonable to draw the conclusions being
presented from the figures available?
Is it reasonable to talk about -year
results when only  of  subjects
in a study have attended the -year
checkup? What is the objective of the
report? Who may profit from the results?
Diagrams can be used when presenting material. They can provide
the reader, i.e. the interpreter, with
both numerical and visual information, but it is important to understand that such visual information
can easily be manipulated by simple
modifications of the diagram.
Data can also be presented in tables.
Good tables must be easy to read and
easy to interpret; otherwise the reader will easily lose interest. Some tables are so detailed that it is impossible to determine which are the
important parts of the table. Identifying the columns in the table by letters or abbreviations can also make it
more difficult to interpret.
When comparing different groups
within a population or when comparing different populations, the
manner in which the groups/populations have been selected should be
described as well as their respective
size(s).
For example, the number of failed
fixtures is of interest only if you
know the total number of fixtures
in the specific groups/population.
When comparing different groups,
it is necessary to mention both the
total number and the number of the
compared sub-groups.
Cut-offs exaggerate
A diagram axis can be “cut off ” to
produce more dramatic differences.
Lifetable
A lifetable includes both actual and
relative numbers (results) and can
be appropriately used to present the
results of a long-term follow-up
study (see figure ), and the long-
95%
40%
94%
20%
93%
b
95
93
c
a
b
c
Figure 1: Two diagrams that describe the same result. The frequency axis
has been “cut off” to exaggerate the percentage differences.
Lasting impressions
10
10
8
8
6
6
4
4
2
2
a
b
c
d
a
b
c
d
Figure 2: Broader bars make differences in a bar chart appear less
dramatic.
60
5
Quality and format
S
60%
a
97
96%
50
4
tatistics make it possible to
organize material for systematic analysis and can be used
to present findings as clear, objective
figures instead of vague, subjective
words (the most common of them
being: “a few” and “usually”). There
is quite a difference between saying:
“He usually does well at competitions” and “Three times out of ,
he has done well at competitions.”
“Usually” means different things to
different people. Statistics serve well
to define the relationship between
any two variables.
By using broader bars in a bar graph,
the differences between different
bars will appear less dramatic.
Broader bars look shorter than thin
ones as can be seen in figure .
Another way of changing the visual impression of a bar chart is to
change the axes so the frequency is
represented along the horizontal axis
(x-axis) instead of the vertical axis
(y-axis) as can be seen in figure .
The vertical axis should, whenever
possible, be the frequency axis because a horizontal frequency axis
makes the differences in the chart
appear to be smaller.
80%
40
30
3
To give the reader an impression of
dramatically decreasing numbers of
failed fixtures, the author can choose
to show only the numbers of failed
fixtures during successive time periods (see figure A). This obscures for
the reader the fact that the number
of controlled implants during the periods in question has decreased successively at the same time (see figure
B) and that the success rate figures
hardly vary at all from one time period to the next (see figure C).
In order to give the reader an overall picture when presenting the results of a comparison, it is important
to carefully state what actually has
been compared. The size of the comparative groups should be stated; not
the results of the comparison alone.
The objective of the investigation
and the method of investigation
ought to be declared. It is also important to spell out the plan of investigation for the reader.
The loss of subjects due to dropout, infirmity or death is a difficulty
faced in most clinical trials. The effects can be far-reaching. Suppose
the objective of a study is to resolve
the proportion of  implanted
fixtures that survive  years after the
operation. If data is only collected on
 of the fixtures and  of the 
have failed, the failure rate may appear to be  percent but, if the other
 have failed, it means that  percent is a more reasonable figure. On
the other hand, if the  uncontrolled fixtures are all survivals it
means that only  percent have actually failed.
In some cases, figures must be
rounded off. If the result is presented
with figures that show “great precision” (i.e. use many decimals) it
looks as if the result is much more
exact than the size of the sample may
justify.
An article can look trustworthy if
numerous statistical analyses are
97%
97
95
93
20
2
Optical illusions
100%
10
Group
1
2
3
4
5
1
term final results can be forecast
with a lifetable even if the study is
not yet completed. Nonetheless, it is
important to be aware that more
than  percent of the initial group
must remain in the study (including
any failed fixtures) to draw any reliable conclusions. The reader will
find it difficult to interpret the results if only one part of the lifetable
is presented, especially if only the
cumulative success rates (CSR) are
presented.
Group
By Christina Bergström
If it is the intention of the author to
exaggerate the differences between
narrow range values (%, % and
%, for example) a diagram axis can
be “cut off ” as seen in figure .
