Accuracy of friction-style and spring-

style mechanical torque limiting devices

for dental implants
Mark C. Vallee, BSc, DDS, MS,a Heather J. Conrad, DMD, MS,b
Saonli Basu, PhD,c and Wook-Jin Seong, DDS, MS, PhDd
School of Dentistry, and School of Public Health, University of
Minnesota, Minneapolis, Minn

Statement of problem. Accurate delivery of torque to implant prosthetic screws is critical to generate ideal preload in
the screw joint and offer protection against screw loosening. Mechanical torque limiting devices (MTLDs) are avail-
able in 2 different styles that have not been compared for accuracy.

Purpose. The purpose of this study was to determine the accuracy of friction-style and spring-style MTLDs in deliver-
ing target torque values.

Material and methods. Five MTLDs from each of 6 different implant manufacturers (n=30) were selected to deter-
mine their accuracy relative to their target torque values. All MTLDs were new; 3 types were of the friction style while
3 were of the spring style. To measure the output of each MTLD, a digital torque gauge with a 3-jaw chuck to hold the
driver was used. Force was applied to the MTLD until either the friction style released at a precalibrated torque value
or the spring style flexed to a precalibrated limit. The peak torque value registered by the digital torque gauge was re-
corded and the procedure was repeated 50 times for each MTLD. Statistical analysis used repeated-measures ANOVA
(=.05) to assess the accuracy of the MTLDs in delivering target torque values.

Results. Both the mean absolute difference (ABSDIFF) and the mean percentage deviation (PERDEV) between mea-
sured torque values and target torque values differed significantly (P<.001) for the friction-style MTLDs (3.83 Ncm,
13.74%) and for the spring-style MTLDs (0.82 Ncm, 2.36%).

Conclusions. Within the limitations of this study, MTLDs that use spring-style components are significantly more
accurate than those that use friction-style components in achieving their target torque values. (J Prosthet Dent
2008;100:86-92)

Clinical Implications
This investigation supports the view that spring-style MTLDs
are more accurate than friction-style MTLDs in delivering the
target torque; however, the clinical significance of this study in
reducing unintentional screw loosening is unknown.

Screw loosening has traditionally ening have varied and include inad- devices (MTLDs) are used in implant
been a reported complication associ- equate torque delivery,5,6 embedment dentistry to precisely set the fastening
ated with implant prosthodontics.1-4 relaxation,6-8 and metal fatigue.9 Pre- force to the abutment screw. Manu-
Causes for unintentional screw loos- calibrated mechanical torque limiting facturers recommend the use of pre-

Presented at the American Academy of Fixed Prosthodontics Annual Scientific Session table clinics, Chicago, Ill, February 2008.

a
Graduate student, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry.
b
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry.
c
Assistant Professor, Division of Biostatistics, School of Public Health.
d
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry.

