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Methods Used to Assess Implant Stability:

Current Status
Mihoko Atsumi, DDS, PhD1/Sang-Hoon Park, DDS, MS2/Hom-Lay Wang, DDS, MSD3

Successful osseointegration is a prerequisite for functional dental implants. Continuous monitoring in

an objective and quantitative manner is important to determine the status of implant stability. Histori-
cally, the gold standard method used to evaluate degree of osseointegration was microscopic or histo-
logic analysis. However, due to the invasiveness of this method and related ethical issues, various
other methods of analysis have been proposed: radiographs, cutting torque resistance, reverse torque,
modal analysis, and resonance frequency analysis. This review focuses on the methods currently avail-
able for the evaluation of implant stability. (More than 50 references.) INT J ORAL MAXILLOFAC IMPLANTS
2007;22:743–754

Key words: cutting resistance analysis, implant stability evaluation, radiographic assessment,
resonance frequency analysis, reverse torque test

uccessful osseointegration has been viewed as a of the surrounding tissues. It is, therefore, of an
S direct structural and functional connection exist-
ing between ordered, living bone and the surface of
utmost importance to be able to quantify implant
stability at various time points and to project a long-
a load-carrying implant1,2 under a light microscope. term prognosis based upon measured implant stabil-
Histologic appearance resembled a functional anky- ity. Presently, various diagnostic analyses have been
losis with no intervention of fibrous or connective suggested to define implant stability: standardized
tissue between bone and implant surface.3–7 radiographs, cutting torque resistance analysis,
Osseointegration is also a measure of implant sta- reverse torque test, modal analysis, and resonance
bility, which can occur at 2 different stages: primary frequency analysis (RFA). Therefore, the purpose of
and secondary. 8 Primary stability of an implant this paper was to review methods currently used to
mostly comes from mechanical engagement with evaluate implant stability.
cortical bone. Secondary stability, on the other hand, An online search for studies in English and Japan-
offers biological stability through bone regeneration ese was performed using MEDLINE, Pre-MEDLINE,
and remodeling.5,9,10 The former is a requirement for and the Cochrane Oral Health Group trials register.
successful secondary stability.10 The latter, however, Publications from January 1970 to March 2006 were
dictates the time of functional loading.11 Degree of selected based on the following search terms:
implant stability may also depend on the condition “implant mobility,” “Periotest,” “resonance frequency
test,” “insertion torque,” “reverse torque,” “cutting
resistance,” “implant stability,” and “mobility.” All of
the search terms were combined with the term
1Assistant Professor, Department of Oral and Maxillofacial Reha- “implant.” A hand search of International Journal of
bilitation, Prosthetics and Geriatric Dentistry Division, Kanagawa Periodontics and Restorative Dentistry, Journal of Clini-
Dental College, Yokosuka, Japan.
2Assistant Professor, University of Maryland, Department of Peri-
cal Periodontology, International Journal of Oral &
odontology, Baltimore, Maryland. Maxillofacial Implants, Clinical Oral Implants Research,
3Professor and Director of Graduate Periodontics, Department of Journal of Periodontology, implant-related textbooks,
Periodontics and Oral Medicine, School of Dentistry, University and implant-related journals was also executed.
of Michigan, Ann Arbor, Michigan. Papers were considered relevant if they included the
Correspondence to: Dr Hom-Lay Wang, University of Michigan,
aforementioned key words and were published in
School of Dentistry, 1011 N. University Avenue, Ann Arbor, MI English or Japanese. Articles published in peer-
48109-1078. Fax: +734 936 0374. E-mail: [email protected] reviewed publications and current publications were

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Table 1 Factors that Influence Implant Stability RADIOGRAPHIC ANALYSIS

