Living the Endless Summer - Nobel Biocare News

Nobel Biocare NEWSInformation for the Osseointegration Specialist Issue 1/2012Designingfor LifeBy Richard Laube, CEOL i v i n g t h e E n d l e s s S u m m e rNobel Biocare implant-based solutions provide longevity and exceptional quality of life.Implants from Nobel Biocareprovide the foundation for athird dentition that can lastto the end of life.By Frederic LoveFor the past 50 years, dentists allover the world have made astrong case for the importanceof keeping one’s teeth. They havesuccessfully argued this case in boththe popular media and the dentaloffice alike.Maintaining good, healthy teethis certainly a worthy goal, but givencurrent demographic trends, keepingthem for a lifetime is not always possible,despite the impressive achievementsof preventative dentistry andthe best efforts of the patient.Trauma, systemic disease and evennormal wear are just a few of the reasonsa tooth may begin to fail.Conscientious brushing, flossingand regular checkups may delay theadvent of serious problems, but thereis likely to come a day—well beforethe tooth falls out of the mouth on itsown—when replacement with abone-anchored solution from NobelBiocare will prove to be a prudent,positively life-changing decision forthe patient.After half a century of gradual discovery,the many benefits of osseointegratedimplants are now wellknown.Implants solve real,widespread problems.Not only do they provide stable,secure solutions that allow patientsto eat virtually anything they want,they preserve the patient’s facial appearanceand prevent bone loss,which provides enormous social andemotional benefits in addition to thepurely physiological ones.Longevity just makes senseWhat is less well-known is that implantsusually make great comparativeeconomic sense as well, partlybecause remaining healthy teeth donot need to be compromised, buteven more so because of the characteristiclongevity of implants fromNobel Biocare.According to Professor Tomas Albrektssonof the University of Gothenburgin Sweden, the maintenanceand replacement costs for an alter-nate lifetime solution—dentures forinstance—should be taken into accountwhen considering implantcosts.“While it’s true that implant-basedtherapy generally represents a greaterinitial investment in treatmenttime and money than traditionalprosthetic solutions,” he said recently,“traditional solutions such as denturesand bridges have recurringcosts in terms of maintenance andthe often-times deleterious effectthey have on the adjoining dentitionand bone.”When asked about the deepervalue of longevity, he added simply,In this Issue2 Brånemark’s 2nd patient.His implants are stillworking 45 years later.8 TiUnite® Quite simplythe gold standard.“From the earliest days, back in thesixties, life-long solutions were alwayswhat we aimed for—and timehas shown that life-long solutions arealso what we achieved.”Of all the companies active in thefield of implant-based prostheticdentistry, none has more experienceor a longer patient follow-up data setthan Nobel Biocare.Because the company understandsthat an implant doesn’t just serve asthe foundation of a prosthetic solution—italso serves to restore ormaintain the patient’s self-esteem—you can count on Nobel Biocare forpromising life-long solutions.

2Nobel Biocare NEWS Issue 1/2012From the EditorA 44-year Success StorySven Johansson has had oral implants longer than anyone else on Earth.Nicolas WeidmannSenior VP Global CommunicationsLongevity comes from carefulplanning, quality productsand treatment, and conscientiousfollow-up.X-ray examinations, a thoroughevaluation of the amount of remainingjawbone and a psychologicalexam, Sven was deemed suitable fortreatment.In the most recent issue of Nobel BiocareNews, I wrote that we want thispublication to be your newsletter aswell as ours. From the enormousoutpouring of good wishes and substantiveideas for new content thatthe editors have received since then,you are obviously of the same mind.Thank you for your kind words andencouraging suggestions!The third dentitionWhen long-term, predictably positiveprognoses are paramount, thereis really no substitute for extensive,well-documented experience, whichapplies to suppliers, as well as thesurgical and prosthetic teams.At Nobel Biocare, we’re preparedto share our experience to supportyour team at every stage of treatment.When you speak to your patientabout a new set of tissue-integratedteeth, you can speak withauthority, confident in the knowledgethat Nobel Biocare stands behindyou.Our wide range of TiUnite surfaceimplants remain at the outer edge ofthe envelope for highest initial stabilityand enduring strength.Our company is a lot like thattoo—pioneering, stable and reliable—apartner you can trust.

Issue 1/2012 Nobel Biocare NEWS3In BriefThere’s an app for thatL a n d m a r k S c i e n c eNobel Biocare has the longest, most extensive follow-up data set.A free app, not surprisingly called “Nobel Biocare News” now makesit possible for you to stay up-to-date with the latest edition of thisnewsletter on your iPad, iPhone or iPod Touch.Just visit the App Store on your Apple mobile device and search for“Nobel Biocare News” to download the most appropriate app foryour device. Naturally, it’s free of charge.Prefer to readNobel Biocare News online?Without two pioneeringstudies from 1981 and 1990,implant dentistry might stillbe in its infancy today.By Frederic LoveMany studies have been carriedout on the procedures and consequencesof osseointegration sincePer-Ingvar Brånemark treated hisfirst implant patient, Gösta Larsson,47 years ago in 1965. Perhaps nonehas been more widely read than “A 15-year study of osseointegrated implantsin the treatment of the edentulousjaw” by Ragnar Adell et al, whichwas published in the InternationalJournal of Oral Surgery in 1981.In this groundbreaking work, andthe follow-up study published in1990, Adell and his colleagues meticulouslydocumented the high successrates generated by implant treatmentad modum Brånemark and producedan impressive yardstick against whichall subsequent studies would be measured.Dr. Adell, formerly head of the Departmentof Oral and MaxillofacialSurgery at the Örebro UniversityHospital in Sweden, recently commented,“When we started our workin the 1960s, the possibility of thebody permanently retaining a titaniumfixture was not widely accepted.By the time our second report on thisstudy was published in 1990, the processof osseointegration had becomeaccepted science.”Thanks in large part to the pioneeringwork of Adell and his colleagues,the viability of the routine placementof endosseous implants became wellknownamong readers of dental literaturein the 1980s and 90s—and therest, as they say, is history.

