In vitro evaluation of the influence of the cortical bone on the primary stability of two implant systems

E93 Med O al Pa ol O al Ci Bucal. 2009 Feb 1;14 (2):E93-7. The co ical bone on he p ima y s abili y o wo implan sys ems Jou nal sec ion: O al Su ge y Publica ion Types: Resea ch In i o e alua ion o he in luence o he co ical bone on he p ima y s abili y o wo implan sys ems Rod igo And és-Ga cía 1, Nu ia Ga cía Vi es 1, Fede ico He e o Climen 1, Ana Fe nández Palacín 2, Vi- cen e Ríos San os 3, Ma iano He e o Climen 3, Ped o Bullón 3 1 Mas e in Pe iodon ics and Implan Den is y 2 Full p o esso o S a is ics. Depa men o Socio-Heal h Sciences 3 Di ec o o Mas e o Pe iodon ics and Implan Den is y Facul y o Den is y; Uni e si y o Se ille (Spain) Co espondence: D . Rod igo And és Ga cía C/ Pablo Ga gallo, 35 C.P. 28035. Mad id and esga [email protected] Recei ed: 09/04/2008 Accep ed: 16/11/2008 And és-Ga cía R, Ga cía-Vi es N, He e o-Climen F, Fe nández-Pala- cín A, Ríos-San os V, He e o-Climen M, Bullón P. In i o e alua ion o he in luence o he co ical bone on he p ima y s abili y o wo im- plan sys ems. Med O al Pa ol O al Ci Bucal. 2009 Feb 1;14 (2):E93-7. h p://www.medicinao al.com/medo al ee01/ 14i2/medo al 14i2p93.pd Abs ac Aims: Immedia e loading has become a p edic able op ion o ea men , while one o he main equi emen s o i s implemen a ion is ob aining app op ia e p ima y s abili y in implan s. Wi h ha aim, conical implan s a e com- me cially a ailable, since, acco ding o specialized li e a u e, hey p o ide g ea e s abili y. One o he me hods o measu e implan s abili y which has e ol ed o u he s ages is esonance equency analysis (RFA). In he p esen pape we a emp o e alua e he in luence o he co ical bone on he p ima y s abili y o wo implan s o simila diame e and leng h. S udy design: 15 esh cow ibs we e selec ed and six di e en implan beds we e p epa ed in each. These p epa a- ions co esponded o wo di e en implan sys ems: A Swiss Plus om Zimme Den al® and an Mk IV om No- bel Bioca e®. Two d illing p o ocols we e used o so bone, ha d bone and bone wi hou co ical. A e p epa ing he beds, he implan s we e placed and implan p ima y s abili y was measu ed wi h he Oss ell® men o . Resul s: Highe ISQ (Implan S abili y Quo ien ) alues we e obse ed o bo h implan sys ems when he co ical bone is main ained han when i is elimina ed, he di e ence being s a is ically signi ican in he case o Mk IV implan s. Conclusions: The esul s om his s udy show he impo ance o p ese ing co ical bone du ing d illing in o de o ob ain g ea e p ima y s abili y. Key wo ds: P ima y s abili y, co ical bone, ISQ. A icle Numbe : 5123658806 h p://www.medicinao al.com/ © Medicina O al S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946 eMail: [email p o ec ed] Indexed in: -SCI EXPANDED -JOURNAL CITATION REPORTS -Index Medicus / MEDLINE / PubMed -EMBASE, Exce p a Medica -SCOPUS -Indice Médico Español E94 Med O al Pa ol O al Ci Bucal. 2009 Feb 1;14 (2):E93-7. The co ical bone on he p ima y s abili y o wo implan sys ems In oduc ion The p ocess o implan osseoin eg a ion in ol es a se ies o physiological p ocesses o bone eso p ion and appo- si ion, in which bone o ma ion a ound he implan akes place, allowing be e bone-implan join . In o de o make his p ocess ake place, i is necessa y o achie e app op ia e ini ial implan s abili y and con ol loadings ac ing on he implan wi h he aim o a oiding ailu e. Such s abili y is known as p ima y s abili y, is de ined as he implan ’s ini ial mechanical subjec ion a e placemen and is mainly de e mined by ini ial bone- implan con ac (1,2). P ima y s abili y is one o he mos impo an ac o s in he osseoin eg a ion p ocess, especially