Required minimum primary stability and torque values for

immediate loading of mini dental implants: an

experimental study in nonviable bovine femoral bone
Ozkan Dilek, DDS, PhD,a Emre Tezulas, DDS,b and Mert Dincel, DDSb Istanbul, Turkey
DEPARTMENT OF ORAL IMPLANTOLOGY, YEDITEPE UNIVERSITY

Immediate loading of implants decreases the period a patient has to remain edentulous. However, for
successful immediate loading in clinical practice, a strong initial fixation with bone is a prerequisite. In the present
study, it is aimed to measure the primary stability, minimum placement, and removal torque values of mini dental
mplants which were originally designed for immediate loading. Therefore, mini dental mplants (10, 13, 15, and 18
mm length and 1.8 and 2.4 mm diameter) were inserted into nonviable femoral bovine bone with a physiodispenser
which can show the torque values digitally. After the implants were inserted, the primary stability values were
measured with Periotest. Then the implants were removed from the bone using the same physiodispenser and the
removal torque values of the implants were measured. Finally, 3 related tables were created, which show the match of
the 3 different values (primary stability, placement, and removal torque) for each implant. The best Periotest values are
8 to 9, which reveal the best primary fixation range. In the tables, placement and removal torque values that
correspond to this range are observed. In conclusion, it is believed that the results will aid the dentists in their decision
for the selection of the Periotest value ranges and their related placement and removal torque values to decide for
immediate loading of the mini dental mplants. Mini dental mplants, which are especially designed for immediate
loading, can only be loaded immediately if their Periotest values (and their related placement and removal torque
values) are measured to be between the range of 8 to 9. It is believed that the placement and removal torque
values below the 8 to 9 Periotest range are not suitable for immediate loading procedure. Because this study
concentrates only on experimental results, further clinical research is needed to be made in order to draw more
definite conclusions about immediate loading of the mini dental implants. (Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2008;105:e20-e27)

Implants have recently begun to be loaded immediately to shorten the edentulous period for patients.
Immediate loading is described as functional loading
after implantation immediatelly without waiting the
healing period.1,2 Implants must have favorable primary stabilities for immediate loading. Primary implant
stability is a function of local bone quality and quantity,
implant design, the surgical technique used, and precise
fit in the bone; and it is a very important parameter in
achieving osseointegration in dental implants.2-9 Poor
fixation may lead to micromovements during implant
healing, potentially causing fibrous encapsulation, and
are associated with higher failure rates.10-22
Success rates of immediately loaded implants are
directly proportional to their length and width. However, short implants of minimum 10 mm length can be

used for immediate loading purposes, but in that case as

many implants as possible should be inserted.23-25
Surface coatings and macro designs of implants also
influence their stability inside the bone and play a
significant role in osseointegration. Rough surfaces are
considered to have better outcomes.26-29 Romanos et
al.30 reported that the type of surface coatings contributes to the provision of high torque resistance after
healing in implants placed in the posterior region of
monkey mandibles.
Another factor affecting the primary stabilities of
implants is bone density. To achieve a favorable primary stability, bone density must be DI or DII according to Misch and Judy.31,32
This study, along with the primary stability, aimed to
determine the criteria of placement torque values,
which are necessary for the fixation of mini dental
mplants (MDIs; Sendax, Imtec Co., Ardmore, OK)
inside the bone.

Received for publication Oct 11, 2006; returned for revision Sep 23,
2007; accepted for publication Oct 4, 2007.
1079-2104/$ - see front matter
2008 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2007.10.003

MATERIALS AND METHODS

This study was established at the Oral Implantology
Department of the Faculty of Dentistry, Yeditepe University, in Istanbul, Turkey. Ball-head MDIs (Sendax)

Assistant Professor.
Dentist.

