J Clin Periodontol 2007; 34: 359–366 doi: 10.1111/j.1600-051X.2007.01047.

Ghada Alsaadi1, Marc Quirynen1,

A biomechanical assessment of Katleen Michiels1, Reinhilde Jacobs2
and Daniel van Steenberghe1,3

the relation between the oral

1
Department of Periodontology and 2Oral
Imaging Centre, School of Dentistry, Oral
Pathology and Maxillofacial Surgery, Faculty

implant stability at insertion and

of Medicine, Catholic University of Leuven,
Leuven, Belgium; 3Catholic University
of Leuven, Leuven, Belgium; holder of
P–I Brånemark chair in osseointegration

subjective bone quality

assessment
Alsaadi G, Quirynen M, Michiels K, Jacobs R, van Steenberghe D. A biomechanical
assessment of the relation between the oral implant stability at insertion and subjective
bone quality assessment. J Clin Periodontol 2007; 34: 359–366. doi 10.1111/j.1600-
051X.2007.01047.x.

Abstract
Aim: The study was set to evaluate the validity of subjective jaw bone quality
assessment.
Materials and Methods: A total of 298 patients (198 females, mean age 56.4) were
treated with oral implants at the Periodontology Department at the University Hospital
of KUL. A total of 761 TiUnitet implants have been installed. Subjective bone quality
assessment was performed on radiographs and by the surgeon’s tactile sensation and
was compared with torque measurements. In a subset of patients, implant stability was
also assessed by implant stability quotient and/or periotest values.
Results: Subjective assessment of bone quality was related to the PTV, ISQ and
placement torque [in the crestal, the second and the apical third (N cm)], respectively;
in grade 1: 5.3, 73.3 (4.2, 9.6, 15.2), and grade 3 or 4: 1.6, 55 (3.3, 5.5, 8.4). For
the surgeon’s tactile sensation, a good correlation was noted for the presence of a thick
cortex: 4.6, 70.3 (4.2, 9.7, 15.1), or a thin one: 0.3, 65.9 (3.6, 6.9, 10.1). For dense
Key words: biomechanics; bone quality;
trabecular bone, the values were 2.8, 69.4 (4.4, 9.7,14.8), while for poor trabecular
dental implants; insertion torque; oral implants;
bone, the values were 1.7, 66.4 (3.6, 6.4, 9.8). osseointegration; periotest; RFA
Conclusions: Subjective assessment of bone quality is related to PTV, ISQ and
placement torque measurements at implant insertion. Accepted for publication 26 November 2006

Several clinical reports on the use of of 99% was reported even after 15 years apposition process on the implant sur-
oral implants mention that poor bone with Brånemark systems implants face and rather lead to fibrous scare
quality, as assessed on pre-operative (Nobel Biocare, Gothenburg, Sweden) tissue formation (Szmukler-Moncler
radiographs, lead to a less predictable (Lindquist et al. 1996), in distal areas of et al. 1998). The assessment of the pri-
outcome (Porter & von Fraunhofer the upper jaw it can be substantially mary stability at insertion may be
2005). While in well-mineralized bone lower (Adell et al. 1990, Nevins & another option to determine the prog-
with proper degrees of corticalization, Fiorellini 1998). It thus seems relevant nosis or to decide whether early or even
like the symphyseal area a success rate to develop measurements of the bone immediate loading can be performed.
quality, especially referring to its miner- The alternative is to let the bone-to-
Conflict of interest and source of al density, as a determinant for the implant interface heal for a few months
funding statement primary stability of endosseous before being exposed to the oral envir-
implants. It has been indeed observed onment as described in the original P–I
The authors declare that they have no
conflict of interest.
that too large micromovements during Brånemark protocol (Brånemark et al.
the healing period can disrupt the bone 1985).
r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard 359
360 G. Alsaadi et al.

