You are on page 1of 7

Int. ,L Oral Maxillqfac. Surg.

1999; 28," 297-303 Copyright 9 Munksgaard 1999

Printed in Denmark, All rights reserved
InternationalJournal of
Oral &
Maxillofacial Surgery
ISSN 0901-5027

B. Friberg 1,2, L. Sennerby 1,2,
A comparison between cutting N. Meredith 2,3, U. Lekholm 1,2
1The Br&nemark Clinic, Public Dental Health
Service and Faculty of Odontology, G~teborg
torque and resonance University; 2Department of Biomaterials/
Handicap Research, Faculty of Medicine,
G6teborg University, Sweden; 3Department of
Oral and Dental Science, Bristol Dental
frequency measurements of Hospital, Lower Maudlin Street, Bristol, UK

maxillary implants
A 20-month clinical study
B. Friberg, L. Sennerby, N. Meredith, U. Lekholm: A comparison between cutting
torque and resonance frequency measurements of maxillary implants. A 20-month
clinical study. Int. J. Oral Maxillofac. Surg. 1999; 28: 297-303. 9 Munksgaard,

Abstract. Oral implant treatment ad modum Br~nemark was undertaken in nine

patients with edentulous maxillae. Cutting torque measurements and resonance
frequency analyses (RFA) were conducted at implant placement and the
corresponding values were subjected to correlation analyses. The implants were
also evaluated with RFA at abutment connection and at one-year follow-up in
order to identify possible changes in implant stability. A total of 61 implants were
inserted, of which 49 were of the Mk II self-tapping type. Two implants were lost
during the study period. The cumulative torque was presented as a mean value
for the upper/crestal, the middle and the lower/apical third of the implant site
respectively, as well as an overall value for the whole site. The highest correlation
(r=0.84, P<0.05) was found when comparing the mean torque values of the
upper/crestal portion with the resonance frequency values at implant placement.
The Mk II implant sites were divided into three groups based on the values of
the cutting torque, i.e. soft (group 1), medium (group 2) and dense bone (group
3). The mean value of each group was plotted against the corresponding mean
value of resonance frequency measured at implant insertion. Statistical analysis
showed significant differences in resonance frequency at implant insertion
between groups 1 and 2 (P=0.047) and between groups 1 and 3 (P=0.002).
When repeating the resonance frequency analyses at second stage surgery and at Key words: resonance frequency; cutting
torque; osseointegration; titanium implants;
one-year follow-up, no significant differences were detected between any of the clinical study.
groups. It was shown that the stability of implants placed in softer bone seemed
to "catch up" over time with more dense bone sites. Accepted for publication 3 December 1998

The use of titanium implants ad modum spite of good results, failures may oc- ameters associated with a higher failure
Br~nemark is well documented in the cur, which are mainly revealed when ex- rate 5'6'13'14'26. Consequently, higher im-
rehabilitation of edentulous and par- posing the implants after the initial plant loss figures have to be expected in
tially edentulous patients 2,11,15,2~ A ri- healing period, as well as during the maxillae, which exhibit bone of a softer
gid fixation of the implant surface is first year of function 1'4'27. Low bone character and are of smaller volume as
thereby achieved and maintained in density and limited jaw bone volumes compared to mandibles 2,4,25.
bone during functional loading 29. In are the most frequently mentioned par- As bone density seems to have a con-
298 Friberg et al.

