The Legends of Implant Dentistry with the History of Transplantology and Implantology Leonard I Linkow
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1The Legends of Implant Dentistry with THE HISTORY OF TRANSPLANTOLOGY AND IMPLANTOLOGY2
3The Legends of Implant Dentistry with THE HISTORY OF TRANSPLANTOLOGY AND IMPLANTOLOGY
Leonard I Linkow DDS DMSC Clinical Prof. Department of Implant Dentistry, New York University College of Dentistry Former Clinical Prof. Dept. of Fixed Prosthodontics, Pittsburgh University, School of Dental Medicine Former Dept. of Implantology - Charge d'Enseignement d'Implantologie Orale a la Faculte de Medicine University of Medicine, Lille, France Former Prof. Department of Removable Prosthodontics and Implantology, Temple University Philadelphia, Pennsylvania Former Attending Associate Chief of Oral Implantology, Jewish Memorial Hospital, New York Former Chief of Implantology, Haifa Center for Continuing Education, Haifa, Israel Former Consultant, Tel-Aviv University, Tel-Aviv, Israel Former Visiting lecturer, Lariboisiere Hospital, Paris, France Royal Society of Medicine, London, England Post Graduate Instructor and Clinician, Institute for Graduate Dentists, New York University of Detroit, Detroit, Michigan; Washington University, St. Louis; Missouri State University of New York at Buffalo School of Dentistry, Buffalo, New York Loyola University, Maywood, Illinois Visiting Faculty, Temple University, School of Dentistry, Philadelphia, Pennsylvania; Oregon University School of Dentistry, Portland Oregon; University of Maryjand, College Park, Maryland Tufts University, Boston, Massachusetts; Boston University, Boston, Massachusetts; University of Bari, Bari, Italy; University of Munich, Munich, Germany; University of Indiana, Indianapolis, Indiana; University of Alabama, Birmingham, Alabama; University of Mississippi Mississippi; Louisiana State University Medical Center, New Orleans, Louisiana; Albert Einstein College of Medicine, Yeshiva University, Bronx, New York Emory University, Atlanta, Georgia; University of Puerto Rico, San Juan, Puerto Rico; University of Manila Manila, Philippines; University of Milano, Milano, Italy; University of Rome, Rome, Italy; University of George Eastman, Rome, Italy; University of Torino, Torino, Italy; University of Pisa, Pisa, Italy; University of Louisville, Louisville, Kentucky University of Missouri, Kansas City, Missouri; University of California, Los Angeles California; University of Zurich, Zurich, Switzerland; University of Rio de Janeiro Rio de Janeiro, Brazil; University of Sidney, Sidney, Australia; Honorary Professor Nihon University, Tokyo, Japan Continuing Lecturer, Brookdale Hospital, New York Founder of the Institute for Endosseous Implants, 1965 Mark McKennon
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The Legends of Implant Dentistry with The History of Transplantology and Implantology
© 2010, Leonard I Linkow
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher.
First Edition: 2010
9788184488753
Typeset at JPBMP typesetting unit
Printed at Ajanta Press
5Dedication to
My beautiful daughter, Robin, whom I hope will live for many more years
Dad
The Legends of Implant Dentistry with The History of Transplantology and Implantology and the Innovators
6
7Foreword
Leonard I Linkow is the man responsible for changing the course of dentistry in one lifetime. Four months after he graduated from dental school (in 1952) he performed his first implant prosthesis, a complete unilateral subperiosteal implant to support a posterior unilateral fixed restoration. He wrote his first implant article in 1953 in “Dental Digest Magazine.” From that time -to the present day - Linkow put oral implantology before everything and everyone else. He has said, “This work is my life.” As a result, all mankind has benefited, especially our profession and the patients we treat.
Dr. Linkow's accolades are many -and an attempt to list them here could be a disservice. But allow me to mention a few things most people do not know.
Dr. Linkow's hand and body skills are incredible. He not only played professional baseball for the NY Giants farm team, today he can still hit a baseball that is going at 80 miles per hour. He can routinely reflect the soft tissue of a complete maxilla or mandible in less than seven seconds. He can balance a long stem rose on his nose.
