Dental Implants

The Histor y of Dental Implants

a report by

Michael R Norton
Visiting Professor, Department of Oral & Maxillofacial Surgery, Marquette University School of Dentistry in Milwaukee

Introduction

Andre Schroder of Berne Switzerland were both focusing their attentions on the properties of titanium. It was Brnemark who, in 1952, had a lucky (some would say serendipitous) discovery. Brnemarks technician,Victor Kuikka, advised that it was impossible to recover any of the bone-anchored titanium microscopes he had manufactured for use in the doctors research. Brnemark discovered that the titanium had apparently bonded irreversibly to the living bone tissue, an observation which contradicted contemporary scientific theory of the day. Brnemark set out to repeat the effect of fusing metal with bone and subsequently demonstrated that under carefully controlled conditions, titanium could be shown at the histological level to structurally integrate with living bone. More importantly, he was able to demonstrate that this could be achieved with a very high degree of predictability and, without long-term soft tissue inflammation, fibrous encapsulation or implant failure. Brnemark named the phenomenon osseointegration. The first practical application of osseointegration was the implantation of new titanium roots in an edentulous patient in 1965 and the first ground breaking study was published 16 years later by Adell et al. in the International Journal of Oral Surgery.This was very clearly the spark that led to what we now recognize as the birth of modern implantology and its acceptance worldwide. The first commercial implants to be sold were called Biotes, but these were renamed to reflect the inventor and indeed the Brnemark implant remains one of the main implant systems available today. Characterized by its machined titanium surface, thread pitch and external hex joint, the implant rapidly became the biggest selling implant on the market, with a virtual monopoly on sound science and products sold on the back of extensive research. It was therefore no surprise that blade implants rapidly faded into obscurity.
The 510K Ruling

Michael R Norton dedicates his time to the practice and study of implant dentistry from his clinic in Harley Street, London, England. He is registered as a specialist in Surgical Dentistry and is Visiting Professor to the Department of Oral & Maxillofacial Surgery at Marquette University School of Dentistry in Milwaukee, US. Dr Norton served for ten years as Honorary Associate Specialist to the Department of Oral & Maxillofacial Surgery at Charing Cross Hospital, London and at Bedford General Hospital, Bedford, England. Dr Norton is the past president and scientific adviser of the Association of Dental Implantology and is the 75th Fellow of the Academy of Osseointegration (AO), being only the 10th from outside North America, and the first from within the UK. He is also editor of the AOs Academy News and a member of the board for the International Journal of Oral & Maxillofacial Implants. Dr Norton lectures internationally, and is widely published in the implant literature. His internationally acclaimed Quintessence textbook: Dental ImplantsA Guide for the General Practitioner, was published in 1995 and was the first on this subject by a British clinician and has been translated into other languages. He is also the joint owner and editor of the journal Dental Implant Summaries, which is read by over 1,600 colleagues worldwide. He graduated from the University of Wales in 1988.

Dental implants are thought to date back to Egyptian times when seashells were trimmed and shaped before being hammered into the jaw to replace missing teeth. These shells may have worked because of their calcium carbonate content. Slots were made into the bone and the shells were wedged in and could potentially fuse with the bone. In more recent times metal is thought to have been introduced as an implantable material. In 1998, Crubzy et al. famously published in Nature magazine the discovery of a wrought iron dental implant found in the jawbone of a second century CE Gallo-Roman in Chantambre (Essonne, France).The implant was said to fit perfectly into its socket with what was described as a radiographic appearance of osseointegration, a modern concept not introduced until the 20th century. This finding has been questioned by Marshall Becker of West Chester University Philadelphia who counters that the data on this implant needs to be re-evaluated.The item is described as severely corroded, but an X-ray reveals a perfectly formed tooth with a smooth, intact surface free from the pitting expected on a small iron object interred for nearly 2,000 years under less than ideal conditions. The production of a small, detailed replica of a human tooth in iron would test the skills of modern crafters. Less likely is that it would be accepted by a human body under questionably sterile conditions. However, chemical analysis indicates that the metal was indeed given its shape through hot hammering and folding, a basic technique of ancient blacksmiths, including those of Gallo-Roman times.
The Birth of Modern Implantology

The true birth of modern implantology, however, can be found in the late 1950s and 1960s.While a number of clinicians were working with metals such as steel and implants of a so-called blade design, which were said to integrate by the formation of a pseudo-periodontal ligament (in truth a connective tissue capsule), Dr PerIngvar Brnemark of Gothenburg Sweden, and Dr

Many companies recognized the massive commercial opportunity that this new highly predictable process of

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Remarkable things are created with all the right pieces.