Table 1. Distribution of implant sites with regard to bone density as classified according to
LEKHOLM & ZARB i n d e x ~a Material and methods
Patient data
Implant position
The present investigation comprised nine pa-
Patient 15 14 13 11 21 23 24 25 26 tients, consecutively treated with oral im-
1 3 3 2 2 3 3 3 plants in edentulous maxillae. Six of the pa-
2 4 3 3 3 3 4 tients were women and the mean age was 67
3 3 2 2 2 2 3 years (range 55-80 yrs). The presurgical
4 3 2 2 2 2 3 evaluation including medical conditions fol-
5 4 4 4 4 4 4 lowed the protocol described by LEKItOLM19,
6 4 4 3 3 3 3 4 4 using the same principles as in connection
7 4 4 4 4 4 4 with any type of oral and maxillofacial
8 4 4 4 4 4 4 4 4 surgery. Available bone density (Table 1) was
9 4 4 3 3 3 3 4 assessed from preoperative radiographs and
during drilling according to the classification
by LEKHOLM& ZARB18. In total, 61 implants
(Table 2) of the BrSnemark System T M were
siderable i m p a c t o n the result of im- ly reduced b o n e volumes a r o u n d im- inserted, of which 49 were of the Mk II self-
p l a n t treatment, it w a r r a n t s evaluation. plants with initial total mobility, as tapping type. All implants were placed ac-
Preoperatively, this is p e r f o r m e d with c o m p a r e d to those regarded as initially cording to a two-stage surgical technique ~.
the use of radiography, including t o m o - Due to the soft character of the bone, how-
stable. Consequently, besides j u d g i n g
ever, the tapping procedure was rarely ex-
grams of various j a w regions 1~ One the b o n e density, a precise m e a n of
ecuted for the implants of standard design or
technique for d e t e r m i n i n g b o n e density m e a s u r i n g the i m p l a n t stability at time of wider diameters. The healing period be-
d u r i n g the o p e r a t i o n was i n t r o d u c e d by of insertion would be beneficial. tween implant placement and abutment con-
JOHANSSON & STRID t7, especially aiming In a series o f publications, MEREDITH nection was also extended from six to eight
at the recognition of b o n e regions with et al. 2~ 23 have r e p o r t e d o n the use of months. Fixed prosthetic constructions were
low density a n d at o b t a i n i n g a n objec- sonic resonance frequency measure- fabricated in highly precious gold alloy 28 and
tive measure o f b o n e h a r d n e s s d u r i n g m e n t s a n d dental implants where a sta- fitted with acrylic teeth. A clinical and radio-
low-speed threading o f i m p l a n t sites. bility value of the implant/tissue inter- graphic check-up was performed one year
after the second stage surgery, i.e. at 20
This m e t h o d of using cutting resistance face at i m p l a n t p l a c e m e n t was ob-
m e a s u r e m e n t s was f u r t h e r explored by tained. T h e study also d e t e r m i n e d t h a t
FRIBERG et al. 7'8, w h o f o u n d the tech- it was possible to m o n i t o r the change in
nique to be reliable a n d applicable in tissue stiffness d u r i n g the initial healing Cutting torque measurements
clinical routine work. period a n d the s u b s e q u e n t follow-up
An electronic instrument (Nobel Biocare AB,
Due to less h a r d tissue support, im- period, indicating the level of osseoin-
G6teborg, Sweden) was used for total torque
plants placed in jaw b o n e o f low den- tegration taking place. measurements during insertion of Mk II im-
sity m a y have a reduced initial stability, T h e aims of the present study were plants. The instrument was connected to a
which in t u r n m a y lead to less ade- to o b t a i n values o f cutting t o r q u e a n d Torque Control T M (Nobel Biocare AB, G6te-
q u a t e i n t e g r a t i o n in b o n e d u r i n g the resonance frequency at the time o f in- borg, Sweden) and the time-torque data was
early healing phases 24. To improve sertion of i m p l a n t s into edentulous recorded by a memory card during low-speed
such a situation by achieving more maxillae, as well as to evaluate w h e t h e r placement of 49 Mk II implants. These were
b o n e a r o u n d the implant, JOHANS- any correlation existed between the inserted with the following distribution: 16
SON & ALBREKTSSON16 advocated, c o r r e s p o n d i n g values of the two tech- incisor, 16 canine and 17 premolar positions
based o n an a n i m a l study, the un- (Table 2). Only the idling speed energy was
niques. R e s o n a n c e frequency measure-
subtracted from the total torque, since both
loaded postsurgical healing period to m e n t s were also c o n d u c t e d o n two
the true cutting resistance and the friction
be prolonged. Different degrees of ini- other occasions, at the end of the heal- torque, the latter including bone material
tial i m p l a n t stability were tested by IV- ing period as well as at the one-year packing around the implant, were regarded
ANOFF et al. ~2, using the r a b b i t as a check-up, in order to follow possible as expressing the resistance of the bone site
model. T h e results revealed significant- changes in i m p l a n t stability over time. and to have an impact on implant stability.

