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Interventional Medicine & Applied Science, Vol. 5 (4), pp. 162–167 (2013)
DOI: 10.1556/IMAS.5.2013.4.3 ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest162
R E V I E W
Role of primary stability for successful
osseointegration of dental implants:
Factors of influence and evaluation
FAWAD JAVED1,*, HAMEEDA BASHIR AHMED2
, ROBERTO CRESPI3
, GEORGIOS E. ROMANOS4
1
Eng. A.B. Research Chair for Growth Factors and Bone Regeneration, 3D Imaging and Biomechanical Laboratory,
College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
2
Department of Dentistry, Al-Farabi Dental College, Riyadh, Saudi Arabia
3
Department of Dentistry, Vita Salute University, San Raffaele Hospital, Milan, Italy
4
Department of Dental Medicine, Stony Brook University, Stony Brook, NY, USA
*Corresponding author: Dr. Fawad Javed; Eng. A.B. Research Chair for Growth Factors and Bone Regeneration, 3D Imaging and
Biomechanical Laboratory, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; E-mail: fawjav@gmail.com
(Received: September 24, 2013; Revised manuscript received: September 29, 2013; Accepted: September 30, 2013)
Abstract: A secure implant primary (mechanical) stability is positively associated with a successful implant integration and long-term successful
clinical outcome. Therefore, it is essential to assess the initial stability at different time-points to ensure a successful osseointegration. The
present study critically reviews the factors that may play a role in achieving a successful initial stability in dental implants. Databases were
searched from 1983 up to and including October 2013 using different combinations of various keywords. Bone quality and quantity, implant
geometry, and surgical technique adopted may significantly influence primary stability and overall success rate of dental implants.
Keywords: dental implants, bone density, implant surface topography, osseointegration, primary stability, surgical technique
Introduction
Traditionally, endosseous implants are loaded once
bone healing has occurred, which takes approximately
3 months in the mandible and 6 months in the maxilla
[1, 2]. Today, modifications of this treatment protocol
using immediate loading of implants are an eminent and
acknowledged treatment strategy for the rehabilitation
of missing teeth [3–5]. Histologic and histomorpho-
metric evaluation of immediately loaded implants re-
covered from humans has also shown a high degree of
bone-to-implant contact percentages [6, 7]. However,
for any implant procedure, successful implant integra-
tion is a prerequisite criterion, which depends on a series
of procedure-related and patient-dependent measures
[8]. Successful osseointegration from the clinical stand-
point is a measure of implant stability, which occurs
after implant integration [9]. Two terms, such as the
primary and the secondary implant stability, are related
to implant therapy. Primary stability is associated with
the mechanical engagement of an implant with the sur-
rounding bone, whereas bone regeneration and remod-
elling phenomena determine the secondary (biological)
stability to the implant [9, 10]. A secure primary sta-
bility is positively associated with a secondary stability
[11]. Extent of implant stability may also depend on the
situation of surrounding tissues [3, 12]. Bone quantity
and quality, implant geometry, and surgical technique
adopted are also among the predominant clinical factors
that affect primary stability [13]. Therefore, it is essen-
tial to assess the implant stability at different time-points
in order to ensure a successful osseointegration. In this
context, the objective of the present review was to assess
the factors that may play a role in achieving a successful
primary stability in dental implants.
Materials and Methods
The National Library of Medicine, Washington DC
(MEDLINE–PubMed) was searched for appropriate ar-
ticles addressing the focused question. Databases were
searched from 1983 up to and including October 2013
using the following terms in different combinations:
“bone,” “dental,” “design,” “implant,” “immediate
Primary stability and osseointegration
Interventional Medicine & Applied Science ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest163
loading,” “implant length,” implant diameter,” “max-
illa,” “mandible,” “narrow implant,” “osseointegration,”
“primary stability,” “surgical technique,” and “wide im-
plant.”
The eligibility criteria were based on human and ex-
perimental studies, use of control group, articles pub-
lished only in English language, and reference list of po-
tentially related original and review studies. The second
step was to hand-search the reference lists of original and
review studies that were found to be relevant in the first
step. After final selection of the papers, those that fulfilled
the selection criteria were processed for data extraction.
