)

Fundamentals and history of implant dentistry

Tamal Kanti Pal
Department of Periodontics, Guru Nanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India

ABSTRACT
The practice of implant dentistry was not there a few decades ago It has its long historical retrospectives.
The quest for rehabilitation of edentulous ridge has intrigued mankind since ancient times. The period from
the time of Egyptian and Mayan civilizations to 1930s was unique when clinicians attempted to replace a Access this article online
missing tooth utilizing various materials. The spark of inquiry began from mid-1930s with the advent of an Website: www.jicdro.org
alloy named “vitallium;” attempts have been made to utilize this new material as an implant. Thereafter, in DOI: ***
early 1950s, a good deal of fundamental and clinical research started taking place. These research data Quick Response Code:
had given a boost to the tremendous growth of the practice of using dental implants made of vitallium that
practically exploded to reach every general practitioner’s clinic across the globe. Critical understanding of
bone physiology, drilling protocol, implant design and surface texture, initial implant stability, single-stage
implant surgery, and immediate loading of implants are the few factors based on which modern implant
practice has become a predictable treatment modality for the replacement of missing teeth.

Key words: Fibrous encapsulation, HA-coating, immediate loading, osseointegration

INTRODUCTION and practically dominated the world of implantology in both

dental and medical fields for decades. The earlier popular
Loss of teeth leads to many edentulous situations. form or design of the dental implant was flat or blade-like.
This creates many problems like loss of aesthetic look, Blade form design was introduced to utilize the narrow
deterioration of chewing efficiency, and problem of speech. alveolar ridge which was undergoing resorption as this narrow
All these three problems lead to handicapping situations. ridge does not support the placement of root form implant.
As a result, replacement of lost teeth becomes a necessity. From 1960s till the early parts of 1980s the popularity of
Attempts have been made since the time of Egyptians and these dental implants reached its zenith. The significant and
Mayan civilizations to reproduce a tooth-like object that can major contribution during this period was from a German
be inserted into the jaw bone.[1] Newer innovations have led dentist Leonard I. Linkow who earned fame for his unilateral
to biologically compatible materials. subperiosteal implants to start with and subsequently, for his
HISTORICAL PERSPECTIVES invention of blade-vent implants in 1967.[3]

The dental implantology can be traced back to earlier

RECOGNITION OF IMPLANT DENTISTRY
civilizations [Table 1]. [2,3] It can, thus, be divided into The research data on dental implants were practically
seven eras [Table 2]. The year 1937 - a remarkable period nonexistent in 1972.[2-6] The American Dental Association
known as the “dawn of the modern era” - can be credited
to Venable et al.[4] for his role in the invention of an alloy This is an open access article distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
material named vitallium, a mixture of cobalt, chromium, License, which allows others to remix, tweak, and build upon the
and molybdenum. Thereafter, in 1939, Strock[5] did animal work non-commercially, as long as the author is credited and the
experimentations using this unique metal alloy and confirmed new creations are licensed under the identical terms.
its biocompatibility. This was a wonderful material of choice For reprints contact: [email protected]

Address for correspondence: Cite this article as: Citation will be included before issue gets online***
Dr. T.K. Pal, Principal, Professor and Head, Department of Periodontics,
Guru Nanak Institute of Dental Sciences and Research, 157/F, Nilgunj
Road, Panihati, Sodpur, Kolkata - 700 114, West Bengal, India.
E-mail: [email protected]

S6 © 2015 Journal of the International Clinical Dental Research Organization | Published by Wolters Kluwer - Medknow
 Pal: History and fundamentals of implantology