e20

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Volume 105, Number 2

having 10, 13, 15, and 18 mm lengths and 1.8 mm

(mandibular) and 2.4 mm (maxillary) diameters were
placed in a nonviable bovine femoral bone (this study
was based on bovine femoral bone of an already dead
animal. No animal was killed for this study, and the
bone was simply supplied from a butcher), and minimum placement torque, primary stability, and removable torque values were determined. In the routine
cavity preparation protocol of MDIs, the cavity depth
should be equal to one-third to one-half (according to
bone resistance) of the implants length. Implants are
then totally inserted using their self-tapping properties.
At this stage, in general clinical use, the lengths and
locations of the implants were established with the help
of panoramic radiography. Panoromic radiographies
give 2-dimensional views and do not indicate bone
quality. In standard protocol, unless bone quantity is
compromized or really insufficient according to panoromic radiography and clinical examination, the implantologist does not turn to computerized tomography.
Computerized tomography reveals 3-dimensional
views of the bone and gives reliable bone quality measures; however, because of high intial costs, it not only
creates an economic burden for the individual patient,
but also is not readily available everywherenot to
mention the releatively high ratio of radiation it
spreads.
Therefore, in standard clinical practice, it is not a
routine procedure to measure the bone quality before
the insertion of implants. On the other hand, this is
definitely a significant parameter to be taken into consideration. However, an inappropriate cavity preparation in a patient with good bone quality may also result
in an undesirable primary stability. For that reason, to
achieve successful immediate loading, it is better to
take the primary stability and torque values into consideration.
By inserting the implants into the bovine femoral
bone with physiodispenser (W&H Dentalwerk Brmoos, Salzburg, Austria), which shows the torque value
digitally, the minimum placement torque values were
measured (Fig. 1). To insert the implants, a ratchet
adaptor (S7007; Sendax) which fits the abutments of
the implants, and a latch adaptor (9020; Sendax) which
was attached to the implantology contra-angle handpiece (975 AE) (W&H Dentalwerk Brmoos) was used
(Figs. 2 and 3). The physiodispenser (W&H Dentalwerk Brmoos) used in this process shows 5, 10, 15,
20, 25, 30, 32, 35, 40, 45, and 50 Ncm torque values.
After the insertion, primary stability values of the
implants were measured with Periotest (Siemens Gulden-Medizintechnik, Bensheim, Germany).24,33 The
Periotest, a noninvasive device, has been used for im-

Dilek, Tezulas, and Dincel e21

Fig. 1. The physiodispenser, which shows the torque values

digitally.

Fig. 2. The latch adaptor 9020 (left) and the ratchet adaptor S
7007 (right).

plant-stability assessment and gives a numerical value

in a scale (Fig. 4).34
Afterward, primary stability values of the implants
were measured with a Periotest device. The best
primary stability values are between 8 to 9, from
the strongest to the weakest. In this study, upmost
attention was paid to the highest thread of the implant inserted until the bone contact was established.
Implants were inserted in different regions of the
bovine femoral bone to provide the different torque
and primary stability values. Also in this study, Periotest values matching the placement torque values,
which were provided for MDIs with several dimensions that were inserted in the bovine femoral bone
were shown on a table (Table I). The corresponding
primary stability values of different placement
torque values are presented in this table. In the
preparation of this table, the mathematic average of 3

e22

Dilek, Tezulas, and Dincel

Fig. 3. The insertion of the mini dental mplants using the

latch adaptor and the ratchet adaptor.

Fig. 4. Measuring the primary stability of the implants with

the Periotest.

different primary stability value measurements for

each torque value was calculated.
After the placement of the implants, the lowest antirotational values were found to remove the implants
by turning the rotational direction in a reverse direction
with the physiodispenser. Two more tables were prepared to indicate the removable torque values and their
corresponding placement torque and primary stability
values (Tables II and III).
RESULTS
The 1.8 mm mandibular implants were placed into
the different regions of the bovine femoral bone, which
shows different bone densities at its different places,
with 5 to 35 Ncm placement torque. When the 35 Ncm
torque value is found to be insufficient to screw the
implant to the desired level, the power of the physio-