The structure of the present literature review was cus-
tomized to mainly summarize the relevant information.
Pre-requisites for a successful primary
stability
Primary stability is accomplished when the implant is
placed in the bone in such a position that it is “well-
seated.” This allows the implant to mechanically adapt to
the host bone until secondary stability is achieved [13].
Impaired primary implant stability has been shown to
jeopardize the osseointegration process [14]. The suc-
cess of this adaptation, however, depends on several fac-
tors, including the density and dimension of the bone
surrounding the implant, the implant design, and surgi-
cal technique used (Fig. 1).
Fig. 1. Factors affecting implant stability
Bone density and quality
The significance of bone density and its association with
implant dentistry has existed for more than two decades.
Several classifications regarding bone density have been
recommended as shown in Fig. 2.
Bone quality is often referred to as the amount (and
their topographic relationship) of cortical and cancel-
lous bone in which the recipient site is drilled. A poor
bone quantity and quality have been indicated as the
main risk factors for implant failure as it may be associ-
ated with excessive bone resorption and impairment in
the healing process compared with higher density bone
[15–17]. Clinical studies have reported dental implants
in the mandible to have higher survival rates compared
to those in the maxilla, especially for the posterior max-
illa [18, 19]. Bone quality has been considered as the
basic cause of this difference. In the posterior maxilla,
there is commonly thinner cortical bone combined with
thicker trabecular bone compared to the mandible [20,
21]. Clinically, a poor degree of bone mineralization or
limited bone resistance is observed in bones with poor
densities, which are often referred to as “soft bones”
[20, 22]. It has been shown that achieving optimum pri-
mary stability in soft bones is difficult and is also related
to a higher implant failure rate for the implants placed
in such bones [15, 23]. Turkyilmaz et al. [24] reported
the bone quality around the implant to be superior in
the mandible compared to the maxilla. A clinical study
[25] with 158 implant sites from 85 patients indicated
a strong correlation between bone density and dental
implant stability. Results by Miyamoto et al. [26] dem-
onstrated that dental implant stability is positively asso-
ciated with the thickness of cortical bone thickness. In
contrast to the previous studies, additional studies in the
posterior mandible showed high failure rates due to the
poor bone quality as well as other additional factors [27,
28].
Computerized tomography (CT) has been regarded
as the best radiographic method for analyzing the mor-
phological and qualitative analysis of the residual bone
[29–31]. It is also a valuable means for evaluating the
relative distribution of cortical and cancellous bone [32].
However, the density of the surrounding bone seems to
play an essential role in high occlusal forces, and there-
fore, the high bone-to-implant (BIC) percentages of
a thin, “carpet”-like bone in contact with the implant
surface seems to be not clinically significant compared
to lower rate of BIC in a thick bone. Intraoperative sur-
gical techniques, such as bone condensing, undersizing
the osteotomy, improve the bone density and increase
the primary (mechanical) stability. In contrast to that,
loading effects on the periimplant bone under delayed
or immediate loading conditions influence the second-
ary (biological) stability increasing the percentage of the
bone-to-implant (BIC) contacts [27, 33].
Javed et al.
ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest Interventional Medicine & Applied Science164
Implant design
Implant design refers to the three-dimensional structure
of an implant with all the components and features that
characterize it. It has been reported that the implant de-
sign is a vital parameter for attaining primary stability
[34]. The texture of an implant’s surface can influence
the bone–implant interface. Studies [6, 33, 35] have
demonstrated a relationship between implant design and
osseointegration. Implants of varying designs, placed in
different bone qualities, reach various degrees of stabil-
ity, which may determine their future clinical perfor-
mance [36, 37]. Originally, implants were fabricated in
a parallel design; however, they were not appropriate for
most applications.
