partial dentures (RPDs) or complete dentures (CDs) [3].
The “father” of dentistry is generally acknowledged to be the French physician Pierre Fauchard (1678–1761) [2] whereas most historians and dentists credit Dr. Greene Vardiman Black (1836–1915) [2, 5, 6] as the “father of modern dentistry.” There are a number of other pioneers in dentistry, including the illustrious Scottish surgeon John Hunter, an early advocate of careful observation and scientific observation in medicine. Not only did Hunter collaborate with his former student Edward Jenner, the pioneer of the smallpox vaccine, but he also dabbled (unsuccessfully) with transplanting teeth, possibly following on from the work of Ambroise Paré (1510–1590). Paré is recognized as the “Father of Modern Surgery” and, interestingly, as the “Foster Father of Dental Surgery.” Interestingly, Paré referred to transplanting of teeth as early as 1564.
Despite its venerable history, the greatest advances in dentistry have really only occurred within the latter half of the twentieth century and, notably, the past 50–60 years. Many influences have transformed dentistry from an ancient quasi‐craft into the evidence‐based technological science it is today, including the innovative work of early dental practitioners, advances in oral medicine, oral surgery and restorative dental techniques, together with an astonishing array of scientific and technology‐driven progress in dental science and dental biomaterials. Table 2.1 indicates a significant number of innovations that have changed modern dentistry, one of which is the endosseous dental implant.
Table 2.1 Innovations in dentistry and dental care.
| Acrylic resin Adhesive dentistry Air‐turbine handpieces |
| Bowen's resin Computer‐aided designed/computer‐aided manufactured restorations Chromium‐cobalt casting alloys Composite restorative materials Cosmetic dentistry Dental Amalgam Digital radiography |
| Direct bonding of orthodontic brackets |
| Electric high‐torque/high‐speed handpieces Endodontic therapy |
| Endosseous oral implants |
| Fluoride‐containing dentifrices |
| Glass ionomers High‐strength dental ceramics |
| Mechanical toothbrushes |
| Orthognathic surgery |
| Porcelain fused to metal restorations Silver‐palladium alloys Visible light‐cured restorative materials Water fluoridation |
The confluence of the advances in the basic sciences, dental biomaterials and clinical technique possibly reached their apex in the endosseous dental implant, perhaps the most successful dental restorative technique ever devised. Virtually no other dental procedure has achieved the long‐term success rate found over the past 15–20 years with dental implants.
Replacing Missing Teeth
The efforts of Ambroise Paré, John Hunter and others to replace missing teeth through implantation of sound teeth from donors were the initial attempts to address this need in patients. Dentures, as such, were not available for the general populace back in the fifteenth and sixteenth centuries and only the very wealthy could avail themselves of transplanted teeth or the rudimentary dentures of that period. Charles Allen of York, England, the author of the first English book solely on dentistry [7] was very dismissive of tooth transplantation.
Patients seemed to accept the limited durability of transplanted teeth and transplantation, probably due to clever publicity and hucksterism, became almost a craze on the European Continent, in England and even America in the late eighteenth century. Sadly, through the sixteenth, seventeenth, and eighteenth centuries, paupers often sold their teeth for cash to earn a little money and the heroine Fantine in Victor Hugo's Les Misérables (1852) was forced to sell her hair, then her incisors and finally her “virtue” in order to survive. Despite its lack of success and almost total disregard of the basic precepts of oral hygiene, tooth transplanting continued well into the nineteenth century. In fact, barrels of teeth extracted from casualties in the American Civil War were regularly shipped to England, and presumably Europe, for both transplantation and to be used in constructing dentures.
This situation changed with the advent of dental schools, the establishment of professional standards and the growing awareness of the general public that dentistry, dental care and oral hygiene were important not only to the oral cavity but also to systemic health. Nevertheless, despite the venerable history of dentures and the remarkable success of modern CDs, FPDs, and RPDs, many patients simply do not like the fact that they must resort to prostheses to preserve masticatory efficiency and maintain facial esthetics. As any dental professional recognizes, there are myriad reasons that patients complain about their dentures. Many complaints, arising from poor denture fit, discomfort, inadequate retention and even pain, are completely understandable and often justified whereas others arise from a basic dislike of a “foreign body” in the mouth. Further, the need for careful oral hygiene and meticulous cleaning of removable appliances is commonly viewed as an unwelcome chore if not an imposition. The perception of many patients is that all of these factors, combined with many others, contribute to the steadily growing appeal of a dental implant that appears to be permanent, painless, and “maintenance‐free.”
Dental Implants
A major problem with CDs, especially for the mandible, is poor retention, often exacerbated by residual alveolar bone above basal cortical bone. Resilient linings, denture creams and other retention aids may alleviate the problem on a temporary basis but rarely “cure” retention or stability issues. One approach to addressing such concerns during the 1970s and, subsequently, was the subperiosteal implant which comprised a metallic framework that closely fit and sat directly on the bone of the mandible.
Subperiosteal Implants
The basic concept of the subperiosteal implant was that a CD rested on abutments that projected through the mucosa, Fig . 2.1. Consequently, masticatory and other stresses were transmitted directly to the supporting bone rather than to the oral mucosa as with conventional CDs. This approach enabled the surgeon to trim the basal bone of any projections or spicules of residual bone to ensure a good fit for the framework but also, incidentally, could help reduce or eliminate any painful sore spots for the final CD.
Fabricating a subperiosteal implant, however, was a long and rather involved procedure. The mandibular mucosa had to be reflected and an impression made of the exposed bone. A wax pattern was then designed on the gypsum cast and used as the pattern for a chrome‐cobalt cast framework. In a subsequent procedure, the mucosa was reflected again, and the framework placed on the exposed bone before the mucosa was restored in position and healing allowed to start. After healing, a CD could be fabricated and seated on the abutments projecting through the mucosa. There were three principal varieties of subperiosteal implant: full mandibular, full maxillary, and unilateral or single‐unit implants. The latter were smaller than full arch implants and had only one protruding abutment. They were particularly useful when used as terminal abutments for edentulous quadrants, i.e., free‐end saddle retention aids.
Figure 2.1 The subperiosteal implant.
Although subperiosteal
