Int. ,L Oral Maxillqfac. Surg.

1999; 28," 297-303 Copyright 9 Munksgaard 1999

Printed in Denmark, All rights reserved
InternationalJournal of
Oral &
Maxillofacial Surgery
ISSN 0901-5027

Research;development
B. Friberg 1,2, L. Sennerby 1,2,
A comparison between cutting N. Meredith 2,3, U. Lekholm 1,2
1The Br&nemark Clinic, Public Dental Health
Service and Faculty of Odontology, G~teborg
torque and resonance University; 2Department of Biomaterials/
Handicap Research, Faculty of Medicine,
G6teborg University, Sweden; 3Department of
Oral and Dental Science, Bristol Dental
frequency measurements of Hospital, Lower Maudlin Street, Bristol, UK

maxillary implants
A 20-month clinical study
B. Friberg, L. Sennerby, N. Meredith, U. Lekholm: A comparison between cutting
torque and resonance frequency measurements of maxillary implants. A 20-month
clinical study. Int. J. Oral Maxillofac. Surg. 1999; 28: 297-303. 9 Munksgaard,
1999

Abstract. Oral implant treatment ad modum Br~nemark was undertaken in nine

patients with edentulous maxillae. Cutting torque measurements and resonance
frequency analyses (RFA) were conducted at implant placement and the
corresponding values were subjected to correlation analyses. The implants were
also evaluated with RFA at abutment connection and at one-year follow-up in
order to identify possible changes in implant stability. A total of 61 implants were
inserted, of which 49 were of the Mk II self-tapping type. Two implants were lost
during the study period. The cumulative torque was presented as a mean value
for the upper/crestal, the middle and the lower/apical third of the implant site
respectively, as well as an overall value for the whole site. The highest correlation
(r=0.84, P<0.05) was found when comparing the mean torque values of the
upper/crestal portion with the resonance frequency values at implant placement.
The Mk II implant sites were divided into three groups based on the values of
the cutting torque, i.e. soft (group 1), medium (group 2) and dense bone (group
3). The mean value of each group was plotted against the corresponding mean
value of resonance frequency measured at implant insertion. Statistical analysis
showed significant differences in resonance frequency at implant insertion
between groups 1 and 2 (P=0.047) and between groups 1 and 3 (P=0.002).
When repeating the resonance frequency analyses at second stage surgery and at Key words: resonance frequency; cutting
torque; osseointegration; titanium implants;
one-year follow-up, no significant differences were detected between any of the clinical study.
groups. It was shown that the stability of implants placed in softer bone seemed
to "catch up" over time with more dense bone sites. Accepted for publication 3 December 1998

The use of titanium implants ad modum
Br~nemark is well documented in the
rehabilitation of edentulous and par-
tially edentulous patients 2,11,15,2~ A ri-
gid fixation of the implant surface is
thereby achieved and maintained in
bone during functional loading 29. In
spite of good results, failures may oc-
cur, which are mainly revealed when ex-
posing the implants after the initial
healing period, as well as during the
first year of function 1'4'27. Low bone
density and limited jaw bone volumes
are the most frequently mentioned par-
ameters associated with a higher failure
rate 5'6'13'14'26. Consequently, higher im-
plant loss figures have to be expected in
maxillae, which exhibit bone of a softer
character and are of smaller volume as
compared to mandibles 2,4,25.
As bone density seems to have a con-
298 Friberg et al.

