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Correlation Between Placement Torque and

Survival of Single-Tooth Implants
Judith Maria Pinheiro Ottoni, MSc1/Zilda Fagundes Lima Oliveira, MSc2/Roberto Mansini, DDS, MS, PhD3/
Antonio Melo Cabral, PhD, MD, DDS4

Purpose: This study evaluated the survival parameters of single-tooth implants through clinical and
radiographic analysis. Materials and Methods: Implants were restored within a 24-hour period with a
provisional crown designed to receive an occlusal masticatory load. This approach was compared to
implants restored after a healing period (the control group). Forty-six implants were placed in 23
patients who were each treated with 2 Frialit-2 implants placed in sites between the second premolar
in the maxilla or mandible. The manufacturer’s recommended formal surgical procedure was followed,
and primary stability was standardized with a minimum insertion torque of 20 Ncm. The sites were
randomly selected, and the clinical and radiographic parameters were standardized with individual
templates. Results: Data were collected at 24 h, and at 1, 3, 6, 12, 18, and 24 months. The experi-
mental group included 10 failed implants; 9 of the failed implants had been placed with an insertion
torque of 20 Ncm. One implant from the control group failed during the 24-month follow-up period. The
survival rate was independent of implant length, site position, and bone quality and quantity. Relative
risk for implant failure was associated with insertion torque (relative risk 0.79 [CI: 0.66–0.930]; Cox
regression) (P
.007), in the experimental group but was not significant for those in the control group
(ie, implants placed after a healing period; relative risk 0.78 [CI: 0.34–1.78]; Cox regression) (P

.057). To achieve osseointegration, it was found that an insertion torque above 32 Ncm was necessary
(2= 15.68; P
.004). Discussion: A careful evaluation is necessary for a better understanding of the
survival rates of immediately loaded implants. In this study, insertion torque was associated with the
potential for risk, which can be decreased by 20% per 9.8 Ncm added. Conclusion: Given these
results, and considering the number of patients treated, immediate provisional crowns should only be
proposed with early loading if an appropriate initial insertion torque has been applied. INT J ORAL MAX-
ILLOFAC IMPLANTS 2005;20:769–776

Key words: immediate provisional crowns, insertion torque, masticatory loading, single-tooth implants

mprovement in the Brånemark1 technique stems

I from comprehensive surveys regarding alterations
in the surface and design of implants, as well as alter-
for the implant surgeon. To evaluate the possibility of
reducing the healing period while still achieving
osseointegration, researchers have investigated 3
ation of the surgical techniques used to place them. fundamental questions: (a) What is the best interface
Satisfying patient expectations remains a challenge between artificial material and living tissue? (b) What
material will provide the best tissue response? and
(c) What is the most advantageous time for implant
placement?
Because of the chemical similarity of the titanium
1Professor of Periodontology, Brazilian Association of Odontology, surface composition, differences in cellular modula-
Vitória, Espirito Santo, Brazil. tion will influence alterations in the implant surface
2Professor of Dental Radiology, Dental School, FAESA, Vitória,
topography. One study suggested that surface
Espirito Santo, Brazil.
3Head, Graduate Radiology Course, Brazilian Dental Association, roughness was responsible for an increase in the
Espirito Santo, Brazil. level of osteoblastic activity in vivo,2 thus supporting
4Professor of Pharmacology, Therapeutics, and Anesthesiology, research findings that have suggested surface
Dental School, FAESA, Vitória, Espirito Santo, Brazil. roughness enables early bone apposition.1,3–5
Biomechanical analysis and histomorphometric
Correspondence to: Dr Judith Ottoni, Av. Américo Buaiz, no. 501,
Salas 907/909, Torre Leste, Ed. Victória Office Tower, Enseada
assessment of placement and removal torque have
do Suá, CEP: 29050-911, Vitória, Espirito Santo, Brazil. Fax: + 55 confirmed a positive correlation between implant
27 33456444. E-mail: [email protected] surface roughness and bone adherence.3–6 Several