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February 2008

dispenser was increased to 50 Ncm torque; however,

this was also insufficient for screwing the implant into
its place. In this case, the implants were screwed into
their places with a thumb wrench (Sendax), but these
implants were broken just under the abutment without
achieving any substantial further integration into the
bone (Fig. 5).
For all different lengths of mandibular implants, the
optimum Periotest values were measured around 30,
32, and 35 Ncm torque (because the ideal Periotest
values were taken as a criterion ranging between 8
and 9). For 15 mm implants inserted with 25 Ncm
placement torque and 18 mm implants placed with 20
Ncm placement torque, sufficient primary stability values ranging between 8 to 9 were measured. In
implants under these placement torque values, the Periotest scores were measured above 9, indicating
weaker primary stability.
The mandibular implants of all lengths implanted
with 35 Ncm placement torque needed more than 50
Ncm removal torque. In the case of 15 mm and 18 mm
mandibular implants, which were inserted with a 32
Ncm placement torque, the removal torque values exceeded 50 Ncm. These implants could not be unscrewed with 50 Ncm removal torque, and they were
broken from the level of bone when they were manually
forced out with the use of a thumb wrench. For the
implants which could not be placed into the desired
level with 35 Ncm placement torque, leaving the last 1
or 2 threads emerging from the bone, the removal
torque values also exceeded 50 Ncm. These implants
were also broken when they were manually forced out
with the use of a thumb wrench. However, the implants
which were not fully screwed into the bone with 35
Ncm placement torque and leaving more than 2 threads
outside the bone could succesfully be unscrewed from
the bone using a removable torque force ranging between 35 and 50 Ncm.
In the case of maxillary implants (2.4 mm in diameter), the placement torque values were measured to a
maximum value of 30 Ncm at those regions where bone
density is thought to be relatively higher. In the case
where 30 Ncm placement torque is found to be insufficient to place the implant, an excessive resistance was
felt when the placement torque value was increased. In
such cases, even the maximum 50 Ncm placement
torque value of the physiodispenser was insufficient to
place the remaining part of the implant any farther.
When manually forced in using a thumb wrench, excessive resistance of the bone was felt, and these implants were broken without achieving any further integration into the bone.
For maxillary implants of 13, 15, and 18 mm, which
were screwed into the bone with a 30 Ncm torque

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Volume 105, Number 2

Dilek, Tezulas, and Dincel e23

Table I. Placement torque values and different primary stability values for implant lengths
Implant
length (mm)
(mandibular)
10
13
15
18

Placement Torque Values (Ncm)

Primary
stability

10

15

20

25

30

32

35

40

45

50

28
25
25
23

25
24
20
13

20
18
16
11

19
16
11
8

16
14
7
6

9
8
6
5

8
6
5
4

7
5
5
4

32

35

40

45

50

40

45

50

Implant
length (mm)
(maxillary)
10
13
15
18

Placement Torque Values (Ncm)

Primary
stability

10

15

20

25

30

19
16
13
11

13
9
5
4

9
5
0
1

1
1
2
2

0
2
4
4

1
5
5
5

Table II. Placement torque values and different removal torque values for implant lengths
Implant
length (mm)
(mandibular)
10
13
15
18

Placement torque values (Ncm)

Removal
torque
values
(Ncm)

Implant
length (mm)
(maxillary)
10
13
15
18

10

15

20

25

30

32

35

5
5
5
5

10
10
15
15

15
20
20
20

20
20
25
25

25
32
32
40

40
40
45
50

45
45
50
50

50
50
50
50

Placement torque values (Ncm)

Removal
torque
values
(Ncm)

10

15

20

25

30

32

35

40

45

50

5
5
5
5

10
10
15
15

15
20
20
20

25
25
32
32

35
40
50
50

50
50
50
50

Table III. Periotest values and different removal torque values for implant lengths
Implant
length (mm)
(mandibular)
10
13
15
18
Implant
length (mm)
(maxillary)
10
13
15
18

