)

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

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

The dental implantology can be traced back to earlier

civilizations [Table 1]. [2,3] It can, thus, be divided into
seven eras [Table 2]. The year 1937 - a remarkable period
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
material named vitallium, a mixture of cobalt, chromium,
and molybdenum. Thereafter, in 1939, Strock[5] did animal
experimentations using this unique metal alloy and confirmed
its biocompatibility. This was a wonderful material of choice
RECOGNITION OF IMPLANT DENTISTRY
The research data on dental implants were practically
nonexistent in 1972.[2-6] The American Dental Association
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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: paltamalkanti@gmail.com

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,
be it in a single metal or in an alloy, takes place in our body.
It was first noticed with stainless steel and subsequently
with vitallium (cobalt-chromium-molybdenum) so rapidly
in medical orthopedic fields that material scientists in
collaboration with biologists started searching for some
suitable materials that can satisfy the need of an implant
clinician. A lot of laboratory research and animal tests were
done in search a novel implant substrate.
In 1951, Leventhal[10] did a unique experiment with titanium
screws on rat femoral model. After inserting the titanium screws
he went on sacrificing the rats at 6, 12, 16 weeks and found that
with the passage of time the screws became increasingly tight.
At one specimen of 16 weeks, the screws were so tight that
the femur was fractured while making an attempt to remove
the screw. This study showed that the titanium can be used in
bone surgery for the need of joining the fractured ends. He
had not performed any experiment on jaw bone of any animal
showcasing the future prospective of his research work could be
applicable as dental implant. A decade later, Swedish anatomist
Prof. P. I. Branemark found that titanium is an ideal metal for
making dental implant as it adheres to bones.
OSSEOINTEGRATION
1952 onwards, Prof P. I. Branemark[12] and his coworkers, at
Goteborg, Sweden, were doing research on vital microcirculation
of blood in mammalian hard tissues especially on fibular model
of rabbit. They also started experiments with commercially
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
ground sections. Branemark[11] et al. in 1985 coined a new term
“osseointegration” for this unique interface and defined as “a
direct structural and functional connection between ordered,
living bone and the surface of a load carrying implant” [Figure 1].
Since then, titanium and its various alloys have been in use in
the dental implant industry. It has got a strong affinity to react
with oxygen and form an oxide layer (TiO, TiO2, TiO3) over the
surface within milliseconds. This oxide layer, a kind of ceramic
in nature, covers the metal and restrict its interactions
with peripheral surroundings; it nevertheless protects the
subjacent metal body in many ways from corrosion due to
external reasons. This has given an extraordinarily unique
characteristic of titanium in terms of its extensive clinical
use. Many other materials that are known to be biologically
inert were also tested. Among them, ceramics and carbon are
worth mentioning. Many workers have used these materials
as implant substrates but because of physical, mechanical,
chemical, electrical differences these materials could not
be permanently considered as an implant material. Above
all inertness, thermal conductivity, modulus of elasticity,
brittleness, and surface reactions to bond with bone are few
notable differences. High-density polymers were also tried
but their relative low strength and high ductility did not allow
them to be considered as an implant material.
IMPLANT SURFACE
Branemark worked with smooth polished surface and
showed how beautifully implant-bone interface can be
Figure 1: scanning electron microscopic view of the implant-bone interface

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

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

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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)

Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015 S9
 Pal: History and fundamentals of implantology
Figure 5: optical microphotograph of interface of HA-coated titanium implant (Ti)
and bone (B). note HA-coating (HA) is intimately bonded to bone (red arrow). the
haematoxylin (violet) stain occupies the space between implant and HA-coating
created through tissue processing
have been reviews made by Kido and Saha (1996)[27] on its
microbiological susceptibility, resorption, fatigue and fracture
in long-term applications. Clinical research has portrayed the
main problem associated with porous surface: The bacterial
colonization. In recent days, HA coating is imparted on the
apical and middle part of the implant leaving the cervical
third of the body in order to avoid bacterial contaminations
from implant-gingival junction.
PARADIGM SHIFT IN PROTOCOL
The surgical implant protocol, based on the fact that
the nature had to be imitated as closely as possible, was
mainly followed by blade implant systems. The procedure
utilizes a high-speed drilling for making bone channels to
accommodate the blades. The high speed itself disrespect the
bone cells (osteocytes) and eventually all bone cells would be
charred and ultimately die. This gives an enormous insult to
bone as a whole and a heavy task to manage the load of dead
tissue debris from around the implant by the macrophages.
The clearance of the periimplant area all through the length of
implant creates a significant gap that leads to a certain degree
of clinical mobility. All these sequential events do not allow
new bone cells (osteoblast) to form satisfactorily from the
traumatized bone wall and will not deliberately promote new
bone formations. This phenomenon of formation of fibrous
interface between implant and bone was desired by the then
implant clinicians led by Linkow. This was how he used to
claim that the fibrous interface mimics periodontal ligament
and this fibrous encapsulation acts as a shock absorber and
protects the implant from occlusal overload. The periodontal
ligament is a highly specialized tissue in terms of its
orientations, innervations, and vascularizations. The fibers
of a periodontal ligament are aligned perpendicular to the
root surface (commonly described as the long axis of tooth),
S10 Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
Figure 6: finite element modeling of alveolar housing for implant shows overall
area is free from stress concentration except at the entry point of implant in the
cortical bone
whereas in implants, these are arranged in parallel to the
implant surface. Moreover, innervations and vascularization
in these fibers are very poor. These implants, thus, was not
a recommended subject in any of the university courses and
curriculum throughout the world.
In the pre-Branemark era (1978-1998), the implants were
used to be loaded following surgical insertion with a view to
generate some amount of occlusal force to play at implant-
bone junction. This would initiate the formation of fibrous
tissue around the implant. The procedure put forward by
Branemark et al. was entirely opposite to the technique
prevalent at that time. On the contrary, they advocated a
long delay of loading implant for 3-8 months and allowing it
to heal under gingiva that would not allow fibrous tissue to
form around the implant. They also emphasized the fact that
the growth of fibrous tissue at the implant-bone interface
was deleterious as it magnified the harmful effects of stresses
that were generated at the implant-bone interface.
With the advent of a new concept of bone-implant interface,
established by Branemark et al.[28] through an evidence-based
human clinical trial, the old concept gradually started to
wear off. The new critically analyzed documentary reports
encompassing highest ever sample size at that point of time
raised a vibrant wave of interest and excitement among
general dental surgeons for starting dental implant practice
at their private clinics. The conceptual shift of paradigm from
fibrous encapsulation around the implant to direct implant-
bone contact has been well-understood by the professionals.
Practically all dental clinicians then started switching over to
the new era of implant dentistry. The protocol of Branemark,
though very strict and rigid, was appreciated by and large
in the late 1980s and 1990s in order to tender a predictable
treatment modality to our edentulous patients. The implant
 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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of missing teeth. 1991. p. 8-18.

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Kincha), Bombay 1995;1:1-2.
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