Nobel Biocare News Information for the Osseointegration Specialist Issue 1/2011

Strength of Mind TheThe Big Big Oxmox Oxmox advised advised When When she she reachedreached the the first first hills hills of theof the Italic Italic and Character Mountains,Mountains, she she had had a last a last view view back back on onthe the skylineskyline of her.of her.

By Richard Laube, CEO

We have come a long way since the 1950s, when a young researcher in Sweden observed that the human body would not only tolerate tita­ nium, but also integrate it into living tissue. Nevertheless, without that young man’s curious mind—and ad- mirable tenacity—we’d be nowhere. The titanium implants used rou- tinely today only exist because of the pioneering work of Professor Per- Ingvar Brånemark. We now have these remarkable objects at our dis- posal because he was prepared to challenge the conventional wisdom of the times, and demonstrated the determination to systematically doc- ument the evidence he needed in order to prevail over well-established opposition. The Titan of Titanium Since those early days, osseointe- grated titanium implants have revo- Professor Per-Ingvar Brånemark grants a rare interview. lutionized the fields of dental, maxil- lofacial and orthopedic rehabili- tation. Based on his original findings, in- with the organization’s lifetime According to the EPO, “more than asked about the award, he replied novative bone-anchored restorative Science is what you know. achievement award for his discovery eight million people have benefited simply, “I have received quite a few solutions have improved the quality Philosophy is what you don’t and development of osseointegra- from Brånemark’s landmark meth- prizes and awards over the years, but of life for millions of people around know. Per-Ingvar Brånemark tion. ods,” since he treated his first osseo- this beats everything else. It repre- the world. At Nobel Biocare, we’re remains interested in both. Regarded as the most prestigious integration patient, Gösta Larsson, sents recognition from colleagues proud to follow in his footsteps, prize for European inventors, the in 1965. and laymen alike that my method ­providing you and your colleagues By Frederic Love award went to Brånemark because, has already helped an enormous with evidence-based products that “During the course of his career, he Serendipity and hard work number of people. What greater are validated by scientific and clini- t its annual inventor awards has continued to refine his approach I met with Professor Brånemark re- commendation can a scientist hope cal research. I trust you’ll enjoy A ceremony this spring, the Euro- into what has become the gold stan- cently, not far from the University of to receive?” the interview with Professor Bråne- pean Patent Office (EPO) presented dard of dental implantation global- Gothenburg, Sweden, where he has mark that begins here to the left on Professor Per-Ingvar Brånemark ly—the method of osseointegration.” worked most of his life. When I more on page 2 this page. < In this Issue Innovation on a Firm Foundation NobelReplace® evolves 6 NobelActive™ 3.0 Smaller and stronger for By Frederic Love also include the standardized step- safe implant placement in by-step drilling protocol, with its areas with limited space. straightforward surgical kit, and the uitable for both experienced color-coded surgical and prosthetic S restorative clinicians and surgi- components, all of which help to re- 9 TiUnite® Eleven years on cal implant users, NobelReplace has duce placement time by enabling the and as stable as ever. evolved into two new versions, both rapid and safe identification of all See the radiographic of which retain the key innovations components. evidence. of NobelReplace Tapered. NobelReplace Conical Connec- These features include the tapered tion (CC) has been designed to implant design, of course, which fa- 9 Reader beware! Not all cilitates high initial stability. They more on pages 3–5 NobelReplace Platform Shift and Conical Connection. studies are the same. 2 Nobel Biocare News Issue 1/2011 From the Editor The Titan of Titanium Exclusive interview with Per-Ingvar Brånemark, continued from the cover

He has come a long way few companies who knew how to

since those early days in the 1950s machine titanium,” says the profes- sor. Thus a long-term relationship Nicolas Weidmann when, as a young researcher, he was began. Senior VP Global Communications completely absorbed in the study of the anatomy of blood flow. Over the years, this relationship As part of that work, he attached a has had its ups and downs, but both After a decade-long hiatus, we are titanium-housed optical component parties have benefited from a long- proud to resume the publication of to a rabbit’s leg, which made it possi- term devotion to the support and Nobel Biocare News. In this first ble to study microcirculation in the practice of good science. When I issue—and every issue that follows— bone tissue through specially modi- asked Brånemark what characterizes we intend to introduce innova- fied microscopes. The work at hand good science for him personally, he tions and disclose trends, as we was completed successfully, but responded thoughtfully. share the stories and experiences of when it came time to remove the “Good science is all about good our readers with the global dental metal-framed optics from the bone, method. Making observations, col- community. Brånemark famously discovered that lecting facts and data and creating a the bone and the titanium had be- hypothesis to explain what you’ve The patient first come virtually inseparable. seen—it all starts there. Then you From the very beginning, back when “Not long afterwards,” Brånemark have to deduce the implications of Nobel Biocare was known as Nobel- said, “we changed the direction of the hypothesis and put the implica- pharma, the company has main- our work to investigate the body’s tions to the test. It is very important tained a determined commitment to ability to tolerate titanium.” that all data be considered, not just develop and support evidence-based those that support your ideas. Final- treatment modalities. This is still the Multidisciplinary enterprise ly, you have to subject your findings Per-Ingvar Brånemark: “It is very important that all data be considered, case today. We promote our prod- To gain a proper understanding of to peer review. At the end of the day, not just those that support your ideas.” ucts and services for the same rea- what he would later call “osseointe- there may be no ‘final’ truth, but in sons you choose them: for the bene- gration,” Brånemark recruited ex- our field, a valid hypothesis will in- and “osseointegration” come imme- stands for reconstructive biology, fit of your patients. perts from other fields—such as evitably lead to practical achieve- diately to mind, of course. When he not carpentry.” Looking toward the This is not an expression of altru- physics, chemistry and biology—to ment as it stands up to the scrutiny introduced the concept of the “third future, he adds, “I’ll be very happy if ism. Ensuring the best interests of his quest. Physicians, dentists and of other researchers in the field.” dentition,” Brånemark got thousands Nobel Biocare keeps the rigorous sci- the patient makes our business a via- ­biologists all joined the effort. To- As successful as Brånemark has of professionals to start thinking of entific philosophy of the early years ble enterprise and your clinic a se- gether they developed diligent, been as a scientist, he has also been implant-based solutions not as “false alive in its corporate culture.” cure place to practice dentistry. ­methodical techniques for the inser- successful as an evangelist for the teeth” but “total rehabilitation.” The editors want Nobel Biocare tion of implants. At the same time, “good news” of osseointegration. “I chose these words because I Eye on the horizon News to be your newsletter as well as engineers, physicists and metallur- When I point out that people listen found them succinctly descriptive. While we’re on the subject of the fu- ours. If there is an insight you would gists studied the metal’s surface and to him, and ask why, he responds There’s a beauty in language like that. ture, I ask, “What’s next?” like to share with your colleagues or how the design of the implant might with a smile on his face. I certainly didn’t anticipate how “If you’ll allow me to speculate a a topic you would like us to explore, have an effect on bone healing and “They listen to me because I know widely they would be accepted, but bit, I believe that we may be on the please do get in touch. growth. what I’m talking about. Before treat- was pleased, of course, to see how threshold of a paradigm shift in the We’re looking forward to the ex- For the best part of two decades, ing the first patient, I had accumulat- quickly they gained traction in both professions we practice. Once we re- change of ideas! < Brånemark faced opposition from ed more than ten years of experience scientific literature and clinical com- alize that biology—especially immu- the medical establishment in his na- in the lab, for example. I don’t rush munication.” nology—lies at the heart of both tive Sweden. “Our findings that the to conclusions, and I think people When asked to comment on the modern dentistry and medicine, I body would accept titanium over the appreciate that.” practicalities of cooperative efforts think we’ll start educating dentists long term, and even allow it to inte- between science and industry, and doctors along similar lines at the grate in bone, flew in the face of Followers everywhere Brånemark takes the high ground. same institutions. Perhaps the tradi- conventional wisdom,” he explains. I follow up with the question, “How “We have always needed each other’s tional partitions between them will Nobel Biocare News “Theorists’ textbook opposition as- much of your success can be ac- expertise and have generally enjoyed even disappear altogether in the next

Published regularly by serted that our implants would trig- counted for by such personal charac- a symbiotic relationship. In an ideal generation or two.” Nobel Biocare Services AG ger initial inflammation and would teristics as perseverance—stubborn- world, maybe talented scientists “As far as my own research is con- ultimately be rejected by the body’s ness, if you will—and how much by would also be gifted production en- cerned, I see great strides being Vol. 13, No. 1, 2011 immune system.” the apostles you recruited around gineers and marketers; and maybe made in the area of osseoperception, Editor-in-Chief Nicolas Weidmann The 1960s were trying times for the world?” industrialists would be able to see whereby bone-anchored prostheses Managing Editor Frederic Love Production Manager Jim Mack Brånemark. Funding from Swedish “One person alone can’t have much beyond the bottom line; but in the transmit information that can be in- research organizations dried up, yet impact on the world. I’ve been privi- real world—in order to achieve our tuitively interpreted via the central Editorial offices he persevered. With his physician’s leged to meet and collaborate with goals—we each do what we do best nervous system. I have patients with Nobel Biocare News Herdevägen 11 certification at stake, he repeatedly some extremely talented people over and turn to others with complemen- osseointegrated limbs, who can actu- 702 17 Örebro, Sweden demonstrated the accuracy of his the years. In addition to all the den- tary skills for help with the rest.” ally ‘feel’ the texture of the rugs on claims and the viability of osseointe- tal and medical students who have To the question, “Do you think which they’re walking today. This as- Telephone: +46 19-330680 Telefax: +46 19-330681 gration. Finally, in the mid-1970s, passed my way, I had something like that Nobel Biocare has succeeded in pect of osseoperception is a bounti- E-mail: [email protected] the Swedish National Board of 44 doctoral candidates at the Univer- being a good steward of the trust ful field for further research.”

