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Oral Implantology Review: A Study Guide
ORAL
IMPLANTOLOGY
REVIEW A STUDY GUIDE
5 4 3 2 1
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or
otherwise, without prior written permission of the publisher.
Topics include:
Medical history • General health evaluation • Oral health evaluation • Hypertension •
Chest pain • Allergic reactions • Bone pathologies • Long-term systemic glucocorti-
costeroid therapy • Cushing’s syndrome • Bleeding disorders • Tic douloureux • Lab-
oratory tests • Bacteremia • Infective endocarditis • Antibiotic prophylaxis • Angina •
Thyroid crisis • Local anesthetic toxicity and overdose • Medical emergencies in the
dental office
Topics include:
Bone modeling and remodeling • Alveolar bone density • HU values • Stress, bruxism,
and other parafunctions • Absolute and relative contraindications to implant therapy •
Diagnostic wax-up • Implant therapy risk factors (gingival, dental, bone, and esthetic) •
Immediate versus delayed implant placement decision-making guidelines • Radiologic
evaluation • CT scan evaluation
Topics include:
Bony anatomy of the oral and facial regions • Arterial anatomy • TMJ • Muscles of facial
expression • Muscles of mastication • Cranial nerves • Anatomy of the nasal cavity •
Maxillary sinus anatomy and physiology • Radiologic anatomy of the oral and sinus
cavities • Buccal fat pad • Nasopalatine canal • Lingual nerve • Inferior alveolar nerve •
Mental nerve • Nerve injury etiology • Mandibular incisive canal • Submandibular fossa
• Anatomy for venipuncture
4 Surgical Procedures and Complications 79
Topics include:
Placement guidelines • Vertical and horizontal spaces of occlusion • Surgical procedures
• Maxillary sinus diseases • Surgical complications • Nerve injury management • Effect
of soft tissue biotype • Mandibular fracture • Implant fracture • Implant stability • Tissue
emphysema • Incision line reopening • Mucositis • Peri-implantitis • Hyperbaric oxy-
gen in implant therapy • Complications of sinus augmentation • Bisphosphonate-related
complications and management • Radiosurgery
5 Pharmacology 121
Topics include:
Antibiotics • Oral versus sublingual routes • Pharmacologic antagonists • Drug potency •
Cumulative interceptive supportive therapy • Treating peri-implant infections • NSAIDs •
Local anesthetics • Epinephrine • Management of the pregnant patient • Anticoagulants
• Management of the anaphylactic episode • Painkillers
6 Biomechanics 155
Topics include:
Wolff’s law • Strain • Torque • Misfit of the implant prosthesis framework • Fatigue
curve • Occlusal overload • Law of beams • Off-axial loading • Tripod configuration
placement • Cantilevers • Number of implants • Tilted implants
Topics include:
Loss of posterior support • Guidelines for the All-on-4 prosthesis • Master cast accu-
racy • Vertical alveolar bone reduction • Causes of excessive gingival display and
management • Anteroposterior spread • Implant-supported overdentures • Cement-
retained versus screw-retained prostheses • Screw loosening • Impression techniques
• Radiographic stents • Biologic seal • Emergence profile • Wide-body implants •
Dental materials • Custom abutments • Short implants
Bibliography 217
Dedicated to
Ibn Zuhr (1094–1162)
Biography
Abu-Marwan Abd-al-Malik ibn Zuhr Al Eyadi Al-Ishbily (Avenzoar) was a Muslim Arab physician
and surgeon who was influential in advancing the progress of surgery. His major work, Al-Taysıˉr
fil-Mudaˉwaˉt wal-Tadbıˉr (Book of Simplification Concerning Therapeutics and Diet), reflects Ibn
Zuhr’s reliance on his own clinical observations, skill in differential diagnosis, and interest in
clinicopathologic correlations. Based on his own experience, he staged and classified diseas-
es in a practical way relevant to their management and prognosis. Furthermore, he enriched
surgical and medical knowledge by describing many diseases never described before, includ-
ing pericarditis, mediastinitis, mediastinal tumors, empyema, meningitis, intracranial throm-
bophlebitis, inflammation of the middle ear, pharyngeal and esophageal paralysis, verrucous
malignancy of the colon, fecal fistula, Peyronie’s disease, purpuric skin rash, and scabies.
