10.59987/ads/2013.2.196-203
Surgical procedures for the application of implants in the lateral-superior sectors are affected by the availability of the residual bone. When this condition is lower than 5 mm it is recommended that techniques involving two therapeutic phases, a reconstructive and an applicative one, as reported in the international literature, are adopted. The authors propose here a new method with the potential to apply implants simultaneously with the reconstructive phase. The aim of this longitudinal retrospective study was to evaluate the stability of implants applied with the fit lock technique in the upper maxillarys in us with bone availability lower than 4 mm by measuring resonance frequency at different follow-up periods The seme as urements, carried out on 30 implants, were analysed with specific statistical procedures. The results indicate that the stability of the implants inserted with the fit lock method increases progressively over time in a statistically significant manner. The stability recorded after one year from the insertion (ISQ T2) is significantly higher than that recorded after six months (ISQ T1), and this is significantly higher than that recorded at the time of implant placement (ISQ T0). The implants inserted in the maxillary zones with scarce bone availability and applied with this technique showed a similar stability as reported with other techniques. In light of the results, the authors confirm that the primary stability represents the basic requirement to guarantee a correct healing of the implant and demonstrate that the fit lock technique also all ows reaching this condition when bone availability is minimal.
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Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study
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                                                                                                                           Case report



                   Implant stability evaluation by resonance frequency
                   analysis in the fit lock technique. A clinical study




                                                                                                                                         li
                                                                                   na
                   Giovanni Falisi, DDS, PhD1                                 nique showed a similar stability as reported with
                   Massimo Galli, MDS1                                        other techniques.




                                                                                 io
                   Pedro Vittorini Velasquez, MDS2                            In light of the results, the authors confirm that the
                   Juan Carlos Gallegos Rivera, DDS3                          primary stability represents the basic requirement
                   Carlo Di Paolo, MDS1                                       to guarantee a correct healing of the implant and
                                                                              demonstrate that the fit lock technique also all ows




                                                                              az
                                                                              reaching this condition when bone availability is
                   1 Department of Oral and Maxillo-Facial Sciences,          minimal.
                     Sapienza University of Rome, Italy
                   2 Maxillo-Facial Clinic Cochabamba, Bolivia.               Key word: resonance frequency analysis, bone graft-




                                                                           rn
                   3 Department of Dentistry, Municipal Japanese              ing, dental implants.
                     University Hospital, Santa Cruz de la Sierra, Bolivia.

                                                                              Introduction




                                                                        te
                   Corresponding author:
                   Giovanni Falisi                                            The pneumatization of the sinus is a frequently occur-
                   Department of Oral and Maxillo-Facial Sciences             ring phenomenon in absence of dental elements, caus-
                   Sapienza University of Rome
                   Via del Vivaio, 19
                                                                     In       ing a vertical reduction of bone availability and limiting
                                                                              the implant placement for prosthetic rehabilitation (1).
                   00172 Rome, Italy                                          The approach strategy to this anatomical zone has al-
                   Phone: +39 06 2304775                                      ways been debated, both in the case of a surgical ap-
                   E-mail: g.falisi@tiscali.it                                proach and concerning the possible post-surgical com-
                                                        ni
                                                                              plications (2-5).
                                                                              From the international literature, it is clear that in cases
                   Summary                                                    where bone availability is less than 4 mm, as in the
                                                                              classification IV of Misch, a first reconstructive-regener-
                                           o

                   Surgical procedures for the application of implants        ative phase is indispensable, followed by a second sur-
                   in the lateral-superior sectors are affected by the        gical phase for the implant placement (6, 7). This
                                       izi


                   availability of the residual bone.                         should be done with the goal of implant primary stabili-
                   When this condition is lower than 5 mm it is recom-        ty, which according to long term studies have a suc-
                   mended that techniques involving two therapeutic           cess similar to the implants inserted in normal bone
                   phases, a reconstructive and an applicative one, as        conditions (8).
                          Ed




                   reported in the international literature, are adopted.     Some authors consider the possibility of placing the im-
                   The authors propose here a new method with the             plants at the same surgical time by using extra-oral au-
                   potential to apply implants simultaneously with the        tologous bone graft (from hip or fibula) in order to ob-
                   reconstructive phase.                                      tain the primary stabilization (9). Other authors
                   The aim of this longitudinal retrospective study was       (Vollmer, Lang, Engelke) proposed resorbable plaques
                   to evaluate the stability of implants applied with the     from extrasinus osteosynthesis, but not for the primary
               C