Proportions are lost with a “cutoff ”, that is, the correct proportions
of the data cannot be seen. Instead of
giving each single unit equal space,
only a specific part of the table has
been presented in figure . If a cut-off
of the axis is necessary to make a
point, the cut-off should be clearly
marked to aid in interpretation.
No. of failed implants
No matter where we turn
today, we find statistics all
around us. In this classic, yet
still up-to-date Nobelpharma
News report, one of Ulf
Lekholm’s co-authors, and a
statistical expert in her own
right, explains how figures
are used to tell a story—or
sometimes to exaggerate
one. Depending on how they
are presented, statistics can
be reliable or misleading.
10 20 30 40 50 60
No. of
failed implants
Figure 3: A change in axis gives a different impression.
Time
period
No. of
inserted/
controlled
implants
No. of
failed
implants
No. of
withdrawn
implants
Success
rate
Cumulative success rate
(CSR)
0–1 year
1000
16
85
98.4%
98.4%
1–2 years
700
8
49
98.9%
97.3%
2–3 years
550
5
45
99.1%
96.4%
3–4 years
250
3
55
98.8%
95.2%
4–5 years
100
1
31
99.0%
94.3%
5 years
12
Figure 4: A lifetable.
used to demonstrate the results. This
gives the reader the impression that
the study encompasses well-controlled material and does not need to
be brought into question.
Nonetheless, statistical analyses
can be deceptive. It is quite possible
that the reader is not familiar with
the methodology used and that the
analyses therefore do not provide
any comprehensible information. If
that is the case, then the statistical
analyses used are of little value. Once
again, it is the duty of the author to
make sure that the article can be understood by the vast majority of
those for whom it has been written.
Correlation
Many statistical analyses are carried
out to examine the relation between
two variables (within a single group
of subjects) in order to assess whether or not the two variables are associated. One may conclude a relation-
more on following page
11
Nobel Biocare NEWS
Issue 1/2012
Research Put into Practice
Know your implant procedures: the use of torque drivers and implant screws
Implant screws are deceptively simple and exquisitely
intricate at the same time.
By Dr. Chandur Wadhwani
I
2
3
A.
4
5
6
Year
2
3
B.
4
100
250
5
6
Year
Rule number 4
Int Journ Oral Maxillofac Implants.
Re-use of screws: Limit the number
of times the screw is tightened and
loosened. Each time this is done, the
subsequent force needed to undo the
screw is reduced.
This affects both the screw and the
implant to such a degree that after six
tightening/loosening events—even if
a new screw is used—it does not improve the fastening properties of the
joint. As a general rule, only tighten/
loosen the screw a maximum of five
times. <
2008.
Jaarda M. et al. “Comparison of
‘look-alike’ implant retaining
screws.” J Prosthod. 1995.
Pai and Hess. “Experimental
study of loosening of threaded
fasteners due to dynamic shear
loads.” Journal Sound and Vibration. 2002.
McCracken M. et al. “Variability
of mechanical torque-limiting
devices in clinical service at a US
dental school.” Int J Prosthodont.
2009.
Weiss et al. “Effect of repeated
closures on opening torque values
More to explore:
Theoharidou et al. “Abutment
in seven abutment-implant sys-
screw loosening in single-implant
tems.” Journal Prosthet Dent.
restorations – a systemic review.”
2000.
Precision-milled Abutments
For Major Implant Systems
50%
550
1
Suvival rate
1
100%
Use as directed. If the manufacturer
states a given torque, the screw has
been designed and tested to that
value. Using a lower or higher torque
than prescribed will result in unpredictable joint behavior.
Check that your torque wrench is
delivering the correct force required. A recent study showed after
repeated use some devices produce
forces far in excess of that needed,
some far less.
In general, it is recommended that
you choose the beam type (see the illustration) as it delivers more consistent force. If you have the toggle type
(not recommended) calibrate or replace your device yearly—ask Nobel
Biocare for details.
12
Year
Rule number 2
No. of controlled implants
10
No. of failed implants
20
Always use original Nobel Biocare
manufacturers components and
parts. “Compatible parts” may look
Tips and Techniques
Rule number 3
1000
Rule number 1
T&T
Use of lubricants, ointments and
medications affects the implant/
abutment joint, especially under vibration. It is not advised and may
lead to premature screw loosening.
700
A systemic review of abutment screw
loosening in single-implant restorations found that abutment screw
loosening is a rare event regardless of
the geometry of the implant abutment connection, provided that appropriate anti-rotation features exist
and proper torque is employed.
the same but cannot be guaranteed
to work the same. Even “compatible”
screws have different thread pitch
and patterns. Studies show that even
though they may look the same, they
do not work in the same way.