In 1983, I worked with Dr. Linkow for six months, in his New York City office. His dental chair was customized to swing to either side of the patient's chair. He is completely ambidextrous and often would make crown preparations on both sides of the mouth -AT THE SAME TIME! I would also see him make incisions at the same time in both posterior quadrants of a mandible, a scalpel in each hand. He then used a periosteal elevator in each hand, reflected the soft tissue on both sides of the mandible, prepared an osteotomy for a blade implant with two handpieces (one in each hand), insert two blade implants, use two hammers and drive them into place -then would suture one side at a time. I cannot imagine anyone even trying this feat - yet Dr. Linkow did this -not to show off (I was the only doctor in the room), but because he believed the faster the procedure, the easier it was for the patient. He would constantly tell me - “You must work in milliseconds, if you want to have the best chance at implant success.”
Not only does Linkow have unbelieveable hand skills -he can create original thoughts. He has obtained 34 patents during his career—and also developed hundreds of original concepts he never considered visionary -for example, x-ray templates, analogs, premade copings for prosthetics, impression copings, surgical guides, and pre-made transitional restorations. It's hard for the younger dentist in the profession to put this into perspective - but in the 1950s, the profession did not even have an elastic impression material for prosthetics. Rubber base was not invented until the mid 1950s. The high-speed handpiece wasn't developed until the 1960s. This is the era during which Linkow developed the basis for implant dentistry. Without this one man, the field of dentistry could not have been prepared to accept the concept of Branemark or others at a later time.
Leonard I Linkow is the “Father of Implant Dentistry” -not because he was the first ever to perform an implant (Greenfield in 1906, Strock in 1936, Dahl in 1945 all were there before him). But a father does more than conceive a child. He feeds it, nurtures it, clothes it, protects it, and is willing to die for it. He always kept an open door to the profession. If doctors couldn't afford to come to him, he would fly to them -for no honorarium and often would pay his own expenses. He was not selling a product for profit -he was nurturing implant dentistry -one doctor at a time when necessary. Nobody had lectured more hours, or in more places (for so little) than Linkow. He felt the teenage years of implant dentistry (the 1970s) were too fragile for anyone to take advantage and profit personally.
Dr. Linkow was the first “implantologist”. His practice was restricted since the 1970s to tooth replacement with implants. I can remember asking him one day in the practice — “Why don't we do a 3 unit fixed prosthesis instead of a single tooth implant?” He said, “Carl, as an implantologist - if people come to me, they know they will get an implant.” Today (40 years later), I tell the profession and my patients the same thing —Do a single tooth implant, they usually last longer and have few complications.
Dr. Linkow's first published book was in prosthetics, not implants (“Full Arch Fixed Oral Reconstruction - Simplified”) in 1960. In Dr. Linkow's last book he quotes the French born Romanian philosopher and artist, Constantine Brancussi, “Create like a god, command like a king, and work like a slave.” This is Dr. Linkow's motto. Another one of Brancussi's quotes also applies to Linkow, “To see far is one thing, going there is another.” It was far from easy for Dr. Linkow. In the beginning few saw him as a pioneer. Organized dentistry attempted to write him off from the profession. But he always kept his vision clear.8
Another thing few people know about this legend is he has a warm heart. The major reason he created new concepts was to help his patients. I would often see him do procedures for a financial loss–because he wanted to help someone. He knew how often a patient's life would change when they could eat in public and not be embarrassed to have relationships with other people. Those close to him say he has the heart of a lion–strong and courageous.
Now that modern implant dentistry is in its mature adult years - like many adults, we forget how important the first 20 years of life is –we forget that we are today a reflection of the past. It's hard to believe one man is primarily responsible for creating a whole new discipline in dentistry–and he is still alive to share and contribute.
I am honored to have been asked by Dr. Linkow to write this foreword. I am honored to have Dr. Linkow as a personal mentor–and I am lucky to be one of the thousands who have been touched by his soul.
Carl Misch
Founder and head of the Misch Institute, Beverly Hills, Michigan
Dr. Linkow is like all men of genius. They are like thunderstorms. They go against the wind. They frighten and enlighten people. But they clear the air.