Table 2. Distribution of implants with regard to position, length and type. All except 12 implants were of 3.75 mm Mark II design, s standard
implants, other diameters within brackets, t=failed implants
Implant position
Patient 15 14 13 11 21 23 24 25 26
1 13 13 13t 13 13 15 10
2 13 13 13 13 15 13s (o4)
3 18 15 13 15 13 18
4 18 15 15 13 13 15
5 10s (o4) t 13 13 13 15 13
6 10 10 8.5s 8.5s 8.5s 7s 7s 10
7 13s (04) 15 13 15 15 15 10 (05)
8 6 (05) 15 13 13 10 13 13 6 (05)
9 10s (04) 15 10 15 I3 10 13
Cutt&g torque and resonance frequency of maxillary implants 299

The cumulative torque was presented as a of the whole site (E-total) were plotted against E3 and E-total. All patient mean E-
mean value in Ncm for the upper/crestal the value of resonance frequency of the corre- values showed a correlation with the
(El), the middle (E2) and the lower/apical sponding implant (n=47). Patient mean corresponding patient mean resonance
(E3) third portion, as well as an overall value torque values (El, E2, E3 and E-total) were
fi'equency values (Fig. 3a-d). However,
for the whole site (E-total) (Fig. 1). The other also plotted against patient mean resonance
the highest correlation was found with
twelve implants were of either standard de- frequency values (n-9). Statistical analyses,
sign or had wider diameters (4 or 5 lllm) and utilizing Spearman's correlation test, were the El-values (r=0.84, P=0.036) (Fig.
were chosen by the surgeon because of vari- conducted to correlate values of resonance 3a), i.e. the patient mean bone resis-
ations in jaw bone anatomy. These implants frequency with the corresponding E-values. tance values of the upper/crestal part of
were not exposed to torque measurements The mean El-value for each patient (n=9) implant sites showed the closest re-
and their distribution is given in Table 2. was plotted against the patient mean differ- lationship with the patient mean reson-
ence in resonance frequency between implant ance frequency values. N o statistically
Resonance frequency measurements placement and abutment connection, i.e. significant correlation was found for in-
against the figure for change in tissue stiffness
After implant placement, a 4 mm long stan- dividual site El-values (Fig. 4a) or for
occuring during healing. Spearman's corre-
dard abutment (Brfinemark SystemTM) was the E2, E3 and E-total -values (Fig. 4b-
lation test was used for statistical analysis.
connected to each individual implant, one at The 47 El-values were divided into three d). Consequently, individual site and
a time. On top of the abutment, a transducer groups based on differences in bone density. patient mean values of E2, E3 and E-
was attached via a screw, according to the The first group comprised 16 sites in which the total were not considered for the sub-
procedure described by MBREDITH et al. 22. crestal bone offered the least cutting torque, sequent correlation analyses.
The transducer had a perpendicular orien- the second group consisted of 16 sites with me- When plotting patient mean torque
tation to the alveolar crest and its upright dium cutting torque and the 15 sites of the values of E1 (n=9) against patient
beam part was placed on the palatal side third group represented the crestal bone with
(Fig. 2). With the use of a frequency response mean difference in resonance frequency
the highest cutting torque values. The mean
analyser (Model 1512; Schlumberger Ltd, between implant placement and abut-
value for each group was plotted against the
Crawley, England), the transducer was ex- ment connection, a negative correlation
corresponding mean value of the resonance
cited by a sinusoidal signal at frequencies frequency at implant insertion (16+ 16+ 15= was revealed ( r = - 0 . 7 3 , P=0.007) (Fig.
over the range of 5-15 kHz in steps of 25 Hz. 47), at second stage surgery (16+ 16+ 15=47), 5). Consequently, jaw bone regions that
The resonance frequency was calculated from and at one-year follow up (9+13+14=36). offered low cutting resistance at implant
the received signal. Data were stored and The Student t-test for independent samples placement (soft bone sites) showed, in