1000
The Science
A beam type torque wrench is the type recommended by the author because it delivers more consistent force than the toggle type.
500
mplant abutments are commonly
fixed to the implant using a screw.
Screw mechanics take advantage
of the metal structure that can be
stretched as the tightening process
occurs. Elongating the screw by
using the recommended torque setting turns the screw into a “spring”
that clamps the components together, improving the joint fixation more
than if the screw is simply tightened.
This produces a robust joint, capable of withstanding the rigors of the
oral environment during function.
But certain rules must be followed
in order to get the most out of this
joint.
1
2
3
C.
4
5
6
Figure 5: Three different ways to present the results of the figure 4 lifetable can be seen in the three diagrams here.
A: The number of failed implants during different years. B: The number of controlled implants during the same
years. C: The survival rate during the same years for the same fixtures.
from the previous page
ship between two variables if one
variable varies simultaneously with
another.
This is called a correlation; it implies no cause/effect relationship.
Although there may be a cause/effect relationship, even a third vari-
able could be the cause of both of
the observed changes.
When reading articles that include statistical analyses in medical
magazines or journals, in newspapers or the popular press—just to
name a few examples—the reader
has to be critical and look for the
figures that underlie the values
under study. If those figures cannot
be found, it is possible that the writer has consciously chosen to present
his or her results in a vague manner.
Be skeptical when you read and
you’ll get more out of the materials
you find interesting. <
Clinical screw with unique TorqTite surface included
NobelProcera™
nobelbiocare.com/nobelprocera
12
Nobel Biocare NEWS
Issue 1/2012
Excellent Initial Stability and
Perfect Esthetic Results
NobelActive™ is the most versatile choice for your implant dentistry practice.
Nobel Biocare. This patented, biocompatible surface has been scientifically proven both in the long and
short term to enhance osseointegration and increase the predictability of
implant treatment (Glauser, Zembic,
et al, ; and Glauser, Portmann, et
al, ).
Many prosthetic solutions
NobelActive now offers a new, true 3.0 mm
small-diameter implant for successful restorations in the anterior region where space is
limited and good esthetics essential.
A third-generation dental
implant, NobelActive has been
designed to meet the high
demands of dental implant
surgery and implant
prosthetics efficiently. Reliably
high initial stability for
immediate loading clearly sets
NobelActive apart from
conventional implant systems.
By Drs. Kai Klimek and Roberto Sleiter
W
ith its innovative thread
design, NobelActive condenses the bone during
insertion at every turn, which differentiates it from other self-tapping implants available on the market.
The expanding, tapered implant
body of NobelActive features a double-lead thread design, which also
contributes to the high initial stability characteristic of this implant.
The innovative implant tip allows
fine adjustments in implant orientation to be made during insertion to
optimize the final position of the implant in the bone, without jeopardiz-
ing initial stability. The implant
thread allows gradual atraumatic
narrow ridge expansion and was developed to attain high initial stability
even in compromised bone situations.
Furthermore, NobelActive has two
reverse-cutting flutes. Rotating the
implant by half-a-turn counterclockwise engages the cutting capability of
these flutes. The coronal region of
NobelActive is back-tapered and designed to maximize alveolar bone
volume around the implant collar for
improved soft tissue support.
These new attributes provide significant advantages for the subsequent prosthetic management and
facilitate co-operation between the
surgical and prosthetic teams.
Groovy™
Macroscopically visible surface
grooves not only promote, but also
accelerate new bone formation in
conjunction with the TiUnite surface
of this implant (Hall et al, ).
TiUnite is a highly crystalline and
phosphate-enriched titanium oxide
surface, available exclusively from
NobelActive has an internal conical
connection. The connection offers
the clinician the option of restoring
the tooth with a wide range of prefabricated prosthetics as well as with
NobelProcera.
Using NobelProcera, the implant
can be restored with a comprehensive
combination of prosthetic options
(e.g. with abutments made either of
zirconia or titanium), to assure the
best possible function and esthetics.
NobelProcera Abutments can be
designed with practically any angle,
taper, finish line, height, width and
cross-section to optimally adapt the
form, arch and axis of the prosthesis
to the peri-implant structures. Each
NobelProcera restoration is individually designed using state-of-the-art
D computer-aided design software
(CAD) and then milled from highstrength zirconia or titanium in a
computer-assisted manufacturing
(CAM) process.
properties of this implant. Nobel Biocare therefore strongly recommends
participating in a practical training
course before using NobelActive.