(ADA) took a cautious attitude toward dental implants and accepted the endosseous dental implants based on some
entitled Natellia et al.[7] to look into the matter in regard to selected criteria and cautions. In 1986, only one endosseous
the feasibility of dental implants for clinical use. The report implant, the Biotes (Nobelpharama, Gothenburg, Sweden),
stated that “there is an obvious limited acceptance of dental was accepted by the ADA.[8] Even up to this period, the ADA
implants by the profession and this is a point of international believed that there was a need for continued scientific review
concern.” They further wrote “dental implantology has and recommended restricted use of them for routine clinical
progressed in the past 20 years and has, in many respects, use. In 1988-1989, three more implant systems received
reached a plateau. The scope of dental implantology will be provisional approval by the Council on Dental Materials and
clear only when systematic experimentations and further Devices; these are IMZ-Interpore Osseintegrated implant
system (Interpore International, Skypark Circle, Irvine,
reporting define some current conceptions.”
CA92714). Oratronics Blade Implant system (Oratronics Inc
In 1974, the ADA recommended[3,4] that “dental endosseous Corporation, 405 Lexington Avenue, New York, NY 10174).
implants be considered as being in the new technique phase Core Vent Implant System (Core Vent Corporation, 14821
and in need of continuing scientific inquiry…endosseous Ventura Boulevard, Encio, CA 91436).
dental implants not be recommended at this time for routine
At this point of time, second National Institute of Health
clinical use.” However, in early part of 1980s, the Council
(NIH) Implant Consensus Conference was held in Bethesda
on Dental Materials and Device of the ADA provisionally (1988). [9] From then, Food and Drug Administration
exercised its control by employing extensive, rigorous, and
Table 1: History of implantology at the time of Mayan
sophisticated animal and human tests of dental implant
civilization[2]
devices prior to marketing.
Investigators Place Period Implant like substances
Popenoe, an Playa-de-los Muertos 600 Artificial tooth carved The transatlantic wave of interest in implant dentistry reached
archaeologist in the Ulna river A.D. from a dark stone—
(1931) valley of Honduras in mandibular left lateral many rich countries throughout the world. Among Asian
middle America incisors countries, Japan, Hong Kong, and South Korea were the early
800 Three tooth-shaped
A.D. pieces of shell—missing
initiators in this regard. Among the developing countries, India
lower incisors— was no way less than Indonesia in the practice of using tooth
alloplastic biomaterials implant. Lot of activities took place in India and Japan on the
platforms of dental societies as well as societies concerning
biomedical engineering, biomaterials, and artificial organs
Table 2: History of Implantology - based on eras [Table 3a and b].
Periods Time
A.D 1000 The ancient year IN QUEST OF AN IDEAL IMPLANT SUBSTRATE
1000-1800 The medieval period
1801-1910 The foundational period For a successful implant therapy, the implant substrate
1911-1935 The premodern era material needs to be biologically acceptable by the body.
1936-1978 The dawn of modern era (Pre-Branemark era)
1978-1998 The scientific basis of implantology (The Neither should it cause any deleterious effects on the
Branemark era) body nor should the body elicit any kind of immunological
1998-present era Post-Branemark era — immediate loading
resistance against it. The search for the ideal material was

Table 3A: Emerging era of Implantology in India (1988-1993)[5-22]

Time period Area Scientists Conference
December 25th Mumbai Dr. F. D. Mirza. Dr. Halina Kay from Chicago, USA, Conference on Implantology
and 26th, 1988, and Dr. Fani Rousmelioti Margariti of Athens, Greece
December 27th, Pune Dental Association Oration Lecture was instituted “Synthografts and Oral Implantology”
1988 (courtesy of M/S Colgate Palmolive (I) Ltd.) in its
Annual conference at the oration lecture
On December Goa, 17th Indian Prosthodontic Society Conference 1-day preconference course on dental implants
1989
September 15th, Dr. F.D. Mirza Bombay Society of Oral Implantology founded
1989 Renamed as Indian Society of Oral Implantology
1991 Mumbai Dr. Pankaj Narkhere Indian Academy of Implant Dentistry, an Indian
Chapter of American Academy Implant Dentistry,
was formed
January 1993 Kolkata, Jadavpur Dr. T.K. Pal - HA-coated dental implant 6th National Conference on Biomaterials and
University Artificial Organ

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 Pal: History and fundamentals of implantology

