Nobel Biocare NEWS · teristic longevity of implants from Nobel Biocare. According to Professor...

Information for the Osseointegration Specialist Issue 1/2012

Nobel Biocare News

In this Issue

nate lifetime solution—dentures for instance—should be taken into ac-count when considering implant costs.

“While it’s true that implant-based therapy generally represents a great-er initial investment in treatment time and money than traditional prosthetic solutions,” he said recent-ly, “traditional solutions such as den-tures 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 al-ways 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 solu-tion—it also serves to restore or maintain the patient’s self-esteem—you can count on Nobel Biocare for promising life-long solutions. <

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 dis-covery, the many benefits of osseo-integrated implants are now well-known. 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 ap-pearance and prevent bone loss, which provides enormous social and emotional benefits in addition to the purely physiological ones.

Longevity just makes senseWhat is less well-known is that im-plants usually make great compar-ative economic sense as well, partly because remaining healthy teeth do not need to be compromised, but even more so because of the charac-teristic longevity of implants from Nobel Biocare.

According to Professor Tomas Al-brektsson of the University of Goth-enburg in Sweden, the maintenance and replacement costs for an alter-

Implants from Nobel Biocare provide the foundation for a third dentition that can last to the end of life.

By Frederic Love

For the past 50 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 pos-sible, despite the impressive achieve-ments of preventative dentistry and the best efforts of the patient.

Trauma, systemic disease and even normal wear are just a few of the rea-sons 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

Designing for Life

By Richard Laube, CEO

At Nobel Biocare, we are committed to improving the quality of life of every patient treated with our inno-vative products.

Our customers—and their pa-tients—can be confident that the solutions we promote for the resto-ration of lost teeth have been de-signed with the objective of provid-ing fully functional, natural-looking results to last a lifetime.

“Designing for Life” is an ambi-tion that covers much more than product design and treatment inno-vation, however.

It is a concise expression of the principle upon which we have es-tablished our business. It permeates everything we do, from scientific discovery and clinical trials to prod-uct information and customer rela-tions.

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—dra-matically improve a person’s life.

Providing this level of care en-hances both the quality of life of the patient and the professional reputa-tion of the clinician. For Nobel Bio-care, such improvements represent a long-term commitment to both our customer and the patient.

Our dedication to improving pa-tients’ quality of life grows from un-paralleled experience. Building on the past 45 years of pioneering sci-entific research and innovation in the field of implant-based restor-ative dentistry, Nobel Biocare will continue designing for life.

Moving forward togetherOn the pages to follow, you’ll find thought-provoking reading on re-cent scientific findings, practical techniques to facilitate treatment, and the living history of osseointe-gration. Join us as we move the noble practice of implant dentistry forward together, one patient at a time. <

Living the Endless SummerNobel Biocare implant-based solutions provide longevity and exceptional quality of life.

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.

Nicolas Weidmann Senior VP Global Communications

In the most recent issue of Nobel Bio-care News, I wrote that we want this publication to be your newsletter as well as ours. From the enormous outpouring of good wishes and sub-stantive 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 dentitionWhen long-term, predictably posi-tive 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 treat-ment. When you speak to your pa-tient about a new set of tissue-inte-grated teeth, you can speak with authority, confident in the knowl-edge that Nobel Biocare stands be-hind you.

Our wide range of TiUnite surface implants remain at the outer edge of the envelope for highest initial sta-bility and enduring strength.

Our company is a lot like that too—pioneering, stable and reli-able—a partner you can trust. <

Nobel Biocare NewsPublished 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.

Nobel Biocare News Issue 1/2012

From the Editor

2

A 44-year Success StorySven Johansson has had oral implants longer than anyone else on Earth.

Longevity comes from careful planning, quality products and treatment, and conscien-tious follow-up.

By Dr. Christer Dagnelid

Gösta Larsson of Gothenburg, Sweden, was the first patient to be treated with implants by

Professor Per-Ingvar Brånemark. That was in 1965. When Larsson passed away in 2006, he had had his im-plants—still in place and fully func-tioning—for more than forty years.

Brånemark’s second patient, Sven Johansson, also of Gothenburg, re-ceived his implants in 1967. This year will mark the 45th anniversary of his treatment, which makes him a part of living history in the field of osseo-integration. Sven’s missing dentition was restored with two full-arch gold/acrylic bridges supported by a total of 11 Brånemark System implants in the upper and lower jaw. Further de-veloped by Nobel Biocare, this signa-ture system is still widely used and much appreciated today.

All too common storyLike so many other members of his generation, Sven had had problems with his teeth from an early age. Born in 1925, by the time he was in his 40s, he was completely edentu-lous. The usual prosthetic solution at that time—the 1960s—was treat-ment 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 pa-tient to the Brånemark Clinic, which was located there, and the passenger turned out to be none other than Gösta Larsson—Patient No. 1—who had not only been the first to be treated with Brånemark System im-plants, 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 be-cause 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 remain-ing jawbone and a psychological exam, Sven was deemed suitable for treatment.

A bold decision paid offSven, by nature, is a brave soul. When he decided to subject himself to im-plant surgery, it had only been car-ried 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 1967 came to an end, Sven felt secure once again in social situa-tions 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 mo-ment.”

In 1976, I took over Professor Brånemark’s dental practice in Mölndal, and thus inherited Sven Jo-hansson as a patient. A good patient, Sven has rarely missed a regularly scheduled dental check-up through-out the 44+ years his implants have been in place. He has practiced good oral hygiene and problems such as peri-implantitis have never been a concern.

Prerequisites for longevityFrom our side, as dentists, it is essen-tial to create the conditions for good oral hygiene through the proper de-sign of bone-anchored prosthetic re-constructions. Well-designed occlu-sion and articulation are also important prerequisites for optimal loading of the implants and essential for implant longevity.

Sven, and thousands of other pa-tients 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 re-call 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

patient in an individualized recall program. In as much as the implant treatment amounts to a major invest-ment for the patient, our objective is uncompromising: “Life-long service.”

Over the last 30 years, I have par-ticipated in and performed thou-sands 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 Profes-sor Brånemark has taught us that good implant-related dental care must be based on a long-standing re-lationship between the patient and dentist, where the number and fre-quency of return visits are tailored to the different stages of life.

I take my hat off to Sven Johans-son, who is rapidly approaching 90, 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-a-century. <

Sven Johansson of Gothenburg, Sweden, was the second patient to ever receive Brånemark System implants. They have been serving him well since 1967.