Table 1. Distribution of implant sites with regard to bone density as classified according to
LEKHOLM & ZARB i n d e x ~a
Implant position
Patient 15 14 13 11
1 3 3 2
2 4 3 3
3 3 2 2
4 3 2 2
5 4 4 4
6 4 4 3 3 3
7 4 4 4 4 4
8 4 4 4 4 4
9 4 4 3 3 3
siderable i m p a c t o n the result of im-
p l a n t treatment, it w a r r a n t s evaluation.
Preoperatively, this is p e r f o r m e d with
the use of radiography, including t o m o -
grams of various j a w regions 1~ One
technique for d e t e r m i n i n g b o n e density
d u r i n g the o p e r a t i o n was i n t r o d u c e d by
JOHANSSON & STRID t7, especially aiming
at the recognition of b o n e regions with
low density a n d at o b t a i n i n g a n objec-
tive measure o f b o n e h a r d n e s s d u r i n g
low-speed threading o f i m p l a n t sites.
This m e t h o d of using cutting resistance
m e a s u r e m e n t s was f u r t h e r explored by
FRIBERG et al. 7'8, w h o f o u n d the tech-
nique to be reliable a n d applicable in
clinical routine work.
Due to less h a r d tissue support, im-
plants placed in jaw b o n e o f low den-
sity m a y have a reduced initial stability,
which in t u r n m a y lead to less ade-
q u a t e i n t e g r a t i o n in b o n e d u r i n g the
early healing phases 24. To improve
such a situation by achieving more
b o n e a r o u n d the implant, JOHANS-
SON & ALBREKTSSON16 advocated,
based o n an a n i m a l study, the un-
loaded postsurgical healing period to
be prolonged. Different degrees of ini-
tial i m p l a n t stability were tested by IV-
ANOFF et al. ~2, using the r a b b i t as a
model. T h e results revealed significant-
Material and methods
Patient data
The present investigation comprised nine pa-
21 23 24 25 26 tients, consecutively treated with oral im-
2 3 3 3 plants in edentulous maxillae. Six of the pa-
3 3 4 tients were women and the mean age was 67
2 2 3 years (range 55-80 yrs). The presurgical
2 2 3 evaluation including medical conditions fol-
4 4 4 lowed the protocol described by LEKItOLM19,
3 4 4 using the same principles as in connection
4 with any type of oral and maxillofacial
4 4 4 surgery. Available bone density (Table 1) was
3 4 assessed from preoperative radiographs and
during drilling according to the classification
by LEKHOLM& ZARB18. In total, 61 implants
(Table 2) of the BrSnemark System T M were
ly reduced b o n e volumes a r o u n d im- inserted, of which 49 were of the Mk II self-
plants with initial total mobility, as tapping type. All implants were placed ac-
c o m p a r e d to those regarded as initially cording to a two-stage surgical technique ~.
Due to the soft character of the bone, how-
stable. Consequently, besides j u d g i n g
ever, the tapping procedure was rarely ex-
the b o n e density, a precise m e a n of
ecuted for the implants of standard design or
m e a s u r i n g the i m p l a n t stability at time of wider diameters. The healing period be-
of insertion would be beneficial. tween implant placement and abutment con-
In a series o f publications, MEREDITH nection was also extended from six to eight
et al. 2~ 23 have r e p o r t e d o n the use of months. Fixed prosthetic constructions were
sonic resonance frequency measure- fabricated in highly precious gold alloy 28 and
m e n t s a n d dental implants where a sta- fitted with acrylic teeth. A clinical and radio-
bility value of the implant/tissue inter- graphic check-up was performed one year
after the second stage surgery, i.e. at 20
face at i m p l a n t p l a c e m e n t was ob-
months.
tained. T h e study also d e t e r m i n e d t h a t
it was possible to m o n i t o r the change in
tissue stiffness d u r i n g the initial healing Cutting torque measurements
period a n d the s u b s e q u e n t follow-up
An electronic instrument (Nobel Biocare AB,
period, indicating the level of osseoin-
G6teborg, Sweden) was used for total torque
tegration taking place. measurements during insertion of Mk II im-
T h e aims of the present study were plants. The instrument was connected to a
to o b t a i n values o f cutting t o r q u e a n d Torque Control T M (Nobel Biocare AB, G6te-
resonance frequency at the time o f in- borg, Sweden) and the time-torque data was
sertion of i m p l a n t s into edentulous recorded by a memory card during low-speed
maxillae, as well as to evaluate w h e t h e r placement of 49 Mk II implants. These were
any correlation existed between the inserted with the following distribution: 16
c o r r e s p o n d i n g values of the two tech- incisor, 16 canine and 17 premolar positions
(Table 2). Only the idling speed energy was
niques. R e s o n a n c e frequency measure-
subtracted from the total torque, since both
m e n t s were also c o n d u c t e d o n two
the true cutting resistance and the friction
other occasions, at the end of the heal- torque, the latter including bone material
ing period as well as at the one-year packing around the implant, were regarded
check-up, in order to follow possible as expressing the resistance of the bone site
changes in i m p l a n t stability over time. and to have an impact on implant stability.