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Ottoni et al

studies have proposed analysis of the interference of at an 18-month follow-up.22 In a prospective multi-
mechanical stress during the initial healing phase center study assessment, Cooper and colleagues23
and its alteration of the tissue present at the bone- evaluated premature placement in function of single
implant interface.1,3,4 Corso and associates7 evalu- free-standing implants in the maxilla and assessed
ated whether implant surfaces played a role in changes in hard and soft peri-implant tissues. The
achieving primary stability when single-tooth cumulative survival rate was 96.2%, independent of
implants were immediately loaded with masticatory implant length, position in the arch, or the quality
forces. They found that there were no alterations of and quantity of bone. They reported that of the 100
crestal bone level when 4 groups of implants with involved papillae analyzed, 74 demonstrated positive
different surfaces were compared. Thus, they con- measures, 8 showed no alteration, and 18 demon-
cluded that no significant effect on treatment could strated negative measures.
be attributed to the surface type. The clinical survival of immediately loaded single-
Immediate implant placement at the time of tooth implants placed in fresh extraction sites was
tooth extraction was the concept of Tübingen compared to that of immediately loaded single-tooth
ceramic implants in the mid-1970s.8 Stable soft- and implants placed in healed sites in 26 patients in
hard-tissue levels could be obtained by placing root- whom 28 implants were placed and immediately
shape implants, especially for single-tooth replace- restored with provisional crowns. 24 Nineteen
ment.9 A period of 3 to 6 months’ healing with no implants were placed in fresh extraction sites and 9
loading was developed using what could be consid- implants (the control group) were placed in healed
ered an empirical approach. The existing dispute in sites. The cumulative survival rates were 82.4% and
the understanding of this matter is complex because 100% for the fresh extraction and healed sites,
experiments and protocols have used different respectively. The follow-up period ranged from 6 to
implant designs, prostheses, and timetables for the 24 months, with an average of 13 months for the
initiation of implant function. Studies developed to fresh extraction sites and 16.4 months for the healed
assess immediately loaded implants in the mandible group.
with restorations having cross-arch stabilization have Based on findings in the related literature, the pur-
shown good treatment results, since micromove- pose of this investigation was to evaluate the sur-
ment is inhibited.10–19 vival parameters of single restored implants with
Wohrle20 obtained 100% clinical and radiographic immediate provisional crown placement and masti-
success in 14 patients treated with single implants catory loading compared to those of implants placed
placed immediately following tooth extraction. All according to a protocol that included an initial 3- to
implants were placed with a minimum torque of 45 6-month healing phase before prosthesis fabrication
Ncm and subsequently restored with a provisional and loading. Assessment included the analysis of
crown placed immediately after surger y. In a accumulated survival, peri-implant health, clinical,
prospective multicenter study that included 10 pri- and radiographic parameters.
vate clinics and 155 patients, 429 Osseotite implants
were placed (3i Implants Innovations, Palm Beach
Gardens, FL) in a single-staged surgical approach and MATERIALS AND METHODS
loaded after 2 months. 21 Single-tooth provisional
restorations, fixed prostheses, and overdentures were In 1999, 1,500 patients with missing teeth were
among the immediate implant restorations investi- examined. Only 23 patients fulfilled inclusion and
gated and followed for 10 to 13 months. Of the 429 exclusion criteria. To be included, patients had to
implants, 83 were single-tooth implants. The cumula- report a condition of good health and had to be
tive survival rate was 99.5% at 10.5 months and missing 2 teeth from the anterior maxilla or
98.5% at 12.6 months. Such preliminary results have mandible, between the left and right second premo-
led the present authors to believe that such a proto- lars. The implant sites were analyzed by panoramic
col can be successful.21 radiographs and tomograms and subsequently clas-
Another study involved 22 patients, 14 of whom sified with regard to bone quantity and quality fol-
received single-tooth implants restored within 24 lowing Lekholm and Zarb25 criteria. To be included in
hours, with provisional crowns relieved in centric and the study, the sites had to be able to suppor t
lateral occlusal contacts. Eight patients treated with implants 3.8 to 4.5 mm in diameter and 10 to 15 mm
the conventional protocol served as a control in length. Smokers, diabetics, patients with degenera-
group.22 The survival rate was 85% in the experimen- tive diseases, those who presented with oral pathol-
tal group. Average marginal bone loss around the ogy or had missing molars, those who were not
implants was similar for the 2 groups, around 0.1 mm properly orally rehabilitated, psychologically unsta-

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Ottoni et al

A = Pocket probing 100

depth 90
B = Relative probing 80
attachment 70

Survival (%)
level
60
B–A = Gingival
margin 50
40
30
A
20 Control group
B 10 Experimental group
0
0 5 10 15 20 25 30
Follow-up (mo)

Fig 1 Individual guide used to register pocket probing depth, Fig 2 Comparison of survival probability (cumulative survival
relative probing attachment level, and gingival margin. Illustration rates) for the experimental and control groups (Kaplan-Meier
adapted with permission from Friadent, Mannheim, Germany. analysis). P = .001 (log-rank test).