Tapered implants were later introduced to enhance
aesthetics and assist implant placement between adja-
cent natural teeth [38]. The hypothesis behind using
tapered implants was to provide a degree of compres-
sion of the cortical bone in an implant site with in-
adequate bone [39]. Cylindrical wide body implants
increase the risk of labial bone perforation especially
in thin alveolar ridges due to presence of buccal con-
cavities, whereas the decrease in diameter of the ta-
pered implants toward the apical region accommodates
for the labial concavity [40]. However, according to
Chong et al. [34], if bone quality and quantity are op-
timal, then they may compensate for implant design
inadequacy.
Implant surface characteristics and diameter have also
been shown to influence primary stability. Rough im-
plant surfaces present a larger surface area and allow a
firmer mechanical link to the surrounding tissues [11].
In vitro studies [41, 42] have shown that sandblasted im-
plant surfaces promote peri-implant osteogenesis by en-
hancing the growth and metabolic activity of osteoblasts
[41, 42]. Studies [6, 43, 44] have shown that surface
topography and roughness positively influence the heal-
ing process by promoting favorable cellular responses
and cell surface interactions. In poor bone quality sites,
implants with an acid-etched surfaces can achieve a sig-
nificantly higher bone-to-implant contact compared to
implants with a machined surface [45]. Clinical studies
have shown that implants with smaller diameters (less
than 3.0 millimeters) provide sufficient primary stability
in cases with a limited bone volume [46, 47].
It is accepted that all implants display some extent
of bone loss after osseointegration and through time of
function. It has been claimed that the introduction of
microthreads or “retention grooves” at the neck of the
implant may assist in reducing distributing stress and
reducing the extent of bone loss following the implant
installation [48]. In the reality, crestal bone preservation
can be associated with the surgical technique and the
presence of platform switching [49]. In addition, the
progressive thread design seems to decrease the com-
pression of the crestal bone preserving in that way the
crestal bone loss [49].
Fig. 2. Bone dentistry classifications
Primary stability and osseointegration
Interventional Medicine & Applied Science ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest165
Surgical technique
Besides the quantity and quality of bone and morphol-
ogy of the implant, the surgical technique adopted also
influences primary stability. Therefore, the undersized
drilling technique was introduced to locally optimize
bone density and subsequently improve primary sta-
bility. Numerous modifications in surgical technique
have been described which might assist in enhanc-
ing primary stability of dental implants. Some studies
[50, 51] recommend the use of a final drill diameter
which is smaller than the diameter of the implant;
however, Summers [52] recommended the technique
of bone condensing, where, after using the pilot drill,
the cancellous bone is pushed aside with “condens-
ers” (osteotomes), thus, increasing the density of the
surrounding bone, increasing in that way the initial
implant stability.
It has been reported high survival rates with the im-
mediate loading of dental implants, which are attrib-
uted to high primary stability [43, 53]. Some studies
have also preferred insertion torque as a determinant
of implant stability, and torque values of 32, 35, or
40 Ncm and higher have been chosen as thresholds for
immediate loading [54, 55]. This threshold seems to
be important due to the selection of implant–abutment
connections, which have the need of this torque to en-
gage the abutment to the implant body via the fixation
screw based on the manufacturer guidelines. Also im-
plants placed in a weak bone (poor bone quality) may
be loaded immediately and demonstrate high survival
rates when the final torque in the implant–abutment
connection is lower, i.e., nearly 15–20 Ncm [13].
Methods of evaluation of the primary
stability
Two methods are usually employed to measure the
clinical stability of an implant, namely, the Periotest
(PT) and resonance frequency analysis (RFA) measure-
ment using Osstell device. The PT gauges temporal
contact of the tip of the instrument during repetitive
percussions on the implant. PT values include a narrow
range over the scale of the instrument and, thus, pro-
vide comparatively less sensitive information concern-
ing implant stability [56]. It has been suggested that
the measurement of the moment of force or torque
(required for seating an implant in bone) can also be
used to measure the primary stability of an implant
[57].