Contributions
1. Experimental surgery: Ibn Zuhr introduced animal testing as an experimental method of
testing surgical procedures before applying them to human patients to know if they would
work, performing the first experimental tracheotomy on a goat before performing it on
humans. He was the first surgeon of his time to apply experimental methodology in evalu-
ating new or controversial surgical procedures. Hence, he was given the title “The Father
of Experimental Surgery.”
2. Clinical anatomical knowledge: Ibn Zuhr emphasized the great importance of a practical
knowledge of anatomy for the surgical trainee. Here is a translation of his words regarding
the management of inflammatory swellings of the neck that are ripe and ready for bursting/
drainage:
And in case you have mastered the science of dissection then drain by the scalpel in the way
that you will not come across a vein, artery or a nerve or anything that its injury will lead to an
extra harm to the patient. But if you were one of the group like me and did not practice dis-
section but knew it only by imitation, keep away from the knife as nothing you know by mere
imagination will be the same in real life; especially in the case of small organs.
ccording to Ibn Zuhr, only the practitioner who has practiced dissection himself and mas-
A
tered the science is entitled to perform an operative intervention. He therefore advocated
that mastering anatomy is essential training for a surgeon.
3. Adequate supervised training: Ibn Zuhr insisted on an adequately supervised and structured
training program for the surgeon-to-be before allowing him to operate independently.
4. Established limits: Ibn Zuhr drew emphatic red lines at which a physician should stop during
his general management of a surgical condition. This was a major step forward in the evo-
lution of general surgery as a specialty of its own. Here is a translation of an example of Ibn
Zuhr’s demarcation:
If the wound caused by a sharp iron has taken into the bones and not extended to the interior,
then the treatment I just mentioned is enough for you, so stick to it. However, if it did penetrate
the bone then in such a case, the surgeon should come and see.
Legacy
Ibn Zuhr was the most well-regarded physician of his era, and his ideas about medicine and
surgery helped to shape our modern concept of standard care. He is an inspiration to those of
us who seek to make the best decisions for our patients and our discipline.
vii
Preface
The goal of this book is to present a study guide for practicing oral implantologists seeking
credentials in this field. The aim was not to encompass the entire scope of oral implantology
but rather to focus on the essential and core knowledge required by the American Board of
Oral Implantology (ABOI) certification examination. Based on the test specifications for this
particular examination, the questions contained herein provide a good review in preparation
for any credentialing examination in oral implantology. Because a true oral implantologist is
involved in both the surgical and prosthetic phases of dental implant treatment, both aspects
are covered extensively in this book.
As important as certification is to professional development, the main goal for any oral im-
plantologist is not to pass a test but to provide the best treatment possible for our patients.
To that end, the following considerations are critical:
• Thorough treatment planning is key: Implant dentistry is neither a prosthetic discipline with
a surgical component nor a surgical discipline with a prosthetic component. It is a surgical-
prosthetic discipline. Both aspects are equally important for clinical success. For example,
what is the point of spending hours developing a prosthetic plan only to find out at the CT
examination that the existing bone does not support that plan? Prosthetic and surgical con-
siderations both inform the treatment plan and the clinical outcome, so both must be given
equal weight.
• Oral implantology is complex: Many factors must be taken into consideration when devel-
oping a treatment plan involving dental implants. These factors include but are not limited
to the general health of the patient, bone density, horizontal and vertical spaces of occlu-
sion, soft tissue biotype, parafunctions (if any), smile line, patient’s age, patient’s sex and
size, opposing dentition, and the location of the implants in the mouth (posterior versus
anterior placement). Any one of these factors, if overlooked, can impact the success of the
clinical outcome. My 2012 book Oral Implantology Surgical Procedures Checklist (Quintes-
sence) systematically outlines all of these treatment-planning factors.