4Nobel Biocare NEWS Issue 1/2012M a n a g i n g S o f t T i s s u e s b y D e s i g nLongevity has many aspects. Good management of the soft tissue/implant interface is one of them.Creating an effective andstable soft tissue barrieraround the abutment isessential for the estheticand functional longevity ofimplant-supported restorations.By Hans GeiselhöringerImplant treatment has proven to bea highly predictable and extremelyreliable option for today’s patients.With sixty years of continuousresearch, innovation and clinical follow-upbehind its implants and relatedcomponents, Nobel Biocarecontinues today to provide optimalsolutions for the patient, both interms of functional and estheticallypleasing outcomes.Nobel Biocare designs products forsolutions in harmony with the adjacentdentition—and ideally invisibleto the human eye.Never complacentDespite the extremely high successrates that have resulted from treatmentoptimization over the years,Nobel Biocare continues to activelypursue scientific research with probableclinical consequences.The maintenance and stability ofthe peri-implant tissue architectureis currently a key area of enquiry.While pathways and cellular responsesduring the osseointegrationof an implant have been described indetail, questions related to soft tissuestability and ideal treatment protocolsare also being explored [Cairoet al, 2008].Clinicians naturally want to createan effective barrier protecting theunderlying bone from intraoral microorganismsand their by-products[Rompen et al, 2006]. In this context,it is generally accepted that the tightand stable soft tissue integration ofan implant-based restoration meansa great deal for long-term success.Although clinical protocols havebeen developed to maintain or improvesoft tissue quality and quantityat implant recipient sites [Thoma etal., 2009], it is important to understandthat the interaction and interdependenciesof the tissue surroundingrestorative components play asvital a role as the general anatomicsituation at the implant site.Nobel Biocare has been among thefirst manufacturers to take this criticalinterface between the oral cavityand the body seriously in every aspectof product development. To ensuresafe, reliable and long-lastingimplant outcomes, Nobel Biocareemphasizes four product characteristicsthat complement patient-relatedfactors and the selection of appropriatetreatment protocols in the questfor such outcomes. These are: implant-abutment interface quality of the screw joint choice of materials and calsituation (e.g. via tactile feedback).Meeting clinical needs andpersonal preferencesEvery patient is unique, as is everyclinical situation. In terms of personalconfidence and professional preferencesfor protocols and components,every dentist is also unique.Recognizing diverse needs andpreferences, Nobel Biocare providesa wide variety of implant platformconfigurations. With recent Nobel-Replace line extensions featuringconical connection and platformshifting interfaces, Nobel Biocare hasonce again proven its commitmentto meeting every clinician’s needs.Nobel Biocare incorporated newconnections into the world’s mostversatile and widely used implantsystem in order to facilitate the use ofa variety of established and highlypredictable treatment protocols.To put it another way, Nobel Biocaredeveloped and launched implantswith conical connection andplatform shifting in order to providenew tools for soft tissue managementand the preservation of the crestalbone.Platform shifting provides a narrowerdiameter prosthetic componenton a wider diameter implant platform(see figure 1 on the next page and theaccompanying case study by Dr.David Lustbader). This creates an exposedridge on the implant platformwhere the soft tissue can develop.Implants with platform shifting increasethe interface between biologicalwidth and retention and may actas a “stop” preventing tissue recession.Literature shows that utilizingplatform shifting results in both significantlyless radiographically detectablebone loss in humans and bettersoft tissue support andmaintenance in the esthetic zone[Atieh MA et al, 2010; Canullo et al,2007; López-Mari et al, 2009].NobelReplace NobelReplace NobelReplaceThe NobelActive conical connection is exceptionally strong, makingfor a tight seal achieved by the use of a special grade of commercially puretitanium and the radial design of the connection, which distributes theforces deep within the robust core of the implant.Tapered Platform Shift Conical ConnectionThe newly launched NobelReplace Platform Shift and NobelReplaceConical Connection demonstrate strength values in the same rangeas NobelReplace Tapered Groovy when evaluated mechanically using ISOtests.Decisive design featuresThe back-tapered collar of theNobelActive regular platform implanthas been designed to maximizethe volume of bone at the alveolarcrest and to improve soft tissue support.Tissue management is furthersupported by the built-in platformshift and the internal conical connection.The expanding tapered Nobel-Active implant body with doubleleadthread is designed to condensebone gradually to provide high initialstability and support for immediateloading.The results of a multi-centerstudy—encompassing 64 partially orfully edentulous patients receiving117 NobelActive implants in 12 centers—showthat the marginal bonelevel as well as the soft tissue level isstable two years after implant insertion.The study demonstrates thatNobelActive can be placed under demandingimmediate loading conditionsas it provides stable bone andsoft tissue levels after two years offunction [Martinez-de Fuentes et al,2010].The perfect balanceWhile the implant platform-abutmentinterface design plays a significantrole in a stable and lasting connection,other design considerationshave also been taken to reduce detrimentaleffects on the peri-implanttissues. Bona fide precision fit andthe ingenious design of the NobelBiocare abutment screw minimizemicromotion, for example.The achievement of proper fit betweenmating components is governedby an apparent paradox: Onthe one hand, precision is paramount,on the other, acceptable tolerancesmake the seating of prostheticcomponents possible. In defining acceptabletolerances, Nobel Biocarehas specified figures that facilitatepassive fit yet remain well below thecritical threshold limits that wouldlead to micromotion and ultimatelyto loosening of the implant-abutmentjoint. (Read more about micromotionin Professor John Brunski’s articleon page 14.)An inconspicuous hero:the TorqTite screwIn the early days of implant dentistry,one of the most commonly reportedmaintenance needs for implant restorationswas retightening or changingthe abutment screws [Goodacre et al,2003]. Nobel Biocare’s engineerssolved the problem by developing ascrew with features outclassing anyother retaining screw.Other implant systems have triedto introduce similar screws, but thefeatures of Nobel Biocare’s TorqTitescrews remain unique. To keep theimplant and abutment interface connectedand to prevent any rotationalmovement upon load application,special features have been integratedinto its design.For one thing, the screw is manufacturedfrom a specific titaniumalloy and coated with a carbon layerthat reduces friction between the internalscrew-threads of the implantand the threads of the retainingscrew.A reduction of friction is namelyneeded to reach the pre-torque valuesrequired to create pre-tension in thescrew shank. (See the Tips and Techniquesarticle by Dr. Chandur Wadhwanion page 11.) Nobel Biocare’sTorqTite screws have been designedand tested to occupy the center ofthe proper torque zone.If screw threads ran all the way upto the head of the screw—as they doin many other implant systems—theshaft could not act as the pre-loadspring necessary to ensure the longevityof the screw-joint.

Issue 1/2012 Nobel Biocare NEWS5P o p u l a r, W e l l - p r o v e n C o n c e p tExperience NobelReplace® Platform Shift from the clinical point of view.UpcomingEventsPlatform shifting, or platformswitching, is a concept thathas come into the mainstreamas it has become anintegral feature of some ofNobel Biocare’s most popularimplants.By Dr. David LustbaderVisit Nobel Biocare at eventsaround the world. They provide agreat opportunity for observingthe latest innovations andscientific research.2012IDEM Singapore20–22 AprilSingaporeOriginally described by Dr.Lazzara, platform shifting isa concept that involves aninward horizontal repositioning ofthe implant-abutment interface (figure1). This connection shifts theperimeter of the implant-abutmentjunction towards the center of theimplant, creating a horizontal componentfor the total linear distancebetween the abutment and crestalbone required for biologic width.This allows for higher tissue volumeand vascularization, ultimatelyleading to more stable crestal boneheights and interdental papilla.Most studies show that a horizontalcomponent of about 0.5 mm resultsin significantly less radiographicallydetectable crestal bone loss andbetter soft tissue support in the estheticzone. Platform shifting can beaccomplished with the NobelReplacePlatform Shift tri-channel (figure 2)or NobelReplace Conical Connection(figure 3), which is identical tothe NobelActive configuration.I have had the good fortune to beable to place both the NobelReplacePlatform Shift and Conical Connectionimplants during the pre-launchand evaluation stages. To date, ourpractice has placed over one hundredof these implants and havefound the marginal bone levels andsoft tissue esthetics to be excellent.The surgical placement and instrumentationis virtually identicalto the standard NobelReplace system,making it ideal from a stafftraining and surgical armamentariumstandpoint. A simple case illustrationwill demonstrate the ease ofuse and predictability.Platform shifting in practiceThe case illustrated in this page is of a78-year-old man who had a verticaland horizontal fracture through tooth#9 (FDI 21), evident clinically and onthe pre-op film (figures 4 and 5). Thetreatment plan was to remove #9 andto immediately place a NobelReplacePlatform Shift with immediate load.This implant was chosen to maximizesoft tissue volume in hopes ofFig. 1. Platform shifting has beendesigned to maximize soft tissuevolume.overcoming any negative tissue influencesfrom a large maxillary frenum.The tooth was atraumaticallyremoved and a surgical guide wasfabricated to assist with depth placementof the implant.The osteotomy was started withtwist drills, but finished with osteotomesto preserve the buccal plate. A5 x 13 mm NobelReplace PlatformShift implant was placed using the4.3 mm implant driver, placing theimplant to just below the facial heightFig. 4–5. Pre-op clinical and radiographic views.Fig. 8. Temporary crown at sixweeks post-op.Fig. 2. NobelReplace PlatformShift. The ease of use of theinternal tri-channel connectioncombined with built-in platformshifting.Fig. 6–7. Extraction site and implant with healing abutment.Fig. 10. CAD/CAM abutmentfabrication using NobelProceraSoftware.Fig. 9. Impression appointment12 weeks post-op.Fig. 11. Final crown insertion at 14weeks. Note continued excellentbone level preservation.Fig. 3. NobelReplace ConicalConnection. The original taperedimplant body combined with thetight conical connection and built-inplatform shifting.of the crestal bone to take full advantageof the platform shift.A 6 x 3 mm healing abutment, 4.3series was placed on the implant (figure7), and the patient was then seenby his restorative dentist for immediatetemporization (figure 8).The patient functioned on the immediatetemporary for 12 weeks, atwhich time the final impression wastaken (figure 9). Note that at all timesthe integrity of the marginal bone waspreserved.A CAD/CAM custom abutmentwas fabricated using the NobelProceraScanner and Software (figure 10).The final crown was inserted at 14weeks (figure 11). As can be seen inthe final restoration (figure 12), tissuelevel integrity is preserved.Our practice has acquired a greatdeal of experience with NobelReplacePlatform Shift and Conical Connectionimplants over the past year. Wehave seen superior esthetic resultswith excellent preservation of soft tissueand crestal bone. Although the follow-upperiod is relatively short, preliminaryresults are very encouraging.This is an excellent addition to theNobel family of implant products.

