VERARDI ET AL IMPLANT DENTISTRY / VOLUME 27, NUMBER 1 2018 5
Osteointegration of Tissue-Level
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Implants With Very Low Insertion Torque
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in Soft Bone: A Clinical Study on SLA
Surface Treatment
Simone Verardi, DDS, MSD,* Jessica Swoboda, DDS, MSD,† Francesco Rebaudi, DDS,‡
and Alberto Rebaudi, MD, DDS‡
rimary stability is widely
P accepted as one of the prerequi-
sites for obtaining osteointegra-
tion.1,2 If primary stability is absent
during early healing, implant mobility
can occur by the application of func-
tional loads. This could lead to fibrous
connective tissue attachment, rather
than osteointegration.3–5 Bone quality
at implant insertion6 and implant
design7 are the most important factors
in achieving primary stability. The
preoperative bone quality-density clas-
sification6 updates on biomechanical
bone properties and predicts implant
stability. Rebaudi et al6 classified bone
in 3 qualities: hard, normal, and soft.
Rebaudi6 described that the implant
site preparation protocol changes in
the base of 3 bone qualities: Larger
drills and bone tapping in the hard
bone, standard drills in the normal
bone, and thinner drills (undersize
preparation) or osteotomes technique
in soft bone. Rebaudi et al6 also
showed that hard and soft bones are
more critical and unsafe for implant
*Affiliate Assistant Professor, Department of Periodontics,
University of Washington, Seattle, WA.
†Affiliate Instructor, Department of Periodontics, University of
Washington, Seattle, WA; Private Practice, Helena, MT.
‡Private Practice, Rebaudi Studio Associato, Genova, Italy.
Reprint requests and correspondence to: Alberto
Rebaudi, MD, DDS, Piazza della Vittoria, 8dGenova
16121, Italy, Phone: +39010594998, Fax:
+39010594998, E-mail: alberto.rebaudi@gmail.com
ISSN 1056-6163/18/02701-005
Implant Dentistry
Volume 27  Number 1
Copyright © 2017 Wolters Kluwer Health, Inc. All rights
reserved.
DOI: 10.1097/ID.0000000000000714
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Introduction: Evidence shows
lower percentage of osteointegration
when implants are placed without
sufficient primary stability. The pres-
ent work tested the hypothesis that
implants unstable at insertion could
achieve osteointegration with proper
implant surface treatment.
Materials and Methods: Eleven
Straumann tissue-level implants with
sandblasted, large-grit, acid-etched
(SLA) surface treatment were placed
in soft bone unfavorable to primary
stability, as indicated by insertion
torque lower than 10 N/cm and slight
mobility on the application of a lateral
load of 250 g. After 4 to 6 months of
healing, a reverse torque of 35 Ncm
was applied to assess osteointegration.
placement, whereas normal bone that
has a medium density is safer. Hard
bone is dangerous because it is less
vascularized and difficult to cut,
increasing the risk of heating bone
during implant site preparation and
bone compression at implant insertion.
Recent histological studies showed the
dangerous effects of heating on os-
teointegration.8 Soft bone is dangerous
because mechanical properties of soft
bone are very low and the bone trabec-
ulae are very thin, so soft bone does
not give strong primary stability at
implant insertion.6 Most implant sta-
Results: All implants appeared
to be clinically osseointegrated
and were successfully restored
and loaded with fixed partial den-
tures or single crowns. After 28.5
months, all implants remained
functional.