analysed in a personal computer. Due to was used to test the null hypothesis. general, a greater increase in stability of
technical problems with the equipment, only When comparing the mean resonance fre- the implant/tissue interface over time,
47 of the 49 Mk II implants were measured quency values at implant placement (n=47),
with resonance frequency at first stage compared to bone regions with higher
at abutment connection (n 47) and at the
surgery. initial resistance (denser sites).
first annual check-up (n=36), the Student t-
All 61 submerged implants were allowed to When analysing the three E l - v a l u e
test for paired samples was used.
heal for eight months, whereafter resonance Regarding repeatability of resonance fre- categories, comprising 16, 16 and 15
frequency measurements (n-47) were ex- quency measurements, MEREDITH et al. 21 sites, respectively, and corresponding to
ecuted at second stage surgery by utilizing found the error to be less than 1%. differences in bone resistance at implant
the aforementioned device and the 4 mm placement, mean values (Ncm) with
long standard abutment. Due to one Mk II
standard deviations were obtained as
implant failing at abutment operation and Results
follows: group 1:3.4_+0.62 ("low bone
ten Mk II implants being provided with per- Clinical findings
manent abutments of non-standard design, density"); group 2:4.5_+0.22 ("medium
only 36 implants were exposed to resonance In six of the nine patients included in bone density"); and group 3:6.3_+1.18
frequency measurements at the one-year fol- this study, some or all of the implant ("high bone density") (Fig. 6). The cor-
low-up visit. Conical and angulated abut- sites were judged as quality 4, i.e. the responding figures for resonance fre-
ments were not possible to use together with bone was regarded to be soft in these quencies (Hz) were: group 1:
the transducer and it was not considered regions (Table 1). All nine patients were 7,165+_512; group 2: 7,486-+383; and
feasible to exchange them for the final regis- free of complications postoperatively, group 3: 7,708-+415, respectively (Fig.
tration procedure. but two implants were found to be mo- 6). When following the three groups
bile at abutment connection, one 13 identified from the torque values with
Radiographic examinations m m M k II implant in central incisor regard to changes in resonance fre-
Postoperative radiographs were taken at position (quality 2) and one 10 m m quency values from implant placement
three occasions, i.e. after the second stage long (4 m m diameter) implant of stan- to abutment connection and to the one-
surgery (at 8 months), after attaching the dard design in premolar position (qual- year follow-up visit, the following fig-
fixed prostheses (at 9.5 months) and at the ity 4) (Table 2). Despite the losses, all ures for resonance frequency at abut-
one-year follow-up (at 20 months). Obtained
patients were provided with fixed pros- ment connection were obtained: group
radiographs were used to check the fit of
components at the fixture/abutment level as theses and no further complications oc- 1: 7,771+439; group 2: 7,915-+397; and
well as at the abutment/prosthesis level. Fur- curred during the first year of function, group 3:7,936-+475 (Fig. 6). At the
thermore, the marginal bone levels m were one-year follow-up, the corresponding
registerred at 8 and 20 months and the mar- values were: group 1: 8,049_+ 384; group
Correlation analyses
ginal bone resorption was determined during 2: 8,060_+480; and group 3: 8,152_+420,
the first year of function. Analyses of individual sites (n=47), as respectively (Fig. 6). When plotting the
well as of patients (n=9), were per- torque and resonance frequency data
Statistical analyses formed to correlate resonance fre- for statistical analyses (Fig. 6), the Stu-
Implant site mean torque values at different quency values at implant placement dent t-test for independent samples re-
depths of the site (El, E2 and E3) (Fig. 1) and with the mean torque values of E l , E2, vealed significant differences at implant
300 Friberg et al.