                   fit lock technique in the upper maxillarys in us with      implant stability (10-12).
                   bone availability lower than 4 mm by measuring             However, as reported by some authors, the survival is
    CI




                   resonance frequency at different follow-up periods         also affected by the quality and density of the bone,
                   The seme as urements, carried out on 30 implants,          which is reduced in these zones and thereby can affect
                   were analysed with specific statistical procedures.        the stability (13, 14).
                   The results indicate that the stability of the im-         The authors have proposed the fit lock technique,
                   plants inserted with the fit lock method increases         which allows the implants to be placed simultaneously
                   progressively over time in a statistically significant     with residual bone thickness less than 4 mm, while har-
©




                   manner. The stability recorded after one year from         vesting intraoral autologous bone (15). Given the long
                   the insertion (ISQ T2) is significantly higher than        term results, a longitudinal study has been conducted
                   that recorded after six months (ISQ T1), and this is       on 11 patients treated with this technique while using a
                   significantly higher than that recorded at the time        new implant design to guarantee better stability of the
                   of implant placement (ISQ T0).                             graft also in cases of insufficient bone density.
                   The implants inserted in the maxillary zones with          The aim of the study, retrospective and longitudinal, is
                   scarce bone availability and applied with this tech-       to evaluate by resonance frequency across the follow-

                   196                                                                          Annali di Stomatologia 2013; IV (2): 196-203
5-Falisi_- 21/06/13 10:42 Pagina 197




                   Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study


                   up periods the degree of the stability of the implants ap-        Osstell Mentor (Osstell instrument, Integration Diagnos-
                   plied with the fit lock technique in the upper sinus with         tics AB, Gothenburg, Sweden) at time 0 (T0) of implant
                   bone availability lower than 4 mm. The stability mea-             placement, after 6 months (T1), and after 12 months
                   surement has been carried out by resonance frequency              (T2), upon progressive load.
                   analysis with Osstel Mentor (Osstell instrument, Inte-            The recordings were carried out with double directional




                                                                                                                                              li
                   gration Diagnostics AB, Gothenburg, Sweden) (16-20).              measurement (vestibular oral or oro vestibular and mesio-
                   The Tekka implants underwent measures of resonance                distal or disto-mesial) on the Smart Peg (Type 49) as re-




                                                                                       na
                   frequency at the time of the initial placement, six months,       ported by the company indications, and the value reported
                   and 12 months after progressive load to evaluate the de-          in Table 1 is the arithmetic mean of the two (21, 22).
                   gree of osteointegration; moreover, radiographic TC
                   dentalscan and Orthopanoramic RX were carried out




                                                                                     io
                   both at the diagnosis time and following treatment.               Statistical analysis

                                                                                     •   Normality test on the distribution of the stability val-
                   Materials and methods                                                 ues (Kolmogorov-Smirnov test, Lilliefors test,




                                                                                  az
                                                                                         Shapiro-Wilk test). Diagrams a-b-c.
                   About 50 patients were visited between January 2011               •   Descriptive statistics of the stability values: mean,
                   and January 2012 for implant-supported rehabilitation                 median, mode, variance, standard deviation standard
                   of the posterior-superior sectors at the Municipal                    error, quartiles) Diagram d.




                                                                               rn
                   Japanese University Hospital of Santa Cruz de la Sier-            •   Non parametric analysis of variance (Friedman
                   ra, Bolivia and at the Department of Odontostomatolog-                ANOVA). Diagram e.
                   ic Sciences, Sapienza University of Rome.                         •   Post hoc tests.




                                                                            te
                   All patients were studied following our clinical-implanto-
                   logic protocol for prosthetic rehabilitation. During this         Aim: to verify if the implant stability, measured by “im-
                   period 11 patients were selected according to the fol-            plant stability quotient” (ISQ), increases progressively,
                   lowing exclusion and inclusion criteria.                          and in a statistically significant manner, from the mo-
                   Exclusion criteria:
                                                                         In          ment of the placement (ISQ T0) up to six months (ISQ
                                                                                     T1) and one year (ISQ T2).
                   •   Low oral hygiene,
                   •   Acute or chronic synusitis of the maxillary sinus,
                   •   Patients with high risk factors,                              Results
                                                             ni
                   •   Patients under Cadwell Luc treatments,
                   •   Patients under radiotherapy,                                  The overall results reported in Table 1 show the loss of
                   •   Patients with a bone height above ≥ 4 mm.                     only two implants in position 24 and 27 on the same
                   •   Inclusion criteria:                                           patient, due to a post-surgical infection occurring 15
                                             o