6Nobel Biocare NEWS Issue 1/2012M e e t i n g O n e - o f - a - k i n d P a t i e n t N e e d sCustom-made devices from Nobel Biocare can make a decisive difference when no one else has a solution to offer.For over 20 years, NobelBiocare has been offering aunique service to itsworldwide customer basethat you may not be aware of.A special custom-madedevice service exists inSweden that makes itpossible to create a one-timesolution for a one-timepatient need.By Jim MackNo matter how far technologymay advance your favoriteproducts, you will always be leftwanting more. But when it comesto a special patient need, or even anemergency, you may not be able tofind your “dream product” in themarketplace.With Nobel Biocare’s custommadedevice service, all you have todo is ask. Your custom-made devicecan be created in a matter of weeks—or even less in cases of extreme medicalemergency.Not your normal solutionCustom-made solutions are tailoredto fit a unique and one-time patientneed. These special solutions extendbeyond the typical esthetic circumstancesand can also be used to assisttrauma victims, including those recoveringfrom such serious injuriesas gunshot wounds. (See article onthe facing page.)One caveat may be in order: Thisservice is not meant to provide individuallydesigned products for doctorsto have in stock for similar indications.There are no catalogs, norare there any product lists.While each item is reviewed by theNobel Biocare regulatory department,custom devices are not CE marked asthey are intended for specific patientsand not for a general market release.For regulatory reasons, an order isbased on a prescription filled out for anamed patient only.Each device is classified into oneof 15 product categories, under theheadings of “abutment components”,“restorative auxiliary”, “surgery components”and “miscellaneous” (whichincludes maxillofacial surgical components).“I have used the custom device workshop at NobelBiocare for many years to provide me andmy patients with bespoke parts to solve large andsmall problems alike.”— Dr. Andrew Dawood, London, United KingdomAttention to detailThe production process typicallytakes around five weeks, unless anothertimeline is decided upon. Eachcase that comes in requires great attentionto detail and must be assessedindividually according toKarin Dahlmo, who manages theCustom Devices and ReplacementParts department at Nobel Biocare inGothenburg, Sweden. “We must lookclosely at all the circumstances ofeach case. Decisions are made basedupon medical, legal and regulatoryrequirements.”As the founder of modern implantdentistry, with more than 45 years atthe forefront of implant-based restora-tions, Nobel Biocare takes the responsibilityof its heritage very seriously.The experience and productioncapability reflected in Dahlmo’sdepartment put the company in aunique position to support cliniciansworldwide in their efforts to improvetheir patients’ quality of life.In addition to simply recreatingdiscontinued products, Nobel Biocarecan further cater to needs beyondits core assortment.In many circumstances, clinicalindications may be so complex thatonly sophisticated custom-made solutionsare the right answer.

Issue 1/2012 Nobel Biocare NEWS7C r o s s - b o r d e r C o o p e r a t i o n S o l v e s C a s eSolution for gunshot victim made possible by custom-made devices and 3D software from Nobel BiocareReconstruction of 3D defectsin the anterior maxilla arechallenging in terms of bothrestored function andesthetics. The Chairman of theDepartment of Oral & MaxillofacialSurgery at UmeåUniversity in Sweden sends usthe following treatment report.By Professor Stefan LundgrenA24-year-old female waswounded by a gunshot duringa robbery in a store. The9 mm bullet, fired from the distanceof a few meters, resulted in a significant3D-defect in the left upper lipand maxilla. The bullet penetratedthe throat and was stopped by theFig. 1. Patient with a significant defect in the left maxilla. The patient wasinjured from a gun shot.Fig. 2. Predominantly cortical bonegraft was harvested from the iliaccrest, seen here in place in thedefect for a 3D reconstruction ofthe bone that will later host threeimplants.Fig. 5. Segmental anterior maxillaryosteotomy with the bone blockincluding the three implants. Acustom-designed distraction deviceacted also as a temporary bridgeduring active distraction and theconsolidation period.cervical vertebrae a few mm from thespinal cord. The 24-year-old Estonianfemale was seen in a consultation visitin Tallin by Dr. Juha Peltola, an oral &maxillofacial surgeon in private practicein Helsinki, who referred the patientfor treatment planning—and ifpossible, treatment—to the Departmentof Oral & Maxillofacial Surgery,Umeå University Hospital.The initial treatment planning wasdone by Dr. Peltola together with meand Dr. Hans Nilson, the planned restorativedentist from the Departmentof Prostetic Dentistry at Umeå.The first step was a contact withNobel Biocare to help with the fundingof travel expenses, laboratorycosts and components. Financial negotiatonswere carried out with theUniversity Hospital and The DentalFig. 3. Implants, placed with theaid of the NobelGuide concept.Fig. 4. Virtual computerizedplanning showing the three plannedimplants in correct interrelatedpositions, but in a remote site.School in order for us to be able tocomplete the planned treatment at nocost to the patient, who was unable tootherwise finance it.Bone graft firstUnder general anesthesia, a bonegraft was harvested from the anteriorleft iliac crest and placed in the defectin order to provide good bone architecturefor the later placement of implants.Three months later, a CT with a radiologicalguide was performed inHelsinki and the implant placementwas virtually planned with Nobel-Guide treatment planning softwarein collaboration with Matts Anderssonand Andreas Pettersson at theNobel Biocare office in Gothenburg.We placed the implants in the officeof Dr. Peltola in Salora, Finland,with help from the surgical guide derivedfrom the preoperative Nobel-Guide planning. At this point, theimplants were placed in good bone,with a nice bone architecture, yetremote from the planned bridge!Placement of the implants—as wellas the planned final navigation of theanterior maxillary segment, includingthe grafted bone and the three implants—wasall performed in the virtual3D environment. The implantswere allowed to heal for two monthsbefore the distraction surgery was initiated.The external distraction devicewas custom-designed by the Departmentof Early Development, NobelBiocare in Gothenburg.A distraction deviceThe custom designed distraction devicewas divided in two parts. A smallProcera bridge connected the threeimplants in order to create a systemof two rods which were parallel andin the direction of the planned vector.The second part of the distractiondevice was incorporated in the temporarybridge, which was retainedwith temporary cement, as a splint,on the posterior dentition.The third surgical phase was performedin Umeå under local anesthesiaand I.V. sedation. The anteriormaxillary segment was osteotomizedand the bone segment, including thethree implants, was mobilized. Thenthe different parts of the distractiondevice were assembled, the temporarybridge was cemented to the posteriormaxillary teeth, and the surgicalwound was closed with sutures.The patient went home to Tallinnthe day after surgery and the activedistraction was started ten days afterFig. 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 activedistraction over ten days was assistedby the patient’s dentist in Tallin andwas followed by two months of consolidationbefore the distraction devicewas removed, and the patientcould receive a temporary bridge inTallin.Then the patient came to Umeå forthe processing of the final bridge,which was temporarily provided.After another few weeks, she returnedagain for the final adjustmentof the bridge. After delivery of thecorrected bridge we did the final surgicalcorrection of the upper lip.Note on techniqueAccording to this treatment protocol,we place the implants in the bonegraft to allow optimal placement inthe bone regardless of the final implantposition. If the implants arecorrectly positioned in relation toeach other, the bone segment (includingthe implants) can later betransported to the final correct positionfor the temporary bridge. Thisrequires treatment planning performedin a virtual 3D environment.The sequence of treatment provides anumber of benefits.The distraction device, retained bythe implants, can be removed in anoninvasive way as the device is extra-mucosallypositioned. The distractiontechnique increases not onlybone tissue but also mucosal volume.With the correct technique, thewidth of the keratinized mucosa canbe increased both on the newlyformed alveolar process and aroundthe implants.

