Received: 27 September 2017 | Revised: 16 November 2017 | Accepted: 17 November 2017

DOI: 10.1111/cid.12574

ORIGINAL ARTICLE

Evaluation of primary stability in modified implants: Analysis

by resonance frequency and insertion torque

Plínio Sciasci DDS, MSc1 | Nicole Casalle MSc2 | Luís Geraldo Vaz DDS, MSc, PhD2

1
Department of Diagnosis and Surgery,
Araraquara Dental School, Unesp – Univ
Abstract
Estadual Paulista, Araraquara, S~
ao Paulo,
Background: Changes in the macrogeometry of dental implants are known to influence primary
Brazil
2
stability and the osseointegration process.
Department of Dental Materials and
Prosthodontics, Araraquara Dental School, Purpose: The purpose of the present in vitro study was to evaluate the mechanical behavior of
Unesp – Univ Estadual Paulista, Araraquara,
geometric changes in the apex region of dental implants.
S~ao Paulo, Brazil
Methods: Thirty-five cylindrical dental implants (Titamax Ti; Neodent) were machined at the apical
Correspondence
third to reproduce the experimental groups: without apical cut (Wc), apical bi-split cut, apical tri-split
Plínio Sciasci, Department of Diagnosis and
Surgery, Araraquara Dental School, cut, apical quadri-split cut (Qs). One (control group) (Titamax Ti Ex) (n 5 7) without any modifications
Unesp – Univ Estadual Paulista, Araraquara, was added. The implants had the same final dimensions (4.1 x 11 mm2). All implants were inserted
Rua Humaita, n8 1680, 48 andar, sala 409, into artificial bone blocks and were evaluated by insertion torque and resonance frequency by ISQ
Araraquara, S~ao Paulo CEP 14801-903,
values (Osstell). Two-tailed analysis of variance (One-way ANOVA) and Tukey’s post-test (P < .05).
Brazil.
Email: psciasci@yahoo.com.br Results: Control and Qs implants showed a significant increase of the insertion torque (P < .001).
For the resonance frequency, Wc and (control) implants had the greatest ISQ values. However,
there’s no significant difference between (control) and Qs for the ISQ values (P < .001).

Conclusion: Within the limitations of the present study, the proposed geometries at the apical
third of dental implants greatly influenced its insertion torque and primary stability in vitro.

KEYWORDS
dental implant, implant design, insertion torque, primary stability, resonance frequency analysis

1 | INTRODUCTION
Dental implants were introduced in the mid-1970s when Branemark
and his colleagues discovered the process of osseointegration, which
occurs between the bone tissue and the titanium surface.1 Since then,
implants have been widely used in unitary, partial, and total rehabilita-
tions of the jaws, with success rates above 90%.2 However, there are a
number of factors that can cause failure of implant treatments, such as
surgical and/or systemic complications, in addition to poor bone quality
and density that may compromise the initial stability of the implant,
which is a prerequisite for the success of osseointegration.3,4
The forces that occur at the implant-bone interface can promote
micromovements in the implant and are the most damaging ones in
the first moments of implant healing.5 Furthermore, the primary sta-
bility of the implant also depends on the quality, density, and thick-
ness of available cortical bone tissue at the surgical site.6 When there
is no amount of sufficient bone tissue for the treatment or when
there is presence of severe bone atrophies, performing bone graft
surgeries may be an option. However, to avoid such procedures,
which may subject patients to multiple surgeries, smaller implants
have been indicated.7
Over time, with the decrease in implant size, the industry studies
change in the geometric design of the implant, such as modifications to
the platform, body, apex region, threads, and/or an increase in its plat-
form diameter in relation to the body. These modifications are pro-
posed with the intention of preventing early movement after