One available technique to determine surrounding bone (Friberg et al. 1999a). ling, as experienced by the surgeon
the bone mineral content is to take The Osstellt device (Mentor, Integration when preparing the fixture site. For the
biopsies of the jaws. This procedure is Diagnostics AB, Sävedalen, Sweden) has latter, a scale, ranging from grade 1
certainly reliable and safe but does not less documentation but also allows regis- (very thick cortex/dense trabecular
seem practical in a routine clinical tration of minute changes in the rigidity bone) to grade 3/4 (thin or very thin
situation. of the bone-to-implant contact. cortex/poorly or very poorly minera-
The most popular current method of The aim of the study was to evaluate lized trabecular bone), was introduced
bone quality assessment is that devel- the validity of subjective jaw bone qual- (Table 1). Indeed, the last two scores
oped by Lekholm & Zarb (1985), who ity assessment by comparing it with an were grouped because a distinction is
introduced a scale of 1–4, based on both objective parameter: the torque force limited.
the radiographic assessment, and the needed to install implants, besides the Besides, the bone quality was
sensation of resistance experienced by primary stability of these implants mea- assessed objectively during implant
the surgeon when preparing the fixture sured either by ISQ or PTV, or both, insertion, by means of an electronic
site. The grading refers to individual were also related to the subjective bone torque force measurement device, which
experience, and furthermore, it provides quality assessment when the measure- is part of a controlled motor device. The
only a rough mean value of the entire ment was available. latter measures the torque force while
jaw. Johansson & Strid (1994) described tapping or inserting the implant at a
a technique whereby bone quality as a slow speed (OsseoCaret, Nobel Bio-
function of density and hardness could Materials and Methods care, Gothenburg, Sweden). The Osseo-
be derived from the torque forces A total of 298 consecutive patient files Caret motor was developed to insert
needed during the implant insertion. (198 females) were analysed. They the implant into the (pre-tapped) bone
They postulated that the energy used in represent the total patient population site with a well-controlled insertion tor-
tapping the site, before or during treated by means of implants at the que of 20, 30, 40 or 50 N cm (Fig. 2a, b).
implant placement, is a combination of Department of Periodontology of the The software controls and registers
the thread placement force from the tip University Hospital of the Catholic Uni- the operation of the hand-piece micro-
of the instrument and the friction created versity Leuven between November 2003 motor, and monitors the torque deliv-
as the remaining part of a tap or implant and June 2005. The mean age was 56.4 ered, as well as the number of turns
enters the site. It has been demonstrated years (range: 18–86). performed. The software records the
in ex vivo human preparations that the All patients have been provided with cutting torque resistance as mean values
cutting resistance during implant instal- a total of 761 Mark III TiUnitet (N cm) at the crestal third, the middle
lation correlates well with the bone implants (Brånemark systems, Nobel third and the apical third of each implant
density as assessed by microradiography Biocare, Gothenburg, Sweden). At insertion trajectory.
(Friberg et al. 1995) implant insertion, a minimal bone height The rigidity of the implant–bone con-
The absence of fixture mobility either of 7 mm had to be available. The classi- tinuum was assessed by the resonance
indicative of a good primary stability or cal surgical protocol with strict sterility frequency analysis method (Osstellt
after a while of an intimate bone-to- measures as defined by Brånemark was Mentor, Integration Diagnostics AB;
implant contact can be objectively used for all surgeries. Bone quality Fig. 3a–c). These measurements were
determined by an electronic measuring assessment was performed using the performed at implant insertion as well as
system, the Periotests (Siemens, AG, Lekholm & Zarb (1985) index. It con- just before the abutment insertion (after
Bensheim, Germany) (Olivé & Aparicio sists of a scale of 1–4 (Fig. 1). A copy of submerged healing). The RFA techni-
1990, Teerlinck et al. 1991, van Steen- this grading system is available. The que analyses the resonance frequency
berghe & Quirynen 1993, van Steen- score was given immediately after (range: 1100–10,000 Hz) of a peg
berghe et al. 1995). This apparatus is implant placement. (Smartpegt, Integration Diagnostics AB),
widely used to assess implant outcome Tactile sensation was assessed as which can be attached to the fixture with
as can be seen from the hundreds of such for both the cortical bone and the the aid of a mount; 4–5 N cm of torque is
papers referring to it (http://www. trabecular part during high-speed dril- enough. Subsequently, the probe is held
periotest.de). The periotest values
(PTV) reveals the increased stiffness of
the implant–bone continuum over time
(Tricio et al. 1995).
Implant stability can also be measured
by resonance frequency analysis, nor-
mally referred to as implant stability
quotient (ISQ) Meredith 1998. The in
vivo experimental findings demonstrate
Fig. 1. Grading system for bone quality assessment (Lekholm & Zarb 1985).
that resonance frequency is related to
implant stiffness in the surrounding tis-
sues, which means a higher bone-to- Table 1. Tactile evaluation of the cortical and trabecular bone during surgery
implant contact percentage (Rasmusson
et al. 1998). Clinically, the increase in Grade 1 Grade 2 Grades 3, 4
implant stability has been measured
Cortical bone Thick Moderate (very) Thin
using ISQ, and the increase in mobility Trabecular bone Dense Moderate (very) Poor
was attributed to corticalization of the
r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard
 Oral implant stability at insertion and subjective bone quality assessment 361

