Yet Another Patient First You Can Expect Innovation from Nobel Biocare Because Nobel Biocare Delivers – Time After Time

Nobel Biocare NEWS Celebrating Twenty Years of Publication Issue 1/2018

In this Issue

3 At the cutting edge Mastering the All-on-4® treatment concept provides a practical pathway toward professional leadership

8-9 Trefoil biomechanics: “Less is more,” said Mies van der Rohe. Professor John Brunski agrees. Don’t miss his article: “The Three Pillars of Trefoil.” Yet Another Patient First You can expect innovation from Nobel Biocare because Nobel Biocare delivers – time after time.

Words like these have been re- to conceive and shepherd unconven- tion of the many unprecedented Nobel Biocare News has been corded over and over again for pa- tional solutions to market; cautious, in steps forward taken by Nobel Bio- reporting on advances in the tients benefitting from either the All- order to be able to substantiate every care over the years. 10 Prof. Tomas Albrektsson field of implant-supported on-4® treatment concept or the claim they make as they deliver, and puts TiUnite to the prosthetic solutions for twenty Trefoil system—but never before then support, a new product. Innovation as a lifestyle ultimate test with years now. In our very first In recent years, Nobel Biocare inno- colleagues from around issue, on the very first page vative thinking has been extended to the world. (in what was then known as “Dr. Jivraj and Dr. Zarrinkelk, who worked on my promoting basic and applied science, Nobelpharma News), we case together, found an extraordinary solution that continuing education and humani- headlined how close ties works very well for me.” tarian projects. between scientists and clinical — Kathleen Mattson, pictured above The company-sponsored Foun- researchers were essential to dation for Oral Rehabilitation, FOR, the success of the burgeoning for instance, has developed a pio- enterprise that would come to from a single patient who has re- The results of this apparent di- neering online platform for dental be known as implant-based ceived both forms of treatment at the chotomy speak for themselves. Nobel education and treatment support. Cellular adhesion to the dentistry. This observation same time. Biocare has been first-to-market Unlike others in this T&E space, TiUnite surface as seen in remains no less true today. Mattson may be the first patient to with such groundbreaking, scientifi- FOR provides unlimited access to an SEM image. benefit from both simultaneously, cally supported innovations as the content created and reviewed by By Frederic Love but she is unlikely to be the last. world’s first successful system of leading experts in the field of den- Thanks in no small part to outstand- dental implants—the original Bråne- tistry, and at no cost to the user. 11 Save the dates now! athleen Mattson’s dental res- ing clinical results, both the All- mark System—then the first digitally Nobel Biocare supports FOR, its The next Nobel Biocare toration comprises a Trefoil on-4® treatment concept and the Tre- designed ceramic crowns; the first ideals, and our customers with a com- Global Symposium will Ksystem solution in her man- foil system continue to win over new zygomatic implants; the first angled mitment to deliver more than prom- be held in Las Vegas. dible and an All-on-4® treatment clinicians and patients every day. abutment; the introduction of pro- ised in every mutual endeavor. < concept solution in her maxilla. She You can read the story of Kathleen prietary cold-worked Grade 4 Tita- benefits from research and develop- Mattson’s treatment, in her own nium; the introduction of the Ti- More to explore! ment supported by Nobel Biocare in words, on page 3. Unite surface; the launch of the Please turn the page and read this an extremely practical way. All-on-4® treatment concept; the issue’s editorial by President Hans In her own words, “I not only Not the paradox it seems often copied, yet never equaled Geiselhöringer, who gives the hope, but feel confident, that the Nobel Biocare has proven itself to be a NobelActive implant; not to mention reader a clue or two about what’s treatment is going to have a positive company of bold—yet scientifically re- the recent advent of the Trefoil sys- coming next. impact on every aspect of my life.” served—professionals. Bold, in order tem; and these are just a small selec- 2 Nobel Biocare NEWS Issue 1/2018 From the President Working at the Cutting Edge The new and improved All-on-4® treatment concept is poised to help you further differentiate.

ing on 25 years of success with Nobel Hans Geiselhöringer, President Progressive clinicians demand Biocare’s zygomatic implants, the progressive solutions. That’s newest Nobel-Zygoma 0° and 45° im- You don’t establish trust overnight. why clinicians looking to plants provide greater surgical and Over four decades, Nobel Biocare has improve treatment outcomes prosthetic flexibility than previous built the business of reliable implant and grow their practice are options. They have an unthreaded dentistry by first fostering scientific using the All-on-4® treatment implant body designed to interface discovery, then translating it into the concept. Today backed by with soft tissue and, depending on the ingenious clinical concepts that you’ll almost 20 years of clinical anatomical situation, parts of the im- find featured on these pages. success, this established and plant body can be located outside of For years we’ve had to defend the proven approach for restoring the maxillary sinus. A new tapered data-based, scientific approach that full arches continues to evolve. apex design has been designed to sup- has produced pioneering products, Thanks to Nobel Biocare’s port high primary stability for Imme- The new Multi-unit Alignment Instrument makes it easy to identify the angulation of the most-suitable Multi-unit Abutment and the rotational only to find our detractors copying latest innovations, the diate Function. All-on-4® treatment concept is position of the implant; and the broad assortment of Titanium Multi-unit these products in the end. But we stay All these options are intended to Healing Caps makes individualized treatment possible. a step ahead—and persevere with more life-changing than ever, make it possible for clinicians to uti- this approach—in order to write the both for patients and dental lize the proven benefits of the All- suitable Multi-unit Abutment and the and mandible. Long-term follow-up next chapter of innovation. professionals. on-4® treatment concept in more rotational position of the implant, shows high cumulative survival rates As we launch one solution after an- cases, helping them build a reputation helping to optimize the final abut- of 94.8% in the mandible after ten By Núria Serra other in the year ahead, you’ll find for rapidly restoring quality of life for ment position and prosthetic design. years and 98.0% in the maxilla after that we retain a firm focus on en- patients who are experiencing the In addition, the Titanium Multi- five years. hancing esthetics and workflow effi- he key principle of the All- problems associated with dentures or unit Healing Cap assortment (see Becoming known for such success ciency while, at the same time, offer- on-4® treatment concept is well a failing dentition. above) facilitates the placement of the can help significantly increase patient ing entirely new options—such as the Tknown—it makes the full, provisional prosthesis. Designed to flow. In fact, 24% of those that attend- industry’s first fully metal-free two- graftless rehabilitation of an edentu- Reduce restorative chair time help individualize treatment, this ed a Nobel Biocare All-on-4® treat- piece ceramic implant solution. lous mandibular or maxillary arch In order for a clinician to be able to newly expanded portfolio of healing ment concept course grew the num- We’re working to establish new possible with just four implants and offer the benefits of the All-on-4® caps provides clinicians with a choice ber of implants they placed by 50% standards that will elevate the quality allows a provisional restoration to be treatment concept to more patients, of dimensions and designs to suit the the following year. of products you deliver to patients. In placed on the day of surgery.* treatment efficiency is also a key con- thickness of the soft tissue. These one- Importantly, this new generation of the process, many small copycats are With the latest innovations from sideration. If patients spend less time piece components are made of titani- componentry is just the next step in sure to fall by the wayside. Nobel Biocare, the next generation of in the chair, they will be more com- um to provide ease of placement, and the continuous evolution of the All- You have made us your partner be- this well-documented treatment pro- fortable during treatment, and clini- are single-use to prevent the deformi- on-4® treatment concept. As the com- cause we are robust and reliable. tocol has arrived. New versions of im- cians will consequently have the ty that can be caused by repeated ster- pany behind the original concept, We’re honoured by the trust you plants and abutments plus versatile chance to successfully treat more pa- ilization. Nobel Biocare is committed to further show and are committed to support- restorative options mean that even tients in a day. When it comes to the final restora- enhancing the componentry and ing your day-to-day work, helping more patients and practices can bene- With this in mind, Nobel Biocare tion, NobelProcera offers a wide va- workflow for All-on-4®. you advance your skills and business fit from the proven benefits of the All- has introduced the Multi-unit Abut- riety of precision-milled CAD/CAM Thanks to this commitment, clini- in order to serve your patients with on-4® treatment concept. ment Plus. The successor to the com- restorations offering easy handling, cians who take advantage of the treat- the best possible treatment. < pany’s original, and extremely popu- long-term predictability and a pre- ment concept’s proven benefits will The right implant lar, Multi-unit Abutment, this cise fit. find themselves firmly at the forefront Today, Nobel Biocare offers more im- updated version is designed to signifi- of their profession not just today, but plant options than ever before for the cantly reduce the chair time required The All-on-4® treatment for the foreseeable future. All-on-4® treatment concept, provid- to perform provisionalization pro- concept – the key to practice Want to become part of the All- ing clinicians with the right implant cesses such as a denture conversion— progression? on-4® treatment concept success story? for every case. a procedure commonly used in the For a dental office to be at the fore- Go to nobelbiocare.com/all-on-4 to Nobel Biocare NEWS The NobelSpeedy implant system, All-on-4® treatment concept. front of the profession, it has to stand download an e-book that will get you the original and widely documented By introducing a snap-fit function out from the competition. If the prac- started by introducing the concept’s Published regularly by Nobel Biocare Services AG option for the All-on-4® treatment between the temporary cylinders and tice team wants to build a strong rep- key principles. You can also sign up concept, is available in more lengths the abutment, screws are no longer utation, they need to offer effective there for a new premier online training Volume 20, Number 1, 2018 and diameters for increased surgical required during the try-in process. treatment that leaves patients satisfied course presented by leading All-on-4® < Editor-in-chief Frederic Love flexibility. Shorter, longer and wider This means the common practice of to the extent that they are willing to treatment concept experts. Managing Editor Jim Mack versions have been added to an ex- removing the temporary cylinders share their positive experiences with * For patients meeting criteria for Assistant Editor Chris Kendall panded NobelSpeedy Groovy range. and the denture several times during others. In this regard, few treatment the immediate loading of implants. Editorial offices All are designed to further help clini- the conversion process can be done in options come close to the proven suc- Nobel Biocare News cians utilize a graftless approach and a few snaps—with no need to tighten cess of the All-on-4® treatment con- More to explore! Herdevägen 11 achieve cortical anchorage, even and loosen four screws each time— cept. 702 17 Örebro Sweden where bone quality and quantity are saving valuable time for the clinician According to research, 95% of All- Contact your local Nobel Biocare limited. These new options will allow and lab technician. on-4® treatment concept patients were representative to find out how you Telephone: +46 19-330680 and your patients can be part of the e-mail: [email protected] even more patients to benefit from For further ease, speed and effi- satisfied with their new teeth, and web: nobelbiocare.com/news the proven advantages of the All- ciency in choosing the correct Multi- fully 88% said they would definitely All-on-4® treatment concept success on-4® treatment concept. unit Abutment rotational position recommend similar treatment to story. More information can be found The contents of contributors’ articles do not necessarily express the opinions In cases where maxillary bone is se- and angulation, the Multi-unit Align- friends and colleagues. at: nobelbiocare.com/all-on-4. of Nobel Biocare. verely resorbed, the placement of zy- ing Instrument is now available for There’s no reason this positive pa- For the complete list of references for this article, please visit: © Nobel Biocare Services AG, 2018. gomatic implants can nonetheless conical connection and Tri-Lobe. tient response won’t last, with long- All rights reserved. make graftless restoration of the full This latest innovation makes it easy to term success documented for All- nobelbiocare.com/news arch on four implants possible. Build- identify the angulation of the most- on-4® in both the edentulous maxilla Issue 1/2018 Nobel Biocare NEWS 3 Science matters “A positive impact on every aspect of my life” Precision design facilitates success The Trefoil system and the All-on-4® treatment concept in one case 10 years’ clinical success with NobelProcera on TiUnite implants placed using computer-guided surgery. (Tallarico and Meloni, Int J Oral Maxillofac Implants. 2017) Kathleen Mattson suffers Published trials evaluating long-term rates of survival and biological compli- from the early-onset of cations following computer-guided implant rehabilitation are rare. Parkinson’s disease, which This retrospective case series study assessed the long-term clinical suc- over time, and in combina- cess of implants planned with NobelClinician and inserted using Nobel- tion with her medication, had Guide (fully guided or pilot) in private practices. In total, 141 fully or partially caused her natural teeth to edentulous patients received 694 TiUnite-surface implants between 2006 deteriorate significantly. and 2015. All patients received NobelProcera CAD/CAM restorations. Anxious to find a solution, Patients were followed for 1–10 years (mean of 4.8 years). Implant sur- Kathleen approached Dr. Saj vival was 97.4% at 10 years. The prevalence of peri-implantitis was 2.8% Jivraj, in California. Dr. Jivraj (4 patients). Two cases of peri-implantitis were judged to be surgically trig- and oral surgeon Dr. Hooman gered and two were diagnosed in patients with concomitant depressive disorders. Zarrinkelk suggested the Authors attributed the high survival and low complication rates to ade- Trefoil system to restore the quate passive fit and a decreased risk of cement-related peri-implantitis due mandible and the All-on-4® to customization of the cement line with NobelProcera. treatment concept to restore the maxilla. Accepting their ncbi.nlm.nih.gov/pubmed/28906510 advice, Kathleen was able to benefit from fixed prostheses from the day of surgery. Modelling osseointegration better Here, she tells her story. Biophysical regulation of osteotomy healing: An animal By Kathleen Mattson study. (Wang et al., Clin Implant Dent Relat Res. 2017)