These eleven implants were placed by Professor Per-Ingvar Brånemark himself and are still fully functional for Sven Johansson.

www.nobelbiocare.com/newsletter

Nobel Biocare NewsIssue 1/2012 3

In Brief

There’s an app for thatA 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.

Just visit the App Store on your Apple mobile device and search for

“Nobel Biocare News” to download the most appropriate app for

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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

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 snapshotsDr. Scott MacLean of Halifax, Nova Scotia, Canada, recently wrote to

the editors about a NobelActive case and sent the following images.

Dr. Scott MacLean: “The molar was placed 5 years ago (one of the first placed in Canada during the initial pre-launch study). The premo-lar was immediately placed during study club in Feb 2011. Look at the bone between the implants ... This implant rocks!”

Landmark ScienceNobel Biocare has the longest, most extensive follow-up data set.

Without two pioneering studies from 1981 and 1990, implant dentistry might still be in its infancy today.

By Frederic Love

Many studies have been carried out on the procedures and con-

sequences of osseointegration since Per-Ingvar Brånemark treated his first implant patient, Gösta Larsson, 47 years ago in 1965. Perhaps none has been more widely read than “A 15-year study of osseointegrated im-plants in the treatment of the edentu-lous jaw” by Ragnar Adell et al, which was published in the International Journal of Oral Surgery in 1981.

In this groundbreaking work, and the follow-up study published in 1990, Adell and his colleagues metic-ulously documented the high success

rates generated by implant treatment ad modum Brånemark and produced an impressive yardstick against which all subsequent studies would be mea-sured.

Dr. Adell, formerly head of the De-partment of Oral and Maxillofacial Surgery at the Örebro University Hospital in Sweden, recently com-mented, “When we started our work in the 1960s, the possibility of the body permanently retaining a titani-um fixture was not widely accepted. By the time our second report on this study was published in 1990, the pro-cess of osseointegration had become accepted science.”

Thanks in large part to the pioneer-ing work of Adell and his colleagues, the viability of the routine placement of endosseous implants became well-known among readers of dental liter-ature in the 1980s and 90s—and the rest, as they say, is history. <

More to explore:

Adell R, Eriksson B, Lekholm U,

Brånemark PI, and Jemt T, “Long-

term 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 BoneAsk questions of the expert panel – in person or in advance.

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.

On June 8, 2012, Nobel Biocare will be hosting a public forum

at Europerio 7 in Vienna, Austria, on the subject of “Maintenance of Mar-ginal 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 publica-tion record. Since tens of millions of

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 im-plants.

After circulating their review pa-pers among themselves, and then meeting for two days of candid ex-changes at Karolinska Institutet in Stockholm last fall, the group formu-lated a set of consensus guidelines, both preventive and therapeutic. They updated their manuscripts and the papers have now been published

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.

as a special supplement to the Euro-pean Journal of Oral Implantology.

This Europerio 7 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

Dr. Ragnar Adell established a tradition for conscientious follow-up study that lives on today at Nobel Biocare.


www.nobelbiocare.com/europerio2012


Creating an effective and stable soft tissue barrier around the abutment is essential for the esthetic and functional longevity of implant-supported restora-tions.

By Hans Geiselhöringer

Implant 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 fol-low-up behind its implants and relat-ed 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 adja-cent dentition—and ideally invisible to the human eye.

Never complacentDespite the extremely high success rates that have resulted from treat-ment optimization over the years, Nobel Biocare continues to actively pursue scientific research with prob-able clinical consequences.

The maintenance and stability of the peri-implant tissue architecture is currently a key area of enquiry. While pathways and cellular re-sponses during the osseointegration of an implant have been described in detail, questions related to soft tissue stability and ideal treatment proto-cols are also being explored [Cairo et al, 2008].

Clinicians naturally want to create an effective barrier protecting the underlying bone from intraoral mi-croorganisms and their by-products [Rompen et al, 2006]. 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 im-prove soft tissue quality and quantity at implant recipient sites [Thoma et al., 2009], it is important to under-stand that the interaction and inter-dependencies of the tissue surround-ing 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 criti-cal interface between the oral cavity and the body seriously in every as-

pect of product development. To en-sure safe, reliable and long-lasting implant outcomes, Nobel Biocare emphasizes four product characteris-tics that complement patient-related factors and the selection of appropri-ate treatment protocols in the quest for such outcomes. These are:• the design and contour of the

implant-abutment interface• the fitofmatingcomponentsand

quality of the screw joint• the abutment morphology and

choice of materials and • easyadaptationtoanygivenclini-

cal situation (e.g. via tactile feed-back).

Meeting clinical needs and personal preferencesEvery patient is unique, as is every clinical situation. In terms of person-al confidence and professional pref-erences for protocols and compo-nents, every dentist is also unique.

Recognizing diverse needs and preferences, Nobel Biocare provides a wide variety of implant platform configurations. With recent Nobel-Replace 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 Bio-care developed and launched im-plants with conical connection and platform shifting in order to provide new tools for soft tissue management

and the preservation of the crestal bone.

Platform shifting provides a nar-rower diameter prosthetic component on a wider diameter implant platform (see figure 1 on the next page and the accompanying case study by Dr. David Lustbader). This creates an ex-posed ridge on the implant platform where the soft tissue can develop.

Implants with platform shifting in-crease the interface between biologi-cal width and retention and may act as a “stop” preventing tissue reces-sion. Literature shows that utilizing platform shifting results in both sig-nificantly less radiographically de-tectable bone loss in humans and bet-ter soft tissue support and maintenance in the esthetic zone [Atieh MA et al, 2010; Canullo et al, 2007; López-Mari et al, 2009].

Decisive design featuresThe back-tapered collar of the NobelActive regular platform im-plant has been designed to maximize the volume of bone at the alveolar crest and to improve soft tissue sup-port. Tissue management is further supported by the built-in platform shift and the internal conical connec-tion.

The expanding tapered Nobel- Active implant body with double-lead thread is designed to condense bone gradually to provide high ini-tial stability and support for immedi-ate loading.

The results of a multi-center study—encompassing 64 partially or fully edentulous patients receiving 117 NobelActive implants in 12 cen-ters—show that the marginal bone level as well as the soft tissue level is stable two years after implant inser-tion. The study demonstrates that NobelActive can be placed under de-manding immediate loading condi-tions as it provides stable bone and soft tissue levels after two years of function [Martinez-de Fuentes et al, 2010].