The contents of contributors’ articles do Health and Welfare approved the sity of Gothenburg over the years, that you long-ago established among Eighty-two years-old and still full of not necessarily express the ­opinions Brånemark method. and almost all of them taught me as dentists?” Brånemark replies: “I enthusiasm for the work at hand, Pro- of Nobel Biocare AG. To reach beyond the world of the much as they learned.” think I see a company today that fessor Per-Ingvar Brånemark remains

© Nobel Biocare Services AG, 2011. university clinic, Brånemark looked Per-Ingvar Brånemark has coined wants to build on its scientific heri- the best known personality in the world All rights reserved. for an industrial partner. “I chose many words and phrases that have tage. Together we ushered in a new of osseointegration to this day. He has Bofors, an antecedent to Nobel Bio- become commonly used terms in era, but we all have to remember to certainly earned the title, “Father of care, because they were one of the dentistry. “Fixtures”, “anaplastology” respect the molecules. Our method modern clinical implantology.” < Issue 1/2011 Nobel Biocare News 3 Brånemark in Brief New NobelReplace® Innovation on a firm foundation, continued from the cover Brånemark, “Unreasonable!” increase soft tissue vol- tri-channel connection of the Nobel-

When Per-Ingvar Brånemark received one of the many honorary ume, which leads to healthier soft Replace PS design provides familiar doctorates awarded to him by universities around the world, British tissue. This new iteration adds an ad- tactile feedback. With NobelReplace Professor Richard Johns of the University of Sheffield told the vanced third generation internal PS, prosthetic components literally assembled dignitaries that he regarded Professor Brånemark as an conical connection and built-in plat- drop into place. “unreasonable man” and went on to quote George Bernard Shaw. form shifting to the well-proven ta- Like all other NobelReplace ta- “All progress depends on the unreasonable man. The reasonable pered NobelReplace implant body. pered implants, the new versions man adapts himself to the world: The unreasonable one persists in (To learn more about the design con- mimic the shape of a natural tooth trying to adapt the world to himself. Therefore, all progress depends siderations behind the development root. Designed for high initial stabili- on the unreasonable man.” of the conical connection and a clini- ty, they can be placed at good advan- cian’s first experiences with Nobel- tage in both extraction sockets and Maximum soft tissue volume Replace CC, please turn the page.) healed sites. Platform shifting designed for more Great movements NobelReplace Platform Shift (PS), With the latest innovations inher- natural-looking soft tissue. begin with one man’s work on the other hand, retains the inter- ent in the platform shift and conical nal tri-channel connection to which connection, Nobel Biocare’s versatile More to explore: A dedicated NobelReplace CC In 2009, osseointegration experts from all over the world gathered experienced NobelReplace Tapered implant portfolio has been further and PS section is available on in Gothenburg, Sweden, to celebrate Professor Brånemark’s 80th users are accustomed, while adding expanded to accommodate the per- the Nobel Biocare website and birthday. Speaking to the assembled guests, Canadian Professor the platform-shifting feature now sonal preferences and treatment offers product information, George Zarb pointed out that “like other scientists working on the available in NobelReplace CC. Plat- needs of every dental professional. first-user comments, course frontiers of knowledge, Per-Ingvar used what at the time must have form shifting promotes expanded The complete assortment includes programs and much more: appeared to be uncertain techniques and materials, often with inad- tissue volume at the soft tissue inter- bone- and tissue-level implants for www.nobelbiocare.com/ equately controlled conditions. He also encountered many obstacles face, thereby creating more natural- all indications, bone types and surgi- < replaceccps and events that could have invalidated his data; but he persisted ... looking esthetics, while the proven cal protocols. and luckily for us—and above all, our patients—he triumphed.” Acknowledging the seminal nature of Brånemark’s applied research, Zarb also said, “He showed [us] that many of the world’s great movements begin with one person’s work, often a single tena- For Natural-looking Esthetics cious conviction.” Then he went on to encourage his listeners. “While few have the greatness and opportunity to bend history itself NobelReplace® with platform shifting the way Brånemark did, all of us can work to change a small portion of events.”

An appetite for NobelReplace Platform Shift (PS) allows existing interdisciplinary cuisine NobelReplace Tapered users to broaden their restorative With tongue in cheek, Swedish Professor Tomas Albrektsson says options without having to that Professor Brånemark’s interdisciplinary commitment some- abandon the surgical times expressed itself in the early days of his research in unexpected protocol and tri-channel Fig. 1. Missing premolar. Fig 2. Implant placement. “exchanges.” connection with which they “My first memory of my most inspiring teacher ever—Per-Ingvar are familiar. Brånemark—dates back to the latter parts of the 1960s when some By Dr. Egon Euwe zoologists wanted to finally prove that eels actually migrated to and from the Sargasso Sea. Per-Ingvar invented a sort of titanium button to mark the eels, on the condition that he would be sent a number of fried specimens should the zoologists be able to later prove their hen crestal bone preservation point.” W and soft tissue volume are Fig 3. Soft tissue development. Fig 4. Final restoration. Brånemark apparently inspired loyalty as well as scientific dedica- critical, the NobelReplace PS has be- tion in his team of young researchers. Albrektsson confirms this come my implant of choice. with a wax-up were used to establish Figure 4. Here you can see the when he adds: “I stayed with Per-Ingvar until I got my own chair in Let’s look at the following case as a ideal implant positioning. definitive screw-retained Nobel- 1985, but I remain one of ‘his boys’ to this day. With a degree of good example of how NobelReplace Figure 2. We placed a NobelRe- Procera implant restoration four fondness, he actually still calls us “his Swedes”, not referring to our PS can be used in a premolar restora- place PS implant (4.3 x 13 mm). Si- months after surgery. The veneering common nationality but to a popular root vegetable at northern lati- tion. In this case, my patient was a multaneously, a connective tissue porcelain is directly applied onto an tudes, the Swedish turnip or rutabaga!” 49-year-old female, who displayed graft was positioned to increase the implant abutment with a reduced good oral hygiene. She is a non- soft tissue volume, which was insuf- anatomical contour. In addition, you smoker and has no parafunctional ficient. In this minimally invasive can see canine crown lengthening For further reading habits. There was actually too much surgical approach the existing papil- and a veneer on the mesial portion space for the missing tooth. lae were left intact . We subsequently of the second premolar. “A System with its Roots in the 1950s,” by Frederic Love in Nobel- Figure 1. The patient presented a implemented a four-month, delayed The ceramics in this case were pharma News, Vol. 1, No. 1, 1987. missing upper left first premolar, a loading protocol to allow for soft tis- done by Pasquale Palmieri from So- “Implanting Hope,” (text and video) on the website of the European rotated second premolar and an ad- sue graft maturation. vico (Milan), Italy. < Patent Office. www.epo.org/news-issues/european-inventor/ jacent canine with short clinical Figure 3. Using a provisional resto- finalists/2011/branemark.html crown. Orthodontic correction was ration, we developed an esthetic More to explore not accepted in this case. She also emergence profile and transferred Watch the surgery of this case at: presented a buccal profile character- 3D information to the working cast www.nobelbiocare.com/ ized by concavity. Mounted casts with a customized impression coping. replaceccps 4 Nobel Biocare News Issue 1/2011 Systematic Evolution Adding a conical connection to a hugely successful implant system.

Hurson: As we have seen with the shape of a tooth root, for use in diffi- The flexibility of the implant Dr. Svenja Rogge, a product success of the NobelActive implant cult-to-treat sites such as type 4 system is frequently referred to as manager at Nobel Biocare, system, there is definitely a global bone, extraction sockets, areas with one of its major assets. What does recently sat down with Steve trend toward conical connection im- converging roots and areas with labi- that mean exactly from a clinical Hurson, the company’s chief plants for the treatment of the par- al undercuts. At the same time, this and prosthetic point of view? scientist, to ask a few tially edentulous patient. implant was designed to perform Hurson: There is literally a product questions about the new For edentulous applications, the well in hard bone qualities, resulting for every application ranging from NobelReplace Conical Replace Select Tapered implant in a system with outstanding all- single-tooth restorations to All-on-4 Connection implants. placed with the smooth collar in the around predictability. graftless solutions. In demanding es- soft tissue—combined with a Nobel- thetic situations, NobelReplace Ta- Procera Implant Bridge or Implant NobelReplace has been developed pered and now NobelReplace Coni- Since NobelReplace was first Bar Overdenture—provides a cost- continuously based on the latest cal Connection are placed at bone launched in 1997, this tapered effective treatment that is hard to scientific research on implants. level and can be restored with pre- implant design has become the beat. This treatment plan results in What important developments fabricated or customized abutments most widely used implant system soft tissue adhesion to the collar of have had a lasting influence on and NobelProcera Crowns. For pos- in the world. Nobel Biocare is now the implant, which remains undis- the system? Because of his accomplish- terior and edentulous applications, ments in research and develop-­ making a conical connection turbed during prosthetic manipula- Hurson: Two aspects of the design Replace Select and Replace Select TC ment at Nobel Biocare, Steve available as part of this popular tion. stand out. The tapered shape of the implants may be placed in a one- system. What benefits does this Hurson is in great demand inter­ implant combined with TiUnite (a nationally as a lecturer on implant stage application, leaving the smooth feature offer? Together with Dr. Jack Hahn, one porous, moderately rough titanium design, prosthetics and implant collar to remain undisturbed in the Steve Hurson: Experience from the of the pioneers in the field, you oxide implant surface) provides ex- surfaces. soft tissue during prosthetic recon- NobelActive implant system demon- developed NobelReplace about 15 cellent primary stability and rapid os- struction. strates that even though conical con- years ago. Which scientific seointegration, allowing the clinician Hurson: It all revolves around predict- We see a revival of screw-retained nection implants can be used for all research outcomes and clinical the flexibility to treatment plan for ability and ease of use. The surgical restorations in the industry. Nobel- indications, they are best suited for experience did you implement one- and two-stage healing—and im- system is state-of-the-art, setting the Procera products range from full- single-tooth and partially edentulous when you were designing the mediate loading. The NobelReplace standard for kit design, color-coding contoured single crowns to full-arch applications. The Nobel Biocare con- original system? tri-channel connection is the easiest and drill design. The predictability of frameworks in titanium and zirconia. ical connection implants have a tight Hurson: Self-tapping parallel-walled to use in the industry and was specif- the straightforward surgical protocol These products set the standard for seal, narrower emergence profile and implants were the predominant mo- ically designed to provide long-term makes this the day-to-day system of fit, strength and soft tissue health.< platform shifting. This type of design dality at the time of the Replace de- trouble-free prosthetic solutions. choice for experienced surgeons, as has been shown to result in outstand- velopment. Dr. Hahn identified a well as for teaching new clinicians. More to explore: ing soft tissue volume and esthetics. need for an implant with a narrower NobelReplace is now the most Restorative dentists choose the sys- A dedicated NobelReplace CC apex, which would achieve higher widely used implant system in the tem because the prosthetics are easy- and PS section is available Is a move towards the conical primary stability in soft bone. The world. Why do you think this to-use and have a proven track record on the Nobel Biocare website: connection something we are concept was to have an implant de- implant system is the first choice of providing high-strength, long- www.nobelbiocare.com/ likely to see around the world? sign that would have the tapered for so many clinicians? term, trouble-free restorations. replaceccps

NobelReplace® Conical Connection Designed for esthetics and ease of use.

Abutments. The NobelReplace Conical CAD/CAM de- Connection (CC) is a new sign of the indi- implant concept that merges vidualized pros- the well-proven implant body thetic restora- of NobelReplace Tapered tions was done with a tight internal conical This is what she presented: Vertical by A. Bonaca, connection. It is a versatile, fracture of the upper right lateral and and the veneer- easy-to-use implant, which central incisors after an incident of ing by P. Paglia performs well in soft and trauma. The extraction of both teeth and M. Moretti, hard bone alike. was necessary. all three of I decided to place two NobelRe- Rome, Italy. The By Professor Alessandro Pozzi place Conical Connection implants The final abutments were placed final result shows excellent soft tissue (3.5 x 16 mm and 4.3 x 16 mm) im- four months after surgery. Depicted development and bone formation. In the following commentary, I mediately after tooth extraction 1 here, we used two customized The X-ray of the final restora- would like to share a case of anterior mm below the buccal crest level, in NobelProcera Abutments in shaded tion was taken four months after restoration in a 50-year-old woman, order to create mesial and distal zirconia. surgery. < who had no parafunctional habits, bone peaks for papilla support. We ments and provisional crowns for Directly afterwards, we cemented

but two inadequate root canal treat- followed an immediate loading pro- optimal shape and gingival architec- two IPS e.max® CAD Crowns by IPS e.max® is a registered trade-mark of Ivoclar ments and severely discolored teeth. tocol including prefabricated abut- ture. ­NobelProcera onto the NobelProcera Vivadent AG. Issue 1/2011 Nobel Biocare News 5 Strong, Tight Fit and Proven Implant Body Experience NobelReplace® Conical Connection from the clinical point of view.