Table 2. Distribution of implants with regard to position, length and type. All except 12 implants were of 3.75 mm Mark II design, s standard
implants, other diameters within brackets, t=failed implants
Implant position
Patient 15 14 13 11 21 23 24 25 26
1 13 13 13t 13 13 15 10
2 13 13 13 13 15 13s (o4)
3 18 15 13 15 13 18
4 18 15 15 13 13 15
5 10s (o4) t 13 13 13 15 13
6 10 10 8.5s 8.5s 8.5s 7s 7s 10
7 13s (04) 15 13 15 15 15 10 (05)
8 6 (05) 15 13 13 10 13 13 6 (05)
9 10s (04) 15 10 15 I3 10 13

The cumulative torque was presented as a
mean value in Ncm for the upper/crestal
(El), the middle (E2) and the lower/apical
(E3) third portion, as well as an overall value
for the whole site (E-total) (Fig. 1). The other
twelve implants were of either standard de-
sign or had wider diameters (4 or 5 lllm) and
were chosen by the surgeon because of vari-
ations in jaw bone anatomy. These implants
were not exposed to torque measurements
and their distribution is given in Table 2.
Resonance frequency measurements
After implant placement, a 4 mm long stan-
dard abutment (Brfinemark SystemTM) was
connected to each individual implant, one at
a time. On top of the abutment, a transducer
was attached via a screw, according to the
procedure described by MBREDITH et al. 22.
The transducer had a perpendicular orien-
tation to the alveolar crest and its upright
beam part was placed on the palatal side
(Fig. 2). With the use of a frequency response
analyser (Model 1512; Schlumberger Ltd,
Crawley, England), the transducer was ex-
cited by a sinusoidal signal at frequencies
over the range of 5-15 kHz in steps of 25 Hz.
The resonance frequency was calculated from
the received signal. Data were stored and
analysed in a personal computer. Due to
technical problems with the equipment, only
47 of the 49 Mk II implants were measured
with resonance frequency at first stage
surgery.
All 61 submerged implants were allowed to
heal for eight months, whereafter resonance
frequency measurements (n-47) were ex-
ecuted at second stage surgery by utilizing
the aforementioned device and the 4 mm
long standard abutment. Due to one Mk II
implant failing at abutment operation and
ten Mk II implants being provided with per-
manent abutments of non-standard design,
only 36 implants were exposed to resonance
frequency measurements at the one-year fol-
low-up visit. Conical and angulated abut-
ments were not possible to use together with
the transducer and it was not considered
feasible to exchange them for the final regis-
tration procedure.
Radiographic examinations
Postoperative radiographs were taken at
three occasions, i.e. after the second stage
surgery (at 8 months), after attaching the
fixed prostheses (at 9.5 months) and at the
one-year follow-up (at 20 months). Obtained
radiographs were used to check the fit of
components at the fixture/abutment level as
well as at the abutment/prosthesis level. Fur-
thermore, the marginal bone levels m were
registerred at 8 and 20 months and the mar-
ginal bone resorption was determined during
the first year of function.
Statistical analyses
Implant site mean torque values at different
depths of the site (El, E2 and E3) (Fig. 1) and
Cutt&g torque and resonance frequency of maxillary implants
of the whole site (E-total) were plotted against
the value of resonance frequency of the corre-
sponding implant (n=47). Patient mean
torque values (El, E2, E3 and E-total) were
also plotted against patient mean resonance
frequency values (n-9). Statistical analyses,
utilizing Spearman's correlation test, were
conducted to correlate values of resonance
frequency with the corresponding E-values.
The mean El-value for each patient (n=9)
was plotted against the patient mean differ-
ence in resonance frequency between implant
placement and abutment connection, i.e.
against the figure for change in tissue stiffness
occuring during healing. Spearman's corre-
lation test was used for statistical analysis.
The 47 El-values were divided into three
groups based on differences in bone density.
The first group comprised 16 sites in which the
crestal bone offered the least cutting torque,