The RFA device measures the resonance frequency
of a transductor attached to the implant body, which
is stimulated by different frequencies. According to
a study by Sul et al. [58], RFA is a reliable indicator
for identifying implant stability with assurance. This
instrument has a graphic display panel showing the
implant stability quotient (ISQ) values, which indicate
the firmness at the implant–tissue interface [59]. ISQ
values greater than 65 have been regarded as most fa-
vorable for implant stability, whereas ISQ values below
45 indicate a poor primary stability [60]. However,
there is no justification for a routine clinical use of the
PT and RFA techniques [61], as a disadvantage of the
ISQ evaluation technique is that the value is depen-
dent on the insertion of the magnet (transducer) to
the implant. When the transducer is not well screwed
on the implant body (without to use the final inser-
tion torque), a low ISQ value has been evaluated. In
addition, the ISQ value is possible to be performed
only before the final abutment is connected and cannot
be performed with the prosthetic restoration. Further
modifications of this technique are needed in order to
be able to evaluate the implant stability in a precise and
clinical reliable way.
Effect of micromotions on primary
stability
When the ends of a fractured long bone are reduced,
then there should be absolutely no movement between
the fragments to endorse fracture healing [62]. This
happens because movements, even at the micrometer
range, can induce a stress or strain that may hinder the
formation of new cells in the gap. The same phenom-
enon is applied at the bone-to-implant interface [63].
The induction of micromotion during functional load-
ing may primarily be responsible for failure of osseoin-
tegration and ultimately implant loss [64]. Micromo-
tions above 50–100 micrometers may negatively influ-
ence osseointegration and bone remodelling by form-
ing fibrous tissues and inducing bone resorption at the
bone-to-implant interface [65–67]. Therefore, a high
initial (mechanical) stability is essential for a success-
ful osseointegration of dental implants. Studies [27, 33,
68] have reported that a well-controlled micromotion
positively influenced bone formation; therefore, more
advanced clinical conditions, like immediate functional
loading of implants placed in healed ridges or also fresh
extraction sockets, seem to improve the peri-implant
bone density and improve the implant integration.
Conclusions
This literature review highlights the importance of
achieving a successful primary stability for successful
implant integration. Bone quality and quantity, implant
geometry, and surgical technique adopted may signifi-
cantly influence implant initial stability and overall suc-
cess rate of dental implants.
Javed et al.
ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest Interventional Medicine & Applied Science166
* * *
Funding sources: The authors thank the College of Dentistry Re-
search Centre and Deanship of Scientific Research at King Saud Uni-
versity, Saudi Arabia for funding this research project (Project # FR
0075).
Authors’ contributions: FJ wrote the manuscript and revised it prior
to submission, HBA performed the literature search and revised the
manuscript for English vocabulary. RC wrote the manuscript and re-
vised it prior to submission. GER designed and mentored the study,
wrote the manuscript and revised it prior to submission.
Conflict of interest: None.
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Role of primary stability for osseointegration

  • 1. Interventional Medicine & Applied Science, Vol. 5 (4), pp. 162–167 (2013) DOI: 10.1556/IMAS.5.2013.4.3 ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest162 R E V I E W Role of primary stability for successful osseointegration of dental implants: Factors of influence and evaluation FAWAD JAVED1,*, HAMEEDA BASHIR AHMED2 , ROBERTO CRESPI3 , GEORGIOS E. ROMANOS4 1 Eng. A.B. Research Chair for Growth Factors and Bone Regeneration, 3D Imaging and Biomechanical Laboratory, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia 2 Department of Dentistry, Al-Farabi Dental College, Riyadh, Saudi Arabia 3 Department of Dentistry, Vita Salute University, San Raffaele Hospital, Milan, Italy 4 Department of Dental Medicine, Stony Brook University, Stony Brook, NY, USA *Corresponding author: Dr. Fawad Javed; Eng. A.B. Research Chair for Growth Factors and Bone Regeneration, 3D Imaging and Biomechanical Laboratory, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; E-mail: fawjav@gmail.com (Received: September 24, 2013; Revised manuscript received: September 29, 2013; Accepted: September 30, 2013) Abstract: A secure implant primary (mechanical) stability is positively associated with a successful implant integration and long-term successful clinical outcome. Therefore, it is essential to assess the initial stability at different time-points to ensure a successful osseointegration. The present study critically reviews the factors that may play a role in achieving a successful initial stability in dental implants. Databases were searched