Many factors influence osseointegration, such as bone type and qual- arkinson’s disease, and side ef- ity of bone-to-implant contact. However, the concept of “ideal” site Pfects of the medication that I was preparation is poorly defined. taking for it, gave me a really dry Wang and coworkers used a mouse model to investigate the mouth. There didn’t seem to be any- effects of heat generation during osteotomy on bone remodeling thing that could provide enough around implants. They used drill diameters and radial velocities that moisture for me to feel good, nor were designed to be representative of site preparation in the clinic. even to help me escape the damage During osteotomy, faster drill speeds led to increased heat genera- that the unrelenting dryness was tion versus slower speeds. Consequently, osteocyte death in the sur- doing to my teeth. rounding bone was more prevalent after faster versus slower drilling. Because I just didn’t know where Also, after three days, less new bone formed in sites where faster ver- to turn, I allowed these difficulties to Confidence regained, Kathleen Mattson has plans for the future: sus slower drill speeds had been used. These results help to better continue for about five years. Then I “I’m considering some voice-over work, getting back to stage plays, and define the cellular repercussions of drilling, and show how carefully found Anacapa Art Dental online, directing.” designed, clinically representative animal models may be useful to and I made an appointment. inform future practice. Going in, the prospect of a surgical Following the surgery, I took some plates would slide. Dr. Jivraj and Dr. procedure terrified me. I thought stronger pain pills for the first few Zarrinkelk, who worked on my case ncbi.nlm.nih.gov/pubmed/28608504 there would be no way I could go days, and then it was just ibuprofen. together, found an extraordinary so- under a general anesthesia. And I Within a week I didn’t need any pain lution that works very well for me. I worried it was simply not going to medication at all. I did have to have a have a lot to thank them for. work—that with my Parkinson’s the soft diet for a short time, but that real- So what is ahead for me now? Be- procedure would just be too much. ly wasn’t so bad. In short, any fears fore I was diagnosed with Parkin- Redefine possibilities But then I met Dr. Jivraj and his that I may have had before the treat- son’s, acting and directing was a pas- ™ Trefoil – the next full-arch office manager, Josee, who took my ment were totally unfounded in my sion of mine. Now, with the restored qualms seriously, and were very kind experience. confidence my new teeth have given revolution to me as they addressed my misgiv- me, I’m considering doing some ings. After this visit, I felt reassured. Like my own teeth voice-over work, getting back to Josee told me, “Anything is possi- As the swelling subsided, I realized stage plays, and directing. Today I ble!” with such conviction that these how comfortable I was with the pros- not only hope, but feel confident, three words encouraged me through- thetics—and am still—because they that the treatment is going to have a out the process ahead. work so well. They actually feel quite positive impact on every aspect of like my own teeth. my life. < From words to action Now, my teeth have matching sur- The full-mouth restoration went re- faces that help me to chew better. I’m More to explore! ally well for me, and I healed quickly. also feeling confident about the fu- To see how the Trefoil system and I am very happy with my new teeth. ture, since the implants should help the All-on-4® treatment concept can For 30 years, I was a physical ther- to forestall bone resorption—so my revolutionize your practice and the apy assistant, so I know the medical face shape shouldn’t change as it lives of many of your patients, field and can attest that the standard might have had I chosen dentures. please visit: of care I received was excellent. Ev- I don’t believe I could wear den- nobelbiocare.com/all-on-4 and erything went very quickly for me, tures in any case because my mouth nobelbiocare.com/trefoil. with no complications. likely wouldn’t hold them—the 4 Nobel Biocare NEWS Issue 1/2018 Moving Forward Five Things You Need to Know about New Executive Director at FOR NobelProcera® Services

