Corporate today Nobel Biocare Global Symposium June 24, 2016

Corporate today Nobel Biocare Global Symposium June 24, 2016

Innovation comes to life at the 2016 Nobel Biocare Global Symposium / From the President / Global Symposium attendees speak out / Interview: “This is the most comprehensive congress I have ever taken part in” / Interview: Manufacturer matters when it comes to ceramic abutments / Taking life at more than face value / Why NobelProcera CAD/CAM bars? / The very definition of synergy / Teamwork - for predictable outcomes / Products / How to optimize the emergence profile / Driving in the fast lane / A nuanced perspective on periimplantitis / Floor plans

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Table of contents

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news

Hans Geiselhöringer

From the President

WORKFLOW ENHANCEMENT
At Nobel Biocare, our innovation efforts are
based on clinical requirements, patient needs
and scientific research. These have led us
to superior products and solutions, as well
as efficient treatment workflows that reduce
treatment time—in other words, shorter time
to teeth.
With our leading integrated workflow, treatment steps that were previously considered
mandatory have been made faster, combined
or even removed entirely. Our new technologies continue to enhance diagnostics and
treatment planning. Digital integration improves collaboration among treatment partners and helps bring the laboratory into the
treatment process as early as the planning
phase, meaning prosthetic considerations are
taken into account right from the start.

the people joining this third global event of
Nobel Biocare have travelled long distances
from all over the world, which reminds us
how important this conference is,” Wöhrle
said.
In addition, Nobel Biocare prepared an
exciting array of forums, including an innovation assembly on Saturday, at which the
company will be exclusively previewing its
upcoming innovations, and a full-day forum
on Sunday that will be focusing on comprised patient treatment.
Under the slogan “Where innovation
comes to life”, Nobel Biocare is unveiling a
number of innovative new products and solutions at the event, including the On1 restorative workflow concept that bridges the
gap between the surgical and prosthetic workflows, a new NobelProcera Crown in a new
high-translucency multi-layered full-contour
zirconia material, and the new NobelZygoma
implant that provides greater surgical and
prosthetic flexibility when treating severe
maxillary resorption without grafting.
“The innovations we are presenting at
the Nobel Biocare Global Symposium 2016
have all been created to address the specific
needs of today’s dental professionals as they
strive to improve care for patients. Informed
by studies confirming the possibilities and
advantages offered by immediate placement
and provisionalization, many of these new
products and solutions are so unique that
they are either patent-protected or in the
patent process,” Geiselhöringer said. 7
More to explore!
More information about the program is
available at www.nobelbiocare.com/globalsymposium-2016.

We are also advancing componentry in order
to improve clinical workflows. The most important new addition to our portfolio in this regard is the On1 concept. This new approach to
the restorative process ingeniously bridges the
gap between the surgical and prosthetic workflows with a modular solution. The On1 Base
connects to the implant at time of surgery and
is then left in place throughout the healing
process, the prosthetic work and the lifetime
of the restoration. This leaves the tissue undisturbed for optimized healing, but unlike with
tissue-level implants, there is no compromise
on restorative flexibility.
In addition, the workflow for the components
has been refined with a view to dramatically
reducing treatment time. As the On1 healing
cap supports an intra-oral scanning approach,
conventional impression-taking procedures for
delivery of the final crown can be eliminated.
This can save time and improve patient comfort. What’s more, the On1 Base offers the clinician placing the implant added peace of mind,
knowing that only precision-engineered Nobel
Biocare components can be used in conjunction
with the implant, thus removing the risks associated with an ill-fitting third-party abutment.
Such advancements mean dental professionals
can treat more patients each day, with better
results. Consequently, more patients experience the improved quality of life dental implant
treatment brings, and both clinicians and technicians can grow their businesses. It is such
outcomes that we at Nobel Biocare strive for
every single day; it is designing for life in action.

Nobel Biocare Global Symposium

Don’t miss!
June 24, 8 a.m. to 12 p.m.
Forum: NEXT GEN
Starlight roof
June 25, 1 to 5 p.m.
Forum: Innovation assembly
Grand Ballroom
June 26, 8 a.m. to 5 p.m.
Forum: The compromised patient
Grand Ballroom

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statements

Global Symposium attendees speak out
Dental professionals from near and far are here to stay on the cutting edge

Bassim Essadi

by Dental Tribune International

Jordan
“This is the biggest event in dental implants, and I am here every three years.
All of the speakers here are very good. This
technology means less discomfort, more predictability and stable results for my patients.
In addition to the very valuable lectures,
I also enjoy being in New York.”

 Dental practitioners from around the
globe have gathered in New York City for the
2016 Nobel Biocare Global Symposium. They
came here to take advantage of the wealth of
information and expertise being shared, to
be among the first to see the latest technological advancements, and to connect with their
compatriots. DTI spoke with a few attendees
to find out what they are hoping to learn here
and take back home to their practices.

Javier Alández

Spain
“I think everything being presented here
at the symposium is very interesting. I have
been using implants in my practice for
27 years. I always work with Nobel Biocare.
With these products I can offer my patients
security and confidence.”
5

Patrik Andrén, Sweden

Patrik Andrén

Sweden
“I only started placing implants two
years ago and have already attended a
number of local Nobel Biocare symposia
in Sweden. However, this is my first
global event and I’m very excited. I’m especially looking forward to learn more
about digital dentistry, because that’s the
way to go.”

Bassim Essadi, Jordan

Javier Alández, Spain

Nobel Biocare Global Symposium

[4] =>

statements

Joe Merheb

years. I am here at the conference to see
what’s new and current, and to see what
I can improve on. I always strive to be on the

Belgium
“I am a surgeon, and I was invited to
attend by Nobel Biocare. I am here to learn
more about implant surgery. A nice smile
and the ability to chew is a very important
part of a person’s happiness and comfort.
Being able to give this to my patients in a
nice and elegant way, which differs a lot from
traditional prosthesis, is a very important
improvement. It helps patients physically,
psychologically and socially. There are a lot of
interesting presentations being offered here.”

Matthias Leupold Hlawitschka, Switzerland

Matthias Leupold Hlawitschka

Mélinda Paris, Canada

user-friendly, and the company’s customer
service is very good.”

Switzerland
“I am here to partake a little bit in the
education, and a little bit for the new products. I also enjoy the social events, meeting
my friends and colleagues. I also enjoy visiting New York. I use three different implant
systems in my practice, and I use Nobel
Biocare in about 80 percent of my cases. This
technology allows me to offer my patients
good function and good esthetics.”

Anthony Sallustio

USA
“I have been using Nobel Biocare implants almost exclusively in my practice in
Ocean Township, New Jersey, for 20 years.
I am here looking for new technologies and

Javier Muñiz, Mexico

Javier Muñiz

Mexico
“I am involved with a many dental clinics
in Mexico, where we place a lot of implants.
I am here for the educational opportunity.
I am signed up for six master classes, and I am
particularly looking forward to the presentations by Prof. Paulo Malo and the presentations
about the All-on-4 treatment concept. I am
here with some of my colleagues. We are always striving to do things better and better.”

Gaurav Malik, India

India
“This is one of the best global events, offering so much innovation. I am here to learn
new things and to incorporate new treatment
modalities in my practice, especially the
All-on-4 treatment concept. We just started incorporating that, and I want to be a little more
sure on all the protocols. Prof. Paulo Malo is
considered a pioneer in this area, and I have
been following him for quite some time. I will be
attending his master class and his hands-on.”

Belgium
“It’s always nice to see some valuable
lectures and to see New York, of course. I am
a regular user of Nobel Biocare implants.
I have heard that they will be introducing new
abutments, and that is something I am looking forward to. There is a lot of science right
now advocating for the immediate placement
of abutments, and I think this will ultimately
lead to a final outcome in a better way.” 7

Anthony Sallustio, USA

USA
“I have been using Nobel Biocare implants in my practice in New York City for six

Nobel Biocare Global Symposium
Chinji Nakajima, Japan

Japan
“I am here at the Nobel Biocare Global
Symposium to study. I have been using implants in my practice in Tokyo for 20 years
now. I am particularly interested in the bone
regeneration class being presented here by
Dr. Istvan Urban of Hungary.”