274 | V
C 2018 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/cid Clin Implant Dent Relat Res. 2018;20:274–279.
SCIASCI ET AL.
placement and also to decrease the effect of harmful loads to the
implant, increasing its bone-implant contact. 6
The primary stability of the implant is the result of its intimate con-
tact with the bone walls.8 This condition can be influenced by the
macro-geometry of the implant, surface roughness, and surgical prepa-
ration.9 Since the macro-geometry of a dental implant can influence
the success of the treatment, many designs are proposed to improve
the contact between the implant and bone tissue.10 However, there is
still no established consensus in the literature regarding different for-
mats related to the geometry changes and implant designs with primary
stability.11
From the bioengineering point of view, it is extremely important to
consider new implant designs in order to maximize its surface area in
contact with bone tissue, thus providing greater ease of installation, bet-
ter bone anchoring, and reduction of stress concentrations at the
implant-bone interface.12 In this context, recent studies have shown that
in order to induce controlled compression forces in the cortical bone
layer during implant insertion, a new hybrid auto-implant has been spe-
cifically designed for use in critical-quality bone, which combines the
advantages of a conical implant with those of a cylindrical shape.13
Considering the increase in the complexity of the cases in oral
rehabilitations, modifications in the macro-geometry in implants should
seek to favor their insertion, promoting the cut and bone compaction
14
to increase their primary stability. This is of extreme importance for
regions where there is low bone height and quality, where implant
interlocking can be compromised.15 The development of implants with
self-drilling apices plays the role of bone shear and compression and
may influence the primary stability of the implant, favoring the success
of the treatment.13
To increase the primary stability and osseointegration of dental
implants, new implant designs have been developed. Jo and Hobo16
have shown that implants with their apical portion expanded through a
screw can present success rates comparable to conventional implants.
Finite element studies were performed with these implants by Xiao and
colleagues,17 who concluded that the implant shape significantly influ-
ences the reduction of stress to the bone tissue. In addition, the
expanded apical implant and a hybrid implant (conic-cylindrical) obtained
a better pattern of force distributions for the bone tissue compared to
the other conventional implant formats in finite element studies.
Different implant designs were also tested by some authors in vivo
and in vitro,12,18,19 to increase the surface area of the implant with the
bone tissue. Lundgren and colleagues,18 and Sivan-Gildor and col-
leagues,12 developed “hollow” implants in their inner portion and both
concluded that the greater contact of the implant with the bone sur-
face favored the success rate of these implants. Meirelles and col-
leagues,19 performed a modification at the apex of the implant creating
a “chamber”, and demonstrated in histological sections, the bone for-
mation in this space in the period of 1 month in rabbits.
Therefore, the present work aims to study the mechanical behavior
of geometric changes in the apex region in dental implants by means of
mechanical tests: insertion torque and resonance frequency analysis in
artificial bone blocks of polyurethane analogous to human trabecular
bone Type III without cortical bone tissue. Four new types of different
| 275
T AB LE 1 Modifications in the apex region of implants Bs, Ts,
and Qs
Geometric changes at the apex—implants Bs, Ts, and Qs
Width of apex cuts 0.8 mm
Height of apex cuts 3.0 mm
apex designs will be compared to a commonly available solution on the
market. Implants with alterations in their apex region were divided into
four groups: without apical cut (Ws), bi-split (Bs), tri-split (Ts), and quad-
split (Qs). A fifth group was added, composed of Titamax Ti Ex implants
(Neodent, Curitiba, Paran
a, Brazil) (control) with the same dimensions.
The null hypothesis is that the new apex designs of the implants
do not influence their insertion torque and primary stability.
2 | MATERIALS AND METHODS
2.1 | Implants macrogeometry modifications
Thirty-five external hexagon cylindrical dental implants (Neodent)
(4.1 3 15 mm length) were machined at the apical region to reproduce
the experimental models: without apical cut (Ws) (n 5 9), bi-split apical
cut (Bs) (n 5 9), tri-split apical cut (n 5 9) (Ts), and quadri-split apical cut
(Qs) (n 5 8). The final diameter and length of the experimental models
were (4.1 3 11 mm2), respectively, and apical modifications are pre-
sented in Table 1. The height and width of the apical crevice was
3.0 mm and 0.8 mm, respectively. One additional group with the same
final dimensions of the experimental implants with geometry of self-
tapered implants (4.1 3 11 mm length) (control) (n 5 7) Titamax Ti Ex
implant (Neodent Ltda, Curitiba, Paran
a, Brazil) were not altered in any
part (Figure 1).
Polyurethane artificial bone blocks (Nacional Ossos, S~
ao Paulo,
Brazil) were used were used to assess the mechanical properties with
2 cm in all its dimensions and 0.32 g/cm3 in density, resembling type III
human bone.
2.2 | Drilling and insertion protocol
All blocks were prepared until a final drill diameter of 3.0 mm using a
BLM 600 surgical electric motor (Driller, S~
ao Paulo, Brazil) adjusted to
1200 rpm and torque of 45 N. The electric motor was attached to a
gicos
vertical milling machine (1000 N; Bio-Art Equipamentos Odontolo
Ltda, S~
ao Paulo, Brazil) to prevent angulation differences between the
(control) and modified-geometry dental implants. Thereafter, the blocks
were placed in a bench vise and with appropriate implant-mounts and
insertion keys, the implants were inserted 9-mm deep into the blocks
using a manual wrench (Neodent).
2.3 | Insertion torque and resonance
frequency analysis
A TQ-680 digital torque meter (Instrutherm, S~ao Paulo Brazil) was used
to record the final 2.0-mm insertion torque of the implants into the
bone blocks. Resonance frequency analysis was determined by implant
276 | SCIASCI ET AL.