                   •   Bone height ≤ 4 mm (X-ray assessment),                        days after placement.
                   •   Bone availability for harvesting at the ramus-symph-          No complications occurred for the remaining 18 im-
                                         izi


                       ysis donor site,                                              plants across the study period.
                   •   Patient’s consent to participate in the clinical study,       The evaluation of the data across the three follow-up
                   •   Patient’s consent to undergo regular clinical follow-up.      periods showed a distribution that significantly deviated
                                                                                     from normality. From the graphs it can be seen that two
                          Ed




                   From the initial 50 patients 15 were excluded, 20 did             of the selected variables (ISQ T0 and ISQ T1) have a
                   not give consent, 4 did not undergo the follow-up. The            skewed distribution, although the deviation from nor-
                   remaining sample consisted of 11 patients.                        mality is statistically significant depending on the test
                   This final sample was composed by 6 men, mean age                 (Diagrams a-b-c).
                   58.2, and 5 women, mean age 59.8. In total there were             The Friedman non parametric test showed that implant
                   15 sinus elevations and 30 implant placements.                    stability (mean and median values) progressively in-
               C




                   All patients where treated with Tekka grade 5 titanium im-        creased over time; ISQ T2 is higher than ISQ T1, and
                   plants, with a half-conical full screw shape, double pro-         this latter is higher than ISQ T0 (Diagram d).
    CI




                   gressive condensing thread, SA2 surface (sandblasted              The differences were statistically significant (Diagrams
                   and double acid etch) that consists in sandblasting trough        e-f).
                   corundum micro beads of 260 micron diameter, followed             Moreover, the post-hoc tests for the three possible
                   by a double chemical treatment with acid tipping.                 comparisons showed the following results: for ISQ T0
                   The allocation of the 30 implants was as follows: 2 in area       vs ISQ T1, z = 3.408; for ISQ T0 vs ISQ T2, z = 7.016;
                   14; 2 in area 15; 6 in area 16; 5 in area 17; 1 in area 24; 2     for ISQ T1 vs ISQ T2, z = 3.608; critical Z = 2.394. The
©




                   in area 25; 7 in area 26; 5 in area 27. All implants were of      critical value for significance was always passed.
                   11.5 lenght and 4.0 mm diameter (Tab. 1).
                   The implantology surgical protocol is the same de-
                   scribed in a previous article by the authors, although            Discussion and Conclusions
                   the operators were not always the same (Figs. 1-13).
                   The Tekka implants were evaluated with measures of                In literature the implant survival in posterior lateral ar-
                   resonance frequency during the follow-up periods using            eas (type SA4) - ranges between 90 and 97%.

                   Annali di Stomatologia 2013; IV (2): 196-203                                                                              197
5-Falisi_- 21/06/13 10:42 Pagina 198




                   G. Falisi et al.


                   Table 1. Specimen description.

                         Patient       Age          Sex        Implant side       Implant         ISQ T0         ISQ T1           ISQ T2
                                                                                  misure
                                                                                  H     Ø




                                                                                                                                            li
                           1            63           F             14             11,5 4            52              52               64




                                                                                 na
                                                                   16             11,5 4            49              54               66

                                                                   17             11,5 4            51              52               71

                           2            58           F             16             11,5 4            42              48               63




                                                                               io
                           3            64           M             25             11,5 4            53              59               67

                                                                   26             11,5 4            54              55               64




                                                                            az
                           4            59           M             26             11,5 4            38              48               66

                                                                   27             11,5 4            42              49               64

                                                                   16             11,5 4            55              56               68




                                                                         rn
                                                                   17             11,5 4            51              51               66

                           5            57           F             27             11,5 4            55              56               71




                                                                      te
                           6            52           M             25             11,5 4            36              49               59

                                                                   26
                                                                   In             11,5 4            41              49               58

                           7            55           M             16             11,5 4            44              49               67

                                                                   17             11,5 4            41              48               68

                           8            50           F             15             11,5 4            42              51               65

                                                                   17             11,5 4            46              53               62
                                                      ni

                                                                   26             11,5 4            44              52               61

                                                                   27             11,5 4            32              43               67
                                           o

                           9            49           M             14             11,5 4            53              62               62
                                       izi


                                                                   15             11,5 4            52              63               63

                                                                   16             11,5 4            55              71               71

                                                                   24             11,5 4            27               0               0
                           Ed




