Dr. Ferro and Dr. Albrektsson

“We can of course do experimental studies…but nothing can replace a proper clinical study and clinical documentation”

In conversation with Prof. Tomas Albrektsson and Dr. Ana Ferro on the research, rationale, and clinical experience behind TiUltra™ and Xeal™ surfaces.

Having begun working on dental implants with Per-Ingvar Brånemark in 1967, Prof. Tomas Albrektsson remains to this day one of the most experienced and respected voices in the dental implant world. As Director of Oral Surgery at the esteemed MALO CLINIC, and participating in several completed or ongoing clinical studies, Dr. Ana Ferro is ideally positioned to provide an informed opinion on implant innovation.

At an exclusive Nobel Biocare Scientific Key Expert meeting in Brunnen, Switzerland, they discuss the science and ongoing research of the Xeal and TiUltra surfaces that build upon Nobel Biocare’s history of anodization excellence to deliver tissue integration at every level.


Why a new surface?

The discussion begins on the fact that implantology has traditionally focused on areas like bone integration, surface roughness and bone behavior, with less attention paid to soft tissue healing and long-term maintenance.

“For us at Nobel Biocare, it was fundamentally important to take the learnings we have had over 20 years with our surface TiUnite® and see what we can improve in order to not only sustain an immediate integration of our implant restorations, but also make sure that the longevity of our restorations is maintained,” said Prof. Stefan Holst, adding that this was the deciding factor in bringing the Mucointegration™ era into being.

What makes these surfaces different?

Prof. Albrektsson explained that, while TiUltra and TiUnite are both anodized surfaces, TiUltra’s design is quite different owing to its differing roughness levels in the coronal and apical regions. In his view, the reduced coronal roughness “makes a more forgiving construction for many clinicians.”

“The reduced coronal roughness makes a more forgiving construction for many clinicians.” Prof Albrektsson, Sweden

The golden hue of TiUltra and Xeal is another important benefit of these surfaces, Prof. Albrektsson said. “If you have patients with a thin biotype, for instance, where the implant can sometimes shine through the tissues, then the golden hue gives it a much more esthetic appearance than what you would have with an ordinary grey implant,” he added.

The value of a new abutment surface

As a profession, dentistry has continued to this day to use smooth abutments similar to those introduced by Per-Ingvar Brånemark in the 1960s. Xeal’s anodized nature, among its other characteristics, has already led to some promising scientific results using a split mouth study design1, Prof. Albrektsson noted.

“It was demonstrated that there was a significantly higher keratinized mucosa around the novel type of abutment,” he said, describing these results as “very promising”.

The clinical importance of Mucointegration™

Dr. Ferro went through the one-year results of a prospective clinical study she, together with the MALO CLINIC’s Dr. Miguel de Araújo Nobre, is conducting on Xeal and TiUltra for the All-on-4® treatment concept.2 She noted that not only was there a 100% implant survival rate among the pilot study’s participants, but that marginal bone loss after one year was an average of just 0.46 mm without any biological complications recorded.

“The clinical feeling that we had was that there is a very nice seal between the abutment and the soft tissue,” she said, adding that “the difference in the surface of the abutment really plays a role.”

“This is a huge breakthrough, in my opinion, on the abutment level.”

Prof. Holst asked Dr. Ferro if she thought the fact that Xeal abutments are placed at the time of surgery contributed to the excellent clinical outcomes she has thus far witnessed in her research.

Her answer? “I’m sure of it.”

“When we evaluate our implants, we evaluate through several parameters: probing the implant, bleeding on probing, the accumulation of bacteria and plaque,” Dr. Ferro said. In the pilot study, patients with a similar level of plaque accumulation displayed less bleeding on probing, fewer periodontal pockets and excellent bone response.

Long-term hygiene maintenance is essential

To ensure the longevity of an implant, regular cleaning and good hygiene are necessary. This is particularly true for edentulous patients like those that Dr. Ferro works with at the MALO Clinic.

“One of our biggest goals is not just immediate success but long-term success,” she said. In practice, this means that the implants should be functional and without biological complications, and that any opportunity to even slightly improve an implant’s clinical outcomes should be seized.

How can you integrate Xeal and TiUltra into your everyday routine?

For Dr. Ferro, the integration of these new surfaces was “very easy” and did not involve any protocol change. Her drilling protocol in soft, medium, and hard bone stayed the same, as did the goal of achieving a high level of primary stability.

This ease of integration is down to Nobel Biocare’s historical emphasis on development supported by extensive research, Prof. Albrektsson said. To demonstrate this, he pointed towards a previous analysis he had conducted of all existing five-year implant studies which found that a staggering 74% of these studies utilized Nobel Biocare machine implants, while 11% focused on TiUnite.

“This is enormously important because we can, of course, do experimental studies and in vitro investigations in some cases, but nothing can replace a proper clinical study,” he said.

Prof. Albrektsson concluded by stating that he was looking forward to seeing the TiUltra surface replace TiUnite as the second-most documented implant surface in the future.


1. Hall J, Neilands J, Davies JR, et al. A randomized, controlled, clinical study on a new titanium oxide abutment surface for improved healing and soft tissue health. Clin Implant Dent Relat Res 2019;21(Suppl 1):55-68.

2. Ferro A, De Araújo Nobre M. All-on-4 concept using TiUltra surface implants and Multi-unit Xeal abutments: Pilot study report. Clin Oral Implant Research 2021; 32(S22):59.