ble individuals, bruxers, and patients medicated with while the positive values indicate an increase in
substances that might affect surgical site healing depth. Negative RPAL values reflect a gain of attach-
were also excluded. ment level, whereas the positive values reflect a loss
Nine male and 14 female patients with ages rang- of attachment level. These parameters were calcu-
ing from 18 to 60 years, median age 35.4 ± 9.1 years, lated for the experimental and control groups. The
were selected. Each patient received a single Frialit-2 gingival margin position was defined in this study as
implant (Friadent, Mannheim, Germany) with an being the difference between the RPAL and PPD
immediate provisional crown made of Protec (Fri- measurements for the control and experimental
adent) and a control implant. The control implants groups (ie, the differences between the sixth month
were restored using a delayed approach. Implant and the first month measurements). Negative values
placement and primary stability were standardized indicated a gain in tissue volume while the positive
as mandated by protocol and placed with a mini- values indicated recession. All patients consented in
mum placement torque of 20 Ncm. The immediate writing to participate in this investigation.
provisional crown was relieved by 1.5 mm on the
occlusal and 1 mm at the incisal and was free of con- Statistical Methods
tact from centric occlusion and lateral movements. The survival time of implants was estimated for both
Individual templates were fabricated for obtaining groups using the Kaplan-Meier curve. The McNemar
periapical radiographs immediately after surgery, at test was applied for paired groups to identify similar-
24 h and 1, 3, 6, 12, 18, and 24 months postsurgery. ities among them. Chi-square tests were used to
Standardized radiographs were processed using an measure the significant statistical correlation with
automatic film processor (AT-2000 Air Technes; the survival or failure in the experimental group, and
Kodak-Ektaspeed Plus; Eastman Kodak, Rochester, Cox regression coefficients were used to determine
NY) with an indirect digital system. Digital images the relative risk between study variables such as
were analyzed by a quantitative method obtained implant diameter, implant length, site, insertion
from INC Software (Schick Technologies, Long Island, torque, and bone quality and quantity for the control
NY ). Radiographic analyses evaluating bone loss and experimental groups.
were obtained using a reference point at the top of
the mesial and distal aspects of the implant at the
cortical bone level. For analysis of the clinical para- RESULTS
meters, the Gingival Index, Plaque Index, and Papilla
Index26 were used with individual guides to register Nine male patients and 14 female patients (39.1%
probing depth and relative attachment level (Fig 1). and 60.9%, respectively) were included in this
The changes in pocket probing depth (PPD) and rela- research, with a mean patient age of 35.4 ± 9.1 years.
tive probing attachment level (RPAL) in the experi- Two experimental sites that initially failed were
mental and control groups were obtained by sub- retreated with the same surgical procedure after 1
tracting the measurements made at the sixth month year of healing but were not included in the analysis.
and the first month postoperatively. Negative PPD The follow-up took between 6 and 24 months. Figure
values were used to indicate a decrease in depth, 2 shows the life table analysis of survival and failure

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Table 1 Absolute (n) and Relative (%) Frequencies of Parameters Related to

Survival and Failure in the Experimental Group
Survival Failure
Variable n % n % 2 P

Age (y)
10–20 — — 1 10.0 6.0 .1988
20–30 5 38.5 1 10.0
30–40 2 15.4 7 70.0
40–50 4 30.7 1 10.0
50–60 2 15.4 — —
Total 13 100.0 10 100.0
Diameter (mm)
3.8 12 92.3 9 90.0 — > .99
4.5 1 7.7 1 10.0
Total 13 100.0 10 100.0
Length (mm)
10 — — 1 10.0 2.17 .5369
11 3 23.0 1 10.0
13 5 38.5 2 20.0
15 5 38.5 6 60.00
Total 13 100.0 10 100.0
Site
8 2 15.4 — — 10.48 .2331
7 — — 1 10.0
5 4 30.8 — —
4 2 15.4 1 10.0
9 — — 1 10.0
11 — — 1 10.0
12 3 23.0 5 50.0
13 — — 1 10.0
24 1 7.7 — —
20 1 7.7 — —
Total 13 100.0 10 100.0
Insertion torque (Ncm)
20 1 7.7 9 90.0 15.68 .0004
32 9 69.2 1 10.0
45 3 23.1 — —
Total 13 100.0 10 100.0
Bone quantity
A 5 38.5 2 20.0 — .3452
B 8 61.5 8 80.0
Total 13 100.0 10 100.0
Bone quality
1 3 23.1 — — 4.54 .1033
2 9 69.2 7 70.0
3 1 7.7 3 30.0
Total 13 100.0 10 100.0