The perfect balance While the implant platform-abut-ment interface design plays a signifi-cant role in a stable and lasting con-nection, other design considerations have also been taken to reduce detri-mental 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 be-tween mating components is gov-

erned by an apparent paradox: On the one hand, precision is para-mount, on the other, acceptable toler-ances make the seating of prosthetic components possible. In defining ac-ceptable 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 micromo-tion in Professor John Brunski’s arti-cle on page 14.)

An inconspicuous hero: the TorqTite™ screwIn the early days of implant dentistry, one of the most commonly reported maintenance needs for implant resto-rations was retightening or changing the abutment screws [Goodacre et al, 2003]. 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 con-nected and to prevent any rotational movement upon load application, special features have been integrated into its design.

For one thing, the screw is manu-factured from a specific titanium alloy and coated with a carbon layer that reduces friction between the in-ternal 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 Tech-niques article by Dr. Chandur Wadh-wani on page 11.) 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 lon-gevity of the screw-joint. <

Managing Soft Tissues by DesignLongevity has many aspects. Good management of the soft tissue/implant interface is one of them.

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.

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.

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

NobelReplace NobelReplace NobelReplace

Tapered Platform Shift Conical Connection



Popular, Well-proven ConceptExperience NobelReplace® Platform Shift from the clinical point of view.

Platform shifting, or platform switching, is a concept that has come into the main-stream as it has become an integral feature of some of Nobel Biocare’s most popular implants.

By Dr. David Lustbader

O riginally described by Dr. Lazzara, platform shifting is a concept that involves an

inward horizontal repositioning of the implant-abutment interface (fig-ure 1). This connection shifts the perimeter of the implant-abutment junction towards the center of the implant, creating a horizontal com-ponent for the total linear distance between the abutment and crestal bone required for biologic width.

This allows for higher tissue vol-ume and vascularization, ultimately leading to more stable crestal bone heights and interdental papilla.

Most studies show that a horizon-tal component of about 0.5 mm re-sults in significantly less radiograph-ically detectable crestal bone loss and better soft tissue support in the es-thetic zone. Platform shifting can be accomplished with the NobelReplace Platform Shift tri-channel (figure 2) or NobelReplace Conical Connec-tion (figure 3), 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 Connec-tion implants during the pre-launch and evaluation stages. To date, our practice has placed over one hun-dred of these implants and have found the marginal bone levels and soft tissue esthetics to be excellent.

The surgical placement and in-strumentation is virtually identical to the standard NobelReplace sys-tem, making it ideal from a staff training and surgical armamentar-ium standpoint. A simple case illus-tration will demonstrate the ease of use and predictability.

Platform shifting in practiceThe case illustrated in this page is of a 78-year-old man who had a vertical and horizontal fracture through tooth #9 (FDI 21), evident clinically and on the pre-op film (figures 4 and 5). The treatment plan was to remove #9 and to immediately place a NobelReplace Platform Shift with immediate load.

This implant was chosen to maxi-mize soft tissue volume in hopes of

Fig. 1. Platform shifting has been designed to maximize soft tissue volume.

overcoming any negative tissue in-fluences from a large maxillary fre-num. The tooth was atraumatically removed and a surgical guide was fabricated to assist with depth place-ment of the implant.

The osteotomy was started with twist drills, but finished with osteo-tomes to preserve the buccal plate. A 5 x 13 mm NobelReplace Platform Shift implant was placed using the 4.3 mm implant driver, placing the implant to just below the facial height

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 advan-tage of the platform shift.

A 6 x 3 mm healing abutment, 4.3 series was placed on the implant (fig-

ure 7), and the patient was then seen by his restorative dentist for immedi-ate temporization (figure 8).

The patient functioned on the im-mediate temporary for 12 weeks, at which time the final impression was taken (figure 9). Note that at all times the integrity of the marginal bone was preserved.

A CAD/CAM custom abutment was fabricated using the NobelProc-era Scanner and Software (figure 10).

The final crown was inserted at 14 weeks (figure 11). As can be seen in the final restoration (figure 12), tissue level integrity is preserved.

Our practice has acquired a great deal of experience with NobelReplace Platform Shift and Conical Connec-tion implants over the past year. We have seen superior esthetic results with excellent preservation of soft tis-sue and crestal bone. Although the fol-low-up period is relatively short, pre-liminary results are very encouraging. This is an excellent addition to the Nobel family of implant products. <

Temporary and final crowns

courtesy of Dr. Craig M. Allen.

Fig. 4–5. Pre-op clinical and radiographic views.

Fig. 8. Temporary crown at six weeks post-op.

Fig. 9. Impression appointment 12 weeks post-op.

Fig. 6–7. Extraction site and implant with healing abutment.

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.

Visit Nobel Biocare at events around the world. They provide a great opportunity for observing the latest innovations and scientific research.

2012

IDEM Singapore

20–22 April

Singapore

Dental Salon Moscow

23–26 April

Moscow, Russia

Scandefa

26–28 April

Copenhagen, Denmark

ODA Spring Meeting

10–12 May

Toronto, Canada

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


9–11 June

Odessa, Ukraine

Sino Dental

9–12 June

Bejing, China


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


19–20 October

Rimini, Italy


19–20 October

Toronto, Canada

To find out more, visit |

nobelbiocare.com/events

Upcoming Events

www.nobelbiocare.com/events


Meeting One-of-a-kind Patient NeedsCustom-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

No 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 custom-made 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 med-ical emergency.

Not your normal solutionCustom-made solutions are tailored to fit a unique and one-time patient need. These special solutions extend

beyond the typical esthetic circum-stances and can also be used to assist trauma victims, including those re-covering 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-

vidually designed products for doc-tors to have in stock for similar indi-cations. 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 15 product categories, under the headings of “abutment components”,

“restorative auxiliary”, “surgery com-ponents” and “miscellaneous” (which includes maxillofacial surgical com-ponents).

Attention to detailThe production process typically takes around five weeks, unless an-

other timeline is decided upon. Each case that comes in requires great at-tention to detail and must be as-sessed 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 45 years at the forefront of implant-based restora-

“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 respon-sibility 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 Bio-care can further cater to needs be-yond its core assortment.

In many circumstances, clinical indications may be so complex that only sophisticated custom-made so-lutions are the right answer. <


For a longer version of this article,

please continue the story in our

enhanced digital edition at:


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.

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

NobelClinician 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 treat-ment directly to the patient,” says Dr. Pascal Kunz, who leads the guided

The Freedom to Choose and an Upgrade, tooNobelClinician™ – for the Mac®, for Windows®, for you!

surgery solutions team at Nobel Bio-care. “A clinician using a software like NobelClinician projects a modern image which can help build up addi-tional confidence with the patient that this is the most favorable treat-ment for him or her.”