Factors Affecting Primary Stability
Radiographic evaluation is a noninvasive method that
Bone quantity and quality can be performed at any stage of healing. Bitewing
Surgical technique, including the skill of the surgeon view is used to measure crestal bone level, which has
Implant (eg, geometry, length, diameter, surface characteristics)
been suggested as an important radiographic indica-
Factors Affecting Secondary Stability tor for implant success.14–16 It has been reported that
1.5 mm of radiographic crestal bone loss can be
Primary stability
Bone modeling and remodeling
expected in the first year of loading in a stable
Implant surface conditions implant, with 0.1 mm of subsequent annual bone
loss. 17–20 However, several problems must be
addressed. First, 1.5 mm is a mean value. Second, due
to a low incidence of implant failure, changes in radio-
graphic bone level alone cannot precisely predict
implant stability. Third, it is impractical for a clinician
to detect changes in radiographic bone loss at 0.1
mm resolution. Fourth, crestal bone changes can only
be reliably measured without distortion when the
preferred to non-peer-reviewed and early publica- central ray of the x-ray source is perfectly parallel with
tions. More than 200 papers matched the inclusion the structures of interest. This would necessitate a
criteria; however, only 114 most relevant series of standardized radiographs with a customized
articles/chapters were selected and reviewed. template for reliable and repeatable measurements,
which is impractical. Lastly, conventional periapical or
panoramic views do not provide information on a
IMPLANT STABILITY facial bone level, and bone loss at this level precedes
mesiodistal bone loss. 21 Neither bone quality nor
Implant stability, an indirect indication of osseointe- density can be quantified with this method. Even
gration, is a measure of the clinical immobility of an changes in bone mineral cannot be radiographically
implant.5,9 It is achieved at 2 levels: cortical bone (pri- detected until 40% of demineralization had
mary stability) and cancellous bone (secondary sta- occurred.22 Numerous limitations exist with the use of
bility). Secure primary stability leads to predictable a conventional radiograph alone in making an accu-
secondary stability.12 Secondary stability has been rate, independent assessment of implant stability.
shown to begin to increase at 4 weeks after implant Computer-assisted measurements of crestal bone
placement.13 At this time point, the lowest implant level change may prove to be the most accurate way
stability is expected. Therefore, the original Bråne- to use radiographic information, as a standard devia-
mark protocol 2 suggested a 3- to 6-month non- tion within 0.1 mm (0.01 to 0.51 mm) has been
loaded healing period to achieve adequate stability reported.23 However, this method is not convenient
before functional loading. for use in clinical practice.24
Osseointegration is, however, a patient-depen-
dent wound healing process affected by various fac-
tors (Table 1). Quantification of implant stability at CUTTING TORQUE RESISTANCE ANALYSIS
various time points may provide significant informa-
tion as to the individualized “optimal healing” time. In cutting resistance analysis (CRA), originally devel-
Raghavendra et al13 proposed that measurement of oped by Johansson and Strid25 and later improved
osseointegration be approached in a quantitative by Friberg et al26–29 in in vitro and in vivo human
manner, as primary and secondary stability are in an models, the energy (J/mm3) required for a current-
inverse relationship. However, in clinical practice, fed electric motor in cutting off a unit volume of
experience-driven decision still dominates, as objec- bone during implant surgery is measured. This
tive guidelines have not been established. energy was shown to be significantly correlated with
Table 2 summarizes currently available methods bone density, which has been suggested as one of
for the objective assessment of implant stability at factors that significantly influences implant stabil-
pre-, intra-, and postsurgical time points. Histologic ity.26,29 To minimize the interoperator variation, hand
or histomorphometric analysis, however, is not feasi- pressure during drilling was controlled.27 CRA can be
ble for daily practice, as this may require unnecessary used to identify any area of low-density bone (or
biopsy. poor-quality bone) and to quantify bone hardness

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Table 2 Currently Available Methods to Evaluate Implant Stability

and the Time of Use for Each Method
Pre Intra Post Noninvasiveness Objectivity

Histologic analysis + + + – +++

Percussion test – ++ ++ + +
Radiographs ++ ++ ++ ++ –
Reverse torque – – ++ – ++
Cutting resistance – +++ – + ++
Vibration analysis
Periotest – ++ ++ ++ ++?
RFA – +++ +++ +++ ++?
+++ = method with highest reliability; ++ = method with certain reliability; + = method
with doubtful reliability; – = application is impossible; ? = More information is needed.