Restorative flexibility Professor Alessandro Pozzi The new NobelReplace implants reports from his state-of-the- offer great restorative flexibility for art private practice in Rome Restorative flexibility Dual-function prosthetic the treatment of a wide variety of where he has begun to use Enhance your treatment flexibility using connection clinical indications, ranging from the new NobelReplace prefabricated and CAD/CAM individualized Internal conical connection for simple single-tooth restoration in the NobelProcera restorations to support all abutments and external platform for Conical Connection implant posterior—via highly challenging temporary and final solutions.* implant-level bridge restorations. in a variety of cases. anterior tooth replacement—to ad- vanced full-arch restoration, based By Professor Allessandro Pozzi on both axial and tilted-implant designs. o say the least, being intro- NobelReplace CC is suitable for duced to the NobelReplace use with prefabricated abutments T Conical Connection (CC) Maximum soft tissue volume and customized CAD/CAM Nobel- was a valuable experience. The Built-in platform shifting designed to Procera Abutments. The clinician is NobelReplace CC has been devel- improve soft tissue for natural-looking provided with a wide range of pros- oped to optimize the biomechanical, esthetics. thetic options to make it easier to Strong sealed connection biological and clinical benefits of a Internal conical connection with provide a treatment solution for vir- widely used basic design. It demon- hexagonal interlocking offers tight tually any restorative challenge. The strates a new implant concept that seal and high mechanical strength. tapered configuration facilitates the merges the biomechanical and pros- achievement of primary stability in thetic advantages of a meticulously post-extraction sockets, in poor engineered third-generation internal Accurate identification quality bone, as well as in anatomi- Color-coded components for accurate connection with practical platform cally restricted areas. and fast identification. shifting, now incorporated into the The instruments are very simple well-proven implant body of the and can be employed according to SEM image of cross-section of NobelReplace Tapered. From all the NobelReplace CC RP the well-proven and easy-to-use experience I have gathered to date, NobelReplace Tapered drilling pro- the NobelReplace CC is a versatile, tocol. easy-to-use implant, which performs Experienced NobelReplace Ta- well in soft and hard bone alike. pered and NobelActive users will feel In recent years, greater biome- familiar with the color-coded surgi- chanical demands have been placed cal and prosthetic kits, which flattens on restorative solutions as the use of * Zirconia abutments with internal conical connection the learning curve. Appropriate for are not indicated for posterior use. implants for single-tooth replace- guided surgery, NobelReplace CC is ment in posterior regions of the fully compatible with this minimally mouth has become more widespread invasive clinical approach. and new restorative designs based on ing “osseointegratable” threads at the damage to the connecting surfaces. shifting to the popular NobelReplace The advent of NobelReplace CC is axial and tilted implants have been neck nor reducing the diameter of In fact, NobelReplace’s conical con- Tapered implant. By equipping the entirely in line with my conviction introduced. These restorations re- the connecting screw. nection is so precise that proper seat- clinically well-proven implant body that modern bone-anchored treat- quire a stronger connection in order In the design of the NobelReplace ing of the prosthetic components of the NobelReplace system with plat- ment should be characterized by a to withstand higher torque, lateral CC implant, the depth of the connec- does not even require radiographic form shifting and a tight prosthetic minimally invasive surgical ap- loading stress and to minimize forces tion has been optimized to obtain all verification (thus concurrently re- connection, the clinician has a better proach, high biocompatible pros- on the retaining screw and prosthetic the biomechanical and clinical bene- ducing total radiation exposure for chance than ever before to secure thetic accuracy and unparalleled pa- components. fits associated with an internal con- the patient). healthy soft tissue around the implant tient comfort. In order to improve the biome- nection without substantially weak- From the taking of the impression in a predictable way. This implant makes it easier to re- chanical characteristics of the com- ening the implant by reducing the to the delivery of the definitive resto- The tight conical connection and store the function, the soft tissue plete restoration, the internal con- thickness of its walls. The anti-rota- ration, one of the main causes of platform shifting both are intended framework and the natural look of a nection concept was introduced to tional design of the conical connec- poor prosthetic precision is the mis- to improve the volume and health of healthy mouth. NobelReplace CC is the world of implant design; but in tion minimizes torsion forces and al- placement of the prosthetic compo- gingival tissue. The tight conical an implant system that meets the de- its first iterations, the internal con- lows the application of high insertion nents in the implant connection. connection is designed to preserve mands and requirements of both cli- nection compromised the strength of torques on the implant without in- NobelReplace CC virtually elimi- the marginal bone by minimizing nician and patient alike. both the connection and the implant curring distortion. nates this problem. The internal con- micro-movements and eventual mi- The result of high-tech innovation itself. ical connection with hexagonal in- cro-leakage, leading to enhanced springing from an evidence-based Finite element analysis reveals that Prosthetics terlocking offers a tight seal, secure pink esthetics. R&D culture, the new NobelReplace stresses resulting from functional The conical connection design facili- positioning of all the prosthetic com- The clinician can now produce a CC has become my implant of loading are concentrated in the neck tates the attachment of prosthetic ponents, and tactile feedback. These natural-looking restoration accom- choice. < area of the implant. Up until now, in- components. From the very first features help to improve the work- panied by healthy, soft tissue archi- ternal connections have exacerbated case, comfortable, easy handling be- flow of both the general practitioner tecture—and do so with fewer soft More to explore: this stress due to the weakness of im- comes the norm, giving the clinician and implant specialist alike. They tissue grafting procedures. Given To read more about the plant walls and deficient load distri- a sense of confidence and security as serve to reduce the likelyhood of today’s high esthetic demands, professional features and clinical bution to the bone, resulting from each connection is made. The design handling error, speed up procedures NobelReplace CC is sure to improve benefits of NobelReplace CC (as the designs themselves. The wall can be characterized as a sliding con- and improve patient comfort. not only patient comfort, but satis- well as those of NobelReplace PS), thickness of the implant in the criti- nection, which allows for contact faction as well. The bottom line: please visit the Nobel Biocare cal stress zones has to be able to resist with the surface of the prosthetic Platform shifting quick and predictable implant treat- global website at: material fatigue and breakage under components, improving final place- In addition to the conical connection, ment with long-term functional and www.nobelbiocare.com/ prolonged use while neither sacrific- ment and minimizing the risk of NobelReplace CC also adds platform esthetic stability. replaceccps 6 Nobel Biocare News Issue 1/2011 NobelActive ™ 3.0 Opening a world of possibilities

In situations where space is limited, I’ve been looking for an New treatment options implant that provides the high initial stability and strength Specifically designed for the replacement associated with the original NobelActive implants, which I’ve of single-unit maxillary lateral incisors as well used for years. Now, I’ve found it. Let me walk you though one as mandibular lateral and central incisors. of the first cases I completed using the new NobelActive 3.0 Maximum soft tissue volume implant. Built-in platform shifting designed to improve Strong sealed connection soft tissue for natural-looking esthetics. Internal conical connection with hexagonal By Dr. Iñaki Gamborena interlocking offers tight seal and secure High initial stability even in positioning of abutments.

My patient is a 22-year-old woman who displays the results of good oral compromised bone situations Expanding tapered implant body with double- ­hygiene. She does not smoke, nor does she have any parafunctional habits. lead thread design condenses bone gradually. Adjustable implant orientation Due to extensive root infection and fractured teeth, unfortunately, we ­needed Reverse-cutting flutes with drilling blades on to extract both of her lower central incisors, leaving a very narrow space for the Maximum bone preservation apex enable experienced clinicians to adjust subsequent two-unit restoration. Apex with drilling blades enables implant position for optimal restorative smaller osteotomy. orientation, particularly in extraction sites. An Implant for Tight Spaces NobelActive™ 3.0—safe and secure

ception to this rule. Thanks to its A pre-operative X-ray to the left shows the failed endodontic treatment that By Frederic Love this narrow diameter implant is was attempted prior to the extraction. therefore equipped with integral expanding tapered implant body, drilling blades, which allow for a with double-helix thread design, arrow diameter implants— smaller initial osteotomy. NobelActive 3.0 compresses bone usually defined as anything In addition to the drilling blades gradually, minimizing trauma and N under 3.5 mm—boast re- on the tip of the implant, reverse cut- providing high initial stability even markable inherent promise. In theo- ting flutes make it possible for clini- in compromised bone situations. ry, they make it possible to treat cians who are experienced with Built-in platform shifting is also almost all cases involving narrow NobelActive implants to adjust the part of the design. This feature pro- interdental spaces, especially in situ- implant position in order to optimize vides a very palpable benefit to the ations where there is a minimum restorative orientation, which is par- patient. It makes it possible for the We decided to place NobelActive 3.0 x 13 mm implants according to an imme- amount of hard tissue. In practice, ticularly useful in the extraction sites clinician to ensure maximum soft diate loading and function protocol that included a connective tissue graft to however, they have to be strong common in single-tooth anterior tissue volume for natural-looking increase soft tissue volume. A surgical guide was used to ensure optimal im- enough to survive demanding bio- restorations. esthetics. What’s more, an internal plant direction. In the post-operative X-ray just above to the right, you can see mechanical loading and torsion— Dr. Scott MacLean of Halifax, conical connection with hexagonal the two NobelActive 3.0 despite their small dimensions—if Nova Scotia, finds NobelActive 3.0 to interlocking offers a tight seal and implants in place. they are going to live up to that be the perfect complement to the secure positioning of the abutment, a In this image to the right, promise. earlier, larger diameter NobelActive must-have characteristic for any you can see the preliminary To provide a safe and predictable implants that he has used for years. first-class, bone-anchored, single- development of an esthetic clinical solution to NobelActive “The NobelActive 3.0 is a great im- tooth restoration. emergence profile three users, Nobel Biocare has now devel- plant to use in tight, esthetically de- According to Dr. Philippe Russe of months after connective oped, and extensively tested, a manding areas of the arch. Like the Reims, France, NobelActive 3.0 has tissue graft maturation. 3.0 mm NobelActive implant that others in the NobelActive family, it become his implant of choice for The final restoration was meets design and material strength fabricated near my clinic in criteria of the highest standards. San Sebastián, Spain, by Iñigo Casares. Here, the two NobelProcera Zirconia Available immediately through the Crowns can be seen directly after having been cemented onto NobelProcera company’s sales channels around the “The NobelActive 3.0 is a great implant to use in Abutments seven months after surgery. world, the NobelActive 3.0 is sure to tight, esthetically demanding areas of the arch.” be welcomed by osseointegration Dr. Scott MacLean professionals everywhere. — The NobelActive 3.0 has been spe- cifically designed for the replace- ment of single-unit maxillary lateral provides excellent results due to its excellent esthetics in challenging incisors as well as mandibular lateral principles of design. The platform single-tooth anterior situations. Of and central incisors. These very visi- shift with conical connection main- NobelActive 3.0 he says, “The extra ble single-tooth sites require highly tains a solid, tight connection that is bony volume around the implant esthetic restorative solutions that can easy to restore. The thread dimen- supports longer papillaes, improving be reliably delivered for the long- sions and design make it the perfect the esthetic outcome of usually diffi- term. NobelActive 3.0 fits the bill. implant for placement in upper later- cult cases. With its well-known ex- Because there is not much bone al and lower incisors, and it feels very cellent initial stability, platform shift- to work with in sites like the ones familiar to place and restore.” ing and conical connection, the new recommended for NobelActive 3.0, Respect for bone as a living tissue NobelActive 3.0 has everything you maximum bone preservation has is key to all research and develop- need in a small diameter implant As an experienced user of the full range of NobelActive implants, I trust this been a key priority in engineering as- ment at Nobel Biocare. The develop- specially designed for narrow ante­ new product for treating narrow space cases. < pects of the new design. The apex of ment of the NobelActive 3.0 is no ex- rior spaces.” < Issue 1/2011 Nobel Biocare News 7 Early or Late Baseline? Recent Findings Not all study protocols are the same.