Conclusions: Within the limita-
tions of the low number of implants
analyzed, it can be concluded
that tissue-level implants with
sand-blasted and acid-etched sur-
face treatment can achieve osteoin-
tegration, even in the absence of
primary stability. (Implant Dent
2018;27:5–9)
Key Words: dental implants,
implant surface, primary stability,
bone density
bility is gained through contact to cor-
tical bone, which is much stronger
than the cancellous bone.6 Thickness
of the cortical bone at the tip of the
alveolar ridge is affected by the pas-
sage of time. Specifically, within a few
months of extraction, cortical bone is
absent or thin. However, it becomes
progressively thicker (1–3 mm) in the
following months and years.9
At insertion, it is true that screw-
type implants achieve primary stability,
but history has shown that osteointegra-
tion can also be achieved with the use
of stabilizing press-fit cylindrical
 6 LOW INSERTION TORQUE IN SOFT BONE
implants, which have no threads.10
Some screw-type implant systems have
thick threads, whereas others have thin
threads. For some systems, it is neces-
sary to prepare the implant site by tap-
ping the bone, whereas other systems
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are self-tapping and have an undersized
preparation protocol for soft bone.6
Therefore, implant design, as well as
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shape and dimension of threads, may
vary, but almost all implant systems
easily achieve primary stability in hard
or medium bone. On the other hand,
when bone is soft, it can be very difficult
to stabilize implants, irrespective of the
implant system.6,11 Soft bone has also
been linked to excessive loss of
machined titanium implants.12
Straumann implants are used in the
present study. They are not self-tapping
and are designed such that the threads
have a large pitch. Straumann implants
are treated with the sandblasted, large-
grit, acid-etched (SLA) surface treat-
ment in which sandblasting with a large
grit (250–500 mm) results in a peak-to-
peak macroroughness of approximately
20 to 40 mm, followed by microrough-
ness of approximately 2 to 4 mm on acid
etching.13 Both the design and surface
of Straumann implants have resulted in
superior performance in many re-
ports.14 The SLA surface showed
a 98.6% success rate when initially sta-
ble implants were loaded at 6 weeks and
followed for 5 years.14
However, in the event of unstable
implants, several protocols have called
for their removal, or, given sufficient
bone density, replacement with another
wider or longer implant to achieve the
desired primary stability.15 This indi-
cates that primary stability remains
a recurring concern among implantolo-
gists.2,3,6,16–18 For example, in 1998,
Orenstein et al16 reported that 3.1% of
some 2641 implants placed were
mobile after placement. Nevertheless,
these mobile implants were not
removed or changed, and after healing
at uncovering, 93.8% of the previously
mobile implants were deemed to be
integrated. The authors compared the
survival rate of implants without pri-
mary stability at placement (93.8%) to
the survival rate of implants that
achieved primary stability at placement
(97.5%). Based on these percentages,
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
VERARDI ET AL
Orenstein concluded that it might be detailed description was provided for
preferable to leave implants in a mobile 7 patients who received a total of 11
state at placement, uncovering them implants (4 women and 3 men with
after 4 to 8 months, rather than remov- mean age of 59; range 32–82). All sub-
ing them and immediately substituting jects were nonsmokers and did not
with longer or larger implants. Oren- report any systemic disease. As com-
stein (1998) also found that the implant monly done, an informed consent was
surface could influence osteointegra- obtained from all patients, and it was
tion of implants without primary included in the respective charts.
stability.16,17 As reported in the charts, all alve-
To the best of our knowledge, no olar ridges were considered adequate in
studies have reported on the success of width and height after clinical and
Straumann SLA-surfaced dental im- radiographic evaluation. None of the
plants (Straumann, Berne, Switzerland) sites had been previously augmented
in cases where primary stability was not by grafting and/or membranes. The
achieved at the time of placement. implants were all Straumann SLA-
Therefore, to test the hypothesis that surfaced implants with various diame-
implants unstable at insertion could ters and lengths (Table 1).
achieve osteointegration with proper The same surgical protocol was
implant surface, the present study used for all implants. To avoid contam-
examined 11 such implants that pre- ination, all patients rinsed with a 0.12%
sented mobility at the time of placement oral chlorhexidine gluconate solution
and had very low insertion torque. (Peridex; Zila Pharmaceutical, Phoenix,
AZ) for 1 minute before surgery; their
MATERIALS AND METHODS faces were also scrubbed with a 4%
A review of clinical charts was chlorhexidine antiseptic/antimicrobial
performed on 274 Straumann tissue- skin cleanser (Hibiclens; Regent Medi-
level SLA implants. Forty-five implants cal Americas, Norcross, GA) before they
had been inserted into soft bone. were covered with sterile drapes.
