Primary and Secondary Stability of Implants

in Postextraction and Healed Sites:

A Randomized Controlled Clinical Trial
Luciano Malchiodi, MD1/Lucio Balzani, MD2/Alessandro Cucchi, DDS3/
Paolo Ghensi, DDS4/Pier Francesco Nocini, MD, DDS1

Purpose: This randomized clinical trial aimed to investigate the relationships between insertion torque,
implant stability quotient (ISQ), and crestal bone loss (CBL) of implants placed in fresh or 12-week healed
extraction sites. Materials and Methods: Forty patients were randomly assigned to one of two groups and
had one implant placed immediately (test group, n = 20) or 12 weeks after extraction (control group, n = 20)
at premolar or molar sites. For all implants, insertion torque and ISQ scores at insertion and loading were
recorded. Patients were followed for up to 12 months. Results: Implant success was 100% in both groups.
No differences were observed concerning both ISQ at insertion and ISQ at loading. A stronger correlation was
detected between ISQ at insertion and insertion torque in the postextractive group (R = 0.83), than in the
delayed group (R = 0.39), while ISQ at loading and insertion torque showed no correlation. CBL at 12 months
was significantly different between test (0.68 ± 0.43 mm) and control (0.40 ± 0.26 mm, P = .02) groups.
Conclusion: Implant placement timing (immediate or delayed) may affect correlation between insertion torque
and ISQ at insertion with ISQ at loading. While insertion torque influences ISQ at insertion, it does not affect ISQ
at loading because of successful osseointegration. Postextraction and delayed implants seem to have similar
ISQ at insertion and at loading, but different CBL after 12 months of follow-up because of postextraction bone
remodeling. Int J Oral Maxillofac Implants 2016;31:1435–1443. doi: 10.11607/jomi.4710

Keywords: crestal bone loss, implant stability quotient, implant success, insertion torque, postextraction
sites, RFA

I mplant primary stability is defined as the mechanical

stabilization that develops immediately after implant
placement. Its role in determining implant success was
established in the original implant placement protocol
defined by Brånemark et al.1 Primary stability has been
shown to depend on several factors, including bone
quality (ie, density) and quantity at the placement site;
implant design, size, and surface; and the placement
technique used (ie, osteotomy undersizing).2 In con-
trast, secondary stability is the mechanical stabiliza-
tion that develops as a consequence of bone formation
and remodeling at the implant surface.3 Micromotion
1Department of Surgery, Section of Dentistry and Maxillofacial
Surgery, University of Verona, Italy.
2 Azienda Usl, Bologna, Italy.
3Department of Biomedical and Neuromotorial Science,
University of Bologna, Italy.
4 Centre for Integrative Biology (CIBIO), University of Trento,
Italy.
Correspondence to: Prof Luciano Malchiodi, Via Solferino 11,
25122 Brescia (BS), Italy. Email: research.univr@hotmail.it
©2016 by Quintessence Publishing Co Inc.
at the bone-implant interface has been shown to in-
terfere with the osseointegration process.4–6 Indeed,
micromotion exceeding 50 to 150 microns is regarded
as a risk factor for increasing the probability of defec-
tive or abortive osseointegration and fibrous implant
encapsulation.7 Accordingly, primary stability is a key
prognostic determinant,8 and achieving a proper de-
gree of primary stability is a fundamental prerequisite
for any implant-supported rehabilitation.9 Sufficient
primary stability becomes of paramount importance
if implants have to be inserted in challenging condi-
tions, such as in fresh postextraction sockets or low-
density or regenerated bone,10 or if early or immediate
loading protocols are involved.11–13
Implant design is another factor affecting primary
stability.14 Implants with an expanded coronal third,
reduced thread pitch design, and a slightly conical
core provide greater primary stability than conven-
tional implant designs, thanks to their ability to com-
press bone upon insertion.15 The implant surface plays
a role later, as osseointegration occurs, by modulating
the implant-tissue interaction at the bone-implant
interface.16 Indeed, surfaces that are roughened via
metal-subtractive techniques, via anodic deposition,

