Paolo Trisi Implant micromotion is related to peak

Giorgio Perfetti
Edoardo Baldoni
insertion torque and bone density
Davide Berardi
Marco Colagiovanni
Giuseppe Scogna

Authors’ affiliations: Key words: bone density, dental implant, immediate loading, insertion torque, micromo-
tion, primary stability
Paolo Trisi, Private Practice, Pescara, Italy, Director,
Laboratory of Biomaterials and Biomechanics,
Galeazzi Orthopaedic Institute, University of Abstract
Milano – Italy
Giorgio Perfetti, Davide Berardi, Marco
Objectives: Measuring peak insertion torque in relation to different bone densities, the
Colagiovanni, Department of Oral Surgery, present study seeks to determine whether micromotion at the interface is related to
University of Chieti, Pescara, Italy primary stability achieved by increasing insertion torque.
Edoardo Baldoni, Giuseppe Scogna, Department of
Oral Surgery, University of Sassari, Sassari, Italy Material and methods: A total of 120 Ti-Bone implants were placed in fresh bovine bone
samples representing three density categories: hard, normal and soft (HNS). Five groups of
Correspondence to:
Dr Paolo Trisi peak insertion torque (20, 35, 45, 70 and 100 N/cm) were evaluated in the three bone
Via Silvio Pellico 68 density categories noted. Customized electronic equipment connected to a PC was used to
65123 Pescara
register the peak and other insertion torque data. A loading device, consisting of a digital
Italy
Tel.: þ 39 0852 8432 force gauge and a digital micrometer, was used to measure the micromovements of the
Fax: þ 39 08 52 8427 implant during the application of 20, 25 and 30 N lateral forces. The data were analyzed for
e-mail: paulbioc@tin.it
statistical significance by ANOVA and Spearman’s rank correlation coefficient tests.
Results: A statistically significant difference between implant micromobility placed with
different levels of torque and in different bone densities was demonstrated by ANOVA.
Spearman’s rank correlation coefficient showed a high dependency between the peak
insertion torque and the observed micromovement. Particularly, in soft bone, it was not
possible to achieve more than 35 N/cm of peak insertion torque.
Conclusions: Results showed that increasing the peak insertion torque reduces the level of
implant micromotion. In addition, micromotion in soft bone was found to be consistently
high, which could lead to the failure of osseointegration. Thus, immediate functional
loading of implants in soft bone should be considered with caution.

Date:
Accepted 24 October 2008
To cite this article:
Trisi P, Perfetti G, Baldoni E, Berardi D, Colagiovanni
M, Scogna G. Implant micromotion is related to peak
insertion torque and bone density.
Clin. Oral Impl. Res. 20, 2009; 467–471.
doi: 10.1111/j.1600-0501.2008.01679.x
Over the past few decades, implant rehabi-
litation has attracted increasing attention
in dentistry as a result of improving success
rates reported in the literature. More re-
cently, the possibility of immediate func-
tional loading of implants has been
explored with particular success for the
anterior mandible and with lesser success
for the upper jaw and posterior mandible
(Del Fabbro et al. 2006). The cause of
failure in these cases has not been attrib-
uted to the fact of immediate loading itself,
but rather micromotion at the interface
induced by the immediate loading, which,
in turn, could ultimately be responsible for
the failure of osseointegration of immedi-
ately loaded implants (Szmukler-Moncler
et al. 1998). These same mechanisms are
thought to be responsible for the failures of
fracture healing according to the strain
theory (Perren 2002). That is, when the
ends of a fractured bone are tightly com-
pressed, leaving only a small gap between
them, then almost no movement should be