8Nobel Biocare NEWS Issue 1/2012TiUnite ® – A Unique BiomaterialA remarkable set of images displays the process of osseointegration as it’s never been revealed before.Implant surface propertiesare of key importance forinitial tissue interactions, theacceleration of bone healingand osseointegration. TiUniteis titanium oxide renderedinto an osteoconductivebiomaterial through sparkanodization. New insightsexplain how TiUnite interactswith tissue and why itremains the osteoconductivesurface of choice.By Drs. Peter Schüpbachand Roland GlauserPlatelet 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.Nobel Biocare first introducedTiUnite to the market in2000 on its Brånemark Systemimplants, and then applied itto Replace Select in 2001. Today,TiUnite is available on all NobelBiocare implants, including thosewith machined collars.Unlike implants with machinedsurfaces, TiUnite has clinically demonstratedthe ability to increase thepredictability and speed at whichdental implants osseointegratethrough osteoconductive bone formation(Glauser et al, 2001).TiUnite is formed by spark anodizationin an electrolytic solutioncontaining phosphoric acid. This resultsin a thickened titanium oxidelayer (up to 10 microns) and a moderatelyrough porous surface topography(Ra 1.2). TiUnite contains anataseand rutile, the most importanttitanium oxides, and is thereby ahighly crystalline biomaterial. Studieshave also shown the presence ofphosphorus in the oxide layer (Lausmaa& Hall, 2000; Schüpbach et al,2005). Thus, TiUnite may have botha topography-related as well as achemistry-related effect on osseointegration.This article explains how TiUniteinteracts with living tissue and accelerateswound healing.S&ESafety and EfficacyAn inevitable chronologyWound healing comprises a cascadeof events that the body brings intoplay to resolve injury. Nature’s firstpriorities are to stop bleeding, restorefunction and to prevent infection.Generally, the wound-healingevents are grouped into four phases:hemostasis, inflammatory, proliferative/repair,and remodeling.Hemostasis (0 to 10 minutesfollowing implant placement)TiUnite shows its strength already atthe time of placement of an implant:Within seconds, blood proteins andplatelets are attracted to the negativelycharged TiUnite surface andbecome immediately activated.This first step is crucial for thewound healing. Their activation isfollowed by the release of growthfactors, such as platelet-derivedgrowth factor (PDGF) and transforminggrowth factor beta (TGF-b).These factors play a crucial role inthe regulation of the wound-healingcascade (Park JY et al, 2001; MarxRE, 2000). During the first ten minutes,fibrin—the reaction product ofthrombin and fibrinogen—will bereleased at the wound site.The resulting stabilized blood clotreveals improved adherence to themoderately rough TiUnite surfacewhen compared to smooth surfaceimplants.Day 1 to 2The inflammatory phaseThe inflammatory phase beginsminutes following the implant insertionand continues for approximatelytwo days.Neutrophils are the first cells attractedby chemical signals releasedby the platelets, followed by macrophages.Both cell types will phagocytizesmall bone debris. The fibrinwill be broken down by the enzymeplasmin and the debris will also beremoved by the leukocytes. Fibrinolysisstarts already during hemostasisbut is slower and thereby contributesto its regulation.The breakdown of the fibrin clotcreates the room in the wound siteneeded for the invasion of fibroblastand thereby the forming of the provisionalmatrix (Schüpbach et al, inpreparation).Day 3 to 5The proliferative/repair phaseThe proliferative phase is characterizedby granulation tissue formation,angiogenesis, collagen deposition,and wound contraction. Ingranulation tissue formation, fibroblastsinvade the wound and form amore on following pageHemostasis: 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 releasegranules containing full batteries of enzymes and growth factors needed for the wound healing.