2) Only precision-engineered cases to NobelProcera production, Leading lab technicians components and the list of supported scanners around the world avoid much NobelProcera’s centralized produc- continues to grow. of the expense associated tion facilities use advanced indus- with production equipment, trial milling technology to provide 4) Intraoral scanner workflow maintenance and stock by technicians with quality restora- with online ordering now working with NobelProcera tions that are designed for a precise available Science, education and better patient treatment are fundamental goals Services instead. Best of all, fit. NobelProcera abutments and As intraoral scanner technology of FOR. The newly appointed Executive Director, Dr. Michael Hotze, getting started has never bars meet the required regulatory continues to improve, uptake brings exemplary expertise to the foundation. With a background in been easier. requirements, e.g., FDA clearance, among clinical teams is likely to in- clinical research, he specializes in the crucial mission of communicating CE marking etc., while all crease. Dental professionals that By Arjun Sarof science in an accessible, digestible and educational way. NobelProcera restorations are prefer to take digital impressions • Tell us about your background, and your new role at FOR. backed by a five-year warranty to using intraoral scanning technology I did my PhD in Biochemistry, before entering the field of dentistry in or busy technicians, Nobel- give technicians and their custom- can now be catered for easily using a 1999 at the research department of Colgate-Palmolive. I joined Strau- Procera Services now offers ers peace of mind. fully digital NobelProcera Services mann in 2004 as their Head of Clinical Research, and I managed their Fmore support options than In addition, Nobel Biocare im- workflow for abutments. Techni- collaboration with an educational institution. Today, I am delighted to ever before. Here are the five facts plants restored with a NobelProcera cians can submit the case to the No- become Nobel Biocare’s first Director of Clinical Communications, you need to know about NobelPro- restoration are covered by a lifetime belProcera team easily using an on- which includes the executive director responsibilities at FOR. I am work- cera’s ever-expanding range of out- warranty. It’s important to note that line order form and uploading ing closely with the FOR Board of Directors to drive a wealth of knowl- sourcing opportunities for the scan, restorations from over 170 other im- 3Shape or NobelProcera scan files. edge and education. design and production of precision- plant platforms are also available via No additional software is required. • When did you first engineered CAD/CAM restorations. NobelProcera Services. discover FOR? NobelProcera’s range of innova- 5) Co-packing for added I registered with FOR back 1) No equipment costs tive restorations for Nobel Biocare convenience in 2013. From the begin- Investing in new in-lab milling implants offer ease-of-use enhanc- CAD/CAM implant bars, abutments ning, it was strongly equipment is one option for ex- ing features such as the angulated and crowns have been available endorsed by many opinion panding a lab’s offering. For some screw channel (ASC) option. The through NobelProcera Services for leaders, and I was capti- lab owners however, the initial in- NobelProcera ASC solution allows some time, but the scope of services vated by the substantial vestment can be off-putting or even the repositioning of the screw ac- offered has now expanded. Newly amount of high-quality prohibitive. Maintenance costs also cess hole in cases where it would added is a co-packing option that resources. need to be taken into account and otherwise be on the facial or incisal provides a simple restorative work- • What are your future aims for FOR? there’s the practical consideration of edge, or when occlusal space is lim- flow for intraoral scan cases. We already have a substantial volume of content and a fast-growing finding space in the laboratory for ited. At the same time, the cement- This allows the technician to re- community of over 27,000 users, which provides a very strong starting new equipment. free ASC option can also improve ceive the NobelProcera Abutment point for three main plans. The first is to develop even more online offer- Outsourcing with NobelProcera retrievability. or Crown co-packed together with a ings, such as our eBooks, ePapers, and treatment guidelines. Secondly, Services means you can offer an ex- 3D-printed model from approved I want to build on face-to-face networking opportunities for our users, panded product range without initial 3) Wide selection of scanners vendor, Dreve. It’s a helpful option especially in regions around the world where dental implantology is still investments. There’s not even a need supported when working with digital impres- in early development. Thirdly, I want us to give support to and collabo- to purchase a scanner or software, as There’s a greater chance than ever sions, where a traditional model is rate with the next generation of experts in order to reflect the significant models can be sent directly to Nobel- before that a dental professional’s not produced as a matter of changes we’re seeing in dentistry professional demographics. Procera’s skilled technicians for scan- scanner of choice is supported by course. < • What do you find most inspiring about FOR? ning and design.* Alternatively, tech- NobelProcera Services. The ambi- * Some products may not be regulatory Having over 27,000 users makes FOR one of the biggest providers of nicians can provide scan data or a tion is for as many scanners as pos- cleared/released for sale in all markets. educational content in dentistry. With our global reach, FOR is an full design for industrial produc- sible to link with the service, pro- important platform to publish and share experience within the scientific tion—the choice is theirs. vided they meet the high standards More to explore! community, helping young and ambitious clinicians to grow and The flexibility of the service is required for implant dentistry. Well- To learn more about the full range develop their careers. Many scientific associations hold classic confer- something that many technicians may known brands such as 3Shape® and of NobelProcera Services, visit: ence and symposia events, which are highly valuable, but often difficult find appealing. NobelProcera Servic- iTero® are among the manufacturers nobelbiocare.com/ at a practical level for professionals to attend. Digital learning platforms es can be utilized whenever the case of the 25 desktop and intraoral nobelproceraservices. will definitely play a stronger role for education in the future, making the requires it, with no risk of expensive scanners compatible for submitting digital pathways provided by FOR an invaluable way to disseminate equipment being underutilized. knowledge and education. What’s more, FOR’s activities also cover the humanitarian aspects of dentistry, promoting patient care in underserved populations, which makes it really unique. In that same vein, FOR has made all content accessible free of charge, in order to encourage engagement by providing resources and education for users across the globe. • What do you look forward to most in working with FOR? When I started back in November, I found a highly motivated team and an inspiring environment. The ongoing projects were all well on track and I could concentrate on the next steps, new projects and stra- tegic plans for the future of FOR. Looking for easy access to NobelProcera Abutments and Implant Bars? By outsourcing to NobelProcera Services you gain more time to focus on the work that provides the greatest return for your lab. What’s more, when for.org/en/user/sign-up using NobelProcera prosthetic components, you benefit from the peace of mind provided by a lifetime warranty for your Nobel Biocare implants, and a comprehensive five-year warranty for your NobelProcera restorations. Issue 1/2018 Nobel Biocare NEWS 5 Digital Integration In Brief From Beginning to End Breaking down boundaries between clinician and technician Get ready for change!

The 2019 Nobel Biocare Global Symposium will be held at the Mandalay Bay in Las Vegas, Nevada, USA from June 27–29, Nobel Biocare recently 2019. Save the dates now and sign up for updates today! introduced an expanded Change is coming. If you can only get to one CAD/CAM offering, designed to symposium in 2019, Nobel Biocare’s premiere enhance flexibility and con- event should be it. Knowledge changes every- nectivity between treatment thing, and true science, original solutions and partners. This new offering is profound innovation are part and parcel of made possible through the this symposium. Join Nobel Biocare for three future-focused company’s close partnership days in Las Vegas, featuring expert speakers, with KaVo. master classes, hands-on training, innovative new solutions and the Nobel Biocare’s expanded CAD/CAM offering includes a new KaVo chance to connect with the best minds in a wide variety of specialties imaging device fully integrated with DTX Studio software. from around the world. Dr. Peter Wöhrle is chairing the scientific commit- tee that is composing a program to enlighten and train an expected 3,500 participants. obel Biocare is expanding its new solutions in connecting the tained restorations in-house. Using In order to secure your seat at the symposium, go to the following CAD/CAM offering with new modern dental professional with the the new KaVo LS 3 scanner in com- website, see the introductory video, and then sign up for the updates that Nflexibility and connectivity. entire treatment team at each stage bination with the DTX Studio de- will make you one of the first to know when registration opens up later New KaVo imaging equipment and of dental implant treatment. It inte- sign software, dental technicians will this year: DTX Studio software are part and grates the very latest technologies be able to access the full portfolio of parcel of the two companies’ collab- and equipment from patient imag- NobelProcera restorations. nobelbiocare.com/global-symposium-2019 orative efforts. ing acquisition to post-treatment With the resulting smooth, fast Bringing complementary areas of follow-up—including diagnostics, workflows, they can choose to pro- expertise to the partnership, these treatment planning, guiding implant duce authentic, precision-engi- Sverker Prize winners two leading dental innovators are surgery and restoration design. neered NobelProcera CAD/CAM so- now developing fully integrated digi- It is now possible to manage 2D lutions outsourced to high-tech At Swedental, the largest annual dental convention in Scandina- tal equipment and software solutions and 3D data from X-ray and optical facilities in Mahwah, New Jersey, via, Drs. Matts Andersson and Agneta Odén were presented with designed to bring about seamless, sources in a single software applica- USA, and Chiba, Japan. the Sverker Prize by the Gothenburg Dental Association and the beginning-to-end treatment work- tion throughout the practice. Manufactured in accordance with American Dental Society of Sweden. flows for clinics and laboratories. DTX Studio for clinics processes the ISO 13485 quality management data in dentistry-relevant work- system and cleared by the FDA They were awarded this celebrated prize—named for the late Swedish New imaging device spaces and is geared towards daily where required, the output quality of dentist and humanitarian, Sverker Toreskog—in connection with a lecture The KaVo LS 3 desktop scanner use in both Windows® and macOS® every prosthetic is monitored. This in digital prosthetics held at the convention. This year the Sverker Prize starts the digital journey for the cli- environments. It provides users results in products demonstrating a was presented in recognition of these two scientists’ efforts “to develop nician and lab high degree of and change the way we work with and manufacture ceramic materials for technician with precision fit. dental care.” speed, color and “The LS 3 delivers precision with increased speed When assistance Professor Matts Andersson invented the digital Procera method for the precision. De- and efficiency—great for my team and even better is needed, direct industrial production of dental crowns in the early 1980s. In cooperation signed to en- for the patient!” local support is with the material researcher, Agneta Odén, he developed a process for hance efficiency, — Professor Paulo Malo available from the production of dental prosthetics with passive fit and high esthetics. it seamlessly Nobel Biocare Nobel Biocare subsequently introduced the first commercially available connects to DTX specialists who ceramic CAD/CAM dental crown in 1989. Studio design for fast restoration with tools for ease and efficiency, are fully trained on the workflow. planning. Dental technicians can such as online collaboration be- goo.gl/5CR2MA save time without compromising tween DTX Studio implant and Digital production on demand quality—a complete jaw scan can be DTX Studio design for laborato- NobelProcera Scan and Design Ser- performed in under 60 seconds with ries—whereby a TempShell provi- vices (see related article on page 4) Two-piece ceramic solution an accuracy, according to ISO 12836, sional can be produced in-house for help laboratories consistently meet of up to 4 μm—even when working same-day, immediate screw-re- increasing demands for high-quality At the 2017 European Association of Osseointegration (EAO) Con- on the most complex cases. tained provisionals. implant-based restorations without gress in Madrid, Spain, Nobel Biocare announced it has entered The KaVo LS 3 desktop scanner is For dental laboratories, the DTX calling for substantial investments in into a partnership agreement with Dentalpoint AG, an interna- equipped with an advanced optical Studio suite brings a new opportuni- new equipment and staff training. tional leader in ceramic dental implants. As a result, Nobel Biocare system that captures the fine textures ty to become the ‘go-to’ lab of the fu- One can send a case from any one will be adding a zirconia implant solution to its portfolio. and colors of the dental model for ture, facilitating flexibility in the of 25 different approved scanners to true visualization; and scans can be choice of workflow and business NobelProcera Scan and Design Ser- The partnership with Dentalpoint AG will add a new implant alternative to managed directly at the scanner it- model. vices, and then receive precision-fit Nobel Biocare’s leading range of titanium dental implants with the clini- self, using its intuitive 5-inch touch- DTX Studio design software will bars, abutments and implant crowns, cally proven TiUnite surface. The innovations from Dentalpoint AG are screen interface. Designed with an accept intraoral scan files from sys- and/or a 3D printed model. intended to help clinicians meet patient demand for metal-free solutions awareness of the virtue of mechani- tems such as TRIOS®, iTero®, 3M™ Whether using an IOS or desktop and high-end esthetics. cal simplicity, its spacious, open de- and Carestream Dental™, as well as scanner, the process is simple—and As a result of the partnership, an all-ceramic solution featuring first-of- sign provides easy access to the case, files from other desktop scanners. within a matter of days, the precisely a-kind technology by DentalPoint will be available from Nobel Biocare.* and makes it possible to mount a full Furthermore, lab owners will benefit manufactured restoration is shipped The introduction of a ceramic implant will further extend Nobel Biocare’s articulator, thus further increasing from the best of two worlds: ‘Direct to the lab with a material authentici- comprehensive offering of innovative solutions for excellent esthetics. efficiency at the dental laboratory. access’ to premium NobelProcera ty certificate and a five-year product centrally manufactured products in- warranty. < * For CE markets only. Under FDA 510k Review. Connectivity for everyone cluding bars, and ‘open output’ with The DTX Studio suite offers exciting the option to produce cement-re- 6 Nobel Biocare NEWS Issue 1/2018 Over a Decade of Dominance Often copied, never equaled – NobelActive celebrates 10+ years of clinical experience with an abundance of evidence.

