At its annual inventor awards ceremony this spring, the European Patent Office (EPO) presented Professor Per-Ingvar Brånemark with the organization’s lifetime achievement award for his discovery and development of osseointegration.

Regarded as the most prestigious prize for European inventors, the award went to Brånemark because, “During the course of his career, he has continued to refine his approach into what has become the gold standard of dental implantation globally—the method of osseointegration.”

According to the EPO, “more than eight million people have benefited from Brånemark’s landmark methods,” since he treated his first osseointegration patient, Gösta Larsson, in 1965.

Serendipity and hard work

I met with Professor Brånemark recently, not far from the University of Gothenburg, Sweden, where he has worked most of his life. When I asked about the award, he replied simply. “I have received quite a few prizes and awards over the years, but this beats everything else. It represents recognition from colleagues and laymen alike that my method has already helped an enormous number of people. What greater commendation can a scientist hope to receive?”

He has come a long way since those early days in the 1950s when, as a young researcher, he was completely absorbed in the study of the anatomy of blood flow.

As part of that work, he attached a titanium-housed optical component to a rabbit’s leg, which made it possible to study microcirculation in the bone tissue through specially modified microscopes. The work at hand was completed successfully, but when it came time to remove the metal-framed optics from the bone, Brånemark famously discovered that the bone and titanium had become virtually inseparable.

“Not long afterwards,” Brånemark said, “we changed the direction of our work to investigate the body’s ability to tolerate titanium.”

Multidisciplinary enterprise

To gain a proper understanding of what he would later call “osseointegration,” Brånemark recruited experts from other fields—such as physics, chemistry and biology—to his quest. Physicians, dentists and biologists all joined the effort. Together they developed diligent, methodical techniques for the insertion of implants. At the same time, engineers, physicists and metallurgists studied the metal’s surface and how the design of the implant might have an effect on bone healing and growth.

Per-Ingvar Brånemark: “It is very important that all data be considered, not just those that support your ideas.”

For the best part of two decades, Brånemark faced opposition from the medical establishment in his native Sweden. “Our findings that the body would accept titanium over the long term, and even allow it to integrate in bone, flew in the face of conventional wisdom,” he explained.

“Theorists’ textbook opposition asserted that our implants would trigger initial inflammation and would ultimately be rejected by the body’s immune system.”

The 1960s were trying times for Brånemark. Funding from Swedish research organizations dried up, yet he persevered. With his physician’s certification at stake, he repeatedly demonstrated the accuracy of his claims and the viability of osseointegration. Finally, in the mid-1970s the Swedish National Board of Health and Welfare approved the Brånemark method.

To reach beyond the world of the university clinic, Brånemark looked for an industrial partner. “I chose Bofors, an antecedent to Nobel Biocare, because they were one of thefew companies who knew how to machine titanium,” says the professor. Thus a long term relationship began.

Over the years, this relationship has had its ups and downs, but both parties have benefited from a longterm devotion to the support and practice of good science. When I asked Brånemark what characterizes good science for him personally, he responded thoughtfully.

“Good science is all about good method. Making observations, collecting facts and data and creating a hypothesis to explain what you’ve seen—it all starts there. Then you have to deduce the implications of the hypothesis and put the implications to the test. It is very important that all data be considered, not just those that support your ideas. Finally, you have to subject your findings to peer review. At the end of the day, there may be no ‘final’ truth, but in our field, a valid hypothesis will inevitably lead to practical achievement as it stands up to the scrutiny of other researchers in the field.”

As successful as Brånemark has been as a scientist, he has also been successful as an evangelist for the “good news” of osseointegration. When I point out that people listen to him, and ask why, he responds with a smile on his face.

“They listen to me because I know what I’m talking about. Before treating the first patient, I had accumulated more than ten years of experience in the lab, for example. I don’t rush to conclusions, and I think people appreciate that.”