Fig. 2. (a) OsseoCaret Unit. The screen shows a graph like (b). The OsseoCaret software curve of the placement torque (N cm) in the first,
second and third during implant placement.

close to the peg in a vestibular-oral and otests device (Siemens AG) after con- The values were only accepted when
in a mesio-distal direction during the necting a temporary abutment (Cekas, two consecutive measurements did not
pulsing time. After the processing time, Alphadent, nv, Antwerp, Belgium) 4 mm deviate more than one unit from each
the ISQ value is presented on the dis- in length. Because of time pressure in the other. The arbitrary values can range
play. The resonance frequency values OR and/or patient-related factors, this pro- from 8 (very stable) to 150 (extre-
are automatically converted into an arbi- cedure was only performed in a subgroup mely mobile) (Fig. 4).
trary index called the ISQ. The ISQ, of 22 patients provided with a total of 44 Although not useful to assess the
which runs from 1 to 100; the higher implants. These PTV were also recorded biomechanics of teeth, it appeared that
the ISQ, the more stable the implant. at abutment surgery. This device measures the Periotests was very useful for the
This index facilitates clinical evalua- the damping capacity of the implant–bone assessment of implant stability (Olivé &
tion (Meredith 1994, Meredith et al. continuum. It consists of a hand-piece Aparicio 1990, Teerlinck et al. 1991,
1996). The device was only available connected to a unit that analyses the van Steenberghe et al. 1995).
at implant placement for the last 141 braking time of the rod projected onto a
patients. Unfortunately, because of tech- surface (Tricio et al. 1995). The rod of the Statistical analysis
nical problems encountered at the begin- device is placed perpendicular to the abut-
ning, measurements could only be made ment at a distance of 2 mm. Then, the rod Data were statistically analysed by
on 71 patients provided with a total of is accelerated electromagnetically. When means of SASs software version 9.1
153 implants. the rod hits the implant, it is decelerated. for windows (SAS Institute, Cary, NC,
The rigidity of implant–bone continuum The faster the deceleration, the greater the USA). Pearson’s correlation coefficients
was also recorded by means of a Peri- implant stability in the bone tissue. were calculated using PROC MIXED
r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard
362 G. Alsaadi et al.

Fig. 3. (a, b) Fixation of the peg on the implant, (c) Osstellt Mentor; stimulation and recording of the resonance frequency of the peg.

Fig. 4. (a) The Periotests device with a digital display and the microphone for the artificial voice, (b) The rod hits the abutment after
acceleration.

fitting a bivariate model. In order to assessed by the surgeon’s tactile sensa- region separately was performed. The
assess mean differences statistically, a tion for the cortical and trabecular bone. p-value was set to 0.05 to detect the
linear model was fitted in PROC Multiple testing corrections by the level of significance.
MIXED with the corresponding res- Tukey’s procedure for pair-wise differ-
ponse value, placement torque values in ences when applicable were used.
the crestal, middle and apical third sepa- The ISQ values at implant insertion
rately, ISQ and PTV and covariates bone were dichotomized (cutoff 5 60). Based Results
quality according to the Lekholm & Zarb on these, a comparison for the place- From a total of 761 implants, installed in
(1985) index and bone quality as ment torque measurements within each the 298 patients, the placement torque
r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard
 Oral implant stability at insertion and subjective bone quality assessment 363