for the control and experimental groups. One implant parameters related to the sites and implants. The chi
restored according to the delayed placement proto- square test measured signficant differences in the sur-
col failed after 9.0 months. vival and failure rates for various factors in the experi-
With regard to potential risk factors such as mental group (Table 1). A significant correlation was
implant diameter (P > .99), length (P = 0.774), site found in regard to insertion torque (2 = 15.68; P =
(P > .99), insertion torque (P = 0.388), bone quantity .004).There were 10 failures in the experimental group;
(P > .99), and bone quality (P > .99), the treatment 9 of the failed implants had been placed with an inser-
and control groups were compared using the McNe- tion torque of 20 Ncm. Only 1 experimental group
mar test. No statistically significant differences were implant placed with an insertion torque of 20 Ncm sur-
revealed; the results were similar for the 2 groups. vived. In the control group, 10 implants were placed
Statistical analysis was performed to determine with an insertion torque of 20 Ncm; just 1 failed 9
possible associations between implant failure and months after restoration. Table 2 shows an association

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Table 2 Cox Regression Coefficients to Determine Risk Factor

Experimental Control
Risk factor Risk 95% CI P Risk 95% CI P

Diameter (per 0.22 mm) 1.54 0.08–22.07 NS 0.01 –0.01–5.7 NS

Length (per 0.7 mm) 1.10 0.76–1.66 NS 0.44 0.08–2.33 NS
Insertion torque 0.79 0.66–0.93 ≤ 0.007 0.78 0.34–1.79 ≤ 0.57
(per 9.8 Ncm)
Bone quantity
A 0.63 0.23–1.36 NS 0.98 0.26–2.17 NS
B 0.98 0.55–1.82 NS 1.03 0.57–2.05 NS
Bone quality
1 0.63 0.23–1.36 NS 0.98 0.36–2.17 NS
2 0.97 0.55–1.86 NS 1.03 0.58–2.18 NS
3 — — — — — —
Site
Canine — — — — — —
Incisor 3.02 0.41–11.06 NS 0.98 0.26–3.27 NS
Premolar 0.56 0.26–1.63 NS 1.03 0.49–3.03 NS
CI = confidence interval; NS = not significant.

Table 3 Gain or Loss of RPAL at All Analyzed Sites

Gain No gain/loss Loss
RPAL Total n % n % n %

Control 84 27 32.14 48 57.14 9 10.72

Experimental
Total 120 11 9.17 54 45.00 55 45.83
Surviving implants 66 11 16.67 38 57.58 17 25.75
Failures 54 0 0.00 17 31.48 37 68.52

Table 4 Decrease or Increase in PPD at All Analyzed Sites

Decrease No decrease/increase Increase
PPD Total n % n % n %

Control 84 22 26.19 57 68.17 5 5.64

Experimental
Total 120 19 15.83 56 46.67 45 37.50
Surviving implants 66 9 13.64 35 53.03 22 33.33
Failures 54 10 18.52 21 38.89 23 42.59

was found between insertion torque and potential risk failed implants showed lost RPAL and increased PPD,
of implant failure. The risk decreased by 20% per 9.8 but no clinical signs of inflammation (such as red-
Ncm added (ie, the standard deviation) (relative risk ness, edema, or suppuration) were observed. The
0.79 [CI: 0.66–0.93]) (P
.007), but no statistically sig- summarized results are shown in Tables 3 and 4.
nificant differences were found for other variables. Recession was demonstrated in both groups, but
it was higher for the experimental group. The per-
Clinical Parameters centage of sites at which there was no alteration in
Both the Plaque and Gingival Indices revealed the position of the gingival margin was 59.52% for
acceptable oral hygiene in these patients. No signs of the control group and 48.17% for the experimental
plaque retention or inflammation were seen in the group (Table 5). After 6 months, increases in scores in
majority of implants for either group. the papilla index introduced by Jemt26 were seen for
The means and standard deviations for PPD and both groups. Increases of 88.2% mesially and 65.7%
RPAL, determined using the method described, distally were seen for the experimental group;
showed gain in RPAL and decrease in PPD for both increases of 83.3% mesially and 50% distally were
groups. When survival and failure were compared, the seen for the control group.