when immedia e loading has been planned (3-5). This s abili y depends on se e al ac o s which may be classi ied as: — Implan - ela ed ac o s: mo phology, leng h, diame e , kind o su ace o dis ance be ween spi es — Su gical p ocedu e- ela ed ac o s: inse ion echnique (non-homogeneous d illing, axiali y loss du ing d illing, e c.), cong uence be ween implan and bone p epa a ion, bico ical ancho age, e c. — Biological ac o s: bone quali y and quan i y, p esence o co ical bone (6,7) The impo ance o p ese ing he co ical bone du ing implan bed p epa a ion becomes especially impo an in egions o cancellous bone, such as he pos e io egion in he uppe jawbone. In hese si ua ions o so bone, he co ical bone will play an impo an ole o p o ide he implan wi h g ea e s abili y. This may be achie ed by placing he implan shoulde sligh ly jux aosseously o e en bu ying i com- ple ely. The inc ease o implan diame e in such egion seems o inc ease implan p ima y s abili y (8,9). S udies show ha co ical bone is up o 10 imes mo e igid han cancellous bone, hus explaining why implan leng h does no play a much ele an ole (10). The use o ana omical implan s —whe e implan diame- e is educed om co onal o apical— and implan s wi h wide pla o m allows be e implan se lemen on he co ical bone. Besides, sho e h ead helps compac can- cellous bone, hus inc easing he con ac be ween bone and implan , and he e o e also p ima y s abili y (11). Un il e y ecen ly, quan i a i e measu emen o p ima y s abili y was ca ied ou wi h in asi e me hods. Fo ins ance, wi h implan ac ion, in o de o ge o know i s emo al o que. This biome ical and des uc i e es is limi ed o in- i o s udies o animal models, since i is no sui able o clinical use (12). Wi hin he g oup o non-in asi e echniques, measu e- men o implan inse ion o que has been used, being —unlike he p e ious one— a clinical and one-s age me- hod. These alues ange be ween 5 and 50 N/cm, bu he o que necessa y o achie e app op ia e p ima y s abili y is no known wi h accu acy; howe e , i is hough ha such s abili y should be a leas 30 N/cm (13,14). Implan inse ion o que has been ela ed o bone mine al densi y, whe e alues lowe han 30 N/cm indica e low mine al densi y, while medium densi y anges be ween 30 and 40 N/cm and would be he s abili y necessa y o implan inse ion; o e 40 N/cm i would be conside ed as high bone mine al densi y (15,16). In he las decade, Me edi h (6) de eloped an easy, non- in asi e and ep oducible me hod o measu e implan s abili y which can be used immedia ely a e implan placemen and du ing he osseoin eg a ion p ocess, o e ing he possibili y o ge o know implan s abili y a any ime du ing he cica isa ion p ocess. This me hod is known as esonance equency analysis (RFA). This measu emen is ca ied ou wi h a machine connec ed h ough a speci ic ansduce o each model o implan , ob aining a nume ical alue known as implan s abili y quo ien (ISQ) whose ange oscilla es be ween 1 and 100 (17). Di e en Oss ell® models ha e been de eloped since he i s model, which appea ed a he end o he 90s; his i s model ope a ed elec ically and he ansduce connec ion was h ough a cable. The las model, ha which i is used nowadays, is magne ic and does no in ol e any cable (co dless). In he elec ical sys em, a piezoelec ic c ys al in he e ical po ion o he p obe is used o s imula e he complex ansduce -implan ; ano he piezoelec ic c ys al a he opposi e side o he p obe is used as ecep o o esponse impulse. In he new magne ic sys em he ansduce has a magne a he end which is s imula ed h ough a magne ic impulse om he wi eless p obe o a millisecond. A e exci ing he ansduce , he pin ib a es, hus emi ing elec ic ol age o he p obe bo