Table 2. Frequency distribution of 720 implants in the upper and lower jaws (UJ and LJ) and the Table 5. Frequency distribution of implants in
corresponding placement torque measurements the upper and lower jaws and the correspond-
ing PTV and ISQ values at implant insertion
Implant No. of Crestal third Middle third Apical third and at abutment connection for the same
position implants (N cm) (N cm) (N cm) implants
Mean SD Mean SD Mean SD Mean No. of At implant At abutment
implants insertion connection
Lower anterior 157 4.52 2.87 10.15 5.66 15.69 6.96
Upper anterior 185 4.46 2.51 8.52 4.39 12.25 5.21 PTV
Lower posterior 177 4.05 2.24 9.41 5.50 14.64 6.30 UJ 11 1.00 3.27
Upper posterior 201 3.86 1.76 7.41 3.77 11.30 5.22 LJ 6 5.00 3.50
LJ 334 4.27 2.56 9.76n 5.58 15.13n 6.63 Total 17 2.41 3.35n
UJ 386 4.15 2.17 7.95 4.11 11.75 5.23 ISQ
Total 720 4.21 2.36 8.79 4.93 13.32 6.15 UJ 36 67.78 72.00
n LJ 17 72.24 69.53
A significant difference was detected for placement torque measurement between upper and the
Total 53 69.21 71.21n
lower jaw (p-valueso0.0001).
n
A significant difference was found between
PTV values at implant insertion and at abutment
Table 3. Placement torque measurements versus bone quality assessment grades according to connection (p-valueo0.05), and between ISQ
Lekholm & Zarb (1985) values at implant insertion and at abutment
connection as well (p-valueo0.0001).
No. of Crestal third Middle third Apical third PTV, periotest values; ISQ, implant stability
implants (N cm) (N cm) (N cm)
quotient.
Grade 1 109 4.22 9.58 15.21
Grade 2 322 4.67
10.03
14.85


5* 5*
Grade 3 241 3.76 * 7.41 11.39 grading. The very few missing data are
Grade 4 47 3.28 3 5.49 * 3 8.38
*
related to for example placement of
A significant relationship was found between the Lekholm & Zarb index and the placement torque implant at the time of tooth extraction,
measurements (po0.0001). the presence of filling material or acci-
n
A significant difference was detected between the grades (p-valueo0.0001). dentally deleted data.
For a total of 713 implants, the place-
ment torque values were compared with
Table 4. Placement torque measurements related to the grades of bone quality assessment the trabecular bone density as assessed
according to the surgeon’s tactile sensation by the surgeon on the basis of his tactile
No. of Crestal third Middle third Apical third grading. Again, the very few missing
implants (N cm) (N cm) (N cm) data are related to factors as mentioned
above (Table 4).
Cortical bone # Comparisons were performed
Thick (grade 1) 323 4.22 9.70

15.06 between ISQ measurements at implant
Moderate (grade 2) 316 4.10 8.32 12.34 * insertion and at abutment connection for
Very thin (grade 3/4) 66 3.58 6.85 * 10.06
those implants (53) where both mea-
Trabecular bone # # #
Dense (grade 1) 295 4.38 9.71 14.83 surements were performed. The same
Moderate (grade 2) 331 4.24 8.60 12.92 was done for PTV (17) (Table 5).
* * * To evaluate the relation between two
Poor (grade 3/4) 87 3.62 6.39 9.84
objective assessments of bone quality,
Significant relationship was detected between the cortical bone grades and placement torque i.e. the insertion torque and ISQ mea-
measurements in the middle and apical thirds (p-value o0.0001), and between the trabecular
surements, a correlation was calculated
bone and placement torque measurements in the crestal (p-value 5 0.03), middle and apical thirds
(p-valueo0.0001).
on the part of the data for which these
n
Significant difference was detected between the grades (p-valueo0.0001). measurements were available. For a
total of 136 implants the insertion torque
as well as the ISQ values during surgery
measurements in the crestal, the second filling material, and therefore the place- were measured (Fig. 5). The correlation
and the apical third were recorded for ment torque for 719 implants in 288 coefficient between these two variables
720 implants installed in 288 patients, patients was measured and compared was calculated. The estimated correla-
and compared with implant position in with the bone quality assessment tion equals r 5 0.20 (SE 5 0.08). This
the jaw. A significant difference was according to the Lekholm & Zarb coefficient is significantly different
detected for placement torque measure- (1985) index. A significant relationship (p-value 5 0.01). From the latter the
ment between anterior and posterior was detected between placement torque placement torque measurement corre-
locations (p-valueo0.01). The missing and the Lekholm & Zarb index (p- sponding to ISQo60 was compared
data are due to inadvertent erasing of the valueo0.0001) (Table 3). with the placement torque measurement
Osseocares data or due to technical The placement torque measurements X60 (Table 6).
problems with the machinery (Table 2). of 705 implants were compared with the ISQ and PTV were also compared
For one implant, bone quality was not cortical bone thickness as assessed by with the bone quality assessed accord-
assessed because of the use of bone- the surgeon on the basis of his tactile ing to the Lekholm & Zarb index. A
r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard
364 G. Alsaadi et al.