E tot

Fig. 1. Cutting torque measurements were conducted for upper/crestal

(El), middle (E2) and apical (E3) third of implant site, as well as
for whole implant site (E-total), when inserting self-tapping Mk II

Fig. 2. Transducer connected to implant/abutment for resonance fre-

quency measurements at one-year follow-up visit.

insertion between groups 1 and 2 (P= values obtained at implant placement

Radiographic results
0.047) and between groups 1 and 3 (P= are mainly explained by differences in
0.002). The corresponding analysis be- Registrations of the radiographic mar- implant/tissue stiffness as a result of
tween groups 2 and 3 was found to be ginal bone level mesially and distally to bone formation and maturation, since
non-significant (P--0.131). When the the implants at 8 and 20 months, as well all implants were properly countersunk
analyses were repeated for values ob- as the recorded marginal bone resorp- and the same abutment length (4 mm)
tained at stage two surgery and at the tion after the first year of function, are was used for measurements. At the
first annual check-up, no significant dif- presented as mean values with standard abutment connection, changes in reson-
ferences were detected for any of the deviations in Table 3. ance frequencies may also be explained
groups due to the tendency that regions by differences in interfacial stiffness,
with softer bone seemed to "catch up" since only a minor change in the mar-
over time with the other two groups. ginal bone level (0.13 mm) had oc-
The mean resonance frequency value The present study showed that the sta- curred during the healing period. How-
obtained for the Mk II implants, ana- bility of implants placed in soft maxil- ever, the marginal bone resorption of
lyzed with the Student t-test for paired lary bone increased with time as meas- approximately 1 mm that was registered
samples, significantly increased between ured with RFA. According to M~RED- during the first year of function may
the first and second stage surgery (425 ITH et al. 21, the resonance frequency is have had a great impact on the reson-
Hz, P<0.001) and between the abut- determined by the stiffness of the im- ance frequency values obtained at the
ment connection and the first annual plant/tissue interface and the distance first annual check-up, i.e. 20 months
check-up (220 Hz, P<0.001) (Fig. 7). from the transducer to the first bone after implant placement. Despite this
One Mk II implant was found mobile at contact. Thus, the interfacial stiffness, increase in distance (1 mm) from the
second stage surgery and the resonance as well as the abutment length and the transducer to the first bone contact,
frequency value was approximately 600 marginal bone resorption, will influence which will lower the resonance fre-
Hz lower than the corresponding one the resonance frequency value. In the quency values, the mean value in-
registered at implant placement (Fig. 7). present study, the resonance frequency creased significantly between abutment
Cutting torque and resonance frequency of maxillary implants 301

connection and the first annual check- a.

El b. E2
up and may be explained by the in- 8200- 8200-
crease in interfacial stiffness. 8000-
r =0.g4
A relationship was found between 7800" 7800"
cutting torque and resonance frequency o
~, 7600- 7600"
at implant placement. A statistically 7400- 7400~
significant correlation was, however,
only seen between resonance frequency o 7200" o 72|
7ooo- /. 7000-
and patient mean cutting torque values
680O 6800'
at the El-level. This finding emphasizes 0 2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18 20
the importance of the marginal bone Cutling torque (Ncrn) Cutting torque (Ncm)
density on implant stability as meas-
C. E3 d, E-total
ured with RFA, since the El-values rep-
8200- 8200' /
resented the bone density of the upper/
crestal third of the site. It may also ex- 8000- 8000.
a., 7800" 78| = 0.62
plain why both short and long im-
plants, when being placed in bone of 7600"
uniform marginal density, present simi- 7400" 9 7400'
lar resonance frequency values, as . 7.oo/ / o =o 7200
shown by MEm~DITH et al. 22. Why the 7000.
patient mean El-value, and not the in- 68013 ' 6800, -
0 2 4 6 8 10 12 14 1.6 18 20 0 2 4 6 8 10 12 i4 16 i8 20
dividual site El-value, showed the clos-
Cutting torque (Ncm) Cutting torque (Ncm)
est relationship with resonance fre-
quency might be coincidental or ex- Fig. 3. Patient mean values of cutting torque at implant insertion for upper/crestal (El, 3a),
plained by the fact that a mathematical middle (E2, 3b) and apical (E3, 3c) third of site, as well as for whole site (E-total, 3d), plotted
calculation of the mean reduces the against corresponding patient mean values of resonance frequency (r=coefficient of corre-
variation. lation).
A statistically significant negative
correlation was found between patient
mean cutting torque values at the El-
a. b.
level and change in resonance frequency E1 E2
from implant placement to abutment 9 0 |
connection. This means that the lower 39 >,
the cutting torque and resonance fre- =
8000- go00 .....
J jr = 0.44
quency values were at first stage
surgery, the greater was the increase of ou 9
7000" 7000' 9 9 9
resonance frequency as measured at o o