The Journal of Prosthetic Dentistry Vallee et al

August 2008
calibrated MTLDs to ensure adequate
torque delivery, thereby reducing un-
intentional screw loosening in the fu-
ture.8,10-12
A screw joint is a unit comprised
of 2 parts tightened together by a
screw.10 Applied torque is distributed
to the screw joint through friction
between the screw head and pros-
thetic abutment, friction between the
threads on the screw and the internal
threads of the implant, and tension
within the screw known as preload.13
Preload is the initial tension in the
screw; it places the abutment-implant
assembly under compression, thereby
keeping the joint closed and protect-
ing it from external forces.6,8-10,14 Maxi-
mizing preload without exceeding the
yield strength of the screw stabilizes
the screw joint and offers protection
against screw loosening.6,12,13,15-17
Hand, mechanical, and electronic
torque drivers are available in implant
prosthodontics to apply torque to the
screw joint. Although hand drivers are
easy to use, have great tactile sensitiv-
ity, and are most commonly used to
initiate the tightening process, they
are limited in the amount and con-
sistency of torque that can be pro-
duced.18-20 When second-year dental
students were asked to apply a maxi-
mum controlled force using a hand
driver, the mean torque obtained was
11.55 Ncm.19 Although experienced
operators may be able to generate
more torque than the recommended
amount, the values are not consis-
tent, and errors may be expected.20
The wide variation in the ability of
clinicians to perceive appropriate
torque application was demonstrated
with oral and maxillofacial surgeons
ranging from 23% to 48% below and
prosthodontists within 15% of the
targeted value.18
A hand driver is not recommended
for final screw tightening21 because
it is difficult to generate more than
20 Ncm of torque, and because it
results in inadequate preload to the
implant screw joint.10 Calibrated
MTLDs are considered mandatory if
proper torque application is expect-
Vallee et al
ed.18 MTLDs may be a solution to ef-
fectively and consistently tighten im-
plant components to specific target
torque values by eliminating operator
variability.18,20 Two studies have vali-
dated MTLDs in delivering consistent
torque, but a change in output may
be expected after continued clinical
use22 or sterilization.5 Other authors
have shown MTLDs to be inaccurate
by as much as 455% higher than the
targeted value, due to the corrosion
of the components, and have recom-
mended annual recalibration.23
Electronic torque controllers, typi-
cally in the form of a latch-type dental
handpiece, are also available to deliv-
er specific desired torque. The driver
is held in the latch of the handpiece
that is designed to release at a tar-
get torque. Although 1 study found
no significant difference between the
mean torque values of new electronic
units and those with several years of
clinical service,24 others have demon-
strated variations in their torque ac-
curacy.11,25 Torque levels were consid-
ered unpredictable, with errors from
1% to 165% away from the target
value in 1 study,25 and errors as large
as those found with torque applied by
hand drivers in another.11 To ensure
optimal output, electronic torque
controllers should also be recalibrat-
ed regularly.21
MTLDs are available either as
friction style or spring style. The fric-
tion-style MTLD is a hex wrench with
a handle-release mechanism preset
by the manufacturer. With a driver
inserted into the wrench, a force is
applied to the screw until the handle
releases at the target torque level and
stops the torque application. The
spring-style MTLD is a ratchet-type
torque wrench with no release mech-
anism. Target torque levels are pre-
marked on the scale and the operator
applies a force to the spring until the
desired torque is achieved visually.11
No research was found comparing the
accuracy between friction-style and
spring-style MTLDs.
The purpose of this study was to
determine the accuracy of friction-
87
style and spring-style MTLDs in de-
livering the target torque values. The
null hypothesis was that there would
be no significant difference in the ac-
curacy of MTLDs that use friction-
style components and those that use
spring-style components in achieving