Science first and foremost
Nobel Biocare is currently conducting a number of multi-center
clinical trials to assess the success,
soft tissue maintenance and bone
remodeling of NobelActive implants
over time. One is a five-year,
randomized, controlled, prospective
study examining the NobelActive
implant in the anterior and posterior
regions of the maxilla and mandible,
and shows that NobelActive can be
used under the demanding treatment
conditions of immediate loading,
with stable bone and soft tissue levels
after two years in function. <
More to explore
To peruse the scientific literature
being accumulated on NobelActive,
visit nobelbiocare.com/resources.
For full references cited in this
article, please visit our enhanced
digital edition at: nobelbiocare.com/
newsletter
Initial situation using NobelActive NP 3.5 x 11.5:
36-year-old female patient in good overall health, non-smoker,
no parafunctional habits
Fig. 1. Extraction of the left upper
central incisor after fracture.
Fig. 2. 10 weeks post-extraction,
flapless insertion of a NobelActive NP
3.5 x 11.5 implant, delayed loading.
Fig. 3. The situation 20 weeks after
extraction.
Fig. 4. Treatment 20 weeks after
extraction, impression taking with
impression coping.
Fig. 5. Fitting of the NobelProcera
Zirconia Abutment.
Fig. 6. Fitting of the NobelProcera
Zirconia Abutment.
Fig. 7. Inserted NobelProcera
single zirconia crown left upper
central incisor, 1 week after
insertion.
Fig. 8. Inserted NobelProcera single
zirconia crown left upper central
incisor, 21 months after insertion.
Getting it right from the start
Product development at Nobel Biocare is based upon the principles
established by Professor Per-Ingvar
Brånemark, namely that all innovation should be based on sound scientific research and subjected to systematic clinical evaluation before
entering full-scale commercial distribution. That is why NobelActive
went through rigorous clinical trials,
eight months of clinical testing and
extensive technical study in the prelaunch phase. Dentists from every
corner of the globe participated in
the endeavor.
At the beginning of this eightmonth period, when over , implants were used, the clinicians received extensive training with regard
to the implant’s remarkable potential.
Experience gained from clinical use
and the subsequent feedback reports
confirmed the effectiveness of this
unique implant design.
The clinician’s response also confirmed how important previous
training was in order to make the
most of the novel and innovative
The photos in figures 1–8 courtesy of Roberto Sleiter (Switzerland).
Issue 1/2012
13
Nobel Biocare NEWS
NobelActive™ Expands its
Range of Components
A few words from the clinical perspective on Nobel Biocare responsiveness
The clinicians who use Nobel
Biocare products often
provide the feedback the
company needs to better
adapt its range of products to
clinical demands.
By Dr. Nik Sisodia
E
ver since its launch four years
ago, I have been using NobelActive. Because I have found that
the surgical versatility and conical
connection of this multi-purpose
implant are so good, I have switched
over to it completely.
I am now exclusively using
NobelActive for all cases and indications. Having a secure and strong
conical connection offers built-in
platform shifting and has meant
that I see crestal bone heights remaining stable to the top of the implant in many more cases than previously.
A pleasure to work with
Many of us who were using the
NobelActive implant early-on found
that—thanks to the new conical
connection—implants could now
be placed deeper when required.
Of course, this also meant that we
needed a range of prosthetic components that were taller in order to
make transmucosal healing possible.
As always, the people at the R&D
department of Nobel Biocare welcomed our queries, were openminded and explored the possibility.
I think it is safe to say that as a direct
result of clinical demand, Nobel
Biocare very quickly added a taller
 mm healing abutment to the
NobelActive range.
Without doubt, this new healing
abutment will make management of
the soft tissues far easier in those
cases where the implant is placed
deeper. For me, it is a very welcome
addition to the Nobel Biocare product portfolio. <
More to explore:
Check out all the NobelActive
components at:
nobelbiocare.com/healing
Restorative Flexibility
7 mm tall healing abutment to accommodate
sub-crestal placement and thick soft tissue.
Modified bridge components
– Healing abutment and impression coping
with natural emergence profile.
– Healing abutments in three heights for
restorative flexibility (3, 5 and 7 mm).
These new restorative components are for use with
both NobelActive and NobelReplace Conical Connection.
Immediate Loading of a Molar, Post-extraction
NobelActive™ – a solution for the restoration of both single- and multi-rooted teeth
Here is a case study of
implant placement immediately after a molar extraction
using NobelActive in
conjunction with immediate
temporary loading.
By Dr. Ira Schecter
T
his patient is a healthy, middleaged male with no medical preconditions and satisfactory oral hygiene.
Figure 1 illustrates a lower left
first molar that had a previous root
canal treatment and was obviously
failing. Retreatment endodontically
was deemed to be unpredictable at
best, and the treatment option selected was to extract the tooth and place
an immediate dental implant into the
socket site.