on ever since we came to know that leaching of element, ground sections. Branemark[11] et al. in 1985 coined a new term
be it in a single metal or in an alloy, takes place in our body. “osseointegration” for this unique interface and defined as “a
It was first noticed with stainless steel and subsequently direct structural and functional connection between ordered,
with vitallium (cobalt-chromium-molybdenum) so rapidly living bone and the surface of a load carrying implant” [Figure 1].
in medical orthopedic fields that material scientists in
collaboration with biologists started searching for some Since then, titanium and its various alloys have been in use in
suitable materials that can satisfy the need of an implant the dental implant industry. It has got a strong affinity to react
clinician. A lot of laboratory research and animal tests were with oxygen and form an oxide layer (TiO, TiO2, TiO3) over the
done in search a novel implant substrate. surface within milliseconds. This oxide layer, a kind of ceramic
in nature, covers the metal and restrict its interactions
In 1951, Leventhal[10] did a unique experiment with titanium with peripheral surroundings; it nevertheless protects the
screws on rat femoral model. After inserting the titanium screws subjacent metal body in many ways from corrosion due to
he went on sacrificing the rats at 6, 12, 16 weeks and found that external reasons. This has given an extraordinarily unique
with the passage of time the screws became increasingly tight. characteristic of titanium in terms of its extensive clinical
At one specimen of 16 weeks, the screws were so tight that use. Many other materials that are known to be biologically
the femur was fractured while making an attempt to remove inert were also tested. Among them, ceramics and carbon are
the screw. This study showed that the titanium can be used in worth mentioning. Many workers have used these materials
bone surgery for the need of joining the fractured ends. He as implant substrates but because of physical, mechanical,
had not performed any experiment on jaw bone of any animal chemical, electrical differences these materials could not
showcasing the future prospective of his research work could be be permanently considered as an implant material. Above
applicable as dental implant. A decade later, Swedish anatomist all inertness, thermal conductivity, modulus of elasticity,
Prof. P. I. Branemark found that titanium is an ideal metal for brittleness, and surface reactions to bond with bone are few
making dental implant as it adheres to bones. notable differences. High-density polymers were also tried
but their relative low strength and high ductility did not allow
OSSEOINTEGRATION them to be considered as an implant material.
1952 onwards, Prof P. I. Branemark[12] and his coworkers, at IMPLANT SURFACE
Goteborg, Sweden, were doing research on vital microcirculation
of blood in mammalian hard tissues especially on fibular model Branemark worked with smooth polished surface and
of rabbit. They also started experiments with commercially showed how beautifully implant-bone interface can be
pure titanium (cp Titanium) fixtures in root form in early
1960s. They made titanium screws and implanted them in
dog’s jaw bone and allowed to heal for a prolonged period
of time under gingiva. Interestingly, it was observed that all
the titanium screws older than 16 weeks were fastened to
the dog jaw bones to the extent that the dogs weighing 20-
25 kg were demonstrated to be suspended through tying a
single implant with a metallic wire. It was so fascinating and
convincing that the world of implantology took its right turn
leaving aside the case reports on personal experiences or
clinical observations only. The work of Branemark et al.[12,13]
was published in 1969. They scientifically proved that it was
possible to establish a direct bone-to-titanium contact at optical
microscopic level. Schroeder et al.[14] in 1976 (English version in
1981) confirmed also this nature of interface on undecalcified Figure 1: scanning electron microscopic view of the implant-bone interface

Table 3B: International Scenario in Asia[23,24]

Time period Area Scientists Conference
February 10-12, 1990 Tokyo Dr. A. K. Das (Prosthodontist) - Indore 1st International Conference on Oral Implant for
Dentistry - Japan Clinical Dental Implant Association
May, 1993. This was Dr. D. Y. Patil Dr. T. K. Pal (Periodontist)—Bone Interface 1st International Conference on Oral Implantology
truly the first ever global Dental College Dr. Amit K. Ray (Prosthodontist)—Use of
conference held in India. in Navi Mumbai titanium on maxillofacio-cranial prostheses

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 Pal: History and fundamentals of implantology

made if proper surgical protocol is followed. The interface seams, firmer implant bone attachment, reduced healing
that he termed “osseointegration” has been challenged by time, and increased tolerance of surgical inaccuracies and
some other workers in the Netherlands. Researchers have inhibition of metal ion release.[17,18] Later, Pal and Pal (1993,
raised questions about the status of osseointegration as 1995)[25,26] had given clinical trial of HA-coated cp titanium
an ideal titanium–bone interface. The union referred to as dental implants to many edentulous patients spanning from
osseointegration between the bone and the implant is a kind 1992 to 1996, and the clinical report of 25 years of HA-
of a tight junction that is not a chemically bonded one. The
coated titanium implant survival is awaiting. However, there
best interface, perhaps, would be when two bone ends join
each other. Experimentally, the same can be seen in case the
bone is subjected to physical trauma (osteotomy induced)
and the healing takes place uneventful [Figure 2]. Employing
various modern techniques, it was revealed that there exist
up to 100 Å noncellular and noncollagenous proteins like
fibronectin, laminin, and osteonectin at osseointegrated
interface.[14,15] The presence of these substances should not
be regarded as ideal union with implant to its neighboring
Figure 2: scanning electron photomicrographs of (a) 12 weeks subperiosteal
bone. Meanwhile the unique biocompatibility and bonding
osteotomy wound surface of a rabbit femur showing joining of a new bone with
characteristics of calcium hydroxyapatite (HA) to bone were the wound margin (arrow). (b) note the formation of new trabeculae (double
revealed by many researchers[16,17] and there have been many arrows) 2 mm below the cortical surface