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Table 5 Rates of Gingival Margin Gain or Loss Obtained from All Analyzed Sites
Gain No gain/loss Loss
PPD Total n % n % n %

Control 84 16 19.05 50 59.52 18 21.43

Experimental 120 23 19.17 59 49.17 38 31.66

The average bone loss observed in the first year of design and should not be calculated with bone
this study was 1.57 (± 0.97) mm mesially and 1.92 (± remodeling.
0.85) mm distally for the control group and 1.36 (± In the present study, bone loss in the first year
0.59) mm mesially and 2.44 (± 1.29) mm distally for averaged 1.57 mm and 1.36 mm mesially for the con-
the experimental group. Although these values were trol and experimental groups, respectively, and 1.92
higher than those reported in similar studies, no sig- mm and 2.44 mm distally, respectively. According to
nificant differences were observed between the 2 the method of Gomez-Roman and colleagues,28 the
groups in regard to bone loss (P > .05). values should be reduced by 0.4 mm to account for
the height of the machined collar. Despite the fact
that these data are higher than those found in the
DISCUSSION related literature,7,16,21,22,29,30 no statistically signifi-
cant differences were noted between the 2 groups.
Several quantitative and qualitative scientific para- The control group had a cumulative survival rate
meters have been identified for determining implant of 95.7%. The experimental group had a survival rate
survival. Changes in the papilla index, a measure of of only 56.5%. Cumulative survival rate was not
peri-implant tissue, were positive in both the experi- directly related to the length or diameter of the
mental and control groups after 6 months. These implants, quantity or quality of bone, position in the
data confirmed the findings of other studies20,23 that arch, or implant placement surgical techniques. How-
revealed gains in papilla length. ever, statistical significance was found for the torque
Recession of the gingival margin was observed in insertion variable (2 = 15.68; P = .004). The potential
both groups; however, it was greater for the experi- for risk (Cox) was 0.79 (0.66–0.93) (P
.007). Nine of
mental group. In the control group, no alteration in the 10 failed implants in the experimental group
gingival margin was observed for 59.52% of sites; in were placed with an insertion torque of 20 Ncm; only
the experimental group, no alteration was observed 1 implant placed with the same torque survived. The
for 49.17% of sites. These results contrast with those failure rate in the control group did not correlate
of Small and Tarnow,27 who reported on 63 implants with the insertion torque values, since 9 (90%) of the
placed following 1- and 2-stage surgical protocols. 10 implants placed using 20 Ncm insertion torque
They found that 80% of sites had buccal recession, were successful. The achievement of high insertion
with the majority of sites showing recession after a torque is likely related to the achievement of higher
postsurgical period of 3 months. 27 Therefore, it is primary fixation. The existence of micro- and macro-
suggested that in such cases, definitive prostheses movements that affect primary stabilization and can
should be placed 3 months after implant placement. induce the presence of fibrous tissue seems to be
The differences in outcome may be attributed to the established. However, the magnitude of the range of
fact that in the present study, a healing abutment movement that may result in failure is not yet clear. It
was not placed in cases of delayed loading. The has been reported that micromovements of 150 to
replacement of healing abutments with anatomically 500 µm are considered excessive and unhealthy.31
prepared crowns, whether acrylic or porcelain, better Brunski32 reported that the critical threshold ranges
maintained gingival margins and papillae. from 50 to 150 µm. Micromovements of 100 µm for
It is not completely understood why bone loss implants with bioinert surfaces may be acceptable.
occurs in the first year. Such loss may be attributed to Nonetheless, such thresholds need to be correlated
the healing and remodeling process, surgical trauma, to surface and design.32
implant design, technical characteristics, or a second Skalak and Zhao33 have suggested that substan-
surgical step for the placement of an abutment and tial forcefitting stresses on the order of several tens
the subsequent establishment of biologic width. of mega pascals can be generated when a titanium
Bone loss may also be directly related to functional cylinder is placed into a hole in bone with a diameter
load. Gomez-Roman and colleagues28 stated that the only 100 microns smaller than the cylinder. Horiuchi
machined collar is part of the subcrestal implant and coworkers34 credited their good results to the