their target torque values.
Material and methods
MTLDs from 6 different implant
manufacturers were selected to de-
termine their accuracy relative to
their target torque values (Table I).
All MTLDs were new; 3 types were
of the friction style, while 3 were of
the spring style (Fig. 1). Five speci-
mens of each torque wrench and their
respective drivers were tested for a
total specimen size of 30 MTLDs. A
power analysis was performed for
a repeated-measures ANOVA using
the fpower macro in statistical soft-
ware (SAS Version 8; SAS Institute,
Inc, Cary, NC). The power to detect
a difference among 6 manufacturers
with a sample size of 30 MTLDs was
more than 80% for a small value of
1.0 for delta ((largest mean small-
est mean)/sigma). Each manufac-
turer was given an abbreviation and
each torque wrench was randomly as-
signed a number from 1 to 5 and then
labeled accordingly. The sequence for
testing the specimens was random-
ized using a spreadsheet formula (Ex-
cel, Microsoft Office 2003; Microsoft
Corp, Redmond, Wash).
To measure the output of each
MTLD, a digital torque gauge (Cha-
tillon DTG-12; Ametek, Largo, Fla)
was used. The digital torque gauge
was calibrated by the manufacturer
to be accurate within 0.5% of the
full scale. The driver for each respec-
tive MTLD was clamped in a 3-jaw
chuck of the digital torque gauge (Fig.
2). The torque wrench was connected
to the driver, and the torque indicator
on the gauge was set to zero. One op-
erator held the digital torque gauge in
one hand and applied the necessary
force to the torque wrench with the
other hand. Care was taken to ensure
88 Volume 100 Issue 2
the driver was collinear with the digi-
tal torque gauge and perpendicular to
the torque wrench during torque ap- Table I. Mechanical torque limiting devices tested
plication.
Force was applied to the MTLD Lot Target Torque
until either the friction style released Manufacturer Number Value (Ncm)
at a precalibrated torque value (Fig.
3) or the spring style flexed to a pre- Friction Style
calibrated limit (Fig. 4). For each trial, Astra Tech (A), Waltham, Mass 612500 25
the peak torque value registered by Lifecore Biomedical (L), Chaska, Minn 014233 30
the digital torque gauge was recorded Zimmer Dental (Z), Carlsbad, Calif IL539 30
while the operator was blinded from
the values. The procedure was repeat-
Spring Style
ed 50 times for each MTLD. All torque
Biomet 3i (3i), Palm Beach Gardens, Fla 645756 35
applications and readings were per-
formed by the same operators. Nobel Biocare USA (NB), Yorba Linda, Calif 54529 35
Statistical analyses were conduct- Straumann USA (S), Andover, Mass E3425 35
ed using statistical software (SAS
Version 8; SAS Institute). The MIXED
procedure in the statistical program
with the restricted maximum likeli-
hood estimation method was used to
perform a repeated-measures analysis
of variance (ANOVA) on this dataset
with a type I error rate () of 5%. In
the repeated-measures ANOVA, each
MTLD was assumed to have a dif-
ferent error variance and the MTLDs
were assumed to be independent. A
repeated-measures ANOVA was first
performed with the wrench style (fric-
tion versus spring) as the predictor,
while the dependent variables were 1 Mechanical torque limiting devices tested. Top left, Astra Tech. Middle
the absolute difference (ABSDIFF) be- left, Lifecore Biomedical. Bottom left, Zimmer Dental. Top right, Biomet
tween the measured torque value and 3i. Middle right, Nobel Biocare USA. Bottom right, Straumann USA.
the targeted torque value and the per-
centage deviation (PERDEV= [ABS-
DIFF/target torque] x 100) of the mea-
sured torque value from the targeted
torque value. The ABSDIFF is the dif-
ference in Ncm taken without regard
to the sign between the measured
torque value and the targeted torque
value. The PERDEV is the difference in
percent taken without regard to the
sign between the measured torque
value and the targeted torque value.
The mean and the standard error (the
estimated standard deviation) were
calculated for both the ASBDIFF and
2 Driver clamped in 3-jaw chuck of digital torque gauge.
the PERDEV. For each of the wrench
styles, a repeated-measures ANOVA
was performed to assess the differ-
ence in accuracy among the 3 manu-
facturers.
The Journal of Prosthetic Dentistry Vallee et al
August 2008 89