Issue 1/2012 Nobel Biocare NEWS9Recent FindingsTiUnite ® 10-year, Immediate LoadingEarly wound healing: The fibrin matrix will be broken down by the enzyme plasmin and their debris will beremoved by neutrophils (green, left) and later macrophages. The healing site will be invaded by fibroblasts and theblood clot replaced by the provisional extracellular matrix. Eventually, osteogenic cells (red arrows) stream to theimplant surface. Once they reach it, they migrate by active locomotion using their pseudopodia and the open poresas attachment points (yellow arrow) to the front of bone formation.Osteoconductive bone formation: Human histology six months following insertion shows bone anchored in theTiUnite pores (left). In extraction sockets, newly formed bone crosses the gap between local bone (LB) and theimplant surface by distance osteogenesis (middle, yellow arrow). As soon as the implant surface is reached, newbone spreads over the surface by contact osteogenesis (middle, red arrow) characterized by woven bone depositeddirectly on and along the surface (right).Already available as an ePub ahead of publication, anarticle in “Clinical Implant Dentistry and Related Research”documents the 10-year outcome of immediately loadedimplants with the TiUnite surface.“10-Year Follow-Up of Immediately Loaded Implants with TiUnitePorous Anodized Surface,“ by Drs. Marco Degidi, Diego Nardi andAdriano Piattelli reports on a prospective study the authors carried outto assess the 10-year performance of TiUnite implants supportingfixed prostheses placed with an immediate loading approach in bothpostextractive and healed sites.All the patients in this study received a fixed provisional restorationsupported by parallel design, self-tapping implants with a TiUnite surface,and an external hexagonal connection.Success and survival rate for restorations and implants, changes inmarginal peri-implant bone level, probing depth measurements, biologicalor technical complications, and any other adverse event wererecorded 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 theauthors conclude that positive results—in terms of bone maintenancein the long-term perspective—are to be expected using immediatelyloaded implants with a TiUnite surface in both post-extractiveand healed sites when adequate levels of oral hygiene are maintained.www.nobelbiocare.com/tiunite-10-year-abstractfrom the previous pageprovisional extracellular matrix(ECM) by secreting collagen andfibronectin. In angiogenesis, newblood vessels are formed by vascularendothelial cells. In contraction, thewound is made smaller by the actionof myofibroblasts, which establish agrip on the wound edges and contractthemselves.Now the benefit of the TiUnitetopography comes into play as themoderately rough surface diminishesthe ECM retraction from the surface—whencompared to smoothsurfaces—and inhibits its retractionfrom the surface. This is a prerequisitefor osteoconductive bone formationas osteogenic cells, again attractedby the chemical signals of theplatelets, may reach the surface onlyif the ECM remains attached.Day 5 to 7 – Osteoconductivebone formationOnce the osteogenic cells havereached the TiUnite surface, they migrateto the front of bone formation,i.e. where wound edges of the localbone of the osteotomy are in contactwith the implant surface or wherebone newly formed by distance osteogenesisalready has reached thesurface. At the front of bone formationthey will become differentiatedto osteoblasts. The latter will formthe bone collagenous bone matrix,which eventually becomes mineralized,and woven bone is formed.The strength of TiUnite in thisphase of the wound healing is obvious:the porous surface is an idealsubstrate for the migration of osteogeniccells along the surface (Schüpbachet al, 2005) and the surfaceproperties (with Ra < 2 μm and Rm> 5 μm) are optimal for the differentiationof stem cells into osteogeniccells (Schwartz et al, 2000). Accordingto these characteristics, TiUnite ishighly osteoconductive and new boneformation occurs rapidly and directlyon and along the implant surface.Moreover, the osteoblasts, beingpolarized cells, secrete collagen matrixonly perpendicularly to the surface—andthereby directly into theopen TiUnite pores (Schüpbach et al,2005). A kinetic study about earlybone formation with TiUnite showedinitial bone formation and its directanchorage already around day 7,thereby maintaining the primary stability(Schüpbach et al, in prep.).ConclusionsTaken together, the unique TiUniteproperties allow teamplay betweentopography-related as well as chemistry-relatedfactors to accelerateosseointegration.Therefore, it’s not surprising that avariety of animal and human studieshave demonstrated enhanced osseointegration,both in terms of speed“The TiUnite surface has improved our results,especially in grafted bone and in bone of lowdensity. It has, without question, significantlyreduced our early failure rate as well.”— Professor Bertil Friberg, Swedenand amount of bone-to-implantcontact on par with that of hydroxyapatitesurfaces, which many stillconsider the gold standard for osteoconductivity(Zechner et al, 2003).From a clinical perspective, Ti-Unite has enabled the predictable applicationof very short implants andimplants placed in very demandingbone conditions. Moreover, TiUnitehas both reduced the healing timenecessary before functional implantloading can take place, and lifted immediatefunction solutions to a veryhigh and very reliable level of success(Glauser 2011).

10Nobel Biocare NEWS Issue 1/2012S t a t i s t i c s c a n b e D e c e i v i n gBe forewarned: Everyone has an axe to grind, a point to prove, or a product to sell.No matter where we turntoday, we find statistics allaround us. In this classic, yetstill up-to-date NobelpharmaNews report, one of UlfLekholm’s co-authors, and astatistical expert in her ownright, explains how figuresare used to tell a story—orsometimes to exaggerateone. Depending on how theyare presented, statistics canbe reliable or misleading.By Christina BergströmStatistics make it possible toorganize material for systematicanalysis and can be usedto present findings as clear, objectivefigures instead of vague, subjectivewords (the most common of thembeing: “a few” and “usually”). Thereis quite a difference between saying:“He usually does well at competitions”and “Three times out of 10,he has done well at competitions.”“Usually” means different things todifferent people. Statistics serve wellto define the relationship betweenany two variables.Quality and formatPresentations of results and conclusionsare often based on statisticalanalyses. Their reliability dependsnot only on the quality and the mannerof presentation, but their interpretationby the reader as well. Interpretationvaries depending on thebackground of the reader and howthe material is presented.It is crucial for the reader to becritical. Many questions need to beasked. A few examples: Is it reasonableto draw the conclusions beingpresented from the figures available?Is it reasonable to talk about 5-yearresults when only 9 of 3000 subjectsin a study have attended the 5-yearcheckup? What is the objective of thereport? Who may profit from the results?Diagrams can be used when presentingmaterial. They can providethe reader, i.e. the interpreter, withboth numerical and visual information,but it is important to understandthat such visual informationcan easily be manipulated by simplemodifications of the diagram.Cut-offs exaggerateA diagram axis can be “cut off ” toproduce more dramatic differences.If it is the intention of the author toexaggerate the differences betweennarrow range values (93%, 95% and97%, for example) a diagram axis canbe “cut off ” as seen in figure 1.Proportions are lost with a “cutoff”, that is, the correct proportionsof the data cannot be seen. Instead ofgiving each single unit equal space,only a specific part of the table hasbeen presented in figure 1. If a cut-offof the axis is necessary to make apoint, the cut-off should be clearlymarked to aid in interpretation.Optical illusionsBy using broader bars in a bar graph,the differences between differentbars will appear less dramatic.Broader bars look shorter than thinones as can be seen in figure 2.Another way of changing the visualimpression of a bar chart is tochange the axes so the frequency isrepresented along the horizontal axis(x-axis) instead of the vertical axis(y-axis) as can be seen in figure 3.The vertical axis should, wheneverpossible, be the frequency axis becausea horizontal frequency axismakes the differences in the chartappear to be smaller.Tables instead of graphs?Data can also be presented in tables.Good tables must be easy to read andeasy to interpret; otherwise the readerwill easily lose interest. Some tablesare so detailed that it is impossibleto determine which are theimportant parts of the table. Identifyingthe columns in the table by lettersor abbreviations can also make itmore difficult to interpret.When comparing different groupswithin a population or when comparingdifferent populations, themanner in which the groups/populationshave been selected should bedescribed as well as their respectivesize(s).For example, the number of failedfixtures is of interest only if youknow the total number of fixturesin the specific groups/population.When comparing different groups,it is necessary to mention both thetotal number and the number of thecompared sub-groups.LifetableA lifetable includes both actual andrelative numbers (results) and canbe appropriately used to present theresults of a long-term follow-upstudy (see figure 4), and the long-term final results can be forecastwith a lifetable even if the study isnot yet completed. Nonetheless, it isimportant to be aware that morethan 75 percent of the initial groupmust remain in the study (includingany failed fixtures) to draw any reliableconclusions. The reader willfind it difficult to interpret the resultsif only one part of the lifetableis presented, especially if only thecumulative success rates (CSR) arepresented.Lasting impressionsTo give the reader an impression ofdramatically decreasing numbers offailed fixtures, the author can chooseto show only the numbers of failedfixtures during successive time periods(see figure 5A). This obscures forthe reader the fact that the numberof controlled implants during the periodsin question has decreased successivelyat the same time (see figure5B) and that the success rate figureshardly vary at all from one time periodto the next (see figure 5C).In order to give the reader an overallpicture when presenting the resultsof a comparison, it is importantto carefully state what actually hasbeen compared. The size of the comparativegroups should be stated; notthe results of the comparison alone.The objective of the investigationand the method of investigationought to be declared. It is also importantto spell out the plan of investigationfor the reader.The loss of subjects due to dropout,infirmity or death is a difficultyfaced in most clinical trials. The effectscan be far-reaching. Supposethe objective of a study is to resolvethe proportion of 1000 implantedfixtures that survive 5 years after theoperation. If data is only collected on500 of the fixtures and 50 of the 500have failed, the failure rate may appearto be 10 percent but, if the other500 have failed, it means that 55 percentis a more reasonable figure. Onthe other hand, if the 500 uncontrolledfixtures are all survivals itmeans that only 5 percent have actuallyfailed.In some cases, figures must berounded off. If the result is presentedwith figures that show “great precision”(i.e. use many decimals) itlooks as if the result is much moreexact than the size of the sample mayjustify.An article can look trustworthy ifnumerous statistical analyses are100%80%60%40%20%TimeperiodNo. ofinserted/controlledimplantsFigure 4: A lifetable.No. offailedimplantsNo. ofwithdrawnimplantsSuccessrateCumulativesuccessrate(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 1293 95 9797%96%95%94%93%a b c a b cFigure 1: Two diagrams that describe the same result. The frequency axishas been “cut off” to exaggerate the percentage differences.108642Figure 2: Broader bars make differences in a bar chart appear lessdramatic.No. of failed implants605040302010Groupa b c d a b c d1 2 3 4 5Figure 3: A change in axis gives a different impression.used to demonstrate the results. Thisgives the reader the impression thatthe study encompasses well-controlledmaterial and does not need tobe brought into question.Nonetheless, statistical analysescan be deceptive. It is quite possiblethat the reader is not familiar withthe methodology used and that theanalyses therefore do not provideany comprehensible information. Ifthat is the case, then the statisticalanalyses used are of little value. Onceagain, it is the duty of the author toGroup1086421 2 3 4 5939597No. of 10 20 30 40 50 60failed implantsmake sure that the article can be understoodby the vast majority ofthose for whom it has been written.CorrelationMany statistical analyses are carriedout to examine the relation betweentwo variables (within a single groupof subjects) in order to assess whetheror not the two variables are associated.One may conclude a relation-more on following page