the second group consisted of 16 sites with me-
dium cutting torque and the 15 sites of the
third group represented the crestal bone with
the highest cutting torque values. The mean
value for each group was plotted against the
corresponding mean value of the resonance
frequency at implant insertion (16+ 16+ 15=
47), at second stage surgery (16+ 16+ 15=47),
and at one-year follow up (9+13+14=36).
The Student t-test for independent samples
was used to test the null hypothesis.
When comparing the mean resonance fre-
quency values at implant placement (n=47),
at abutment connection (n 47) and at the
first annual check-up (n=36), the Student t-
test for paired samples was used.
Regarding repeatability of resonance fre-
quency measurements, MEREDITH et al. 21
found the error to be less than 1%.
Results
Clinical findings
In six of the nine patients included in
this study, some or all of the implant
sites were judged as quality 4, i.e. the
bone was regarded to be soft in these
regions (Table 1). All nine patients were
free of complications postoperatively,
but two implants were found to be mo-
bile at abutment connection, one 13
m m M k II implant in central incisor
position (quality 2) and one 10 m m
long (4 m m diameter) implant of stan-
dard design in premolar position (qual-
ity 4) (Table 2). Despite the losses, all
patients were provided with fixed pros-
theses and no further complications oc-
curred during the first year of function,
Correlation analyses
Analyses of individual sites (n=47), as
well as of patients (n=9), were per-
formed to correlate resonance fre-
quency values at implant placement
with the mean torque values of E l , E2,
299
E3 and E-total. All patient mean E-
values showed a correlation with the
corresponding patient mean resonance
fi'equency values (Fig. 3a-d). However,
the highest correlation was found with
the El-values (r=0.84, P=0.036) (Fig.
3a), i.e. the patient mean bone resis-
tance values of the upper/crestal part of
implant sites showed the closest re-
lationship with the patient mean reson-
ance frequency values. N o statistically
significant correlation was found for in-
dividual site El-values (Fig. 4a) or for
the E2, E3 and E-total -values (Fig. 4b-
d). Consequently, individual site and
patient mean values of E2, E3 and E-
total were not considered for the sub-
sequent correlation analyses.
When plotting patient mean torque
values of E1 (n=9) against patient
mean difference in resonance frequency
between implant placement and abut-
ment connection, a negative correlation
was revealed ( r = - 0 . 7 3 , P=0.007) (Fig.
5). Consequently, jaw bone regions that
offered low cutting resistance at implant
placement (soft bone sites) showed, in
general, a greater increase in stability of
the implant/tissue interface over time,
compared to bone regions with higher
initial resistance (denser sites).
When analysing the three E l - v a l u e
categories, comprising 16, 16 and 15
sites, respectively, and corresponding to
differences in bone resistance at implant
placement, mean values (Ncm) with
standard deviations were obtained as
follows: group 1:3.4_+0.62 ("low bone
density"); group 2:4.5_+0.22 ("medium
bone density"); and group 3:6.3_+1.18
("high bone density") (Fig. 6). The cor-
responding figures for resonance fre-
quencies (Hz) were: group 1:
7,165+_512; group 2: 7,486-+383; and
group 3: 7,708-+415, respectively (Fig.
6). When following the three groups
identified from the torque values with
regard to changes in resonance fre-
quency values from implant placement
to abutment connection and to the one-
year follow-up visit, the following fig-
ures for resonance frequency at abut-
ment connection were obtained: group
1: 7,771+439; group 2: 7,915-+397; and
group 3:7,936-+475 (Fig. 6). At the
one-year follow-up, the corresponding
values were: group 1: 8,049_+ 384; group
2: 8,060_+480; and group 3: 8,152_+420,
respectively (Fig. 6). When plotting the
torque and resonance frequency data
for statistical analyses (Fig. 6), the Stu-
dent t-test for independent samples re-
vealed significant differences at implant
300 Friberg et al.