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Malchiodi et al
and/or via contamination by ions accelerate the osseo-
integration process.17,18 Therefore, while primary sta-
bility depends on mechanical anchorage, secondary
stability bonds develop because of bone remodeling
processes occurring at the bone-implant interface at
healing.17
Several methods have been proposed to assess
implant stability,19 including histomorphometry ob-
servations, reverse-torque analysis,20 pull- and push-
through tests,21,22 and radiographic and computed
tomography (CT) examination.23,24 However, due to
problems of invasiveness or accuracy, these methods
are not suitable for clinical assessments. A noninvasive
measurement procedure, first devised to assess dental
mobility and later used to evaluate implant stability,
was introduced in the early 1980s by Schulte et al.25
The so-called Periotest device involves measuring the
implant’s mechanical response to percussion. Unfor-
tunately, readings are strongly affected by the percus-
sion direction and position and may not always relate
to an actual biomechanical parameter.26 Meredith et
al27–29 later introduced a method based on the fre-
quency analysis of the implant’s response to a trans-
ducer excited with a proper, steady-state wave form.
The method, resonance frequency analysis (RFA), mea-
sures the stiffness of the implant with respect to the
surrounding tissue, thereby providing an assessment
of its mechanical stability, expressed as the implant
stability quotient (ISQ). This method seems to provide
more reliable information in comparison with other
tests.30–33 Torque at insertion is another parameter
that is often recorded,34 and the extent of implant mi-
cromotion has been shown to be inversely correlated
with peak torque at insertion.35–37 The question of
whether insertion torque represents a reliable primary
stability indicator is still open, however. A strong cor-
relation between insertion torque and primary stabil-
ity as assessed using RFA has been observed by some
authors,38,39 but others have not found any significant
correlation.40–42 Available data do not allow for defini-
tion of an optimal insertion torque value to obtain good
primary stability. However, insertion torque correlates
with the initial bone-to-implant contact (BIC).43,44 Con-
sequently, implants that have a shape and/or thread
design allowing for higher insertion torque values may
enable achievement of greater BIC, possibly resulting
in higher primary stability and in a greater probability
of successful osseointegration.
The aim of this randomized controlled clinical trial
was to investigate the relationships between inser-
tion torque, ISQ, and 1-year crestal bone loss (CBL) of
implants with a cylindrical design and regular single
threads placed in fresh or 12-week healed postextrac-
tion sites. Specifically, the aims of this study included
evaluation of (1) significant differences of primary
1436 Volume 31, Number 6, 2016
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stability (insertion torque and RFA at insertion), sec-
ondary stability (RFA at loading), and CBL after 1 year
of functional loading in the two groups; and (2) sig-
nificant correlation between insertion torque and RFA
scores at insertion and at loading in the two groups.
MATERIALS AND METHODS
Patients presenting at the Department of Dentistry and
Maxillofacial Surgery, University of Verona, between
March 2011 and March 2012, seeking implant-pros-
thetic rehabilitations that required a dental extraction
at premolar or molar sites that could be successfully
restored with either a delayed or immediate postex-
traction implant were screened for the study. Included
patients had to meet the following criteria: a single
postextraction socket with a containing alveolus (four
bone-wall defects); more than 9 mm of bone height
in the maxilla and more than 11 mm in the mandible.
At least 3 mm of bone beyond the root apex should
be available for following implant placement; if 3 mm
were not available, the patient was excluded from the
study, because of the difficulty of implant stabilization.
They had to need a fixed prosthesis (single crown was
preferred), sign an informed written consent, accept
treatment based on a new implant system, and be will-
ing to take part in a follow-up program.
Patients were excluded if they had ASA (American
Society of Anesthesiologists) ratings of 4, 5, or 6; were
pregnant; had osteoporosis or other bone diseases;
were currently undergoing bisphosphonate therapy;
suffered from any psychiatric disease, neoplasia, or
drug and/or alcohol abuse; had a history of chemo-
therapy or radiotherapy in the head or neck region at
any time in the previous 2 years; were immunocompro-
mised; and had any acute oral infections or coagulation
disorders. Heavy smoking and poor oral hygiene were
also considered exclusion criteria. Finally, patients with
uncontrolled diabetes or other uncontrolled conditions
that were documented to have a negative influence on
implant success were not included in the study.
The enrolled patients were randomly divided into
two groups: 20 who had implants placed at the time
of tooth extraction (test group), and 20 with implants
placed 12 weeks after tooth extraction (control group).
Only one of the investigators, who was not involved
in the selection and treatment of the patients, was
aware of the randomization sequence and had access
to the randomization list. The randomized codes were
enclosed in identical, sequentially numbered opaque
sealed envelopes. Envelopes were opened in sequence
only after teeth were extracted to conceal the treat-
ment group to which the patient was assigned.