Issue 1/2012 Nobel Biocare NEWS11R e s e a r c h P u t i n t o P r a c t i c eKnow your implant procedures: the use of torque drivers and implant screwsImplant screws are deceptivelysimple and exquisitelyintricate at the same time.By Dr. Chandur WadhwaniImplant abutments are commonlyfixed to the implant using a screw.Screw mechanics take advantageof the metal structure that can bestretched as the tightening processoccurs. Elongating the screw byusing the recommended torque settingturns the screw into a “spring”that clamps the components together,improving the joint fixation morethan if the screw is simply tightened.This produces a robust joint, capableof withstanding the rigors of theoral environment during function.But certain rules must be followedin order to get the most out of thisjoint.The ScienceA systemic review of abutment screwloosening in single-implant restorationsfound that abutment screwloosening is a rare event regardless ofthe geometry of the implant abutmentconnection, provided that appropriateanti-rotation features existand proper torque is employed.Rule number 1Always use original Nobel Biocaremanufacturers components andparts. “Compatible parts” may lookA beam type torque wrench is the type recommended by the author because it delivers more consistent force than the toggle type.the same but cannot be guaranteedto work the same. Even “compatible”screws have different thread pitchand patterns. Studies show that eventhough they may look the same, theydo not work in the same way.T&TTips and TechniquesRule number 2Use as directed. If the manufacturerstates a given torque, the screw hasbeen designed and tested to thatvalue. Using a lower or higher torquethan prescribed will result in unpredictablejoint behavior.Use of lubricants, ointments andmedications affects the implant/abutment joint, especially under vibration.It is not advised and maylead to premature screw loosening.Rule number 3Check that your torque wrench isdelivering the correct force required.A recent study showed afterrepeated use some devices produceforces far in excess of that needed,some far less.In general, it is recommended thatyou choose the beam type (see the illustration)as it delivers more consistentforce. If you have the toggle type(not recommended) calibrate or replaceyour device yearly—ask NobelBiocare for details.Rule number 4Re-use of screws: Limit the numberof times the screw is tightened andloosened. Each time this is done, thesubsequent force needed to undo thescrew is reduced.This affects both the screw and theimplant to such a degree that after sixtightening/loosening events—even ifa new screw is used—it does not improvethe fastening properties of thejoint. As a general rule, only tighten/loosen the screw a maximum of fivetimes.

12Nobel Biocare NEWS Issue 1/2012Excellent Initial Stability andPe r f e c t E s t h e t i c R e s u l t sNobelActive is the most versatile choice for your implant dentistry practice.A third-generation dentalimplant, NobelActive has beendesigned to meet the highdemands of dental implantsurgery and implantprosthetics efficiently. Reliablyhigh initial stability forimmediate loading clearly setsNobelActive apart fromconventional implant systems.By Drs. Kai Klimek and Roberto SleiterNobelActive now offers a new, true 3.0 mmsmall-diameter implant for successful restorationsin the anterior region where space islimited and good esthetics essential.With its innovative threaddesign, NobelActive condensesthe bone duringinsertion at every turn, which differentiatesit from other self-tapping implantsavailable on the market.The expanding, tapered implantbody of NobelActive features a double-leadthread design, which alsocontributes to the high initial stabilitycharacteristic of this implant.The innovative implant tip allowsfine adjustments in implant orientationto be made during insertion tooptimize the final position of the implantin the bone, without jeopardizinginitial stability. The implantthread allows gradual atraumaticnarrow ridge expansion and was developedto attain high initial stabilityeven in compromised bone situations.Furthermore, NobelActive has tworeverse-cutting flutes. Rotating theimplant by half-a-turn counterclockwiseengages the cutting capability ofthese flutes. The coronal region ofNobelActive is back-tapered and designedto maximize alveolar bonevolume around the implant collar forimproved soft tissue support.These new attributes provide significantadvantages for the subsequentprosthetic management andfacilitate co-operation between thesurgical and prosthetic teams.Groovy Macroscopically visible surfacegrooves not only promote, but alsoaccelerate new bone formation inconjunction with the TiUnite surfaceof this implant (Hall et al, 2005).TiUnite is a highly crystalline andphosphate-enriched titanium oxidesurface, available exclusively fromNobel Biocare. This patented, biocompatiblesurface has been scientificallyproven both in the long andshort term to enhance osseointegrationand increase the predictability ofimplant treatment (Glauser, Zembic,et al, 2007; and Glauser, Portmann, etal, 2001).Many prosthetic solutionsNobelActive has an internal conicalconnection. The connection offersthe clinician the option of restoringthe tooth with a wide range of prefabricatedprosthetics as well as withNobelProcera.Using NobelProcera, the implantcan be restored with a comprehensivecombination of prosthetic options(e.g. with abutments made either ofzirconia or titanium), to assure thebest possible function and esthetics.NobelProcera Abutments can bedesigned with practically any angle,taper, finish line, height, width andcross-section to optimally adapt theform, arch and axis of the prosthesisto the peri-implant structures. EachNobelProcera restoration is individuallydesigned using state-of-the-art3D computer-aided design software(CAD) and then milled from highstrengthzirconia or titanium in acomputer-assisted manufacturing(CAM) process.Getting it right from the startProduct development at Nobel Biocareis based upon the principlesestablished by Professor Per-IngvarBrånemark, namely that all innovationshould be based on sound scientificresearch and subjected to systematicclinical evaluation beforeentering full-scale commercial distribution.That is why NobelActivewent through rigorous clinical trials,eight months of clinical testing andextensive technical study in the prelaunchphase. Dentists from everycorner of the globe participated inthe endeavor.At the beginning of this eightmonthperiod, when over 30,000 implantswere used, the clinicians receivedextensive training with regardto the implant’s remarkable potential.Experience gained from clinical useand the subsequent feedback reportsconfirmed the effectiveness of thisunique implant design.The clinician’s response also confirmedhow important previoustraining was in order to make themost of the novel and innovativeproperties of this implant. Nobel Biocaretherefore strongly recommendsparticipating in a practical trainingcourse before using NobelActive.Science first and foremostNobel Biocare is currently con -ducting a number of multi-centerclinical trials to assess the success,soft tissue maintenance and boneremodeling of NobelActive implantsover time. One is a five-year,randomized, controlled, prospectivestudy examining the NobelActiveimplant in the anterior and posteriorFig. 1. Extraction of the left uppercentral incisor after fracture.Fig. 3. The situation 20 weeks afterextraction.Fig. 5. Fitting of the NobelProceraZirconia Abutment.Fig. 7. Inserted NobelProcerasingle zirconia crown left uppercentral incisor, 1 week afterinsertion.regions of the maxilla and mandible,and shows that NobelActive can beused under the demanding treatmentconditions of immediate loading,with stable bone and soft tissue levelsafter two years in function.