E tot

Fig. 1. Cutting torque measurements were conducted for upper/crestal

(El), middle (E2) and apical (E3) third of implant site, as well as
for whole implant site (E-total), when inserting self-tapping Mk II
implant.

Fig. 2. Transducer connected to implant/abutment for resonance fre-

quency measurements at one-year follow-up visit.

insertion between groups 1 and 2 (P= values obtained at implant placement

0.047) and between groups 1 and 3 (P=
0.002). The corresponding analysis be-
tween groups 2 and 3 was found to be
non-significant (P--0.131). When the
analyses were repeated for values ob-
tained at stage two surgery and at the
first annual check-up, no significant dif-
ferences were detected for any of the
groups due to the tendency that regions
with softer bone seemed to "catch up"
over time with the other two groups.
The mean resonance frequency value
obtained for the Mk II implants, ana-
lyzed with the Student t-test for paired
samples, significantly increased between
the first and second stage surgery (425
Hz, P<0.001) and between the abut-
ment connection and the first annual
check-up (220 Hz, P<0.001) (Fig. 7).
One Mk II implant was found mobile at
second stage surgery and the resonance
frequency value was approximately 600
Hz lower than the corresponding one
registered at implant placement (Fig. 7).
Radiographic results
Registrations of the radiographic mar-
ginal bone level mesially and distally to
the implants at 8 and 20 months, as well
as the recorded marginal bone resorp-
tion after the first year of function, are
presented as mean values with standard
deviations in Table 3.
Discussion
The present study showed that the sta-
bility of implants placed in soft maxil-
lary bone increased with time as meas-
ured with RFA. According to M~RED-
ITH et al. 21, the resonance frequency is
determined by the stiffness of the im-
plant/tissue interface and the distance
from the transducer to the first bone
contact. Thus, the interfacial stiffness,
as well as the abutment length and the
marginal bone resorption, will influence
the resonance frequency value. In the
present study, the resonance frequency
are mainly explained by differences in
implant/tissue stiffness as a result of
bone formation and maturation, since
all implants were properly countersunk
and the same abutment length (4 mm)
was used for measurements. At the
abutment connection, changes in reson-
ance frequencies may also be explained
by differences in interfacial stiffness,
since only a minor change in the mar-
ginal bone level (0.13 mm) had oc-
curred during the healing period. How-
ever, the marginal bone resorption of
approximately 1 mm that was registered
during the first year of function may
have had a great impact on the reson-
ance frequency values obtained at the
first annual check-up, i.e. 20 months
after implant placement. Despite this
increase in distance (1 mm) from the
transducer to the first bone contact,
which will lower the resonance fre-
quency values, the mean value in-
creased significantly between abutment
 Cutting torque and resonance frequency of maxillary implants 301

connection and the first annual check- a.