Mélinda Paris

Canada
“I am from Quebec City, and I am here to
get more expertise in the All-on-4 treatment
concept. I am particularly looking forward
to the hands-on educational opportunity
here. I use Nobel Biocare implants in my
practice. I like the stability. The technology is

Nobel Biocare Global Symposium

Andy Temmerman, Belgium

Imprint—About the Publisher

today Nobel Biocare Global Symposium is published by Nobel Biocare in collaboration with Dental Tribune International
Dental Tribune International GmbH
Holbeinstr. 29
04229 Leipzig
Germany
Tel.: +49 341 48474 302
Fax: +49 341 48474 173
E-mail: info@dental-tribune.com
Internet: www.dental-tribune.com

Nobel Biocare Services AG
P.O. Box CH-8058
Zürich-Flughafen
Switzerland
Tel.:+41 43 211 42 00
Fax:+41 43 211 42 42
E-Mail: info.switzerland@nobelbiocare.com
Internet:www.nobelbiocare.com

Chinji Nakajima

Andy Temmerman

Garry Shnayder

Joe Merheb, Belgium

leading edge of technology for the benefit of
my patients.”

ways to improve delivery of care to my patients, improving their lives. With this technology I can offer predictability, improvement
of function and form, and better esthetics.”

Gaurav Malik

Garry Shnayder, USA

Dental Media Manager
Lissette Cabrera

Excecutive Producer
Gernot Meyer

Public Relations Manager
Michael Stuart

Designer
Franziska Dachsel

Manager Marketing Content & Dental Media
Jim Mack

today is published during the Nobel Biocare Global Symposium at the
Waldorf Astoria hotel in New York, USA, on June 24 and 25. The newspaper and all articles and illustrations therin are protected by copyright.
Any utilization without prior consent from the editor or publisher is inadmissible and liable to prosecution. Neither Nobel Biocare nor DTI will
be liable for any damages of any kind or loss of profits that might arise
from information found in this publication, regardless of whether Nobel
Biocare or DTI has been advised of the possibility of the damages. While
all attempts have been made to endure the accuracy of the provided information, neither Nobel Biocare nor DTI can be held responsible for any
errors or omissions.

Managing Editor
Claudia Duschek
Editoral Assistance
Fred Michmershuizen
Copy Editors
Sabrina Raaff & Hans Motschmann

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interview

“This is the most comprehensive congress I have ever taken part in”
An interview with scientific committee chairmen Drs. Bertil Friberg and Peter Wöhrle
by Dental Tribune International
n Drs. Friberg and Wöhrle, could you please
introduce yourselves to the readers by telling
them how you became involved in the scientific committee of the 2016 Nobel Biocare
Global Symposium?
Dr. Bertil Friberg: I have been a member
of the Brånemark Clinic in Gothenburg, Sweden, since its founding in 1986. For the past
30 years, I have been working in close collaboration with Nobel Biocare regarding lectures, research and clinical activities.
Dr. Peter Wöhrle: During my doctoral and
postdoctoral training at Harvard in the 1980s,
I was introduced to the work of Prof. Per-Ingvar
Brånemark. Ever since then, implant dentistry has been the focus of my professional
career. Over the years, I have become increasingly involved in research and teaching in addition to clinical work. My formal training in
the interrelated areas of implant dentistry,
namely surgery, prosthetics and laboratory
technology, allows me to help improve outcomes based on understanding the effects
and synergies on each other and streamlining
of the different aspects of treatment.
What did you consider most important in
compiling the scientific program for the
symposium?
Friberg: This is the most comprehensive
congress I have ever taken part in. It covers
all topics of importance in daily implant practice, the laboratory, preclinical evaluations
and treatment planning, implant placement
and prosthetics, maintenance considerations,
complications and how to handle them, and
how to interpret result data.
Wöhrle: This symposium has something
to offer for every attendee, as it covers all aspects of topics related to implant dentistry.
We went to great lengths to develop several
different tracks based on specific topics of
interest. Once the attendee decides which
topic is most interesting, the schedule allows
and encourages full exploration of that subject via lectures, master classes and hands-on
courses. We will have multiple activities every minute of the symposium, offering unprecedented learning opportunities based on
individualized interests and scheduling.
The theme of this year’s event is “Where
innovation comes to life.” Which innovations can participants look forward to in
particular?
Friberg: In addition to various new components, including NobelParallel, NobelActive
WP and angulated screw channel abutments,
which aim to facilitate the work of clinicians, participants will learn about the latest
in digitization, handling research data, cell
biology and osseointegration, as well as the
latest in the treatment and prevention of
periimplantitis.
Wöhrle: There will be ample innovations
presented during the symposium, culminating in the innovation assembly forum on
Saturday afternoon. The entire session will
be devoted to new and upcoming products
and trends in implant dentistry. This is an
event not to be missed.
What are the implications of these new
developments for daily clinical practice, and
how can both dentists and patients benefit?
Friberg: These developments will help
facilitate treatment in the posterior region,



Dr. Bertil Friberg

avoid cementation in the anterior region and
prevent complications. They also offer various
implant designs for specific clinical situations
and represent further developments in hardand soft-tissue management.
Wöhrle: The overriding goal of significant innovations in implant dentistry is to allow practitioners to achieve better long-term
clinical outcomes in more patients. The graftless approach and the digital workflow, including 3-D planning and implant placement
with CAD/CAM-generated surgical templates,
are prime examples of how innovations can
transform long-established protocols for the
benefit of the patient.
Both of you have many years of experience
in implant surgery. How has the field progressed in the last 20 years, and how can
events like the Nobel Biocare Global Symposium support dentists in keeping up with
these changes?
Friberg: This meeting addresses the
main innovations we have seen over the past
several years, such as improved techniques
in both surgery and prosthetics. With the
technology and methodology today we are,
for example, able to treat severely compromised cases in terms of poor bone volume
and poor bone texture much better. At the
symposium, participants will have the opportunity to interact during treatment planning
sessions, and ahead of the event, they have
been able to suggest topics of individual interest that will be presented by various
speakers.
Wöhrle: Major milestones in the last
20 years have been the introduction of the
TiUnite surface, significantly decreasing
early failures in certain applications and
groups of patients, and immediate loading in



Dr. Peter Wöhrle

select cases, shortening treatment time and
thus cost for patients. Currently, the digital revolution—CT-based planning programs,
CAD/CAM-generated surgical templates, and
digitally designed and manufactured restorations—has changed the way we practice
dentistry today, and it will change it even
more in the future.
Digitization is becoming increasingly important in all kinds of industries and dentistry
is no exception. Will the symposium also
address this topic, as outcomes of implant
placement may become significantly more
predictable with digital technologies?
Friberg: In my opinion, computer planning of implants is much more important
when treating patients with severely resorbed jaw bone and in patients in whom implants may interfere with various anatomical
landmarks, and for whom exact positioning
of the implants may be the difference between success and failure. Straightforward
cases are normally solved without digitization.
Wöhrle: Digitalisation will absolutely be
addressed. Digital implant planning and
placement deliver more efficient care with
consistently better outcomes, especially in
the partially edentulous patient. Placing an
implant that is restorable is no longer the
aspiration; with today’s technology, one can
do better. Properly executed guided surgery,
combined with
proper treatment

planning, elevates the level of excellence
while increasing efficiency and safety.
Another major topic in implant dentistry is
the treatment and prevention of periimplantitis. What is the current scientific evidence
on this issue?
Friberg: This is a topic addressed in
many congresses today. We must keep in
mind that there is still not an accepted definition of periimplantitis and, thus, prevalence figures vary a great deal. Several efforts have been made to gather expertise
from all over the world to provide consensus
statements on the problem.
At the moment, we do not sufficiently
understand the periimplantitis issue, its site
specificity, its sometimes very poor response
to treatment, the impact of microbes, the foreign body reaction and so on. However, all
these topics will be addressed at the symposium to provide clinicians with the latest
research on periimplantitis.
Wöhrle: As Dr. Friberg just explained,
there is no consensus on the definition of
periimplantitis, its cause or even its treatment. I am looking forward to the latest
research and updates that will be
presented during the
symposium. 7

Nobel Biocare Global Symposium

[6] =>

interview

Manufacturer matters when it comes to ceramic abutments
An interview with Prof. J. Robert Kelly
by Nobel Biocare

ments, with the NobelProcera product, we
ran out (no fractures at 25 million cycles),
so the load had to keep going higher and
higher.

n A new study conducted by leading materials scientist Prof. J. Robert Kelly has confirmed that not all dental implant restorations are created equal. In this interview,
Kelly discusses the research, which has very
recently been published in the International
Journal of Oral and Maxillofacial Implants.1
The findings make for positive reading for
NobelProcera customers.