Issue 1/2012 Nobel Biocare NEWS13N o b e l A c t i v e Expands itsR a n g e o f C o m p o n e n t sA few words from the clinical perspective on Nobel Biocare responsivenessThe clinicians who use NobelBiocare products oftenprovide the feedback thecompany needs to betteradapt its range of products toclinical demands.By Dr. Nik SisodiaEver since its launch four yearsago, I have been using Nobel-Active. Because I have found thatthe surgical versatility and conicalconnection of this multi-purposeimplant are so good, I have switchedover to it completely.I am now exclusively usingNobelActive for all cases and indications.Having a secure and strongconical connection offers built-inplatform shifting and has meantthat I see crestal bone heights remainingstable to the top of the implantin many more cases than previously.A pleasure to work withMany of us who were using theNobelActive implant early-on foundthat—thanks to the new conicalconnection—implants could nowbe placed deeper when required.Of course, this also meant that weneeded a range of prosthetic componentsthat were taller in order tomake transmucosal healing possible.As always, the people at the R&Ddepartment of Nobel Biocare welcomedour queries, were openmindedand explored the possibility.I think it is safe to say that as a directresult of clinical demand, NobelBiocare very quickly added a taller7 mm healing abutment to theNobelActive range.Without doubt, this new healingabutment will make management ofthe soft tissues far easier in thosecases where the implant is placeddeeper. For me, it is a very welcomeaddition to the Nobel Biocare productportfolio.

14Nobel Biocare NEWS Issue 1/2012M i c r o m o t i o n a n d D e n t a l I m p l a n t sA research update in two parts – with thought-provoking consequences for longevityA well-known and oftenquotedpioneer in the field ofbiomechanics—who notincidentally holds the positionof Senior Research Engineer,Division of Plastic & ReconstructiveSurgery at StanfordUniversity in California—sends us this report on thestate of the art.By Professor John B. BrunskiMost clinicians already appreciatethat it is beneficialto insert dental implants“tightly” (e.g., with adequate primarystability) into a freshly-preparedbone site. But how “tight” is tight?What constitutes “adequate” primarystability? And if an implant is somewhat“loose”, how does this loosenessrelate to “micromotion”? Moreover,why is the “tightness” vs. “looseness”of an implant important from a mechanicaland biological (i.e. biomechanical)standpoint?Finding some answers starts withtwo initial points.Point 1First, an implant that is not firmlyanchored in bone won’t be clinicallyuseful in a functional, load-bearingsense when that implant is calledupon to support a prosthesis. This iseasy to see from a simple examplewith six implants installed in a lowerjaw to support a typical full-archprosthesis that’s screwed or cementedonto all six implants (Figure 1a).Suppose that two out of the six implantsare not as “tightly” attached tothe surrounding bone as the otherfour. (This situation around the twoimplants could be caused by one orboth of the following problems: [1]the bone around the implants wasquite porous and therefore muchmore deformable, leading to a somewhat“soft” interface; [2] the surgeryto install the implants might havedamaged more bone than normal,Vertical loadEstimatedneutral axisof implantsalso thereby leading to a “softer”, lessstiff interface.)Now, we know from both measurementsand calculations that when relatively“stiff ” implants exist in thesame distribution as “less stiff ” implants,then the stiffer implants endup taking most of the load—effectivelyconverting a six-implant situation(in this example) into a four-implantcase (Figure 1b).Overall, the general result is thatwhen a prosthesis is supported bymultiple dental implants, load-sharingamong the implants depends onthe relative stiffness of the implants,with “softer” (less stiff) implants takingless load than the “stiffer” implants.It follows that if one wants allsix implants to perform to their fullload-bearing capability, they shouldall be equally well “fixed” (or “tight”)in the bone.Point 2The second reason why “loose” implantsare a problem stems from thebiological consequences of the associated“micromotion” at the bone-implantinterface. The term “micromotion”refers to relative displacementsof a loaded implant with respect tothe surrounding interfacial bone.A simple example of rather extrememicromotion is to imagine a4 mm diameter implant that’s loadedafter being placed into a 4.5 mm diameterhole; such an implant wouldnot be engaged with the bony walls ofthe hole and would therefore not bewell-supported when any load is exertedon it; and as a result the implantwill tend to “wobble around”—i.e.,experience micromotion —in thehole.But why is this micromotion a biologicalproblem (besides the fact thatthe implant would not function wellin load support)? The answer is thatmany studies demonstrate that micromotion—ifit is “excessive”—willinterfere with the biology of properinterfacial bone healing. For example,some authors have proposed thatFig. 1a & 1b. Changes in the force distribution when implants no. 1 and 6have about 10 to 20 times lower stiffness than implants 2–5.Axial load (N)3002001000–100–200 = All implants equally stiff = Implants no. 1 & 6 less stiff–300 | | | | | |6 5 4 3 2 1Implant numberTHREADTHREADFig. 2a. Unstrained: Cells and fibrinare intact and not damaged in anyway.Used and modified from Marx, 2008, with permission.R&DResearch and Development“excessive” micromotion could beanywhere from 20 to 150 µm (dependingon the author), i.e., thisrange of values represents the thresholdbeyond which there will be interferencein bone healing.However, it is also clear that thisthreshold has not been establishedvery precisely or whether it even pertainsto all the differently-shaped implantsthat exist. Most significantly,the search is still on for the underlyingmechanism(s) by which micromotioninteracts with the interfacialbiology to either negatively (as mostauthors believe) or perhaps positively(as at least some authors have suggested)influence interfacial reactions.Searching for claritySo, what is micromotion and howmight it operate at an interface? Wehave been exploring the hypothesisthat implant micromotion producesstrain (deformation) in the interfacialtissue, and that it is this strain in theinterfacial tissue —and not the implantmicromotion per se—that is thekey factor in regulating the interfacialbiology of healing. So what’s involvedwith this hypothesis and how do wetest it?First, it is instructive to considersome examples of the meaning ofstrain and how implant micromotioncan create interfacial strain.Strain is an engineering term relatedto deformation. When it comes tostrain in interfacial tissues, Figure 2depicts two highly magnified, idealizedviews of a bone-implant interfaceas it might look soon after implantation(e.g., seconds to a fewFig. 2b. Strained: In this example,implant threads move to the right,compressing the cells and fibrinagainst the bone.hours). Figures 2a and b show the“before” and “after” states of the interfacefollowing some amount of implantmicromotion.In this example, the micromotionconsists of a bodily displacement ofthe implant threads to the right, towardthe cut edge of the bone thatborders the interface. Figures 2a andb also show a small gap between theimplant’s threads and the cut edge ofthe bone, which is meant to depictthat at least in some regions of a typicalinterface, there is the possibilitythat the threads of a freshly-installedimplant may not directly interdigitatewith bone of the site.Figure 2a goes on to illustrate that,early after surgery, such a small gapbetween implant and cut bone willordinarily fill with a blood clot comprisedof fibrin, red blood cells, platelets,growth factors, etc. Strain of theinterface comes about as we considerthe difference between the state of affairsin Figure 2a (which depicts theimplant threads before there has beenany micromotion of the implant relativeto the cut surface of the bone)and Figure 2b (after the threads ofthe implant have been displacedsome distance to the right).In comparing these two images, weobserve (Figure 2b) regions of deformationof the interface, e.g., regionsof compression, tension (stretching),and shearing of the cells and fibrin inthe gap region. So at least qualitatively,what this example shows is theidea that implant micromotion canend up deforming (straining) the interfacialtissue.So what? Before we answer thatquestion in the next issue of NobelBiocare News, a few more words onstrain. For one thing, the nature andsize (magnitude) of the interfacialstrain will depend on location in theinterfacial gap. That is, a comparisonof Figures 2a and 2b reveals that insome regions there is compression(“squeezing”) of the red blood cellsagainst the bone surface, while inother regions there is mainly stretching(tension, “pulling”) of the yellowishfibrin fibers. A detailed quantitativeengineering strain analysis atdiscrete points in this image could bedone, but the key take-home messagesconnected with strain are these: the interface, one can define a stateof strain—which is also called thestrain state at that point. can depend on many factors—includingthe amount and directionof the implant’s micromotion aswell as the implant’s shape and fitin the drill hole, etc. terfacecan simultaneously involvemore than one type of strain at thesame spot, e.g., compression,stretching, and shearing can allexist simultaneously at the samelocation in a material. (A commonexample of this situation is duringthe stretching of a common rubberband: At any point in the middle ofthe rubber band there is simultaneouslytension or stretching alongthe length dimension but alsocompression in the width andthickness directions.) state at a point is described by amathematical quantity known asthe strain tensor, a full explicationof which goes far beyond the scopeof this article, but one importantfeature of the strain tensor is that itallows us to compute the so-calledprincipal strains, which are thelargest and smallest magnitudes ofstrain at the point of interest. the strains (which are related to thestresses) become too large—a factthat applies for both biological materials(such as bone and soft tissue)and man-made materials(such as titanium).

