How Do I Assess Primary Stability?

Hi, There are several parameters to consider prior to immediately temporizing a dental implant in a fresh extraction socket. First of all, primary stability is a purely mechanical phenomenon, which is usually assessed with your torque control system of choice. You do not need RFA equipment for that (this will measure the osseointegration, which will not be the case for a while). You do not want to engage too much of the apical bone beyond the socket so that the platform of the implant is too far apically with respect to the CEJ level and interproximal contact points of the adjacent teeth. (papilla maintenance). Therefore you may want to choose an implant that can take advantage of some lateral compression of the socket walls in addition to engaging the apical bone. Lastly, one needs to consider the coronal gap between the implant surface and the socket wall and whether grafting is indicated and if this could negatively impact the success rate of your immediately temporized implant. Also, check out the NobelActive line of implants, which are more or less designed for this purpose (they do carry a high price tag though).

I thought that the Nobel active is a compression implant and should be used in soft bone situations? What is the patients bone quality in the anterior maxilla? If it's type 1-2, I would stay away from the Active. I do like the aggresive thread design of the Active implant, but I prefer an aggesive design that is self tapping AND can be torqued down at 50 ncm at time of placement. I use my hand-piece to go down half-way, then rachet the rest down. Hand-racheting provides a higher torque value than what a hand-piece can provide, which I've noticed offers higher stability. The higher the torque value = greater stability. 30-35 in my opinion is too low for immediates. I don't want to sound bias in which implant to choose, but check out the major companies and you may find one you like.

To Robert Gougaloff and Dr. R - Resonance frequency does not measure osseointegration. It measures Bone to implant contact. You can assume Osseointegration is taking place as your reading increases...but really Osseointegration is increasing bone to implant contact. Think of it like a tuning fork. You can absolutely use the "osstell" unit to get a "reading" at the time of placement. The point is that there doesnt need to be osseointegration to use Resonance frequency analysis. This unit is quite accurate and will let you know how solid your implant is in a SLIGHTLY more scientific manner. keep in mind this is not an absolute end all be all. There are studies that show a direct correlation to RFQ, and torque values measured with wrenches and other means. Also in regard to Nobel Active...the implant is very technique sensitive, and the data that is out there is not all that positive. ie..more bone loss than replace. The nobel active will go where you tell it to. Not where your ossteotomy was carefully placed. User beware....not saying its a bad implant...just be careful of the marketing machine.

I almost forgot to answer the 2nd part of your question....... You can get an Osstell Mentor from Neoss. Do a google search to find a phone number. They have a good implant system as well including some interesting Peek temporary abutments that I've taken a liking to. As far as primary stability....usually manufacturers suggest 30-35NCM to provisionalise an implant, but thats probably the most simple factor when deciding when to temporize. Do some google searches and you'll find a ton of info.

I do agree with Dr. Awsome: The NobelActive is a tricky implant to place and all things being equal, I would also prefer other implants because the NobelActive line does not really offer the greatest temp abutments. To Dr. Awsome: thanks for clarifying the RFQ issue.

Highest implant stability occurs when a tapered implant is placed into a tapered drill hole aka.the Nobel Replace Tapered Implant because the compression occurs and increases progressively at the apex as the implant wedges into the tapered osteotomy. On the other hand, if you use a tapered implant placed into a straight osteotomy, aka. Nobel Straight or Speedy, it will bind or compress predominantly in the crestal region which in a funnel extraction socket will not give you very much compression fixation. All implants of course will compress bone in an undersized osteotomy but the more surface area contact of the body of the implant with bone surface the better will be the fixation. Nobel Active implants in spite of their promotion as a compression implant really is not the best for bone compression unless the osteotomy is greatly undersized. If not significantly undersized the aggressive fin-type threads of the Active will cut nicely into the bone but the surrounding cancellous bone simply will reside in between the threads without being compressed very much. Different implant designs are necessary for different requirements. One design cannot do all things well. So while Nobel Replace Tapered excels in immediate extraction socket sites in the anterior Maxilla it contrarily is difficult to place in the mandibular symphisis where the bone is very dense. In this location straight walled implants are better suited and even then may need tapping.

If the torque is more than 35 ncm at the time of placement and the removal torque is also more than 35 ncm, you can do immidiate loading.

hi, i don,t know what you mean by the primary stabilisation more than 35 ncm,what do you need in a post exraction case?i think 30-35 ncm will be desirable and the result will be good for a temp.fixture and crown,specially if the gap bitween the coronal part of fixtur and bone cavity is filled by bone(from osteotomy site of cavity or sinthetic bone befor suturing

Caution with immediate loading of dental implants in anything less than type 1 bone, especially the pre-maxilla. High smile line?, How about bonding natural tooth with root cut off, provisonal or essix with tooth until adequate time for integration. If you lose the implant in the pre-maxilla it will be one of your worst days requiring removal of implant, follow on block grafting, 1 year later a crown and best of luck with soft tissue profiling. We are seeing a lot of science reverting back to very isolated cases of immediate loading. If you want some great guidance pick up Misch's surgical text book and look at the immediate loading section. Best of luck, Duke Aldridge, MAGD, MICOI