Dr Ole Krogsgaard Jensen
Copenhagen, 1978
President of Danish
Academy of Oral Implantology
9Preface
Rarely in life we do have the opportunity to know and be around true legends in any field. Leonard Linkow is one of these men. He has truly been one of the most important figures in Implant Dentistry. He is a real pioneer in every sense of the word, and he has been one of the most inventive dentists in the field. Lenny had to do almost everything on his own since organized dentistry was not ready to accept some of his novel and innovative ideas. He lectured extensively all over the world. He was relentless in his passion to help other dentists wherever he went.
When New York University College of Dentistry formed the Leonard I Linkow Chair in Implant Dentistry in 1988-1989, it was the first time that Len was officially recognized by organized dentistry. To show the kind of love and respect that so many people had to Len, this chair was funded from dentists and patients from all over the world. This is truly unheard of in dental schools. He has always shared his knowledge and clinical skills with everyone. He would do live surgeries all over the world to help others gain from his pioneering works.
He is also very inventive. When Len was asked why he developed so many different implant designs instead of just one or two, he responded by saying, “I had to come up with multiple ways to help my patients. They all come in with different amounts of bone and with different problems. I needed to make different implants for each of the problems I was presented with.”
This is the kind of doctor that Dr. Linkow is. He always put the patients' needs first.
Len is a dynamic man. He always gets things moving around him. When he has a passion about something he will go after it with everything he has. He will stimulate others to think and be better dentists as well.
He is a true teacher, clinician and academician. Most of what we are teaching today in implant dentistry in dental schools and specialty programs around the world was actually taught by Lenny over 40 years ago. In fact, it is all in his multiple volume textbooks for people to see and learn from.
Lenny is a great friend and caring person. He is in every sense of the word a true pioneer and a renaissance man. I am honored to write this preface and I wish him good luck and good health in his well-deserved retirement.
Respectfully
Dennis Tarnow DDS
Professor and Chair Dept. of Periodontology and Implant Dentistry
New York University College of Dentistry
New York, USA
10
11Introduction, Acknowledgments and Prologue
The author is particularly well qualified for the preparation of this book. He has spent the greater part of his research and clinical practice in the field of implantology. He has lectured widely, written extensively, and taught numerous graduate classes. This book bears the imprint of the vigor and excitement of the author for his field of endeavor.
This book represents an important contribution to the literature in a discipline that, up to now, has been vague and confusing, while at the same time controversial. Implantology still remains for most of us at the border of the “twilight zone”.
Those of us who have implanted natural teeth realized that in a relatively short time the roots would resorb. From these observations came the concept of using a foreign substance. Today the purity of the material used in implants is not as important as its toleration by the tissues.
At the present time we are transplanting entire human organs, including hearts, kidneys and lungs. What is feared and far from being entirely understood is the rejection by the body of these so-called foreign substances. In dental implants we are similarly faced with the process of rejection. However, dental implants, unlike organ transplants, are inorganic, thus eliminating rejection. It is the hope of the author that successful answers will be found so that implantology will be on a firmer foundation. When any technique, dental or otherwise, reaches the threshold of being used by a growing number of practitioners who are experienced in their fields, serious consideration must be given the technical point of view, even though some practitioners may feel it is ahead of its time. Such resolute treatise by an innovator, using commonly accepted scientific principles and documentary evidence of trialand- error, success-and-failure decrees must elicit respect for the innovator and the experimentation. The work of this author has been guided by such principles. His books Theories and Techniques of Oral Implantology, (C.V. Mosby Co. Vol. I, 11) written several decades ahead of their time, are evidence of such forward-looking activity.
All forms of experimentations in any field have always been attempted with confidence; an assurance of success is an integral part of the desires of the experimenter.
The majority of our later attempts have been successful. In those later cases where failure resulted, it was not because of basic flaws in the concept of an endosseous implant procedure but because of overenthusiasm in attempting an intervention. But we have learned from our mistakes.