Followers everywhere

I follow up with the question, “How much of your success can be accounted for by such personal characteristics as perseverance—stubbornness, if you will—and how much by the apostles you recruited around the world?”

“One person alone can’t have much impact on the world. I’ve been privileged to meet and collaborate with some extremely talented people over the years. In addition to all the dental and medical students who have passed my way, I had something like 44 doctoral candidates at the University of Gothenburg over the years, and almost all of them taught me as much as they learned.”

Per-Ingvar Brånemark has coined many words and phrases that have become commonly used terms in dentistry. “Fixtures”, “anaplastology” and “osseointegration” come immediately to mind, of course. When he introduced the concept of the “third dentition,” Brånemark got thousands of professionals to start thinking of implant-based solutions not as “false teeth” but “total rehabilitation.”

“I chose these words because I found them succinctly descriptive. There’s a beauty in language like that. I certainly didn’t anticipate how widely they would be accepted, but was pleased, of course, to see how quickly they gained traction in both scientific literature and clinical communication.”

When asked to comment on the practicalities of cooperative efforts between science and industry, Brånemark takes the high ground.

“We have always needed each other’s expertise and have generally enjoyed a symbiotic relationship. In an ideal world, maybe talented scientists would also be gifted production engineers and marketers; and maybe industrialists would be able to see beyond the bottom line; but in the real world—in order to achieve our goals—we each do what we do best and turn to others with complementary skills for help with the rest.”

To the question, “Do you think that Nobel Biocare has succeeded in being a good steward of the trust that you long-ago established among dentists?” Brånemark replies: “I think I see a company today that wants to build on its scientific heritage. Together we ushered in a new era, but we all have to remember to respect the molecules. Our method stands for reconstructive biology not carpentry.” Looking toward the future, he adds, “I’ll be very happy if Nobel Biocare keeps the rigorous scientific philosophy of the early years alive in its corporate culture.”

Eye on the horizon

While we’re on the subject of the future, I ask, “What’s next?”

“If you’ll allow me to speculate a bit, I believe that we may be on the threshold of a paradigm shift in the professions we practice. Once we realize that biology—especially immunology—lies at the heart of both modern dentistry and medicine, I think we’ll start educating dentists and doctors along similar lines at the same institutions. Perhaps the traditional partitions between them will even disappear altogether in the next generation or two.”

“As far as my own research is concerned, I see great strides being made in the area of osseoperception, whereby bone-anchored prostheses transmit information that can be intuitively interpreted via the central nervous system. I have patients with osseointegrated limbs, who can actually ‘feel’ the texture of the rugs on which they’re walking today. This aspect of osseoperception is a bountiful field for further research.”

Eighty-two years-old and still full of enthusiasm for the work at hand, Professor Per-Ingvar Brånemark remains the best known personality in the world of osseointegration to this day. He has certainly earned the title, “Father of modern clinical implantology.”

At that annual check-up, Dr. Glauser took the following X-ray. 

Two Brånemark System Mk IV implants with the TiUnite surface were placed in positions 45 and 46 in March 2000. This recently taken X-ray shows both implants restored with screw-retained, connected porcelain-fused-to-metal crowns and reveals excellent marginal bone levels.

Her Brånemark System treatment had begun much earlier. Back in the early 1990s, the patient had received Brånemark System implants with the traditional machined surface in the upper jaw to replace lost molars on both sides. Then, in March 2000, she became the first patient to receive Brånemark System Mk IV implants with Nobel Biocare’s new TiUnite surface. Two were placed in the lower right jaw to replace a lost premolar and the adjacent molar.

The long-term results speak for themselves. 

This lateral view of the two crowns—which have now been in place for more than eleven years—indicates that the surrounding soft tissues are both robust and healthy

More to explore:

www.nobelbiocare.com/tiunite

www.nobelbiocare.com/tiunite-abstract 

Demographic data indicates that the number of edentulous patients will continue to grow in the years to come, and in a world full of readily available digital information, patients’ expectations—as well as their awareness of available treatment options—are increasing at the same time.