I am not in aggreement with immediate "loading" in anterior maxilla single-unit implant which are placed in the fresh socket. Too many risk factors! However, you can do immediate "restoration" in such cases (with no occlusal touch not in centric not in eccentric movements), if flipper cannot be placed for any reasonable cause. Our patients should know about the risk of implant loss after immediate restoration. I think we can satisfy our patients with explaining them the consequences. DO NOT RELY ON LOW-EVIDENCE AND COMMERTIAL RESEARCHES IN YOUR PRACTICE. Immediate loading is now suggested for mandibular overdentures (good bone quality and low occlusal forces) and multi-unit splinted mandibular implants (good bone quality and low risk of implant rotation)with high ISQ level (more than 60 ISQ) in implant insertion time. Good luck

I have been utilizing the benefits of the enhanced design of the 3i tapered implant for immediate load procedures for 2 years now with great success. It does not carry the pricetag of the NobelActive but does have aggressive threads which is fantastic for immediate load cases. My implant drill usually torques out at around 30ncm and I usually utilize the hand ratchet to finally seat the implant. I know there is a lot of bad press abpout the old design of the 3i tapered but I do have to say that the enhanced design is a huge step in the right direction.

I have been immediately placing implants and temporizing provisional in the anterior maxilla for the last three years with great successes. I do keep in mind few factors. 1. I always inform the patient of risks and possible complications. I let the patient decide whether he/she would like to wear a flipper after he/she was fully informed. I understand your desire to help the patients the best way possible, but sometimes it is best to have the patent decide these matters 2. It is my humble opinion that no matter which implant system you are using, if you can place an implant in an undersized osteotoy and obtain primary stabilization of 40 Ncm or more, most likely that that implant will integrate. Therefore I always choose an implant that can take advantage of some lateral compression of the entire socket walls in addition to engaging the coronal bone. (I spend some time making sure that the coronal part of the implant / implant platform is in contact with bone). I never leave a gap between the implant and the bone at the coronal site. If a gap is present, I bone graft it, and I give a flipper another consideration. 3. I make sure that my temporary is accurate on your temporary abutment, and that the patient can maintain good hygiene. Also I make sure that there is passive contact between the abutment / provisional and the gingival tissue. I have placed implant from most of the major manufactures and I had the same successes like some of the less expensive one. I instruct the patient not to directly bite on its anterior teeth for the healing period and I make sure that the tooth is off occlusion. Good luck

What about Dentsply's Ankylos Implant for these cases?

OSSTEM IMPLANT also distributes the Osstell Mentor and in my opinion has a much better implant line up than Neoss.

i completly agree n-moslemi , the willing or interest of the patiant is respectable but it must not lead you doing somthing wrong . be careful , be aware of commercial advises,just do base on scientific recommendations .

Hi First, primary stability is mandatory not only for provesional work but also for implant success. In my point of view, you can attaian primary stability through: 1- Atraumatic extraction 2- Using straight implants to assure engagement of the lateral walls of the socket 3- using a 3mm longer implant than the extracted root. Please discuss with me if any of you have better ideas

hi, I agree with Neda-moslemi, you should weigh the pros and cons very carefully while venturing into immediate temps....and by the way OSSEOINTEGRATION IS A HISTOLOGICAL FEATURE AND NOT A CLINICAL OBSERVATION.

I am in agreement with the above comments. Plan case prior to consultation with open communications in writting with patient. This should explain the expected result post surgery and final restoration. I leave a opening that treatment my very depending on what I find at the time of surgery. I have opened the maxillia and found the need to graft bone at poor sites not around socket spaces but defects in the buccal plate where immediate temporization would in my judgement put the outcome of the case in question. The patient will understand your concern for sucess better than why the case didn't turn out how THEY expected it to turn out. Be a little pesemistic in your outlook because cases will not always end up looking like the ones you see in the journals. As this reads like your first case along there lines be sure all the basics of immidate placement into extraction site are achieved and temporization is accomplished with no foreign substance at the surgical site. Stress good post operative carewith patient.The buccal plate my fracture upon tooth removal, then what? You need to have all forseeable problems thought out and the supplies chairside. It is easier to put membrane and tacks back than to eyeball a patient waiting for an assistant to run out looking for supplies to deal with a complication. How would you feel as that patient? Think it out, do the surgery on the study models, I write out all steps in a implant surgery, review them with staff, them post them in the opratory for the staff to help keep all moving smoothly. Patients will often comment on this surgical script and to date all comments have been favorable. Plan it out, communicate with patient, preform the surgery,and stress postcare. Happy New Years

I completly agree dr Walid and i would add something else: the lateral straigt engagement with the socket is very important, in fact i use a mono implant with progressive enlargement of the coils like certains shells. for me is too important the pre medication of the socket to obtain the best replay: i introduce in the socket cfristalline cephalospèorrine and betametasone and this metod i use from 30 years without any inconvenient and without any bloccage of osseous breeding. after few weeks or days i can already put a temporary crown out of occlusal load.,