How would you explain this apparent weakness of the other abutments?
The vast differences were unexpected,
as the macro-designs are similar across the
manufacturers. To help determine why we
were seeing such varied results, I asked my
colleague Dr. Isabelle Denry to do scanning
electron microscopy analyses. Looking at
one of the poorest performing abutments in
the study, she identified that the weakness
was the result of damage arising from the
manufacturing process—subsurface grinding
damage, large cracks, inhomogeneous crystals and a diffuse layer of porosity. From this,
it was evident that manufacturer matters.

Nobel Biocare News: Your latest research
tested the fatigue behavior of zirconia implant abutments from four major manufacturers. What led you to take this approach?
Prof. J. Robert Kelly: We wanted to study
commercial products not in order to make
commercial comparisons, but to study realistic products. Our goal was to look for processing problems and design issues, so it
made sense to see what would happen with
products on the market. We selected Straumann Bone Level (BL) Implants as our reference and the study received funding from
the ITI Foundation. Our search for comparison
third-party abutments for the BL implants
led us to abutments from NobelProcera and
Glidewell—for BL implants these two manufacturers only produce hybrid zirconia abutments that have a titanium insert interface
to the implant—and the available abutments
from Astra and Straumann that are fully
zirconia.

Science First
Strong NobelProcera®
Abutments
tested them with repeated loads of 200 N.
What was your methodology for testing
5

these products?
For the first phase, we first took six of
the abutments in each of the four groups and

Prof. J. Robert Kelly

We chose 200 N for the accelerated aging
based on our previous work. We did not
want to break the implants, so we thought

Zirconia abutments with titanium base
NobelProcera

1 million
cycles

that was a fair load to start with. The results
then allowed us to design the second phase,
by determining the loads that we would use
in testing with another 12 implants.
However, by the time we received the
data from the first phase, we were astounded. There were clearly significant differences between manufacturers in each of
the categories. This was subsequently verified in full-sample testing.

Considering that the NobelProcera abutment
for BL implants outperformed all of the others,
what are your thoughts?
NobelProcera is produced in a highquality process, since Nobel Biocare fabricates components that are designed, tested
and then verified for the BL implant system. 7

You found that the NobelProcera product
outperformed the other abutments in this
test significantly.
Yes, absolutely. While we had to reduce the load with some of the other abut-

Reference:
1. Kelly, J.R. & Rungruanganunt, P., “Fatigue behavior of
computer-aided design/computer-assisted manufacture
ceramic abutments as a function of design and ceramics
processing”, International Journal of Oral and Maxillofacial Implants, 31/3 (2016), 601–9.

1 sextillion cycles

Glidewell

Extrapolated cycles
for 10% failure at
70N (expected
clinical load)

There are many reports of issues caused
by third-party abutments being used with
a system that they were not designed for.
Considering that manufacturer matters, do
you advocate using only authentic components?
In general, I advise against using lower
cost third-party abutments. There is too
much to lose. From what we have seen over
the years, the quality of the materials is inferior, and the outcome has such a high
value: the patient has very high expectations of the clinician—why would you risk
that to save $100?

1014

107

1021

Full zirconia abutments
Straumann®
30 million
cycles

Atlantis™
20 million
cycles

“Manufacturer matters”: the four abutments look very similar in clinical examination,
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Nobel Biocare Global Symposium
Visit nobelbiocare.com/nobelprocera

Zirconia abutment D1.

[7] =>

science & research

Taking life at more than face value
The face can express who we are as well as what we mean to say
by Prof. Jill A. Helms, U.S.
 We come into this world primed to connect
with the faces around us. This ability is literally hardwired into our neural circuitry.
There is a specialized region in our brain, located in the temporal lobe in a region called
the fusiform gyrus, that is filled with neurons
that preferentially fire whenever a face
comes into view. Within minutes of birth, babies begin using this brain region; studies
demonstrate that even very young infants
show a strong preference for looking at faces
over all other objects.
The brain is responsible for coordinating
every single activity that keeps you alive;
and some terribly precious real estate in the
brain is allocated to a pint-sized structure
whose only apparent purpose is to become
activated in response to a face. Since evolution is constantly shaping the brain and
adapting its function to ensure our survival,
the fact that a brain region is dedicated to
this task indicates that facial recognition
must be essential for our survival.

But why?
One reason is that the face is the means
by which we communicate. Thirteen years
after On the Origin of Species was published,
Charles Darwin addressed this very question in The Expression of the Emotions in
Man and Animals. In this book, Darwin
wrote, “The welfare of mankind depends
on the expression and recognition of emotion.”
And if you do not believe Darwin, then
witness any adult with an infant. Of all the
motor skills that infants must master, none is
as important as mimicking the facial gestures of people around them. Even at a very
early age, humans devote a great deal of



The face is the means by which we communicate. Of all the motor skills that infants must master in the fi rst few years of life, none is as important as mimicking the facial
gestures of people around them.

and you will get a stick figure with a lollipop-sized head, complete with a face. The
face defines the entity.
Illustrators of children’s books exploit
this very characteristic: Everything of emotional importance to a child is illustrated
with a face. The sun has a face. The moon has
a face. Thomas the Tank Engine has a face. It
is a way to personalize the world.
© Eugene Sergeev/Shutterstock.com



Across all ethnic groups and epochs, the general hallmarks of beauty have been symmetry and a balance in
proportions.

attention and energy to teaching infants the
movements required for facial expression. In
fact, we know that children who are incapable of or uninterested in learning this task
are often later diagnosed with conditions
such as autism.
This focus on the face ultimately translates into our faces becoming central to our
sense of identity. One does not need to look
much further than children’s drawings to see
this. Ask a 5-year-old to draw a human being

Beauty, a sign of well-being
The face is not only important as a means
to communicate; it also serves to advertise
our health, youth and vitality. A face that
projects an image of great health indicates
a good choice for a mate.
Across all ethnic groups and epochs, the
general hallmarks of beauty have been symmetry and a balance in proportions. Surprisingly perhaps, people universally agree that
the most beautiful faces are actually those

that are the most average-looking. Experiments using composite images based on hundreds of women’s faces have demonstrated
that when people are confronted with the image of Ms. Average-Face World—regardless of
the viewers’ ethnic background—they uniformly agree that she is more beautiful than
the individual faces that make up the composite. In short, as a species, we find the average face to be the most beautiful.

Reverse side of the coin
Diseases and injuries can create asymmetries and imbalances in the proportions
of the face that can be fatal for social interaction.
Because the face is often the calling card
of a disease, people often intuitively shy
away from disfigured people. Looking different on the outside, of course, does not mean
that you are different on the inside. Nevertheless, there is no denying that a physical
transformation of our face powerfully affects
the way we view ourselves and the way others respond to us.
Although beauty is best defined by
the kindness, compassion, intelligence and
warmth of an individual, it is also expressed
as optimism and perseverance in the face of
adversity.
For those who have suffered a mishap or
a disease that leaves them looking different,
reconstructive surgery and/or prostheses
supported by osseointegrated implants can
be decisive for living a good life outside the
confines of the home. 

About the Author
A member of the
scientific committee for the 2016
Nobel Biocare Global
Symposium and a
professor in the Department of Surgery
at Stanford University, Dr. Jill A. Helms carries out research in the field of regenerative
medicine, collaborating with experts in bioengineering, materials science, physics and
the life sciences. In this article, she explains
why reconstructive craniofacial surgery can
be decisive for the well-being of a deformed
or injured patient.autaeratem nis estiunt
otatur?

More to explore!
To view Prof. Jill A. Helms’s TEDx Talk, titled
“Reconsidering beauty,” please visit bit.ly/
TED-helms.