• Every patient is an individual: Mainstreaming treatment protocols can be helpful, but it is
not always practical or possible for patients seeking dental implant treatment. For example,
is it okay to place only four implants in an edentulous arch and restore them with a full-arch
fixed implant prosthesis? The answer in general is no, but if the patient is on the older side
with opposing removable prostheses, and if those implants are of good size and placed in
dense bone without the need for a cantilever in the prosthetic design, then the answer may
be yes. Based on the evaluation factors mentioned above, not every patient is suited for the
same treatment plan, so the specific conditions of the patient should inform an individual-
ized treatment plan.
• Anatomy matters: Proper anatomical review is vital before engaging in the surgical aspect
of oral implantology. This book offers sufficient anatomical review to prepare you for a certi-
fication examination, but further study and review are always wise, especially if you are just
beginning in oral implantology. My 2013 publication Surgical and Radiologic Anatomy for
Oral Implantology (Quintessence) is a great resource for anatomical study.
• Surgical execution is paramount: Implant surgery starts with numbing the patient and con-
tinues with the incision and flap elevation, implant placement with or without bone grafting,
flap release and suturing, provisionalization, and finally postoperative instructions, follow-up,
and prescription of the right medication(s). Every step in this sequence must be done to the
best of your ability. Giving proper postoperative instructions and delivering a proper provi-
sional appliance are as vital to the surgical outcome as executing the surgical protocol itself.
viii
• Complications happen: Do not feel intimidated by complications. Implant dentistry is very
predictable as long as the surgical and prosthetic rules/protocols are followed. Most compli-
cations are very easily resolved. What is important to know here is that when you encounter
a complication, you basically have three choices: (1) prescribe medications, (2) surgically
intervene, and/or (3) refer the patient in a timely manner to a general dentist, periodontist,
oral and maxillofacial surgeon, or ear, nose, and throat doctor, depending on the type of
complication. You must act quickly and decisively when a complication arises.
• Training is crucial: Dentists who are making an entry into oral implantology have a multitude
of options when it comes to good implant training programs. It is important to acquire an
adequate amount of surgical training before engaging in the practice of oral implantology.
Supervised live patient training is a must until you feel comfortable going solo.
Implant dentistry is changing at a startling rate, primarily driven by the results of modern
research. Only by updating our knowledge base constantly will we be able to keep pace with
current trends. This book provides an overview of the discipline of oral implantology as it is
practiced today. It is my hope that it will prepare the next generation of oral implantologists
not only to pass certification examinations but also to improve patient care.
Acknowledgments
As always, several people need to be acknowledged for their help in producing this book:
I would like to thank Christopher Church for contributing the maxillary sinus questions,
Mamaly Reshad for most of the prosthodontic chapter, and Jim Rutkowski for the pharmacol-
ogy chapter.
I would like to thank Lisa Bywaters from Quintessence Publishing for selecting me for this
book. As with my earlier publications, she helped to make this book possible through her
technical expertise, accuracy, and perseverance. She offered valuable suggestions on how
to present the material most effectively. It was an honor and privilege to work with her again.
I would also like to thank Leah Huffman for doing a great job editing and contributing to the
organization and design of this book.
I would be remiss not to include my wife, Rana, and our angels Nadia, Omar, and Tim. Their
support was invaluable.
My prime motivations for writing this book, however, are my students at the California Im-
plant Institute, who inspired me to ensure that a new generation of oral implantologists bene-
fit from this book. My honest hope is that its readers will find it a useful resource and valuable
addition to their practice and knowledge base.
ix
Contributors
Christopher Church, md
Director
Loma Linda Sinus and Allergy Center
Associate Professor
Department of Otolaryngology, Head and Neck Surgery
Loma Linda University School of Medicine
Loma Linda, California
Former Chairman
Section of Fixed Prosthodontics and Operative Dentistry
University of Southern California
Los Angeles, California
Private Practice
Los Angeles, California
x
1
Medical
Evaluation of
the Implant
Patient
An accurate and thorough medical evaluation is a critical component of
implant therapy. This chapter discusses the many medical factors that
must be considered when a patient presents for treatment, including
pathologic conditions, bleeding risk, allergy, and medical contraindica-
tions. Implant therapy is not without risk, and medical emergencies can
occur even when the proper precautions are followed; it is therefore im-
perative that all clinicians understand what to do in such situations, espe-
cially for individuals already compromised by certain medical conditions.