3 Friction-style mechanical torque limiting devices. Top 4 Spring-style mechanical torque limiting devices. Top
represents neutral position. Bottom displayed releasing at represents neutral position. Bottom displayed flexing to
precalibrated torque value. precalibrated limit.

Table II. Repeated-measures analysis of variance

Numerator Denominator F P F P
Effect df df (ABSDIFF) (ABSDIFF) (PERDEV) (PERDEV)

Wrench Style 1 28 2432 <.001 2118 <.001

Friction Style 2 12 48 <.001 120 <.001

Spring Style 2 12 55 <.001 55 <.001

Table III. Summary statistics for 2 accuracy measures for 2 different wrench styles
Mean Standard Error Mean Standard Error
Wrench ABSDIFF ABSDIFF PERDEV PERDEV
Style (Ncm) (Ncm) (Percent) (Percent)

Friction Style 3.83 0.06 13.74 0.25

Spring Style 0.82 0.02 2.36 0.05

Results
Table II summarizes the results
from the repeated-measures ANOVA
with the wrench style as the predictor
variable. The wrench styles were sig-
nificantly different (P<.001) for both
accuracy measures (ABSDIFF and
PERDEV). The model with different
error variances for the MTLDs was a
significantly better fit to the dataset
as compared to assuming the same
error variance for all MTLDs, which
indicated that the error variances for
the MTLDs were significantly different
Vallee et al
from each other. Table II also shows
that for both friction-style MTLDs
and spring-style MTLDs, the prod-
ucts of different manufacturers were
significantly different from each other
(P<.001) for both accuracy mea-
sures.
Table III represents the summary
statistics for the 2 different accuracy
measures (ABSDIFF and PERDEV) at
the wrench style level. According to
Table III, the overall mean for both
variables ABSDIFF and PERDEV was
higher for the friction-style MTLDs
than for the spring-style MTLDs. This
implies that, on average, the friction-
style devices showed higher deviation
from the targeted torque value as
compared with the spring-style de-
vices. This difference was significant
(P<.001) (Table II). The standard
error column reflects the variabil-
ity among the MTLDs within each
wrench style in terms of their devia-
tion from the targeted torque value.
The overall variability was again lower
for the spring-style MTLDs.
Table IV represents the summary
statistics for the 2 different accuracy
measures (ABSDIFF and PERDEV) at
90 Volume 100 Issue 2

Table IV. Summary statistics for 2 accuracy measures for 6 different manufacturers
Mean Standard Error Mean Standard Error
ABSDIFF ABSDIFF PERDEV PERDEV
Manufacturer (Ncm) (Ncm) (Percent) (Percent)

Friction Style
Astra Tech 4.40 0.09 17.59 0.37
Lifecore Biomedical 3.23 0.11 10.77 0.42
Zimmer Dental 3.86 0.13 12.87 0.48

Spring Style
Biomet 3i 0.88 0.04 2.53 0.10
Nobel Biocare USA 0.59 0.02 1.70 0.08
Straumann USA 1.00 0.03 2.84 0.09

Table V. Post-hoc tests among 3 manufacturers within each wrench style

t Value t Value
Effect Manufacturers df (ABSDIFF) (PERDEV) P

Friction-style MTLDs AL 12 9.45 14.76 <.001

Friction-style MTLDs AZ 12 6.06 11.17 <.001
Friction-style MTLDs LZ 12 2.23 2.23 .046

Spring-style MTLDs 3i NB 12 8.54 8.54 <.001

Spring-style MTLDs 3i S 12 0.41 0.41 .687
Spring-style MTLDs NB S 12 8.61 8.61 <.001