FIGURE 1 The implant Titamax Ti Ex (control), (Wc), (Bs), (Ts), and (Qs)

FIGURE 2 Insertion torque an implant stability analysis

stability quotient (ISQ) values with the Osstell device (Osstell AB, Goth-
enburg, Sweden). An appropriate smartpeg transducer (Type 1; Integra-
tion Diagnostics, Gothenburg, Sweden) was attached to external
hexagon implants and the measurements were performed in four dia-
metrically opposite directions (buccal, lingual, mesial, distal). The mean
value was used to determine the final ISQ of each implant (Figures 2
and 3).3
2.4 | Statistical analysis
Data from insertion torque and resonance frequency were subjected to
the Shapiro-Wilk normality test. Statistical significance was determined
by 2-tailed One-way analysis of variance (One-way ANOVA) and
Tukey’s multiple comparison tests at the level of 5%. All statistics were
performed using the Prism 5.0 software (GraphPad, La Jolla, California).
3 | RESULTS
The results of the test (ANOVA - one factor) showed that there were
statistically significant differences between groups for insertion torque
and primary stability (P < .001) (Tables 1 and 2), respectively.
For the insertion torque, the implants of group Qs and (control)
obtained the highest mean, while for groups Wc, Bs, and Ts, the values
were statistically similar. There is also statistical equality for the means
obtained between groups Wc, Ts, and Qs (Table 2 and Figure 3).
For primary stability, the group Wc and (control) implants obtained
the highest mean when compared to the other groups that registered
statistically similar values. However, there is no significant difference
between ISQ values for the Qs group and (control) (P < .05) (Table 3
and Figure 4).

4 | DISCUSSION

In the present study, cylindrical dental implants were structurally modi-

fied in their apex region, while one group was composed of Titamax Ti
Neodent dental implants. The implants had the same dimensions,