Making a good impressionNothing says “cutting edge” like dem-onstrating a treatment plan to a pa-tient 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. <


Please continue reading in our



NobelClinician Software version 1.5 is now available as an upgrade for current users or for purchase as new.

Here’s some good news: opening up for other implant systems,

NobelClinician v1.5 includes Strau-mann® implants fully integrated into the system for planning for the first time.

What’s more, reports in the new version contain more clinical infor-mation than ever before. The OPG cross-sectional X-ray views are in-cluded 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 3D model. Caused by metal fill-ings in remaining teeth, these arti-facts are now history, leaving a clean 3D bone model that makes for faster planning, good-looking lecture pic-tures and easier-to-understand pa-tient presentations.

In version 1.5, tooth roots can now be visualized in the 3D 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 extrac-tion in the 3D scene so the extraction socket can be visualized.

New clinical warnings have also been added. You will now get a plan-ning 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. <

See more: Streak artifacts are gone and tooth roots are now shown in 3D.

➜


www.nobelbiocare.com/custom



Fig. 1. Patient with a significant defect in the left maxilla. The patient was injured from a gun shot.

Fig. 8. Bridge delivery followed by lip correction.

Fig. 4. Virtual computerized planning showing the three planned implants in correct interrelated positions, but in a remote site.

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. 3. Implants, placed with the aid of the NobelGuide concept.

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. 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.

Cross-border Cooperation Solves CaseSolution 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 & Maxil-lofacial Surgery at Umeå University in Sweden sends us the following treatment report.

By Professor Stefan Lundgren

A 24-year-old female was wounded by a gunshot dur-ing a robbery in a store. The

9 mm bullet, fired from the distance of a few meters, resulted in a signifi-cant 3D-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 24-year-old Estonian female was seen in a consultation visit in Tallin by Dr. Juha Peltola, an oral & maxillofacial surgeon in private prac-tice in Helsinki, who referred the pa-tient for treatment planning—and if possible, treatment—to the Depart-ment 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 re-storative dentist from the Depart-ment of Prostetic Dentistry at Umeå.

The first step was a contact with Nobel Biocare to help with the fund-ing of travel expenses, laboratory costs and components. Financial ne-gotiatons were carried out with the University Hospital and The Dental

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 archi-tecture for the later placement of im-plants.

Three months later, a CT with a ra-diological guide was performed in Helsinki and the implant placement was virtually planned with Nobel-Guide treatment planning software in collaboration with Matts Anders-son and Andreas Pettersson at the Nobel Biocare office in Gothenburg.

We placed the implants in the of-fice of Dr. Peltola in Salora, Finland, with help from the surgical guide de-rived from the preoperative Nobel-Guide 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 im-plants—was all performed in the vir-tual 3D environment. The implants were allowed to heal for two months before the distraction surgery was ini-tiated. The external distraction device was custom-designed by the Depart-ment of Early Development, Nobel Biocare in Gothenburg.

A distraction deviceThe custom designed distraction de-vice 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 tem-porary bridge, which was retained with temporary cement, as a splint, on the posterior dentition.

The third surgical phase was per-formed in Umeå under local anesthe-sia 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 tempo-rary bridge was cemented to the pos-terior maxillary teeth, and the surgi-cal wound was closed with sutures.

The patient went home to Tallinn the day after surgery and the active distraction was started ten days after

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 con-solidation before the distraction de-vice 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 re-turned again for the final adjustment of the bridge. After delivery of the corrected bridge we did the final sur-gical correction of the upper lip.

Note on techniqueAccording to this treatment protocol, we place the implants in the bone graft to allow optimal placement in the bone regardless of the final im-plant position. If the implants are correctly positioned in relation to each other, the bone segment (in-cluding the implants) can later be transported to the final correct posi-tion for the temporary bridge. This

requires treatment planning per-formed in a virtual 3D 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 ex-tra-mucosally positioned. The dis-traction 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. <

More to explore:

Breine U, Brånemark P-I.

“Reconstruction of alveolar jaw

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.


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

Nobel Biocare first introduced TiUnite to the market in 2000 on its Brånemark Sys-

tem implants, and then applied it to Replace Select in 2001. Today, TiUnite is available on all Nobel Biocare implants, including those with machined collars.

Unlike implants with machined surfaces, TiUnite has clinically dem-onstrated the ability to increase the predictability and speed at which dental implants osseointegrate through osteoconductive bone for-mation (Glauser et al, 2001).

TiUnite is formed by spark anod-ization in an electrolytic solution containing phosphoric acid. This re-sults in a thickened titanium oxide layer (up to 10 microns) and a mod-erately rough porous surface topog-raphy (Ra 1.2). TiUnite contains ana-tase 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.

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.

TiUnite® – A Unique BiomaterialA remarkable set of images displays the process of osseointegration as it’s never been revealed before.

titanium oxides, and is thereby a highly crystalline biomaterial. Stud-ies have also shown the presence of phosphorus in the oxide layer (Laus-maa & Hall, 2000; Schüpbach et al, 2005). Thus, TiUnite may have both a topography-related as well as a chemistry-related effect on osseoin-tegration.

This article explains how TiUnite interacts with living tissue and ac-celerates wound healing.

An inevitable chronologyWound healing comprises a cascade of events that the body brings into play to resolve injury. Nature’s first

priorities are to stop bleeding, re-store function and to prevent infec-tion. Generally, the wound-healing events are grouped into four phases: hemostasis, inflammatory, prolifer-ative/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 nega-tively 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 trans-forming growth factor beta (TGF-b).

These factors play a crucial role in the regulation of the wound-healing

cascade (Park JY et al, 2001; Marx RE, 2000). During the first ten min-utes, 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 phaseThe inflammatory phase begins minutes following the implant in-sertion and continues for approxi-mately two days.

Neutrophils are the first cells at-tracted by chemical signals released by the platelets, followed by macro-phages. Both cell types will phago-cytize small bone debris. The fibrin will be broken down by the enzyme

plasmin and the debris will also be removed by the leukocytes. Fibrino-lysis starts already during hemosta-sis but is slower and thereby con-tributes 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 pro-visional matrix (Schüpbach et al, in preparation).

Day 3 to 5The proliferative/repair phaseThe proliferative phase is character-ized by granulation tissue forma-tion, angiogenesis, collagen deposi-tion, and wound contraction. In granulation tissue formation, fibro-blasts invade the wound and form a

S&Esafety and efficacy

more on following page


Recent Findings

TiUnite® 10-year, Immediate Loading

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 sur-

face, and an external hexagonal connection.