Issue 1/2012 Nobel Biocare NEWS15A Case in 12 PicturesThe Best Marketing Toolis a Satisfied PatientNobelProcera bars on four NobelReplace implants in themandible and six NobelReplace implants in the maxilla.By Dr. Stefan HolstCase history: A 73-year-old patient presented with a failing mandibularrestoration necessitating removal of the remaining teeth and atrophiedalveolar ridges in the edentulous maxilla. Due to extensive atrophy ofthe alveolar ridges and the amount of hard and soft tissue missing, fixedimplant retained restorations were not an option.Dr. Ronald Goldstein says thatmeeting the patient on his orher own terms is essential inthat crucial first conversationabout implants.Is there any one best way toexplain implant procedures to thepatient?Goldstein: No, it all depends on the patient.The most successful offices havea good understanding of the psychologicalmake-up of each patient. Initialinsights from a treatment coordinator,dental hygienist, or even adental assistant should be taken intoconsideration by the dentist.Q&AQuestions and AnswersIf a satisfied patient referred the newpatient, he or she may just want toget started with the treatment.If, on the other hand, the new patienthas approached you because ofyour website, then you need to realizethat this patient has probably alreadydone a considerable amount of homework.I like to ask patients like thesewhat more they want to know andthen build the presentation fromDr. Ronald E. Goldstein, is a dentist from Atlanta, Georgia, USA, an activespeaker and a prolific writer of both consumer and academic literature onthe topics of esthetic dentistry and implants.there. Practical benefits and the sciencethat makes them possible shouldalways be a part of the conversation.Comparison shoppersThen there are the self-assured patientswho already know—or thinkthey know—everything they need toknow about implants. They want tocompare you to others. Tell themabout your experience, any warrantiesyou offer, and be specific aboutfinances. Chances are, your treatmentplan will differ from other offices’so be prepared with back-upgraphics and maybe even a video tolet them know why your plan is thebest choice.Remember, every patient is different.Before having that first conversationabout implants, gather inputfrom your staff about the patient’s interest,knowledge and motivation, andthen listen carefully to what the patienthas to say.

16Nobel Biocare NEWS Issue 1/2012Celebrating the Triumphof OsseointegrationRevolutionary breakthroughs – 30 and 60 years on300 Years of ExperienceTake 300 Years to GainWorld-renowned expertsare the voice of experience todayThis year, scientific symposiawill mark the dual anniversariesof the advent andacknowledgement of osseointegration.by Frederic Loven 1952, Per-Ingvar Brånemark discoveredthe principles of osseointe-Igration in Sweden. Thirty years later,in 1982, the discovery was acknowledged,and his subsequent findingsconfirmed, at an epoch-makingmeeting of dental authorities organizedby George Zarb in Canada. Yetanother thirty years have now passed,and Nobel Biocare is celebrating boththese 30- and 60-year anniversaries inSweden, Canada, and four other locations,too.Starting the year-long celebrationin the hometown of osseointegration—Brånemark’sGothenburg—Nobel Biocare brought together someof the best-known names in the fieldon March 21–23. The event beganwith a surprise entrance from Brånemarkhimself who delivered adviceand thoughts for the future. Ulf Lekholmthen led experts not only fromScandinavia, but the far corners of theworld, as they exchanged ideas anddiscussed promising areas for furtherexploration at this meeting.Nobel Biocare NEWSPrinted on non-chlorine bleachedFSC-certified paper.Design and printing: www.linkgroup.chPrefer e-mail delivery? Then visit:www.nobelbiocare.com/enewsHeadquartersNobel Biocare Services AGP.O. Box8058 Zürich-Flughafen, SwitzerlandOffices:Balsberg, Balz Zimmermann-Strasse 78302 Kloten, SwitzerlandPhone +41 43 211 42 00Fax +41 43 211 42 42Web contact: www.nobelbiocare.com/contactProf. George Zarb at this year’s first Nobel Biocare Symposium.Pioneers from the heady days ofthe Toronto Conference of 1982, suchas George Zarb and Ragnar Adell,were honored and other speakers remindedparticipants of how far Per-Ingvar Brånemark, Nobel Biocare andtheir band of supporters have broughtosseointegration since those days ofbreakthrough 30 and 60 years ago.Eyes on the horizonThe programs of all five of the remainingNobel Biocare Symposia2012 will celebrate the origins andevolution of osseointegration as apractical and trusted treatment modalityover the last six decades.Each program will also include lectureson recent advances in treatment,presented from surgical, prostheticand laboratory perspectives.Europe and RussiaAustriaNobel Biocare AustriaPhone: +43 1 892 89 90BelgiumNobel Biocare BelgiumPhone: +32 2 467 41 70DenmarkNobel Biocare DenmarkPhone: +45 39 40 48 46FinlandNobel Biocare FinlandPhone: +358 9 343 69 70FranceNobel Biocare FrancePhone: +33 1 49 20 00 30GermanyNobel Biocare GermanyPhone: +49 221 500 85 590HungaryNobel Biocare HungaryPhone: +36 1 279 33 79IrelandNobel Biocare IrelandPhone: toll free 1 800 677 306Speakers will look towards the futureas well, presenting current trends andpossible future developments forbone-anchored restorative dentistry.Under the common theme, “Celebrating60 years of osseointegrationand 30 years of international acknowledgement,”meetings will beheld in Avignon, France (June 1-2),Odessa, Ukraine (June 9–11), Hamburg,Germany (June 15–16) and Rimini,Italy (October 19–20), with thefinal symposium planned for Toronto,Canada (October 19–20) wherethe international breakthrough forosseointegration first took place.