c 2009 The Authors. Journal compilation 

 c 2009 John Wiley & Sons A/S 467
Trisi et al . Micromotion vs. peak insertion torque and bone density
allowed between the fragments. Other-
wise, even movements in the micrometer
range could induce a stretch, or a strain,
which could destroy the new cells and
vessels forming in the gap. In such a case,
osteoclasts enter the gap and begin to resorb
bone in order to increase the space over the
critical threshold of strain of the regener-
ated tissue. Hence, if the bone is heavily
loaded during this period, bone resorption
further increases the mobility of the frag-
ment ends, thus inducing even more mo-
bility, which finally brings about the
failure of fracture healing (Rahn 2002). A
similar mechanism can be hypothesized to
be involved in the failure of immediately
loaded implants. In fact, previous studies
have experimentally evaluated animals and
reported a threshold of micromotion be-
tween 50 and 100 mm, above which micro-
motion induces bone resorption at the
interface, thus producing fibrosis around
endosseous implants (Soballe et al. 1992,
1993; Szmukler-Moncler et al. 2000).
Implant stability depends on the direct
mechanical connection between its surface
and the surrounding bone and can be di-
vided into primary and secondary stability.
Classically, the clinical parameter relative
to micromotion is ‘primary stability,’
which has been defined as ‘a sufficiently
strong initial bone–implant fixation’ (Ro-
berts 1999). Primary stability is achieved
when the implant is positioned into the
host bone site such that it is well seated.
With this initial advantage, the implant
then relies on immediate mechanical adap-
tation between itself and the host bone.
The success of this adaptation, however,
depends on several factors, including the
density and dimension of the host bone,
the implant geometry and the surgical
technique used. Secondary stability is at-
tained when new bone forms at the im-
plant interface.
Currently, there are two available instru-
ments on the market, by which the clinical
stability of an implant can be estimated,
the Periotest (PTV) and the Osstel (RFA)
device, which measure resonance fre-
quency. The PTV measures temporal con-
tact of the tip of the instrument during
repetitive percussions on the implant,
while the Osstel device measures the re-
sonance frequency of a small transductor
that is attached to the implant abutment
and that is stimulated by a wide range of
468 | Clin. Oral Impl. Res. 20, 2009 / 467–471
frequencies. Although these instruments
have been widely used in the scientific
literature, their measurements have never
been directly related to implant micromo-
tion. Yet, based on the factors that impact
primary stability and, consequently, the
ultimate success of immediate load im-
plant, micromotion is a key and measur-
able variable. Moreover, the EAO
consensus conference stated that ‘the lack
of normative values and the ranges of
reported values for stable implants and
those with an increased potential to fail
indicate that there is currently no justifica-
tion for routine clinical use of PTVs and
RFA’ (Hammerle & van Steenberghe
2006). Thus, it has been suggested that
the measurement of the moment of force,
or torque, which is required to properly seat
an implant in its bone bed, is also a mea-
sure of an implant’s primary stability.
Although the statement has never been
validated experimentally, high peak inser-
tion torque has been considered advanta-
geous in improving primary stability
(O’Sullivan et al. 2000). For this reason,
it is worthwhile confirming the validity of
this assumption by correlating the peak
insertion torque of an implant to its pri-
mary stability by the direct measurements
of implant micromobility, taking into ac-
count such factors as host bone density.
Therefore, the aim of the present study was
to conduct an experimental in vitro test of
the micromotion of implants immediately
after placement with increasing insertion
torque into fresh bovine bone of different
densities in order to assess the degree of
primary stability achieved at each insertion
torque value.
Material and methods
The test was performed on 2 cm  2 cm
samples of fresh humid bovine bone repre-
sentative of the following quality cate-
gories: hard, normal and soft (HNS). The
bone qualities were selected according to
(1) drilling resistance (Trisi & Rao 1999)
and (2) a preliminary histologic analysis of
the bone structure. Hard bone is dense with
a completely compact structure. Normal
bone is average hard bone with a 2–3 mm
cortical layer and a normal cancellous
structure inside. Soft bone has low drilling
resistance and a 1 mm cortical layer with a
c 2009 The Authors. Journal compilation 
 c 2009 John Wiley & Sons A/S
Fig. 1. Implant with a fixed long abutment used for
the micromotion analysis.
Fig. 2. Digital torque wrench.
low-density cancellous structure. Ti-bone
implants (Ti-Bone AG, Lugano, Switzer-
land) 4 mm in diameter and 13 mm in
length (Fig. 1) were specifically prepared
for this study. Each implant was fitted
with a one-piece fixed straight abutment
11 mm in length to allow for the applica-
tion of the lateral load. The implants were
placed according to the manufacturer’s in-
structions using the appropriate burs. A
customized digitally controlled hand
wrench was used to measure the peak
insertion torque. In addition, electronic
equipment consisting of a digital hand-
operated torque wrench (Fig. 2), equipped
with a calibrated strain gauge and con-
nected to a PC reading the peak insertion
torque value every 0.5 ms, was customized
for this study. To obtain the peak insertion
torque, the signal was subsequently evalu-
ated by the MECODAREC software (A-
Tech s.r.l., Bergamo, Italy).
After implant placement, the bone
blocks were fixed on a customized loading
device for evaluation of micromovement
(Fig. 3). This device consisted of a digital
force gauge [Akku Force Cadet (range of
0–90 N and accuracy of 0.5%), Ametek,
Largo, FL, USA] and, on the opposite side,
a digital micrometer (Mitutoyo Digimatic
Micrometer, Kawasaki, Japan) that mea-
sured the micromovements of the abut-
ment during the lateral load application.
Horizontal forces of 20, 25 and 30 N/mm
 Trisi et al . Micromotion vs. peak insertion torque and bone density