/
El b. E2
up and may be explained by the in- 8200- 8200-
crease in interfacial stiffness. 8000-
r =0.g4
8o00.
A relationship was found between 7800" 7800"
cutting torque and resonance frequency o
~, 7600- 7600"
at implant placement. A statistically 7400- 7400~
significant correlation was, however,
only seen between resonance frequency o 7200" o 72|
7ooo- /. 7000-
and patient mean cutting torque values
680O 6800'
at the El-level. This finding emphasizes 0 2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18 20
the importance of the marginal bone Cutling torque (Ncrn) Cutting torque (Ncm)
density on implant stability as meas-
C. E3 d, E-total
ured with RFA, since the El-values rep-
8200- 8200' /
resented the bone density of the upper/
crestal third of the site. It may also ex- 8000- 8000.
a., 7800" 78| = 0.62
plain why both short and long im-
plants, when being placed in bone of 7600"
uniform marginal density, present simi- 7400" 9 7400'
lar resonance frequency values, as . 7.oo/ / o =o 7200
shown by MEm~DITH et al. 22. Why the 7000.
patient mean El-value, and not the in- 68013 ' 6800, -
0 2 4 6 8 10 12 14 1.6 18 20 0 2 4 6 8 10 12 i4 16 i8 20
dividual site El-value, showed the clos-
Cutting torque (Ncm) Cutting torque (Ncm)
est relationship with resonance fre-
quency might be coincidental or ex- Fig. 3. Patient mean values of cutting torque at implant insertion for upper/crestal (El, 3a),
plained by the fact that a mathematical middle (E2, 3b) and apical (E3, 3c) third of site, as well as for whole site (E-total, 3d), plotted
calculation of the mean reduces the against corresponding patient mean values of resonance frequency (r=coefficient of corre-
variation. lation).
A statistically significant negative
correlation was found between patient
mean cutting torque values at the El-
a. b.
level and change in resonance frequency E1 E2
9000"
from implant placement to abutment 9 0 |
connection. This means that the lower 39 >,
the cutting torque and resonance fre- =
8000- go00 .....
9
J jr = 0.44
quency values were at first stage
surgery, the greater was the increase of ou 9
7000" 7000' 9 9 9
resonance frequency as measured at o o

second stage surgery, which suggests

9o00,
that the tissue response was more in- 60O0 60001
0 5 10 15 20 25 30 0 1'0 2'0 3'0
fluential on implant stability in bone of Cutting torque (Ncm) Cutting torque (Ncm)
low density. The hypothesis may be put
C. d.
forward that the relation between inter- E3 E-total
face stiffness and implant stability is of 90oo1
a specific nature. A further increase of
the bone/implant contact may be more 80| .."" " =
or less important for the implant sta- ~~'
i 80| ~ " ~ 9 ~ "" 9 9 r=0.47
bility and this relation seems to depend 7000"
on the initial bone density. Thus, an in- g
crease from 10% to 30% may have a
great impact on implant stability, whilst 6000 6000
0 1'0 2'0 3'0 0 5 10 15 20 25
an increase from 70% to 90% may not. Cutting torque (Nern) Cutting torque (Ncrn)
This theory is supported by the findings
of FRmERG et al. 9, who evaluated one- Fig. 4. Individual site mean values of cutting torque at implant insertion for upper/crestal
stage mandibular implants with sequen- (El, 4a), middle (E2, 4b) and apical (E3, 4c) third of site, as well as for whole site (E-total,
tial resonance frequency measurements 4d), plotted against corresponding individual site mean values of resonance frequency (r=
during the initial healing period of 15 coefficient of correlation).
weeks. It was found that the stability
did not increase, but slightly decreased
in dense bone. The lowered resonance ducer to the first bone contact 21. In the the second stage surgery and the first
frequency was assumed to be a result of present study, an increase in the mean annual check-up. Consequently, in bone
the change in the marginal bone level of resonance frequency value was ob- of low density, the increase in bone/im-
0.4-0.7 mm, with a corresponding in- tained, despite a greater change in the plant contacts as a result of osteogen-
crease in the distance from the trans- marginal bone level (0.9 mm) between esis may have a greater impact over
302 Friberg et al.

800 ~" 1000-.

