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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:
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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
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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.
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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.
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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
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