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Dental Implants

osseointegration offered and the market became flooded with clone implants or implants of moderately differing design but based principally on the work of Brnemark. This was aided by an important ruling of the US Food and Drug Administration (FDA); the 510K ruling essentially stated that any implant which was fabricated from titanium and was of a screw design could be given approval for use as a human dental implant device. On the back of this ruling the market swelled with devices that offered little in the way of clinical documentation, a problem that persists to this day.
The ITI System

The Microtextured Surface

Of equal interest, but perhaps less well known was the work of Schroder in Switzerland. Working with his colleague, Dr Ledermann, they introduced the titanium plasma spray (TPS) coating concept with the one-piece transmucosal screw. Working closely with the Straumann Company and the ITI Institute they published their early work in 1981 at the same time Adell and Brnemark were publishing their findings. Unfortunately for Schroder and Ledermann, their work was being published in the German literature and so failed to capture the attention of the US. Indeed, these articles were the introduction of the early ITI one-piece hollow cylinder implants, which were the precursor to the Bonefit system of the early 1990s. In fact it was only when Schroder, with Buser, published their famous two-part article in the International Journal of Oral & Maxillofacial Implants in 1988, presenting the engineering concepts, design and clinical results with the hollow cylinder that his earlier work received any recognition. From 1988, Buser took over the mantle of developing the ITI system, publishing numerous reports on the various designs and, in particular, convincing the implant community that one-piece or so-called transmucosal implants actually worked. This was in direct conflict with Brnemark whose protocol clearly stated that it was a prerequisite to successful osseointegration that implants be submerged during their healing phase. With wider acceptance for a onestage technique, the ITI system and Buser himself became the first real scientific contenders to the work of Brnemark and the machined titanium screw. In the 1990s much work was published on the comparative success of machined titanium vs TPS coating vs hydroxapatite coatings, such as on the Calcitek implant. In addition, a greater emphasis was beginning to be placed on the mechanics of these small, engineered devices. A focus on joint design, screw design, and material properties all led to an explosive development of this area of implant dentistry.
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One person working in the background in the mid 1980s, was Dr Stig Hansson. Hansson had an unyielding belief that tissue response around an implant was intrinsically related to the biomechanics of the system and he helped to develop a whole new implant concept.The fundamental features which would evolve through his research were the ground-breaking development of the microtextured surface, achieved by a pure titanium grit-blasting technique to roughen the implant to within 15 microns, and the discovery that a so-called micro-thread located on the coronal collar would also improve load distribution, which would help retain vital crestal bone. Another feature of the Astra implant was the incorporation of an internal conical joint, compared to the external hex used in over 90% of systems on the market at that time, but much like the one that Schroder and Buser had presented in 1988. Subsequently, it was demonstrated that this kind of joint offered much greater mechanical stability which Hansson postulated would more favorably distribute functional load into the crestal bone. Hanssons concepts were adopted into a new implant, which was introduced into clinical use in 1992 and presented all three features of microtexturing to the top of the implant, internal cone, and micro-threading. During the last decade there has been a rather slow but gradual shift towards widespread acceptance of these concepts, with virtually all implants today presenting with their own version of a microtextured surface, some of which are now also taken to the top, an internal joint of one form or another, and most recently the introduction of grooves, laser lines and micro-threads, thereby replicating all the features proposed by Hansson in his 1997 thesis.
The Future

The future now seems to be looking to nanotechnology, as illustrated by the recent introduction of a chemically-modified implant surface, or biotech concepts such as the possible incorporation of bone morphogenetic proteins onto the implant surface. Certainly it seems there is more development and evolution to come, which will ultimately add to the history of these small metal devices, but only until such time as the very notion of screwing metal into bone becomes historical itself, which it surely will as genetic engineering gathers pace. A longer version of this article containing references can be found in the Reference Section on the website supporting this briefing (www.touchbriefings.com).

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