700' 800-
r
600-"
= 600 s
~D r 400"
500- 9 "" 9 r =-0.73
9 d~
G~ 200"
= 400' = 0"

300. -2001
.fi 200" "'=
~ -600~
-4001 "N,, 9 failed implant
~o 100
g
. -s001
0 . . . . !
- 1000/ , , . . . . , , I I
I l

3 4 5 6 7 ~) ' 8 ' 20 months

Implant Abutment 1st annual
Cutting torque (Ncm) placement connection check-up
Fig. 5. Patient mean El-values at implant insertion plotted against Fig. 7. Changes in mean resonance frequency values (with standard
patient mean change in resonance frequency between first and second deviations) from implant placement to abutment connection and to
stage surgery (r=coefficient of correlation). first annual check-up (***P<0.001). A lowered resonance frequency
value of 600 Hz was seen for the failed implant at second stage
surgery (arrow).

time on implant stability. The relation and plotted against the corresponding The differences diminished over time
between bone density and the increase resonance frequency values. Statisti- and at the one-year follow-up, i.e. 20
in implant stability over time was cally significant differences were seen months after implant insertion, the res-
further demonstrated by dividing the when comparing groups 1 and 2 and, onance frequency values were similar
bone sites into three groups, based on more especially, when comparing for all three groups. The result indicates
cutting torque values at the El-level groups 1 and 3 at implant placement. that implants over time will reach a
similar stability, irrespective of the bone
density present at implant placement.
The surgical trauma from implant in-
8200-
sertion and probably loading may pro-
duce bone density changes in relation to
8000-
the implant. A progressive tissue re-
sponse over a long period of time also
7800- coincides with the view of BR~NEMARK
et al. 3, who stated that, after implant
7600" insertion, the remodelling period of
I ~ i a t i o n s
•* [-" / I D. . . . Int. . . . diate Soft bone will continue for at least 18
7400" l~ /" ~nonths bone ( A ) bone ( O ) bone ( 9 months.
|* / I0" ...... 415 383 512
[ / [8 475 397 439 The present study, though limited in
7200" L I" [ 20 420 480 384 numbers and follow-up time, comprised
a higher percentage of bone sites classi-
7000 fied as quality group 4 ~8 (30/61) than
0 8 20 months
most other studies 5,6'13,14 and, yet, only
Fixture Abutment 1 year
placement connection of loading one implant out of the 30 (3.3%) ex-
hibited mobility during the 20 months.
Fig. 6. Three groups of implant sites, based on El-values of cutting torque at implant place- A possible explanation for the positive
ment, plotted against corresponding values of resonance frequency at first and second stage result may be the prolonged healing
surgery, as well as at first annual check-up (*P-0.047, **P=0.002). Standard deviations of period used in this study, i.e. eight in-
resonance frequency values for the three groups at the three measurement occasions are shown
stead of six months, which, according
in incorporated table.
t o JOHANSSON 8Z; ALBREKTSSON 16, will
allow for more bone to grow around the
Table 3. Mean marginal bone levels at 8 and 20 months and mean marginal bone loss during implants. Another reason might be the
first year in function use of wider implants inserted in the
most soft bone regions (Table 2), with-
Abutment connection 1st annual check-up
out a corresponding widening of the
(8 months) (20 months)
site diameter during drilling, thereby
Mean marginal bone level (mm_+S.D.) 0.13-+0.20 1.03+0.29 providing for an improved initial im-
Mean marginal bone loss (mm-+S.D.) 0.90• plant stability.

In summary, it may be concluded
f r o m the present investigation t h a t vari-
ous b o n e densities can be identified dur-
ing i m p l a n t p l a c e m e n t with the use of
cutting t o r q u e a n d resonance frequency
measurements. A n increase in i m p l a n t
stability over time, as m e a s u r e d with
resonance frequency, was clearly f o u n d
in sites of low density. Consequently, an
extended healing period m a y be sug-
gested for i m p l a n t s placed in b o n e of
low density.
Acknowledgements. The authors would like
to acknowledge Kerstin Gr6ndahl, Associate
Professor, Oral Diagnostic Radiology, G6te-
borg University, Sweden, and Thomas B~ick,
MSc, Nobel Biocare AB, G6teborg, Sweden,
for valuable support with the research pro-
tocol.
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Address:
Bertii Friberg
The Brdnemark Clinic
Faculty of Odontology
Medicinaregatan 12 C
S-413 90 G6teborg
Sweden
Tel: +46 31 773 3626
Fax. +46 31 827829