from 1983 up to and including October 2013 using different combinations of various keywords. Bone quality and quantity, implant geometry, and surgical technique adopted may significantly influence primary stability and overall success rate of dental implants. Keywords: dental implants, bone density, implant surface topography, osseointegration, primary stability, surgical technique Introduction Traditionally, endosseous implants are loaded once bone healing has occurred, which takes approximately 3 months in the mandible and 6 months in the maxilla [1, 2]. Today, modifications of this treatment protocol using immediate loading of implants are an eminent and acknowledged treatment strategy for the rehabilitation of missing teeth [3–5]. Histologic and histomorpho- metric evaluation of immediately loaded implants re- covered from humans has also shown a high degree of bone-to-implant contact percentages [6, 7]. However, for any implant procedure, successful implant integra- tion is a prerequisite criterion, which depends on a series of procedure-related and patient-dependent measures [8]. Successful osseointegration from the clinical stand- point is a measure of implant stability, which occurs after implant integration [9]. Two terms, such as the primary and the secondary implant stability, are related to implant therapy. Primary stability is associated with the mechanical engagement of an implant with the sur- rounding bone, whereas bone regeneration and remod- elling phenomena determine the secondary (biological) stability to the implant [9, 10]. A secure primary sta- bility is positively associated with a secondary stability [11]. Extent of implant stability may also depend on the situation of surrounding tissues [3, 12]. Bone quantity and quality, implant geometry, and surgical technique adopted are also among the predominant clinical factors that affect primary stability [13]. Therefore, it is essen- tial to assess the implant stability at different time-points in order to ensure a successful osseointegration. In this context, the objective of the present review was to assess the factors that may play a role in achieving a successful primary stability in dental implants. Materials and Methods The National Library of Medicine, Washington DC (MEDLINE–PubMed) was searched for appropriate ar- ticles addressing the focused question. Databases were searched from 1983 up to and including October 2013 using the following terms in different combinations: “bone,” “dental,” “design,” “implant,” “immediate
  • 2. Primary stability and osseointegration Interventional Medicine & Applied Science ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest163 loading,” “implant length,” implant diameter,” “max- illa,” “mandible,” “narrow implant,” “osseointegration,” “primary stability,” “surgical technique,” and “wide im- plant.” The eligibility criteria were based on human and ex- perimental studies, use of control group, articles pub- lished only in English language, and reference list of po- tentially related original and review studies. The second step was to hand-search the reference lists of original and review studies that were found to be relevant in the first step. After final selection of the papers, those that fulfilled the selection criteria were processed for data extraction. The structure of the present literature review was cus- tomized to mainly summarize the relevant information. Pre-requisites for a successful primary stability Primary stability is accomplished when the implant is placed in the bone in such a position that it is “well- seated.” This allows the implant to mechanically adapt to the host bone until secondary stability is achieved [13]. Impaired primary implant stability has been shown to jeopardize the osseointegration process [14]. The suc- cess of this adaptation, however, depends on several fac- tors, including the density and dimension of the bone surrounding the implant, the implant design, and surgi- cal technique used (Fig. 1). Fig. 1. Factors affecting implant stability Bone density and quality The significance of bone density and its association with implant dentistry has existed for more than two decades. Several classifications regarding bone density have been recommended as shown in Fig. 2. Bone quality is often referred to as the amount (and their topographic relationship) of cortical and cancel- lous bone in which the recipient site is drilled. A poor bone quantity and quality have been indicated as the main risk factors for implant failure as it may be associ- ated with excessive bone resorption and impairment in the healing process compared with higher density bone [15–17]. Clinical studies have reported dental implants in the mandible to have higher survival rates compared to those in the maxilla, especially for the posterior max- illa [18, 19]. Bone quality has been considered as the basic cause of this difference. In the posterior maxilla, there is commonly thinner cortical bone combined with thicker trabecular bone compared to the mandible [20, 21]. Clinically, a poor degree of bone mineralization or limited bone resistance is observed in