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Ottoni et al

use of a drill with small diameter, 2.85 mm, for the 3. Buser D, Schenk RK, Steinemann S, Fiorellini JP, Fox CH, Stich H.
placement of a 4-mm-diameter implant to increase Influence of surface characteristics on bone integration of
titanium implants. A histomorphometric study in miniature
mechanical engagement and add additional stabil-
pigs. J Biomed Mater Res 1991;25:889–902.
ity. Wohrle20 obtained 100% success in 14 patients 4. Carlsson L, Rostlund T, Albrektsson B, Albrektsson T. Removal
with primarily fixed implants placed with a minimum torques for polished and rough titanium implants. Int J Oral
torque of 45 Ncm. However, no mention was made of Maxillofac Implants 1988;3:21–24.
how many patients were treated to establish this 5. Gotfredsen K, Wennerberg A, Johansson C, Skovgaard LT,
Hjorting-Hansen E. Anchorage of TiO2-blasted, HA-coated,
experimental group.
and machined implants: An experimental study with rabbits. J
A careful evaluation is necessary for a better Biomed Mater Res 1995;29:1223–1231.
understanding of 3 questions: Should osteotomy 6. Cochran DL, Schenk RK, Lussi A, Higginbottom FL, Buser D.
diameter be reduced for the purpose of increasing Bone response to unloaded and loaded titanium implants
initial stability, thus providing a desirable level of ini- with a sandblasted and acid-etched surface: A histometric
study in the canine mandible. J Biomed Mater Res 1998;40(1):
tial fixation sufficient to improve the implant success
1–11.
rate when implants are placed in function early? 7. Corso M, Sirota C, Fiorellini J, Rasool F, Szmukler-Moncler S,
What should the bone cell deformity pattern and Weber HP. Clinical and radiographic evaluation of early loaded
response be when implants are subjected to free standing dental implants with various coatings in beagle
increased mechanical stress and heat arising from dogs. J Prosthet Dent 1999;82:428–435.
8. Schulte W, d ‘Hoedt B, Axmann D, Gomez-Roman G. 15 Jahre
their placement in narrower bone sites? With regard
Tübinger Implantat und seine Weiterentwicklung zum FRI-
to implants that have surfaces treated with a particu- ALIT-2 System. Z Zähnarztl Implantol 1992;8:77–96.
late for increased roughness and/or biologic charac- 9. Gomez-Roman G, Schulte W, d’Hoedt B, Axmann-Krcmar. The
teristics that favor bone adherence, would it be pos- Frialit-2 Implant System: Five-year clinical experience in sin-
sible to maintain the integrity of such surfaces gle-tooth and immediately postextraction applications. Int J
during placement in sites with smaller diameters? Oral Maxillofac Implants 1997;12:299–309.
10. Lefkove MD, Beals RP. Immediate loading of cylinder implants
Additional research is needed on alterations of the with overdentures in the mandibular symphysis: The titanium
protocol technique when the early loading of single plasma-sprayed screw technique. J Oral Implantol 1990;16(4):
implants is attempted. 265–271.
11. Henry P, Rosenberg I. Single-stage surgery for rehabilitation of
the edentulous mandible: Preliminary results. Pract Periodon-
tics Aesthet Dent 1994;6(9):15–22.
CONCLUSION 12. Salama H, Rose LF, Salama M, Betts NJ. Immediate loading of
bilaterally splinted titanium root-form implants in fixed
Within the limits of the present study, it has been prosthodontics—A technique reexamined: Two case reports.
concluded that the routine immediate loading of sin- Int J Periodontics Restorative Dent 1995;15:344–361.
13. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded
gle implants should not be proposed, since the data
implants at stage 1 surgery in edentulous arches: Ten consec-
presented herein demonstrated unacceptable sur- utive case reports with 1- to 5-year data. Int J Oral Maxillofac
vival rates of implants using this treatment approach. Implants 1997;12:319–324.
Immediate loading in single-tooth indications should 14. Piattelli A, Corigliano M, Scarano A, Quaranta M. Bone reac-
only be considered if the implant can be placed with tions to early occlusal loading of two-stage titanium plasma-
sprayed implants: A pilot study in monkeys. Int J Periodontics
an insertion torque greater than 32 Ncm.
Restorative Dent 1997;17:162–169.
15. Testori T, Wiseman L, Woolfe S, Porter SS. A prospective multi-
center clinical study of the Osseotite implant: Four-year
ACKNOWLEDGMENTS interim report. Int J Oral Maxillofac Implants 2001;16:193–200.
16. Randow K, Ericsson L, Nilner K, Petersson A, Glantz PO. Imme-
The authors would like to thank Friadent for its support of the diate functional loading of Brånemark dental implants. An 18-
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