Patients were provided a detailed explanation of
the study protocol and signed an informed written
consent, which had already been previously approved
by the local Ethics Committee for Human Research.
The study was conducted in accordance with the fun-
damental principles of the Helsinki Declaration, origi-
nally described in 1977 and subsequently revised in
2000, concerning research on human subjects.
All implants used in the study (SybronPRO XRT, Syb-
ron Implant Solutions) had a cylindrical design and
regular single threads. These implants have coronal mi-
crothreads, self-tapping blades, a rounded apex, a cor-
onal flare, and a resorbable blast media (RBM) surface.
Surgery
Patients received professional oral hygiene 1 day be-
fore the operation and were instructed to rinse with
chlorhexidine 0.2% for 1 minute, 2 times a day, start-
ing 3 days prior to the intervention and thereafter for
14 days. All patients received prophylactic amoxicil-
lin and clavulanic acid (Augmentin, GlaxoSmithKline)
2 g 1 hour prior to the intervention and 1 g 6 hours
postoperatively.
Following the administration of local anesthesia
using articaine with adrenaline 1:100,000 (Dentsply), a
careful circular fiberotomy was performed using perio-
tomes and small elevators to achieve atraumatic tooth
extraction. After removal of all granulation tissue, the
integrity of the four socket bone walls was checked
with a periodontal probe. If the facial socket walls
were damaged, surgical flaps were elevated to allow
for guided bone regeneration procedures to be per-
formed, and these sites were excluded from the study.
Immediately after tooth extraction, the envelope
containing the randomization code was opened to let
the surgeon know whether to proceed with immediate
implant placement.
In the test group, no flap was elevated, and the im-
plant site preparation at the fresh extraction sockets
was performed according to standard techniques, drill-
ing osteotomies that followed the socket bone walls as
a guide. Bone was underdrilled apically to the extrac-
tion sockets, leaving at least 3 mm of bone beyond the
root apex. No countersinking was used. Implants were
placed 1 mm below the alveolar crest buccal level, to
(1) improve primary stability because of the increase
of BIC, and (2) balance out the bone resorption of
the buccal plate, reducing the risk of implant dehis-
cence. In all cases, any gap between the implant and
surrounding bone at the facial aspect was filled with
a mixture of autogenous bone collected during drill-
ing and deproteinized bovine bone (Bio-Oss, Geistlich
Pharma). For the control group, alveolar sockets were
left to heal spontaneously for 12 weeks. Implants were
then placed according to the manufacturer’s protocol
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Malchiodi et al
after raising a full-thickness flap extended to the adja-
cent mesial and distal teeth.
In both groups, at the end of the surgical procedure,
a healing screw was placed and soft tissues were su-
tured to obtain the most complete possible closure of
surgical sites. Patients were instructed to avoid brush-
ing the treated area. Ibuprofen 600 mg (Brufen 600,
Abbott Laboratories) was to be taken as needed. The
bone type at the site of insertion was classified accord-
ing to Lekholm and Zarb’s system.45
For both groups, a definitive impression was made
after 3 months. Custom abutments and definitive pros-
theses were manufactured and positioned 1 or 2 weeks
after the impression was obtained, thus concluding the
treatment. The definitive rehabilitation included single
crowns that were cemented at the juxtagingival level
and placed in occlusion. The occlusal surface was thor-
oughly modeled so that it was in contact with reduced
areas during laterality and protrusion excursions, in
order to reduce the dislocating vectorial components.
More contacts were maintained in maximum intercus-
pidation. Patients followed a maintenance program
comprising professional oral hygiene every 6 months
and two chlorhexidine digluconate 0.2% rinses per day
during the first 2 weeks.
Resonance Frequency Analysis
Implant stability measurements were performed at the
time of implant placement and at the time of loading
by measuring ISQ values for each implant with a RFA-
analysis device (Osstell, Osstell). The transducer was
screwed onto each implant and tightened to 5 to 10
Ncm. The device probe was aimed at the small magnet
at the top of the transducer and held still, at a distance
between 2 and 3 mm, until measurement was com-
plete and the device displayed the ISQ value. If two
ISQ values were displayed simultaneously, their mean
value was recorded. Measurements were taken twice
in the buccolingual direction and the mesiodistal di-
rection. The mean of all measurements was rounded
to the nearest integer and regarded as representative
of the ISQ.
Insertion Torque Measurements
Peak insertion torque values were recorded by means
of the same motor used for implant placement (Osseo-
Care Nobel Biocare). This motor features an insertion
torque control system to avoid mechanical overload
either of the equipment or the bone tissue and allows
for torque visualization. For each implant, torque was
increased in 5-Ncm steps from an initial value of 20
Ncm up to complete insertion, and the final insertion
torque value was recorded. Such values were double-
checked with a manual torque wrench featuring a 15-
to 70-Ncm graduated scale.
The International Journal of Oral & Maxillofacial Implants 1437
Malchiodi et al
Table 1  Characteristics of Treated Patients at Baseline
Sex Smokers (< 20
Study group Age (median) (Male:Female) cigarettes/day)
Immediate (test) 54 y 11:9
Delayed (control) 51 y 13:7
Bone Level Measurement
Crestal bone levels were assessed using standardized
radiographs performed with a parallel technique at
the time of implant surgery, reopening surgery, func-
tional loading, and at the 12-month follow-up visit.
Radiographs were collected for each implant placed.
All radiographs were scanned, digitized in JPG for-
mat, converted to 600 dpi resolution TIFF images, and
stored in a personal computer.
Peri-implant marginal bone levels were measured
by two different blinded examiners using analysis soft-
ware (Image J, National Institutes of Health) that was
calibrated for every single image using the known im-
plant diameter at the most coronal portion of the im-
plant neck. The distance from the implant-abutment
interface to the most apical point of the crestal bone
observed to be in intimate contact with the implant
was measured to the nearest 0.01 mm on both the me-
sial and distal sides. The values recorded by two differ-
ent examiners were used to calculate the mean value
of CBL for each implant. The values obtained were then
averaged and compared with the bone levels observed
at baseline. Additionally, 1-year CBL variations were re-
corded and correlated with stability parameters at in-
sertion and loading.
Implant Success
Implant success was assessed according to the criteria
described in Buser et al46 and modified by Albrektsson
and Zarb,47 including: (1) absence of persistent pain
or dysesthesia or paresthesia in the implant area; (2)
absence of peri-implant infection with or without sup-
puration; (3) absence of perceptible mobility of the im-
plant; and (4) absence of persistent peri-implant bone
resorption > 1.5 mm during the first year of loading
and 0.2 mm/year during the following years. Implants
were considered successful when all the aforemen-
tioned conditions were met.
Statistical Analysis
The sample size was calculated for the primary out-
come measures (implant failure): a two group conti-
nuity corrected chi-square test with a 0.050 two-sided
significance level will have 80% power to detect the
difference between a proportion of 0.100 and a pro-
portion of 0.500 for patients experiencing at least one
implant failure (odds ratio of 2.922) when the sample
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Controlled
Controlled diabetes periodontitis
10.0% (n = 4) 2.5% (n = 1) 17.5% (n = 7)
15.0% (n = 6) 0.0% (n = 0) 22.5% (n = 9)
size in each group is 82. However, it was decided for
clinical reasons to recruit only 20 patients in each
group.
Differences, if any, between the test and the control
groups concerning insertion torque and ISQ at inser-
tion were investigated by means of Student t tests.
To investigate differences between primary and sec-
ondary stability, ISQ at insertion and loading for all
patients, and for patients belonging to the test and
control groups, were compared by means of t tests
for paired samples. Correlations between ISQ at inser-
tion or ISQ at loading with the insertion torque, and
between ISQ at insertion and ISQ at loading were in-
vestigated by calculating the Pearson R coefficient and
performing simple linear regression analyses. A multi-
ple linear regression was performed to investigate the
correlation of ISQ at surgery with insertion torque and
the placement position (maxilla or mandible). Finally,
a multiple linear regression was performed to investi-
gate whether immediate or delayed insertion, implant
diameter, or implant length had an effect on CBL at 1
year. All tests were regarded as significant if P < .05.
Statistical analyses were performed with the SPSS
software (version 16; SPSS). A biostatistician with ex-
pertise in dentistry analyzed the data, without know-
ing the group codes. The patient was the statistical
unit of the analyses. All results are expressed as mean
± SD.
RESULTS
Forty patients were enrolled in the study, and each
patient received one implant to restore a single lost
tooth. Records of 40 implants placed in 40 subjects
(ages 35 to 75 years; 16 women and 24 men) were
analyzed. The main baseline patient characteristics are
presented in Table 1.
The distribution of implants according to their sites
in the two study groups is described in Table 2; the dis-
tribution according to implant length and diameter is
described in Table 3.
In the immediate postextraction group, all implants
were inserted in bone types II to IV; the same findings
were observed for the control group (bone types II to
IV) because extraction sockets were left to heal for only
3 months, and bone type I could not be present.
 Malchiodi et al