bones with poor densities, which are often referred to as “soft bones” [20, 22]. It has been shown that achieving optimum pri- mary stability in soft bones is difficult and is also related to a higher implant failure rate for the implants placed in such bones [15, 23]. Turkyilmaz et al. [24] reported the bone quality around the implant to be superior in the mandible compared to the maxilla. A clinical study [25] with 158 implant sites from 85 patients indicated a strong correlation between bone density and dental implant stability. Results by Miyamoto et al. [26] dem- onstrated that dental implant stability is positively asso- ciated with the thickness of cortical bone thickness. In contrast to the previous studies, additional studies in the posterior mandible showed high failure rates due to the poor bone quality as well as other additional factors [27, 28]. Computerized tomography (CT) has been regarded as the best radiographic method for analyzing the mor- phological and qualitative analysis of the residual bone [29–31]. It is also a valuable means for evaluating the relative distribution of cortical and cancellous bone [32]. However, the density of the surrounding bone seems to play an essential role in high occlusal forces, and there- fore, the high bone-to-implant (BIC) percentages of a thin, “carpet”-like bone in contact with the implant surface seems to be not clinically significant compared to lower rate of BIC in a thick bone. Intraoperative sur- gical techniques, such as bone condensing, undersizing the osteotomy, improve the bone density and increase the primary (mechanical) stability. In contrast to that, loading effects on the periimplant bone under delayed or immediate loading conditions influence the second- ary (biological) stability increasing the percentage of the bone-to-implant (BIC) contacts [27, 33].
  • 3. Javed et al. ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest Interventional Medicine & Applied Science164 Implant design Implant design refers to the three-dimensional structure of an implant with all the components and features that characterize it. It has been reported that the implant de- sign is a vital parameter for attaining primary stability [34]. The texture of an implant’s surface can influence the bone–implant interface. Studies [6, 33, 35] have demonstrated a relationship between implant design and osseointegration. Implants of varying designs, placed in different bone qualities, reach various degrees of stabil- ity, which may determine their future clinical perfor- mance [36, 37]. Originally, implants were fabricated in a parallel design; however, they were not appropriate for most applications. Tapered implants were later introduced to enhance aesthetics and assist implant placement between adja- cent natural teeth [38]. The hypothesis behind using tapered implants was to provide a degree of compres- sion of the cortical bone in an implant site with in- adequate bone [39]. Cylindrical wide body implants increase the risk of labial bone perforation especially in thin alveolar ridges due to presence of buccal con- cavities, whereas the decrease in diameter of the ta- pered implants toward the apical region accommodates for the labial concavity [40]. However, according to Chong et al. [34], if bone quality and quantity are op- timal, then they may compensate for implant design inadequacy. Implant surface characteristics and diameter have also been shown to influence primary stability. Rough im- plant surfaces present a larger surface area and allow a firmer mechanical link to the surrounding tissues [11]. In vitro studies [41, 42] have shown that sandblasted im- plant surfaces promote peri-implant osteogenesis by en- hancing the growth and metabolic activity of osteoblasts [41, 42]. Studies [6, 43, 44] have shown that surface topography and roughness positively influence the heal- ing process by promoting favorable cellular responses and cell surface interactions. In poor bone quality sites, implants with an acid-etched surfaces can achieve a sig- nificantly higher bone-to-implant contact compared to implants with a machined surface [45]. Clinical studies have shown that implants with smaller diameters (less than 3.0 millimeters) provide sufficient primary stability in cases with a limited bone volume [46, 47]. It is accepted that all implants display some extent of bone loss after osseointegration and through time of function. It has been claimed that the introduction of microthreads or “retention grooves” at the neck of the implant may assist in reducing distributing stress and reducing the extent of bone loss following the implant installation [48]. In the reality, crestal bone preservation can be associated with the surgical technique and the presence of platform switching [49]. In addition, the progressive thread design seems to decrease the com- pression of the crestal bone preserving in that way the crestal bone loss [49]. Fig. 2. Bone dentistry classifications