Primary Stability
7

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Removal
50
torque 50 45
values 50 45 32
(Ncm) 50
50 40

45
40

25

40

25
20

15

32

25
20
20

20

20

15

15

10
10 5
5
5

Primary stability
5
Removal
torque 50
values 50
(Ncm) 50

4 3 2 1

10 11 12 13 14 15 16 17 18 19

50
50

35

20

25

15

20
15

15
10

10

5
5

40
32
32

50
25

20

value, 50 Ncm removal torque was found to be insufficient to replace the implant back from the bone. A 50
Ncm removal torque value was sufficent only to remove a 10 mm maxillary implant. The maxillary im-

5
5

plants of 15 and 18 mm, which were placed with 25

Ncm placement torque, could also be removed from the
bone with 50 Ncm removable torque. However, for the
removal of 15 and 18 mm maxillary implants which

e24

Dilek, Tezulas, and Dincel

Fig. 5. The inserted and broken O-Ball mini dental mplant.

were not successfully placed with up to the 30 Ncm

placement torque to the desired level, leaving the last 2
threads outside the bone, more than 50 Ncm removal
torque values were necessary. When forced out manually with the use of thumb wrench, these implants, too,
were broken. The maxillary implants which were not
fully placed with 30 Ncm placement torque, leaving
more than two threads outside the bone, could be removed from the bone with 35 to 50 Ncm removal
torque without breaking.
DISCUSSION
It is highly desirable to have a quantitative method
for establishing the primary stability of an implant at
the time of placement, especially if early or immediate
loading of the implant is desired, even though it is still
unknown what the minimal stability of that implant has
to be before loading. During implant placement, primary stability is often defined by the surgeon as the
lack of clinically detectible motion when using 2 opposing instruments in a lateral direction.2 When making
a decision on immediate loading of the implants, we
can benefit from the Periotest, the Ostell device which
shows resonance frequency values, and torque resistance mechanical tests which help the determination of
implant stability.35,36
In an animal study, Romanos et al.30 reported histologically similar values in implants placed in the anterior regions of the mandible, following delayed and
immediate loading. They concluded that the placement
of implants in the anterior region of the mandible plays
a major role in the overall success, because this area has
the highest bone quality. Piatelli et al.37 reported the
formation of mature, compact, and cortical bone around
the implants 8-9 months after the immediate loading.
They also drew attention to the significance of bone
quality in immediate loading. In a study by Tarnow et

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February 2008

al.,38 34 cylindric implants were immediately loaded

with 100% success. Horuichi et al.39 reported a success
rate of 95.5% in 44 immediately loaded implants. Tarnow et al.38 and Horuichi at al.39 suggested that Periotest and torque values should be evaluated before
making a decision on immediate loading. In those studies, the results were based on values obtained using
conventional implants and standard cavity preparation
techniques. The sufficiency of bone quality has been
reported to be a prerequisite in studies concerning immediate loading.40-43 On the other hand, panoramic
radiographs are generally used for preoperative planning. It is not possible to establish the bone quality
completely by using only panoramic radiographs. Furthermore, even in cases with a high bone quality, an
incorrect cavity preparation may exert a negative impact on primary stability and torque values. Thus, it is
more appropriate to measure primary stability, placement, and reverse torque values before making a decision on immediate loading. Reverse torque tests are
used as a definitive clinical verification of critical integration or the establishment of the adequacy of the
implant bone interface in stage 2 surgery.44-46
The Periotest is a nondestructive, objective, and useful test to determine implant movement.47 In a study of
single tooth implants in the anterior mandibular region
which were loaded immediately, Lorenzoni et al.48
reported a success rate of 100% after 12 months. They
further indicated that they reached a torque value of 45
Ncm during the insertion of implants. They also
achieved 2 to 2 Periotest values before immediate
loading.48
Drago49 reported that Periotest is a highly accurate
device that can be very practical in clinical studies.
Drago indicated that the long term stability values are
achieved with the highest accuracy at the time of placement and proposed that the primary and long-term
stability of implants must be evaluated with gathering
all of the clinical data rather than concentrating on a
single criterion.49 Odont et al.46 reported that countertorque values vary in implants with different surface
characteristics. Some authors support the opinion that
the surface characteristics influence primary stability;
however, the lengths and diameters have no effect on
removal torque values.47
In the present study, it was observed that the length
and diameter of implants have an influence on the
primary stability, placement, and removal torque values. Odont et al.46 evaluated removal torque values
after the healing period following the insertion of implants. In our study, however, only initial stability
parameters were measured after the implants insertion.
This may account for the dissimilarity with the study of
Odont et al.46