second stage surgery, which suggests

that the tissue response was more in- 60O0 60001
0 5 10 15 20 25 30 0 1'0 2'0 3'0
fluential on implant stability in bone of Cutting torque (Ncm) Cutting torque (Ncm)
low density. The hypothesis may be put
C. d.
forward that the relation between inter- E3 E-total
face stiffness and implant stability is of 90oo1
a specific nature. A further increase of
the bone/implant contact may be more 80| .."" " =
or less important for the implant sta- ~~'
i 80| ~ " ~ 9 ~ "" 9 9 r=0.47
bility and this relation seems to depend 7000"
on the initial bone density. Thus, an in- g
crease from 10% to 30% may have a
great impact on implant stability, whilst 6000 6000
0 1'0 2'0 3'0 0 5 10 15 20 25
an increase from 70% to 90% may not. Cutting torque (Nern) Cutting torque (Ncrn)
This theory is supported by the findings
of FRmERG et al. 9, who evaluated one- Fig. 4. Individual site mean values of cutting torque at implant insertion for upper/crestal
stage mandibular implants with sequen- (El, 4a), middle (E2, 4b) and apical (E3, 4c) third of site, as well as for whole site (E-total,
tial resonance frequency measurements 4d), plotted against corresponding individual site mean values of resonance frequency (r=
during the initial healing period of 15 coefficient of correlation).
weeks. It was found that the stability
did not increase, but slightly decreased
in dense bone. The lowered resonance ducer to the first bone contact 21. In the the second stage surgery and the first
frequency was assumed to be a result of present study, an increase in the mean annual check-up. Consequently, in bone
the change in the marginal bone level of resonance frequency value was ob- of low density, the increase in bone/im-
0.4-0.7 mm, with a corresponding in- tained, despite a greater change in the plant contacts as a result of osteogen-
crease in the distance from the trans- marginal bone level (0.9 mm) between esis may have a greater impact over
302 Friberg et al.

800 ~" 1000-.

700' 800-
= 600 s
~D r 400"
500- 9 "" 9 r =-0.73
9 d~
G~ 200"
= 400' = 0"

300. -2001
.fi 200" "'=
~ -600~
-4001 "N,, 9 failed implant
~o 100
. -s001
0 . . . . !
- 1000/ , , . . . . , , I I
I l

3 4 5 6 7 ~) ' 8 ' 20 months

Implant Abutment 1st annual
Cutting torque (Ncm) placement connection check-up
Fig. 5. Patient mean El-values at implant insertion plotted against Fig. 7. Changes in mean resonance frequency values (with standard
patient mean change in resonance frequency between first and second deviations) from implant placement to abutment connection and to
stage surgery (r=coefficient of correlation). first annual check-up (***P<0.001). A lowered resonance frequency
value of 600 Hz was seen for the failed implant at second stage
surgery (arrow).

time on implant stability. The relation and plotted against the corresponding The differences diminished over time
between bone density and the increase resonance frequency values. Statisti- and at the one-year follow-up, i.e. 20
in implant stability over time was cally significant differences were seen months after implant insertion, the res-
further demonstrated by dividing the when comparing groups 1 and 2 and, onance frequency values were similar
bone sites into three groups, based on more especially, when comparing for all three groups. The result indicates
cutting torque values at the El-level groups 1 and 3 at implant placement. that implants over time will reach a
similar stability, irrespective of the bone
density present at implant placement.
The surgical trauma from implant in-
sertion and probably loading may pro-
duce bone density changes in relation to
the implant. A progressive tissue re-
sponse over a long period of time also
7800- coincides with the view of BR~NEMARK
et al. 3, who stated that, after implant
7600" insertion, the remodelling period of
I ~ i a t i o n s
•* [-" / I D. . . . Int. . . . diate Soft bone will continue for at least 18
7400" l~ /" ~nonths bone ( A ) bone ( O ) bone ( 9 months.
|* / I0" ...... 415 383 512
[ / [8 475 397 439 The present study, though limited in
7200" L I" [ 20 420 480 384 numbers and follow-up time, comprised
a higher percentage of bone sites classi-
7000 fied as quality group 4 ~8 (30/61) than
0 8 20 months
most other studies 5,6'13,14 and, yet, only
Fixture Abutment 1 year
placement connection of loading one implant out of the 30 (3.3%) ex-
hibited mobility during the 20 months.
Fig. 6. Three groups of implant sites, based on El-values of cutting torque at implant place- A possible explanation for the positive
ment, plotted against corresponding values of resonance frequency at first and second stage result may be the prolonged healing
surgery, as well as at first annual check-up (*P-0.047, **P=0.002). Standard deviations of period used in this study, i.e. eight in-
resonance frequency values for the three groups at the three measurement occasions are shown
stead of six months, which, according
in incorporated table.
allow for more bone to grow around the
Table 3. Mean marginal bone levels at 8 and 20 months and mean marginal bone loss during implants. Another reason might be the
first year in function use of wider implants inserted in the
most soft bone regions (Table 2), with-
Abutment connection 1st annual check-up
out a corresponding widening of the
(8 months) (20 months)
site diameter during drilling, thereby
Mean marginal bone level (mm_+S.D.) 0.13-+0.20 1.03+0.29 providing for an improved initial im-
Mean marginal bone loss (mm-+S.D.) 0.90• plant stability.
Cutting torque and resonance fi'equency o f maxillary implants 303