Nobel Biocare Global Symposium

[8] =>

science & research

Why NobelProcera CAD/CAM bars?
For the sake of quality, function, esthetics and good business
by Michael Stuart, Nobel Biocare
n Certified dental technician Thomas Wade
is the owner of New Horizons Dental Laboratory on the outskirts of Denver, Colorado,
U.S. According to him, the quality and efficiency gains that result from outsourcing the
production of bars to NobelProcera is rewarding for everyone involved.



bars themselves and of the finished cases
both in his brochure and on his website.
“In the early days, I actually took the first
few bars I did around to key clients to show
them the accuracy and beauty of these bars
first hand,” he explained. “Today, I not only
show the bars, but also use screenshots
taken from the design, including the all-important 2-D cross-section to help highlight

NobelClinician facilitates teamwork
Especially in cases involving edentulous
or nearly edentulous arches, clinicians who
use NobelClinician treatment planning software become natural collaborators for a laboratory like New Horizons.

Thomas Wade makes a convincing argument that “a bar is best designed by a skilled technician with experience in intra-oral biomechanics.”

Wade has chosen NobelProcera technology as his exclusive provider of CAD/CAMmilled titanium bars for two main reasons:
“First of all,” explained Wade, “the NobelProcera software allows us to access and
provide a wide variety of solutions entailing
many different types and styles of bars, customization features, and attachments—all in
order to better address the patient’s individual needs.”
Secondly, it is Wade’s view that this technology puts design control in the proper hands.
“A bar is best designed by a skilled technician
with experience in intra-oral biomechanics,”
he stated simply. He went on to explain that,
since the bar is only one of several components in a successful restoration, the bar designer must fully understand how the bar
will support the other components, such as
denture teeth and the PMMA base, in order to
provide long-lasting function and esthetics.
Wade cited other reasons for using
NobelProcera CAD/CAM bars. Broad and
comprehensive technical support is high on
his list, as is the state-of-the-art design software that keeps him competitive as he works
at the technological cutting edge.
“Meticulous quality control by NobelProcera, especially as it relates to passivity of
fit and finish,” Wade added, “all but eliminates
remakes,” saving time, effort and money.

the purposeful and deliberate choices I have
made in the design process.”
Wade believes that the combination of
design screenshots and final product photographs create a powerful statement about
the quality of the engineering and biomechanics.
“Demonstrated quality serves as a strong
marketing tool,” he said. “Also, at a time
when most bar cases have been oversimplified to a one-size-fits-all treatment plan of full
wrap design, I have made my clients aware
that we can offer a multitude of design styles

Clear advantages
In order to convince clients to adopt this
technology, Wade uses photographs of the

8

to better, more effectively treat a patient’s
specific intra-oral needs.”



NobelProcera free form milled and Dolder bar.

Nobel Biocare Global Symposium

“Digital planning—which identifies any
obstacles, defines the parameters for any necessary bone augmentation or reduction, and
indicates strategic placement of the implants—
is the key to overall prosthetic success,” Wade
asserted. “What the implant surgeon does, or
does not do, on the day of surgery sets the
tone for the overall success of the case moving
forward, but make no mistake, even though
implant placement is a surgical procedure, it
is prosthetically driven.”
According to Wade, NobelClinician software makes it possible to bridge the gap be-

tween the surgeon and the restorative team,
and encourages collaboration and communication between the two.
“Success used to be measured simply by
the percentage of surviving, well-osseointegrated implants. Today, success needs to be
redefined to take good restorative planning
and strategic implant placement into account. To serve the patient well, we want to
be able to fabricate a prosthesis that will
work well, look good and prove durable.
Planning with NobelClinician is the best option available to achieve this.”
According to Wade, both the process and
end result are always superior—with improved predictability, repeatability, enjoyment and profitability—when working with
dentists who use NobelClinician. “It also prevents stress and heartache, and saves us all
time!” he emphasized.
Having NobelClinician software running
at his laboratory has become a major boon to
his business, by vastly increasing his stature
as a valued team member, according to
Wade.
“I do not plan cases for the clinicians, but
I do review a wide variety of restorative criteria, and verify that the plan will facilitate
the fabrication of a highly successful prosthesis.”
Even when the team is geographically
separated, “the ability to share a plan between the three corners of the ‘golden triangle’ (i.e. the surgeon, the restorative dentist
and the laboratory) offers unprecedented
opportunities for success.”
Using NobelClinician on the front end
and NobelProcera bar technology for the
final restoration on the back end makes for
a powerful combination.
Wade concluded: “In short, it is a beautiful thing!” 7

NOTE:
Thomas Wade will be lecturing two sessions twice today. His lecture, titled “The
All-on-4® treatment concept for an immediate temporary bridge,” will take place
at 8 a.m. and again at 11 a.m. In addition,
he will be presenting a lecture on the topic
“Fixed versus fixed-removable prostheses”
at 1 p.m. and 4 p.m.

[9] =>

science & research

The very definition of synergy
The whole is greater than the sum of its parts
by Dr. Stefan Holst, Germany

Parameters that influence
long-term performance

n Nobel Biocare does not develop individual
products but entire solutions that provide
fully functional, natural-looking, long-lasting
results. In order to ensure long-term clinical
performance, safety and cost-efficiency for
everyone involved in the treatment process,
each Nobel Biocare component has been designed to fit and function perfectly with its
related components. Together, they produce
a finely tuned system.

Computerized simulation tools, such as
finite element analysis, and biomechanical
testing in the laboratory have served to identify parameters that can impact the performance of an implant system. These parameters include joint compression (the force that
acts at the implant–abutment interface under loading conditions), preload (the tensile
force keeping the components together) and
the friction coefficient (which depends on
the surface materials that
are in contact with each
other).
Other significant parameters include the force
that the patient exerts on
the system by chewing
(masticatory force), as
well as the length of the
contact between the abutment and the implant, as
well as—when using a conical connection implant—
the angle of the abutment.
A small change in any
of these parameters—even
one not visible to the eye—
can lead to extreme load
and stress conditions that
result in system failure.

Precise fit for joint
stability



Precise fit ensures long-term performance. For conical connection implants,
joint compression (p) depends on a number of variables, such as preload (tensile
force, Fa), friction angle () and contact length (l). Small changes in any of these
parameters can lead to extreme load and stress conditions, which can cause
implants to fracture.

The interface between
the implant and abutment
is critical for joint stability. Manual adjustment of
a cast or the use of a substitute abutment can alter
the contact angle and contact length. Such an undefined contact situation



Dr. Stefan Holst, Vice President of Implant Systems and Research at Nobel Biocare: “Clinically relevant conclusions
can only be reached when a component is tested within the system of which it is a part.”

on the implant itself, but may also have an
impact on performance-relevant parameters.

Preload, the force that holds the
components together
Preload is defined as the tensile force created in the clinical screw as the result of
screw tightening. It is generated by the application of torque to the screw, although only
a fraction of the torque force is stored as preload, while a much larger percentage is spent
on overcoming friction.
To account for this major loss of torque,
and to ensure that the system
is sufficiently held together, the
screw has to be inserted at the recommended torque. Fully manual
screw insertion is likely to result
in lower torque and, consequently,
suboptimal preload.
Insufficient preload leads to increased relative motion between the
system components, and this can
contribute to screw loosening and/
or component failure. Conversely,
preload values that are too high can
result in component fracture.