during the low-speed threading of implant

Table 3 Advantages and Disadvantages of CRA
osteotomy sites. A torque gauge incorporated within
the drilling unit (eg, Osseocare; Nobel Biocare, Göte- Advantages
borg, Sweden) can be used to measure implant inser- 1. Detect bone density
tion torque in Ncm to indirectly represent J/mm3. 2. High correlation between cutting resistance and bone quality
Insertion torque values have been used to measure 3. Reliable method to assess bone quality
4. Identify bone density during surgery
bone quality in various parts of the jaw during
5. Can be used in daily practice
implant placement.30
CRA gives a far more objective assessment of bone Disadvantages
density than clinician-dependent evaluation of bone 1. Can only be used during surgery
quality based on Lekholm and Zarb classification.31
Clinical relevance was demonstrated by studies that
showed the highest frequency of implant failures in REVERSE TORQUE TEST
jaws with advanced resorption and poor bone qual-
ity, often seen in maxilla.17,18,32–34 Therefore, cutting Unlike CRA, which measures the bone density and
resistance value may provide useful information in the resistance to cutting torque, the reverse torque
determining an optimal healing period in a given test (RTT), proposed by Roberts et al38 and devel-
arch location with a certain bone quality.26 oped by Johansson and Albrektsson,39–41 measures
The major limitation of CRA is that it does not give the “critical” torque threshold where bone-implant
any information on bone quality until the osteotomy contact (BIC) was destroyed. This indirectly provides
site is prepared. CRA also cannot identify the lower information on the degree of BIC in a given implant.
“critical” limit of cutting torque value (ie, the value at In the study conducted by Johansson and Albrekts-
which an implant would be at risk).29 Furthermore, son, a reverse torque was applied to remove implants
longitudinal data cannot be collected to assess bone placed in the tibiae of rabbits 1, 3, 6, and 12 months
quality changes after implant placement. Its primary postsurgery. Reverse torque value and histologic
use, therefore, lies in estimating the primary stability evaluation showed that greater BIC could be
of an implant. For instance, in Misch’s 6 time-depen- achieved with a longer healing time. Similar observa-
dent stages of implant failures—(1) surgical, (2) tions at the histologic level have been made in other
osseous healing, (3) early loading, (4) intermediate, (5) animal studies.42–44 Removal torque value (RTV) as
late, and (6) long-term 35 —CRA can only provide an indirect measurement of BIC or clinical osseointe-
information on the first 2 stages. Estimation of gration was later reported to range from 45 to 48
implant primary stability alone from CRA is still of Ncm in 404 clinically osseointegrated implants in
value, as high implant failure rates are observed in humans.45 Sullivan et al further speculated that any
the first 3 phases.36,37 Nonetheless, long-term evalua- RTV greater than 20 Ncm may be acceptable as a cri-
tion of implant stability after implant placement, terion for a successful osseointegration, since none
phases 3 to 7, is desired and should not be over- of the implants in their study45 could be removed
looked. This limitation has led to development of during abutment connection at 20 Ncm. It was fur-
other diagnostic tests. Table 3 summarizes CRA. ther suggested that RTT is, therefore, a reliable diag-
nostic method for verification of osseointegration.