In summary, it may be concluded conjunction with insertion of titanium bility of implant-tissue interface using
f r o m the present investigation t h a t vari- implants. A pilot study in jaw autopsy resonance frequency analysis. Clin Oral
ous b o n e densities can be identified dur- specimens. Clin Oral Impl Res 1995: 6: Impl Res 1996: 7:261 7.
ing i m p l a n t p l a c e m e n t with the use of
9. ERIBERG B, SENNERBY L, LINDEN B, T, SENNERBY L. Resonance frequency
cutting t o r q u e a n d resonance frequency
GRONDAHL K, LEKHOLM U. Stability measurements of implant stability in vivo.
measurements. A n increase in i m p l a n t measurements of one-stage Br~nemark A cross-sectional and longitudinal study
stability over time, as m e a s u r e d with implants during healing in mandibles. A of resonance frequency measurements on
resonance frequency, was clearly f o u n d clinical resonance frequency study. Int J implants in the edentulous and partially
in sites of low density. Consequently, an Oral Maxillofac Surg: in press. dentate maxilla. Clin Oral Impl IRes 1997:
extended healing period m a y be sug- 10. GRONDAHL K, EKESTUBBEA, GRONDAHL 8: 226-33.
gested for i m p l a n t s placed in b o n e of HG. Radiography in oral endosseous 23. MEREDITH N, SHAGALDI F, ALLEYNE D,
low density. prosthetics. G6teborg, Sweden: Nobel SENNERBY L, CAWLEYP.. The application
Biocare AB, 1996. of resonance frequency measurements to
11. HENRY R LANEu WR, JE~vIT T, et al. study the stability of titanium implants
Acknowledgements. The authors would like
Osseointegrated implants for single-tooth during healing in the rabbit tibia. Clin
to acknowledge Kerstin Gr6ndahl, Associate
replacement: a prospective 5-year multi- Oral Impl Res 1997: 8: 23443.
Professor, Oral Diagnostic Radiology, G6te-
center study. Int J Oral Maxillofac Impl 24. SENNERBYL, THOMSEN P, ERICSSON L. A
borg University, Sweden, and Thomas B~ick,
1996: 11: 450-5. morphometric and biomechanic com-
MSc, Nobel Biocare AB, G6teborg, Sweden,
12. IVANOEE C J, SENNERBY L, LEKHOLM U. parison of titanium implants inserted in
for valuable support with the research pro-
Influence of initial implant mobility on rabbit cortical and cancellous bone. Int J
the integration of titanium implants. Clin Oral Maxillofac Impl 1992: 7: 62-71.
Oral Impl Res 1996: 7:120 7. 25. VAN STEENBERGHE D, QUIRYNEN M,
13. JAFFIN RA, BERMAN CL. The excessive CALBERSON L, DEMANET M. A prospec-
References loss of Branemark fixtures in type IV tive evaluation of the fate of 697 con-
bone: a 5-year analysis. J Periodontol secutive intraoral fixtures ad modum
1991: 62: 2~,. Br~memark in the rehabilitation of eden-
BR~NEMARK P-I. A 15-year study of
14. JEMT T, LEKHOLM U. Implant treatment tulism. J Head Neck Pathol 1987: 6: 53-
osseointegrated implants in the treatment
in edentulous maxillae: a 5-year follow- 8.
of the edentulous jaw. Int J Oral Surg up report on patients with different de- 26. VAN STEENBERGHE D, LEKHOLM U,
1981: 10: 387416. grees of}aw resorption. Int J Oral Maxil- BOLENDER C, et al. The applicability of