The advent of NobelActive The One and Only NobelActive represented a major breakthrough in implant design. Imitation may be the sincerest form of flattery, but proof of performance only comes with a huge body of scientific evidence. Today, over a decade later, a wealth of evidence proves it to be a triumph of applied biotechnology.

By Chris Kendall PRIMARY STABILITY – RIGHT t is the leading, most prominent FROM THE START implant solution in Nobel Bio- care’s extensive and diverse Launched over 10 years I ago, this unique implant range of implants. Its name: No- design enables good belActive. primary stability, even 2008 To date, 42 clinical studies have in soft bone and fresh extraction sockets – evaluated over 14,300 NobelActive already shown in multiple implants involving over 2,600 pa- publications in 2009. tients—and this count only includes (Irinakis et al., 2009(1); 2009 studies that examined a minimum Irinakis et al., 2009(2); of ten NobelActive implants fol- Kielbassa et al., 2009) lowed-up for more than one-year.

Count on good primary stability The infographic on this spread 2010 highlights just a few of the many studies that have shown Nobel- EXCELLENT TREATMENT Active can accomplish good prima- OUTCOMES USING ALL-ON-4 ry stability in demanding situa- NobelActive is demonstrated to enable efficient tions. and reliable full-arch restorations with the All- The reverse-cutting flutes with on-4® treatment concept. 2011 drilling blades on the apex enable (Babbush et al., 2012) the adjustment of the implant position during placement for an opti- mized restorative orientation, par- ticularly in extraction sites. 2012 Furthermore, internal conical connection with hexagonal inter- locking offers high mechanical 2013 strength. Given such applicability, NobelActive’s mean implant survival rate of 98.5%—in studies with up to, and including, 5 years of follow-up—is all the more impressive.

Count on excellent esthetics AN IMPLANT FOR EVERY NEED Studies show that NobelActive pre- MARGINAL BONE serves the critical marginal bone RESPONSE and soft tissue over time for natu- NobelActive is proven to preserve the ral-looking esthetics. Its back-ta- critical marginal bone and soft tissue over pered collar—together with a strong time for natural-looking esthetics. conical connection and built-in (Gultekin et al., 2013; Pozzi et al., 2014; Kolinski platform shifting—can aid crestal- et al., 2014; Cosyn et al., 2016) bone and soft-tissue preservation. In the end, of course, it’s all about the final results; and in 3.0 NP 3.5 RP 4.3 RP 5.0 WP 5.5 Patented back-tapered terms of esthetics, self-esteem, collar provides the space speech, sense and function, pa- for additional marginal bone. tients treated with NobelActive implants have given high marks FIND OUT MORE to its use from pre-treatment, to prosthetic delivery, all the way Discover even more about this through three-year follow-up. < groundbreaking solution: nobelbiocare.com/nobelactive Issue 1/2018 Nobel Biocare NEWS 7

Over ABUNDANCE OF RESEARCH THAT MATTERS 42 14,300 In peer-reviewed publications, with a Over minimum of 10 NobelActive implants and clinical implants minimum of 1-year follow-up time. 98.5% clinically studies mean survival* 2,600 studied patients *Up to 5 years of follow-up evaluated

SAFE IMPLANT PLACEMENT IN AREAS WITH 100% SURVIVAL LIMITED SPACE

Published in 2018, this At a mean of 6 years (range 4.7 new study confirms years up to 6.7 years), with 24 that NobelActive 3.0 patients in a 6-year retrospective 2018 is a reliable solution analysis. for narrow interdental space situations. (Polizzi et al., 2017) (Kolinski et al., 2018) 2017

IMPLANT DESIGN IS IMPORTANT FOR ACHIEVING PRIMARY STABILITY In a study that used a polyurethane 2016 foam sandwich model, the mean implant insertion torque of NobelActive implants was 36.52 Ncm – significantly higher than both Straumann Bone Level Tapered (BLT) and Dentsply OsseoSpeed EV (Astra). 2015 (Karl & Irastorza Landa., 2017) STUDY SHOWS REMARKABLE BONE PRESERVATION 1 mm cortical NobelActive BLT Astra EXCELLENT Up to 5 years from a baseline of bone (density 0.48 g/cm3) 2014 CLINICAL OUTCOMES implant insertion. A study with immediately loaded 5 mm low (Cosyn et al., 2016) NobelActive implants placed quality bone flaplessly with NobelGuide finds (density 3 high patient satisfaction, a high 0.16 g/cm ) 2.6 mm 2.6 mm 2.6 mm survival rate, stable bone levels and a predictable treatment method. NobelActive 36.52 p<0.001 p<0.001 (Yamada et al., 2015) p<0.001 I BLT 27.6 m

g e

c o Astra 23.7 u r te PAPILLA SIZE IMPROVES s y 0 10 20 30 40 50 o f SIGNIFICANTLY P ro IT (Ncm) f. A less ly An extraction-site study using NobelActive andro Pozzi, Ita (Karl M, Irastorza-Landa A. Does implant design affect primary implants with immediate loading protocol shows stability in extraction sites? Quintessence Int. 2017;48(3):219-224) significant overall increase in papilla score from implant placement to the 3-year follow-up.