  • 4. Primary stability and osseointegration Interventional Medicine & Applied Science ISSN 2061-1617 © 2013 Akadémiai Kiadó, Budapest165 Surgical technique Besides the quantity and quality of bone and morphol- ogy of the implant, the surgical technique adopted also influences primary stability. Therefore, the undersized drilling technique was introduced to locally optimize bone density and subsequently improve primary sta- bility. Numerous modifications in surgical technique have been described which might assist in enhanc- ing primary stability of dental implants. Some studies [50, 51] recommend the use of a final drill diameter which is smaller than the diameter of the implant; however, Summers [52] recommended the technique of bone condensing, where, after using the pilot drill, the cancellous bone is pushed aside with “condens- ers” (osteotomes), thus, increasing the density of the surrounding bone, increasing in that way the initial implant stability. It has been reported high survival rates with the im- mediate loading of dental implants, which are attrib- uted to high primary stability [43, 53]. Some studies have also preferred insertion torque as a determinant of implant stability, and torque values of 32, 35, or 40 Ncm and higher have been chosen as thresholds for immediate loading [54, 55]. This threshold seems to be important due to the selection of implant–abutment connections, which have the need of this torque to en- gage the abutment to the implant body via the fixation screw based on the manufacturer guidelines. Also im- plants placed in a weak bone (poor bone quality) may be loaded immediately and demonstrate high survival rates when the final torque in the implant–abutment connection is lower, i.e., nearly 15–20 Ncm [13]. Methods of evaluation of the primary stability Two methods are usually employed to measure the clinical stability of an implant, namely, the Periotest (PT) and resonance frequency analysis (RFA) measure- ment using Osstell device. The PT gauges temporal contact of the tip of the instrument during repetitive percussions on the implant. PT values include a narrow range over the scale of the instrument and, thus, pro- vide comparatively less sensitive information concern- ing implant stability [56]. It has been suggested that the measurement of the moment of force or torque (required for seating an implant in bone) can also be used to measure the primary stability of an implant [57]. The RFA device measures the resonance frequency of a transductor attached to the implant body, which is stimulated by different frequencies. According to a study by Sul et al. [58], RFA is a reliable indicator for identifying implant stability with assurance. This instrument has a graphic display panel showing the implant stability quotient (ISQ) values, which indicate the firmness at the implant–tissue interface [59]. ISQ values greater than 65 have been regarded as most fa- vorable for implant stability, whereas ISQ values below 45 indicate a poor primary stability [60]. However, there is no justification for a routine clinical use of the PT and RFA techniques [61], as a disadvantage of the ISQ evaluation technique is that the value is depen- dent on the insertion of the magnet (transducer) to the implant. When the transducer is not well screwed on the implant body (without to use the final inser- tion torque), a low ISQ value has been evaluated. In addition, the ISQ value is possible to be performed only before the final abutment is connected and cannot be performed with the prosthetic restoration. Further modifications of this technique are needed in order to be able to evaluate the implant stability in a precise and clinical reliable way. Effect of micromotions on primary stability When the ends of a fractured long bone are reduced, then there should be absolutely no movement between the fragments to endorse fracture healing [62]. This happens because movements, even at the micrometer range, can induce a stress or strain that may hinder the formation of new cells in the gap. The same phenom- enon is applied at the bone-to-implant interface [63]. The induction of micromotion during functional load- ing may primarily be responsible for failure of osseoin- tegration and ultimately implant loss [64]. Micromo- tions above 50–100 micrometers may negatively influ- ence osseointegration and bone remodelling by form- ing fibrous tissues and inducing bone resorption at the bone-to-implant interface [65–67]. Therefore, a high initial (mechanical) stability is essential for a success- ful osseointegration of dental implants. Studies [27, 33, 68] have reported that a well-controlled micromotion positively influenced bone formation; therefore, more advanced clinical conditions, like immediate functional loading of implants placed in healed ridges or also fresh extraction sockets, seem to improve the peri-implant bone density and improve the implant integration. Conclusions This literature review highlights the importance of achieving a successful primary stability for successful implant integration. Bone quality and quantity, implant geometry, and surgical technique adopted may signifi- cantly influence implant initial stability and overall suc- cess rate of dental implants.
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