instead. As far as loading protocols Since a relatively late baseline ™ At the 25th Anniversary are concerned, immediate loading misses the pronounced initial mar- NobelActive two-year results Meeting of the Academy of cases were relatively underrepresent- ginal bone remodeling typical after Osseointegration, an interna- ed in articles written about both implant insertion, the choice of dif- At the IADR general session in Barcelona, Spain, the tional group of Nobel Biocare Astra Tech and Straumann implants. ferent time-points makes it very dif- results of a two-year follow-up study of NobelActive researchers presented the In the material under review, sig- ficult to compare results between implants was presented in July 2010. This multi-center results of a literature review nificant differences were also seen articles. study evaluated bone and soft tissue remodeling around that applied strict inclusion between the points-in-time at which In summary, the review showed NobelActive implants in immediate function. criteria comparing the a radiographic baseline was estab- that the study groups in which Nobel preferred study protocols of lished for the assessment of marginal Biocare implants had been used re- The results show stable bone and soft tissue levels after two years in three major implant bone level change. ported the highest percentage (84%) function for the NobelActive implant. The results also demonstrate that manufacturers – Astra Tech, of one-stage protocols and the high- the implant can be used under the demanding treatment conditions Nobel Biocare, and Radiographic Baseline est percentage (45%) of immediate associated with immediate loading. Straumann. loading protocols; and that they 100% began measuring marginal bone re- www.nobelbiocare.com/nobelactive-abstract modeling most frequently (79%) at he study also compared the base- 80% implant insertion. < T line chosen for radiographic ® evaluation when assessing marginal 60% TiUnite 7-year, immediate loading bone level change. More to explore Covering clinical articles pub- 40% Count For more information about An article in “Clinical Implant Dentistry and Related lished in peer-reviewed journals over “Comparison of Radiographic Research” documents the 7-year outcome of immediately Nobel Biocare a span of more than 14 years, the re- 20% Baselines and Loading Protocols loaded implants with the TiUnite surface. It can be found view demonstrates noteworthy dif- Utilized in Implant-studies”, as an ePub online. Astra Tech Straumann ferences in the types of surgical and please go to the following URL: Astra Tech Nobel Biocare Straumann loading protocols followed in these www.nobelbiocare.com/ “Implants with an Oxidized Surface Placed Predominately in Soft Bone n Unknown n Implant insertion iadr-protocols Quality and Subjected to Immediate Occlusal Loading: Results from a articles. While the vast majority of n Later n No baseline the “study groups” reviewed in the For further reading, see also: 7-Year Clinical Follow-Up,” demonstrates that the immediate loading articles on Nobel Biocare implants Transparent reporting on radio- www.nobelbiocare.com/study- protocol used in the underlying study is a successful treatment alterna- have followed a one-stage surgical graphic data is essential in order protocols tive even in regions exhibiting soft bone conditions. TiUnite enabled protocol, for instance, almost three to compare radiographic data this approach and has proven very successful in the long-term, show- between studies, as well as to ing stable bone levels and high survival rates. out of four featuring Astra Tech im- report the total bone level change. plants report on a two-stage protocol www.nobelbiocare.com/tiunite-abstract

Cold-worked C.P. Titanium Zirconia-based ceramic copings Brånemark called it “Titanium held to a higher standard!” A recent study published in The Journal of Prosthetic Dentistry has demonstrated that computer-aided technology can produce zirconium oxide-based ceramic Strength in all diameters which has nearly the same yield copings with a clinically acceptable marginal fit. Since his discovery of osseo- Nobel Biocare’s cold-worked c.p. ti- strength as the titanium alloy Ti-6Al- integration, Professor P.I. tanium is especially suited for the 4V used in Nobel Biocare titanium Of the four systems tested in the study, the highest marginal accuracy Brånemark has prescribed unique NobelActive implant design, abutments and all abutment screws. was achieved with the Procera system. commercially pure (c.p.) providing the enhanced material NobelActive Ø5.0 implants are pro- The authors were motivated by the fact that it had proven virtually titanium for use in dental strength needed for the required fa- duced from the MTA 009 material. < impossible to compare results from studies on the marginal accuracy implant restorations. tigue strength as well as the thin-cut- of zirconium oxide-based restorations, because a variety of different ting threads. Cold-working process for assessment methods had previously been used for each of the differ- he strongest standard grade of c.p. The strength of Nobel Biocare’s c.p. titanium ent computer-assisted systems. T titanium is ASTM Grade 4 with a c.p. titanium also benefits the perfor- Die 0.2% yield strength of 480 MPa. Nobel mance of smaller diameter implants. www.nobelbiocare.com/zirconia-abstract Drawing Biocare surpassed this standard by de- Nobel Biocare has over 10 years of veloping a proprietary cold-working experience in smaller diameter im- Titanium process for Grade 4 Titanium to plants beginning with the year 2000 achieve even higher yield strength. launch of the Ø3.3 Brånemark Sys- For further reading From market introduction, follow- tem MK IV until the current release ing extensive material- and pre-clini- of NobelActive 3.0. If you would like to read more detailed information relating cal testing, Nobel Biocare’s cold- Smaller diameter implants offer “Cold-working” is a strengthening to NobelActive 3.0—including its many features and worked c.p. titanium and patented less invasive dental implant solutions process. At a specific temperature clinical benefits—a product-specific website is available at TiUnite surface have been docu- for patients with narrow bone ridges, (near room temperature) and the following address: drawing rate, titanium is deformed mented as exceptionally strong and and limited space between teeth. A in a die, resulting in material strain clinically proven to enhance osseoin- smaller diameter can also minimize hardening. www.nobelbiocare.com/active3 tegration. Nobel Biocare has used the need for guided bone regenera- c.p. titanium for over 20 years and tion procedures. The Ø3.0, Ø3.5 and For one very interesting appli­ this specially processed version has Ø4.3 NobelActive implants are pro- cation of this material, see the been used in all Nobel Biocare im- duced from the specially processed articles about NobelActive 3.0 on plants for over 10 years. c.p. titanium MTA 010 material, the facing page. 8 Nobel Biocare News Issue 1/2011 Diagnostics, Treatment Planning and Guided Surgery

tion that meets the patient’s needs is to be able to do in their practice. an essential aspect of the practice of Some people may only want help dentistry. with diagnostics, while others would prefer a full range of diagnostic, In which situations do you choose treatment planning and guided sur- guided surgery today? gery options in the same package. Glauser: In quite a few different situa- tions, actually: For example, when- Nobel Biocare has launched a new ever a grafting case has to be trans- version of the company’s diag- ferred figuratively into a non-grafting nos­tics and treatment planning case. In medically compromised pa- software, called NobelClinician. tients—such as hemophiliacs—or As a user of the previous system, whenever minimal invasiveness and what’s in it for you? reduced working times are prefera- Glauser: For one thing, I am now able ble, so is guided surgery. Naturally, I to review all the CT scans within one also often use guided surgery when software environment. For another, meager hard tissue and a demanding the new software certainly makes it restorative set-up dictate precise im- easier to share data and to communi- plant positioning. Finally, whenever cate one’s intentions with colleagues a provisional restoration has to be and lab technicians. That’s very im- produced in advance of the sur- portant. I’m happy to see that the new gery—in cases calling for immediate package works equally well on the function, for instance—there is no Mac as it does on a Windows PC and, better solution than guided surgery. as one might expect from Nobel Bio- care, the user-friendly interface is Always on the go at his clinic in Zürich, Dr. Roland Glauser uses NobelClinician Software as a diagnostics and Over the last few years, more and highly intuitive in both design and treatment planning aid on both stationary and laptop computers. more computerized systems for 3D execution. imaging, diagnostics, treatment For entry-level doctors, there’s ment options—especially in regards and also the stress level on the day of planning and even guided surgery even a built-in treatment assistant to The first patient was treated to immediate function and the pre- surgery. With a well-planned treat- have been introduced to the guide the novice through the com- using guided surgery more fabrication of provisionals. The diag- ment already mapped out and im- market, complicating purchasing plete workflow, tracking all actions than a decade ago, in 2000. nostics and planning software was plants installed at ideal prosthetic decisions for clinicians. If some- as they are carried out, and providing Subsequently, the concept always quite straightforward to use. positions, the restorative process be- one were to ask you about task-specific information at each was cleared by the FDA and The new NobelClinician Software comes a smooth, step-by-step proce- introducing these technologies in step of the process. < launched by Nobel Biocare in goes a step further, however, by of- dure. their clinic or practice, how would the spring of 2005. No other fering even more options, particular- It should also be noted that com- you suggest they get started? More to explore: company has such extensive ly in general diagnostics. municating the treatment plan to Glauser: I think they should start www.nobelbiocare.com/ experience with guided With this system, I can reference colleagues—or the patient him- with a wish list that includes all the nobelclinician surgery and 3D diagnostics. significant visual information in a self—is made much easier when a things they would like such a system www.nobelbiocare.com/nobelguide virtual 3D world to test for—and ul- digital diagnostics and planning timately identify—locations for the tool such as NobelClinician Soft- r. Pascal Kunz, who is re­ best possible implant placement ware is used. spon­sible for guided surgery from both a prosthetic and surgical D solutions at Nobel Biocare, point of view. Rather than being Have you seen a change in the posed some questions this month to type of questions posed by Dr. Roland Glauser on the current prospective implant patients over state of guided­ surgery. the years? An accomplished dentist as well as Glauser: Certainly, today’s implant a respected academic, Dr. Glauser patient is better informed than his or lectures internationally and runs a Q &A her counterpart ten years ago. A va- successful private clinic in Zürich, Questions and Answers riety of media—not least of all the Switzerland. He is also an expert in Internet—are full of information and emerging technologies that help im- commentary on dentistry in general prove patient care, such as Nobel- and implants in particular. Patients Guide and NobelClinician. forced to compromise between re- simply know more today about the storative requirements and surgical dental implant option—and many of You were one of the first to work imperatives, I like to think that we the specific procedures, as well. with the NobelGuide system. How can optimize instead. I find that questions are less gener- has it affected the way you have From the patient’s point of view, al and more focused on the types of diagnosed and treated patients comfort has been improved, as a re- materials, procedures and prognoses over the last eight years? duction of chair-side time and less today. What’s more, the sheer vol- Dr. Roland Glauser: First and foremost invasive procedures have become ume of questions asked is greater Dr. Roland Glauser says, ”I am now able to review all the CT scans using NobelGuide has increased possible. The concept allows one to than it used to be. within one software environment [and] the new software certainly makes it treatment predictability and given obtain a complete picture before sur- More than ever before, correct and easier to share data and to communicate one’s intentions with colleagues and lab technicians.” me access to more advanced treat- gery. This reduces potential surprises compelling pre-treatment informa- Issue 1/2011 Nobel Biocare News 9 Rely on the Evidence In Brief