Among these, 34 achieved primary After local anesthetic was given by
stability, whereas 11 did not, as deter- infiltration and/or block (2% xylocaine
mined by insertion torque lower than 10 with 1:100,000 Epinephrine; Dentsply
N/cm and slight mobility of implant on Pharmaceutical, York, PA), a midcres-
application of a lateral load of 250 g. tal incision was made on the ridge, and
Between February 2002 and October intrasulcular incisions were extended
2005, we found that these 11 Straumann mesially and distally to the adjacent
SLA implants had been placed with teeth. In some cases, an “H” design was
initial instability in subjects treated at preferred, consisting of a midcrestal
the Graduate Periodontics Clinic, Uni- incision and mesial and distal perisulc-
versity of Washington at Seattle. A ular incisions. This method was chosen
Table 1. All Implants Placed With Lacking Primary Stability Even Placed in Different
Positions Achieved Osteointegration, Were Successfully Restored and Showed to be
Functional at 18 Months Control
Replacing No. of Months Since
Subject Age Sex Tooth No. Implant Size Restoration Survival
1 82 F 6 4.1 3 12 RN 18 Yes
2 61 F 19 4.8 3 12 WN 18 Yes
2 61 F 20 4.1 3 12 RN 18 Yes
2 61 F 21 4.1 3 12 RN 18 Yes
3 68 M 18 4.8 3 10 WN 52 Yes
4 32 F 30 4.8 3 12 WN 40 Yes
5 56 M 6 4.8 3 14 RN 34 Yes
6 45 F 18 4.1 3 8 RN 38 Yes
6 45 F 31 4.8 3 8 RN 38 Yes
7 69 M 13 4.1 3 10 RN 20 Yes
7 69 M 14 4.8 3 10 RN 20 Yes
 VERARDI ET AL
to avoid possible recession on the adja-
cent teeth. A surgical guide was used to
achieve ideal 3-dimensional placement
of fixtures. The drills were used in the
sequence recommended by the implant
manufacturer. Based on the lack of
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bone density, the screw tap was not
used before insertion of the fixture.
Bone type was assessed by computed
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tomography examinations before prep-
aration of the osteotomy using the clas-
sification proposed by Rebaudi.6 All
mobile implants were placed in soft
bone and tested by applying a lateral
mild load with a probe to verify mobil-
ity immediately after placement. A 5.0
suture was used, either silk, Ethibond,
or chromic gut (Ethicon, Somerville,
NJ), to reapproximate the tissues. The
presence of vertical (V) or horizontal
(H) mobility was reported in the chart.
After the surgery, subjects were
given prescriptions for analgesics (ibu-
profen 600 mg 3 times a day or hydro-
codone 5 mg/acetaminophen 500 mg
1–2 q 4–6 hours) and 0.12% chlorhex-
idine gluconate to rinse with twice
daily. No antibiotics were prescribed.
Patients were also instructed not to
chew on the surgical site and not to wear
their removable partial dentures in the
treated areas. Follow-up postoperative
visits were scheduled at 1 and 4 weeks.
Nonresorbable sutures were removed at
the 1-week post-op appointment. When
a chromic gut suture was used, it was
left in place until it was resorbed. All the
implants were restored 4 to 6 months
after placement. Before passing to the
restorative phase, a periapical radiograph
was taken, and a torque/counter-torque
test of 35 Ncm was conducted. Single
implants were restored with a single-
unit cement-retained porcelain-fused-to-
metal (PFM) crown. Multiple adjacent
implants were restored with splinted
cement-retained PFM crowns. The resto-
rations have now been functional for
a minimum of 18 months. The patients
were recalled, examined, and periapical
radiographs were taken.