reports documenting the ability of HA-coating of implant

to bond with bone.[18,19] This bonding possesses a chemical
fixation between the implant and the bone; the new bone is
deposited directly onto the surface of implant coating, thus
making the implant fixed with the surrounding bone. The
chemical nature of bonding of implant to the bone can be
attributed by means of coating the surface of titanium with
calcium HA. Accordingly, de Groot et al.[19] in 1987 reported
a technique of plasma spraying of HA to deposit a thin (in
µm) and dense layer onto the surface of titanium substrate
[Figure 3]. Bond strength of such apatite coating with the
substrate as well as the influence of coating process on
fatigue properties of the substrate were measured,. Animal
studies showed similar favorable histological reactions to
apatite coatings. Pal et al. (1993)[20,21] investigated the same Figure 3: scanning electron microscopic view of the smooth surface of titanium
(a) and after coating with HA (b)
contention through rabbit transcortical femoral model. They
utilized calcium HA developed from extracted human teeth,[21]
and prepared the plasma-sprayed HA-coated titanium screws
(size = 1.6 mm diameter × 4 mm length) [Figure 4]. Surgically
these screws were inserted into rabbit femur bone and after
various time intervals these specimens were sectioned parallel
to long axis to implants (hemisection) while the implants were
seated into bone with special microtome. Optical microscopy
revealed the chemical bonding of HA coating (of implant) to
the surrounding bone after 12  weeks and 16 weeks [Figure 5].
This kind of interface was given a name “osseocoalescence”
or “biointegration” by Daculsi (1990).[22] The predictable early
healing of such HA-coated implant was faster than that of
machined smooth implants and the finite element computer
modeling was conducive to bone physiology [Figure 6]. The
Figure 4: scanning electron microscopic view of HA-coated cp titanium screw
HA-coated titanium dental implant system gained popularity (size = 1.6 mm × 4 mm) suitable for rabbit femur as per the american society for
for its faster bony adaptation, absence of fibrous tissue testing and materials (ASTM)

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 Pal: History and fundamentals of implantology

Figure 5: optical microphotograph of interface of HA-coated titanium implant (Ti) Figure 6: finite element modeling of alveolar housing for implant shows overall
and bone (B). note HA-coating (HA) is intimately bonded to bone (red arrow). the area is free from stress concentration except at the entry point of implant in the
haematoxylin (violet) stain occupies the space between implant and HA-coating cortical bone
created through tissue processing