T AB LE 2 Mean and standard deviation for insertion torque test in

N/cm

Control Implant Wc Implant Bs Implant Ts Implant Qs

Mean 18.43b 13.81a,c 13.26a 14.40a,c 16.19b,c

FIGURE 3 Mean and standard deviation of insertion torque of SD 2.378 1.047 1.857 1.123 2.638
implants control, Wc, Bs, TS, and in N.cm. The same letters
indicate statistical equalities between the groups Same letters indicate statistical similarity between the implants.
SCIASCI ET AL.
TA BL E 3 Mean and standard deviation for primary stability in ISQ
Control Implant Wc Implant Bs Implant Ts Implant Qs
Mean 56.93a,c 58.03a 44.44b 46.50b 49.06b,c
SD 4.344 2.303 7.079 8.055 4.756
Same letters indicate statistical similarity between the implants.
thread pitch and platform, differing only at their apex region. The
implants were installed using the same drilling protocol and their inser-
tion torque and primary stability were measured.
Implants that received modifications in the apex region showed
satisfactory results according to the methodology used for the insertion
torque and for primary stability. As a focus of the research, it was
decided to formulate several apex geometries to the implants that
were accessible and easily reproducible on an industrial scale, proposi-
tioning new implant geometries for the apex region. The aim of the
present study was to verify the influence of these modifications under
unfavorable conditions for installation of the implant, such as low bone
density and absence of cortical bone tissue. 20
The cuts in the apex region of the Bs and Ts implants do not
improved their drilling ability and their insertion compared to the con-
trol group which presented better results. However, the Qs implant
presented insertion torque and ISQ values statistically equal to the
Titamax implant (Tables 2 and 3, Figures 3 and 4). The Titamax Ti (con-
trol) implant had good cutting ability and easy insertion, in view of the
fact that its engineering design is designed with blades at the apex,
which facilitates its insertion and interlocking. The implants with cuts
or self-taper have advantages over implants that do not have cuts in
their apex region, since a smaller number of milling cutters is required
for their installation, reducing thermal damage to bone tissue, making
surgery easier and faster. 21
In addition, with less preparation during
drilling, the amount of bone tissue viable in contact with the implant
increases, favoring the osseointegration.22
FIGURE 4 Mean and standard deviation of the primary stability
obtained by the resonance frequency analysis of implants control,
Wc, Bs, Ts, and Qs. The same letters indicate statistical equalities
between the groups
| 277
Regarding the insertion torque, we found that the Qs (16.19 N.cm)
and (control) (18.43 N.cm) implants obtained the highest values in com-
parison to the other implants. These insertion torque values are in
accordance with a study by Valente and colleagues22 that evaluated
the insertion torque and primary stability in implants with different
prosthetic connections in different artificial bone blocks and in sheep
bones. Cylindrical implants inserted in blocks with a density of 0.32 g/
cm3 obtained insertion torque values ranging from 9.44 to 17.89 N.cm.
However, for primary stability, the mean ISQ values obtained were
higher than those of the present study ranging from 60.22 to 61.24.
The implant that obtained the highest mean for primary stability
was implants (control) and Wc, while the other implants obtained stat-
istically similar values. However, were verified that has no significant
differences between Qs and (control) for the ISQ values. According to
Kim and colleagues,23 for the success of the treatment with implants,
the ISQ values should be greater than 65, and values lower than 50
may indicate a possible failure of osseointegration of the implant. In
the present study, only implant (control) and Wc had a ISQ value
greater than 50 and the other implants had ISQ values below 50.
In Chang and colleagues,24 the differences in substrate densities
between the bone blocks significantly influenced the insertion torque
and primary stability of the implants. In another study, Valente and col-
leagues,3 evaluated a new implant design in blocks of polyurethane
artificial bones with a higher density of 0.64 g/cm3 and obtained high
values of insertion torque and primary stability.
There is a consensus in the literature that the greater the bone
density at the surgical site, the greater the primary stability of the
implant.25,26 Therefore, the low values of insertion torque and ISQ val-
ues for the implants due to the low density of the bone blocks used in
the present study are plausible. Conversely, the low bone density and