1
1 Medical Evaluation of the Implant Patient
1. What key medical considerations must the clinician take into account when formulating a treat-
ment plan for a dental implant patient?
a. Hemostasis
b. Drug actions and/or interactions
c. Predisposition to infection
d. All of the above
d: All of these could have a profound effect on the healing response and thereby compromise
the treatment result. If there is a hemostasis problem, excessive bleeding may result. Drug
actions may interfere with proper healing, and drug interactions may affect cardiovascular
integrity. A compromised immune system could lead to postoperative infections.
b: The patient’s systemic health will dictate how well he or she will be able to sustain the
stress of the procedure and the response to administered medications.
3. Which of the following are essential components of a medical history? (MULTIPLE ANSWERS)
a. Medications
b. Previous hospitalizations, illnesses, and/or surgeries
c. Information regarding prosthetic joint replacements
d. Childhood immunizations
e. All of the above
, b, c: A complete medical history should include an organ systems review, height, weight,
a
exercise tolerance, present illnesses, as well as any medications the patient is taking, any pre-
vious hospitalizations or illnesses, and information regarding prosthetic joint replacements.
The medical history can be done as an interview of the patient or as a printed questionnaire
that the clinician reviews with the patient.
4. According to the ASA (American Society of Anesthesiologists) Physical Status (PS) classifica-
tion, what would the classification be for a patient who can walk up a flight of stairs or the
equivalent of two city blocks but has to stop along the way because of distress or shortness
of breath?
a. ASA I
b. ASA II
c. ASA III
d. ASA IV
c: ASA III is defined as a patient with severe systemic disease. A consultation with this patient’s
physician is recommended prior to initiating dental treatment for this individual. Periopera-
tive sedation and special monitoring may be necessary in the treatment of ASA III patients.
2
5. What would the ASA classification be for a patient who is able to walk up a flight of stairs or
the equivalent of two city blocks but has to rest at the end of the walk because of distress?
a. ASA I
b. ASA II
c. ASA III
d. ASA IV
6. A healthy 38-year-old woman presents for a dental implant. She takes no medications and is
not anxious about the treatment. What is her ASA classification?
a. ASA I
b. ASA II
c. ASA III
d. ASA IV
7. What would the ASA classification be for a patient with well-controlled diabetes who is insulin
dependent?
a. ASA I
b. ASA II
c. ASA III
d. ASA IV
c: ASA III
8. What would the ASA classification be for a patient whose diabetes is well controlled with diet
and oral hypoglycemic agents?
a. ASA I
b. ASA II
c. ASA III
d. ASA IV
b: ASA II
9. What percentage of patients, when asked “Are you in good health?”, respond “yes” but are
actually found to be medically compromised on closer examination?
a. 10%
b. 20%
c. 30%
d. 40%
c: Studies reveal that 30% of patients who respond in the affirmative are actually deemed
medically compromised by the treating clinician. (Source: Brady WF, Martinoff JT. Validity of
health history data collected from dental patients and patient perception of health status. J
Am Dent Assoc 1980;101:642–645.)
3
1 Medical Evaluation of the Implant Patient
10. When a patient presents with a burning mouth or tongue, which of the following could be the
possible medical cause?
a. Alcoholism
b. Neoplasm
c. Renal failure
d. Primary or secondary neuropathy
d: Patients with primary or secondary neuropathy often present with the symptom of a burn-
ing mouth or tongue.
11. When a patient presents with gingival overgrowth, which of the following could be a possible
medical cause?
a. Leukemia
b. Gastroesophageal reflux disease (GERD)
c. Immune suppression from HIV
d. Mouth breathing
12. When a patient presents with rampant dental caries, which of the following could be a possible
medical cause?
a. Addison’s disease
b. Sjögren’s syndrome
c. Vitamin deficiency
d. Liver cirrhosis
b: Patients with Sjögren’s syndrome often present with a dry mouth that leads to rampant
dental caries. In elderly patients, it often presents as root caries.