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Table 4 Implant Stability Measurement Based on be difficult to excite because of a damping effect
Modal or Vibration Analysis from boundary conditions such as the periodontal
ligament (PDL) in an in vivo model. 49 By altering
Theoretical Modal Analysis
boundary conditions such as the bone level, FEM can
1. Finite element method theoretically be used to calculate the anticipated
stress and strain in various simulated peri-implant
Experimental Modal Analysis
bone levels.50,51
1. Percussion test Experimental or dynamic modal analysis, on the
2. Impact hammer method (Periotest, Siemens, Bensheim,
other hand, measures structural changes and
Germany; Dental Mobility Checker, J. Morita, Suita, Japan)
3. RFA (Osstell, Integration Diagnostics, Göteborg, Sweden; dynamic characteristics (eg, natural characteristic fre-
Implomate, Bio Tech One, Taipei, Taiwan) quency, characteristic mode, and attenuation) of a
4. Others (pulsed oscillation waveform by Kaneko) system that is excited in an in vitro model via vibra-
tion testing (eg, impactor or hammer). This in vitro
approach provides a more reliable assessment of an
object than a theoretical model. This analysis has
However, this method has been criticized as being been applied in dentistry to quantify the degree of
destructive.8 Brånemark et al2 cautioned about the osseointegration and implant stability.49 Frequency
risk of irreversible plastic deformation within peri- analysis and mechanical impedance analysis can be
implant bone and of implant failure if unnecessary used for detecting response waves in modal
load was applied to an implant that was still under- analysis.52 By combining the vibration and response
going osseointegration. Furthermore, a 20-Ncm detecting methods, various kinds of vibration analy-
threshold RTV for successful osseointegration has ses can be performed.53 Some techniques derived
not yet been supported by scientific data. The from these theoretical concepts are being tested for
threshold limit varies among patients depending on use in evaluating implant mobility.
the implant material and the bone quality and quan-
tity. A threshold RTV may be lower in type 4 bone Percussion Test
than in denser bone, for instance. Hence, subjecting A percussion test is one of the simplest methods that
implants placed in this bone type to RTV may result can be used to estimate the level of osseointe-
in a shearing of BIC interface and cause implant fail- gration. 8,54–56 This test is based upon vibrational-
ure. Furthermore, RTV can only provide information acoustic science and impact-response theory. A clini-
as to “all or none” outcome (osseointegrated or cal judgment on osseointegration is made based on
failed); it cannot quantify degree of osseointegration. the sound heard upon percussion with a metallic
Hence, RTT is mainly used in experiments. instrument. A clearly ringing “crystal” sound indicates
successful osseointegration, whereas a “dull” sound
may indicate no osseointegration. However, this
MODAL ANALYSIS method heavily relies on the clinician’s experience
level and subjective belief.Therefore, it cannot be used
Modal analysis measures the natural frequency or experimentally as a standardized testing method.
displacement signal of a system in resonance, which
is initiated by external steady-state waves or a tran- Impact Hammer Method
sient impulse force (Table 4). Modal analysis, in other Impact hammer method is another example of tran-
words, is a vibration analysis. It is widely used as an sient impact as a source of excitement force during
effective test method for structural analysis in engi- experimental modal analysis.53,57 It is an improved
neering and the health-care field.46,47 Dental applica- version of the percussion test except that sound gen-
tions include the quantification of osseointegra- erated from a contact between a hammer and an
tion. 48–51 Modal analysis can be performed in 2 object is processed through fast Fourier transform
models: theoretical and experimental.52 (FFT ) for analysis of transfer characteristics. By
Two or 3-dimensional finite element modeling enhancing the response detection using various
(FEM) is an example of computer-simulated theoreti- devices, such as a microphone, an accelerometer, or a
cal modal analysis, which is mathematically con- strain gauge, and by processing the detected
structed using known biomechanical properties (eg, response with FFT, it becomes possible to quantify
Young’s modulus [Pa], Poisson ratio, and density in and qualify the response wave in the form of disloca-
g/cm3) of structures of interest. Theoretical modal tion, speed, acceleration, stress, distortion, sound, and
analysis such as FEM may be useful in investigation other physical properties. Periotest (Siemens, Ben-
of the vibrational characteristics of objects that may sheim, Germany) and Dental Mobility Checker (DMC;