whereas in implants, these are arranged in parallel to the

have been reviews made by Kido and Saha (1996)[27] on its implant surface. Moreover, innervations and vascularization
microbiological susceptibility, resorption, fatigue and fracture in these fibers are very poor. These implants, thus, was not
in long-term applications. Clinical research has portrayed the a recommended subject in any of the university courses and
main problem associated with porous surface: The bacterial curriculum throughout the world.
colonization. In recent days, HA coating is imparted on the
apical and middle part of the implant leaving the cervical In the pre-Branemark era (1978-1998), the implants were
third of the body in order to avoid bacterial contaminations used to be loaded following surgical insertion with a view to
from implant-gingival junction. generate some amount of occlusal force to play at implant-
bone junction. This would initiate the formation of fibrous
PARADIGM SHIFT IN PROTOCOL
tissue around the implant. The procedure put forward by
The surgical implant protocol, based on the fact that Branemark et al. was entirely opposite to the technique
the nature had to be imitated as closely as possible, was prevalent at that time. On the contrary, they advocated a
mainly followed by blade implant systems. The procedure long delay of loading implant for 3-8 months and allowing it
utilizes a high-speed drilling for making bone channels to to heal under gingiva that would not allow fibrous tissue to
accommodate the blades. The high speed itself disrespect the form around the implant. They also emphasized the fact that
bone cells (osteocytes) and eventually all bone cells would be the growth of fibrous tissue at the implant-bone interface
charred and ultimately die. This gives an enormous insult to was deleterious as it magnified the harmful effects of stresses
bone as a whole and a heavy task to manage the load of dead that were generated at the implant-bone interface.
tissue debris from around the implant by the macrophages.
The clearance of the periimplant area all through the length of With the advent of a new concept of bone-implant interface,
implant creates a significant gap that leads to a certain degree established by Branemark et al.[28] through an evidence-based
of clinical mobility. All these sequential events do not allow human clinical trial, the old concept gradually started to
new bone cells (osteoblast) to form satisfactorily from the wear off. The new critically analyzed documentary reports
traumatized bone wall and will not deliberately promote new encompassing highest ever sample size at that point of time
bone formations. This phenomenon of formation of fibrous raised a vibrant wave of interest and excitement among
interface between implant and bone was desired by the then general dental surgeons for starting dental implant practice
implant clinicians led by Linkow. This was how he used to at their private clinics. The conceptual shift of paradigm from
claim that the fibrous interface mimics periodontal ligament fibrous encapsulation around the implant to direct implant-
and this fibrous encapsulation acts as a shock absorber and bone contact has been well-understood by the professionals.
protects the implant from occlusal overload. The periodontal Practically all dental clinicians then started switching over to
ligament is a highly specialized tissue in terms of its the new era of implant dentistry. The protocol of Branemark,
orientations, innervations, and vascularizations. The fibers though very strict and rigid, was appreciated by and large
of a periodontal ligament are aligned perpendicular to the in the late 1980s and 1990s in order to tender a predictable
root surface (commonly described as the long axis of tooth), treatment modality to our edentulous patients. The implant

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 Pal: History and fundamentals of implantology

dentistry, thus, became an easy solution for a problem of

edentulousness.

A couple of clinical points were highlighted “in the studies

of Branemark’s technique”. The biggest being the two stages
of surgeries to allow the implant to completely heal in an
environment of no mechanical and microbial disturbances.
The aseptic/sterile surgical protocol brings about the assurance
of noninfection of the operative procedure during insertion.
The skilled low rotary speed with profuse cold irrigation for
osteotomy ensures atraumatic bone drilling and respects all the
bone cells. This is also one of the greatest contributory factors
of predictable healing. The only delay of at least 3-8 months
before implant loading and, of course, the second surgery to
uncover the implant top, have been, somehow, not appreciated
both by clinicians and patients by and large.

CHANGES IN CLINICAL PROTOCOL

The facts that two NIH consensus conferences on dental
implants were held for a period of 10 years indicate how much
priority was given to this treatment modality. The clinical
world of implantology was sailing smoothly on the concept
of Branemark’s implant strategy. But in 1997, Dr. Serge
Szmukler-Moncler won the first prize for his research
work on immediate implant loading at the meeting of the
European Association for Osseointegration.[29] Same year
in November, Prof. G. Favero and Prof. A Piattelli organized
the world convention exclusively focussed on immediate
loading for one day and a half in Venice, Greece. About
300 delegates from around the world participated in this
conference[29] and witnessed the introduction of a newer
implant technique where a mandatory waiting for submerged
implant healing was not a necessity. The initial stability is a
primary prerequisite; the stability is attributed through the
strength of coronal part of the alveolar bone where more of
the thick trabecular bone are present compared to the middle Figure 7: optical photomicrographs of vertical sections of human cadaveric
and apical thirds [Figure 7].[30] It is the clinician’s duty to see alveolar bone to show the width of trabecular bone at various levels of coronal,
middle, and apical thirds. note that the trabecular width decreases toward apical
that the trabeculae are made engaged for tight contact of direction with concomitant increase of marrow spaces
implant body by judicious and precised drilling protocol.

In 1998, the first review of the literature on immediate

Financial support and sponsorship
loading implants was published.[28] The next year, Prof. Nil.
Branemark, the father of osseointegration, overturned his
Conflicts of interest
recommendations for immediate loading by publishing his
There are no conflicts of interest.
first paper on immediately loaded mandibular implants.[23,24,31]
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