ine. This ol age measu emen eaches he esonance equency analyse , which emi s an ISQ alue (18-21). The highe he ISQ alue is, he g ea e he implan an- cho age o bone will be. Specialized li e a u e desc ibes ISQ alues om 57 o 82 o co ec osseoin eg a ion wi h an a e age o 69 a e one yea o loading (22,23) and indica es which alues lowe han 40 in ol e high- isk si ua ions o he implan , while alues highe han 55 a e conside ed as a ou able. The alues ecommendable o immedia e loading a e s ill o be es ablished (24). Some esonance equency analyses demons a e ha implan s wi h app op ia e ini ial s abili y keep such s abili y om h ee o ou mon hs a e hei pu in o ope a ion, while implan s wi h low s abili y alues un- de go high ailu e isk a e he i s o second mon h o immedia e loading (25). Once we ha e analysed he impo ance o p ese ing he co ical bone du ing he d illing p ocess, he main aim o he p esen s udy is o asce ain p ima y s abili y achie ed by he di e en d illing p o ocols o e ed by wo implan sys ems in an animal model wi h ype II-III E95 Med O al Pa ol O al Ci Bucal. 2009 Feb 1;14 (2):E93-7. The co ical bone on he p ima y s abili y o wo implan sys ems bone quali y, p ese ing he co ical bone and elimina ing i subsequen ly. Ma e ial and Me hods We selec ed 15 esh cow ibs o simila ana omical cha- ac e is ics. Each ib was selec ed in di e en blocks in o de o ob ain homogeneous a eas o unde ake implan p epa a ion. All ibs we e ob ained om a bu che ’s shop and came om he same animal, a cow o a ound wo and a hal yea s o age. These ibs se ed as a model o human eden ulous jawbone due o hei mac oscopic composi- ion o co ical and medulla bone. The mos p oximal egion o he ib, o highe diame e , has a mino po ion o co ical bone and g ea e medulla p opo ion, being simila o a ype-III (o D3 o D4) quali y, espec i ely (26,27). Bea ing such p emise in mind, we did wi hou bo h ib ex emes wi h he aim o ob aining a II-III in e media e-quali y bone. Six implan beds we e p epa ed in each ib block, which co espond o he ollowing d illing p o ocols: a) S anda d d illing p o ocol ecommended by he ma- nu ac u e b) S anda d d illing p o ocol ecommended by he ma- nu ac u e and elimina ion o he co ical bone by using a coun e sink Each bed should ha e a leas a pe ime e o 5 millime es o bone a ound and an in e -implan dis ance o 7 milli- me es was main ained. Each p epa a ion was ca ied ou by ollowing he d illing p o ocol ecommended by he manu ac u e . Each ib block was i mly subjec ed o a able when ca ying ou p epa a ions and measu emen s. Loca ions we e andomly assigned by ossing a coin. P e- pa a ions co esponded o wo di e en implan sys ems: A conical Swiss Plus SPB o 3.7 x 10 mm (Zimme ® Den al) and an Mk IV o 4 x10 mm (Nobel Bioca e®). The d illing p o ocol ecommended by he manu ac- u e o he placemen o Swiss Plus implan s was he ollowing: a) The milling p ocess ecommended by he manu ac u e is composed o : — Ball-end milling cu e ; pilo milling cu e ; 2.3-mi- lling cu e ; 2.8-milling cu e ; and 3.4-milling cu e b) The milling p ocess ecommended by he manu ac u- e and elimina ion o co ical bone: — Ball-end milling cu e ; pilo milling cu e ; 2.3- milling cu e ; 2.8-milling cu e ; 3.4-milling cu e ; and coun e sink The milling p ocess ecommended by he manu ac- u e o he placemen o Mk IV implan s was he ollowing: a) The milling p ocess ecommended by he manu ac u e is composed o : — Ball-end milling cu e ; pilo milling cu e ; p o ile milling cu e ; 3.15-milling cu e ; and 3.35-milling cu e b) Milling p ocess ecommended by he manu ac u e and elimina ion o co ical bone: — Ball-end milling cu e ; pilo milling cu e ; p o ile milling cu e ; 3.15-milling cu e ; 