Figure 2 illustrates how the tooth
was extracted atraumatically, preserving as much of the surrounding
bone as possible. We chose a NobelActive dental implant because its
surgical protocol dictates minimal
osteotomy preparation and thus allowed me to utilize the available inter-septal bone between the two root
socket sites. The implant was submerged below the adjacent crestal
bone heights and was totally engaged
in host bone. No bone grafting was
carried out in the adjacent sockets as
we expected the sockets to fill-in via
the natural host healing process.
The implant was torque challenged to greater than  Ncm and
was tested for initial stability in the
host bone utilizing an Osstell Mentor
frequency resonator.
Figure 3. The implant passed all
tests for initial biomechanical stability, and an impression was taken at
the time of placement after suturing
the tissue.
Figure 4. An immediate acrylic
temporary restoration was made,
which was secured to the implant
and inserted  hours post-op.
Figures 5–7. The surrounding
bone was allowed to heal for a period
of six months and a new impression
was taken to index the healed tissue
around the temporary acrylic crown
restoration. A custom NobelProcera
Titanium Abutment was inserted
and torqued to  Ncm and then an
all ceramic NobelProcera Zirconia
Crown restoration was cemented on
top of the abutment, completely covering the metal underneath.
Fulfilling high expectations
Patients today want to be treated in
an efficient and expedient manner.
For years, we have been able to ex-
Fig. 1. The molar to be extracted.
Fig. 2. X-ray of Immediate
temporary.
Fig. 3. Immediate placement and
impression.
Fig. 4. Immediately loaded
temporary.
Fig. 5. Custom NobelProcera
Titanium Abutment.
Fig. 6. X-ray of NobelProcera
Titanium Abutment.
tract single-rooted teeth, place implants immediately into the socket
sites and immediately load the implants thanks to well-developed
protocols for such cases.
With the NobelActive implant, we
can now do the same in multi-rooted
teeth situations—and with very pre-
dictable long-term results, I believe—as long as we carefully follow
the surgical and implant placement
guidelines. <
More to explore:
nobelbiocare.com/nobelactive
Fig. 7. Permanent NobelProcera
Crown.
14
Nobel Biocare NEWS
Issue 1/2012
Micromotion and Dental Implants
A research update in two parts – with thought-provoking consequences for longevity
A well-known and oftenquoted pioneer in the field of
biomechanics—who not
incidentally holds the position
of Senior Research Engineer,
Division of Plastic & Reconstructive Surgery at Stanford
University in California—
sends us this report on the
state of the art.
By Professor John B. Brunski
M
ost clinicians already appreciate that it is beneficial
to insert dental implants
“tightly” (e.g., with adequate primary
stability) into a freshly-prepared
bone site. But how “tight” is tight?
What constitutes “adequate” primary
stability? And if an implant is somewhat “loose”, how does this looseness
relate to “micromotion”? Moreover,
why is the “tightness” vs. “looseness”
of an implant important from a mechanical and biological (i.e. biomechanical) standpoint?
Finding some answers starts with
two initial points.
Point 1
First, an implant that is not firmly
anchored in bone won’t be clinically
useful in a functional, load-bearing
sense when that implant is called
upon to support a prosthesis. This is
easy to see from a simple example
with six implants installed in a lower
jaw to support a typical full-arch
prosthesis that’s screwed or cemented onto all six implants (Figure a).
Suppose that two out of the six implants are not as “tightly” attached to
the surrounding bone as the other
four. (This situation around the two
implants could be caused by one or
both of the following problems: []
the bone around the implants was
quite porous and therefore much
more deformable, leading to a somewhat “soft” interface; [] the surgery
to install the implants might have
damaged more bone than normal,
also thereby leading to a “softer”, less
stiff interface.)
Now, we know from both measurements and calculations that when relatively “stiff ” implants exist in the
same distribution as “less stiff ” implants, then the stiffer implants end
up taking most of the load—effectively converting a six-implant situation (in this example) into a four-implant case (Figure b).
Overall, the general result is that
when a prosthesis is supported by
multiple dental implants, load-sharing among the implants depends on
the relative stiffness of the implants,
with “softer” (less stiff) implants taking less load than the “stiffer” implants. It follows that if one wants all
six implants to perform to their full
load-bearing capability, they should
all be equally well “fixed” (or “tight”)
in the bone.
Point 2
The second reason why “loose” implants are a problem stems from the
biological consequences of the associated “micromotion” at the bone-implant interface. The term “micromotion” refers to relative displacements
of a loaded implant with respect to
the surrounding interfacial bone.