The strongest evidence for any of living tissues, may provide impetus In dental practice—as in given therapeutic intervention is pro- for new areas of research, but rarely— other areas of day-to-day vided by the systematic review of according to the principles of EBM— life—not all evidence merits randomized, (triple) blind, placebo- provide immediate guidance on how TiUnite® – 11 Years On the same respect. Evidence controlled trials. When they incorpo- to treat patients on a day-to-day basis. with the fewest inherent rate a high percentage of follow-up Therefore, in vitro and animal studies biases and highest direct involving a homogeneous patient are normally not included in the pyr- Well over eleven years ago, the first patient was treated using relevance generally deserves population and medical condition, amid of evidence. Nobel Biocare implants with the TiUnite surface. Now seventy- the greatest consideration. they become even more reliable. This The most common definition of nine years old, this Swedish-Swiss dual citizen recently visited sort of evidence stands at the top of EBM is taken from Dr. David Sackett her dentist, Dr. Roland Glauser, at his offices in Zürich. the hierarchical pyramid of evidence. et al, a pioneer in evidence-based By Dr. Alexandra Rieben At that annual check-up, Dr. Glauser took the following X-ray. In contrast, case reports and expert medicine. (See “Evidence based opinion have little value as proof of medicine: What it is and what it isn’t. ccording to the widely dis- efficacy because of the biases inherent Br Med J. 1996;312:71-72) It is “the cussed and generally accept- in observation and the reporting of conscientious, explicit and judicious A ed concept of evidence- use of current best evidence in mak- based medicine (EBM), five steps are ing decisions about the care of the usually followed. Step 1 is to translate individual patient. It means integrat- a clinical uncertainty into an answer- ing individual clinical expertise with able question. Step 2 consists of the S &E the best available external clinical systematic retrieval of the best evi- Safety and Efficacy evidence from systematic research.” dence available. In step 3, this evi- However, the most reliable types, dence is critically appraised for va- as outlined above, may not always be lidity (closeness to the truth) and cases, difficulties in ascertaining who available for every field of clinical in- applicability (usefulness in clinical is an experienced reporter, and so on. quiry. A sham operation may not fall practice) and then applied, in step 4, Laboratory research, including valu- within the scope of good ethics, for in practice. Finally, in the last step, able animal studies designed to learn example, or blinding may not always one evaluates the clinical results. more about the microscopic structure be feasible in every field of research. Sackett et al pointed out that “Evi- dence-based medicine is not restrict- Two Brånemark System Mk IV implants with the TiUnite surface The most to least reliable types of evidence ed to randomized trials and meta- were placed in positions 45 and 46 in March 2000. This recently taken analyses. It involves tracking down X-ray shows both implants restored with screw-retained, connected according to Sackett and co-workers: porcelain-fused-to-metal crowns and reveals excellent marginal bone the best external evidence with levels. which to answer our clinical ques- 1A = Systematic Review of Randomized Controlled Trials (RCTs) tions.” The TiUnite literature listed Her Brånemark System treatment had begun much earlier. Back in the 1B = RCTs with Narrow Confidence Interval below falls into the upper range of early 1990s, the patient had received Brånemark System implants with 1C = All or None Case Series < the reliable types of evidence. the traditional machined surface in the upper jaw to replace lost molars 2A = Systematic Review Cohort Studies on both sides. Then, in March 2000, she became the first patient to 2B = Cohort Study/Low Quality RCT More to explore: receive Brånemark System Mk IV implants with Nobel Biocare’s new 2C = Outcomes Research “Recommended reading for TiUnite surface. Two were placed in the lower right jaw to replace a 3A = Systematic Review of Case-Controlled Studies TiUnite®” – Fifteen key publications lost premolar and the adjacent molar. 3B = Case-Controlled Study supporting the safety and efficacy 4 = Case Series, Poor Cohort Case Controlled of TiUnite” is available for down- The long-term results speak for themselves. 5 = Expert Opinion loading at: www.nobelbiocare.com/ tiunite-support

NobelClinician™ Now Available For Mac OSX and Windows

nal NobelGuide Software but also of- workflow. Via built-in patient man- fers additional functionality that agement functionality and the reaches beyond the scope of guided NobelConnect module, you can col- surgery. laborate efficiently and securely on- Any DICOM (digital imaging and line with select treatment partners. communications in medicine) file NobelClinician Software is the This lateral view of the two crowns—which have now been in produced by a cone beam (CB)CT first diagnostics and treatment plan- place for more than eleven years—indicates that the surrounding soft NobelClinician is Nobel scanner can now be reviewed and ning software from Nobel Biocare to tissues are both robust and healthy. Biocare‘s next generation analyzed using new workspaces and run with the same look and feel on software for digital new tools that expedite patient diag- Windows and Mac OS X, so now you diagnostics and treatment nostics and team collaboration. can work with the operating system More to explore: planning. NobelClinician Software has been of your choice. Existing users cur- www.nobelbiocare.com/tiunite devised for the work at hand. An in- rently paying the annual mainte- www.nobelbiocare.com/tiunite-abstract Fully compatible with the Nobel- teractive digital assistant keeps track nance fee qualify for a free upgrade. Guide workflow and tooling for of planning tasks and offers addi- Please contact your local Nobel Bio- guided surgery, it replaces the origi- tional guidance throughout the care office for details of this offer. < 10 Nobel Biocare News Issue 1/2011 Screw- or Cement-Retained Restorations Upcoming Events Good choices abound in the era of modern cad/cam technology.

studies do not support such asser- ability difficulties when peri-implant cision of the manufactured com­ Providing the patient with a tions, reporting comparable out- tissue assessment and/or the mainte- ponents. Non-passively fitting Visit Nobel Biocare at events around the world. They pro- reliable and lasting resto- comes instead. Furthermore, argu- nance of prosthetic components are implant-supported superstructures vide a great opportunity for ration is essential in today’s ments of increased rates of screw required. Despite the fact that some are still considered to be a potential observing the latest innova- highly competitive dental loosening and fractures in screw-re- studies suggest the use of temporary cause for the high incidence of tech- market. tions and scientific research, tained abutments should be classi- luting agents to make retrievability nical complications associated with but also for meeting and fied according to their publication practicable, such protocols should be these restorations. By Hans Geiselhöringer and interacting with the dental date and the type of components carried out with great care when im- In cement-retained implant super- Dr. Stefan Holst community and industry used at that time (e.g. formerly used plementing all-ceramic restorations. structures, the cement layer can experts. Nobel Biocare parti­ gold screws instead of currently- Although widely recognized for compensate for dimensional discrep- cipates in a number of key he long-term clinical success of used titanium retaining screws; cast years, the detrimental effect that ce- ancies between the abutment and the industry events and symposia an implant-supported restora- instead of industrially manufactured ment remnants can have on peri-im- restoration to some extent, working across the globe each year T tion depends on a multitude of prosthetic components). plant tissue health and integrity has as a filling medium to more uni- and hosts its own leading biological and component-/material- formly transfer loads to the implant– scientific congresses to better related factors. Choices concerning prosthesis–bone complex. gauge and meet the needs the type of connection and the re- This type of compensation for of customers and their taining system between an implant misfit is not possible in screw-re- patients. and the prosthetic restoration are tained superstructures, where even 2011 two key aspects of the clinical deci- small dimensional discrepancies re- AAID 60th Annual Meeting sion-making process. sult in localized loads and stress con- 19–22 October Las Vegas, Nevada, USA While some clinicians favor the centrations that are transferred to the American Academy of Implant Dentistry use of cement-retained restorations, implant-abutment complex/compo- (AAID) others consider screw-retained pros- nents. Scientific evidence shows that Competence in Esthetics 2011 theses to be the best choice. While with conventional fabrication meth- 11–12 November Vienna, Austria this issue is being debated in clinics, ods, three-dimensional distortions of AAP Annual Meeting scientific studies have yet to provide the finished restorations inevitably 12–15 November conclusive data demonstrating supe- occur, thus precluding passive fit. Miami Beach, Florida, USA American Academy of Periodontology (AAP) rior outcomes for one technique over The computer-aided design-/com- Swedental the other. Therefore, the clinician puter-aided manufacturing (CAD/ 17–19 November must evaluate and be aware of the CAM) of restorations has been Stockholm, Sweden advantages and potential disadvan- shown, however, to result in signifi- DGI Congress 24–26 November tages of each solution and their spe- cantly greater accuracy when com- Dresden, Germany cific implications in any given clini- pared to traditional fabrication tech- Deutsche Gesellschaft für Implantologie (DGI) cal situation. niques such as casting. Greater New York Dental Meeting Due to the above-mentioned qual- 25–30 November New York, USA Pros and cons ity-of-fit shortcomings of cast com- AAOMS Dental Implant Conference Aside from personal preferences or ponents, cement-retained restora- 2–4 December scientific data, the primary factor in tions became the predominant Chicago, Illinois, USA American Association of Oral and Maxillo­ the decision-making process is the High quality standards and precision ensure longevity for both screw- solution for multiple-implant resto- facial Surgeons (AAOMS) position and angulation of the im- (left) and cement-retained (right) NobelProcera custom solutions. rations in the past. With the avail- plant in relation to the anticipated ability of CAD/CAM systems and 2012 Yankee Dental Congress final restoration. If the screw access Cement-retained restorations on only recently become the focal point high quality precision products, 25–29 January is favorable (e.g. in the central fossae custom titanium or ceramic abut- of professional presentations and sci- however, a trend towards an in- Boston, Massachusetts, USA of a bicuspid/molar or on the palatal ments, on the other hand, allow for entific articles. To reduce the risk for creased use of screw-retained solu- CIOSP 28–31 January side of an anterior crown), a screw- the compensation of misaligned im- cement trapping, it is essential to po- tions is evident today, due to fast and São Paulo, Brazil retained restoration may be fabri­ plants and can be treated like natural sition the height of the crown-abut- simple clinical protocols and other Congresso Internacional de Odontologia de cated. teeth. The non-disrupted morpholo- ment interface at, or slightly below, attendant advantages. São Paulo (CIOSP) ICOI Winter Symposium Porcelain is directly fired onto the gy of the occlusal table may be con- the gingival margin to allow for easy In summary, it can be concluded 16–18 February abutment, and the abutment-crown sidered a favorable aspect of this access and complete removal of luting that the decision to cement- or San Diego, California, USA complex is screwed onto the implant. choice, eliminating the requirement materials. This prerequisite means screw-retain an implant-supported International Congress of Oral Implantologists This type of restoration offers effi- for subsequent closure with compos- that a customized implant abutment crown or FDP depends on the per- CDS Midwinter Meeting 23–25 February cient and fast clinical handling pro- ite resin and potential impairment of must be used in most cases. sonal preference of the clinician and Chicago, Illinois, USA tocols and easy maintenance. Re- the esthetic outcome that occurs the patient-specific clinical situation. Chicago Dental Society (CDS) trievability and the absence of when metal-based frameworks are Changing the odds via cad/cam The availability of CAD/CAM man- LMT Lab Day Chicago 24–25 February cement between the abutment and used. The choice between screw- and ce- ufacturing technology and biocom- Chicago, Illinois, USA the crown are two of the greatest ad- Zirconia-based frameworks, how- ment-retained prostheses does not patible materials, such as titanium Lab Management Today (LMT) vantages vis-à-vis cement-retained ever, eliminate this disadvantage. If only need to be made for single-unit and zirconia offer a multitude of pa- AO Annual Meeting solutions. white or shaded substructures are implant restorations. It is equally tient-specific treatment options and 1–3 March Phoenix, Arizona, USA A disadvantage often discussed is used, then easy, fast and esthetically important for multiple splinted alternatives, which make it feasible Academy of Osseointegration (AO) the presence of an occlusal access pleasing closure of the screw access implants. to routinely provide patients with the Nobel Biocare Symposium 2012 channel for the screw that interferes channel can be achieved with con- Whenever an implant-retained best possible quality solutions. < 21–23 March Gothenburg, Sweden with the morphological integrity of ventional composite resin materials. bridge framework (i.e. fixed dental the occlusal table. While laboratory The main disadvantages of ce- prosthesis, or “FDP”) is connected to More to explore: trials have shown a potential detri- ment-retained restorations are the implants, the clinical longevity and www.nobelbiocare.com/ To find out more, visit | mental effect upon the application of potential risk for cement trapping in need for maintenance repair de- nobelprocera www.nobelbiocare.com/events load, clinical long-term follow-up the peri-implant tissues and retriev- pends to a great extent on the pre­ Issue 1/2011 Nobel Biocare News 11 Implant Cementation, Step by Step Guidance and advice to help you acquire confident technique.