Table 2  Distribution of Implants According to Their Sites in the Two Groups

Study group No. of implants Molar sites Premolar sites Maxilla Mandible
Immediate (test) 50.0% (n = 20) 20.0% (n = 8) 30.0% (n = 12) 27.5% (n = 11) 22.5% (n = 9)
Delayed (control) 50.0% (n = 20) 37.5% (n = 15) 12.5% (n = 5) 22.5% (n = 9) 27.5% (n = 11)
Total 100.0% (n = 40) 57.5% (n = 23) 42.5% (n = 17) 50.0% (n= 20) 50.0% (n = 20)

Table 3  Distribution of Implants According to the Implant Length and Diameter in the Two Groups
9-mm-long 11-mm-long 13-mm-long 3.3-mm-wide 4.1-mm-wide
Study group No. of implants implants implants implants implants implants
Immediate (test) 50.0% (n = 20) 20.0% (n = 8) 17.5% (n = 7) 12.5% (n = 5) 12.5% (n = 5) 37.5% (n = 15)
Delayed (control) 50.0% (n = 20) 20.0% (n = 8) 25.0% (n = 10) 5.0% (n = 2) 20.0% (n = 8) 30.0% (n = 12)
Total 100.0% (n = 40) 40.0% (n = 16) 42.5% (n = 17) 17.5% (n = 7) 32.5% (n = 13) 67.5% (n = 27)

Table 4  Distribution of Insertion Torque Measurements

Torque range Test group Control group
(Ncm) No. of implants % (immediate) % (delayed) %
< 35 0 0.0 0 0.0 0 0.0
35–50 26 65.0 15 75.0 11 55.0
51–60 9 22.5 4 20.0 5 25.0
61–70 5 12.5 1 5.0 4 20.0
> 70 0 0.0 0 0.0 0 0.0
Total 40 100.0 20 100.0 20 100.0

No deviations from the study protocols occurred,
and no patients dropped out during the follow-up
period. All patients attended follow-up visits regu-
larly and maintained good oral hygiene. During the
12-month follow-up, no implants were lost, and no
implants failed because of excessive bone resorption,
providing a 100% implant success rate.
Insertion Torque
Mean insertion torque for all implants was 49.0 ±
9.95 Ncm (median 50 Ncm; range, 35 to 70 Ncm;
Table 4). Twenty-six implants (65.0%) had insertion
torques ranging from 35 to 50 Ncm; nine implants
(22.5%) scored between 51 and 60 Ncm; and five im-
plants (12.5%) scored between 61 and 70 Ncm. The
mean insertion torque value for implants in the test
group was 46.0 ± 9.95 Ncm (median 45 Ncm; range,
35 to 70 Ncm). Fifteen implants (75.0%) had insertion
torque values ranging from 35 to 50 Ncm. The mean
insertion torque for implants in the control group
was 52.0 ± 9.23 Ncm (median 50 Ncm; range, 35 to 70
Ncm). Eleven implants (55.0%) had insertion torque
values ranging from 35 to 50 Ncm. No insertion torque
values less than 35 Ncm or greater than 70 Ncm were
observed.
ISQ at Insertion
The mean RFA score at implant insertion (ISQ0) for
all implants was 63.95 ± 8.81 (median 64.5; range, 42
to 82; Table 5). ISQ values for most implants (n = 21;
52.5%) ranged from 60 to 69.
The mean RFA score at implant insertion (ISQ0) in
the test group was 61.90 ± 9.99 (median 62.0; range,
42 to 82). ISQ values for most implants, n = 11 (55%),
ranged from 60 to 69; one implant (5%) scored from
70 to 79; and one implant (5.0%) scored from 80 to 89.
Similarly, the mean ISQ reading at implant insertion
(ISQ0) in the control group was 66.00 ± 8.25 (median
66.5; range, 51 to 81). ISQ values for most implants,
n = 10 (50%), ranged from 60 to 69; no implants (0%)
showed readings from 40 to 49; five implants (25%)
scored from 70 to 79; and two implants (10%) scored
from 80 to 89.
ISQ at Functional Loading
At the reopening surgery, the mean RFA score (ISQ1)
for all implants was 67.48 ± 5.95 (median 66; range,
56 to 80). ISQ values for most implants, n = 24 (60%),
ranged from 60 to 69 (Table 5).
The mean RFA score at loading (ISQ1) in the test
group was 68.15 ± 5.97 (median 66.0; range, 61 to 80).
ISQ values for most implants, n = 12 (60%), ranged
from 60 to 69; seven implants (35%) scored from 70
to 79; and one implant (5%) scored from 80 to 89. The
mean RFA score at implant loading (ISQ1) in the con-
trol group was 66.80 ± 6.01 (median 66.5; range, 56 to
77): ISQ values for most implants, n = 12 (60%), ranged
from 60 to 69; six implants (30%) scored from 70 to 79.

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Malchiodi et al

Table 5  ISQ Scores at Insertion and Reentry

At insertion At reentry
Test group Control group Test group Control group
ISQ
All (immediate) (delayed) All (immediate) (delayed)
score
range No. % No. % No. % No. % No. % No. %
< 40 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0
40–49 2 5.0 2 10.0 0 0.0 0 0.0 0 0.0 0 0.0
50–59 8 20.0 5 25.0 3 15.0 2 5.0 0 0.0 2 10.0
60–69 21 52.5 11 55.0 10 50.0 24 60.0 12 60.0 12 60.0
70–79 6 15.0 1 5.0 5 25.0 13 32.5 7 35.0 6 30.0
80–89 3 7.5 1 5.0 2 10.0 1 2.5 1 5.0 0 0.0
> 90 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0
Total 40 100.0 20 100.0 20 100.0 40 100.0 20 100.0 20 100.0
ISQ = implant stability quotient.

Table 6  Results of Comparisons Between Test Table 7  Comparisons Between ISQ at

and Control Groups Insertion and Loading
Test group Control group Parameter ISQ at insertion ISQ at loading P
Parameter (immediate) (delayed) P
All implants 63.95 ± 8.81 67.48 ± 5.95 .005*
IT (Ncm) 46.0 ± 9.9 52.0 ± 9.2 .0553*
Test group 61.90 ± 9.99 68.15 ± 5.97 .005*
ISQ at insertion 61.90 ± 9.99 66.00 ± 8.25 .14 (immediate)
ISQ at loading 68.15 ± 5.97 66.80 ± 6.01 .48 Control group 66.00 ± 8.25 66.80 ± 6.01 .46
CBL (mm) 0.68 ± 0.43 0.40 ± 0.26 .02* (delayed)
IT = insertion torque; ISQ = implant stability quotient; CBL = crestal *Indicates significance.
bone loss.
*Indicates significance.