36 may help the clinician to decide whether

34 such deviation of the classical osseoin-
32 tegration protocol can be considered.
30 Indeed, very large micromovements of
28 endossesous implants can lead to fibrous
26 encapsulation rather than bone apposi-
24
tion (Szmukler-Moncler et al. 1998),
and this risk increases with a lower
22
degree of bone density.
20
Although biomechanical assessments
Ncm

18
were only performed on a fraction of the
16
patients for a variety of reasons, these
14 data substantiate the main findings and
12 provide new perspectives. The workload
10 and the medical considerations or tech-
8 nical reasons sometimes led to the need
6 to pursue only the patient treatment, and
4 prevented data registration.
2 The insertion torque measurements
0 were higher in the lower jaw, especially
25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 the symphyseal area, when compared
ISQ with the upper jaw. The posterior region
of the upper jaw has the lowest torque
Fig. 5. Linear regression for placement torque at the apical third (N cm) and implant stability value, which is in agreement with a
quotient (ISQ) values at implant insertion.
previous study (Friberg et al. 1999a).
In the posterior maxilla, there is indeed
Table 6. The mean of placement torque measurements and corresponding ISQ values with a cut- frequently a (very) thin cortical bone
off at 60 n(p-value 5 0.05) combined with less dense trabecular
Torque measurements Crestal third Middle third Apical third bone (Jacobs 2003). Thus, clinicians
(N cm) (N cm) (N cm) generally observe a poor degree of
bone mineralization on the radiographs
Correspondent to ISQo60 3.94 8.00 10.41  and a limited bone resistance while
Correspondent to ISQX60 4.34 9.13 13.52 * drilling in this area (Friberg et al.
ISQ, implant stability quotient. 1995, 1999b).
Johansson et al. (2004) also found
that cutting torque values correlated
Table 7. ISQ of 146 implants compared with Table 8. PTV values versus the grades of bone with the Lekholm & Zarb index of
bone quality assessment according to Lekholm quality assessment according to Lekholm & bone quality.
& Zarb index Zarb for 44 implants Homolka et al. (2002) found a sig-
No. of ISQ No. of PTV nificant correlation between bone miner-
implants implants al density measurements and the
3 # insertion torque measurements in cada-
Grade 1 14 73.29 Grade 1 7 5.29 ver mandibles.
Grade 2 65 69.61 5 Grade 2 19 3.74 A number of studies indicated that the
Grade 3 64 70.15 Grade 3 18 1.61
* failure rate is greater in the category of
Grade 4 3 55.00 Grade 4 0 /
* quality IV bone according to the
n n
A significant difference was detected between A significant difference was detected between Lekholm & Zarb (1985) classification
the grades (p-valueo0.02). the grades (p-valueo0.05). (Engquist et al. 1988, Friberg et al.
ISQ, implant stability quotient. PTV, periotest values. 1991, Jaffin & Berman 1991). Implant
stiffness indeed means a higher bone-to-
implant contact percentage (Rasmusson
significant relationship was detected Discussion et al. 1998), which can explain the better
(p-value 5 0.01; Tables 7 and 8). prognosis.
Furthermore, ISQ and PTV recorded Subjective assessments seem to have a In the literature, the ISQ readings
at implant insertion were also compared limited value when trying to discrimi- obtained during the early phases of
with the bone quality assessed according nate among bone qualities; the present osseointegration revealed higher
to the surgeon’s tactile sensation. A data indicate that definitely for the implant stability in the mandible com-
significant relationship was detected extreme categories (1 and 4), the rela- pared with the maxilla (Ersanli et al.
between ISQ, PTV and cortical bone tionship with objective parameters is 2005). It is striking that this difference
grades (p-value 5 0.02, o0.0001, good. Especially today, where early or seems to decrease in the present study
respectively), and between ISQ and tra- immediate loading of endosseous (see Table 5) during the osseointegra-
becular bone grades (p-value 5 0.01; implants is being considered more and tion process. It may indicate that a better
Tables 9 and 10). more, these biomechanical parameters marrow content in the upper jaw may
r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard
 Oral implant stability at insertion and subjective bone quality assessment 365