3.35-milling cu e ; coun e sink A e comple ing he beds, each implan was placed un il he ough a ea was comple ely co e ed and he co es- ponding ansduce o each implan was also placed, igh ening hem by hand. Subsequen ly, we measu ed p ima y s abili y in each implan h ough he Oss ell® men o sys em, ob aining ou igu es o each implan . The p obe was always posi ioned wi h a 90º angle ega - ding he posi ion o he ansduce . O he ou measu es ob ained o each implan , only he highes alues we e used in he s udy. Resul s Once he alues o each milling sequence ha e been ob ained, we p oceeded o in oduce he da a ob ained in a da abase d awn up wi h MS Access so wa e (Mic oso O ice 2000 e sion; SR-1 Pen ium). Da a analysis was ca ied ou wi h SPSS 13.0 so wa e o MS-Windows. Fi s ly, we unde ook he Shapi o-Wilk es o check he no mali y o he di e ences. In case ha no mali y was ul illed, we unde ook T-s uden in no mal g oups o alua e he signi icance o he di e ences and he Wil- coxon es in non-no mal g oups. In case ha he Shapi o- es dis ibu ion is non-no mal, we unde ook F iedman’s non-pa ame ic es o a- lua e he signi icance o he di e ences. In case ha any signi icance was de ec ed, we esea ched whe e such disc epancies we e o be ound h ough he Holm- Bon e oni me hod. Such de ailed me hod was ca ied ou o esonance e- quency analysis o milling sequence g oup in each ype o implan , i s in an independen manne and subse- quen ly by compa ing he esul s o di e en implan s. The wo kinds o milling p o ocols (p epa a ions) es a- blished o each implan sys em a e he ollowing: a) Milling p ocess ecommended by he manu ac u e b) Milling p ocess ecommended by he manu ac u e and elimina ion o co ical bone ISQ alues ob ained in p epa a ions ca ied ou o Swiss Plus implan s anged om 65 o 78 (p o ocol a) and om 65 o 75 (p o ocol b). The ange o ISQ measu emen s o Mk IV implan was 65-75 (p epa a ion a) and 62-71 (p epa a ion b). The mean o ISQ alues ob ained ( oge he wi h s anda d de ia ions) o he Swiss Plus implan was 70.86 (±3.352) in p epa a ion a, and 68.40 (± 3.157) in p epa a ion b; lowe alues a e epo ed in p epa a ions in which he co ical bone had been elimina ed. E96 Med O al Pa ol O al Ci Bucal. 2009 Feb 1;14 (2):E93-7. The co ical bone on he p ima y s abili y o wo implan sys ems The mean o ISQ alues ob ained ( oge he wi h s anda d de ia ions) o he Mk IV implan was 70.00 (± 3.779) in p epa a ion a, and 66.60 (± 3.924) in p epa a ion b. Analysing he means o he di e ences (pai ed da a), i can be obse ed ha hey a e qui e close alues (di e- ences a e small). We obse ed s a is ically signi ican di e ences be ween s anda d p epa a ions o he Mk IV implan in ela ion o he cases in which he co ical bone had been elimina ed (p = 0.01). Howe e , he di e ences ound be ween he wo milling modali ies o he Swiss Plus implan we e no s a is ica- lly signi ican (p = 0.055). Table 1 shows he means o he esul s ob ained when compa ing bo h milling p ocesses ecommended by he manu ac u e and he same milling p ocess a e elimina ing he co ical bone, when compa ing bo h implan sys ems. In his case, no s a is ically signi ican di e ences we e ound. Discussion Acco ding o wha has been es ablished in o he expe i- men al pape s which used cow ibs as model o s udy, he mos dis al egion o he ib —which is o lowe diame e and con ains g ea e co ical bone and lowe p opo ion o medulla bone— would be simila o a ype-II bone, acco ding o he classi ica ion made by Leckholm & Za b (1985) (25) o o a D2 o D3 bone acco ding o he classi ica ion de eloped by Misch (1990) (26). The ac o ob aining so simila esul s may be due o simila i y in implan design, since bo h implan s a e o conical mo phology: hei diame