(Kolinski et al., 2014)

100% Jemt’s JEMT’S PAPILLA INDEX* Papilla 80% Index

60% 0 1 40% 2 Score 0 Score 1 Score 2 Score 3 Score 4 More to explore! 3 20% No papilla. Less than half Half or more Optimal soft tissue contour Hyperplastic papilla Papilla score in % Papilla 4 of the papilla of the with papilla filling up the covering too much For the complete list of 0% height. papilla height. entire proximal space. of the restoration references for this article, and/or adjacent 0 12 36 tooth. please visit: Time after implantation (months) * Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodont Rest Dent 1997;17:327-33 nobelbiocare.com/news 8 Nobel Biocare NEWS Issue 1/2018 The Three Pillars of Trefoil™ Trefoil has been designed and developed to extend the benefits of osseointegration to a new patient population.

sions. So in this spirit, let’s explore Fig. 1A Fig. 1B In the most recent issue of more details of a stress analysis of Nobel Biocare News, the Trefoil, with a focus on framework editors introduced our readers design. to Trefoil. In the article below, A common clinical evaluation of you are invited to dive deeply a framework’s design involves mea- into the innovative bioengi- suring the “AP (anterior-posterior) neering that has made this spread”, which is the distance from a solution possible. line drawn between the posterior aspects of the two most distal abut- By Professor John B. Brunski ment interfaces and the midpoint of the most anterior abutment/implant Figures 1A and B: Here is the first pre-manufactured in the arch. Depending on whom bar with passive fit.Anatomically designed for the you read, the recommended maxi- natural arch of the lower jaw, the standardized Trefoil ven to the casual observer, it’s system bar contains adaptive joints that adjust to mum cantilever length of a frame- obvious that Trefoil has a par- compensate for horizontal, vertical and angular devia- work almost always falls between 1.5 Eticularly innovative feature. tions from the ideal implant position. and 2.5 times the AP implant Its prefabricated framework contains The results indicated that cast spread. Fig. 1C a special adaptive fixation mecha- p = 0.00025 bars show significantly higher levels Trefoil’s AP implant spread is nism at each implant connection that of misfit and more uneven distribu- 8.7 mm, while the AP bar spread is 1500 functions to create a precision fit by p = 0.00124 tions of strain compared to other 14.5 mm. This a ratio of 1.67, compensating for any slight angular comparison groups (Figure 1C). The which—according to this widely ac- (± 4°), horizontal (± 0.4 mm), and/or Trefoil and CAD/CAM bars each had cepted “AP spread rule”—is well 1000 vertical (± 0.5 mm) misalignment of a low level of misfit and more even below the maximum recommended the implants. (Figures 1A and 1B.) n.s. distribution of strain. The two sys- range for this configuration. As exciting as this feature is, there tems were not statistically different But a calculation based on the 500 is so much more to the design of Tre- from each other. AP spread is not a stress analysis; foil. A great deal of biomechanical The articulating disks of the Tre- it’s only a guideline, with its predic- engineering insight has been incor- foil system tackle the issue of misfit tive value depending upon numer-

Strain development (µm/m) development Strain 0 porated into its design and subse- Trefoil NobelProcera Cast at the implant-framework interface ous factors such as strength of bite quent clinical application. (n=5) (n=5) (n=5) while maintaining the integrity of force, material used in the bar, Consider the words of Steve Jobs: the individual components. While whether the patient is a bruxer, etc. “Design is a funny word. Some peo- Figure 1C: A recent in vitro study conducted at Saarland University in no system showed a strain measure- (see Dr. Steven E. Eckert’s excellent ple think design means ‘how it looks.’ which the Trefoil Bar was directly compared to both traditional cast bars ment of 0 µm/m, Trefoil’s innovative discussion on this topic at re- But of course, if you dig deeper, it’s and CAD/CAM individualized bars, cast bars show significantly higher compensation mechanism enabled a searchgate.net). levels of misfit and more uneven distributions of strain compared to other really ‘how it works.’ ” premanufactured bar to fit as well as For more enlightenment about comparison groups. (See “More to explore” for the source reference.) In this article, I hope to explain a state-of-the-art individualized res- framework design, the required ap- Trefoil’s biomechanical design in toration. proach involves stress analysis and the spirit of this quote. With a nod the consideration of possible me- of appreciation to the late Philip Ka- “Design is a funny word. Some people think Pillar 2: Practice chanical failure (in order to avoid it). pleau and his book, The Three Pil- design means ‘how it looks.’ But of course, if you A cantilever’s dimensions and loading Consider three example cases, lars of Zen, I’d like to introduce you dig deeper, it’s really about ‘how it works.’” govern how it’s stressed. each of which is formulated in 3D to the “Three Pillars of Trefoil.” — Steve Jobs An in-depth stress analysis of finite element (FE) models. Case 1 Trefoil needs to go beyond the involves four upright implants Pillar 1: Teachings above. A relevant quote from the (each 4 mm in diameter); Case 2 in- Individualized fit can be provided ed to excess mechanical strain due By contrast, with the Trefoil sys- architect Mies van der Rohe speaks volves four All-on-4® implants with a standardized device. to a lack of passive fit. tem, a dental team can deliver—on to a key issue: “No design is possi- (each 4 mm in diameter, with the Small deviations in implant place- Historically, there have been the day of surgery—a definitive solu- ble until the materials with which distal two implants tilted); and Case ment can greatly influence the many approaches to achieve passive tion that fits like a custom solution. you design are completely under- 3 involves three Trefoil implants strain distribution on the implants, fit. This has included cutting pros- This is evidenced by a recent in stood.” (each 5 mm in diameter). As can be the framework and surrounding thetic bars and piecing them back vitro study conducted at Saarland Indeed, from a bioengineering seen in the top row of Figure 2B, anatomy. Ideally, a prosthetic frame- together intraorally. From an engi- University in which the Trefoil Bar perspective, the mechanical success the implants support a metal framework should not introduce strain on neering perspective, one might was directly compared to both tra- vs. failure of any oral implant sys- work that’s 5.5 mm wide (bucco- CAD/CAM the supporting implants and sur- worry that this approach could af- ditional cast bars and tem depends not only on how many 300 N rounding bone in the absence of an fect the integrity of the prosthetic customized bars. In this study, five implants are used and how they are external load. This is known as pas- superstructure. Alternatively, the replicates of each comparison loaded, but also on the sizes of the sive fit. development of CAD/CAM individu- framework were seated on three implants, the bone anchorage area, Many studies throughout the sci- alized solutions has made great NobelParallel CC Tissue Collar RP and the size and rigidity of the entific literature reveal that, in the strides to address the issue of pas- 5.0 x 13 mm implants placed in resin framework. past, cast bars and some premanu- sive fit. However, individualized models representing edentulous In other words, “size matters” be- factured prosthetics experienced bars are still subject to deviations in jaws using the Trefoil surgical cause the ultimate failure limits of unfavorable levels of implant and implant placement and they can be guides and templates. Strain gauges materials—such as the ultimate ten- Figure 2A: Illustration of the prosthetic failures. While many fac- expensive for many patients due to were mounted to each system and sile strength and the fatigue strength setup in the 3D finite element modeling of a bar supported by tors can contribute to failures, me- the need for multiple clinical visits recorded the strain development at of commercially pure titanium (CP three Trefoil implants. Similar chanical complications such as im- and the use of a provisional prosthe- all three implant sites when the clin- Ti), Ti-6Al-4V alloy, and bone—are setups were used for the four plant and prosthetic fractures and sis while the definitive solution is ical screws were tightened to 35 expressed in terms of stress, not upright implants and All-on-4® screw loosening have been attribut- manufactured. Ncm. force, and stress depends on dimen- treatment concept implants. Issue 1/2018 Nobel Biocare NEWS 9