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Volume 105, Number 2

The MDIs were designed for immediate loading.

Fixture and abutments of the implants are 1 piece. In
fact, the narrow diameters of MDIs (1.8 mm mandible,
2.4 mm maxilla) might have been found to be disadvantageous for immediate loading. Because bone contact surface of these implants is less than the widerdiameter implants, they have negative effects on
primary stability, which is an important criterion for the
success of immediate loading. To overcome this disadvantage, contrary to the common principle to deepen
the cavity to the length of the conventional wide-diameter implants osteotomy, the cavity should be deepened to one-third to one-half of the implants length,
according to the resistance felt by the surgeon while
inserting the MDIs, which is related to the bone density.
When the cavity is opened with a single pilot drill
(Sendax) of 1.1 mm diameter, far better primary stability is achieved. The implants cavity should be prepared narrower than its diameter, to have better primary
stability and to benefit from the self tapping feature of
the implant. Another point to pay attention to is that the
MDIs could only be applied to the ossified bone and not
to fresh extraction sockets.
In this study, for 35 Ncm placement torque, the best
primary stability values were measured to be 4 for the
mandibular MDIs. As for maxillary implants, for 30
Ncm placement torque, ideal primary stability value of
5 was reached. Maxillary implants were faced with
more bone resistance and therefore gave higher primary
stability values for lower placement torque values, despite the fact that maxillary implants had wider diameters. This was due to the fact that the same 1.1 mm
diameter drill was used while preparing the implant
cavity. The reason for producing maxillary implants
thicker than the mandibular implants is that the bone
density of maxilla is lower than that of mandible.
The highest placement torque value was measured as
35 Ncm for 1.8 mm mandibular implants. In case these
implants can not be placed into the bone to the desired
level by 35 Ncm placement torque, instead of applying
more placement torque, deepening the cavity more than
one-third of its size would be more appropriate to place
the implant successfully. The suggested cavity depth is
half of its size. The main reason for this is that, when
excessive placement torque is applied through physiodispenser or thumb wrench, the implants do not move
in the bone once the 35 Ncm placement torque value is
exceeded, and the implant is broken from the level of
the bone if further force is applied. The fact that all
mandibular implants were placed sucessfully (with all
threads in the bone) by 35 Ncm placement torque, and
the 15 and 18 mm mandibular implants were placed
succesfully with 32 Ncm placement torque, the removal
torque values were measured as more than 50 Ncm,