Peri-implant biology The crown is painted internally Remove the CCA, then remove the Inspect the inside of the crown for an Cementing crowns and fixed Many clinicians consider implants to with a water-soluble lubricant such PTFE and clean out the inside of the even cement layer. If you find any partial dentures (bridges) be similar to teeth, but they differ in as KY jelly (Vaseline can be used but crown (important!) to remove the “bare” areas, just add a little extra. onto implants has become many important ways. A weak adhe- it must be adequately cleaned later). KY jelly or Vaseline. Then seat the crown in the mouth. increasingly popular, but it is sion exists between soft tissue con- This allows PTFE (plumbers tape, not without issue. nective tissues and implant surfaces, which is 50 microns thick!) to be Many advantages of the CCA for example, whereas teeth have a adapted to the inside of the crown A fast, inexpensive, simple tech- By Drs. Chandur Wadhwani and more robustly developed attachment using a dry brush. Complete the ad- nique, this approach limits excess ce- Alfonso Piñeyro system. The clinician should be aptation by gently pushing the abut- ment to an absolute minimum, and aware of the fact that the weaker soft ment into the crown and then care- makes cleanup quicker and easier. ne cause of local tissue in- tissue adhesion seen with implants is fully removing it. Inspect the inside The CCA can be used for custom, flammation associated with more susceptible to complications of the crown to see if the PTFE is well stock and even multiple abutments! O dental implants that has re- caused by excess cement and the hy- formed. cently come to light is dental cement. drostatic force of cement being Removing the CCA and the PTFE. Cements have been directly linked pushed into the tissues during crown with peri-implant diseases and have placement. Now you have a chair-side copy been blamed for bone loss and im- abutment. The CCA is 50 microns plant failure. One aspect of the dis- Cementation techniques smaller than the inside of the crown ! ease process that is especially con- Clinicians often do not understand Inspect it, compare it to the actual cerning is the time between restoring that only a very limited amount of abutment, and make sure you know the implant and the disease pro- cement is needed to fix a restoration the orientation. cess—on average three years pass be- to an implant abutment. A recent fore dentists discover a problem, survey of over 400 dentists showed with a range of four months to be- that many dentists placed in excess yond nine years! of 20 times more cement into the crown than was required. This over- load of cement means that 95% are extruded out at the restorative mar- gin, which is frequently found below the gum, making cement removal The inside of the crown has a Check for defects and orientation. Multiple CCA abutments can be T&T layer of PTFE tape adapted to it. easily made, and used to remove virtually impossible. Tips and Techniques (KY jelly was used to help the PTFE The CCA is now ready for use. Place excess cement. stick to the inside) the abutment in the patient’s mouth, confirm that it sits, and torque the The CCA is an improvement over Dentists should be made aware of screw to the appropriate Ncm value. using the actual abutment, or labora- the differences between implants The crown is now ready to be ce- tory abutments, which do not pro- and teeth. Because their peri-im- mented. vide quite enough cement space to plant biology is not the same, the ap- Load the crown with any amount assure suitable amounts of cement propriate cementation techniques, of cement you wish—the CCA will for problem-free crown retention. suitable cement selections, and even subsequently be pushed into the The CCA produces the ideal the procedures for the clean-up of Actual photo of how some crown, and the excess cement will be amount! < excess cement are different. This ar- dentists loaded crowns with extruded chair-side and easily re- ticle will briefly highlight these is- cement as if they were to be placed Further adapt the PTFE against moved. (This is done outside of the Special thanks to Drs. Ken Akimoto on implants in their offices! sues and offer solutions to overcome the walls of the crown by gently mouth.) and Franco Audia for providing the the attendant problems. placing the abutment. When cases and the associated photographs Solution complete, remove the abutment and make sure that the tape is even. in this article. Limit the amount of cement that is placed in the crown. As teachers, we To make the CCA: Using a fast- train clinicians to understand that setting impression or bite registra- More to explore: too much is undesirable. We often tion (Blu-Mousse) material, fill the “The positive relationship between equate the amount needed to every- inside of the crown and continue to excess cement and peri-implant day, well-known subjects, for exam- overfill until a “handle” is produced. disease,“ by T. Wilson, in Radiograph and photograph of ple: “The space provided for cement (Hint: Use a fine-tip nozzle.) J Periodontol, 2009; 80: 1388–92 failed implant with cement on the inside of the crown during the “Technique for controlling the remnants. making of the crown is the same cement for an implant crown,” by thickness as a layer of nail polish.” C. Wadhwani and A. Pineyro, in This layer is often about 50 microns J Prosthet Dent, 2009; 102: 57–8. thick, which is about the thickness of a human hair! And keep your eyes open for a A technique has been developed soon-to-be-published article on this using a spacer and some fast-setting topic by Wadhwani, Pineyro et al Making the CCA. The crown with The CCA is seated into the in an upcoming issue of IJOMI. This patient presented five years dental impression material to make a the PTFE lining being filled with crown, allowing excess to be after the crown was cemented. chair-side copy abutment (CCA) Blu-mousse. A handle is being removed extra-orally. (Hint: When When a flap was raised the bone that can be used to coat the inside of formed. you first try this, use a cement with loss became apparent, as did the the crown with close to the 50 mi- an extended setting time.) cement around the implant! crons needed. 12 Nobel Biocare News Issue 1/2011 Customized Implant Abutments To make your decision easier, consider the many clinical and laboratory advantages they offer.

For the benefit of the patient, the clinic and the laboratory, Customized CAD/CAM Abutments Customized CAD/CAM Abutments collaboration across pro- Clinical Advantages Laboratory Advantages fessional boundaries is essential. • Long-term clinical stability through biocompatible and • Free-virtual design options homo­genous materials • Screw- or cement-retained restorations By Hans Geiselhöringer • Formation of tight soft tissue contact • Optimal support of peri-implant soft tissue through individual • Eliminates the risk of contact corrosion between dissimilar abutment profile metals and alloys • Round contours, no sharp edges hen restoring dental • Maximizes long-term esthetic results through application • Facilitates ideal positioning of cement line implants, the clinician of shaded zirconia • Independent from implant system and connection type W is met with an ever-ex- panding variety of treatment op- tions. As a result, the task of select- ing the most appropriate com- cement. If remnants of the cementa- sion at the same time. The key bene- when the newest generation of CAD of detrimental micro-cracks that can ponents is often delegated to the tion medium remain, potential risk fit of homogeneous materials such as software is used to virtually design increase the risk for catastrophic fail- dental technician. This course of of peri-implant inflammation and titanium and zirconia is that their any desired abutment shape. At the ure under clinical function. What’s action has become common despite adverse tissue reactions increase sig- use eliminates material incompati- same time, industrialized fabrication more, the application of veneering the demonstrated fact that collabor- nificantly. (See cementation article bilities and corrosive phenomena guarantees standardized product ceramics to provide ample tissue sup- ative discussion between the clini- on page 11.) arising from dissimilar metal alloys quality and precision of fit, while re- port provides inferior clinical out- cian and dental technician is key to and interfaces between cast and ma- ducing cost-intensive manual labor come as shown in research studies. providing the best possible service The advantages of titanium chined components. at the same time. From both a clinical and labora­ for the patient. The objective of the and zirconia materials for Using prefabricated abutments, on tory perspective it can therefore be following overview is to emphasize clinical use The choice: stock or custom the other hand, has numerous disad- concluded that custom implant abut- not only the need for cooperation Research indicates that the type of implant abutments? vantages. These range from time- ments offer the best possible treat- and joint decision-making within material used in implant-retained The restorative team may choose consuming and unpredictable cus- ment option for patients today. < the treatment team, but also to ac- restorations affects both the amount from prefabricated or customized tomizing processes in the laboratory centuate the clinical and laboratory and the quality of the surrounding abutments for both implant-retained to the need for intraoral adjustments advantages of routinely using cus- tissues. While cast gold abutments single- or multi-unit restorations. As and suboptimal support of peri-im- tom-made implant abutments in are still used extensively today, scien- indicated previously, the primary ob- plant tissues. The greatest uncertain- everyday practice. tific data strongly indicate that the jective must always be proper sup- ty is related to the uncontrolled ma- reaction of cells towards materials port of the surrounding tissues, opti- nipulation of oxide ceramic The clinical challenge: with a corrosive potential—such as mal morphology to support the components. Post-sintering manipu- Long-term tissue stability cast alloy components or veneering restoration without impairing hy- lation significantly increases the risk In addition to establishing a satisfac- porcelain—is inferior to the reaction giene maintenance, and anatomic tory implant site and ensuring a con- of living cells towards homogenous design to allow for ideal support of gruent blending of the restoration materials. Among the homogenous the veneering ceramics in screw- with the neighboring dentition, the materials available for implant abut- retained abutments. While these greatest challenge facing the restor- ments and superstructures, titanium requirements can practically be ative team is to ensure long-term and zirconia are the most auspicious. achieved with either conventional stability of the peri-implant tissue Titanium abutments provide a bio- laboratory processes and stock com- architecture. Destructive processes compatible and clinically well-prov- ponents, or computer-aided design/ resulting from poor quality en treatment option in areas computer-aided manufacturing implant superstructures in- where high strength is re- (CAD/CAM) technology and cus- crease the risk for inflam- quired or only limited space tom products, recent scientific evi- mation and the continu- is available—and is far dence strongly suggests that the ap- ous loss of supporting superior to cast alloys. plication of the latter is preferable. hard and soft tissues. Extensive research and This is because industrial manufac- Consequently, the development in ceram- turing offers numerous benefits selection of suit- ic materials have result- compared to manual framework fab- able materials and ed in the availability of rication. Time-consuming wax or NobelProcera Software for the design of custom abutments includes an optimal design non–silica-based ceramics in den- resin setups becomes redundant valuable visual information on the abutment/gingiva interface. of the definitive restoration are para- tistry that demonstrate excellent mount for success. characteristics in terms of biocom- When designing an abutment, the patibility, esthetics, and long-term position of the implant in relation to clinical function. Today, zirconia Guaranteed satisfaction

the final crown contour, the thick- (ZrO2) is considered by many clini- ness and biotype of the surrounding cians to be the material of choice for – Lifetime warranty on all Nobel Biocare tissue, as well as the location within abutments. In addition to material implants including prefabricated prosthetic the arch must be taken into account. properties that allow its application components. For cement-retained superstruc- in any area of the mouth, the greatest – Five-year warranty on all NobelProcera

tures, it has been established that the advantage of ZrO2 is its unrivalled individualized restorations.* location of the abutment-crown support of adjacent tissue. Zirconia Serving you and your patients margin should always be located at, observably enhances tight adherence or slightly below, the gingival crest of peri-implant tissues while mini- in the best possible way. to allow for the complete removal of mizing bacterial and plaque adhe- Issue 1/2011 Nobel Biocare News 13 Redefining the Gold Standard Ask yourself, “What is the best way to restore the patient functionally, esthetically and biologically today?”