Case 1: Case 2: Four All-on-4® implants Case 3: tween the ideal and worst cases (Fig- Four upright implants (Ø 4 mm). (Ø 4 mm), distal implants tilted 30°. Three Trefoil™ implants (Ø 5 mm). “Less is more.” ure 4B); the mean fatigue limit (here Bar is 5.5 mm wide, 4 mm thick. Bar is 5.5 mm wide, 4 mm thick. Bar is 5.5 mm wide, 5.5 mm thick. — Mies van der Rohe quoted in terms of force, since these were tests on whole bars) was statistically the same for both cases, at Pillar 3: Enlightenment about 313 N. Thanks to proper design, the Trefoil What these data show is that the framework works nicely. compensation mechanism supports 300 N down on bar, into page 300 N down on bar, into page 300 N down on bar, into page During the design stage of Trefoil, reliable and predictable resistance to Nobel Biocare’s stress analysis of the mechanical fatigue within its full detailed geometry of Trefoil’s bar compensation range. (see Figure 3A) went beyond my While fatigue tests are usually de- FEA examples above; Nobel’s more signed to compare different systems detailed analysis of the bar (using its with each other, to gain insight into actual geometry instead of the sim- the role of various material charac- Max stress Max stress Max stress 398 MPa 218 MPa 201 MPa ple U-shape assumed for FEA) teristics on fatigue life, it is enlight- showed that under large cantilever ening nevertheless to consider how loading, “hot spots” of high stress we can estimate a practical in vivo Surface: First principal stress (N/m2) developed at the base of the cantile- lifetime of a Trefoil Bar. Figure 2B: Overhead views of the bar and implant arrangements (top row) and distributions of tensile stress in the ver (Figure 3B). Notably, those hot For instance, since it’s known bars for 300 N acting at the right cantilever (bottom row). spots of stress matched well with the from the tests that the bar can with- locations of fatigue fractures seen in stand at least 300 N of cyclic bite laboratory fatigue testing of bars in force at the cantilever without fail- Fig. 3A Applied Fig. 3B saline solution. Such agreement being after 2 million cycles (the point force tween FEA predictions and experi- at which the testing was stopped for “Hot spot” mental test data gives validity to the practical reasons), how long—in of high stress FEA and confidence in the safety days or years—does this mean that and efficacy of the final bar. the bar will last? An approximate The thoroughness of Trefoil’s de- answer can be based on estimates in sign emerges more fully when con- the literature of a typical chewing sidering Nobel Biocare’s fatigue com- rate in humans—60 to 80 cycles per parative testing on bars supported by minute—and a typical length of aligned vs. misaligned implants (Fig- time spent chewing each day— ure 4A). That is, tests were run on about 9 to 17 minutes per day. Figures 3A and 3B. During the design stage of Trefoil, Nobel Biocare’s stress analysis of the detailed geometry of bars that fit perfectly on aligned im- Assuming 60 chewing cycles/min Trefoil’s bar went beyond the author’s FE examples depicted in Figure 2B. Nobel Biocare’s more detailed analysis of plants (i.e., on implants placed ac- during 10 minutes/day of chewing, the bar (using its actual geometry instead of the simple U-shape depicted in Figures 2A and 2B) showed that under cording to the ideal surgical plan) this produces 600 chewing cycles large cantilever loading, “hot spots” of high stress developed at the base of the cantilever (Figure 3B). Such and bars in which the compensation per day. We know from fatigue tests agreement between FE predictions and experimental test data gives validity to the FE analysis, and confidence in mechanism became “active” in ac- that the Trefoil Bar can withstand at the safety and efficacy of the final bar. commodating a passive fit of the bar least two million cycles with 300 N to misaligned Trefoil implants (i.e., a on the cantilever. So this translates lingually) in each case; but 4 mm situation where two of the implants into a minimum survival time for the thick for Cases 1 and 2 vs. 5.5 mm “No design is possible until the materials with were misaligned to their maximum Trefoil Bar of at least 9 years—and it thick for Case 3. Each bar is loaded which you design are completely understood.” angular and lateral shifts). could very well last much longer. downward at the right distal end of A typical fatigue test was conduct- There has really been nothing like the cantilever with a force of 300 N. — Mies van der Rohe ed by applying a known cyclic this to emerge from the lab to the Each case is formulated and ana- force—say 300 N—at 1 cycle/sec to clinic before! < lyzed using 3D FEA. The results (Figure 2B, bottom and the comparable value for the the end of the cantilever, and then al- These models, like all other ideal- row) reveal that the maximum ten- Ti-6Al-4V alloy used in the Trefoil lowing the test to keep running until More to explore! izations, are subject to the usual list sile stress (1st principal stress) on Bar is ≈620 MPa—both of which either “runout” occurred (no bar For the complete list of references for of limitations, of course, such as the the top surface of each bar concen- provide ample margins above failure at 2 million cycles) or fatigue this article, please visit: fact that the models here neglect the trates at the location expected— maximum stress. Bars made of failure occurred (e.g., cracks formed) nobelbiocare.com/news fine geometric details of the wide near the fixed end of the cantilever these materials, used in cases like at a specific number of cycles. variety of bars, implants, and bone region. Case 1 (upright 4) shows the these, would not be expected to The fatigue tests revealed no dif- encountered clinically; but they do largest stress (398 MPa); Case 2 fail in fatigue. ference in fatigue performance be- provide the analytical advantage of (All-on-4®) has a lower stress (218 uniformity. MPa); and Case 3 (Trefoil) has the Fig. 4A Fig. 4B Well-aligned vs. misaligned implants Here all three models have the lowest stress of all (201 MPa). 350 same setup of materials—apart from What this means in terms of a p = 0.292 implant diameter, location and bar likelihood of bar fracture is as fol- size—so it is a straightforward process lows: If the bars happened to be 300 to make meaningful comparisons be- made of CP Ti, the ultimate tensile tween these three crucial variables. strength of some grades of CP Ti is The Young’s elastic modulus of the Ti over 700 MPa, so none of the bars 250 alloy bars is 115 GPa, the modulus of made from such a material would the commercially pure (CP) Ti im- be in danger of fracturing. However, 200 plants is 105 GPa, and the modulus of since the fatigue endurance limit of the mandibular bone is that of dense some grades of CP Ti is only 300

Median fatigue limit (N) Median fatigue 150 cortical bone ≈20 GPa. As seen in MPa—which is less than the stress No compensation Maximum compensation Figures 2A and B, the chosen load at seen in the Case 1 bar (398 MPa)—a (n=6) (n=6) the cantilever is 300 N. CP Ti bar in Case 1 would be at risk Figures 4A and 4B. Trefoil’s exemplary design became clearly evident when tests were run on bars that fit Now we’re ready to answer the of failing by metallurgical fatigue. perfectly on aligned implants (i.e., on implants placed according to the ideal surgical plan, left column above) and question, “What stresses develop in On the other hand, the fatigue en- bars in which the compensation mechanism became “active” in accommodating a passive fit of the bar to the three bars, and how do those durance limit of specially cold- misaligned Trefoil implants (i.e., a situation where two of the implants were purposely misaligned by known angular stresses relate to possible failure?” worked Grade 4 CP Ti is ≈430 MPa; and lateral shifts, a.k.a. the “Trefoil Worst Case,” depicted in the column to the right). TiUnite®

10 Nobel Biocare NEWS Issue 1/2018 ® Putting TiUnite TiUnite® To the Ultimate Test An interview with Professor Tomas Albrektsson Setting the scientific standard. Again. TiUnite®

and ten-year studies than implant Involved as he has been with surfaces from the majority of its The evidence points to TiUnite® dental implantology from the competitors. When it comes to sup- The largest ever meta-analysis of a single implant brand unequivocally confirms the very beginning, Professor porting evidence, Nobel Biocare im- clinical success of the TiUnite surface. Tomas Albrektsson was a plants have the advantage. keen observer when Nobel Biocare launched its moder- How can the findings of this ately rough TiUnite surface in meta-analysis be used to 2000. optimize clinical practice? A serious implant surface backed Albrektsson: I think that we have to by serious scientific data strive for continuous improvement. TiUnite supports peri-implant health, bone maintenance and overall success. In the 1800s, if you had 19% mortali- oday, 17 years after the advent ty in appendicitis cases, you were of TiUnite, Albrektsson is the better than the average doctor. Today Tco-author—together with Pro- such a mortality rate would see you 95.1% 1.36 % –-0.9 mm 10 - year implant survival Peri-implantitis Bone level change fessor Matthias Karl—of a landmark Professor Tomas Albrektsson lose your license because we have at implant level Lowest estimate at 5-year follow-up meta-analysis* screening all the pro- began work as part of Per-Ingvar new techniques. It’s a similar story (Authors postulated that peri-implantitis did not spective studies since published on Brånemark’s research team in with dental implants—we have to occur in studies where Gothenburg, Sweden, in 1967. In it was not explicitly this remarkable surface. The study constantly challenge what we cur- reported.) has been called the most extensive the years that followed, he earned rently consider to be the ultimate im- his PhD in anatomy and a Swedish analysis ever of a single dental brand. plant solution in order to have even professorship in the subject of Insurmountable TiUnite It comprises 106 papers in total, fea- handicap research. One of the better solutions for patients in future. Unequivocally confirmed by the largest ever meta-analysis assessing a single implant brand. turing well over 12,000 TiUnite im- most quoted scientists in his It is a continuing mission, and I plants. In the following interview, Al- chosen field, Albrektsson lectures know that Nobel Biocare is involved brektsson explains the significance of around the world and often in a number of studies with a view to the findings. moderates symposia and confer- making further improvements. I 106 ences on osseointegration-based prospective studies think this is exactly the right ap- 32,519 treatment and research. publications screened What is the relevance of proach because in the ideal situation No cherry picking looking at research on the we’ll have a 100% survival and suc- Includes all patients with a 4,694 TiUnite implant prospectively patients TiUnite surface in such detail? ty of cases. There are actually five cess rate at ten years. We aren’t there evaluated in a clinical study Professor Albrektsson: with a minimum of 20 patients It is always rel- different ten-year studies on TiUnite yet, but that’s the goal. and 12 months post-loading. evant to have proper clinical studies that demonstrate well-maintained You have been involved with 12,803 conducted. But it is the sheer wealth bone levels. TiUnite implants of evidence on TiUnite implants that research evaluating Nobel made this meta-analysis possible. What does your study tell us Biocare implants for many Nobel Biocare is definitely leading about rates of peri-implantitis years. Have the findings of the way here. There are some other with TiUnite implants? your analysis changed your Albrektsson: perception of the TiUnite systematic reviews on a single im- The publications assess- Prospective studies provide the advantage of proper plant surface or brand, but not many. ing biological complications revealed surface in any way? baseline assessments, longitudinal follow-up and relatively fewer sources of bias. And the more we know, of course, a low prevalence of peri-implantitis Albrektsson: The meta-analysis is an- the better it is for dental profession- with TiUnite implants. This is also other validation of TiUnite’s efficacy, als and for patients. no big surprise. The figures we’ve but other types of clinical studies Research of this nature highlights seen widely reported in the literature have previously confirmed its high the stark contrast between high- are exaggerated. They say that any performance. Meta-analysis offers The highest-level evidence quality implants and the copycat ver- bone loss after the first year is caused high-quality insight, but you need a sions that are likely not backed by by disease, which is—to put it mild- wide range of supporting evidence, Strongest evidence documentation. Even if they seem- ly—incorrect. and TiUnite is backed not just by ingly look like the implant that We see maintained bone levels in prospective studies, as we examined, they’re trying to imitate, this does this study and in other ten-year fol- but by retrospective research and Meta-analyses not mean they will work in the same low-up studies with TiUnite. If peri- other study types as well. The state- way. So this is really the most impor- implantitis is a disease—which is ments we make about TiUnite im- Systematic reviews tant thing—that a dental implant re- being widely discussed at the mo- plants today can therefore be made Randomized controlled trials ally works as planned and that there ment—it may affect one percent of with great confidence. Cohort studies is high-quality evidence to prove it. implants at ten years. So, if by ‘dis- I observed TiUnite being launched Clinical case studies ease’ we mean bone loss that threat- in the year 2000. I believed in it then What were the key findings of ens the survival of the implant, it’s on and now I know that my beliefs were Animal studies this TiUnite meta-analysis the order of one percent. correct. It is a superb implant sur- In vitro studies and why are they important? Nobel Biocare’s implant systems face. < Albrektsson: It was reported, not to are not the only ones showing good Weakest evidence any great surprise, that there is a results with respect to peri-implanti- More to explore! very high implant survival rate for tis, but if I were to choose an implant * Matthias Karl and Tomas Albrektsson have co-authored the For more information about the implants with the TiUnite surface. today, I would look at the document- “Clinical performance of dental implants with a moderately rough TiUnite surface and its supporting We know today that TiUnite has a ed research, which is so much better (TiUnite) surface: A meta-analysis of prospective clinical studies,” clinical evidence, visit Results very good clinical record with main- with Nobel Biocare. The TiUnite im- Int J Oral Maxillofac Implants. 2017 Jul/Aug;32(4):717-734. doi: nobelbiocare.com/tiunite. tained bone levels in the vast majori- plant surface is backed by more five- 10.11607/jomi.5699. Profound osseointegration, long-term survival