Taking each patient’s clinical situation, expectations, available time, and financial situation into account, the dental team has to decide first and foremost on the most appropriate treatment protocols and materials to recommend.

Then they must communicate the benefits of competing treatment alternatives and explain the availability of low-cost, yet high-quality, restorative options such as titanium frameworks with acrylic veneering, denture teeth or treatment concepts such as All-on-4, which uses four implants to support an immediately loaded full-arch prosthesis.

Edentulous patients commonly present extensive loss of hard and soft tissue, which can be attributed to a variety of factors, ranging from severe periodontal breakdown to external trauma. Making matters worse, the longtime use of full-arch dentures leads inevitably to atrophy of the alveolar ridges.

While many additive techniques for the reconstruction of missing anatomic morphology are employed on a routine basis today, surgical intervention may not always lead to the desired outcome. Physiologically, some patients may be poor candidates for extensive grafting, or they may simply decline such treatment on emotional or financial grounds.

In these situations, treatment concepts that make it possible to provide reliable bone-anchored support in minimal volumes of hard tissue become especially relevant, as does the use of soft tissue-colored resin or porcelain in the final restoration.

One promising and fast growing treatment concept is based on the use of bar-retained over dentures (often called, “fixed-removable”). Overdentures allow for the proper support of extra-oral tissue, which restores facial appearance and esthetics, and provide complete functional stability at the same time. They also allow for easy, fast and simple hygiene maintenance by the patient. This characteristic is recognized as one of the most critical predictors for the long-term survival and success of any implant restoration.

Other considerations

The loading protocol also needs to be taken into consideration. While staging implant therapy over time is a highly predictable option, the extraction of remaining teeth and roots, simultaneous or delayed implant placement, and immediate provisionalization also represent protocols that are routinely performed with good success.

Loading dental implants immediately after their placement has tremendous advantages for both the dentist and the patient. The protocol results in minimized trauma and immediate esthetics, adequate function, and preservation of hard and soft tissue contours.

The positive psychological benefit for the patient—who is not left with a transitional, mostly unacceptable denture—can be very substantial indeed.

In this context, the All-on-4 concept—whose reliability has been substantiated by extensive long-term documentation and scientific evidence—provides not only an immediate provisionalization protocol, but also a definitive treatment solution.

No matter which clinical protocol is selected, the manufacturing and quality of the definitive restoration is of fundamental importance for longevity, as functional forces acting on the prostheses are extensive.

When combined with aligned centralized milling strategies, computer-aided design (CAD) offers many advantages over conventional manual laboratory manufacturing techniques. Among these advantages are fit, material quality and reliability. The NobelProcera System provides custom-design options for frameworks made of titanium or zirconia.

The extent of atrophy, the amount and quality of bone and soft tissue available, and the inter-occlusal distance are all factors that need to be taken into consideration when choosing between a fixed and removable implant-retained restoration—as are the anticipated number and position of implants and the clinical protocol preferred by the restoring dentist.

Whether the restorative team decides to proceed with superstructures made from zirconia and ceramic veneering on a large span or in multiple sections, or a cost-saving NobelProcera Implant Bridge made of titanium—finished with composite resin or conventional denture teeth—, they can be sure they are working with the best possible quality.

Thanks to these products and services from Nobel Biocare, poor fitting frameworks and the need for chair-side sectioning and soldering are a thing of the past!

By Hans Geiselhöringer

 

Essential criteria

Optimal function and esthetics require comprehensive treatment planning. Criteria for esthetically pleasing, long-lasting, and well-functioning implant reconstructions are:

• Meticulous examination, diagnosis, and treatment planning with a full-contour wax-up, following basic esthetic principles, function, and phonetics.

• A properly planned and appropriately fabricated CAD/CAM framework adhering to biomechanical principles and providing passive fit.

• An easy-to-handle restoration to expedite treatment and facilitate hygiene.