By Dr. Steven Lewis

s relatively early Brånemark System adopters in North A America, our team at UCLA went full-speed into offering this treatment modality to patients with an edentulous arch. Proven predict- ability, accompanied by an extremely low potential for morbidity, gave rise to great working relationships be- tween the surgeons, prosthodontists UCLA abutment approach: With a GoldAdapt as foundation, the abutment cylinder is modified and added to with wax, which is then burned out and and dental technicians providing this cast to produce the abutment for a cemented crown. With a stock component and wax, any abutment design can be produced that is mechanically new form of treatment. By the mid- compatible. 1980s, Brånemark and his colleagues had developed a complete system of provided unique advantages. This gold cylinder and then wax and cast teeth, which was especially useful for More to explore inter-related components for the component made it possible to by- any type of abutment design appro- the occasional misaligned implant “Implant treatment in the treatment of the edentulous arch, pass the standard abutments and priate for single-tooth and multiple- that needed a cemented crown or edentulous maxillae: a 15-year which even made it possible to treat gold cylinders of the day by bringing unit cemented restorations. bridge. follow-up study on 76 consecutive severe craniofacial defects resulting the restoration directly to the im- Despite this practical benefit and On the other hand, when these patients provided with fixed from trauma, tumor ablation or con- plant. With the UCLA abutment: the fact that I am a member of the cast gold abutments extend 4 mm or prostheses,” by T. Jemt and genital disfigurement. • single tooth restorations could be team that originally developed the deeper subgingivally, soft tissue sel- J. Johansson, in Clin Implant Dent When treatment began to be of- fabricated utilizing the implant UCLA abutment technique, I use it dom appears as healthy as in shal- Relat Res. 2006; 8 (2): 61–9. fered to the partially edentulous pa- hexagon; only rarely today. I still prefer to do lower situations. This should not “Implant Treatment in the tient, new clinical challenges were • porcelain could be brought closer screw-retained restorations whenev- come as a surprise. The work of Edentulous Mandible: A encountered that the available com- to the implant head; er feasible, but because the multi-unit Abrahamsson and others demon- Prospective Study on Brånemark ponents were not designed to ad- • the occasional labial trajectory of abutment of today has advantages in strates that one doesn’t get the same System Implants over More than dress. For instance, the partially a screw access hole (that might both collar height and interarch epithelial attachment to gold as to ti- 20 Years,” by J-A Ekelund, edentulous patient sometimes pre- otherwise interfere with an esthet- clearance dimensions over the origi- tanium, aluminum oxide or zirconia. L. Lindquist, G. Carlsson, G and sented with much less interarch space ic outcome) could now be correct- nal standard abutments, I find it a Given the fact that NobelProcera T. Jemt, in Int J Prosthodont. than the average edentulous patient. ed with a cast abutment and a compelling choice. What’s more, can provide customized abutments 2003; 16: 602–608. At the time, the shortest trans-muco- cemented crown covering the there are also angled abutments at made of titanium or zirconia, mak- “Single Tooth Implant Supported sal abutment available was 4 mm, screw access hole; and our disposal today that had not yet ing it possible for virtually any de- Restorations,” by S. Lewis, and required a 4 mm gold cylinder • less space was required in situa- been developed in the mid-1980s sign to receive a cementable crown J. Beumer, G. Perri and W. Hornburg, on top of that to make a cast frame- tions characterized by a limited when the UCLA abutment was first or bridge, there is really no longer in Int J Oral Maxillofac Implants. work. Prosthetic complications arose interarch gap. introduced. any justification for settling for the 1988; 3: 25–30. because there wasn’t always enough For most screw-retained solutions lesser biocompatibility of gold in “The mucosal attachment at interarch space left to accommodate Looking back, it is a little surprising today, I choose multi-unit abutments these subgingival sites. Today I use different abutments. An ex- an adequate amount of restorative that what was designed at the time to and a NobelProcera milled titanium only NobelProcera CAD/CAM cus- perimental study in dogs,” by materials. be no more than a problem-solving framework rather than UCLA abut- tom titanium or zirconia abutments I. Abrahamsson, T. Berglundh, PO There were other problems too. In expedient continues to be the prima- ments. for these cementable applications. Glantz and J. Lindhe in J Clin an attempt to provide an esthetic res- ry treatment modality of many den- When presented with a new case, I Periodontol. 1998 Sep; 25 (9): 721–7. toration in the maxilla, using the tists and technicians to this day. The UCLA always ask myself, “What is the best “The mucosal barrier at implant shortest 4 mm transmucosal abut- Perhaps practical aspects, espe- abutment had its day way to restore this patient function- abutments of different materials,” ment sometimes resulted in visually cially from a dental technician’s For single teeth and short-span ce- ally, esthetically and biologically?” by M. Welander, I. Abrahamsson exposed titanium. Additionally, even standpoint, are responsible for the mentable restorations, the UCLA As I answer this question and choose and T. Berglundh in Clin Oral when working with top surgeons, the continued widespread use of the abutment did allow varied abutment my materials, I find myself moving Implants Res. 2008 Jul; 19 (7): occasional implant/abutment access UCLA abutment. After all, it makes designs and made it possible to de- away from metallic gold towards a 635–41. hole ended up in an esthetically com- it possible to take a “one size fits all” sign abutments to look like prepared new gold standard: NobelProcera. < promised position due to facially in- clined implants. It should be recognized that the Brånemark System, as introduced in the early 1980s, remains an ideal sys- tem today if used only to treat edentu- lous jaws with moderate to severe re- sorption; the fact that 15 years documentation for the maxilla and 20 years for the mandible were pub- lished, confirms the continued via­ bility of Brånemark’s design rationale and the durability of this treatment. Nevertheless, to meet the specific NobelProcera CAD/CAM approach: A dental technician can use either a scan of an abutment design or complete virtual process to produce an abutment challenges mentioned earlier, the in either titanium or zirconia. With design possibilities matching the UCLA abutment, more biocompatible materials are able to be used, with the added UCLA abutment, introduced in 1987, possibility of shaded zirconia for esthetics. 14 Nobel Biocare News Issue 1/2011 Solutions for the Edentulous Patient Esthetics and performance can go hand in hand.

traction of remaining teeth and The number of edentulous roots, simultaneous or delayed im- patients is on the rise. As plant placement, and immediate pro- a group they are becoming visionalization also represent proto- increasingly important to cols that are routinely performed every dentist. with good success. Loading dental implants immedi- By Hans Geiselhöringer ately after their placement has tre- mendous advantages for both the emographic data indicates that dentist and the patient. The protocol D the number of edentulous pa- results in minimized trauma and im- tients will continue to grow in the mediate esthetics, adequate function, years to come, and in a world full of and preservation of hard and soft tis- readily available digital information, sue contours. patients’ expectations—as well as The positive psychological benefit their awareness of available treat- for the patient—who is not left with The quality, precision and cost ment options—are increasing at the a transitional, mostly unacceptable efficiency associated with state- same time. denture—can be very substantial of-the-art CAD/CAM production keep overdenture solutions Taking each patient’s clinical situa- indeed. competitive. tion, expectations, available time, In this context, the All-on-4 con- and financial situation into account, cept—whose reliability has been sub- the dental team has to decide first Bar-retained overdentures—often called, “fixed-removable”—provide stantiated by extensive long-term tance are all factors that need to be and foremost on the most appropri- for the proper support of extra-oral tissue, which restores facial appearance documentation and scientific evi- taken into consideration when ate treatment protocols and materi- and esthetics, while providing complete functional stability at the same dence—provides not only an imme- choosing between a fixed and re- time. als to recommend. diate provisionalization protocol, but movable implant-retained restora- Then they must communicate the also a definitive treatment solution. tion—as are the anticipated number benefits of competing treatment al- for the reconstruction of missing an- (often called, “fixed-removable”). No matter which clinical protocol and position of implants and the ternatives and explain the availability atomic morphology are employed on Overdentures allow for the proper is selected, the manufacturing and clinical protocol preferred by the re- of low-cost, yet high-quality, restor- a routine basis today, surgical inter- support of extra-oral tissue, which quality of the definitive restoration is storing dentist. ative options such as titanium frame- vention may not always lead to the restores facial appearance and es- of fundamental importance for lon- Whether the restorative team de- works with acrylic veneering, den- desired outcome. Physiologically, thetics, and provide complete func- gevity, as functional forces acting on cides to proceed with superstruc- ture teeth or treatment concepts such some patients may be poor candi- tional stability at the same time. the prostheses are extensive. tures made from zirconia and ce- as All-on-4, which uses four im- dates for extensive grafting, or they They also allow for easy, fast and When combined with aligned cen- ramic veneering on a large span or plants to support an immediately may simply decline such treatment simple hygiene maintenance by the tralized milling strategies, computer- in multiple sections, or a cost- loaded full-arch prosthesis. on emotional or financial grounds. patient. This characteristic is recog- aided design (CAD) offers many ad- saving NobelProcera Implant Edentulous patients commonly In these situations, treatment con- nized as one of the most critical pre- vantages over conventional manual Bridge made of titanium—finished present extensive loss of hard and cepts that make it possible to provide dictors for the long-term survival laboratory manufacturing tech- with composite resin or conven- soft tissue, which can be attributed to reliable bone-anchored support in and success of any implant restora- niques. Among these advantages are tional denture teeth—, they can be a variety of factors, ranging from minimal volumes of hard tissue be- tion. fit, material quality and reliability. sure they are working with the best severe periodontal breakdown to come especially relevant, as does the The NobelProcera System provides possible quality. external trauma. Making matters use of soft tissue-colored resin or Other considerations custom-design options for frame- Thanks to these products and ser- worse, the longtime use of full-arch porcelain in the final restoration. The loading protocol also needs to works made of titanium or zirconia. vices from Nobel Biocare, poor fit- dentures leads inevitably to atrophy One promising and fast growing be taken into consideration. While The extent of atrophy, the amount ting frameworks and the need for of the alveolar ridges. treatment concept is based on the staging implant therapy over time is and quality of bone and soft tissue chair-side sectioning and soldering While many additive techniques use of bar-retained overdentures a highly predictable option, the ex- available, and the inter-occlusal dis- are a thing of the past! <