1- year implant survival 10 - year implant survival

>99% 95.1% at implant level at implant level

>99% at patient level 91.5% at patient level

12,803 implants 100

Implant survival (%, regression analysis) 0 0 1 2 3 4 5 6 7 8 9 10

Years after implant placement

Results of implant survival regression analysis expressed as estimated survival rates.

Low prevalence of peri-implantitis

Lowest estimate Highest estimate 1.36% 5.2%

Peri-implantitis*

4,694 Patients evaluated

1,229 patients in studies where peri-implantitis was directly reported*

64 Patients with peri-implantitis

Up to 98.6% of 4,694 patients had no reported peri-implantitis

*Of 106 studies, 47 reported biological complications. Of these 47 papers, 19 reported cases of peri-implantitis in 5.2% of patients (64/1229). The authors postulated that, if peri-implantitis did not occur in studies where it was not explicitly reported, its prevalence would be 1.36%.

Marginal bone level change: exceeding the standard for success

≤ -2.0 mm -1 mm -0.9 mm considered from implant insertion at 5-year follow-up a success*

-2 mm

-3 mm

-4 mm

-5 mm

4,837 implants evaluated 0

-1

-2 ICOI Pisa Implant Quality of Health lower limit of implant success*

-3

-4

Marginal bone level change from implant change from Marginal bone level insertion (mm, regression analysis) -5 0 1 2 3 4 5 6 7 8 9 10

Years after implant placement

* Misch CE, et al. Implant success, survival, and failure: the International Congress of Oral Implan- tologists ICOI) Pisa Consensus Conference. Implant Dent 2008 Mar;17:5–15.

Conclusions

99TiUnite promotes a healthy bone response during the first year which remains stable over the long term.

99Strong evidence of high implant survival with TiUnite surface.

99Low rates of reported peri-implantitis in patients with TiUnite surface implants.

Karl, M. and Albrektsson, T. Clinical performance of dental implants with a moderately rough (TiUnite) surface: a meta-analysis of prospective clinical studies. Int J Oral Maxillofac Implants 2017;32(4):717-734. Issue 1/2018 Nobel Biocare NEWS 11

Building on a Strong Foundation Upcoming Together with Nobel Biocare Events An ingenious, elegant model for success Meet Nobel Biocare at events around the world. strong clinical team that greatly in- These professional A team of three American creased the scope and size of their gatherings provide a great periodontists has developed practice and enabled the delivery of opportunity for catching and refined a practical method continuing education programs that up with the latest for professional success that far exceeded what either could have innovations and scientific has made it possible for their achieved individually. research. referral-based practice to consistently increase Continuing education is key • 2018 • revenue—at a remarkable rate Through diligent documentation of of 10 percent per year—for his cases, Dr. Kolinski had developed Centennial Meeting of the Academy of Prosthodontics decades. Drs. Crosby, Kolinski years of clinical material that he pre- May 9–12 and Trahan have been able to pared and presented for programs Chicago, IL, USA do this despite an evolving and seminars held by the Chicago SEPES Primavera market that is challenged by Dental Society, the American Acade- May 19 increasing numbers of den- my of Periodontology and the Acad- Madrid, Spain tists placing implants, a na- emy of General Dentistry. EAED European Academy of Esthetic tional trend toward corporate- According to Kolinski, “Dr. Cros- Dentistry, 32nd Spring Meeting based dentistry, and attrition by brought not only outstanding May 24–27 of the referral base due to the treatment planning and surgical Sorrento, Italy retirement of referring doctors. abilities to our practice, she also EuroPerio9 brought finely-honed lecturing and June 20–23 By Richard M. Sullivan, DDS demonstration skills that were im- Amsterdam, Netherlands mediately used to refine and im- FDI World Dental Congress hen he started his peri- prove our presentations.” September 5–8 odontal practice in 1980, The long-term successes and ver- Buenos Aires, Argentina Dr. Martin Kolinski had satility of Nobel Biocare implant Periodontists, Drs. Martin Kolinski and Tricia Crosby have followed W three basic ground rules in order to establish and maintain a highly EAO European Association of the insight and good judgement to es- systems significantly contributed to successful dental implant practice. Osseointegration tablish three important ground rules. the materials that Drs. Kolinski and October 11–13 First, he would build strong interdis- Crosby were able to develop. Within the ongoing, prospective Nobel- down the cost and, in some cases, the Vienna, Austria ciplinary relationships with well-edu- three years of joining the practice, Active 3.0 study, recent results of resulting quality of implant therapy, American Academy of Periodontology cated, referring restorative dentists. Crosby had contributed an impres- which were just published. the practice will continue to place 104th Annual Meeting Second, he would commit his practice sive repertoire of cases to their joint Opening doors for referring den- emphasis on the expertise and quali- October 27–30 Vancouver, Canada to unparalleled customer service for educational effort and achieved pro- tists to provide new or improved ty that they will always make avail- his patients and their referring doc- fessional recognition of her own as a collaborative procedures has result- able to a patient base that demands American College of Prosthodontists tors (which, as it would turn out, certifying examiner for the Ameri- ed in beneficial growth for the refer- optimum treatment. 48th Annual Session October 31–November 3 would ensure a flow of new and con- can Board of Periodontology. ring dentists as well as for the perio- Back in 1980, Dr. Kolinski was Baltimore, MD, USA tinuing patients for the lifetime of his From the beginning of their collab- dontists’ office, which allowed them just a young visionary who was de- expanding specialty practice). Third, oration, these two periodontists have to bring a new associate, Dr. Wil- termined to build a successful prac- Swedental Annual Dental Congress November 15–17 as implants were to become a signifi- committed themselves to developing liam Trahan, into the practice over tice based on three simple premises. Gothenburg, Sweden cant part of his new practice, he new topics each year for the continu- two years ago. Well-established today, he and his would choose to work with a compa- ing education programs they organize. “Our practice now has three doc- colleagues enjoy the fruits of devel- Greater New York Dental Meeting November 25–28 ny that had a well-established reputa- “We do our best to create presenta- tors,” says Dr. Kolinski, “each of oping professional relationships New York, NY, USA tion for excellence. tions with timely relevance in the areas whom are working hard to docu- that continue to ensure quality care, He needed to find a company that of implantology and periodontics,” ex- ment cases in order to contribute to delivered through interdisciplinary ADF Association Dentaire Française could become an integral part of the plains Dr. Crosby. These presentations the literature and the profession.” rigor, and supported by well-con- Annual Meeting November 27–December 1 practice’s reputation and profession- are based solely on their own clinical The two senior partners also ceived continuing education. Paris, France al development. Nobel Biocare cases and related experiences. “We typ- serve as adjunct faculty at the Uni- Their emphasis on state-of-the- proved to be the perfect match. ically present our programs to over one versity of Illinois at Chicago’s Col- art, quality treatment, combined AAOMS Dental Implant Conference November 29–December 1 Looking back, it now seems all but hundred doctors and dental hygienists lege of Dentistry. with impeccable customer care has Chicago, IL, USA inevitable that the practice Kolinski each year, and our seminars serve as a paid high dividends and created a founded would become a Diamond basis for enduring collaborative rela- Essential collaboration template for longevity that grooms DGI 32nd Congress November 29–December 1 partner with the company, a status tionships that provide stability and Over the lifetime of the practice, Drs. each doctor from associate to part- Wiesbaden, Germany he and his colleagues have main- growth for our practice.” Crosby, Kolinski and Trahan have ner, fostering mutual achievement. tained for over 25 years. Dr. Kolinski adds, “In order to en- placed over 20,000 Nobel Biocare Together, Crosby, Kolinski and Tra- • 2019 • From the outset, Kolinski began sure optimum results, we always implants, which renders them han have developed a solid, well- providing continuing education emphasize the importance of using among the most experienced of im- proven, specialty practice model Nobel Biocare Global Symposium programs for his referring doctors original Nobel Biocare components. plant surgeons and provides excel- that bodes well for the future of June 27–29 Las Vegas, NV, USA while, at the same time, serving as a Many of the problems with screw lent experience and credentials for their enterprise. < clinical professor at the University loosening, for example, can be at- their teaching endeavors. of Illinois School of Dentistry. It was tributed to using substandard parts.” For the foreseeable future, these More to explore! there that he met his future practice Always interested in staying at the three will continue to collaborate Find out how Nobel Biocare can More to explore! | partner, Dr. Tricia Crosby, who cutting edge of his profession, Dr. with the lifeblood of their practice, help you grow your practice, please For the most recent updates, began as an associate in 2007 and Kolinski was one of the original in- the referring doctors. Facing mount- visit: nobelbiocare.com/events visit the Practice Resource Center established partnership in the prac- vestigators for the NobelActive im- ing pressure by insurance companies at: nobelbiocare.com tice in 2010. Together, they formed a plant. He was also the lead author for and corporate institutions to drive 12 Nobel Biocare NEWS Issue 1/2018 Brånemark Osseointegration Award The man behind the breakthrough Trefoil system receives recognition from colleagues for a lifetime of good work.