This book is a synthesis of my experiences in the field of implantology, and the experiences of many others. It describes many techniques that are successful because they have been carefully designed to be compatible with the laws of nature. It explores the reasons why an implant succeeds or fails, from both operatory and physiologic viewpoints. It prepares the reader for the kind of experience that can be gained only through actual clinical work. It tells the individual operator why the procedures should work; his own experiences based on a thorough understanding of the factors involved will finally prove that they do work.
I sincerely feel that this book is important because the information herein explores what an ever-increasing number of operators are proving is the modern miracle in dentistry.
I wish to express my appreciation to all those people who contributed so unselfishly in one way or another to the preparation of this volume by providing information, suggestions, and constructive criticism. I also wish to express my gratitude and sincere appreciation to all those who gave me my start in the field of oral implantology by allowing me to bring forth my acquired knowledge in the field.
To Dr. Malvin E. Ring, the true pioneer on the history of Dentistry, I give my sincerest thanks for the help he gave me with some of the very early Peruvian and Inca skulls with implants. I wish to give special thanks to Dr. Myron M. Lieb, Director of the Institute for Graduate Dentists (which is no longer in existence) for expressing faith in me by allowing me to teach implantology in the middle 1960s, while it was still in its early development and none of the universities at that time accepted my teaching.
Most of all I thank my wife, Cecilia, a companion and true friend because without her excellent help the book would still be a file of jotted notes and clippings from articles, periodicals, books and newspapers.12
Why did I take the time and energy to write a book of this sort? Certainly not to be well compensated. I'll be frank-just how many dentists in our profession are interested in the history of Implant Dentistry? Most of them are only interested in books written for them to gain instant monetary gratifications.
However, someone had to write this very important history because those not knowing the mistakes of the past are sure to repeat them in the future.
During all the long, spiritually intense years that it took to produce this very important history of Implant Dentistry where I had to search far back in time so as not to leave anyone out who made early contributions to the field. I am happy that it is over.
This book was written solely to immortalize many of those great pioneers on whose shoulders most of you have stood, but few of you can recall by name, much less give them credit for the devices or applications they developed. What you may take for granted today was 50 years ago a leap of faith, of men tinkering and thinking, analyzing and applying, trial and error.
To those great men and women of our profession who are presently practicing implant dentistry, and to those who had previously paved the way through their unselfish work and their strong determination to continue despite the overwhelming skepticism from their colleagues trying to constantly disprove the principles of implantology, there are not enough words that can express my respect and admiration for them.
In the last few decades, many new techniques in the fields of medicine and dentistry have been introduced to the world. Until these techniques and methodologies had been pioneered by men of vision, ambition, patience, courage and the understanding of a great human need, thousands, perhaps millions of people suffered and even succumbed to their maladies.
As an anonymous writer once said: “Even a conventional approach was once considered a radical idea.”
I am sure all of us are aware of the tremendous controversies that arise when new developments are announced. Implantology is not and never was an exception.
Pioneers are treated today as in years gone by: they are noted for the failures, criticized for their innovations, resisted in success, resented in triumph. One would think that, as a rising tide lifts all boats, their breakthroughs would be uniformly welcomed because the benefits of evolution get passed around and become general, common and, yes, profitable applications. But something predictable often happens on the way to the human jaw via the patent office: those who did not think of the new development are among the first to disapprove.
In anything like a perfect world, inventors and innovators, implantology innovators, should be aided by their peers to further improve their concepts. It stands to reason that if one is critical, then the onus should be on the criticizer to step up and offer a well-reasoned alternative. However, professionals who continually undermine advancements owe it to their colleagues and themselves to at least be fully informed about the current state of the art before passing judgment. Implantation can enable many patients, even though totally edentulous, to again have fixed teeth. Each case may be different, posing a unique challenge, but the technology to cover virtually any contingency is here now, and has been for some time. Not informing a suffering patient that he or she might be a candidate for fixed teeth is like not treating a person who is blind when some techniques may be available to restore sight.
When an idea is first conceived, it must go through many stages in the eye of the profession before it can be finally and fully accepted. It first must pass a stage of discovery, then years of questioning by the inexperienced or underinformed, then further experiments and revisions, then clinical studies, then re-evaluation by the profession and eventual acceptance.