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J. Morita, Suita, Japan) are currently available mobility processed by FFT for conversion for analysis in the
testers designed according to the impact hammer time axis. Hence, the duration of the first wave gener-
method. The former has an electromagnetically dri- ated by the impact was detected.62 DMC uses a small
ven and electronically controlled tapping head that impact hammer as an excitation device. It is easily
hammers an object at a rate of 4 times per second. used even in molar regions. DMC may provide quite
Contact time between the tapping head and the stable measurement for osseointegrated implants.63
object is also measured. DMC utilizes the same prin- There are some problems, however, such as the diffi-
ciple of tapping a tooth or implant with a dental culties of double-tapping and difficulty in attaining
hammer. A frequency response function is built-in to constant excitation. Furthermore, the application of a
detect bone-quality–dependent sound. small force to an implant immediately after placement
may jeopardize the process of osseointegration.2
Pulsed Oscillation Waveform
Kaneko et al58,59 described the use of a pulsed oscil- Periotest
lation waveform (POWF) to analyze the mechanical Periotest has been thoroughly studied and advo-
vibrational characteristics of the implant-bone inter- cated as a reliable method to determine implant sta-
face using forced excitation of a steady-state wave. bility.8,64–71 Unlike DMC, which applies impact force
POWF is based on estimation of frequency and with a hammer, Periotest uses an electromagnetically
amplitude of the vibration of the implant induced by driven and electronically controlled tapping metallic
a small pulsed force. This system consists of acousto- rod in a handpiece. Response to a striking or “bark-
electric driver (AED), acoustoelectric receiver (AER), ing” is measured by a small accelerometer incorpo-
pulse generator, and oscilloscope. Both the AED and rated into the head. Like DMC, contact time between
AER consist of a piezoelectric element and a punc- the test object and tapping rod is measured on the
ture needle. A multifrequency pulsed force of about time axis as a signal for analysis. The signals are then
1 kHz is applied to an implant by lightly touching it converted to a unique value called the Periotest
with 2 fine needles connected with piezoelectric ele- value (PTV), which depends on the damping charac-
ments. Resonance and vibration generated from teristics of tissues surrounding teeth or implants.72
bone-implant interface of an excited implant are Although they use different types of receivers for
picked up and displayed on an oscilloscope impulse responses, DMC and Periotest are similar in
screen.58,59 An in vitro study showed that the sensi- terms of their theoretical background. They both use
tivity of the POWF test depended on load directions a transient impulse as an excitation force, and in both
and positions.58 Sensitivity was rather low for the cases analysis is conducted on the time axis. In addi-
assessment of implant rigidity. tion, both were originally developed to measure the
mobility of a natural tooth.64,65
In the case of a natural tooth, the buffering capac-
IMPLANT STABILITY ity of the PDL poses a problem in analyzing the dis-
EVALUATION METHODS tribution of impact force exerted on a tooth. When
dynamic characteristics are analyzed based upon an
DMC and Periotest are based on the impact hammer assumption that the whole periodontal structure
method, in which impact force is used as the excita- functions as a mechanical unit, it is difficult to model
tion force. In this theory, “the width of the first peak the attenuation from the PDL. The soft tissue, includ-
on the time axis of the spectrum generated by tran- ing the periosteum, is considered a viscoelastic
sient impulse is inversely proportional to the time medium; thus, Hooke’s law does not apply to the
axis of the impulse.”57,60,61 Therefore, in the presence behavior of the PDL under an applied load. Thus, vis-
of impact force, lower rigidity of the tested substance coelasticity of the PDL has always posed a difficulty
results in a longer time axis. in analysis of the physical characteristics of peri-
odontal tissue. By contrast, bone-implant interface
Dental Mobility Checker with no PDL is believed to be similar to the serial
The DMC, which was originally developed by Aoki60 spring model which follows Hooke’s law, and mobil-
and Hirakawa, 61 measures tooth mobility with an ity measurement is considered easier.
impact hammer method using transient impact Most reports of the use of a natural tooth mobility
force. Aoki and Hirakawa successfully detected the detector such as Periotest to measure implant mobil-
level of tooth mobility by converting the integration ity have pointed out a lack of sensitivity in these
(ie, rigidity) of tooth and alveolar bone into acoustic devices. 55,68 Such devices permit a ver y wide
signals. A microphone was used as a receiver. The dynamic range (in case of Periotest, PTV is –8 to +50)
response signal transferred from the microphone is to permit the measurement of a wide variety of nat-