e is e y simila , since ha o Swiss Plus is 3.7 mm and ha o Mk IV is 4 mm, hei leng h is also he same (10 mm) and p epa a ions we e ca ied ou andomly in a simila ib block. Lowe ISQ alues ha e been obse ed when he bone was ins umen ed o a g ea e le el; ha is, when he co ical bone was elimina ed, which coincides wi h he s a egy o di e en clinicians, who —in si ua ions o mo e abecu- la bone— do wi hou he las milling cu e s in o de o p ese e he co ical bone o a g ea e ex en , so ha i is he implan i sel which ends up p epa ing he bed. In spi e o no inding s a is ically signi ican di e en- ces in p epa a ions o he Swiss Plus implan , he le el o signi icance ob ained (p = 0.055) is close o wha is conside ed as op imum in heal h sciences li e a u e (p = 0.05). Encou aged by such inding and conside ing ha i may be he esul o a sample o educed size, we decided o calcula e he ideal sample size wi h he da a ob ained. Th ough he exp ession minimum sample o de ec di e ences o 2.4 uni s be ween he s anda d p epa a ion o he Swiss Plus implan and co ical p epa a ion, assuming an alpha e o o 0.05 and a con as powe o 80 % wi h a ypical de ia ion o he es ima ed di e ences (conside ing ou own s udy as a pilo s udy) o 4.6, we can conclude ha ideal sample size should be 31. Howe e , s a is ically signi ican di e ences we e ound in Mk IV implan (p = 0.01). On he o he hand, no s a- is ically signi ican di e ences we e ound ega ding p ima y s abili y ob ained o bo h sys ems. Ano he ac o o be bo ne in mind is ha ansduce igh ening o he co esponding implan s was ca ied ou manually, which may gi e ise o he al e a ion o some esul s. This is due o he inexis ence o a dynamome ic sys em o igh ening. Unlike he p e ious Oss ell® models, he cu en Oss ell® model is wi eless, which acili a es i s use and handling; howe e , when ob aining alues, one aces he p oblem ha —keeping he p obe pe pendicula o he ansduce — di e en alues a e ob ained acco ding o he posi ion on he ho izon al plane in which i s is placed. These di e ences in he alues ob ained a e explained by he manu ac u e as he alues o “highe ” o “lowe ” s abili y shown by he implan ; e ms no alued in li e- a u e. The e o e, we chose he highe alue ob ained in each ba ch o 4 lec u es, each o hem ca ied ou a 90º deg ees o sepa a ion be ween hem and ano he one on he ho izon al plane. We may conclude he p esen pape s a ing ha no s a- is ically signi ican di e ences be ween bo h implan s we e ound, p obably due o he exis ing simila i y be ween hem, and ha di e ences ega ding implan s abili y we e only o be ound when he co ical bone was elimina ed and when i was kep . Rela ed di e ences Sig. (bila e al) A e age alues Typical de ia ion 95 % Con idence in e al o he di e ence In e io Supe io Pai 1 So SP – So MK IV 0,86667 4,43793 -1,59098 3,32431 ,462 Pai 2 Co ical SP – Co ical MK IV 1,80000 5,53173 -1,26337 4,86337 ,228 Table 1. A e age alues and s anda d de ia ion a e compa ing p epa a ions o bone laye ollowing he ecommenda ions o he manu ac- u e and a e he elimina ion o he co ical bone, compa ing bo h implan sys ems. E97 Med O al Pa ol O al Ci Bucal. 2009 Feb 1;14 (2):E93-7. The co ical bone on he p ima y s abili y o wo implan sys ems Re e ences 1. He mann I, Lekholm U, Holm S, Kul je C. E alua ion o pa ien and implan cha ac e is ics as po en ial p ognos ic ac o s o o al implan ailu es. In J O al Maxillo ac Implan s. 2005;20:220-30. 2. Coch an DL, Buse D, Ten B uggenka e CM, Weinga D, Taylo TM, Be na d JP, e al. The use o educed healing imes on ITI implan s wi h a sandblas ed and acid-e ched (SLA) su ace: ea ly esul s om clinical ials on ITI SLA implan s. 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