Success and survival rate for restorations and implants, changes in

marginal peri-implant bone level, probing depth measurements, biologi-

cal 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

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 StudyAlso 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-

ular Overdentures: Early versus Delayed Loading,” by Drs. Ilser Tur-

kyilmaz, 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.

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 predict-ability and speed of dental implant osseointegration. Help us celebrate a decade of success by reading all about it:

More to explore:

nobelbiocare.com/resources

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.

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).

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 con-tract themselves.

Now the benefit of the TiUnite topography comes into play as the moderately rough surface diminish-es the ECM retraction from the sur-face—when compared to smooth surfaces—and inhibits its retraction from the surface. This is a prerequi-site for osteoconductive bone forma-tion as osteogenic cells, again attract-ed 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 mi-grate 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 os-teogenesis already has reached the surface. At the front of bone forma-tion they will become differentiated to osteoblasts. The latter will form

the bone collagenous bone matrix, which eventually becomes mineral-ized, and woven bone is formed.

The strength of TiUnite in this phase of the wound healing is obvi-ous: the porous surface is an ideal substrate for the migration of osteo-genic cells along the surface (Schüp-bach et al, 2005) and the surface properties (with Ra < 2 μm and Rm

> 5 μm) are optimal for the differen-tiation of stem cells into osteogenic cells (Schwartz et al, 2000). Accord-ing 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 ma-trix only perpendicularly to the sur-face—and thereby directly into the open TiUnite pores (Schüpbach et al, 2005). A kinetic study about early bone formation with TiUnite showed initial bone formation and its direct anchorage already around day 7, thereby maintaining the primary sta-bility (Schüpbach et al, in prep.).

“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

ConclusionsTaken together, the unique TiUnite properties allow teamplay between topography-related as well as chem-istry-related factors to accelerate osseointegration.

Therefore, it’s not surprising that a variety of animal and human studies have demonstrated enhanced osseo-integration, both in terms of speed

and amount of bone-to-implant contact on par with that of hydroxy-apatite surfaces, which many still consider the gold standard for osteo-conductivity (Zechner et al, 2003).

From a clinical perspective, Ti-Unite has enabled the predictable ap-plication 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 im-mediate function solutions to a very high and very reliable level of success (Glauser 2011). <

from the previous page

www.nobelbiocare.com/tiuite-10-year-abstract

www.nobelbiocare.com/resources


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.

By Christina Bergström

S tatistics make it possible to organize material for system-atic 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 competi-tions” and “Three times out of 10, he has done well at competitions.” “Usually” means different things to different people. Statistics serve well to define the relationship between any two variables.

Quality and format Presentations of results and conclu-sions are often based on statistical analyses. Their reliability depends not only on the quality and the man-ner of presentation, but their inter-pretation by the reader as well. Inter-pretation 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 reason-able to draw the conclusions being presented from the figures available? Is it reasonable to talk about 5-year results when only 9 of 3000 subjects in a study have attended the 5-year checkup? What is the objective of the report? Who may profit from the re-sults?

Diagrams can be used when pre-senting material. They can provide the reader, i.e. the interpreter, with both numerical and visual informa-tion, but it is important to under-stand that such visual information can easily be manipulated by simple modifications of the diagram.

Cut-offs exaggerate A diagram axis can be “cut off ” to produce more dramatic differences.

If it is the intention of the author to exaggerate the differences between narrow range values (93%, 95% and 97%, for example) a diagram axis can be “cut off ” as seen in figure 1.

Proportions are lost with a “cut-off ”, 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 1. If a cut-off of the axis is necessary to make a point, the cut-off should be clearly marked to aid in interpretation.

Optical illusions 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 2.

Another way of changing the visu-al 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 3. The vertical axis should, whenever possible, be the frequency axis be-cause a horizontal frequency axis makes the differences in the chart appear to be smaller.

Tables instead of graphs?Data can also be presented in tables. Good tables must be easy to read and easy to interpret; otherwise the read-er will easily lose interest. Some ta-bles are so detailed that it is impos-sible to determine which are the important parts of the table. Identi-fying the columns in the table by let-ters or abbreviations can also make it more difficult to interpret.

When comparing different groups within a population or when com-paring different populations, the manner in which the groups/popula-tions 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.

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 4), and the long-

Statistics can be DeceivingBe forewarned: Everyone has an axe to grind, a point to prove, or a product to sell.

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 75 percent of the initial group must remain in the study (including any failed fixtures) to draw any reli-able conclusions. The reader will find it difficult to interpret the re-sults if only one part of the lifetable is presented, especially if only the cumulative success rates (CSR) are presented.

Lasting impressions 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 peri-ods (see figure 5A). This obscures for the reader the fact that the number of controlled implants during the pe-riods in question has decreased suc-cessively at the same time (see figure 5B) and that the success rate figures hardly vary at all from one time peri-od to the next (see figure 5C).

In order to give the reader an over-all picture when presenting the re-sults of a comparison, it is important to carefully state what actually has been compared. The size of the com-parative 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 impor-tant to spell out the plan of investiga-tion for the reader.

The loss of subjects due to drop-out, infirmity or death is a difficulty faced in most clinical trials. The ef-fects can be far-reaching. Suppose the objective of a study is to resolve the proportion of 1000 implanted fixtures that survive 5 years after the operation. If data is only collected on 500 of the fixtures and 50 of the 500 have failed, the failure rate may ap-pear to be 10 percent but, if the other 500 have failed, it means that 55 per-cent is a more reasonable figure. On the other hand, if the 500 uncon-trolled fixtures are all survivals it means that only 5 percent have actu-ally failed.

In some cases, figures must be rounded off. If the result is presented with figures that show “great preci-sion” (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

Figure 4: A lifetable.

Time period

No. of inserted/controlled implants

No. of failed implants

No. of withdrawn implants

Success rate

Cumula-tive suc-cess 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

100%

80%

60%

40%

20%

97%

96%

95%

94%

93%

Figure 1: Two diagrams that describe the same result. The frequency axis has been “cut off” to exaggerate the percentage differences.

a b c a b c

93 95 97

93

95

97

10

8

6

4

2

10

8

6

4

2

Figure 2: Broader bars make differences in a bar chart appear less dramatic.

a b c d a b c d

60

50

40

30

20

10

10 20 30 40 50 601 2 3 4 5

Figure 3: A change in axis gives a different impression.