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ural tooth mobility.68 However, the dynamic range PTV of an osseointegrated implant falls in a relatively
used for measuring implant mobility is very limited. narrow zone (–5 to +5) within a wide scale (–8 to
Thus, the sensitivity of these devices is insufficient to +50).64 Other studies have indicated that the PTVs of
measure implant mobility. clinically osseointegrated implants fall within an
Although many similarities do exist between the even narrower zone (–4 to –2 or –4 to +2).76,78 There-
tissue structures around an implant and a natural fore, the measured PTV may falsely be interpreted as
tooth, conclusions from periodontal studies may not having a small standard deviation and therefore
be directly applicable to implants.73 In the use of viewed as having a good accuracy. PTV cannot be
mobility measurement to assess implant stability, the used to identify a “borderline implant” or “implant in
presence or absence of a PDL makes a crucial differ- the process of osseointegration” which may or may
ence. Similar to impact/vibration testing, values mea- not continue to a successful osseointegration.77 No
sured with Periotest are significantly influenced by conclusion has been made with regard to this issue.
excitation conditions, such as position and direction. It has been suggested that these limitations of
The Periotest user’s manual contains clear instruc- Periotest measurement have been suggested to be
tions about striking point position and angle: “The strongly related to the orientation of excitation source
Periotest measurement must be made in a midbuc- or striking point. In vitro and in vivo experiments
cal direction” and “During measurement the Periotest demonstrated that the influence of striking point on
handpiece must always be held perpendicular to the PTV is much greater than the effects from increased
tooth axes.”72 Considering the intraoral environment, implant length due to marginal bone resorption or
and the pen-grip–shaped handpiece of the Periotest, other excitation conditions such as the angle of the
it is clear that it can be used quite easily for the ante- handpiece or repercussion of a rod.55,75 Unfortunately,
rior region. However, its use for the molar region is controlling these influential factors is extremely diffi-
extremely difficult because of the presence of buccal cult. Despite some positive claims for Periotest,68,69
mucosa.74 Derhami et al 75 used a fixing device to the prognostic accuracy of PTV for implant stability
hold a handpiece at the correct angle. This fixing has been criticized for a lack of resolution, poor sensi-
device was used for an in vitro measurement using a tivity, and susceptibility to operator variables.8,79
cranial bone model, and its clinical application seems
difficult. However, Periotest is believed to be an effec- RFA
tive evaluation method once the difficulty of control- RFA has recently gained popularity. It is a noninvasive
ling impact force is solved. diagnostic method that measures implant stability and
Long-term data on Periotest have shown that it bone density at various time points using vibration and
can be an objective clinical measurement of the sta- a principle of structural analysis.57 RFA utilizes a small L-
bility of bone-implant anchorage.70,71 Aparicio used shaped transducer that is tightened to the implant or
Periotest to measure implant stability and found a abutment by a screw. The transducer comprises 2
direct correlation between PTV and the degree of ini- piezoceramic elements, one of which is vibrated by a
tial osseointegration.69 It was further suggested that sinusoidal signal (5 to 15 kHz). The other serves as a
PTV should be included in the current success crite- receptor for the signal. Resonance peaks from the
ria. Another study with sample size of more than received signal indicate the first flexural (bending) reso-
2,900 implants showed a similar finding.70,71 How- nance frequency of the measured object. In vitro and in
ever, differences with respect to implant design, vivo studies have suggested that this resonance peak
diameter, length, and bone quality and quantity were may be used to assess implant stability in a quantitative
not accounted for in that study; analysis in a pattern manner.
of changes over time may be more reasonable. A Currently, 2 RFA machines are in clinical use: Osstell
measured bone value only represents its condition at (Integration Diagnostics) and Implomates (Bio Tech
the moment of measurement. Bone is subject to life- One). Osstell has combined the transducer, computer-
long metabolism, which will in turn affect PTV over ized analysis and the excitation source into one
time. Thus, average value is not a proper way to machine closely resembling the model used by
determine a critical value for implant stability. Meredith. In the early studies, the hertz was used as
Even if it could be assumed that PTV precisely the measurement unit.28,54,56,80–89 Later, Osstell cre-
reflects the condition of BIC as reported by previous ated the implant stability quotient (ISQ) as a measure-
studies, 76,77 an average PTV has no importance. ment unit in place of hertz. 90–103 Resonance fre-
Johansson and Albrektsson observed that “implants quency values ranging from 3,500 to 8,500 Hz are
inserted in different people do not necessarily attain translated into an ISQ of 0 to 100. A high value indi-
the same degree of integration.”39 Despite a wide cates greater stability, whereas a low value implies
variation in host factors such as bone density, normal instability. The manufacturer’s guidelines suggest that