lofac Impl 1995: 10:303 11. osseointegrated oral implants in the re-
BR~NEM.A~K P-I, JEMT T. Long-term fol-
15. JEMT T, CHAI J, HARNETT J, et al. A 5- habilitation of partial edentulism: a pros-
low-up study of osseointegrated implants pective multicenter study on 558 fixtures.
year prospective multicenter follow-up re-
in the treatment of totally edentulous
port on overdentures supported by osseo- Int J Oral Maxillofac Impl 1990: 5: 272-
jaws. Int J Oral Maxillofac Impl 1990: 5:
integrated implants. Int J Oral Maxillo- 81.
347-59. fac Impl 1996: 11: 291-8. 27. WORTHINGTON P, BOLENDEREL, TAYLOR
16. JOHANSSON C, ALBREKTSSON T. Inte- TD. The Swedish system of osseointe-
et al. Osseointegrated implants in the grated implants: problems and compli-
gration of screw implants in the rabbit:
treatment of the edentulous jaw. Experi-
a l-year follow-up of removal torque of cations encountered during a 4-year trial
ence from a 10-year period. Scand J Plast
titanium implants. Int J Oral Maxillofac period. Int J Oral Maxillofac Impl 1987:
Reconstr Surg 1977:11 (Suppl. 16): 39 94. Impl 1987: 2:69 75. 2: 77-84.
4. Cox JF, ZARB GA. The longitudinal clin-
17. JOHANSSON P, STRID CG. Assessment of 28. ZARB GA, JANSSONT. Prosthodontic pro-
ical efficacy of osseointegrated dental im- bone quality from cutting resistance dur- cedures. In: BR$,NEMARKP-I, Z ~ B GA,
plants: A 3-year report. Int J Oral Maxil-
ing implant surgery. Int J Oral Maxillo- ALBREKTSSON T, eds.: Tissue-integrated
lofac Impl 1987: 2:91 100. prostheses: osseointegration in clinical
fac Impl 1994: 9:279 88.
18. LEKHOLM U, gARB GA. Patient selection dentistry. Chicago: Quintessence, 1985:
LINDEN U. A retrospective multicenter
and preparation. In: Brfinemark P-I, 241 82.
evaluation of osseointegrated implants 29. ZARB GA, ALBREKTSSONT. Osseointegr-
Zarb GA, Albrektsson T, eds.: Tissue-in-
supporting overdentures. Int J Oral Max- ation: a requiem for the periodontal liga-
tegrated prostheses: osseointegration in
illofac Impl 1988: 3: 129-34. ment? Int J Periodont Rest Dent 1991:
clinical dentistry. Chicago: Quintessence,
1985:199 209. 11:88 91.
failures in 4,641 consecutively placed
19. LEKHOLMU. The surgical site. In: LINDHE
Brgmemark dental implants: a study from J, KARRING T, LANG NP, eds.: Clinical
stage 1 surgery to the connection of com-
periodontology and implant dentistry.
pleted prostheses. Int J Oral Maxillofac 3rd ed. Copenhagen: Munksgaard 1997:
Impl 1991: 6: 142-6.
890-905. Address:
SON E STRID CG, LEKHOLM U. Evalu- HERRMANN I, et al. Osseointegrated im- The Brdnemark Clinic
ation of bone density using cutting resis- plants in the treatment of partially eden- Faculty of Odontology
tance measurements and microradio- tulous jaws: a prospective 5-year multi- Medicinaregatan 12 C
graphy. An in vitro study in pig ribs. Clin
center study. Int J Oral Maxillofac Impl S-413 90 G6teborg
Oral Impl Res 1995: 6: 164~71.
1994: 9: 627-35. Sweden
21. MEREDITH N, ALLEYNE D, CAWLEY P. Tel: +46 31 773 3626
HOLM U. Identification of bone quality in
Quantitative determination of the sta- Fax. +46 31 827829