No.

of

faile

d im

pla

nts

No. of failed implants

Group

1

2

3

4

5

Gro

up

more on following page

used to demonstrate the results. This gives the reader the impression that the study encompasses well-con-trolled 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 un-derstood 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 wheth-er or not the two variables are associ-ated. One may conclude a relation-


Implant screws are decep-tively simple and exquisitely intricate at the same time.

By Dr. Chandur Wadhwani

Implant 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 set-ting turns the screw into a “spring” that clamps the components togeth-er, improving the joint fixation more than if the screw is simply tightened.

This produces a robust joint, capa-ble 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.

The Science A systemic review of abutment screw loosening in single-implant restora-tions found that abutment screw loosening is a rare event regardless of the geometry of the implant abut-ment connection, provided that ap-propriate anti-rotation features exist and proper torque is employed.

Rule number 1 Always use original Nobel Biocare manufacturers components and parts. “Compatible parts” may look

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.

Rule number 2 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 unpre-dictable joint behavior.

Use of lubricants, ointments and medications affects the implant/abutment joint, especially under vi-bration. It is not advised and may lead to premature screw loosening.

Rule number 3 Check that your torque wrench is delivering the correct force re-quired. 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 il-lustration) as it delivers more consis-tent force. If you have the toggle type (not recommended) calibrate or re-place your device yearly—ask Nobel Biocare for details.

Rule number 4 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 im-prove the fastening properties of the joint. As a general rule, only tighten/loosen the screw a maximum of five times. <

More to explore:

Theoharidou et al. “Abutment

screw loosening in single-implant

restorations – a systemic review.”

Int Journ Oral Maxillofac Implants.

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 Vibra-

tion. 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

in seven abutment-implant sys-

tems.” Journal Prosthet Dent.

2000.

Research Put into PracticeKnow your implant procedures: the use of torque drivers and implant screws

A beam type torque wrench is the type recommended by the author because it delivers more consistent force than the toggle type.

T&TTips and Techniques

ship between two variables if one variable varies simultaneously with another.

This is called a correlation; it im-plies no cause/effect relationship. Although there may be a cause/ef-fect relationship, even a third vari-

able could be the cause of both of the observed changes.

When reading articles that in-clude statistical analyses in medical magazines or journals, in newspa-pers 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 writ-er 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. <

from the previous page

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.

Year 1 2 3 4 5 6 Year 1 2 3 4 5 6 Year 1 2 3 4 5 6

No.

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Precision-milled Abutments For Major Implant Systems

NobelProcera™

Clinical screw with unique TorqTite surface included

nobelbiocare.com/nobelprocera

www.nobelbiocare.com/nobelprocera


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

Fig. 5. Fitting of the NobelProcera Zirconia Abutment.

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. 6. Fitting of the NobelProcera Zirconia Abutment.

Fig. 3. The situation 20 weeks after extraction.

Fig. 4. Treatment 20 weeks after extraction, impression taking with impression coping.

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.

Initial situation using NobelActive NP 3.5 x 11.5: 36-year-old female patient in good overall health, non-smoker, no parafunctional habits

The photos in figures 1–8 courtesy of Roberto Sleiter (Switzerland).

Excellent Initial Stability and Perfect Esthetic ResultsNobelActive™ is the most versatile choice for your implant dentistry practice.

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 con-denses the bone during

insertion at every turn, which differ-entiates it from other self-tapping im-plants available on the market.

The expanding, tapered implant body of NobelActive features a dou-ble-lead thread design, which also contributes to the high initial stabili-ty characteristic of this implant.

The innovative implant tip allows fine adjustments in implant orienta-tion to be made during insertion to optimize the final position of the im-plant in the bone, without jeopardiz-

ing initial stability. The implant thread allows gradual atraumatic narrow ridge expansion and was de-veloped to attain high initial stability even in compromised bone situa-tions.

Furthermore, NobelActive has two reverse-cutting flutes. Rotating the implant by half-a-turn counterclock-wise engages the cutting capability of these flutes. The coronal region of NobelActive is back-tapered and de-signed to maximize alveolar bone volume around the implant collar for improved soft tissue support.

These new attributes provide sig-nificant advantages for the subse-quent 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, 2005). TiUnite is a highly crystalline and phosphate-enriched titanium oxide surface, available exclusively from

Nobel Biocare. This patented, bio-compatible surface has been scientifi-cally proven both in the long and short term to enhance osseointegra-tion and increase the predictability of implant treatment (Glauser, Zembic, et al, 2007; and Glauser, Portmann, et al, 2001).

Many prosthetic solutionsNobelActive has an internal conical connection. The connection offers the clinician the option of restoring the tooth with a wide range of prefab-ricated 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 individu-ally designed using state-of-the-art 3D computer-aided design software (CAD) and then milled from high-strength zirconia or titanium in a computer-assisted manufacturing (CAM) process.

Getting it right from the startProduct development at Nobel Bio-care is based upon the principles established by Professor Per-Ingvar Brånemark, namely that all innova-tion should be based on sound sci-entific research and subjected to sys-tematic clinical evaluation before entering full-scale commercial dis-tribution. That is why NobelActive went through rigorous clinical trials, eight months of clinical testing and extensive technical study in the pre-launch phase. Dentists from every corner of the globe participated in the endeavor.

At the beginning of this eight-month period, when over 30,000 im-plants were used, the clinicians re-ceived 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 con-firmed how important previous training was in order to make the most of the novel and innovative

properties of this implant. Nobel Bio-care therefore strongly recommends participating in a practical training course before using NobelActive.

Science first and foremostNobel Biocare is currently con -ducting 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

NobelActive now offers a new, true 3.0 mm small-diameter implant for successful restora-tions in the anterior region where space is limited and good esthetics essential.

www.nobelbiocare.com/resources



Here is a case study of implant placement immedi-ately after a molar extraction using NobelActive in conjunction with immediate temporary loading.

By Dr. Ira Schecter

T his patient is a healthy, middle-aged male with no medical pre-

conditions and satisfactory oral hy-giene.

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 select-ed was to extract the tooth and place an immediate dental implant into the socket site.

Figure 2 illustrates how the tooth was extracted atraumatically, pre-serving as much of the surrounding bone as possible. We chose a Nobel- Active dental implant because its surgical protocol dictates minimal osteotomy preparation and thus al-lowed me to utilize the available in-ter-septal bone between the two root socket sites. The implant was sub-merged 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 chal-lenged to greater than 50 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 stabili-ty, 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 24 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 35 Ncm and then an all ceramic NobelProcera Zirconia Crown restoration was cemented on top of the abutment, completely cov-ering the metal underneath.