Essential criteria Optimal function and esthetics re- Nobel Biocare Wins “Best Medical Website” quire comprehensive treatment plan- ning. Criteria for esthetically pleasing, long-lasting, and well-functioning dividuals involved in available dental courses Global Communications. Acknowl- implant reconstructions are: Competing in a large field of the process of develop- from all around the edging the award, he added, “Our • Meticulous examination, diag- international competitors, ing websites for organi- world, both on dental website will build on this success and nosis, and treatment planning Nobel Biocare is honored for zations, companies and implants and prosthetic stay at the forefront of technology, with a full-contour wax-up, fol- its well-conceived and government, the inter- restorations. The quality design and content.” lowing basic esthetic principles, well-executed website. national Web Award of the site’s content and Now in its 15th year, the Web- function, and phonetics. Competition recognizes the use of technology to Award is the premier international • A properly planned and appro- n September 15, the interna- outstanding website de- communicate that con- annual website award competition, priately fabricated CAD/CAM tional Web Marketing Asso- velopment and online communica- tent were also cited as decisive as- naming the best websites in 96 in- framework adhering to biome- O ciation presented Nobel tion in virtually every field. Taking pects of nobelbiocare.com/dental. dustries each year and thereby set- chanical principles and provid- Biocare with its 2011 “Best Medical home the honors for Best Medical “The Nobel Biocare Dental Profes- ting the standard of excellence for all ing passive fit. Website” award on the basis of supe- website called for the effective fusion sionals website is a key communica- website development. < • An easy-to-handle restoration to rior design, innovation, content, of form and function. tion channel and a cornerstone for expedite treatment and facilitate technology, interactivity, copywrit- The Nobel Biocare website won information not only for Nobel Bio- More to explore hygiene. ing and ease of use. particular recognition for its useful care but the entire dental industry,” www.iacaward.org/winner. Open to all organizations and in- course finder feature, which presents said Nicolas Weidmann, Senior VP asp?eid=16103 Issue 1/2011 Nobel Biocare News 15 Understanding the Integrity of Implant System Design

ment into the implant helps resist and making claims of compatibility tegrity of the entire implant system. Careful treatment planning, lateral tipping forces, which cause with that system. Recently, the com- Higher incidences of screw loosen- meticulous surgery, proper screw loosening. patibility of one such company’s RP ing and possible fatigue fracture of prosthetic design and 2. The TorqTite abutment screw and NP titanium abutments were fa- the components will cost the care occlusion, and patient achieves a high preload. tigue-tested with NobelReplace Ta- provider far more in terms of ex- hygiene all contribute to 3. Implants are manufactured from pered Groovy Ø4.3 implants and pense, lost chair time and—not least long-term dental implant special high-strength cold-worked NobelReplace Platform Shift NP- of all—lost good will with the pa- Proceedings of the First success. Grade 4 Pure Titanium for high Ø4.3 implants respectively. The test- tient, than is saved with the use of P-I Brånemark Scientific fatigue strength. ing was conducted to the ISO 14801 third-party components. < By Steve Hurson Symposium, Gothenburg 4. Abutments are manufactured standard by an independent labora- 2009 from high-strength titanium alloy tory. The results can be seen in the qually important is the inter- and zirconia. adjacent bar diagram. More to explore component integrity of the im- The fatigue strengths shown have “Resistance of Internal-Connection er-Ingvar Brånemark’s discovery E plant system, which can help At the core of the NobelReplace Ta- been normalized to 100% for the re- Implant Connectors Under P of osseointegration in 1952 to prevent such complications pered Ø4.3 system design is the spective NobelReplace system abut- Rotational Fatigue Loading,” by A. changed the field of dentistry for­ as screw loosening and fa- TorqTite screw, a unique technol- ments and abutment screw. As Wiskott, R. Jaquet, S. Scherrer and ever, creating a world of possibilities tigue fracture of the compo- ogy proprietary to Nobel Biocare. shown in the graph, the fatigue U. Belser, in Int J Oral Maxillofacial for dental reconstruction. nents. The TorqTite screw achieves strengths of both systems suffered Implants. 22, 2007; 249–257. The First Brånemark Symposium, Nobel Biocare implant double the preload of a standard when the third-party abutments and “Implant-abutment interface held in 2009, honored the lifetime systems are designed with titanium alloy screw. In Me- screws were combined with the No- design affects fatigue and fracture work of Brånemark, promoting co- all components working chanical Engineering Design, belReplace original implant. strength of implants,” by operative efforts among and between together in harmony to Joseph Shigley writes, “The im- It may be tempting for the clini- L. Steinebrunner, S. Wolfart, medical and dental disciplines. This ensure long-term integrity portance of preloading of cian or dental laboratory to substi- K. Ludwig and M. Kern, in Clin. Oral richly illustrated book of proceedings of the systems. Two exam- bolts cannot be overestimat- tute low-cost, third-party compo- Impl. Res. 19, 2008; 1276–1284. ples of this are the NobelRe- ed. A high preload improves nents for original components to “Mechanical Engineering place Tapered Ø4.3 product both the fatigue resistance of a save expense. As can be seen in the Design,” by Joseph Shigley. New line and the NobelReplace bolted connection and the test results, this jeopardizes the in- York: McGraw Hill, Inc, 1977. S &E Platform Shift NP-Ø4.3 locking effect.” product line. The recently developed Safety and Efficacy The NobelReplace Ta- NobelReplace Platform Shift Fatigue Test Comparisons pered Ø4.3 product line, de- NP-Ø4.3 system presented a 100% from the symposium features a vast veloped in 1998, is suitable unique design challenge of array of knowledge related to osseo- for all applications through- applying NP (Ø3.5) abut- 80% integration, such as mechanobiology, out the mouth but was spe- ments to the NobelReplace nanostructured surfaces, orofacial re- cifically designed with the Tapered Groovy Ø4.3 im- 60% constructions, and orthopedic appli- high strength and stability plants. Through careful design cations. necessary for single-tooth optimization of each of the 40% Edited by Drs. Robert Gottlander restorations. components, high fatigue and Daniel van Steenberghe, it also To ensure high strength and strength equivalent to the origi- 20% features information regarding asso- stability – design, materials and nal RP system was achieved with ciated diagnostic and treatment mo- surface modifications all play this system as well. NobelReplace Ø4.3 NobelReplace PS NP Ø4.3 dalities, such as full-ceramic crowns, important roles: Many companies are making cop- 30° Fatigue Test 30° Fatigue Test CAD/CAM techniques, and guided 1. Long engagement of the abut- ies of the NobelReplace product line n NobelReplace abutment n Third-party abutment surgery applying cone beam com- puted tomography. Quality-of-life considerations and treatment simplification are also dis- cussed. New Lifetime Warranty Some fine print The symposium was held in Pro- concerning our fessor Brånemark’s hometown of Go- thenburg, Sweden. Osseointegration trademarks experts and opinion leaders from all n the rare and regrettable event of a Listening to customer feedback is over the globe attended. I product failure, Nobel Biocare ex- essential for providing the highest The people of Nobel Biocare The proceedings offer cutting- tends a lifetime warranty to cover all possible level of support. Our life- are very proud of the many edge insight from these experts, the company’s implants, as well as time warranty is just another sign of ­products, services and brands making it the perfect choice for the prefabricated prosthetic compo- our responsiveness as we serve our they have developed over the student, researcher, or clinician who nents, if restored. customers and their patients in the years. wants to better understand the con- In addition, all NobelProcera indi- best possible way. In order to improve read- cept of osseointegration, its many ap- vidualized restorations are covered Please contact your local Nobel ability, we do not use [™] or [®] plications, and its influence in dental by a five-year warranty regardless of Biocare representative at the num- in the running text of Nobel and medical world of today. the implant platform (excluding bers listed on the following page Biocare News. Please note, And please note: a follow-up sym- Earlier this year, Nobel temporary acrylic restorations). for more information regarding cus- however, that Nobel Biocare posium will be held in Gothenburg Biocare instituted a new In all instances, products will be tomer support and other services. < does not waive any right to the next March. lifetime warranty to make it replaced at no additional cost. For trademark or registered mark and easier for customers to do detailed warranty information, More to explore nothing herein shall be construed 395 pages hardbound business and to instill peace please visit us online at the address www.nobelbiocare.com/warranty to the contrary. ISBN 978-1-85097-207-9 of mind. on the right. 16 Nobel Biocare News Issue 1/2011 Nobel A Creative Approach Biocare University to Higher Education Partners Karolinska Institutet of Sweden becomes a Nobel Biocare University Partner.

as the home of the Nobel Assembly, Since 2004, Nobel Biocare has > Stockholm, Sweden fifty distinguished professors, who entered into a series of agreements By Anne Berit Heieraas choose the Nobel Prize laureate in with universities around the world in Physiology or Medicine each year. order to encourage dental schools to obel Biocare has recently com- implement advanced implant educa- N mitted resources to provide Global outreach tion programs. support for the undergraduate dental “We are very proud to enter into this With the support of Nobel Bio- education program at Karolinska In- collaboration with Karolinska Institu- care, select universities have incor- stitutet in Stockholm, Sweden. tet and look forward to long and fruit- porated implant therapy, treatment One of Europe’s most prominent ful cooperation,” says Ingo Braun, planning and diagnosis—as well as medical universities, Karolinska In- Global Head of Clinical Research at digital dentistry—into undergrad­ stitutet, is perhaps best known abroad Nobel Biocare headquarters. uate dental education curricula, thus promoting optimal patient care. To stimulate the exchange of knowl- edge, initiative and experience, Nobel Biocare University Partners also become part of a dynamic com-

munications network comprised of Photo: Johan Bergmark Photo: Camilla Svensk many of the world’s leading dental Professor Kaj Fried, Chairman of Well educated students, like universities. the Department of Dental Medicine these at Karolinska Institutet, are at Karolinska Institutet. learning innovative techniques to A helping hand provide optimal care. The collaboration with Karolinska Institutet includes various forms of support, such as training in a variety Department of Dental Medicine at of implant and prosthetic solutions, Karolinska Institutet. More to explore: treatment planning and guided sur- Professor Fried’s department con- For more information about gery, both for students and faculty at ducts research and offers education the Global University Partner this influential institute. in dentistry, dental hygiene and den- Program, and how it drives “This agreement enables us to tal technology. It also operates a stu- innovation in education by helping

Photo: Camilla Svensk offer our students know-how of dent clinic open to the public. The institutions better leverage their Behind these walls, the Nobel Assembly, a group of fifty distinguished some of the best treatment solutions department is made up of approxi- resources, professors, chooses the Nobel Prize laureate in Physiology or Medicine the dental industry has to offer,” says mately 250 employees, 500 under- please visit our website: each year. Professor Kaj Fried, Chairman of the graduates and 40 PhD candidates. < www.nbgupp.org/

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