Our hope is that now our peers will strive together for the true and unselfish advancements of implantology. This would result in more benefits for mankind.
Regarding my own experiences in this process, I must say that none of my roads were ever paved for me. I had to plow through every inch of unbroken terrain with fortitude, a state of mind enhanced by full knowledge that I was building on and evolving techniques initiated by those before me. It was proper for them, in their time; as my peers and I picked up the baton, it became doubly so for us. When the time of an idea has come, like faith, it moves mountains. But sometimes it takes faith to move the mountains. The mountains of bias, envy, and favoritism. By its very nature, implantology threatened to upset a long established hierarchy following a set of dental principles that had scarcely changed in decades. Then, within a few years, everything changed. Regarding their hardships, a very dear patient of mine once told me while I was gasping for air, “It's not how many breaths we take during our lifetime but how many moments can take our breath away.” Thanks so very much, dearest Judy, I love you for your words, and believe me the enthusiasm I had toward my work did take my breath away.13
The howls are still heard today, long after implantology has been validated.
Years, sometimes decades, are spent trying to develop techniques that will solve a particular health problem. The early attempts usually fail, for a variety of reasons. Sometimes the basic idea is not valid but the material or information necessary for its further development is not available. It may not be accurate to fault the proponent if he has no reliable studies to support his vision. Out of his work, however, the studies emerge. Then he becomes a pioneer. When success ultimately occurs, it is a result of an inspired coordination of various factors, including the work of the first minds to examine the problem and propose solutions.
It has been said that history is the science of things which do not repeat themselves. For medicine and dentistry, it is the science of trials which are repeated until the day when they succeed.
The great French philosopher and mathematician, Blaise Pascal, one of the blazing lights, once said, “The long series of men during the course of so many centuries should be considered as only one man, who always subsists, and who learns continually.”
A pioneer, in any field of endeavor, in medicine or dentistry no less than many other technical specialities, spends most of his life as a controversial figure. It is not his choice to be considered in this light, especially during those struggling years when he is doubted, perhaps ostracized, or even condemned by his colleagues and peers.
They are only afraid, but the effect of their fear is compounded by their certainty.
The course of a pioneer is not a straightforward drive to a goal. There are detours. Philosophically speaking, I have believed that the journey and its lessons - hard and many they may be - and the destination or the desired reward, is a core value of life. It may even be a blessing and, moreso, life's sole or central purpose. But knowing this and matching that knowledge to one's daily routine can be a woefully confusing enterprise. As mark Twain said, “Life would be infinitely happier if we could only be born at the age of eighty and gradually approach eighteen.” So as my renown grew, and my reputation - good and bad - expanded accordingly, I was obliged to continually accept life's disenchantments, like being misquoted in the media and hearing the opprobrium of peers, or being snubbed because my innovations had sometimes shown the limits of others.
One of life's central difficulties can be trying to negotiate with people who have all the answers to questions they don't understand. I tried to take a brighter view of the bigger Legends of Implantology: The History of Transplantology and Implantology picture, one obvious conclusion being that I have been in places, met many people and have done things that few are ever privileged to enjoy.
I tried very hard to include as many of the original pioneers in this book. Though some of them are no longer with us, over the years I managed to include them in many of the photographs I took myself or were given to me by others. However, there were some who ignored my pleas, and for those I am sorry - but I sure tried.
I would like to end this foreword with one of the observations made by the great poet Kahlil Gibran on January 6, 1883.
“I cannot say much now about that which fills my heart and soul. I feel like a seeded field in midwinter and I know that spring is coming. My brooks will run and the little life that sleeps in me will rise to the surface when called.”
I have always taken these to be beautiful words from a man of great sensitivity and passion. Let us as dentists and humanitarians become more sensitive and attune ourselves to the requests of our patients, and enlighten ourselves to the benefits of implantology, and the first ones who shared their knowledge.
THE TREASURED WRITINGS OF KAHLIL GIBRAN
AUTHOR OF THE PROPHET