Table 9. ISQ of 146 implants compared with 1995). The same applies for ITI during the osseointegration period. Journal
bone quality assessment according to surgeon implants (Buser et al. 1990) and TPS of Periodontology 76, 1066–1071.
tactile sensation assessment (Salonen et al. 1993). Friberg, B., Jemt, T. & Lekholm, U. (1991)
Bone quality assessment according to Early failures in 4641 consecutively placed
No. of ISQ Brånemark dental implants, a study from
implants Lekholm & Zarb (1985) in the present
stage 1 surgery to the connection of com-
study could be related to insertion tor- pleted prostheses. International Journal of
Cortical bone que measurements, ISQ and PTV.

Oral and Maxillofacial Implants 6, 142–146.
Thick (grade 1) 64 70.27 Quirynen et al. (2005) observed that Friberg, B., Sennerby, L., Roos, J. & Lekholm,
Moderate (grade 2) 61 71.86 * the PTV value of an implant was domi- U. (1995) Identification of bone quality in
Thin/very thin 21 65.9
(grade 3/4) nated by the cortical/crestal bone. This conjunction with insertion of titanium
Trabecular bone is illustrated by ‘‘peri-apical lesions’’ implants. A pilot study in jaw autopsy speci-
Dense (grade 1) 71 69.42 around implants where PTV values mens. Clinical Oral Implants Research 6,
Moderate (grade 2) 52 72.53 remain low, although much of the tra- 213–219.
Poor/very poor 23 66.43 Friberg, B., Sennerby, L., Gröndahl, K., Berg-
becular bone contact has disappeared.
strom, C., Back, T. & Lekholm, U. (1999a)
(grade 3/4) The Periotests showed a correlation On cutting torque measurements during
n
A significant difference between grades with the crestal cortical bone penetrated implant placement, a 3-year clinical prospec-
(p-valueo0.05). by the implants in the buccal aspect of tive study. Clinical Implant Dentistry and
ISQ, implant stability quotient. the implant site. Previously, van Steen- Related Research 1, 75–83.
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PTV values were lower for implants Lekholm, U. (1999b) A comparison between
Table 10. PTV values versus the grades of with a bicortical versus a monocortical cutting torque and resonance frequency mea-
bone quality assessment according to the contact. surements of maxillary implants. A 20-month
surgeon tactile sensation assessment for 44 clinical study. International Journal of Oral
implants and Maxillofacial Surgery 28, 297–303.
Homolka, P., Beer, A., Birkfellner, W., Now-
No. of PTV otny, R., Gahleitner, A., Tschabitscher, M. &
implants Conclusions Bergmann, H. (2002) Bone mineral density
The present clinical data illustrate that measurement with dental quantitative CT
Cortical bone
Thick (grade 1) 21 4.62

several objective measurement devices prior to dental implant placement in cadaver
are available to assess bone-to-implant mandibles: pilot study. Radiology 224, 247–
Moderate (grade 2) 13 2.83 252.
* contact and primary or early stability.
Thin/very thin 10 0.30 Jacobs, R. (2003) Preoperative radiologic plan-
(grade 3/4) These measurements seem to be related ning of implant surgery in compromised
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Dense (grade 1) 23 2.78 Zarb index, which subjectively assesses Jaffin, R. A. & Berman, C. L. (1991) The
Moderate (grade 2) 14 4.00 bone quality on the basis of radio- excessive loss of Brånemark fixtures in type
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sensation.
n
A significant difference was detected between Johansson, B., Back, T. & Hirsch, J. M. (2004)
the grades (p-valueo0.0001). Cutting torque measurements in conjunction
PTV, periotest values. References with implant placement in grafted and non-
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Clinical Relevance Frequency Analysis and insertion Practical implications: The biome-
Scientific rationale for the study: torque. chanical assessments of implant pri-
While clinicians mostly base their Principal findings: The present clin- mary stability and bone resistance
decision making on traditional ical data suggested that the subjec- during implant insertion may help
opinions, the present paper offers tive assessment of bone quality is the clinician to decide when early
objective parameters to determine a related to PTV, ISQ and placement or immediate loading can be consid-
proper timing for the loading of torque measurements at implant ered reasonable.
oral implants: PTV, Resonance insertion.

r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard