Insertion Torque of Variable-Thread Tapered Implants in the

Posterior Maxilla: A Clinical Study

Habib L. Abi-Aad, DCD, CES,1 Fadi I. Daher, DCD, CES,2 Nadim Z. Baba, DMD, MSD, FACP,3
Giampiero Cordioli, MD, DDS,4 & Zeina A.K. Majzoub, DCD, DMD, MScD2
1
Department of Prosthodontics, Faculty of Dental Medicine, Lebanese University, Hadath, Lebanon
2
Department of Periodontics, Faculty of Dental Medicine, Lebanese University, Hadath, Lebanon
3
Advanced Specialty Education Program in Prosthodontics, School of Dentistry, Loma Linda University
4
Private Practice, Padova, Italy

Keywords
Bone quality; cortical anchorage; dental
implant; primary stability.
Correspondence
Habib L. Abi-Aad, Department of
Prosthodontics, Faculty of Dental Medicine,
Lebanese University, Rafic Hariri Campus,
Hadath, Lebanon.
E-mail: habibabiaad@hotmail.com
This study was partially funded by Nobel
Biocare AG Kloten, Switzerland (grant number
2010–954) in the form of material support. No
other financial contribution were received by
any of the authors or their institutions. The
study sponsors did not contribute to the
study design, data collection, analysis and
interpretation of data, in the writing of the
manuscript, and in the decision to submit it
for publication.
Accepted July 13, 2018
doi: 10.1111/jopr.12965
ABSTRACT
Purpose: Primary stability is a key factor for successful implant osseointegration,
especially in poor bone quality and early/immediate loading. In the immediate loading
protocol, insertion torque values (ITVs) have been suggested to be the most valid
prognostic factor for osseointegration of maxillary implants. The objectives of this
study were to: (1) evaluate ITVs achieved by a variable-thread tapered implant in
the posterior maxilla; and (2) assess the impact of bone quality, implant dimensions,
bicortical anchorage, and implant location on ITVs.
Materials and Methods: Twenty-six adult, systemically healthy patients received
173 variable-thread tapered implants in maxillary premolar and molar healed eden-
tulous sites with a minimum subsinus height of 8 mm. Implant sites were prepared
using the bone-quality adjusted drilling sequence according to manufacturer’s recom-
mendations. Bone quality was recorded subjectively during drilling based on Misch
criteria (D1-D4), and ITVs were measured with a manual torque wrench. Univariate
and multivariate analyses were performed at the 0.05 significance level.
Results: First and second molar sites accounted for 46.8% of all implants. D4
bone was encountered in 61.3% of the sites. Most of the implants were 4.3 mm in
diameter (59.5%), and lengths of 11.5 and 13 mm were most commonly used (75.2%).
Approximately half of the implants were associated with apical cortical anchorage
(51.4%). The overall mean ITV was 44.5 ± 23.0 Ncm, with 65.5 ± 15.6 Ncm, 55.5 ±
19.6 Ncm, and 36.6 ± 21.7 Ncm for D2, D3, and D4 bone, respectively. Bone quality
and implant location significantly affected ITVs, while implant dimensions and apical
cortical anchorage did not.
Conclusions: ITVs of variable-thread implants were significantly influenced by
variations in bone quality and implant position in the posterior maxilla. Despite the
influence of bone quality on primary stability, the mean ITVs attained with variable-
thread tapered implants in poor bone quality were within the recommended range for
immediate loading.

Implant primary stability is a key factor in achieving os-
seointegration and is one of the prerequisites for successful
immediate/early loading procedures.1 Primary stability is
affected by multiple factors such as bone quality,2 bone
density,3 bone morphology,4 implant design,5 implant surface
roughness,6 preparation of the implant site,5-8 crestal bone
anchorage,9 apical anchorage through the cortical floor of
the sinus or nasal cavities,10 lateral cortical anchorage,11 and
implant dimensions.2,12,13
Optimal implant stability is more difficult to achieve in low-
density bone, such as that of the posterior maxilla. While modi-
fication of implant site preparation using smaller drills or bone-
condensing techniques can enhance primary stability in poste-
rior maxillary sites, implant design also seems to have a crucial
effect on improving stability in soft bone densities.5,14 Implant
engineering strategies to increase primary stability include self-
tapping design and tapered morphology.14 Implants combining
the ability to laterally condense bone while being inserted15
with a self-tapping conical morphology and a variable-thread
design were reported to consistently achieve high primary sta-
bility in poor or poor-to-medium bone quality14,15 and fresh
extraction sites.16

Journal of Prosthodontics 0 (2018) 1–7 

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Insertion Torque in Posterior Maxilla
A number of investigations have evaluated the clinical out-
come of variable-thread tapered implants under various loading
protocols.15-19 However, although several studies have reported
on the primary stability achieved with this implant design under
clinical conditions,15,17,19 in artificial bone blocks,14 and fresh
cadaver specimens,20 specific data related to the posterior re-
gion of the maxilla are still practically lacking. The objectives
of the present clinical study are to: (1) assess insertion torque
values (ITVs) (main outcome variable) achieved by variable-
thread tapered implants in the posterior maxilla; and (2) eval-
uate the impact of bone quality, implant dimensions, apical
cortical anchorage, and implant location (secondary variables)
on ITVs.
Materials and methods
Study design
This study reports the partial cross-sectional data from an on-
going split-mouth randomized controlled trial (RCT) designed
to compare short- and long-term outcomes of variable-thread
tapered implants loaded immediately or conventionally in pa-
tients with bilateral partial maxillary posterior edentulism.
Here, data from both arms at implant insertion were pooled
into a single cohort for analysis.
Patient population
Systemically healthy adult patients and candidates for bilateral
maxillary posterior implant-supported fixed partial prostheses
were consecutively selected for the study from the patient popu-
lation attending the postgraduate Department of Periodontics at
the Lebanese University, Faculty of Dental Medicine, Hadath,
Lebanon based on the following inclusion criteria:
r 3 to 5 consecutive teeth missing bilaterally in the poste-
rior maxilla (premolar and molar teeth positions);
r teeth at the implant sites extracted or lost at least 9 months
before the date of implant surgery;
r adequate bone quantity at the implant sites consisting of
at least 8 mm of subsinus bone height and a minimum
of 1 mm of bone buccally and palatally to the implants
without the use of bone augmentation techniques.
Patients with the following local or systemic conditions were
not included in the trial:
r systemic conditions contraindicating implant surgery;
r pregnancy or lactation;
r ongoing or history of pathologies or medications influ-
encing bone metabolism;
r untreated gingivitis or periodontitis;
r oral inflammatory and autoimmune diseases;
r history of head and neck irradiation therapy;
r presence of osseous lesions in the selected sites;
r previous bone augmentation surgery.
The patients were recruited and treated between March 2013
and February 2015 at the Lebanese University with the last
surgery performed in February 2015. All patients were in-
formed about the study procedures and the evidence-based
outcome of implant therapy in the posterior maxilla. Patients’
2 Journal of Prosthodontics 0 (2018) 1–7 
Abi-Aad et al
informed written consent to use their data for research pur-
poses was obtained. The study protocol and informed consent
were in full accordance with the ethical principles of the Dec-
laration of Helsinki of 1975 as revisited in 2013 and were
approved by the Ethical Committee of the Lebanese University
(CUEMB85/4/2017).
Implant surgery and experimental design
Preoperative evaluation included clinical examination, pano-
ramic radiographs and cone-beam computed tomography where
needed. Surgeon’s calibration relative to bone quality rating
was performed once, 1 week before the first surgical implant
procedures. The oral surgeon was asked to rate bone quality
in four samples of fresh bovine bone simulating D1, D2, D3,
and D4 bone qualities, as described by Misch.21 Rating was
performed during high-speed drilling with a 2 mm pilot twist
drill at 800 rpm, to a depth of 8 mm at 15 different times, with
an interval of 1 hour between assessments with the purpose of
calibration and evaluation of intra-observer reliability.
Implant surgery was conducted under aseptic conditions
with prophylactic antibiotic therapy of 2 g of amoxicillin (or
equivalent) 1 hour preoperatively. Following elevation of a
full-thickness mucoperiosteal flap without releasing incisions,
implant sites were prepared using the bone-quality adjusted
drilling sequence according to manufacturer’s recommenda-
tions. Bone quality was assessed for all implants based on
the surgeon’s tactile sensation during high-speed drilling at
800 rpm with the 2 mm pilot twist drill and recorded as de-
scribed above.
Variable-thread tapered implants (NobelActive; Nobel Bio-
care AB, Göteborg, Sweden) of 10, 11.5, 13, and 15 mm lengths
were used in the study. Implant diameter (3.5, 4.3, 5 mm) was
selected according to the buccopalatal width of the implant
sites. When subsinus bone height was approximately 8 mm, im-
plant length was chosen so that a modest portion of the implant
protruded into the sinus cavity, thereby allowing engagement
with the sinus floor cortex. All implants were inserted using the
manual driver. Implant insertion torque was measured at place-
ment using a customized manual torque ratchet (RT; Medical
Research & Technologies, Albignasego, Italy) that measures
torque values from 10 to 70 Ncm with 5-Ncm incremental
markings. Maximum ITV was recorded during the last ¼ turn
(90°) before the desired insertion depth was reached, and mea-
surements were rounded to the closest 5 Ncm. Additional data
collected included implant dimensions (length and diameter),
apical engagement of the cortical floor of the maxillary sinus,
and implant location. All implants were inserted by a single
oral surgeon highly experienced in implant surgery.
Statistical evaluation
A power analysis was performed to calculate the sam-
ple size based on the requirements of the ongoing split-
mouth RCT. The criteria for significance was set at ɑ =
0.05 and the power at β = 0.2. Assuming a difference
of 0.25 mm in peri-implant bone levels between test and con-
trol implant groups with a standard deviation of 0.5 mm, the
required sample size was 29 patients contributing with one test
and one control implant using the t-test. In the interim pooled
C 2018 by the American College of Prosthodontists
Abi-Aad et al
cohort analysis presented here, the implant was considered the
statistical unit for the analyses.
Descriptive statistics expressed as means, standard devia-
tions, medians, and ranges were generated for the main outcome
variable (ITV). ITV was also stratified by secondary variables:
bone quality, implant dimensions, apical cortical anchorage,
and implant location. Both univariate and multivariate statistical
analyses were performed. For the former, the Mann-Whitney U-
test or Kruskal-Wallis test was used to test correlation between
the main variable (ITV) and dichotomous or continuous sec-
ondary variables, respectively. Multivariate models for analysis
were calculated using both a parametric approach with stepwise
forward-selection at significance level 0.15 for initial inclusion
and a significance level of 0.05, and a nonparametric approach
treating all variables as discrete variables in an additive model.
Data were processed using the Statistical Package for Social
Sciences (IBM SPSS, V24.0; IBM Corp., Armonk, NY).
Results
Twenty-six patients (12 men, 14 women) ranging in age be-
tween 34 and 67 years (mean age 49.5 ± 9.7 years) participated
in the study and received 173 implants in maxillary premolar
and molar sites, with three to four implants in each of the two
posterior sextants. Distribution of the study implants accord-
ing to bone quality, implant length, implant diameter, apical
cortical anchorage, and location are reported in Tables 1 and 2.
High intra-observer agreement of 0.956 was calculated for bone
quality assessment using the Fleiss’ kappa. First and second
molar sites accounted for 46.8% of all implants (Table 1). The
most commonly used implants were 4.3 mm in diameter and
11.5 mm/13 mm in length. Bone quality was predominantly D4
and was found in 83.9% of the second molar and 100% of the
third molar sites (Table 2). D2 bone quality was found in 11/173
(6.4%) of the implant sites, mainly in the premolar area. Ap-
proximately half (51.4%) of the implants were associated with
apical cortical anchorage (Table 1).
The ITVs stratified by bone quality, implant dimensions, api-
cal anchorage, and implant location, are reported in Table 1. The
Kruskal-Wallis test showed a statistically significant difference
in ITVs between the three bone qualities (p < 0.0001) and
between different implant locations (p < 0.0001). In contrast,
no significant differences in ITVs were observed with different
implant lengths (p = 0.077) or diameters (p = 0.062), or be-
tween implants that engaged the sinus floor cortical bone and
those without apical anchorage (p = 0.27). Similarly, multivari-
ate analysis, using both parametric (Table 3) and nonparametric
approaches (Table 4), showed that variation in bone quality and
implant position were the variables associated with significantly
different ITVs.
The distribution of the study implant ITVs in different bone
qualities is presented in Figure 1. In bone qualities 2 and 3,
100% (11/11) and 87.5% (49/56) of the implants, respectively,
were inserted with ITVs ࣙ 35 Ncm. When results were re-
stricted to the 106 sites with D4 bone quality, ITVs were vari-
able, with nearly half (49.1%) of the implants demonstrating
ITVs ࣙ 35 Ncm and 27.4% within the 60 to 70 Ncm range.
Journal of Prosthodontics 0 (2018) 1–7 
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Insertion Torque in Posterior Maxilla
Figure 1 Box plot summarizing distribution of insertion torque values
in different bone qualities. Note the differences in mean torque values
between D2, D3, and D4, and the large variability of torque measure-
ments in D3 and D4 bone qualities. The light grey shaded area repre-
sents torque values within the manufacturer’s recommended range for
immediate loading of 35 to 70 Ncm.
Discussion
In this study, intraoperative ITVs were used as a surro-
gate measure to assess primary stability. Insertion torque has
been closely associated with implant micromotion at the im-
plant/bone interface22 and has been significantly correlated with
initial bone-to-implant contact at insertion.23 ITV has been sug-
gested to be a good indicator of implant primary stability24 and
the most valid prognostic factor for osseointegration of immedi-
ately loaded implants in the maxilla.1 Other stability parameters
such as implant stability quotient measured by resonance fre-
quency analysis and Periotest values were not evaluated in this
study intraoperatively, as they have shown lower specificity than
ITV as potential predictors for the risk of non-osseointegration
of immediately loaded splinted implants in partially and eden-
tulous maxilla.1
This study demonstrated mean ITVs of 44.5 ± 23.0 Ncm
with variable-thread tapered implants in the posterior maxilla.
This area is anatomically characterized by a thin bony cortex
and significantly lower values of bone volume fraction, surface
density, and trabecular thickness and number than the anterior
maxilla and zygomatic bone,25 making initial stability difficult
to achieve. A significant parameter that may have contributed to
the observed primary stability was implant geometry that inte-
grated a tapered body, sharp drilling apical blades, and double-
lead, sharp, widely spaced (1.2 mm), and gradually expanding
deep threads with a steeper angle (35°) than most root-form im-
plants (60°). This design allowed narrower initial osteotomy,
gradual bone expansion, and lateral bone condensation as the
implant advanced in a clockwise motion.8 The self-cutting char-
acteristics of the implant were further enhanced by two reverse
cutting flutes that engaged bone when the implant was turned
(½ turn) counterclockwise and enabled gradual widening of the
osteotomy. Although several of the design features of the No-
belActive implant can be found individually in other implant
3
Insertion Torque in Posterior Maxilla Abi-Aad et al

Table 1 Descriptive and univariate analyses of insertion torque values (ITVs) according to bone quality, implant dimensions, apical cortical anchorage,
and implant location

ITV (Ncm)

Number of implants (%) Mean (SD) Median (Min; Max)

Bone quality a
p < 0.0001
D2 11 (6.4%) 65.5 (15.6) 70.0 (35.0; 80.0)
D3 56 (32.4%) 55.5 (19.6) 65.0 (10.0; 80.0)
D4 106 (61.3%) 36.6 (21.7) 30.0 (0.0; 70.0)
Implant length a
p = 0.077
10 mm 36 (20.8%) 36.3 (21.7) 30.0 (10.0; 80)
11.5 mm 69 (39.9%) 45.7 (22.7) 40.0 (0.0; 80.0)
13 mm 61 (35.3%) 48.7 (23.5) 50.0 (0.0; 80.0)
15 mm 7 (4.0%) 39.3 (21.5) 30.0 (20.0; 70.0)
Implant diameter a
p = 0.062
3.5 mm 40 (23.1%) 46.9 (21.0) 45.0 (10.0; 80.0)
4.3 mm 103 (59.5%) 46.0 (23.5) 40.0 (0.0; 80.0)
5 mm 30 (17.3%) 36.3 (23.1) 25.0 (10.0; 80.0)
Apical cortical anchorage b
p = 0.27
Yes 89 (51.4%) 42.6 (23.4) 35.0 (0.0; 80.0)
No 84 (48.6%) 46.6 (22.6) 45.0 (0.0; 80.0)
Implant location a
p < 0.0001
First premolar 41 (23.7%) 54.9 (19.9) 65.0 (10.0; 80.0)
Second premolar 45 (26.0%) 49.3 (21.3) 50.0 (10.0; 80.0)
First molar 50 (28.9%) 43.5 (22.8) 35.0 (10.0; 80.0)
Second molar 31 (17.9%) 29.4 (22.4) 20.0 (0.0; 80.0)
Third molar 6 (3.5%) 25.0 (7.1) 25.0 (15.0; 35.0)
Total 173 44.5 (23.0) 40.0 (0.0; 80.0)

SD = standrd deviation.
a
Kruskal-Wallis test for continuous variables.
b
Mann-Whitney U-test for dichotomous variables.

systems, the combination of these macro-design characteris- Table 2 Frequency distribution of bone types in different implant
tics with the straight drilling protocol15 and under-preparation locations
of the implant bed7,8 allowed achievement of high levels of
Implant location
primary stability.
Overall mean ITVs achieved in this study were compara- First Second Second Third
ble to the clinical data reported by Irinakis and Wiebe,15 who premolar premolar First molar molar molar
found mean values of 47.5 Ncm with the same variable-thread
tapered implant inserted in the maxilla. However, Irinakis and D2 4 (9.8%) 4 (8.9%) 3 (6.0%) 0 (0%) 0 (0%)
Wiebe did not distinguish between anterior and posterior sites. D3 20 (48.8%) 19 (42.2%) 12 (24.0%) 5 (16.1%) 0 (0%)
This study did not include matched samples of other implant D4 17 (41.5%) 22 (48.9%) 35 (70.0%) 26 (83.9%) 6 (100%)
systems, rendering difficult any direct comparison with other
implant designs under similar clinical conditions. Indirect com-
parison with previously published data on ITVs achieved clin- Clinically, there has been a consensus that immediate loading
ically with Brånemark System Mk II implants (Nobel Biocare protocols are associated with higher patient satisfaction and re-
AB) in maxillary D4 quality bone,26 TiUnite Mk III implants duction of the number of visits.29 However, many investigators
(Nobel Biocare AB) in maxillary posterior sites,6 SLA implants have stated that immediate loading should be limited to clinical
(Institute Straumann AG, Basel, Switzerland) in the posterior situations that provide primary stability with ITV thresholds
maxilla,27 SLActive Bone Level (Institute Straumann AG), and of 30 Ncm and proper prosthetic position.29 These require-
Neobiotech CMI IS-II active implants (Neobiotech Co., Seoul, ments make the NobelActive implant a satisfactory choice in
Korea) in the posterior maxilla,28 suggests that the implants immediate loading cases with less-than-ideal bone quality be-
used in this study attain ITVs as high as other implant sys- cause of its enhanced ITVs and the possibility of redirecting
tems in maxillary posterior sites of poor bone quality. Such it during manual insertion while maintaining high levels of
conclusions, however, have limitations related to differences in stability.
insertion torque assessment methods, ITV measurement round- ITVs at implant placement can be objectively recorded us-
ing, and surgeon’s experience. ing several types of devices including: (1) electronic digital