Table 8  Summary of Regression Analysis respectively, P = .0553, while ISQ at insertion was
Results not significantly different between the two groups
(P = .14; Table 6).
Variables Control
(dependent vs Test group group ISQ at loading was not significantly different be-
independent) All (immediate) (delayed) tween the two groups (P = .48).
ISQ at insertion vs ISQ at loading and ISQ at insertion were signifi-
R = 0.66 R = .83 R = 0.39
insertion torque cantly different for all implants (67.48 ± 5.95 vs 63.95
ISQ at loading vs ± 8.81, P = .005) and for implants placed immediately
N.S. N.S. N.S.
insertion torque after extraction (test group, 68.15 ± 5.97 vs 61.90 ±
ISQ at loading vs
R = 0.55 R = 0.39 R = 0.82
9.99, respectively, P = .005; Table 7). The ISQ values at
ISQ at insertion the two points in time were not significantly different
ISQ = implant stability quotient; N.S. = not significant. for the delayed implants (66.00 ± 8.25 vs 66.80 ± 6.01,
respectively, P = .46).
Crestal Bone Loss A moderate/strong correlation was detected be-
Mean CBL for all 40 implants at the 12-month follow- tween ISQ and torque at insertion (ISQ0 vs insertion
up was 0.54 ± 0.38 mm (median 0.40 mm; range, 0.05 torque, R = 0.66; Table 8) considering all implants both
to 1.50 mm). CBL in the test group was 0.68 ± 0.43 mm by linear and multiple regression analyses. The correla-
(median 0.70 mm; range, 0.10 to 1.50 mm), while in the tion was stronger in the postextraction group (ISQ0 vs
control group, it was 0.40 ± 0.26 mm (median 0.35 mm; insertion torque, R = 0.83, test group) than in the de-
range, 0.05 to 0.90 mm). No implant failed according to layed group (ISQ0 vs insertion torque, R = 0.39, control
Albrektsson and Zarb’s criteria. group). A significant negative correlation was found
between RFA scores at surgery (ISQ0) and the site
Statistical Analysis Results (maxilla or mandible) of insertion. Inserting implants
Insertion torque was slightly different between the in the maxillary arch corresponded to a 5-unit mean
control and test groups, 52.0 ± 9.2 vs 46.0 ± 9.9 Ncm, RFA score decrease.