RESULTS
All the surgical sites healed without
any complications. No unexpected
events were reported by any of the
patients. Among 274 implants placed,
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 27, NUMBER 1 2018
263 achieved primary stability at place-
ment, whereas 11 (4.1%) did not. Of
274 implants, 45 (16.42%) were in-
serted in soft bone. Thirty-four of 45
implants inserted in soft bone achieved
primary stability, whereas 11 (24.44%)
did not.
All 45 implants placed in soft bone,
including the 11 mobile implants,
achieved osseointegration. All 11 im-
plants that did not achieve primary
stability still had a survival rate of
100% after the observation period and
were classified as successful using the
Pisa consensus conference classifica-
tion.19 No mobility, signs of radio-
graphic bone loss, suppuration, or
inflammation were present. The im-
plants placed were 4.1 or 4.8 mm in
diameter with a regular or wide plat-
form and a length of 8, 10, 12, or
14 mm. All implants were stable when
tested 4 to 6 months after placement and
deemed to be osteointegrated. They
were then restored without any compli-
cations, and they remain in place at this
time. The average time since restoration
is 28.5 months, with a range of 18 to 52
months.
DISCUSSION
Successful osteointegration is
characterized by the formation of
a strong link at the bone-implant inter-
face. However, it can be influenced by
damaging external factors that disturb
the periimplant microenvironment at
implant site preparation or during the
healing phase.1,3,6 This can occur as
a result of physical damage during
implant site preparation, biological or
chemical contamination, or a lack of
primary stability.3,18,19 In the present
work, care was taken during implant
site preparation to avoid physical dam-
age or biological or chemical contami-
nation. This step allowed us to exclude
these factors in the context of this
study, which is based on the hypothe-
sis that osseointegration would be
achieved in these cases, irrespective
of primary stability at insertion.
Indeed, among all implants inserted
in the present study, only a few
(4.01%) did not achieve primary sta-
bility. These data agree with the pre-
vious findings of Orenstein, who
7
reported on 2770 implants placed,
among which 89 (3.1%) were mobile
at the time of implant surgery.16,17
We also found that all implants
placed in hard or normal bone quality/
density achieved primary stability,
whereas all implants that did not
achieve primary stability were placed
in soft bone. This finding indicates that
bone quality is a strong determinant for
the achievement of primary stability in
agreement with Makary (2011)2,18 who
observed a correlation between implant
insertion torque and bone density.
In the present study, 83.58% of all
implants placed were inserted in hard or
medium bone, whereas only 16.42%
were inserted in soft bone. Most im-
plants placed in soft bone (24.44%) did
not reach enough torque at insertion and
were therefore unstable at that time.
Soft bone was mainly found in the
posterior upper maxillae and in sites
of the alveolar ridge where teeth were
recently extracted (less than 3 months).
This finding agrees with studies show-
ing that bone density is very low in the
first weeks or months after extraction
and that delaying implant surgery might
improve stability.8 Studies on implant
stability indicate that a lack of stability
may lead to harmful implant micro-
movements during the healing phase.2,3
This phenomenon becomes evident
when functional applied loads over-
come the resistance of the primary
bone-implant link at the implant inter-
face.2,3,5,6,12,16,19 This concept follows
Szmukler-Moncler who reported a criti-
cal threshold of micromotion (between
50 and 150 microns) above which fibrous
encapsulation prevails over osteointegra-
tion3 and also follows Pillar who reported
that micromovements can be tolerated up
to an intensity of 150 mm and displace-
ments beyond that can be considered as
excessive micromotion.4
Soft bone also lacks mechanical
properties otherwise required to ensure
stability at the time of insertion, as also
underscored in studies reporting on
insertion torque of implants.15,20 Previ-
ous observations highlighted the fact
that soft bone is at higher risk for the
achievement of osteointegration. For
example, based on a 5-year clinical
analysis on 1054 Brånemark implants
(Nobel Biocare, Yorba Linda, CA),
 8 LOW INSERTION TORQUE IN SOFT BONE
Jaffin and Berman12 reported an exces-
sive loss of screw implants with
a machined surface in soft bone.