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Abi-Aad et al
Table 3 Multivariate analysis at implant level using the parametric
forward-selection stepwise approach
Variable
Bone quality
D3
D4
Implant location
Second premolar
First molar
Second molar
Table 4 Multivariate analysis at implant level using a nonparametric
approach
Variable
Bone quality
Implant length
Implant diameter
Apical cortical anchorage
Implant location
drivers not integrated in the implant drilling unit; (2) manual
mechanical spring-style or friction-style wrenches; (3) implant
handpieces incorporated in the traditional electronic-controlled
surgical motors; and (4) implant handpieces connected to
the newly introduced instantaneous torque-measuring systems
equipped with calibrated high-precision dynamometers.30 The
authors believe that although these latter devices seem to pro-
duce highly consistent and reliable torque measurements, their
use is still limited in routine practice. The simplest and most
commonly used torque-measuring systems in clinical settings
include the manual ratchets and conventional surgical implant
motors with various ranges of adjustable torque limits and ad-
justment scales. When mechanical wrenches are considered,
relative errors to the pre-set torque levels have been shown
to vary according to design, manufacturer, clinical service,
wear, sterilization procedures, corrosion, and operator-related
parameters.31 Variations in torque output from pre-set values
are not limited to manual ratchets and have been documented
with surgical implant motors32 with torque levels up to 30%
higher than set levels when not continuously calibrated each
time a new torque level has been set.33 In this study, a mechani-
cal spring-style manual wrench with 5-Ncm incremental mark-
ings was used, and measurements were rounded to the closest
5 Ncm. Such measurement resolution (which refers to how fine
a detail can be measured) is likely to affect the ability of a
statistical test to detect differences and may therefore influence
conclusions. It should, however, be emphasized that in most
mechanical wrenches and surgical handpieces that have been
investigated, including those with 5-Ncm scale-adjustment
or continuous 1-Ncm adjustments, the mean differences be-
tween actual and set torque values often exceed measurement
resolution.31-33 Although most studies investigating accuracy of
torque output in implant dentistry focused on the screw com-
ponents, it could be extrapolated that the mechanical torque
wrenches have a lower variation than electronic ones and
Journal of Prosthodontics 0 (2018) 1–7 
C 2018 by the American College of Prosthodontists
Insertion Torque in Posterior Maxilla
that the passive torque determination mode with the use of
spring-style beam devices seems to yield fairly accurate torque
delivery.31
p-Value
Bone quality assessment using subjective surgeon’s tactile
<0.0001 perception has been documented by several authors and has
0.1857 demonstrated a significant correlation with ITVs.26 This con-
0.0004 curs with the findings of this study, where ITVs were also
0.0032 closely related to bone quality.
0.3133 While some investigators reported improved implant stabil-
0.1151 ity with wider diameter implants in all bone qualities,2,34 other
0.0003 studies showed such impact mainly in soft bone.12,13 Similarly,
there is a lack of consensus relative to the impact of implant
length on ITVs. Implant length seems to be critical in obtaining
higher primary stabiltiy in some studies,34 while others reported
no influence of implant length on ITVs.2 The impact of implant
p-Value
diameter and length on primary stability was not evident in
this study, as ITVs did not significantly differ between various
<0.0001 implant diameters and lengths in all three bone qualities taken
0.2124 jointly or in D4 bone considered separately. Similar findings
0.1133 were reported in a human cadaver maxilla model evaluating the
0.1105 primary stability of variable-thread tapered implants of differ-
0.0004 ent diameters.20 The lack of statistically significant differences
in ITVs between different implant lengths is in line with the
clinical findings of Gómez-Polo et al.2 This can be justified
by the fact that implant design may prevail over implant di-
mensions as a contributing factor in primary stability in some
implant systems.