When assessing any implantsupported restorative solution for
a patient, one has to keep in mind
that the entire system under consideration is only as strong as its
weakest link. The performance of
each specific component depends
not only on the quality and design
of the component itself but also
on its interface with the rest of the
restorative system. Consequently,
each component should not be evaluated on its own. Clinically relevant
conclusions can only be reached
when a component is tested withOptimized to the last detail
in the system it is a part of.
Nobel Biocare abutments are
Nobel Biocare therefore conducts
delivered with a dedicated clinical
testing and research on both indiscrew that has been optimized for
vidual components, such as imthe implant–abutment system it
plants, abutments and screws—and
is a part of. Depending on the
how they work together—as well as
abutment, connection type and
the entire system that they consti-  Mismatching components can have severe consequences. Imprecise fit leads to platform size, screws come with or
tute.
without a surface coating.
uncontrolled peak forces, which may result in implant fracture.
We at Nobel Biocare study sysThe absence or presence of the
tems from their initial design to long after
entails a degree of risk for the patient that is
coating and the coating
difficult to predict, much less manage.
type all affect the predelivery to the end-user, the patient. We deFurthermore, in vitro force application
load. For examvelop and scrutinize engineering and manuto an implant-supported prosthesis may
ple, with
facturing processes, and we carry out quality
additionally exacerbate such misfit. Conseassurance, clinical research and post-market
quently, using an abutment designed and
surveillance. Only with this approach can
engineered by Nobel Biocare to match the
we be certain that the system will funcimplant is crucial for system performance.
tion safely and reliably for many years to
It not only affects the fit of the restoration
come.

a diamond-like carbon coating, screws marketed under the TorqTite brand show higher
preload values compared with screws that have
a standard titanium surface. Nobel Biocare
provides an appropriate screw type for every
implant–abutment connection, ensuring a
tight and stable fit for long-term performance.

Avoid substitutes,
minimize patient risk
If substitute components are used, the
parameters governing system performance
are no longer controlled. Consider maximum
joint compression—which defines the load
that the implant collar can bear—as an example: A substitute may result in a force that is
higher than the allowed maximum, causing
the implant to fracture.
To prevent such catastrophic results, the
peak forces have to be distributed in a controlled way. This can only be achieved by using
high-quality, precision-manufactured components that have been designed and tested
both individually and as part of the system
for which they have been designed. 7

NOTE:
Dr. Stefan Holst will be giving a presentation
today as part of the main program session,
titled “Prosthetic concepts—Reaching optimal esthetic outcomes with CAD/CAM
solutions,” which will run from 1 to 5 p.m.

Nobel Biocare Global Symposium

[10] =>

science & research

Teamwork, for predictable outcomes
“Working as a team allows us to make the most of our individual strengths and expertise.”
by Nobel Biocare

nicians to give hope to many patients who
once had few or no encouraging options. Now
we can dramatically change the lives of these
patients for the better.
Agarwal: And because this treatment concept is more affordable for patients, a greater
number of patients become implant candidates. For us, the All-on-4 treatment concept
has virtually created a new market.

n Dr. Tarun Agarwal, a general dentist, and
Dr. Uday Reebye, an oral surgeon, advocate a
team approach to implant dentistry that entails a surgical specialist, an anesthesiologist,
a restorative dentist and a dental technician or
laboratory. The editors of Nobel Biocare News
recently asked these two doctors in the U.S. for
their insights about teamwork in general and
the All-on-4 treatment concept in particular.
How did you begin working together?
Dr. Tarun Agarwal: I first met Uday while
he was a medical student at the University of
North Carolina at Chapel Hill. Later, after he
had completed his oral surgery residency and
opened his practice here in North Carolina,
I began sending him the surgical cases that
I was not comfortable treating. Our professional relationship flourished when Uday encouraged me to collaborate on our surgical
cases. He was very open to sharing tips and
tricks, even allowing me to participate in the
surgery.
Dr. Uday Reebye: At the same time, Tarun
taught me about prosthetic and implant advancements that had a great impact on my
work.
Agarwal: It became quite clear that the
cases we did together were the cases that
turned out best and had the fewest complications. I think it was the strategic collaboration
and taking a holistic (surgical and restorative)
approach to the cases that made the difference.



Drs. Uday Reebye (left) and Tarun Agarwal agree that well-organized teamwork is beneficial for the patient and
clinician alike.

experience. Each member of the team is focused on his or her core competency, and this
leads to better results. I should also mention
that practice productivity has steadily increased. As our mutual caseload has grown,
so have referrals and our reputation within
the community. It is like a snowball gaining
size and momentum going downhill.
Would you say that you each bring different
qualities to the partnership?
Agarwal: Without question. Uday is a
dual-degree (M.D. and D.M.D.) board-certified

Dr. Uday Reebye (left): “As similar as we are, I think we have a completely different approach to problems. The dichotomy in the way we think, I believe, is what provides strength and success. Often, at the end of arguing about
the correct treatment plan, we end up with a beautiful hybrid that otherwise would never have been realized.”

For you, your dental practices and the patient, what are the main benefits of the team
approach?
Reebye: Implant dentistry is rapidly evolving and its complexities require solid prosthetic and surgical knowledge. Working as a team
allows us to make the most of our individual
strengths and expertise. Sharing knowledge
is essential for making advances in our field.
Often, the greatest changes I make to my surgeries are due to what Tarun has taught me on
the restorative side; and conversely, Tarun has
changed his treatment and prosthetic planning
since he became involved in surgeries.
Agarwal: What’s more, I now have the
confidence to treat complex cases that I would
never have even started in the past. The patients truly benefit from our teamwork approach in that they have a seamless treatment



oral-maxillofacial surgeon. His expertise and
knowledge of surgery are far ahead of mine.
I am an esthetically focused general dentist
who has tremendous experience in digital
dentistry. By each having an open mind, we
are able to blend the digital technologies of
restorative dentistry with the surgical world
of complex implant dentistry. Over time, we
have learned a great deal from each other and
now have a greater appreciation for the complexities and issues that the other deals with
in the treatment process.
Do you ever have a difference of opinion
when it comes to planning the treatment?
Agarwal: Of course we do! Sometimes we
have to negotiate on the surgical side and
sometimes we have to negotiate on the restorative side.

Nobel Biocare Global Symposium

Reebye: And it usually works out that
whoever wins the argument has thought
through the issue at hand a little longer and
harder.
Agarwal: I can give you an example. Uday
was hesitant to begin using computer-guided
implant surgery. Initially, it was slower than
the traditional technique he was used to, but
for me, it made the restorative component absolutely more predictable and quicker. After
our first case, he became aware that the extra
20–30 minutes of his time saved the patient
multiple visits on the restorative side.
Reebye: It was an easy trade-off to make.
At the end of the day, we resolve any differences of opinion guided by a single principle:
do what is in the best interests of the patient.
Is the All-on-4 treatment concept especially
appropriate for your team approach?
Reebye: Yes, in my opinion, the All-on-4
treatment concept can only be successful as
a team effort. It is a beautiful treatment concept that marries surgical and prosthetic
philosophies. I have to tell you that teamwork
brings a great deal of enjoyment to the clinic.
If you are happy when working, patients are
happier and assistants are happier, and somehow that combination results in great outcomes.
Agarwal: It really does! In our
team approach, the restorative
dentist creates the case blueprint,
the surgical specialist serves as
an engineer—by verifying the
blueprint is surgically feasible—
and the anesthesiologist is totally
focused on patient comfort. Starting with the endpoint in mind and
collaborating to make it possible
have routinely led to great outcomes.
What do you regard as the main
benefits of the All-on-4 treatment
concept, for both clinicians and
patients?
Reebye: We see many edentulous or about-to-be edentulous patients who need new teeth. Previous treatment modalities were so
expensive and difficult that these
patients left our clinics depressed,
with no hope in sight. The All-on-4
treatment concept allows us as cli-



What would you say to clinicians thinking
about starting with the All-on-4 treatment
concept?
Agarwal: Go learn about it with an open
mind! There are literally millions of patients
who can benefit from this treatment. Nobel
Biocare has a predictable workflow with a tremendous support system to make you successful.
Reebye: Before I took my first All-on-4
class, all I heard from many clinicians (none
of whom had taken a class or performed
All-on-4 surgery) was that the concept was
flawed and a recipe for disaster. Seven years
later, all I can say is that I am so happy we did
not listen to them. My advice? Keep an open
mind, take a course and see for yourselves
what a great service you can provide for your
patients.
For any clinicians considering adopting a
team approach like yours, is there a secret to
a successful partnership?
Agarwal: You have to let go of your ego.
We are all equals to the patient, after all, each
bringing a different area of expertise to the
team.
Reebye: Let me add this: Listen to your
patients. Be willing to talk to other clinicians,
to share ideas and never be afraid to reach out
when you need help. Most of us love to share
what we know with each other—to be of help
and to learn more at the same time. And finally, enjoy! It is a wonderful journey. 7
More to explore!
To learn more about the All-on-4 treatment
concept,please visit www.nobelbiocare.com/
all-on-4.