A simple example of rather extreme micromotion is to imagine a
 mm diameter implant that’s loaded
after being placed into a . mm diameter hole; such an implant would
not be engaged with the bony walls of
the hole and would therefore not be
well-supported when any load is exerted on it; and as a result the implant
will tend to “wobble around”—i.e.,
experience micromotion—in the
hole.
But why is this micromotion a biological problem (besides the fact that
the implant would not function well
in load support)? The answer is that
many studies demonstrate that micromotion—if it is “excessive”—will
interfere with the biology of proper
interfacial bone healing. For example, some authors have proposed that
= All implants equally stiff
= Implants no. 1 & 6 less stiff
Vertical load
300
Estimated
neutral axis
of implants
Axial load (N)
200
100
0
–100
–200
–300
|
6
|
|
|
|
5
4
3
2
Implant number
|
1
Fig. 1a & 1b. Changes in the force distribution when implants no. 1 and 6
have about 10 to 20 times lower stiffness than implants 2–5.
THREAD
THREAD
Fig. 2a. Unstrained: Cells and fibrin
are intact and not damaged in any
way.
Used and modified from Marx, 2008, with permission.
“excessive” micromotion could be
anywhere from  to  µm (depending on the author), i.e., this
range of values represents the threshold beyond which there will be interference in bone healing.
However, it is also clear that this
threshold has not been established
very precisely or whether it even pertains to all the differently-shaped im-
R&D
Research and Development
plants that exist. Most significantly,
the search is still on for the underlying mechanism(s) by which micromotion interacts with the interfacial
biology to either negatively (as most
authors believe) or perhaps positively
(as at least some authors have suggested) influence interfacial reactions.
Searching for clarity
So, what is micromotion and how
might it operate at an interface? We
have been exploring the hypothesis
that implant micromotion produces
strain (deformation) in the interfacial
tissue, and that it is this strain in the
interfacial tissue—and not the implant micromotion per se—that is the
key factor in regulating the interfacial
biology of healing. So what’s involved
with this hypothesis and how do we
test it?
First, it is instructive to consider
some examples of the meaning of
strain and how implant micromotion
can create interfacial strain.
Strain is an engineering term related to deformation. When it comes to
strain in interfacial tissues, Figure 
depicts two highly magnified, idealized views of a bone-implant interface as it might look soon after implantation (e.g., seconds to a few
Fig. 2b. Strained: In this example,
implant threads move to the right,
compressing the cells and fibrin
against the bone.
hours). Figures a and b show the
“before” and “after” states of the interface following some amount of implant micromotion.
In this example, the micromotion
consists of a bodily displacement of
the implant threads to the right, toward the cut edge of the bone that
borders the interface. Figures a and
b also show a small gap between the
implant’s threads and the cut edge of
the bone, which is meant to depict
that at least in some regions of a typical interface, there is the possibility
that the threads of a freshly-installed
implant may not directly interdigitate
with bone of the site.
Figure a goes on to illustrate that,
early after surgery, such a small gap
between implant and cut bone will
ordinarily fill with a blood clot comprised of fibrin, red blood cells, platelets, growth factors, etc. Strain of the
interface comes about as we consider
the difference between the state of affairs in Figure a (which depicts the
implant threads before there has been
any micromotion of the implant relative to the cut surface of the bone)
and Figure b (after the threads of
the implant have been displaced
some distance to the right).
In comparing these two images, we
observe (Figure b) regions of deformation of the interface, e.g., regions
of compression, tension (stretching),
and shearing of the cells and fibrin in
the gap region. So at least qualitatively, what this example shows is the
idea that implant micromotion can
end up deforming (straining) the interfacial tissue.
So what? Before we answer that
question in the next issue of Nobel
Biocare News, a few more words on
strain. For one thing, the nature and
size (magnitude) of the interfacial
strain will depend on location in the
interfacial gap. That is, a comparison
of Figures a and b reveals that in
some regions there is compression
(“squeezing”) of the red blood cells
against the bone surface, while in
other regions there is mainly stretching (tension, “pulling”) of the yellowish fibrin fibers. A detailed quantitative engineering strain analysis at
discrete points in this image could be
done, but the key take-home messages connected with strain are these:
r "UBOZHJWFOiQPJOUuMPDBUJPO
JO
the interface, one can define a state
of strain—which is also called the
strain state at that point.
r 5IJT TUSBJO TUBUF JO UIF JOUFSGBDF
can depend on many factors—including the amount and direction
of the implant’s micromotion as
well as the implant’s shape and fit
in the drill hole, etc.