Some authors also suggested that
implant surface may play an important
role in the osteointegration of implants
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inserted in soft bone.11,21,22 Based on
a clinical histomorphometric study, Tri-
si et al (1999)11 observed that a rough
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titanium surface dramatically enhanced
the amount of bone-to-implant contact
compared with a smooth titanium sur-
face in low-density bone after 3, 6, and
12 months.11 These results were con-
firmed by similar histomorphometric
studies on different rough-surface treat-
ments compared with machined surfa-
ces.21,22 Histomorphometric studies
and bone quality/density highlight the
fact that soft bone seems to be at higher
risk of implant failure because implants
inserted in soft bone often show lower
torque levels, higher failure rate and,
sometimes, mobility immediately after
insertion.6,11,21,22 The results of the
present study confirm these histomor-
phometric studies on rough implant sur-
face11,21,22 because we showed that all
implants lacking primary stability had
successfully osseointegrated at the end
of the healing period. Thus, if the
implant surface is highly osteoconduc-
tive, then implants inserted with low
insertion torque into soft bone may
acquire secondary stability, that is, os-
teointegration, even in the absence of
primary stability.
In the present study, we observed
that implant design does not always
guarantee implant stability in soft bone,
allowing us to reject the null hypothesis
and affirm that successful osteointegra-
tion was achieved in these 11 cases as
a direct result of SLA implant surface
treatment, providing secondary stabil-
ity, even if primary stability was lack-
ing. Therefore, this finding is in
agreement with that of Orenstein16
who found that all hydroxyapatite-
coated (HA) implants were mobile at
placement, but still achieved osteointe-
gration. On the contrary, only 81.5% of
the mobile non–HA-coated implants
obtained osteointegration. Based on
this finding, the authors concluded that
it might be preferable to leave implants
with a rough surface treatment in their
mobile state at placement, uncovering
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
them after 4 to 8 months, rather than
taking them out and substituting larger
implants.16
Similar findings were found in
a subsequent study published by the
same authors.17 Of 2770 implants
placed, 89 (3.1%) implants were mobile
at the time of implant surgery.17 These
mobile implants had a lower survival
rate of 79.8% when compared with im-
plants that achieved primary stability
with a survival rate of 95.9%. They also
found that implant surface might play
an important role in osteointegration
of unstable implants because HA im-
plants had an increased survival rate
when compared with machine-
surfaced implants (92.8% vs 53.6%).
Comparing the present study with the
study of Orenstein, differences involve
implant number, survival rate, and dif-
ferent implant types and surface treat-
ment, for example, HA-coated versus
SLA. Thus, the higher success rate of
the present report could have resulted
from the obvious limitation of our study
with respect to the small patient cohort,
which prevented statistical analysis, but
also from the relatively short period
between placement of restorations and
last evaluation (mean: 28.5 months).
However, this analysis still shows suc-
cess with mobile implants and contra-
dicts the notion that primary stability
must be achieved at implant placement
to ensure implant success. Recent stud-
ies clarified the important role of
implant displacement and micromotion
during immediate and early healing,
highlighting the importance of the ef-
fects of functional loading directly or
indirectly applied on implants.23–27
These studies along with the results of
the present study indicate that low pri-
mary stability may not be a determinant
for implant failure if implant micromo-
tion is low and implant surface osteo-
conductive. Future research will
attempt to prospectively follow a larger
number of mobile implants for a longer
period after placement, as well as use
more objective measurements when
classifying the degree of mobility.
CONCLUSION
The present study observed that all
implants with initial mobility obtained
VERARDI ET AL
a successful outcome. Within the limi-
tations of this study, because of the low
number of implants observed, success
seems to be due to implant surface
treatment coupled with the absence of
mobility due to function during healing.
However, further investigation is still
necessary to positively link successful
osseointegration with the primary sta-
bility of sand-blasted and acid-etched–
treated implants.
DISCLOSURE
The authors claim to have no
financial interest, either directly or
indirectly, in the products or informa-
tion listed in the article.
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