Dr. Tarun Agarwal (left): “Over time, we have pushed each other to take
a closer look at each other’s perspective.”

[11] =>

products

Introducing creos xenografts
Designed by nature, developed for clinicians
by Nobel Biocare
 Sufficient bone quantity and quality are
essential for successful dental implant treatment. For that reason, Nobel Biocare introduced creos regenerative solutions, an extensive array of options for guided bone
regeneration and guided tissue regeneration
procedures.
The latest addition to the creos range is
the creos xenogain bone substitute. Together
with the creos xenoprotect resorbable collagen membrane, it now offers clinicians a comprehensive set of xenogeneic options for a
wide variety of indications and preferences.

A foundation for implant treatment—
creos xenogain
The creos xenogain bone substitute has
been developed with clinical needs in mind.
It has been proven to be biocompatible,1–4 and
unique processing methods remove the bovine proteins and lipids.5, 6 The natural bone
matrix of creos xenogain is characterized by
micro- and interconnected macropore structures.5, 6 With a calcium phosphate ratio that
reflects the composition of human bone and
a low crystalline structure, creos xenogain is
accepted by the body as a suitable framework



Creos xenogain is available in a bowl ready for mixing, eliminating the need for an additional sterile dappen dish.

trimmed when dry for accurate placement at
the graft site.9

tages in terms of suture retention.10 As it is
highly resistant to degradation, creos xenoprotect offers prolonged protection of the
graft site, while its excellent vascularization
behavior and tissue compatibility support
fast healing.11
Each product in the creos range of xenogeneic solutions has been developed to optimize treatment results. This comprehensive selection offers biocompatibility, easy handling,
slow resorption rates and variety. Whichever
option the clinician chooses, he or she can be
confident of building a reliable foundation for
implant treatment success.1–11 
References:



The comprehensive creos xenogain portfolio features a range of creos xenogain xenogeneic bone substitutes and creos
xenoprotect, a resorbable collagen membrane.

for bone formation.6–8 Bone substitutes in the
creos xenogain range have a slow resorption
rate and act as a long-lasting scaffold, maintaining space for bone regeneration.2

Once hydrated, creos xenoprotect is
stronger than other non-cross-linked and
chemically cross-linked membranes.10 With
a higher pullout force, it also offers advan-

1. Park, H.N., Han, S.H., Kim, K.H., Lee, S.C., Park, Y.J.,
Lee, S.H., Kim, T.I., Seol, Y.J., Ku, Y., Rhyu, I.C., Han,
S.B. & Chung, C.P., “A study on the safety and efficacy
of bovine bone-derived bone graft material (OCS-B)”,
Journal of Korean Academy of Periodontology, 35/2
(2005), 335–43.
2. Park, J.B., Hwang, Y.J., Seol, Y.J., Lee, Y.M., Kim, T.I., Ku,
Y., Rhyu, I.C., Han, S.B., Lee, S.C., Park, Y.J., Rhee, S.H.
& Chung, C.P., “Maxillary sinus floor augmentation
using deproteinized bovine bone-derived bone graft
material (OCS-B): Clinical and histologic findings in
human”, Journal of the Korean Dental Association,
45/8 (2007), 491–9.
3. Shin, S.Y., Hwang, Y.J., Kim, J.H. & Seol, Y.J., “Long-term
results of new deproteinized bovine bone material in

a maxillary sinus graft procedure”, Journal of Periodontal and Implant Science, 44/5 (2014), 259–64.
4. Data on file for biocompatibility tests for OCS-B and
OCS-B collagen (NIBEC).
5. Data on file from NIBEC.
6. Data on file for material properties of creos xenogain/
biomaterials, TER 147668 (Nobel Biocare).
7. Kyriazis, V. & Tzaphlidou, M., “Skeletal calcium/phosphorus ratio measuring techniques and results. I.
Microscopy and microtomography”, Scientific World
Journal, 4 (2004), 1027–34.
8. Data on file for atomic emission spectrometry analysis
(NIBEC).
9. Arrighi, I., Wessing, B., Rieben, A. & De Haller, E.,
“Resorbable collagen membranes expansion in vitro”,
Journal of Dental Research, 93 (Special Issue B), Abstract 631, (2014).
10. Gasser, A., Wessing, B., Eummelen, L., Bühren,
A. & Leemhuis, H., “Mechanical stability of collagen
membranes: An in vitro study”, Journal of Dental
Research, 95 (Special Issue A), Abstract 1683, (2016).
11. Bozkurt, A., Apel, C., Sellhaus, B., van Neerven, S.,
Wessing, B., Hilgers, R.D. & Pallua, N., “Differences
in degradation behavior of two non-cross-linked collagen barrier membranes: An in vitro and in vivo
study”, Clinical Oral Implants Research, 25/12 (2014),
1403–11.

More to explore!
For more information about creos regenerative solutions, including articles and cases,
visit www.nobelbiocare.com/creos.

Easy to handle—creos xenogain
For quick and easy application of the
graft, creos xenogain is delivered sterile and
comes either in a vial or in a bowl ready for
mixing. There is also a choice of two granule
sizes and up to four volume options, offering
a wide variety of alternatives depending on
the clinical indication and preference.

The natural barrier—
creos xenoprotect
Once the bone substitute has been applied, the resorbable creos xenoprotect membrane can be used to hold it in place and act
as a barrier to soft-tissue ingrowth. Manufactured using highly purified collagen and elastin fibers, it possesses outstanding handling
properties that make it easy to reposition and
unfold. Hydrated in seconds, but with minimal size increase, creos xenoprotect can be



The creos xenoprotect membrane exhibits higher strength than other non-cross-linked and chemically cross-linked membranes once hydrated.

Nobel Biocare Global Symposium

[12] =>

products

KaVo MASTERsurg LUX Wireless surgical unit
Taking dental surgery to a whole new level
by KaVo Kerr Group

users, a clinician can customize up to ten programs, each with ten individually programmable steps.

n The KaVo MASTERsurg LUX Wireless was
designed to redefine surgical standards, offering all dentists and oral surgeons an ideal
surgical solution, no matter what their individual needs.
With an eye toward maximizing comfort,
the unit features wireless foot control, allowing the user great freedom of movement, and
a modern touchscreen with a non-reflecting
display to allow optimal viewing from all angles. Valuable for the comfort that comes
from peace of mind, the data documentation
function supports procedures with real-time

These outstanding features are the foundation for the quality and high performance
provided by the INTRA LUX S600 LED, one
of the world’s lightest surgical motors.

display of the torque and other important
digital data, saving it concurrently.
Another critical feature is the customizable programming to address individual

requirements. With simple and
intuitive settings for different bone densities,
implant systems and

Delivering on the promise of innovation
and quality KaVo users worldwide have
come to expect, the KaVo MASTERsurg LUX
Wireless is taking dental surgery to a whole
new level, providing a feature set that makes
a substantial difference in delivering maximum performance on a daily basis. 7

Treatment planning: Begin with the end in mind
The value of planning for final results before treatment initiation
by Dr. Gary Orentlicher, US
n I have frequently remarked that in the last
15 years there has not been a greater practice builder for me, as an oral and maxillofacial surgeon, than my involvement in guided
surgery. Using my i-CAT (Imaging Sciences
International), in combination with NobelClinician Software (Nobel Biocare), has made
me a better, more accurate dental implant
surgeon, and most importantly, has greatly
improved my patients’ case outcomes. It
has changed the way I practice daily in all
aspects of patient diagnosis, planning and
surgery.
i-CAT and NobelClinician allow for treatment planning and surgical predictability
with full 3-D and restorative outcomes in
mind. i-CAT’s high-resolution volumetric images provide complete views for a more thor-



ough analysis of bone volume and structure
and of tooth and implant orientation. This
means more precise evaluations, minimally
invasive procedures, more predictable treatment results, shorter appointment times and
happier patients.
In a presentation I made this spring,
I spoke about what I regard as the indications for guided surgery. They include
8 three or more implants in sequence
8 cases with anatomical and/or structural
issues
8 implant position critical to a planned restoration
8 problems related to proximity of adjacent
teeth
8 fully edentulous patient cases
8 immediate extraction and implant placement

Treatment planning software used for fully edentulous patients.

