Dr. Per-Ingvar Brånemark: A pioneer in osseointegration and modern dental implants

Early life and education

Per-Ingvar Brånemark, born on May 3, 1929, in Karlshamn, Sweden, was a distinguished physician and anatomist. He earned his medical degree from the University of Lund in 1956 and completed his PhD in 1959. Born as Per Ingvar Persson, he initially published his early work under this name. Later, he adopted the surname 'Brånemark’, which translates to "one who breaks the ground." This name symbolized his groundbreaking achievements in medicine and science. Known as the father of modern dental implantology, Brånemark revolutionized dental implants and prosthetics through his pioneering research in osseointegration, transforming the quality of life for countless individuals.^[1], ^[2] ([Figure 1]).

The accidental discovery of osseointegration

Brånemark's PhD research focused on "Vital Microscopy of Bone Marrow," utilizing an optical device encased in a titanium mesh to examine blood flow in rabbit tibia bone. He observed that, over time the titanium had fused so securely with the bone that it could not be removed without fracturing. After consulting with a university linguist, Brånemark later coined the term "osseointegration" to describe the secure attachment of titanium to bone tissue. ^[3] He chose to investigate this occurrence independently, despite the fact that it was not the intended focus of the study. ^[4], ^[5] Per-Ingvar's extensively cited thesis on microcirculation in bone, fetched him a post of associate professor and ultimately, Professor at the Department of Anatomy in Gothenburg the following years. He established his own laboratory and engaged in collaborative research with others and continued his study on microcirculation in animals and eventually expanded the investigations to include humans. ^[6]

Challenges in proving osseointegration

Brånemark was convinced beyond doubt that his experimental titanium mesh had anchored in bone tissue in rabbits. ^[7] This ran counter to the ideas of the time, which held that metal could never be directly anchored to bone, as it will produce foreign body reaction leading to its rejection. ^[8], ^[9] Unfortunately, his attempts to prove his theory of bony union relied on low-power images or specimens that had been decalcified, necessitating the removal of the implant before bone could be sectioned. In the process of removing the implant, the interfacial soft tissues were also inevitably removed, causing others to doubt the bony anchorage. Later on, Donath's discovery of the cutting and grinding approach allowed for the examination of entire bone-to-metal interface.^[10] Brånemark's theories on integration between titanium and bone were confirmed at the light microscope resolution. Before the establishment of bony anchorage, he struggled to secure funding for his investigations.

In 1965, Brånemark implanted optical titanium chamber in the left upper arm of twenty staff volunteers working in his lab to conduct crucial microscopic investigations on human microcirculation and intravascular behavior of blood cells at high resolution. Fortunately, the titanium chambers showed no unfavorable inflammatory reactions and his experiment validated the suitability of titanium for use in the human body. Because he believed that the implants' bone anchorage would enable them to work successfully in a clinical context, he applied the notion of osseointegration to dental implants in the edentulous jaw without waiting for the resolution of academic disagreement. ^[11]

Development of modern dental implantology

In 1965, Brånemark placed the titanium dental implants in the first human patient, Gösta Larsson, who had severe jaw deformities, including cleft palate and edentulous lower arch. These implants remained functional for the rest of the patient’s life, demonstrating their long-term success. This marked a turning point in dentistry and Brånemark's pioneering work laid the foundation for modern dental implants, greatly enhancing patients' quality of life by offering a reliable solution for missing teeth. Following this, Brånemark’s journey continued relentlessly, with his vision captured in a poignant quote: "No one should die with their teeth sitting in a glass of water." This statement underscores his unwavering dedication to restoring dignity and improving the lives of those who had lost their teeth.

Overcoming skepticism in implantology

At this time, academic dentistry did not support the use of oral implants, and Swedish dental professionals heavily criticized his clinical practices. It was not until 1977 that the issue began to be solved, following a largely favorable clinical report by several Swedish academicians on the success of dental implants. ^[12] After significant effort and evidence, Brånemark obtained the financial backing necessary to advance his research, ultimately leading to the development of widely recognized and adopted osseointegration procedures. His journey serves as a testament to the importance of perseverance and resilience in scientific exploration.^[12]

Pioneering osseointegration research

Brånemark originally defined osseointegration as a direct structural and functional connection between ordered living bone and the surface of a load-carrying implant. ^[13] He later expanded on this concept, and stated that “osseointegration in theory and practice is defined as continuing structural and functional coexistence, possibly in a symbiotic manner, between differentiated, adequately remodeled, biologic tissues and strictly defined and controlled synthetic components, providing lasting, specific clinical functions without initiating rejection mechanisms”. His definition highlighted a continuing coexistence between the implant and surrounding tissues, emphasizing the importance of biocompatibility and the absence of immune rejection. Osseointegration was explained by Brånemark through three distinct stages. ^[5], ^[14]