Table 1. Mean  SD micromotion (lm) of implants loaded with 20 N lateral force in

relation to D, N, and S bone
Newton 20 35 45 70 100
insertion
torque
D bone 34.02  3.34 29.24  3.95 27  3.58 24.38  3.39 24.4  3.61
Fig. 3. Schematic drawing of the micromotion-test- N bone 39.01  4.72 35.98  3.81 33.6  3.34 33.92  4.9 30.43  4.95
ing tool. The bone specimen (4) is located in the S bone 90.48  25.41 71.34  14.51
middle with the implant in place. On the right side,
the digital force gauge (2) is powered on the implant
long abutment (3), and on the left side, the micro-
Table 2. Mean  SD micromotion (lm) of implants loaded with 25 N lateral force in
meter (3) reveals the movement of the implant. relation to D, N, and S bone
Newton 20 35 45 70 100
insertion
were tested on each implant, and the lateral torque
movement of the abutment was measured
D bone 43.6  4.67 37.02  4.54 33.8  4.26 30.64  3.76 31.64  5.27
by the digital micrometer at 10 mm above N bone 49.53  6.18 45.42  5.35 41.42  3.9 42.68  6.02 37.96  6.04
the crest. On each implant, the load appli- S bone 117.97  36.57 92.88  21.93
cation was repeated five times for 2 s,
simulating the occlusal load in a patient’s
mouth. The average value of these five Table 3. Mean  SD micromotion (lm) of implants loaded with 30 N lateral force in
relation to D, N, and S bone
measurements was calculated for each im-
Newton 20 35 45 70 100
plant and for each applied load. A total of
insertion
120 implants were tested in groups of 10 torque
implants for each insertion torque in each
D bone 53.54  5.33 45.52  5.54 41.72  5.11 37.1  5.03 38.24  5.5
bone quality. Five groups of peak insertion N bone 60.01  7.91 55.62  7.03 52.08  4.46 51.54  7.39 45.86  7.65
torque were evaluated: 20, 35, 45, 70 and S bone 147.95  46.42 113.66  29.38
100 N/cm each for the three different bone
qualities, including hard, normal and soft,
as defined above.
In the soft bone, it was only possible to
reach the first two levels of peak insertion
torque because the bone became damaged
beyond 35 N/cm, and the implants started
spinning. Because, as noted above, three
tests were performed for each implant (at
20, 25 and 30 N), a total amount of 1800
measurements were obtained.
All data were reported as mean and
standard deviation (SD), and are reported
in Tables 1–3 and Fig. 4.
Differences between micromotion for
insertion torques of 20 and 35 N were
tested with the Mann–Whitney test for Fig. 4. Regression line of micromotion relative to insertion torque in N/cm for different Newton lateral forces
each of the three lateral forces. and D or N bone.
The overall reduction of micromotion
relative to an increase of insertion torque as correlated to bone density and applied torque (r ¼  0.54; Po0.001), indicating
was evaluated preliminarily by the Kruskal– force. The Kruskal–Wallis test demon- that micromotion decreased with increas-
Wallis test, while the variation of single strated a statistically significant difference ing peak insertion torque (Fig. 5). In S bone,
lines was evaluated with linear regression between the various levels of torque the micromotion increased for both peak
analysis and Spearman’s rank correlation (Po0.05). In H and N Bone, the different insertion torques (20 and 35) with increas-
coefficient. Statistical analysis was per- micromotion decreases were insignificant ing lateral force (Fig. 4). In this bone type, it
formed using SPSS Advanced Statistical above 45 N/cm. In other words, the micro- was not possible to achieve more than
11.0 software (SPSS Inc., Chicago, IL, USA). mobility variations within the 45, 70 and 35 N/cm of peak insertion torque because
100 N/cm insertion torque groups were not on passing this threshold, the implants
Results statistically significant. Regression analy- showed a tendency to spin as a result of
sis and Spearman’s rank correlation coeffi- interfacial bone damage. The Mann–Whit-
Tables 1–3 show the mean values and cient showed a high dependence between ney test demonstrated a statistically signif-
standard deviation of the micromovement the micromotion and the peak insertion icant (Po0.05) difference of micromotion