Nobel Biocare Global Symposium

8 significant alteration of bony anatomy (e.g., trauma, grafting, distraction and pathology)
8 medical problems (e.g., radiation
therapy, bleeding dyscrasias, and
orthopedic and psychological problems).
In each case, there are four primary
steps to a successful guided surgery
workflow:
8 Step 1: 3-D imaging with a scanning
prosthesis or optical scans
8 Step 2: 3-D treatment planning with
planning software
8 Step 3: Creation of a computergenerated guide, laboratory and surgery
 Dr. Gary Orentlicher
8 Step 4: Knowledge of the appropriate
implant-specific drilling instrumentation.
I have my CBCT scans converted into
DICOM data sets and imported into NobelIn my clinical exClinician for treatment planning. I have used
perience, the quality
most implant software on the market and
of the products one
I feel strongly that NobelClinician is the preuses makes a signifimier product.
cant difference in
the process and final
treatment result. I
For clinicians with an interest in using
look for quality, ease
the power of 3-D to create implant treatment
of use and support
plans, they will be making an investment in
that helps me practheir clinical skills and improving their patice with the greattients’ experiences and outcomes. This will
est amount of confilay the groundwork for increasing treatment
dence.
acceptance rates and implant practice
growth. 7
I use the i-CAT
cone beam 3-D unit,
which offers many
About the author
valuable features, including flexible imDr. Gary Orentlicher is Chief of Oral and
aging control. This
Maxillofacial Surgery at White Plains Hosallows me to custompital in White Plains, New York. He is a dipize my scans by minlomate of the American Board of Oral and
imizing the field of
Maxillofacial Surgery, a fellow of the Amerview and radiation
ican Association of Oral and Maxillofacial
dosage while maxiSurgeons, and a member of many regional
mizing resolution.
and national dental and oral and maxillofaWith i-CAT, I gain
cial surgery organizations. He is a partner
greater control over
in the New York Oral, Maxillofacial, and Immy workflow and the
plant Surgery private practice in Scarsdale,
entire scanning proNew York.
cess.

[13] =>

special feature

How to optimize the emergence profile
An interview with clinician Dr. Léon Pariente
by Michael Stuart, Nobel Biocare
n According to Dr. Léon Pariente, a leading
clinician based in Paris, France, the emergence profile matters. In this short interview
on the topic, he explains why efforts to optimize the emergence profile should begin
at the planning stage.
Nobel Biocare: Dr. Pariente, what are the
most important things to consider in working to establish an optimal emergence profile?
Dr. Léon Pariente: The emergence profile
should be considered holistically: It is the
portion of the prosthesis that allows the
implant to turn into a natural-looking tooth.
It is the border between the surgical and
prosthetic worlds.
An optimal emergence profile gives a
smooth transition from the circular implant
platform to the natural shape of the tooth at
the gingival level. It should be customized
for every restoration.
To be ideal, it should be considered
during the implant planning phase, particularly in selecting a suitable implant, both in
terms of connection type and platform diameter, as well as in determining the implant
positioning in all three dimensions. Clinical
factors to take into consideration are the
thickness of the gingiva in the area of implant placement, the size of the horizontal
cross-section of the future crown at the gingival level, and the position of the future
crown relative to the bone.
How does the choice of implant affect the
emergence profile?
Firstly, the discrepancy between the diameter of the platform of the implant and
the diameter of the cross-section of the future crown at the gingival level needs to be
compensated for by the abutment. The contour of the abutment from the platform to
the gingival level constitutes the emergence
profile. The angle between the platform of



Dr. Léon Pariente

nection, which can be placed under the
bone level, therefore allow more flexibility
when placing the implant. Smaller-platform
implants should be placed deeper, leaving more vertical room to compensate for
the discrepancy in diameter between the
horizontal cross-section of the future crown
at the gingival level and the platform itself.
Why is it worth investing time and effort in
optimizing the emergence profile?
An optimal emergence profile supports
the gingiva around the implant-retained
crown. This prevents the formation of proxi-

PEEK performance: In this case, Dr. Léon Pariente used a PEEK Healing Abutment to shape the soft tissue.

the implant and the wall of the abutment
should be as wide as possible to avoid creating a bacteria reservoir.
In addition, the connection type (external or internal) and the collar of the implant,
whether polished or not, have a direct influence on the depth to which an implant can
be placed to protect the surrounding bone
from physiological resorption while retaining the biological width. Internal connections such as Nobel Biocare’s conical con-

The main challenges that prevent a
clinician achieving an optimized emergence
profile are improper choice of implant
diameter or incorrect implant placement
depth.
Furthermore, in anterior cases, an ideal
gingival contour must be created with a provisional crown before taking the impression
for the final crown. The main challenge in
this case can be transferring the soft-tissue
contour to the cast accurately.

mal or buccolingual food traps and allows
the patient to maintain the required level of
hygiene around the implant. Furthermore,
it is a prerequisite for the formation of
pseudo-papillae in the interproximal spaces.
Poor emergence profile design can have consequences that can ultimately lead to the
loss of the implant.

Finally, what are the main misconceptions about establishing the emergence
profile?



More to explore!
In order to see an ideal
emergence profile in one
of Dr. Léon Pariente’s
case reports, scan the
following QR code:

abutments with a customized emergence
profile. The accessibility of the NobelProcera
solution should make customized abutments
the standard of care. 7

The lateral view after crown placement shows proper support of the soft tissue.

Because of the popularity of standard
abutments that are cheap and easy to use,
people often think that
it is very complicated
or expensive to
create

What are the main challenges in establishing an optimal emergence profile?

Nobel Biocare Global Symposium

[14] =>

special feature

Driving in the fast lane
He has made a place for himself on two different kinds of podiums
by Michael Stuart, Nobel Biocare
n Dr. Arturo Llobell likes a challenge. Right
from the start of his dental career, one specialty was not enough. He opted to become
both a periodontist and a prosthodontist, so
no two days would ever be the same. It paid
off. Today, Llobell enjoys a busy and varied
dental practice in Valencia, Spain.
Though just 28, Llobell’s first career was
not dentistry. To say his previous vocation
was also fast-paced would be an understatement. As a junior racing driver, Llobell was
among the best in the world, having been
twice named Spanish national champion and
finishing fifth in an international competition.
Many of Llobell’s former opponents became Formula One stars, and he previously
tested cars alongside Sebastian Vettel and
Lewis Hamilton, both of whom went on to become world champions.

Patient care comes first
Eventually there came a time when
Llobell had to choose between a career as a
clinician and pursuing the path to Formula One.
A bad crash, among other factors, led him to
opt for dentistry, and he has not looked back
since. Interestingly, he says, the two fields
are not as different as one might think.
“In both racing and dental surgery you
need a significant amount of preparation,”
Llobell explained. “Then, during the task at
hand, you need a high level of concentration



Both a periodontist and a prosthodontist, Dr. Arturo Llobell speaks on the advantages of implants from two different, yet related, perspectives.

and attention to detail. You also need to react
to changing variables if you are to succeed.”
Today, Llobell has swapped one podium
for another. He now speaks at implantology
events around the world and has recently
accepted faculty positions at the University
of Valencia in Spain and the University of
Pennsylvania in the U.S.

Dual specialties,
one implant provider
At the heart of Llobell’s progression are
the positive treatment outcomes he achieves
for his patients. A Nobel Biocare customer
since the start of his career, Llobell says the
company’s products have helped give him
the confidence to use increasingly progressive treatment protocols.
“I started working with Nobel Biocare
during my residency in both periodontics
and periodontal prostheses. I chose Nobel
Biocare because it is both an established and
leading implant company that offers products for both specialties,” he explained.
Llobell added: “A number of important
clinicians use their products on a daily basis,
and that gives me confidence in the brand.”

“Primary stability without
surprises”



A former champion racing car driver turned implantologist, Dr. Arturo Llobell has established himself as a
respected clinician in his native Spain and as a sought-after speaker at major dental events around the world.

Nobel Biocare Global Symposium

Llobell is particularly impressed with
the new NobelParallel Conical Connection
implant: “I find the NobelParallel Conical
Connection implant easy to use in multiple
clinical scenarios. It has a straightforward
drilling sequence, which makes it easy to
maintain the direction during insertion,
while also giving me the chance to achieve
primary stability without surprises.”—“Being
able to achieve adequate primary stability
permits me to opt for immediate loading protocols more often than before,” he added.

A leader of tomorrow
Llobell was named a member of the
Emerging Leaders program by the Foundation for Oral Rehabilitation (FOR), which he
says helped him develop as a speaker. “Being
part of FOR’s Emerging Leaders group was a
great experience for me as I had the chance
to get in touch with world-renowned clinicians who were more than happy to give me
—and the other young clinicians involved—
a hand in every aspect of clinical dentistry,
as well as lecturing advice.”
With its new Guide to Growth program,
Nobel Biocare is hoping to help more aspiring implantologists follow Llobell’s example.
Combining advanced clinical training with
practice management advice, this development program seeks to help ambitious clinicians fulfill their potential by growing their
implant practices.
Llobell is proof that with the appropriate
skills, partners and advice, the sky is the
limit. He is part of the lineup at the 2016
Nobel Biocare Global Symposium in New
York that reads like a who’s who of implant
dentistry. “To be sharing the podium with
some of Nobel Biocare’s top speakers is an
honor. I am really looking forward to it.” 7

More to explore!
More information about Llobell’s presentation,
titled “Emerging technology—Integrated
workflow improvements in everyday routine”, which he held yesterday at the Nobel
Biocare Global Symposium can be found at
www.nobelbiocare.com/global-symposium2016.

[15] =>

special feature

A nuanced perspective on periimplantitis
“We see bone remodeling and bone loss for very different reasons,” according to osseointegration pioneer
by Dr. Stefan Holst, Nobel Biocare
n According to some widespread, but crude,
definitions, periimplantitis can be characterized by a periimplant bone loss of as little as
1 mm in the first year after initial treatment.
Since some post-treatment bone loss is all but
inevitable during initial bone remodeling in
even the most successful and long-lasting
cases, such definitions lead, as a matter of
course, to controversy.
One of the most widely quoted scientists
in dental implantology, Prof. Tomas Albrektsson worries that periimplantitis is increasingly being used as an alarming label for
benign marginal bone loss around implants.
On a recent visit to Zurich, Switzerland, he
spoke with Dr. Stefan Holst, Nobel Biocare’s
Vice President of Implant Systems and Research, on this topic.



Dr. Stefan Holst: Periimplantitis is currently
a prominent topic of discussion at various
events and congresses. Is the nature of this
debate beneficial for the implantology community or could it be a threat to our reputation?

From the clinician’s standpoint, we
should take all types of marginal bone loss
seriously—even if the great majority of implants with some bone loss will never develop periimplantitis. The problem is that we
do not know which ones this applies to.



Prof. Tomas Albrektsson: “The frequency of periimplantitis has been grossly exaggerated in the literature. All bone loss that occurs in the first year is definitely not periimplantitis.”

“Implant systems that say they are similar to other documented implants and therefore need no documentation of
their own are not to be trusted.”

Prof. Tomas Albrektsson: If the biological reasoning is not sound, then it is always
a threat. When we look at the clinical outcomes in long-term studies, they are so much
better than many of those that we hear and
read about. I am very critical of this, since
it creates problems where there may not be
anything problematic. The frequency of periimplantitis has been grossly exaggerated in
the literature. All bone loss that occurs in the
first year is definitely not periimplantitis. We
see bone remodeling and bone loss for very
different reasons. This bone loss is benign in
that it does not threaten the implant.
Periimplantitis, with controlled implants
placed by properly trained individuals, is a
rare disease, but still one of some magnitude.
With 1–2 percent of modern controlled implants showing clear signs of disease at ten
years or more of follow-up, we cannot ignore
it, but we are not helped by the exaggeration
of the figures. There are 13 different definitions available for periimplantitis, and we
could do without the great majority of those.
How does a clinician determine whether
bone loss is a natural physiological reaction
or due to disease?

For example, one reason for problems
with bone loss is cement remnants in the soft
tissue. If this is removed in time, the bone
loss stops. The implant can then function
properly ever after without any problems.
However, there is also the possibility that if

the cement remnants are left in place for ten,
15 or 20 years, periimplantitis affecting the
same implant may follow.
A clinician should always take action
when he or she sees marginal bone loss or
rather the preface of it, which is called mucositis. Mucositis is only the first sign of an
immunological reaction; it has nothing to do
with anything other than immunology, but
this is unfortunately not understood by many
of our clinical colleagues.
Recent studies among the Swedish population imply that implant brand plays a role in
periimplantitis. Is this not misleading given
that so many factors influence treatment
outcomes?
Many of the figures that are being
quoted, be that in the recent Swedish publication or others, are lamentably unrealistic.
They have used the most liberal definitions
of what they call a disease when in reality it
is no such thing.
Our own studies of long-term follow-up of
implants demonstrate very clearly a similar,
small percentage of implants that are affected by periimplantitis. This is between
1 and 2 percent—whether one of the major
implant systems or another is used, it makes
no difference.
However, implant systems that say they
are similar to other documented implants
and therefore need no documentation of
their own are not to be trusted. Clinicians
need to choose an implant system that has

its own documentation published in peerreviewed papers. If that does not exist, do
not buy it. Buying a cheap implant that is
undocumented can prove to be very expensive.
Based on your clinical experience, what are
the factors that play a role in bone loss?
Treatment complications cause bone
loss. We call it the “triad of poor.” First is the
use of poor implant systems. As mentioned,
these exist and are sold at a cheap price.
Again, these implant systems should be
avoided.
Second is poor clinical handling by clinicians without the necessary skills. Third is
what we can term poor patients—those patients that are difficult to treat. These are the
causes of bone loss that in some instances,
although rare, may in the long term lead to
periimplantitis, but in most cases do not.
So what can we as dental implant professionals do to prevent the proliferation of
misinformation about periimplantitis?
I am increasingly irritated with people
calling benign bone loss a disease. Those who
are doing so have to read the new research
that is out and realize they are wrong.
The profession must unite to protest
against alarming reports in a much stronger
and united manner than we have done to
date. However, we must, of course, continue
to take patients very seriously. We cannot
ignore bone loss, even if it proves to be benign. We have to be active all the time and
work to the best of our knowledge for our
patients. 7
More to explore!
To read more about this and related topics,
such as findings about screw versus cement
retention, please visit nobelbiocare.com/news



Dr. Stefan Holst: “What can we do to prevent the proliferation of misinformation about periimplantitis?”
Prof. Tomas Albrektsson: “The profession must unite to protest against alarming reports in a much stronger and
united manner than we have done to date.”

Nobel Biocare Global Symposium

[16] =>

floor plan

16

Nobel Biocare Global Symposium

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[cover] => Corporate today Nobel Biocare Global Symposium June 24, 2016

[toc] => Array ( [0] => Array ( [title] => Innovation comes to life at the 2016 Nobel Biocare Global Symposium [page] => 01 ) [1] => Array ( [title] => From the President [page] => 02 ) [2] => Array ( [title] => Global Symposium attendees speak out [page] => 03 ) [3] => Array ( [title] => Interview: “This is the most comprehensive congress I have ever taken part in” [page] => 05 ) [4] => Array ( [title] => Interview: Manufacturer matters when it comes to ceramic abutments [page] => 06 ) [5] => Array ( [title] => Taking life at more than face value [page] => 07 ) [6] => Array ( [title] => Why NobelProcera CAD/CAM bars? [page] => 08 ) [7] => Array ( [title] => The very definition of synergy [page] => 09 ) [8] => Array ( [title] => Teamwork - for predictable outcomes [page] => 10 ) [9] => Array ( [title] => Products [page] => 11 ) [10] => Array ( [title] => How to optimize the emergence profile [page] => 13 ) [11] => Array ( [title] => Driving in the fast lane [page] => 14 ) [12] => Array ( [title] => A nuanced perspective on periimplantitis [page] => 15 ) [13] => Array ( [title] => Floor plans [page] => 16 ) ) [toc_html] =>

Table of contents

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