absence of cortical bone in the present study allowed us to better eval-
uate the mechanical imbrication created by the new apex designs. Low
density blocks have a lower effect in the implant body and platform
compared with higher density blocks.20 Therefore, interlocking and pri-
mary stability depend less on the density of the bone block, where
there’s no cortical bone tissue.
According to Freitas and colleagues,27 the influence of primary sta-
bility on implants is difficult to predict since the stability of the implant
depends on several factors, such as insertion torque, bone density and
the macro and micro-geometry of the implant. The best performance
for ISQ values of implant Wc and (control) can be explained due to its
greater surface area in contact with the substrate, while in the other
implants (Bs, Ts, and Qs), with the presence of notches, the material
was cut and compacted in its cavities, as reported in a study by Valente
and colleagues3 Since implant Wc and (control) self-tapered does not
have cuts in the apex region, the threads act more to expand the mate-
rial by inflicting greater pressure, which does not occur with the other
implants, which have slices at the apex, and allow cutting and com-
pressing bone within the surgery site.
Wu and colleagues,28 studied the insertion torque of cylindrical
and tapered implants with notches in the apex region and related that
the apex cuts facilitate insertion of the implant promoting bone shear
and compaction. In the present study, all the implants presented a
278 | SCIASCI
cylindrical shape with notches in the apex region that can favor implant
installation and interlocking. In addition, different implant designs were
also tested by some authors in vivo and in vitro12,18,19 to increase the
area of implant surface with the bone tissue. Lundgren and col-
leagues,18 and Sivan-Gildor and colleagues,12 developed “hollow”
implants in their inner portion and both concluded that the greater con-
tact of the implant with the bone surface favored the success rate of
these implants. Meirelles and colleagues,19 performed a modification at
the apex of the implant creating a “chamber” inside, and demonstrated
in histological sections, the bone formation in this space in a period of
1 month in rabbits.
Different designs of implants are available on the market providing
the dentist with a wide variety of options for performing simple and
complex rehabilitations. The development of new implant designs can
significantly increase the primary stability of the implant, favoring bone
healing, and increasing bone-implant contact.29 Thus, changes in the
geometry of implants should seek to increase the implant-bone contact
surface area favoring the distribution of forces. Therefore, according to
the aforementioned studies, the alterations developed at the apex of
the implants in the present study may have a posterior biological
advantage, considering its complete osseointegration process.
5 | CONCLUSION
With the limitations of the present study, it was possible to conclude
that:
1. Geometric changes in implants in the apex region significantly
influence their insertion torque and primary stability.
2. The proposed modifications for the apex region of implants Bs, Ts,
and Qs need more further investigations to better understand
yours advantages and disadvantages by aplication of this cuts in
dental implants.
CONFLIC T OF I NTE R ES T
The authors declare that they have no competing interests.
ORCI D
Plínio Sciasci DDS, MSc http://orcid.org/0000-0002-0170-2405
RE FE RE NCE S
[1] Liang R, Guo W, Qiao X, et al. Biomechanical analysis and compari-
son of 12 dental implant systems using 3D finite element study.
Comput Methods Biomech Biomed Engin. 2015;18(12):1340–1348.
[2] Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical compli-
cations with implants and implant prostheses. J Prosthet Dent. 2003;
90(2):121–132.
[3] Valente ML, de Castro DT, Shimano AC, Lepri CP, dos Reis AC.
Analyzing the influence of a new dental implant design on primary
stability. Clin Implant Dent Relat Res. 2016;18(1):168–173.
[4] Sevimay M, Turhan F, Kiliçarslan MA, Eskitascioglu G. Three-dimen-
sional finite element analysis of the effect of different bone quality
ET AL.
on stress distribution in an implant-supported crown. J Prosthet
Dent. 2005;93(3):227–234.
[5] Misch CE, Steigenga J, Barboza E, Misch-Dietsh F, Cianciola LJ,
Kazor C. Short dental implants in posterior partial edentulism: a
multicenter retrospective 6-year case series study. J Periodontol.
2006;77(8):1340–1347.
[6] Huang YM, Chou IC, Jiang CP, Wu YS, Lee SY. Finite element analysis
of dental implant neck effects on primary stability and osseointegration