r 4USBJOBUBDFSUBJOQPJOUJOUIFJOterface can simultaneously involve
more than one type of strain at the
same spot, e.g., compression,
stretching, and shearing can all
exist simultaneously at the same
location in a material. (A common
example of this situation is during
the stretching of a common rubber
band: At any point in the middle of
the rubber band there is simultaneously tension or stretching along
the length dimension but also
compression in the width and
thickness directions.)
r *O FOHJOFFSJOH UFSNT UIF TUSBJO
state at a point is described by a
mathematical quantity known as
the strain tensor, a full explication
of which goes far beyond the scope
of this article, but one important
feature of the strain tensor is that it
allows us to compute the so-called
principal strains, which are the
largest and smallest magnitudes of
strain at the point of interest.
r -BTUMZBOZNBUFSJBMXJMMGBJMXIFO
the strains (which are related to the
stresses) become too large—a fact
that applies for both biological materials (such as bone and soft tissue) and man-made materials
(such as titanium). <
There’s more to this story!
Professor Brunski will return in the
next issue to answer the question,
“What are the biological
consequences of micromotion and
the associated interfacial strains?” If
you can’t wait until then, both
articles are available now in our
enhanced digital edition at:
nobelbiocare.com/newsletter
Issue 1/2012
15
Nobel Biocare NEWS
A Case in 12 Pictures
NobelProcera bars on four NobelReplace implants in the
mandible and six NobelReplace implants in the maxilla.
By Dr. Stefan Holst
Case history: A 73-year-old patient presented with a failing mandibular
restoration necessitating removal of the remaining teeth and atrophied
alveolar ridges in the edentulous maxilla. Due to extensive atrophy of
the alveolar ridges and the amount of hard and soft tissue missing, fixed
implant retained restorations were not an option.
The Best Marketing Tool
is a Satisfied Patient
Dr. Ronald Goldstein says that
meeting the patient on his or
her own terms is essential in
that crucial first conversation
about implants.
Is there any one best way to
explain implant procedures to the
patient?
Goldstein: No, it all depends on the patient. The most successful offices have
a good understanding of the psychological make-up of each patient. Initial insights from a treatment coordinator, dental hygienist, or even a
dental assistant should be taken into
consideration by the dentist.
Q&A
Questions and Answers
Dr. Ronald E. Goldstein, is a dentist from Atlanta, Georgia, USA, an active
speaker and a prolific writer of both consumer and academic literature on
the topics of esthetic dentistry and implants.
there. Practical benefits and the science that makes them possible should
always be a part of the conversation.
Comparison shoppers
If a satisfied patient referred the new
patient, he or she may just want to
get started with the treatment.
If, on the other hand, the new patient has approached you because of
your website, then you need to realize
that this patient has probably already
done a considerable amount of homework. I like to ask patients like these
what more they want to know and
then build the presentation from
Then there are the self-assured patients who already know—or think
they know—everything they need to
know about implants. They want to
compare you to others. Tell them
about your experience, any warranties you offer, and be specific about
finances. Chances are, your treatment plan will differ from other offices’ so be prepared with back-up
graphics and maybe even a video to
let them know why your plan is the
best choice.
Remember, every patient is different. Before having that first conversation about implants, gather input
from your staff about the patient’s interest, knowledge and motivation, and
then listen carefully to what the patient has to say. <
There’s more to this story!
Dr. Goldstein answers more
questions in our enhanced digital
edition at:
nobelbiocare.com/newsletter
“The best decision I ever made!”
Meet Pat, 69, who had her first implant 23 years ago.
By Pat Farrell
Treatment performed: Four implants were placed in the interforaminal area of the mandible and six
implants in the maxilla for bar retained fixed-removable restorations.
Case notes: The long-term success of an implant-retained restoration depends to a great extent on
the accurate and precise fit of a
superstructure, biocompatibility of materials selected and easy hygiene
maintenance for the patient. If a patient’s manual skills are impaired or
significant amounts of hard and soft tissue need to be replaced by prosthetic means, a fixed-removable overdenture is both a well-accepted
and excellent treatment option, allowing for simple and easy handling.
The CAD/CAM design of the NobelProcera Implant Bars Overdenture
and the final restorations were made by DentalX, Munich, Germany.
I
feel very lucky, when I look at my
friends who are around my age.
They are mostly over seventy. Struggling with loose dentures, afraid to
socialize because they cannot smile
or chew properly—I knew early on
in my life, that I never wanted to experience that.
I always had problems with my
teeth and oral health in general. I remember a time when I wasn’t comfortable to smile or open my
mouth—which is difficult when you
are a teacher. You are always in front
of people, and obviously you serve
as an example to others. I needed to
be confident in my job. My dentist
was a real life-saver. I suppose you
could describe him as a pioneer,
since he placed my first implant
over twenty-three years ago!