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a successful implant typically has an ISQ greater than of implant and bone are constant. The only factor
65. An ISQ < 50 may indicate potential failure or that could significantly influence the stiffness and
increased risk of failure.104 resonance frequency of the implant would be the
It is assumed that an implant and the surrounding exposed implant length, as shown in several stud-
bone function as as a single unit; thus, a change in ies. 8,56,80,102,107–109 Therefore, measurement of the
stiffness is considered to represent the change of stiffness at the interface provides reliable informa-
osseointegration of an implant. A steady-state sinu- tion as to the implant stability.
soidal force in a form of sine wave is applied to the Stiffness of supporting structure may, however,
implant-bone unit to measure the implant stability via influence the stiffness of the interface of an area of
resonance. Frequency and amplitude are then picked interest.80,81,109–111 In most in vitro studies,107,109,110
up as a response.90,91 An in vitro model showed that such as that of Meredith et al,54 an aluminum block
resonance frequency of an implant placed in an alu- material with uniformity and linearity has been used
minum block ranged from 8 to 9 kHz.8,54 An in vivo as a supporting structure. Therefore, in this model, an
human study also showed that, although amplitude implant behaves in a mathematically predictable
of the resonance peak was smaller than in vitro data, manner in which resonance frequency is inversely
the peak resonance frequency of clinically osseointe- proportional to the length of the cantilever beam.
grated implants was also about 8 to 9 kHz.8 Moreover, Bone, on the other hand, is composed of calcium
resonance frequency increased as polymerization of phosphate (85%), calcium carbonate (10%), and fluo-
the resin progressed.54 ride ions (~ 5%), the amounts of which continuously
Effective implant length (EIL) was a value calcu- change to maintain a dynamic equilibrium.112 There is
lated by adding the amount of exposed implant great interindividual variation. Furthermore, bone
threads and the length of each abutment. EIL has does not behave like a uniform material under func-
been shown to be inversely proportional to the level tional loading. Hence, in modal analysis, the sharpness
of resonance frequency, with a correlation coefficient and amplitude of the resonance peak of an implant
of r = –0.94 in vitro and r = –0.78 in vivo.8,54 Several in embedded in bone tend to be lower than those of an
vivo animal and human clinical studies have con- implant in an aluminum block. In a nonlinear object
curred with this finding.56,80,102 No resonance peak with a large attenuation (eg, PDL), a theoretical modal
was observed in failed implants with clinical mobility.8 analysis is a more feasible analysis than an experi-
Longitudinal changes in resonance frequency have mental modal analysis, as stress and strain do not
also been evaluated. Implants placed in the rabbit behave proportionally to one another. Many influenc-
tibia were measured over 168 days from the time of ing factors render interpretation of implant stability
implant placement81; resonance frequency increased difficult from a single resonance value.
over time. Other studies have evaluated longitudinal Like Osstell, Implomates, which was developed by
changes in ISQ more in detail.90–92,94,95,98,105 ISQ was Huang et al,52,107–110 uses RFA. However, it utilizes an
found to decrease significantly after implant place- impact force to excite the resonance of implant
ment for several weeks. However, a recovery to the ini- instead of a sinusoidal wave. Impact force is provided
tial ISQ level was found at the time of implant loading. by a small electrically driven rod inside the trans-
Furthermore, a greater increase of resonance fre- ducer. The received response signal is then trans-
quency over time was observed with implants placed ferred to a computer for frequency spectrum analysis
in softer bone.28,91,98 In the case of an implant placed (range, 2 to 20 kHz). The first biggest amplitude indi-
in grafted bone in an in vivo human study,106 very low cates the resonance frequency of interest. Higher fre-
resonance frequency (4 to 5 kHz) was observed. quency and sharp peak indicate a more stable
Based upon these findings, the following 3 con- implant, whereas a wider and lower peak and lower
clusions have been suggested.106 First, “stiffness” of frequency indicate implant failure. Currently, few
an implant is a function of its geometry and material studies have been reported regarding the efficacy of
composition (length, diameter, overall shape). Sec- this machine.
ond, the stiffness of the implant-tissue interface
depends on the bond between the surface of the
implant and the surrounding bone. Third, the stiff- CLINICAL APPLICATION OF RFA
ness of the surrounding tissue is determined by the
ratio of cancellous to cortical bone and the density of Presently, clinical application of RFA includes estab-
the bone with which an implant engages.8 Stiffness lishing (1) a relationship between exposed implant
found at the bone-implant interface (second point) length and resonance frequency or ISQ values; (2)
changes over time. The factors affecting stiffness differential interarch and intra-arch ISQ values for
remain relatively stable, as the mechanical properties implants in various locations; 83,90–92,98,103,105 (3) prog-

