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The Titan of Titanium

by: Frederic Love

Science is what you know. Philosophy is what you don’t know. Per-Ingvar Brånemark remains interested in both. Nobel Biocare News brings you one of his rare interviews.

The Titan of Titanium

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.”

Brånemark, 'Unreasonable!'

When Per-Ingvar Brånemark received one of the many honorary doctorates awarded to him by universities around the world, British Professor Richard Johns of the University of Sheffield told the assembled dignitaries that he regarded Professor Brånemark as an “unreasonable man” and went on to quote George Bernard Shaw. “All progress depends on the unreasonable man. The reasonable man adapts himself to the world: The unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.”

Great movements begin with one man’s work

In 2009, osseointegration experts from all over the world gathered in Gothenburg, Sweden, to celebrate Professor Brånemark’s 80th birthday. Speaking to the assembled guests, Canadian Professor George Zarb pointed out that “like other scientists working on the frontiers of knowledge, Per-Ingvar used what at the time must have appeared to be uncertain techniques and materials, often with inadequately controlled conditions. He also encountered many obstacles and events that could have invalidated his data; but he persisted … and luckily for us - and above all, our patients - he triumphed.” Acknowledging the seminal nature of Brånemark’s applied research, Zarb also said, “He showed [us] that many of the world’s great movements begin with one person’s work, often a single tena- cious conviction.” Then he went on to encourage his listeners. “While few have the greatness and opportunity to bend history itself the way Brånemark did, all of us can work to change a small portion of events.”

An appetite for interdisciplinary cuisine

With tongue in cheek, Swedish Professor Tomas Albrektsson says that Professor Brånemark’s interdisciplinary commitment some- times expressed itself in the early days of his research in unexpected “exchanges.” “My first memory of my most inspiring teacher ever - Per-Ingvar Brånemark - dates back to the latter parts of the 1960s when some zoologists wanted to finally prove that eels actually migrated to and from the Sargasso Sea. Per-Ingvar invented a sort of titanium button to mark the eels, on the condition that he would be sent a number of fried specimens should the zoologists be able to later prove their point.” Brånemark apparently inspired loyalty as well as scientific dedication in his team of young researchers. Albrektsson confirms this when he adds: “I stayed with Per-Ingvar until I got my own chair in 1985, but I remain one of ‘his boys’ to this day. With a degree of fondness, he actually still calls us “his Swedes”, not referring to our common nationality but to a popular root vegetable at northern latitudes, the Swedish turnip or rutabaga!”

For further reading

“A System with its Roots in the 1950s,” by Frederic Love in Nobelpharma News, Vol. 1, No. 1, 1987. “Implanting Hope,” (text and video) on the website of the European Patent Office.

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.”