In the present sample, the impact of implant location on ITVs
was statistically significant, with premolars achieving higher
primary stability than molars. This finding can be related to
the engagement of the lateral buccal and/or lingual cortices in
the premolar areas. The positive effect of such interfacing of
implants with a lateral cortical anchorage has been reported to
improve primary stability of implants in a fresh bovine bone
model.11 Different bone morphologies and differences in prox-
imity of the implant surface to the cortical plates between pre-
molar and molar sites might have contributed to the increased
ITVs in the premolar sites.
Bicortical anchorage aims at increasing implant stability in
the maxillary posterior region by engaging cortical bone both in
the crestal area and apically into the sinus floor. Intentional si-
nus penetration by implants was reported by Brånemark as early
as 1984. Animal35 and in vitro10 studies that conducted inser-
tion/removal torque or resonance frequency analysis observed
increased implant stability with bicortical anchorage compared
to unicortical fixation. Conversely, Hsu et al36 reported that pri-
mary stability of implants with bicortical fixation did not signif-
icantly differ from that of implants with unicortical anchorage
under clinical conditions. This lack of contribution of bicortical
anchorage to primary stability agrees with the findings of this
study and can be attributed to several factors. Animal models
and artificial bone blocks do not reproduce the anatomical com-
plexity of the human maxilla.24 It is also possible that the apical
implant portion at the level of the sinus floor perforation was
wider than the corresponding drill-generated sinus opening,
rendering impossible a tight sinus cortical fixation.36 Finally,
the presence of thicker crestal cortex, which is associated with
increased ITVs,6,14 could have concealed the potential impact
of apical anchorage.
5
Insertion Torque in Posterior Maxilla
A large variablity in ITVs was observed, as indicated by the
high standard deviations in the overall implant sample as well
as within the subgroups of bone qualities, implant dimensions,
apical anchorage, and implant locations. This finding is mainly
related to the presence of extremely low and extremely high
outliers (i.e., implants with ITVs less than 10 Ncm and those
with 70 Ncm or more). This is not particularly surprising given
the large 3D microstructural variability of bone24 and the sig-
nificant concomitant impact of two confounding variables, (i.e.,
bone quality and implant location).
All implant surgical procedures in the present investigation
were performed by a single clinician with high intra-observer
reliability in rating bone quality. Although this should be con-
sidered one of the strengths of the study, the high level of ex-
perience of the surgeon may limit generalization of the present
results to general practitioners and to all patients with similar
characteristics. Another limitation of the study is that calibra-
tion was not repeated, and intra-observer reliability was not
re-assessed on a regular basis to ensure that rater consistency
did not change.
In the context of an ongoing split-mouth RCT, the 6 to 8
variable-thread tapered implants placed in each patient were
allocated to be either immediately loaded with 3- to 4-unit tem-
porary screw-retained resin fixed partial dentures on the test side
or to be treated according to the one-stage conventional loading
protocol on the contralateral control side. The currently avail-
able short-term interim results comparing the 1-year outcomes
between the two loading protocols demonstrate no significant
differences. The study findings are currently being finalized.
Conclusions
1. Variable-thread tapered implants inserted in the poste-
rior maxilla with poor bone quality achieved mean ITVs
higher than those recommended for immediate loading.
2. Bone quality and implant location were the most signif-
icant parameters in initial implant stability.
3. Other modifying variables such as implant dimensions
and apical cortical anchorage appeared to have limited
impact on ITVs.
Acknowledgments
The authors gratefully acknowledge assistance in statisti-
cal evaluation from Statistiska Konsultgruppen, Göteborg,
Sweden.
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