Post healing phase

Vital bone tissue directly contacts the surface of the implant fixture, with no intervening connective tissue. The bone in the surrounding zone remodels in response to the masticatory forces applied during function. ([Figure 2]C)

In unsuccessful implants, nonmineralized connective tissue can develop in the border zone around the implant ([Figure 3] ). This outcome is often triggered by factors such as excessive trauma during preparation, infection, premature loading during the healing period before sufficient mineralization and organization of hard tissue, or excessive loading at any point, even years after initial integration. Branemark advocated delayed loading and cautioned against premature or excessive loading of the implant during the healing process. He recommended waiting until sufficient mineralization and organization of the bone tissue had occurred to avoid implant failure. While Brånemark initially focused on a delayed loading approach, he did not completely dismiss the idea of immediate loading. Over time, his research and clinical practices evolved, paving the way for immediate loading protocols in certain cases.

Collaboration and global impact

Recognizing the transformative potential of osseointegration, Brånemark shifted his focus to exploring other practical applications of this discovery. Bofors, now Nobel Biocare, played a pivotal role in globalizing his innovation by commercializing the Brånemark Implant System and its associated treatment protocol.

Other applications of osseointegration in dentistry

Expanding applications of osseointegration

Beyond dental applications, Brånemark's research extended to other medical fields. He explored osseointegration to anchor limb prosthetics directly to the skeleton, providing amputees with more stable and functional artificial limbs. This method called "osseointegrated prosthetics," has changed the lives of many people who used to have trouble with regular socket prosthetics. By connecting the prosthesis right to the bone, these new prosthetics are more stable, help people move better, and feel more natural.

Implant supported maxillofacial prosthesis

Since their introduction in 1977 for use with bone conduction hearing aids, percutaneous endosseous implants have remained an important constituent part of prosthetic rehabilitation of patients with maxillofacial abnormalities, especially when surgical reconstruction is not feasible. Prior to their advent, the only methods available for securing these prostheses involved the use of adhesives, anatomical undercuts in soft or hard tissues, or glasses. However, these methods have limitations, including issues with adhesives, such as discoloration of the prosthetic materials. Additionally, adhesives and solvents can lead to both mechanical and chemical irritation of the skin and mucosal surfaces. Endosseous implants provide an excellent solution to these challenges, offering superior stability to the craniofacial prosthesis and eliminating the need for adhesives. Additionally, they enhance the aesthetic profile by allowing for precise prosthetic margins, leading to improved patient acceptance and satisfaction. ^[12]

Legacy and honors

Dr. Brånemark, widely regarded as the father of dental implantology, has received extensive recognition for his contributions, earning numerous awards and honors, including more than 29 honorary doctorates from universities worldwide. He received prestigious awards such as the Swedish Medical Association's Söderberg Prize in 1992 and the European Inventor Award by the European Patent Office. His legacy continues through the institutions and organizations he founded, including the Brånemark Osseointegration Center (BOC) in Gothenburg, Sweden, a leading center for research and training. In 2012, he was awarded the lifetime achievement award by the Greater New York Academy of Prosthodontics (GNYAP). He was also honored with honorary membership to the American Dental Association (ADA), one of the few non-dentists to receive this recognition. ^[1]

Impact on patient care

The practical outputs of Brånemark's work include so much. Dental implants as an outcome of his discovery of osseointegration have become, through millions of procedures annually, today the gold standard for tooth replacement. These implants have several virtues above traditional dentures or bridges, which include aesthetics and function and patient comfort. As stated, dental implant patients can have better oral health and the ability to function while eating and speaking without causing any discomfort. ^[7]

Osseointegrated prosthetics are full of promise for amputees with higher mobility and much comfort over conventionally fitted prosthetics. This growth has been rewarding for military veterans as well as others who have suffered through traumatic loss of limb[s]. ^[8]

Research and future directions

The field of osseointegration continues to evolve, with ongoing research aimed at improving implant materials, techniques, and outcomes. Advances in biomaterials, surface treatments, and imaging technologies hold promise for further enhancing implant integration and longevity. Brånemark's initial discoveries have paved the way for interdisciplinary collaborations, pushing the boundaries of reconstructive surgery and rehabilitation. ^[9], ^[10]

Personal reflections and humanitarian efforts

Beyond his scientific achievements, Brånemark was known for his compassionate approach to patient care. He believed in listening to patients and understanding their needs and experiences, driving his desire to improve their quality of life through innovative medical solutions. His humanitarian efforts extended beyond his clinical practice, as he was committed to providing dental and orthopedic care to underserved populations worldwide. His work has had a lasting impact on the field of medicine and the lives of countless individuals, underscoring the importance of using scientific advancements for the betterment of society.