Since then, I have had a further
fourteen placed, and I have never
regretted it. My teeth feel like my
own—so secure, that I know I never
have to worry about them ever
again. I socialize a lot, and love my
foods. I play golf, and meet my
friends—and when I spot someone
with an old-fashioned denture, I feel
so lucky. Getting implants is the best
decision I have ever made! <
Nobel Biocare NEWS
Celebrating the Triumph
of Osseointegration
Revolutionary breakthroughs – 30 and 60 years on
This year, scientific symposia
will mark the dual anniversaries of the advent and
acknowledgement of osseointegration.
I
Prof. George Zarb at this year’s first Nobel Biocare Symposium.
Pioneers from the heady days of
the Toronto Conference of , such
as George Zarb and Ragnar Adell,
were honored and other speakers reminded participants of how far PerIngvar Brånemark, Nobel Biocare and
their band of supporters have brought
osseointegration since those days of
breakthrough  and  years ago.
Eyes on the horizon
The programs of all five of the remaining Nobel Biocare Symposia
 will celebrate the origins and
evolution of osseointegration as a
practical and trusted treatment modality over the last six decades.
Each program will also include lectures on recent advances in treatment, presented from surgical, prosthetic and laboratory perspectives.
Europe and Russia
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300 Years of Experience
Take 300 Years to Gain
World-renowned experts
are the voice of experience today
Despite their small numbers,
members of the Associated
Brånemark Osseointegration
Centers represent an enormous amount of cumulative
experience in the field of
osseointegration.
by Frederic Love
n , Per-Ingvar Brånemark discovered the principles of osseointegration in Sweden. Thirty years later,
in , the discovery was acknowledged, and his subsequent findings
confirmed, at an epoch-making
meeting of dental authorities organized by George Zarb in Canada. Yet
another thirty years have now passed,
and Nobel Biocare is celebrating both
these - and -year anniversaries in
Sweden, Canada, and four other locations, too.
Starting the year-long celebration
in the hometown of osseointegration—Brånemark’s Gothenburg—
Nobel Biocare brought together some
of the best-known names in the field
on March –. The event began
with a surprise entrance from Brånemark himself who delivered advice
and thoughts for the future. Ulf Lekholm then led experts not only from
Scandinavia, but the far corners of the
world, as they exchanged ideas and
discussed promising areas for further
exploration at this meeting.
Issue 1/2012
Speakers will look towards the future
as well, presenting current trends and
possible future developments for
bone-anchored restorative dentistry.
Under the common theme, “Celebrating  years of osseointegration
and  years of international acknowledgement,” meetings will be
held in Avignon, France (June -),
Odessa, Ukraine (June –), Hamburg, Germany (June –) and Rimini, Italy (October –), with the
final symposium planned for Toronto, Canada (October –) where
the international breakthrough for
osseointegration first took place. <
Mark your calendar now!
For further information—or to
register online—please go to:
nobelbiocare.com/symposia2012
R
ecently, a small group of osseointegration pioneers, all of them
representatives of the Associated
Brånemark Osseointegration Centers
(ABOC), gathered in Gothenburg,
Sweden, for the organization’s annual
meeting.
Among the well-known names
in attendance were Drs. Per-Ingvar
Brånemark, James Chow, Remesh
Chowdhary, Edward Hui, Yataro
Komiyama, Ulf Lekholm, Ulf Nannmark, Patrick Palacci, Laércio Vasconselos, Mats Wikström, William
Becker and Lars Sennerby.
Together, this small band of implant experts has accumulated more
than  years of experience of implant treatment ad modum Brånemark.
In their discussions, one of the
participants, Patrick Palacci, pointed
out that “less is more” has always
been the central philosophy behind
the very successful original protocol
itself—and its further development.
“By respecting Mother Nature,” he
said, “continuous development of
simpler and safer techniques has
been going on ever since the first
patient was treated.”
Yataro Komiyama added, “To provide predictable long-term prognoses
for patients, we should reevaluate the
past and respect living tissues. The
living tissue is wiser than the human
being.”
According to Palacci, the members
of the global ABOC network undertake to improve existing diagnostic,
surgical and restorative techniques,
and to spread awareness and knowledge of osseointegration.
At the Gothenburg meeting, the
group underlined the central importance of the team approach to successful outcomes, and in a formal statement prepared for publication in
Clinical Implant Dentistry and Related
Research, they also wrote that the
“prerequisites for a successful longterm implant treatment outcome include good patient selection, adequate
evaluation and correct diagnosis,
careful planning, suitable techniques,
and regular maintenance.” <
More to explore:
Read the entire reprint at
nobelbiocare.com/300-years
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