Protocol for Determining Osseointegration

Dr. Stewart asks:

With the increased frequency of immediate provisionalization on dental implants today, I am wondering how your “protocol” for determination of osseointegration sucess may have changed.

Having placed dental implants since 1984 and having gone from 6 months submerged healing to ‘progressive loading” of healing caps, to immediate loading in select cases, it seems that the determinants of osseointegration “success” have become a bit more vague. In the past, radiographs (along with percussion testing) were used to qualify “success” ( with little scientific justification). Now it seems that the primary determinant of osseointegration is the ability of the abutment to withstand the manufacturers “maximum torque value” after an appropriate time of healing. Current research says that “Caution should be used when judging dental implant systems on the basis of resonance frequency analysis and torque value.”

So, I am wondering what the current thinking is on this subject ? What determinants of osseointegration “success” do you use and why? Thanks.

15 thoughts on “Protocol for Determining Osseointegration

  1. Having done the same since 92 I always thought that the only real measure of success was that implants and rehab together could withstand the pass of 10 years(I am just starting to think I was succesfull with my first cases).
    I also did reverse torque tests and used resonance system to predict and periotest to check stabylity and every other thing you could think of.
    Finally I have come to realize that I was right in the begining. The good cosmetic result, with good function and adecuate duration is my meassure of succes.

  2. If you are using Straumann ITI implants they have an electronic gizmo that will give a number for osseointegration. I know some people who are “pinging” their implants to get a quantitative number for it’s osteointegration. Ask you Straumann Rep to explain it.

  3. Your talking about RFA and it’s controversial as to its clinical efficacy. I tend to agree with Alejandro that the true test is the one of time. I gues to paraphrase Justice Holmes ” We can’t define sucess with implants, but we all know it when we see it”.

  4. I believe that 3i has a study that shows if implants are torqued to 35ncm with no movment or sensation that the loss of these fixtures is less than 1%. If after a year of function thereafter without symptoms the failure rate drops even further. It has been my experience that the torque test is very reliable regarind integration. that dosent mean that bone loss cannot take place however

  5. RFA (resonance frequency analysis) is actually best used over a period of time in the same patient. there have been studies that actually show that over a period of time if used in the same patient, it’s a good tool for measuring the stability curve of the implant. While the ISQ values might differ between patients and between systems (so you can’t say – this person has a 65 at time of placement so it’s ok to immediately load), if you measure the ISQ values of the same patient, it can show you that yes, this implant has passed through the dip in the curve. It also can be used with more than just Straumann/ITI – but is sold exclusively by Straumann. I can give you the sources of the studies if you want.

  6. I sent a patient for an implant and the surgeon needed to do a sinus lift first as there was only 2mm of bone. The radiographs post sinus lift looked good in volume but not dense, but after 6 months the surgeon placed the implant but said the bone was pretty soft-D4. Six months after the healing collar was placed and 4 weeks later I was called and told the implant was fine at 20Ncm but moved at 30Ncm with discomfort. He offered to remove the implant or leave it static another 3 months and recheck the torque. He told me that sometimes works (doesn’t more than it does), but the patient was motivated to try. Is that a prudent approach ? Since it is a second molar, not sure the patient would want to have the area regrafted, but if it failed, is that what would need to be done ? Or could the implant be removed and the osteotomy prep be grafted alone and then have the implant done later as many courses I’ve taken, indicated the osteo-potential for osseointegration is higher in a grafted site (as long as mostly autogenous bone). Any thoughts ?

  7. The Osstell machine which measures RFA is a good tool and has plenty of research to back up the resulting ISQ measurement in regards to implant stability. It does not replace your clinical expertise in regards to when an implant is ready to restore or even when an immediate might be a good idea. It confirms your expertise. So in cases where the intent was to do an immediate and the quality of bone is not what was expected it makes for a much clearer conversation with a referral who may have just forwarded their first case to your office. It also allows you to measure initial ISQ and timepoint ISQ’s without torquing something in that may torque out the implant. You are able to show an initial primary stability ISQ followed by an ISQ that demonstrates the body has moved to secondary stability. Which is of value when conservative treatment planning timepoints are based on implants that are no longer used by the surgeon or even available. As an example using Nobel Guidlines when you don’t place Nobel implants.

  8. Dr. Begley,
    I don`t have the personal experience of trhying to re-submerge the implant and give another chance to the osseointegration to occur, but my collegues already told me some cases that this approach was tried with a successfull ending.
    In the worst case scenario, the removal of the implant and the new graft will be a little delayed.

  9. I must disagrea with the comment that there is plenty of research with the Osstell. There is actually no normative value with this instrument, only suppositions. The probleme is that to make a valuable research to find “ISQ treshold numbers for failure”, there are not enough failures to make it significant, so the number of implants required for a good study would be too high, espescially if you take into account other variables such as the bone type, maxilla vs mandible, anterior vs posterior etc…
    The instrument is a nice research tool, but I would be prudent to use it to decide if you can do immediate loading or not.

  10. Dr Begley,
    Always assume that a retorqued ‘spinner’ will reintegrate. They usually do. I have seen a study which confirms this and mine always have.

  11. Many are doing a torque test and as highlighted above torque in an abutment thinking the implant is ready to restore and having the implant move with patient discomfort. By using RFA you avoid this problem and can wait until the ISQ level returns to something closer to the initial placement. In the case above if RFA was used it may have prevented a situation that may result in a failed implant, with all the hassles associated.

    1: J Periodontol. 2005 Jul;76(7):1066-71. Resonance frequency analysis of one-stage dental implant stability during the osseointegration period.

    2: Clin Implant Dent Relat Res. 2006;8(4):218-22 Correlation between implant stability quotient and bone-implant contact: a retrospective histological and histomorphometrical study of seven titanium implants retrieved from humans.

    3: Int J Prosthodont. 2006 Jan-Feb;19(1):77-83; discussion 84. Resonance frequency analysis measurements of implants at placement surgery.

    It is nice for research but has clinical applications. And as a poster said earlier it doesn’t replace your expertise about immediates or when to load it only confirms it.

  12. we ask every time if we have the osseointegration, but what type of integrations surface? and how many days we need to obtain an integrations in a D1 bone or in the cortical side of a D2 type.sometimes when i use rfa i can have same ratings typical of the osseointagration after one minute the surgery!!!do u know if depend of the high density of the bone stucture?? thanks

  13. Ciao Dr. hamidifar!
    i made this question because in these last time an implant factory give us the opportunity to use same fixture with 70N/cm of insertions. every time i think at the phisiology of the bone tissues but if we use this torque rating,in the cortical part maybe we have not a little gap, for the blood between the implant surface and the cortical bone. we have not a blood inside this gap that usually we can obtain if we place the implants with torque

  14. Dr. Hamidifar, in response to your inquiry, I would rather quote the formal stance of the European Association of Osseointegration (EAO). The consensus report of the working group says; “Although resonance frequency analysis (RFA) is extensively used in clinical research as one parameter to monitor implant stability, it has to be realized that RFA is affected by factors such as bone tissue characteristics and effective implant length, diamater and surface characteristics. Research indicates that implants yielding high implant stability quotient (ISQ) values during follow-up appear to maintain stability. Low or decreasing ISQ values may be indicative of developing instability.No established normative range of ISQ values is available as yet.Single determinations of the ISQ value do not define bone/interface characterisitics or provide a quantitative evaluation of bone tissue integration.No prognostic value for developing instability can be attributed to RFA.The lack of normative values and the ranges of the reported values for stable implants and those with an increased potential to fail indicate that there is currently no justification for routine clinical use of RFA.”Sorry for being so late in response.

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