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Trisi et al . Micromotion vs. peak insertion torque and bone density
Fig. 5. Mean  SD of micromotion relative to Newton lateral force for 20 and 35 N insertion torque for S
bone (nPo0.05 Mann–Whitney test).
between 20 and 35 N for each of the three
lateral forces.
Discussion
It is suggested in this paper that the success
of dental implantation is not related to
either immediate or delayed loading
(Brunski 1999; Szmukler-Moncler et al.
2000), but is rather, a critical function of
micromotion threshold, which, as deter-
mined by the results obtained above, should
not exceed 50–100 mm at the interface.
Previously, it was generally agreed that
implant interface failure was a conse-
quence of bone resorption due to excessive
load (Perren 2002). In contrast to this
hypothesis, a series of experiments have
been conducted where both the displace-
ment and the load were controlled, and it
was clear that the resorption was induced
by instability, even when only small loads
were applied (Ganz et al. 1975); (Hente et
al. 2001; Perren 2002). These experiments
showed that, in cortical bone, a displace-
ment of only a few micrometers at the bone
interface can induce resorption of the bone
surface. This resorption process increases
the distance between the mobile surfaces,
thus placing deformation or ‘strain’ on
regenerating tissues (Hente et al. 2001;
Perren 2002). The basic working hypoth-
esis of the ‘strain’ theory (Perren 2002) is
that, when given tissue elements are
tightly compressed, leaving only a small
gap between them, then almost no move-
ment should be allowed between them.
Otherwise, even movements in the micro-
meter range could induce a stretch, or a
strain, that could destroy the new cells and
vessels forming in the gap. In such a case,
osteoclasts enter the gap and begin to resorb
470 | Clin. Oral Impl. Res. 20, 2009 / 467–471
bone in order to increase the space over the
critical threshold of strain of the regener-
ated tissue. A similar mechanism can be
hypothesized to be involved in the failure
of immediately loaded implants. Previous
studies have experimentally evaluated ani-
mals and reported a threshold of micromo-
tion between 50 and 100 mm, above which
micromotion induces bone resorption at
the interface, thus producing fibrosis
around endosseous implants (Soballe et al.
1992, 1993; Szmukler-Moncler et al.
2000).
Despite the experimental definition of
these thresholds, there are no instruments
currently available to dentists that are cap-
able of clinically discriminating tolerable
levels of micromotion of an endosseous
dental implant. It is, however, possible to
find electronic devices (Osstel and Periot-
est), which, although they claim to mea-
sure the primary stability of implants, have
never been tested in relation to micromo-
tion. To gain a true measure of primary
stability in relation to immediately loaded
functional implants, it was therefore
worthwhile evaluating collectively all the
clinical parameters relevant to implant mi-
cromobility, including host bone density,
insertion torque and implant geometry.
Because it is possible to clinically measure
the peak insertion torque of an implant and
because this parameter is related to the
mechanical condition of implants after pla-
cement, the present study aimed to deter-
mine the correlation between peak
insertion torque and implant micromotion
as measured by various bone densities in
order to give clinicians a better insight into
the degree of primary stability to be ex-