Dilek, Tezulas, and Dincel e25

indicating that these implants had achieved excellent

fixation rates within the bone. The implants which were
placed with 35 Ncm torque leaving their last 2 threads
outside the bone required more than 50 Ncm removal
torque, which in turn resulted in the breaking of the
implants. It seems that it is better to leave these implants as they are. In cases where more than 2 threads
of the implant are left open, a 30-50 Ncm removal
torque value is sufficient to remove these implants. In
such cases, after removing the implants if the cavity is
deepened to the level of one-half of the implants size,
this would be sufficient for the successful placement.
For maxillary implants, the ideal placement torque
value was measured as 30 Ncm. Compared with that
value, the Periotest gave a very good primary stability
value of 5. If the 30 Ncm placement value is exceeded, high resistance occurs and the bone may heat,
leading to necrosis and microcracks. Application of
excessive placement torque via physiodispenser or
thumb wrench does not help the implant move any
further inside the bone. In such cases, instead of applying excessive amounts of placement torque, it is suggested to remove the implant and deepen the implant
cavity, reaching to one-third of the size of the implant.
In cases where last 2 threads of the maxillary implants
placed with 30 Ncm torque were outside the bone, the
excessive removal torque required to remove these
implants resulted in the breaking of the implants under
the abutment. In such cases, it seems better to leave the
implants as they are, rather than removing and possibly
breaking them. If more than 2 of the last threads of the
implant are left open, 40-50 Ncm removal torque value
would be sufficient to remove all of these implants. In
this case, it is suggested to remove the implant and
deepen the cavity to the level of one-half of the size of
the implant, which will then allow successful placement of the implant into the bone. In clinical application, because of the fact that maxillary implants are
thicker than mandibular implants, and the bone density
of the maxilla is lower than that of the mandible, the
breaking risk of maxillary implants is lower than that of
the mandibular implants.
In the available literature, the optimal placement
torque threshold was first thought to be between 35 to
45 Ncm for conventional large-diameter implants.2 It
was also suggested that the implants placed with more
than 40 Ncm torque have good primary stabilization
rates and therefore can be loaded immediately.23 Implants with placement torque values less than 40 Ncm,
smaller than 8.5 mm (wide platform) or 10 mm (regular
platform) in length, or associated with bone grafting
should probably be submerged.13 The MDIs provide
higher primary stability rates with lower placement
torque values. This can be explained by the fact that

e26

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February 2008

Dilek, Tezulas, and Dincel

although the diameters of these implants are narrower,

the implant cavity is prepared shorter than the implant
size and narrower than its diameter. Because different
MDIs of various sizes, diameters, and different placement procedures provided different placement torque
values in the literature, the present study suggests that
only placement torque values are to be taken into consideration when deciding for immediate loading of
MDIs.
Mandibular MDIs of 10 and 13 mm size placed with
30 Ncm torque, 15 mm size placed with 25 Ncm torque,
and 18 mm size placed with 20 Ncm torque provided
sufficient primary stability values, and therefore they
can safely be immediately loaded. All other MDIs
under these placement values did not provide enough
primary stability and therefore are not appropriate for
immediate loading. Maxillary MDIs of 10 mm placed
with minimum 15 Ncm torque and 13, 15, and 18 mm
placed with 10 Ncm torque can also be loaded immediately. All other maxillary MDIs placed with lower
torque values are not appropriorate for immediate loading.
Eventually, placement torque or primary stability
values taken from the MDIs which were loaded immediately in the routine protocole enlighten the operator
about the long-term prognosis of the implants as well as
their availability for successful immediate loading. At
the same time, owing to the knowledge of optimum
placement torque values for different sizes and diameters of MDIs available in the present study, when
implants are inserted into high-density bone, breakage
of the implants is prevented at the antirotational movement by sticking in the bone if high placement torque
force is applied. When designing removable prostheses,
if sufficient primary stability or ideal placement torque
values is not achieved, postponing of the functional
loading of implants would prevent the loss of those
implants.
We believe that the results of this study provide
insight to clinical operators in deciding whether or not
to load the placed MDIs immediately. However, the
experimental results provided by this preliminary study
must be compared and supported by clinically achieved
values. We are looking forward to further clinical studies reporting the long-term success rates of immediately
loaded MDIs according to their placement torque values and primary stability values.

3.

4.

5.
6.

7.

8.

9.

10.
11.

12.

13.

14.
15.

16.

17.

18.

19.
20.

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Reprint requests:
Ozkan C. Dilek
Yeditepe Universitesi, Dishekimligi Fakultesi
Bagdat Cad. No: 238 Goztepe
Istanbul, Turkey
ozkand@yeditepe.edu.tr