the manufacturer level. Three manu-
facturers were considered within each
wrench style. According to Table IV,
Nobel Biocare products showed the
lowest average deviation from the
targeted torque value, whereas As-
tra Tech products had the highest
average deviation from the targeted
torque value. The standard error col-
umn of Table IV shows that the spring-
style MTLDs had similar variability in
terms of the deviation from the tar-
geted torque value and the variability
was generally lower than the friction-
style MTLDs. The low standard errors
reported reflect the minimal variation
from the mean between the repeti-
tions of a particular manufacturers
products. No apparent trend in the
variation of the torque delivered after
50 repetitions was found.
The Journal of Prosthetic Dentistry
Table V represents a pairwise
comparison for the friction-style and
spring-style MTLDs for both accuracy
measures. In order to correct for mul-
tiple testing using Bonferroni correc-
tion, P values were compared against
the significance threshold (.02). Ac-
cording to Table V, Astra Tech MTLDs
were significantly different from the
friction-style wrenches of the other 2
manufacturers. Nobel Biocare MTLDs
were statistically different from the
spring-style wrenches of the other 2
manufacturers.
Discussion
The data support rejection of the
null hypothesis, as there was a sta-
tistically significant difference in the
accuracy of MTLDs that use friction-
style components and those that use
spring-style components in achieving
their target torque values (P<.001).
An interesting finding for the friction-
style MTLD was that all of the record-
ed torque values were lower than the
target torque, while the values for the
spring style varied from slightly below
to slightly above the target torque.
Even though the friction-style MTLDs
were, on average, 3.83 Ncm lower
than the target torque value, they were
consistent, as the standard error was
low relative to the mean. Whether or
not underdelivery of the target torque
by 3.83 Ncm combined with embed-
ment relaxation6-8 or function13 would
increase the chance of screw loosening
in the long term is unknown. Further
study on this issue using an artificial
oral environment with the capability
Vallee et al
August 2008
to perform several years of simulated
function is warranted.
Statistical differences were also
found among the products of differ-
ent manufacturers within both wrench
styles (P<.001). The Nobel Biocare
MTLD was the most accurate spring-
style wrench, while Lifecore Biomedi-
cal and Zimmer Dental friction-style
MTLDs were comparable (P=.046),
but more accurate than Astra Tech
friction-style MTLDs (P<.001). The
accuracy of MTLDs is dependent not
only on the wrench style, but also on
the manufacturer. Since the manufac-
turers have different target torque val-
ues for their products, ranging from
25 to 35 Ncm, the results are reported
as both an absolute difference and a
percent deviation between the mea-
sured torque value and the targeted
torque value. An absolute difference
of 4 Ncm for a 25-Ncm MTLD would
have a larger impact reported as a
percent deviation (16%) than an ab-
solute difference of 4 Ncm for a 35-
Ncm MTLD reported as a percent de-
viation (11.4%).
Since there is wide variation in
the ability of clinicians to deliver
manufacturer-recommended torque
tightening levels through hand driv-
ers, calibrated torquing devices are
neccessary to ensure consistency in
tightening implant components.12,18-
20
MTLDs are available to eliminate
operator variability due to clinical
experience while delivering a spe-
cific target torque value.18 Although
clinical use of these devices is rec-
ommended, studies have shown that
they may produce substantial error in
torque delivery after being in clinical
service for several years.23,25 Electronic
torque controllers, in addition to be-
ing more expensive and cumbersome
than MTLDs, have also been shown
to exhibit substantial variation in de-
livering the target torque value.11,25
One of the limitations of this in
vitro study was that the MTLDs were
new and had not been exposed to clin-
ical or sterilization procedures. Fric-
tion-style MTLDs have been shown to
deliver substantial error after clinical
Vallee et al
use due to corrosion through auto-
claving.23 Excessive torque delivery
may cause the screw to go beyond
its yield strength, thereby affecting
the stability of the screw joint.21 To
reduce any potential for inaccurate
torque application, clinicians should
use an MTLD that is recalibrated an-
nually.20,21,23 Another limitation of
this study is the error introduced by
the digital torque gauge. With a cali-
bration accuracy of 0.5%, an error
of 0.15 Ncm could be expected on a
30-Ncm measurement; however, this
error is low and would have been the
same for all wrenches.
Although the friction-style MTLDs
were not as accurate as the spring
style, the use of an MTLD is still rec-
ommended due to the inconsistencies
in hand tightening.18 Until a clinically
acceptable safety zone around the
target torque is established, manufac-
turers of friction-style MTLDs should
improve their torque delivery system
to reach the target value. At the same
time, guidelines for recalibration of
MTLDs should be developed by the
manufacturer and provided to the
clinician to avoid the possibility of
excessive torque delivery and subse-
quent screw fracture.
Conclusions
This study evaluated the accu-
racy of friction-style and spring-style
MTLDs in delivering the target torque
values. Within the limitations of this
study, MTLDs that use spring-style
components are significantly more ac-
curate in achieving the target torque
values than those that use friction-
style components.
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Volume 100 Issue 2
trollers following time in clinical service. Int Acknowledgements
J Oral Maxillofac Implants 2001;16:394-9. The authors thank Astra Tech (Waltham,
25.Standlee JP, Caputo AA. Accuracy of an Mass), Biomet 3i (Palm Beach Gardens,
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Int J Oral Maxillofac Implants 1999;14:278- Straumann USA (Andover, Mass), and Zimmer
81. Dental (Carlsbad, Calif ), for donating implant
MTLDs used for this study.
Dr Heather J. Conrad Copyright 2008 by the Editorial Council for
Division of Prosthodontics, Department of The Journal of Prosthetic Dentistry.
Restorative Sciences
University of Minnesota, School of Dentistry
9-450a Moos Tower
515 Delaware St SE
Minneapolis, MN 55455
Fax: 612-626-1496
E-mail: conr0094@umn.edu

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The Journal of Prosthetic Dentistry Vallee et al