pected based on the peak insertion torque.
Moreover, we found a range of micromo-
tion that is not exactly at a micrometer
c 2009 The Authors. Journal compilation 
 c 2009 John Wiley & Sons A/S
scale, because a movement of 100 mm is in
the visible range of resolution. For this
reason, it is possible that a wider range of
micromotion could be perceived by the
naked eye.
Our results showed that peak insertion
torque and implant micromotion are sta-
tistically related and that significant differ-
ences can be found between hard and
normal bone as compared with soft bone
in relation to the correlation between peak
insertion torque and micromotion. Specifi-
cally, a small range of micromotion, be-
tween 24 and 34 mm, was found in hard
bone with a peak insertion torque ranging
from 20 to 100 N/cm and an applied lateral
force of 20 N. When the applied force
increased to 30 N/cm2, the range of micro-
motion increased to 53–38 mm. In normal
bone, the range of micromotion was
slightly higher, between 39 and 30 mm,
with an applied lateral force of 20 N/cm2,
and between 60 and 45 mm for an applied
force of 30 N. Finally, while a much higher
micromotion range was found in soft bone,
the peak insertion torque could not reach
more than 35 N/cm. Under such condi-
tions, the range of micromotion for this
bone quality was between 90 and 71 for an
applied force of 20 N and 147 and 113 for a
force of 30 N.
The measurements of implant micromo-
tion were performed 10 mm over the im-
plant neck, an area that corresponds to the
bone crest. It has been shown that under
lateral load, the most coronal portion of the
bone supports the highest stress (Rieger et
al. 1990; Bidez & Misch 1992; Kitamura et
al. 2004). It is possible to hypothesize that
the fulcrum of implant bending is therefore
the bone crest. If true, then the tolerable
level of implant micromotion, as demon-
strated in the present study, should be
found 10 mm above the crest into cancel-
lous bone. Moreover, given the results
indicated above, micromotion would be
below the risk threshold of 50 mm when
the applied force is 20 and 25 N/cm2 and
around this threshold when the applied
force is 30 N. However, when the implants
were placed using a peak insertion torque of
100 N/cm, the micromotion was always
below the risk threshold. It was also found
that there were only minor changes and no
statistical difference between 45 N/cm and
a higher insertion torque, as related to
micromotion.

Taken together, these results support the
use of high insertion forces during implant
placement to reduce the risk of micromo-
tion above the threshold, thereby achieving
a higher success rate in immediate implant
loading. Ottoni et al. (2005) have validated
this hypothesis in a clinical study showing
that an increase in the peak insertion tor-
que may significantly improve the clinical
success rate of immediately loaded im-
plants. Furthermore, in an animal experi-
mental study, the effects of up to 110 N/
cm insertion torque were tested histologi-
cally and showed that high torques induce
increased bone remodeling, but not peri-
implant fibrosis (Trisi et al. 2007). On the
other hand, in soft bone, we found that
micromotion was significantly higher and
above the risk threshold; therefore, it was
not possible to achieve a peak insertion
torque 435 N due to the stripping of the
peri-implant bone. High insertion torques
in hard bone do not induce peri-implant
fibrosis, but they do increase bone remo-
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