in a type IV bonemandible. Biomed Mater Eng. 2014;24(1):1407–1415.
[7] Kheiralla LS, Younis JF. Peri-implant biomechanical responses to
standard, short-wide, and mini implants supporting single crownsun-
der axial and off-axial loading (an in vitro study). J Oral Implantol.
2014;40(1):42–52.
[8] Elias CN, Rocha FA, Nascimento AL, Coelho PG. Influence of
implant shape, surface morphology, surgical technique and bone
quality on the primary stability of dental implants. J Mech Behav
Biomed Mater. 2012;16:169–180.
[9] Marco F, Milena F, Gianluca G, Vittoria O. Peri-implant osteogenesis
in health and osteoporosis. Micron. 2005;36(7–8):630–644.
[10] Chowdhary R, Jimbo R, Thomsen C, Carlsson L, Wennerberg A. Bio-
mechanical evaluation of macro and micro designed screw-type
implants: an insertion torque and removal torque study in rabbits.
Clin Oral Implants Res. 2013;24(3):342–346.
[11] Javed F, Almas K, Crespi R, Romanos GE. Implant surface morphol-
ogy and primary stability: is there a connection? Implant Dent.
2011;20(1):40–46.
[12] Sivan-Gildor A, Machtei EE, Gabay E, et al. Novel implant design
improves implant survival in multirooted extraction sites: a preclini-
cal pilot study. J Periodontol. 2014;85(10):1458–1463.
[13] Toyoshima T, Wagner W, Klein MO, Stender E, Wieland M, Al-
Nawas B. Primary stability of a hybrid self-tapping implant com-
pared to a cylindrical non-self-tapping implant with respect to dril-
ling protocols in an ex vivo model. Clin Implant Dent Relat Res.
2011;13(1):71–78.
[14] Lee JH, Frias V, Lee KW, Wright RF. Effect of implant size and
shape on implant success rates: a literature review. J Prosthet Dent.
2005;94(4):377–381.
[15] Romanos GE, Ciornei G, Jucan A, Malmstrom H, Gupta B. In vitro
assessment of primary stability of Straumann® implant designs. Clin
Implant Dent Relat Res. 2014;16(1):89–95.
[16] Jo HY, Hobo PK, Hobo S. Freestanding and multiunit immediate
loading of the expandable implant: an up-to-40-month prospective
survival study. J Prosthet Dent. 2001;85(2):148–155.
[17] Xiao JR, Li DH, Chen YX, Chen SJ, Guan SM, Kong L. Evaluation of
fixation of expandable implants in the mandibles of ovariectomized
sheep. J Oral Maxillofac Surg. 2013;71(4):682–688.
[18] Lundgren D, Slotte C, Gro €ndahl K. A novel type of dental tube
implant for areas with limited bone height. Clinical and radiographic
data from three patients with 5-year follow-up. Clin Implant Dent
Relat Res. 2013;15(4):509–516.
[19] Meirelles L, Brånemark PI, Albrektsson T, Feng C, Johansson C. His-
tological evaluation of bone formation adjacent to dental implants
with a novel apical chamber design: preliminary data in the rabbit
model. Clin Implant Dent Relat Res. 2013;17(3):453–460.
[20] Staedt H, Palarie V, Staedt A, et al. Primary stability of cylindrical
and conical dental implants in relation to insertion torque-A com-
parative ex vivo evaluation. Implant Dent. 2017;26(2):250–255.
[21] Heidemann W, Terheyden H, Louis Gerlach K. Analysis of the osse-
ous/metal interface of drill free screws and self-tapping screws.
J Maxillofac Surg. 2001;29(2):69–74.
SCIASCI ET AL.
[22] Valente ML, de Castro DT, Shimano AC, Lepri CP, dos Reis AC.
Analysis of the influence of implant shape on primary stability using
the correlation of multiple methods. Clin Oral Investig. 2015;19(8):
1861–1866.
[23] Kim DS, Lee WJ, Choi SC, et al. Comparison of dental implant
stabilities by impact response and resonance frequencies using arti-
ficial bone. Med Eng Phys. 2014;36(6):715–720.
[24] Chang CL, Chen CS, Huang CH, Hsu ML. Finite element analysis of
the dental implant using a topology optimization method. Med Eng
Phys. 2012;34(7):999–1008.
[25] Dorogoy A, Rittel D, Shemtov-Yona K, Korabi R. Modeling
dental implant insertion. J Mech Behav Biomed Mater. 2017;68:
42–50.
[26] Romanos GE. Bone quality and the immediate loading of implants-
critical aspects based on literature, research, and clinical experience.
Implant Dent. 2009;18(3):203–209.
| 279
[27] Freitas AC Jr, Bonfante EA, Giro G, Janal MN, Coelho PG. The
effect of implant design on insertion torque and immediate micro-
motion. Clin Oral Implants Res. 2012;23(1):113–118.
[28] Wu SW, Lee CC, Fu PY, Lin SC. The effects of flute shape and
thread profile on the insertion torque and primary stability of dental
implants. Med Eng Phys. 2012;34(7):797–805.
[29] Atsumi M, Park SH, Wang HL. Methods used to assess implant stabil-
ity: current status. Int J Oral Maxillofac Implants. 2007;22(5):743–754.
How to cite this article: Sciasci P, Casalle N, Vaz LG. Evaluation
of primary stability in modified implants: Analysis by resonance
frequency and insertion torque. Clin Implant Dent Relat Res.
2018;20:274–279. https://doi.org/10.1111/cid.12574