1440 Volume 31, Number 6, 2016

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No significant correlations were found between RFA
scores at loading and insertion torque. This was true
for all 40 implants considered as a group and for the
two groups separately.
ISQ at loading and ISQ at insertion showed a mod-
erate correlation when all implants were considered
(ISQ0 vs ISQ1, R = 0.55, all implants). The correlation
was stronger in the delayed group (ISQ0 vs ISQ1,
R = 0.82, control group) than it was in postextraction
one (ISQ0 vs ISQ1, R = 0.39, test group). Among factors
influencing CBL, immediate postextraction insertion
had an almost significant and negative effect (–0.23
mm, P = .054) in comparison with delayed place-
ment, confirming the significant difference (P = .02)
observed between the two groups as far as CBL was
concerned (0.68 ± 0.43 mm in the test group vs 0.40 ±
0.26 mm in the control group).
DISCUSSION
Implant mechanical stability at insertion, defined as
primary stability, has been shown to be one of the
most important prognostic factors conditioning im-
plant success. Micromotion at the bone-implant inter-
face, when exceeding a 50- to 150-µm threshold, may
lead to formation of fibrous instead of bone tissue,
hindering proper osseointegration. Considering inser-
tion torque, it has been shown that insertion torque
scores less than 20 Ncm are predictive of a greater
failure rate for immediately loaded implants.48 If RFA is
considered, failure rates increase when the ISQ is less
than 55.49 Implant primary stability has been shown
to depend on different factors. Patient-related factors
include bone quantity and, above all, bone density.
Implant-related factors include the design (shape of
the body and threads, thread spacing), length, and
diameter. Implant surface modifications modulate the
biologic interaction between the implant and the sur-
rounding tissues that leads to secondary stability, ie,
osseointegration. The importance of achieving proper
primary stability at insertion is enhanced when chal-
lenging rehabilitation plans are involved, eg, immedi-
ate postextraction implants. Immediate postextraction
placement is a clinical procedure aiming to diminish
the discomfort for the patient, eliminating the need for
a second surgery, and shortening the time to complete
rehabilitation.50 Implants are given primary stability
by the residual alveolar bone at the apical position,
while a part of the implant surface is surrounded by
the clot or the graft and undergoes osseointegration
over time as bone regeneration occurs around the im-
plant. For this reason, this condition is challenging for
the success and even the survival of osseointegrated
implants.51 When considering postextraction insertion
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Malchiodi et al
at premolar and anterior sites, there is a trend showing
an increased probability of failure.52 When only molar
sites are considered, success and survival rates at 1
year are significantly lower (83% on average) than they
are for all possible positioning sites.53,54
The present study investigated the performance of
implants inserted either in fresh extraction sockets or
after a 12-week healing period. One-year implant suc-
cess and survival rates, when assessed at the 12-month
follow-up, were 100% in both groups.
Primary stability at insertion, as measured with the
RFA method, was not significantly different for the
groups. RFA analysis also showed no significant dif-
ference between the two groups as far as secondary
stability, measured at loading, was concerned. Imme-
diate postextraction and delayed insertion provided
the same outcome. RFA scores at insertion correlated
with insertion torque values, when all implants were
considered (R = 0.66). The correlation was stronger in
the immediate postextraction group (R = 0.83) and
weaker in the delayed one (R = 0.39). This difference
could be attributed to the different conditions at the
time of insertion for the two groups. In the postextrac-
tion group, RFA analysis measures the stiffness of an
implant engaging bone only in its more apical portion,
while in the delayed group, the presence of a surround-
ing regenerated volume may introduce a bias lower-
ing the extent of correlation. Insertion torque scores
in regenerated, softer bone, therefore, should not be
regarded as reliable as in those in nonregenerated
sites as far as primary stability measurement is con-
cerned. RFA scores at loading showed no correlation
with insertion torque, either when all implants were
considered as a group or when the two groups were
considered separately. Even if insertion torque corre-
lates with greater BIC at insertion, though, remodeling
processes at the bone-implant interface occurring over
time may override this initial “advantage” and produce
a similar degree of osseointegration at the loading
time. This could be more evident when postextractive
surgeries (either immediate or delayed) are concerned,
since they may involve enhanced bone healing activity
around the implant in comparison with other kinds of
implant placement conditions.
RFA scores at loading were significantly different
(and greater) than RFA scores at insertion when all
implants were considered. This was also true for the
postextraction implants but was shown to not be true
for the delayed group, for which the two scores were
substantially identical. This may reflect the fact that,
while implants at immediate postextraction sites have
their stability provided only by the more apical portion
and acquire additional stability over time as bone re-
generation occurs (ie, their stability can only increase
over time), implants inserted in delayed, regenerated
The International Journal of Oral & Maxillofacial Implants 1441
Malchiodi et al
bone get primary stability via the mechanical inter-
action of their entire surface with the already-regen-
erated volume, and their overall stability develops
following the well-known trend over time that involves
first a decrease and then a subsequent increase as os-
seointegration develops. The choice to graft socket
gaps around implants in the test group was related to
unpredictability of buccal bone resorption in postex-
traction sockets, while in healed sites, the buccal bone
resorption had already occurred and implants could
be placed without a risk of dehiscence.55
Considering CBL at 1 year, a significant difference
was encountered between the two groups. Significant-
ly more bone loss was observed in the postextraction
group, as also indicated by the trend of the multiple
linear regression analysis assessing factors affecting
CBL. Long-term studies should be planned to investi-
gate if this discrepancy varies over time.
According to statistical analysis, there are signifi-
cant, or in some cases, not significant, results, such as
ISQ at insertion, ISQ at functional loading, or insertion
torque, which could have important clinical implica-
tions. In the case of CBL, the difference between con-
trol and test groups, although statistically significant,
was small, and the question remains if this difference
clinically has any practical meaning.
Even if the most significant variations in crestal bone
levels are observed during the first year after implant
placement, as described by Buser et al46 and Albrekts-
son and Zarb,47 longer follow-up studies are neces-
sary to assess CBL over time when implants are being
placed in fresh extraction sockets. Studies should be
planned to verify if the results of the present study are
valid for a greater number of implants, increasing their
statistical significance.
CONCLUSIONS
Within the limits of the sample size, cylindrical im-
plants with regular single threads were equally suc-
cessful when inserted in fresh or 12-weeks healed
extraction sockets. The correlation between RFA scores
at insertion and insertion torque may be strongly af-
fected by the timing of insertion. Moreover, insertion
torque may not be predictive of secondary stability, as
measured by RFA scores at the time of loading. While
insertion torque influences ISQ at insertion, it does not
affect ISQ at loading because of successful osseointe-
gration. Postextraction and delayed implants seem to
have similar ISQ at insertion and at loading, but dif-
ferent CBL after 12 months of follow-up because of
postextraction bone remodeling.
1442 Volume 31, Number 6, 2016
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ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this
study.
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