Fulfilling high expectationsPatients today want to be treated in an efficient and expedient manner. For years, we have been able to ex-

Immediate Loading of a Molar, Post-extractionNobelActive™ – a solution for the restoration of both single- and multi-rooted teeth

Fig. 1. The molar to be extracted.

Fig. 7. Permanent NobelProcera Crown.

Fig. 5. Custom NobelProcera Titanium Abutment.

Fig. 4. Immediately loaded temporary.

Fig. 3. Immediate placement and impression.

Fig. 6. X-ray of NobelProcera Titanium Abutment.

Fig. 2. X-ray of Immediate temporary.

tract single-rooted teeth, place im-plants immediately into the socket sites and immediately load the im-plants 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 be-lieve—as long as we carefully follow the surgical and implant placement guidelines. <

More to explore:

nobelbiocare.com/nobelactive

NobelActive™ Expands its Range of ComponentsA 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 Nobel-

Active. 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 indica-tions. Having a secure and strong conical connection offers built-in

platform shifting and has meant that I see crestal bone heights re-maining stable to the top of the im-plant in many more cases than pre-viously.

A pleasure to work withMany 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 com-ponents that were taller in order to make transmucosal healing possi-ble.

As always, the people at the R&D department of Nobel Biocare wel-comed our queries, were open-minded 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 7 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 prod-uct portfolio. <

More to explore:

Check out all the NobelActive

components at:

nobelbiocare.com/healing

Restorative Flexibility7 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.

www.nobelbiocare.com/healing

www.nobelbiocare.com/nobelactive


A well-known and often-quoted pioneer in the field of biomechanics—who not incidentally holds the position of Senior Research Engineer, Division of Plastic & Recon-structive Surgery at Stanford University in California—sends us this report on the state of the art.

By Professor John B. Brunski

Most clinicians already ap-preciate 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 some-what “loose”, how does this looseness relate to “micromotion”? Moreover, why is the “tightness” vs. “looseness” of an implant important from a me-chanical and biological (i.e. biome-chanical) standpoint?

Finding some answers starts with two initial points.

Point 1First, 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 cement-ed onto all six implants (Figure 1a).

Suppose that two out of the six im-plants 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: [1] the bone around the implants was quite porous and therefore much more deformable, leading to a some-what “soft” interface; [2] 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 measure-ments and calculations that when rel-atively “stiff ” implants exist in the same distribution as “less stiff ” im-plants, then the stiffer implants end up taking most of the load—effec-tively converting a six-implant situa-tion (in this example) into a four-im-plant case (Figure 1b).

Overall, the general result is that when a prosthesis is supported by multiple dental implants, load-shar-ing among the implants depends on the relative stiffness of the implants, with “softer” (less stiff) implants tak-ing less load than the “stiffer” im-plants. 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 2The second reason why “loose” im-plants are a problem stems from the biological consequences of the associ-ated “micromotion” at the bone-im-plant interface. The term “micromo-tion” refers to relative displacements of a loaded implant with respect to the surrounding interfacial bone.

A simple example of rather ex-treme micromotion is to imagine a 4 mm diameter implant that’s loaded after being placed into a 4.5 mm di-ameter 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 ex-erted 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 bio-logical problem (besides the fact that the implant would not function well in load support)? The answer is that many studies demonstrate that mi-cromotion—if it is “excessive”—will interfere with the biology of proper interfacial bone healing. For exam-ple, some authors have proposed that

“excessive” micromotion could be anywhere from 20 to 150 µm (de-pending on the author), i.e., this range of values represents the thresh-old beyond which there will be inter-ference in bone healing.

However, it is also clear that this threshold has not been established very precisely or whether it even per-tains to all the differently-shaped im-

plants that exist. Most significantly, the search is still on for the underly-ing mechanism(s) by which micro-motion interacts with the interfacial biology to either negatively (as most authors believe) or perhaps positively (as at least some authors have sug-gested) influence interfacial reac-tions.

Searching for claritySo, 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 im-plant 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 relat-ed to deformation. When it comes to strain in interfacial tissues, Figure 2 depicts two highly magnified, ideal-ized views of a bone-implant inter-face as it might look soon after im-plantation (e.g., seconds to a few

hours). Figures 2a and b show the “before” and “after” states of the in-terface following some amount of im-plant micromotion.

In this example, the micromotion consists of a bodily displacement of the implant threads to the right, to-ward the cut edge of the bone that borders the interface. Figures 2a 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 typi-cal interface, there is the possibility that the threads of a freshly-installed implant may not directly interdigitate with bone of the site.

Figure 2a goes on to illustrate that, early after surgery, such a small gap between implant and cut bone will ordinarily fill with a blood clot com-prised of fibrin, red blood cells, plate-lets, growth factors, etc. Strain of the interface comes about as we consider the difference between the state of af-fairs in Figure 2a (which depicts the implant threads before there has been any micromotion of the implant rela-tive to the cut surface of the bone) and Figure 2b (after the threads of the implant have been displaced some distance to the right).

In comparing these two images, we observe (Figure 2b) regions of defor-mation of the interface, e.g., regions of compression, tension (stretching), and shearing of the cells and fibrin in the gap region. So at least qualitative-ly, what this example shows is the idea that implant micromotion can end up deforming (straining) the in-terfacial 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 2a and 2b 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 stretch-ing (tension, “pulling”) of the yellow-ish fibrin fibers. A detailed quanti-tative engineering strain analysis at discrete points in this image could be done, but the key take-home messag-es connected with strain are these:• Atanygiven“point” (location) in

the interface, one can define a state of strain—which is also called the strain state at that point.

• This strain state in the interfacecan depend on many factors—in-cluding the amount and direction of the implant’s micromotion as well as the implant’s shape and fit in the drill hole, etc.

• Strainatacertainpointinthein-terface 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 simulta-neously tension or stretching along the length dimension but also compression in the width and thickness directions.)

• In engineering terms, the strainstate 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.

• Lastly,anymaterialwill failwhenthe strains (which are related to the stresses) become too large—a fact that applies for both biological ma-terials (such as bone and soft tis-sue) and man-made materials (such as titanium). <


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



Micromotion and Dental ImplantsA research update in two parts – with thought-provoking consequences for longevity

Fig. 2a. Unstrained: Cells and fibrin are intact and not damaged in any way. Used and modified from Marx, 2008, with permission.