13. When a patient presents with ptosis of the chin, which of the following could be a possible
medical cause?
a. Anemia
b. Use of skeletal muscle relaxants
c. Scleroderma
d. Myasthenia gravis
d: Myasthenia gravis is a neuromuscular disease that results in muscle fatigue and weakness.
Patients with myasthenia gravis will have decreased muscle tone that can result in ptosis.
14. When a patient presents with a radiographic finding of reduced cortical bone density, which of
the following could be a possible medical cause?
a. Primary hyperparathyroidism
b. Scleroderma
c. Osteoarthritis
d. Multiple myeloma
a: Hyperparathyroidism results in the secretion of excess parathyroid hormone, which stimu-
lates osteoclast catabolic effects on bone, resulting in the loss of calcium and density.
4
15. When a patient presents with a radiographic finding of degenerative damage to the condyle
or temporomandibular joint (TMJ), which of the following could be a possible medical cause?
a. Osteonecrosis
b. Paget disease
c. Hyperparathyroidism
d. Rheumatoid arthritis
d: Rheumatoid arthritis has an unknown etiology; however, genetic, environmental, hormonal,
and immunologic factors as well as infection are possibly involved in the process. A genetic
susceptibility may provoke an autoimmune reaction that leads to hypertrophy of the synovial
lining of the TMJ and endothelial cell activation that results in an uncontrolled inflammatory
response and destruction of the bone.
16. When a patient presents with a radiographic finding of carotid artery calcification, which of the
following could be a possible medical cause?
a. Cardiac disease
b. Sickle cell anemia
c. Hyperparathyroidism
d. Renal disease
a: Carotid artery calcium deposits have been identified as an independent predictor of cor-
onary heart disease events. Therefore, clinicians should be surveying panoramic radiographs
and computed tomography (CT) scans that are obtained for dental reasons for these calcium
deposits in the coronary artery.
17. When assessing the bleeding risk for a dental implant procedure, the clinician must consider
which of the following?
a. Inherited defects of hemostasis
b. Medications
c. Acquired defects of hemostasis
d. All of the above
18. On review of the medical history, you find that the patient has severe Addison’s disease. Why
is severe adrenal insufficiency significant?
a. The stress of an extensive dental implant surgical procedure may induce cardiovascular collapse.
b. Soft tissue healing will be severely compromised.
c. Implants may not integrate.
d. The patient may experience a hypertensive crisis with the administration of more than 72 μg of
epinephrine within a 10-minute time period.
a: A patient with Addison’s disease will not be able to release the extra cortisol needed to
deal with the stress of the surgical procedure. Cortisol is a glucocorticosteroid that is re-
sponsible for glucose metabolism as well as potentiation of catecholamines that will assist in
maintaining circulatory pressure.
5
1 Medical Evaluation of the Implant Patient
19. What oral clinical finding may indicate that a patient has adrenal insufficiency?
a. Severe tooth erosion
b. Sloughing of the buccal mucosal tissues
c. Hyperpigmentation of the buccal or labial mucosal tissues
d. Gingival hyperplasia
20. What is a medical reason for a patient to take long-term systemic glucocorticosteroids?
a. Liver, lung, or heart transplant recipient
b. Lupus erythematosus
c. Inflammatory bowel disease
d. All of the above
d: Long-term glucocorticosteroid therapy is indicated for each of these conditions. Dental
clinicians should consider increasing the patient’s normal daily steroid dose when the patient
undergoes a surgical or stressful dental procedure.
21. Which of the following blood tests are generally thought to identify a patient with a possible
bleeding disorder? (MULTIPLE ANSWERS)
a. Complete blood count (CBC) and platelet count
b. Prothrombin time (PT) and partial thromboplastin time (PTT)
c. Lipoprotein panel
d. Bleeding time
e. White blood cell (WBC) count
f. All of the above
, b, d: Each of these laboratory tests will act as a screening test for possible bleeding disor-
a
ders. The sum of these tests will measure platelet activity and coagulation factors.
c: Factor VIII
a: Factor IX
6
24. The dental implant patient who presents with chronic liver failure should have which of the
following hematology tests performed prior to the surgical procedure?