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Table 5 Factors that Influence RFA gated. The most challenging factors to overcome are
the dynamic characteristics (eg, damping effect, total
Constants
mass, and stiffness) of various factors surrounding
Implant length the object of interest, 111 bone-implant interface.
Implant diameter Without controlling these factors, information
Implant geometry (implant system)
gained from RFA is no better than guessing value. To
Implant surface characteristics
Placement position improve its prognostic value of RFA, longitudinal
Abutment length studies and comparison of RFA values with histologic
studies are essential. Development of simulation
Variables models on various EILs associated with various
Bone quality defect types may further assist in the assessment of
Bone quantity implant stability.
Damping effect of marginal mucosa The shape of the transducer (an L shape) restricts
BIC (3-dimensional)
EIL
its orientation, which adds a significant length to the
Connection of transducer exposed implant length, potentially masking a small
amount of bone resorption.54 Osstell Mentor (Inte-
Primary stability gration Diagnostics) eliminates the use of an
attached L-shape transducer by generating “pulse
Secondary stability trains” from a contact-free probe. Impact signals are
then picked up by a receptor called a “smart-peg.”
Hence, the measurement is believed to be more
accurate than the original Osstell machine. Moreover,
in cases of Kennedy III partial edentulism, this con-
tact-free smart-peg allows assessment of implant
stability from any direction. However, due to the dif-
nostic criteria for long-term implant success; and (4) ference in EIL and various bending forces from the
diagnostic criteria for implant stability.94,95,105 different design of the transducer, data collected
EIL has been shown to significantly influence ISQ with the original Ostell machine and that collected
value.8,54,56,80,102,107–109 Although the stiffness of the with the new contact-free Osstell should be com-
implant is generally constant, it can sometimes vary pared with caution.
in the presence of other contributing stiffnesses The establishment of diagnostic criteria for suc-
(Table 5). Classification of ISQs based upon various cess, survival, and/or failure is another clinical appli-
conditions may be a grand task. However, if these cation with RFA. However, RFA can only give informa-
variables are ignored, the reliability of the measure- tion regarding success; it cannot provide information
ment will be low.101,102 Therefore, only series of intra- with respect to survival or failure. ISQ can be fairly
patient RFA values over various time points may pro- reliable when an implant has achieved osseointegra-
vide useful information as to the stability of an tion and the bone-implant interface is rigid. 98 In
implant under investigation. Furthermore, these cases where rigid integration is doubtful, however,
series of values may not indicate the success or fail- the ISQ tends to fluctuate. Some doubtful implants
ure of the implants.105 result in failure, whereas some implants showing low
This concurs the research of Friberg et al with ISQ later stabilize and achieve a satisfactory out-
respect to cutting torque resistance measure- come.83 Hence, clinicians will continue to test the
ment.28,29,83 Insertion torque was also highly associ- implant stability until they get a reasonable value.
ated with resonance frequency of implants.30 Lower When unacceptable values are displayed, however,
resistance and lower resonance frequency values these values are often rejected. If the repeated mea-
were associated with poor bone quality. This may be surements still indicate an unfavorable result, these
related to the finding that implant success and sur- values are unwillingly accepted. Hence, small stan-
vival rates are greater in the mandible than in the dard deviation is often reported with high ISQ.
maxilla.101,113,114 Prolonged healing time is required The evaluation of implant stability using RFA
in cases with poor bone quality. Therefore, even machines such as Osstell and Implomates still has
though an implant placement in softer bone shows some uncertain issues. It is clinically being used with-
low stability, it seems to “catch up” to dense bone out much conclusive data on the bone-implant inter-
sites over time.28 face and resonance frequency values. 79,91 Further
The prognostic value of RFA machines such as research is needed to establish higher reliability of
Osstell and Implomates has, therefore, been investi- these diagnostic devices.

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CONCLUSION 14. Attard NJ, Zarb GA. Long-term treatment outcomes in eden-
tulous patients with implant overdentures: The Toronto
study. Int J Prosthodont 2004;17:425–433.
To date, no definite method to evaluate implant sta-
15. Attard NJ, Zarb GA. Long-term treatment outcomes in eden-
bility has been established. Although the theory tulous patients with implant-fixed prostheses: The Toronto
behind RFA is sound, the technology cannot provide study. Int J Prosthodont 2004;17:417–424.
a critical value that can determine the success, fail- 16. Hermann JS, Schoolfield JD, Nummikoski PV, Buser D, Schenk
ure, or long-term prognosis of an implant. Hence, RK, Cochran DL. Crestal bone changes around titanium
implants: A methodologic study comparing linear radi-
present position from this review is that information
ographic with histometric measurements. Int J Oral Maxillo-
should be assembled from many diagnostic aids to fac Implants 2001;16:475–485.
assure long-term implant stability. More research in 17. van Steenberghe D, Lekholm U, Bolender C, et al. Applicability
this field is certainly needed. of osseointegrated oral implants in the rehabilitation of par-
tial edentulism: A prospective multicenter study on 558 fix-
tures. Int J Oral Maxillofac Implants 1990;5:272–281.
18. Adell R, Lekholm U, Rockler B, Brånemark P-I. A 15-year study
ACKNOWLEDGMENT of osseointegrated implants in the treatment of the edentu-
lous jaw. Int J Oral Surg 1981;10:387–416.
This work was partially supported by the University of Michigan 19. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-
Periodontal Graduate Student Research Fund. term efficacy of currently used dental implants: A review and
proposed criteria of success. Int J Oral Maxillofac Implants
1986;1:11–25.
20. Smith DE, Zarb GA. Criteria for success of osseointegrated
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COPYRIGHT © 2007 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS
ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER