CATEGORY 76 AUSTRALASIAN DENTIST characterising the range of roughness and surface character optimal for osseointegration. Major advances in laser confocal microscopy now have the ability to quantitatively characterise all aspects of an implant surface. Treatment protocols themselves have been introduced to enable immediate loading and provisionalisation of implant supported full arch bridges. It is fitting that one of thefirst techniques describedwas the Brånemark Novum solution utilising only three implants to support a full arch bridge. This method used a series of jigs and guides to prepare the bone site for standardised components. Other techniques utilising LINICAL Figure 4. The global reach of Osseointegration c. 1985 Figure 6. Super hydrophilic implant surface exhibiting low contact angle (Neoss Ltd; Harrogate UK) Figure 5. Laser confocal profile of an implant cross section One of the first was Professor George Zarb in Toronto who undertook parallel studies validating the treatment protocol. The Toronto conference in May 1982 was probably the ‘Tipping Point’ when Osseointegration became internationally recognised. A number of innovative clinicians visited Brånemark to study his methods. These included Dr Kenji Higuchi from Spokane, Dr Yataro Komiyama from Japan and more locally Dr Patrick Henry from Perth. Patrick made a commitment to bring this treatment to Australia and his team carried out a number of parallel studies to further validate the protocol. It is believed that Patrick joked “Our big advantage is that we are a long way from everyone”. A key area for Brånemark in the development and introduction of his protocol was Training and Education. He and his colleagues believed very strongly that clinical success only followed a clear knowledge and understanding of the principles involved as well their application. Barbro Svensson was one of the first such educators and went onto to make a substantive contribution to the field. Here in Australia Patrick Henry too was concerned that training standards were maintained andmet future needs. In a number of articles Dr Henry has expressed concerns that education in dental implantology has fallen outside the remit of undergraduate education and future clinicians will not be appropriately trained and educated. Brånemarks protocol was conservative. It was designed to achieve the optimal and most successful outcome for dental implant placement. In recent years there has been much research and many studies seeking to ‘stretch’ the protocol with early and immediate implant placement and loading; shortening healing times and accelerating osseointegration. The largest area of research and development in accelerating osseointegration probably lies in implant surface topography and chemistry. Ann Wenneburg and Tomas Albrektsson led the founding working in this area It has been demonstrated that altered surface, roughened implants can accelerate bone formation by the establishment of contact osteogenesis. In addition changes in surface chemistry can accelerate the rate of early healing and potentially bone formation. Surface hydrophilicity is now being used by a number of implant systems in different ways to enhance wettability, blood flow and protein attachment with some success. Coatings can be visualised on implant surfaces. four implants, immediately placed and loaded, have also been described with emphasis on angling the distal implants to extend the cantilever length, minimise the number of implants and avoid the sinus and inferior dental nerve. Although, these techniques have become popular assurance of their longevity and success is essential. Dental implant systems commonly comprise a catalogue of fixtures, abutments, instruments and prosthetic components to facilitate a full range of solutions. Manufacturers have been keen to introduce new articles regularly to be seen to be active in research and development. Professor Brånemark had a clear view on this ever ballooning number of components “Dental implantology is like a fashion show. Soon there will be a Spring, Summer and Autumn collection”. There are always new products and reworks of old ideas. some products not remaining on the market long enough to be clinically tested. So, it is reassuring that there are a few implant systems that have successfully remained unchanged for over 20 years demonstrating long term clinical success (Neoss Ltd; Harrogate, UK). P-I could never have predicted the impact of modern technology in the field of dentistry, particularly in the area of CADCAM. It is satisfying to note that some of the earliest research and development in this area was undertaken by Nobel Pharma and Procera with excellent engineering input from a UK company, Renishaw. Clinicians are now making wide use of digital technology to capture 3D imaging and radiographic data combining it to enable planning of implant placement and prosthesis construction. Materials used in provisional and permanent restorations now incorporate printing, milling and laser sintering technologies at high levels of accuracy. The profession seems as keen to adopt these technologies as industry does to promote them. However, longevity and success remain the key and with our patients living longer lives they are expecting their prostheses to continue to function successfully throughout their lifetime. Training and education seems to sit in the background but remains as essential a part of successful treatment protocols today as it was when Brånemark and Henry first introduced modern implantology in 1980. Professor P-I Brånemark has given the world a Legacy of Osseointegration which can be defined as ‘what is passed on’. But he has contributed more than that; he has established a Provenance that adds ‘the Authority of Authenticity’ which makes his work invaluable. In modern terms we could say that P-I set the benchmark. As clinicians we would all do well to remember it. u
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