a. CBC, platelet count, PT
b. CBC, bleeding time, PTT
c. Platelet activation study (PAS), platelet count, WBC
d. PAS, bleeding time, PTT
a: Patients with chronic liver failure are likely to have problems with blood coagulation. The
CBC, platelet count, and PT will evaluate the coagulation factors that can be affected by the
liver. The CBC and platelet count will screen for anemia and thrombocytopenia, while the PT
will confirm a deficiency of vitamin K.
d: The tongue loses the ability to taste sweetness, sourness, bitterness, and saltiness. Com-
plete or true ageusia is rare, and what patients most often have is the partial loss of taste,
known as hypogeusia.
27. What are the most common reasons for alteration in taste? (MULTIPLE ANSWERS)
a. Autoimmune disease
b. Periodontal disease
c. Infection
d. Poor oral hygiene
e. GERD
f. All of the above
, c, d: Periodontal disease, infection, and poor oral hygiene are known to alter the sensation
b
of taste.
7
1 Medical Evaluation of the Implant Patient
a: Tic douloureux, or idiopathic trigeminal neuralgia, is a condition that creates episodes of
acute-onset, severe facial pain. It is most frequently found in patients of middle to old age.
Intraoral or facial trigger points initiate the pain, which can be excruciating but is usually not
long lasting. The trigeminal nerve’s mandibular branch is most often involved, but the etiol-
ogy is unknown.
29. Which of the following endogenous pigmentation sources is the most common?
a. Melanin
b. Bilirubin
c. Iron
d. Heavy metals
a: Melanin is a term used to describe natural pigments in the body. It is produced by melano-
cytes via the oxidation of tyrosine.
30. Which of the following diseases can cause an abnormal melanin deposit in the oral mucosa?
a. Diabetes mellitus type 1
b. Acute myelogenous leukemia (AML)
c. Addison’s disease
d. Thrombocytopenia purpura
c: Patients with Addison’s disease frequently have bluish-black or dark-brown areas on the
buccal or labial mucosa and possibly on the gingiva.
31. Which of the following laboratory tests measures the intrinsic coagulation pathway?
a. PT
b. PTT
c. International normalized ratio (INR)
d. PAS
b: The PTT is a measure of the efficacy of the intrinsic pathway that mediates fibrin clot for-
mation. All coagulation factors are measured by this test except factor VII. Normal values
are between 25 and 40 seconds. Values that are extended by 5 to 10 seconds represent a
mild bleeding disorder; those values beyond 10 seconds may be an indicator of a clinically
significant bleeding problem.
32. What is the recommended INR therapeutic range for standard oral anticoagulant therapy?
a. 1.0 to 2.0
b. 1.5 to 2.5
c. 2.0 to 3.0
d. 2.5 to 3.5
c: A value between 2.0 and 3.0 is the recommended therapeutic range for the prevention
of deep vein thrombosis, pulmonary embolism, hypercoagulable states, transient ischemic
attack, atrial fibrillation, dilated cardiomyopathy, rheumatic mitral valve disease, and stroke.
8
33. A patient who presents with a prosthetic heart valve replacement should have an anticoagu-
lant therapeutic range (INR) of:
a. 1.0 to 2.0
b. 1.5 to 2.5
c. 2.0 to 3.0
d. 2.5 to 3.5
d: 2.5 to 3.5
34. Known risk factors for ischemic heart disease (IHD) include which of the following?
a. Smoking
b. Obesity
c. Diabetes mellitus
d. All of the above
d: Each of these conditions can either decrease the oxygen supply to the heart or increase
the cardiac workload.
35. An implant patient presents with a recent history of myocardial infarction (MI). At what time
point post MI is the typical cardiac patient’s normal reinfarction risk level back to baseline?
a. 3 months
b. 4 months
c. 5 months
d. 6 months
d: The highest risk of reinfarction is between 0 and 3 months post MI. A lower risk is present
from 3 to 6 months post MI, with the risk returning to baseline after 6 months. Naturally, this
is somewhat patient dependent.
9
Another random document with
no related content on Scribd:
DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.