Fig. 2b. Strained: In this example, implant threads move to the right, compressing the cells and fibrin against the bone.

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.

R&DResearch and Development

THREAD

THREAD

Axi

al lo

ad (N

)

n = All implants equally stiff

s = Implants no. 1 & 6 less stiff

300

200

100

0

–100

–200

–300 | | | | | |

6 5 4 3 2 1

Implant number

Vertical load

Estimated neutral axis of implants



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.

Treatment performed: Four im-

plants were placed in the interfor-

aminal area of the mandible and six

implants in the maxilla for bar re-

tained fixed-removable restorations.

Case notes: The long-term suc-

cess of an implant-retained resto-

ration 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 pros-

thetic 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.

The Best Marketing Tool is a Satisfied Patient

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.

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 pa-tient. The most successful offices have a good understanding of the psycho-logical make-up of each patient. Ini-tial insights from a treatment coordi-nator, dental hygienist, or even a dental assistant should be taken into consideration by the dentist.

there. Practical benefits and the sci-ence that makes them possible should always be a part of the conversation.

Comparison shoppersThen there are the self-assured pa-tients 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 warran-ties you offer, and be specific about finances. Chances are, your treat-ment plan will differ from other of-fices’ 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 differ-ent. Before having that first conversa-tion about implants, gather input from your staff about the patient’s in-terest, knowledge and motivation, and then listen carefully to what the pa-tient has to say. <


Dr. Goldstein answers more

questions in our enhanced digital

edition at:


Q&AQuestions and Answers

By Pat Farrell

I feel very lucky, when I look at my friends who are around my age.

They are mostly over seventy. Strug-gling 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 ex-perience that.

I always had problems with my teeth and oral health in general. I re-member a time when I wasn’t com-fortable 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

“The best decision I ever made!”Meet Pat, 69, who had her first implant 23 years ago.

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! <

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 pa-tient has approached you because of your website, then you need to realize that this patient has probably already done a considerable amount of home-work. I like to ask patients like these what more they want to know and then build the presentation from



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Design and printing: www.linkgroup.ch

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PolandNobel Biocare PolandPhone: +48 22 549 93 50Cust. support: +48 22 549 93 52

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CanadaNobel Biocare CanadaPhone: +1 905 762 3500Cust. support: +1 800 939 9394

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BrazilNobel Biocare BrazilPhone: +55 11 5102 7000Cust. support: 0800 169 996

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AustraliaNobel Biocare AustraliaPhone: +61 2 8064 5100Cust. support: toll free 1800 804 597

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IndiaNobel Biocare IndiaPhone: +91 22 6751 9999Cust. support: toll free 1 800 22 9998

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South AfricaNobel Biocare South AfricaPhone: +27 11 802 0112

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Distributor Markets

Bahrain, Bulgaria, Croatia, Cyprus, Czech Republic, Greece, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Malta, Oman, Romania, Saudi Arabia, Serbia, Slovakia, Slovenia, Turkey, United Arab Emirates and Qatar

Phone: +48 22 549 93 56Cust. support: +48 22 549 93 55

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Headquarters

Nobel Biocare Services AG P.O. Box 8058 Zürich-Flughafen, Switzerland

Offices: Balsberg, Balz Zimmermann-Strasse 7 8302 Kloten, Switzerland Phone +41 43 211 42 00 Fax +41 43 211 42 42

Web contact: www.nobelbiocare.com/contact

This year, scientific symposia will mark the dual anniver-saries of the advent and acknowledgement of osseoin-tegration.

by Frederic Love

I n 1952, Per-Ingvar Brånemark dis-covered the principles of osseointe-

gration in Sweden. Thirty years later, in 1982, the discovery was acknowl-edged, and his subsequent findings confirmed, at an epoch-making meeting of dental authorities orga-nized by George Zarb in Canada. Yet another thirty years have now passed, and Nobel Biocare is celebrating both these 30- and 60-year anniversaries in Sweden, Canada, and four other loca-tions, too.

Starting the year-long celebration in the hometown of osseointegra-tion—Brånemark’s Gothenburg—Nobel Biocare brought together some of the best-known names in the field on March 21–23. The event began with a surprise entrance from Bråne-mark himself who delivered advice and thoughts for the future. Ulf Lek-holm 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.

Pioneers from the heady days of the Toronto Conference of 1982, such as George Zarb and Ragnar Adell, were honored and other speakers re-minded participants of how far Per-Ingvar Brånemark, Nobel Biocare and their band of supporters have brought osseointegration since those days of breakthrough 30 and 60 years ago.

Eyes on the horizonThe programs of all five of the re-maining Nobel Biocare Symposia 2012 will celebrate the origins and evolution of osseointegration as a practical and trusted treatment mo-dality over the last six decades.

Each program will also include lec-tures on recent advances in treat-ment, presented from surgical, pros-thetic and laboratory perspectives.

Celebrating the Triumph of Osseointegration Revolutionary breakthroughs – 30 and 60 years on

300 Years of Experience Take 300 Years to GainWorld-renowned experts are the voice of experience today

Speakers will look towards the future as well, presenting current trends and possible future developments for bone-anchored restorative dentistry.

Under the common theme, “Cele-brating 60 years of osseointegration and 30 years of international ac-knowledgement,” meetings will be held in Avignon, France (June 1-2), Odessa, Ukraine (June 9–11), Ham-burg, Germany (June 15–16) and Ri-mini, Italy (October 19–20), with the final symposium planned for Toron-to, Canada (October 19–20) 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

Prof. George Zarb at this year’s first Nobel Biocare Symposium.

Despite their small numbers, members of the Associated Brånemark Osseointegration Centers represent an enormous amount of cumulative experience in the field of osseointegration.

Recently, a small group of osseoin-tegration 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 Nann-mark, Patrick Palacci, Laércio Vas-conselos, Mats Wikström, William Becker and Lars Sennerby.

Together, this small band of im-plant experts has accumulated more than 300 years of experience of im-plant treatment ad modum Bråne-mark.

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 pro-vide 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 under-take to improve existing diagnostic, surgical and restorative techniques, and to spread awareness and knowl-edge of osseointegration.

At the Gothenburg meeting, the group underlined the central impor-tance of the team approach to success-ful outcomes, and in a formal state-ment prepared for publication in Clinical Implant Dentistry and Related Research, they also wrote that the “prerequisites for a successful long-term implant treatment outcome in-clude 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

www.nobelbiocare.com/300-years

www.nobelbiocare.com/symposia2012

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