ship with Professor Brånemark.” “Dr. Higuchi worked side-by-side Dr. Kenji W. Higuchi, an Dr. Higuchi played a key role in with Professor Brånemark,” Sevetz American oral and maxillo- the original development of Bråne- continued, “and became one of the facial surgeon, and the man mark’s Novum concept, making him earliest surgeons in the U.S. to recog- who first devised and gave the ideal candidate to pick up the nize the breakthrough of osseointe- impetus to the development torch from the well-known Swedish gration, and how it would vastly im- of the Trefoil system for professor, in order to bring its new prove the quality of the lives of full-arch mandible rehabili- incarnation, Trefoil, to doctors and patients.” tation, recently became the patients around the world today. The OF President considers the 11th recipient of the Nobel award winner to be a humanitarian Biocare Brånemark Osseoin- Well-deserved recognition as well as an innovator: “Dr. Higuchi tegration Award. Known not only for his research, but annually took time out of his own also as an educator of rank and an private practice to coordinate pro- he Nobel Biocare Brånemark elder statesman in the profession, he fessional training sessions to ‘raise Osseointegration Award is was clearly pleased for the implicit the bar’ of those wishing to help pa- Tpresented each year by the Os- acknowledgement of a job well done. tients in their own locales.” seointegration Foundation (OF), the “It is personally meaningful to be Dr. Higuchi is a diplomate of the Academy of Osseointegration’s (AO) recognized by the Osseointegration American Board of Oral and Maxil- philanthropic arm. It honors an indi- Foundation for past involvement in lofacial Surgery. His private practice vidual whose impact on implant research, education, and humanitar- (Drs. Higuchi and Skinner PS) em- dentistry is exemplary in any or all of ian service,” he said, “as all these ac- phasized reconstructive oral and the Foundation’s mission categories: tivities have been of central impor- maxillofacial surgery. Since 1984, he research, education and charitable tance to me.” has been the director of The Spo- causes. Dr. Higuchi has been a force The President of the Osseointe- kane Center for Tissue Integrated to reckon with in all three areas. gration Foundation, Dr. Edward Se- Reconstruction, and since 2007, Dr. As a thought leader and innova- vetz, presented the award to Dr. Hi- Higuchi and Professor John Brunski, tor, taught and inspired by Professor guchi during the Opening Stanford University, have been the Per-Ingvar Brånemark, Dr. Higuchi Symposium of the Academy’s 2018 principals in OsseoConception LLC. has always focused on the patient Annual Meeting in Los Angeles, From 1986 to 2018, Dr. Higuchi first. Still active today, he continues California. participated in ten separate multi- to be instrumental in the develop- Introducing the laureate, he said, center prospective clinical trials, ment of revolutionary forms of “Dr. Kenji Higuchi’s professional most recently relating to his brain- treatment that make implant solu- and personal experiences and char- child, the Trefoil system. < tions accessible to an ever growing acteristics qualify him for being a number of patients. role model for anyone in the dental More to explore! For more information about the On hearing of the award, Dr. Hi- healthcare field. Almost 40 years “With his humanitarian heart, science-oriented mind and openly guchi said, “I am deeply honored. ago, he developed a close working revolutionary Trefoil full-arch friendly personality, Dr. Higuchi (pictured above) is an exemplary role model This is especially gratifying because relationship with the discoverer of solution: nobelbiocare.com/trefoil. to all of us on how to lead our professional and personal lives,” says the of my close and long-term relation- osseointegration. President of the Osseointegration Foundation, Dr. Edward Sevetz.

Americas Asia Pacific Europe, Middle East and Africa

Brazil Australia Austria Italy Sweden Nobel Biocare Brazil Nobel Biocare Australia Nobel Biocare Austria Nobel Biocare Italy Nobel Biocare Sweden Phone: 0800 16 999 6 Phone: 1800 804 597 Phone: +43 1 892 89 90 Phone: +39 800 53 93 28 Phone: +46 31 335 49 00 Belgium Lithuania Switzerland Nobel Biocare NEWS Canada China Nobel Biocare Belgium Nobel Biocare Lithuania Nobel Biocare Switzerland Nobel Biocare Canada Nobel Biocare China Phone: +32 2 467 41 70 Phone: +370 5 268 3448 Phone: 0800 211 424 Printed on non-chlorine bleached Phone: +1 800 939 9394 Phone: +86 400 081 7707 Netherlands United Kingdom Nobel Biocare, theAll Nobel rights Biocare reserved. logotype and all other in a trademarks certain case, are, trademarks if from nothing the context of else Nobel is stated Biocare. or is evident FSC-certified paper. Denmark Nobel Biocare Denmark Nobel Biocare Netherlands Nobel Biocare UK Chile Hong Kong Phone: +45 39 40 48 46 Phone: +31 30 635 49 49 Phone: +44 208 756 3300 Dental Biocare Nobel Biocare Hong Kong Read us online at: Phone: +56 220 19282 Phone: +852 2845 1266 Finland Norway Distributor Markets nobelbiocare.com/news Nobel Biocare Finland Nobel Biocare Norway Algeria, Bulgaria, Croatia, Colombia India Phone: +358 20 740 61 00 Phone: +47 64 95 75 55 Cyprus, Czech Republic, Greece, Hospimedics S.A. Nobel Biocare India France Poland Jordan, Kuwait, Lebanon, Malta, Headquarters Phone: +57 1 640 0608 Phone: 1800 266 9998 Nobel Biocare France Nobel Biocare Poland Macedonia, Qatar, Romania, Saudi Phone: +33 1 49 20 00 30 Phone: +48 22 395 73 60 Nobel Biocare Services AG Arabia, Serbia and Montenegro, Mexico Japan P.O. Box Germany Portugal Slovenia, Slovakia, Tunisia, Turkey, Nobel Biocare Mexico Nobel Biocare Japan 8058 Zürich-Flughafen, Switzerland Nobel Biocare Germany Nobel Biocare Portugal United Arab Emirates Phone: +52 55 524 974 60 Phone: +81 3 6408 4182 Offices: Phone: +49 221 500 850 Phone: +351 800 300 100 Phone: +34 933 560 562 Balsberg, Balz-Zimmermann-Strasse 7 USA New Zealand Hungary Russia 8302 Kloten, Switzerland Southeast Asia Distributor Markets: Nobel Biocare USA Nobel Biocare New Zealand Nobel Biocare Hungary Nobel Biocare Russia Phone +41 43 211 42 00 Indonesia, Malaysia, Singapore, Phone: +1 800 322 5001 Phone: 0800 441 657 Phone: +36 1 279 33 79 Phone: +7 495 974 77 55 Fax +41 43 211 42 42 South Korea, Thailand, Vietnam Ireland South Africa Phone: +852 28238925 Taiwan Nobel Biocare Ireland Nobel Biocare South Africa Nobel Biocare Taiwan Phone: +44 208 756 3300 Phone: +27 11 802 0112 South Asia Distributor Markets: Phone: +886 080 00 779 Israel Spain Bangladesh, Nepal, Pakistan and Nobel Biocare Israel Nobel Biocare Spain Sri Lanka Phone: +972 3 9291000 Phone: +34 900 850 008 Phone: +91 22 67519999

Web contact: nobelbiocare.com/contact v 18.1 GMT 56109 GB 1804, Printed in the EU © Nobel Biocare Services AG, 2018. GMT Services 56109 GB AG, 1804, Printed in the EU © Nobel Biocare Please contact the local Nobel Biocare sales office for current product not be regulatory cleared/released for sale in all markets. Please refer to nobelbiocare.com/trademarks for more information. Product images are not necessarily scale. Disclaimer: Some products may and precautions. to sale by or on the order of a licensed dentist. See Instructions for Use full prescribing information, including indications, contraindications, warnings restricts this device (United States) law Caution: Federal prescription use only. For assortment and availability.