                                                                   26             11,5 4            39              47               59

                                                                   27             11,5 4            30               0               0

                           10           51           M             26             11,5 4            61              61               71

                                                                   27             11,5 4            52              55               69
               C




                                                                   16             11,5 4            55              55               66
    CI




                                                                   17             11,5 4            41              49               59

                           11           50           F             26             11,5 4            44              49               58



                   These data are influenced by several factors (Del Fab-             non treated implants is about 85.6%, while the per-
©




                   bro, 2004):                                                        centage rises to 95.8% if implants are treated su-
                   - for example, the survival of the only autologous                 perficially and made rough ones;
                       bone is about 87.70%, while in combination with        -       timing of the insertion - the implant can be applied
                       bone substitutes is about 94.88% and when only                 in the same surgical procedure (one-stage surgery)
                       bone substitutes are used the survival is about                or when the regeneration is complete: in first case
                       95.98%;                                                        the survival rate is 92.17%, while in the second
                   - implant production methodology - the survival of                 case is 92.93% (23).

                   198                                                                             Annali di Stomatologia 2013; IV (2): 196-203
5-Falisi_- 21/06/13 10:42 Pagina 199




                   Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study




                                                                                                                                             li
                                                                                         na
                                                                                       io
                   Figure 1. Pre-surgical intraoral view of the patient.




                                                                                    az
                                                                                     Figure 4. Intrasurgical measurement with caliper for resid-
                                                                                     ual bone evaluation.




                                                                                 rn
                                                                              te
                                                                           In
                   Figure 2. Pre-surgical orthopanoramic X-ray.
                                             o               ni
                                         izi
                          Ed




                                                                                     Figure 5. Sampling of the inlay bone from the mandibular
                                                                                     ramus.
               C




                   Figure 3. Pre-surgical Tc Panorex.
    CI




                   Some surgical protocols suggest that, if the bone avail-
                   able is thinner than 4 mm, as in Misch IV classification,
                   first is necessary a reconstructive-regenerative phase
                   and then a second surgical phase of implant insertion
                   (6, 7). These protocols are justified by the fact that, as
©




                   reported by the authors, the survival of the implant is al-
                   so influenced by the quality and density of the bone
                   which is reduced in these areas (13, 14). Nedir et al, in
                   2009, proposed one-stage surgery with simultaneous
                   insertion of implants in patients with atrophic maxilla
                   without grafting, provided that primary stability was             Figure 6. Placement and stabilization of the implant with
                   guaranteed (24). Later other authors have proposed, in            the inlay bone.


                   Annali di Stomatologia 2013; IV (2): 196-203                                                                             199
5-Falisi_- 21/06/13 10:42 Pagina 200




                   G. Falisi et al.




                                                                                                                                              li
                                                                                      na
                                                                                    io
                                                                                  Figure 11. Tc Panorex control.

                   Figure 7. Analysis of implant stability with ostellmentor in




                                                                                 az
                   surgical phase.




                                                                              rn
                                                                           te
                                                                        In
                                                                                  Figure 12. Analysis of implant stability with ostellmentor at
                                                                                  the time of application of the healing screws.
                                            o             ni
                                        izi
                           Ed




                   Figures 8 and 9. Filling with heterologous bone of the
               C




                   residual spaces of the maxillary sinus.
    CI




                                                                                  Figure 13. Provisional prosthesis.


                                                                                  a wider caseload, the contextual placement of the im-
                                                                                  plant without filling or with PRF (platelet-rich fibrin), re-
©




                                                                                  porting a 100% of success also in cases of lower bone
                                                                                  availability (25, 26).
                                                                                  The described technique seems to ensure a good suc-
                                                                                  cess rate in cases of Misch IV class with contextual im-
                                                                                  plant placement, with a success percentage of 93.4%
                                                                                  one year after placement. The technique allows an im-
                                                                                  mediate stabilization of the implants also due to the
                   Figure 10. Post-surgical orthopanoramic X-ray.                 new design that improves performance in those cases

                   200                                                                               Annali di Stomatologia 2013; IV (2): 196-203
5-Falisi_- 21/06/13 10:42 Pagina 201




                   Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study




                                                                                                                                             li
                                                                                       na
                                                                                     io
                                                                                  az
                    A                                                                 B




                                                                               rn
                                                                            te
                                                                         In          Diagrams a-b-c. Frequency distribution of implant stability
                                                                                     values (ISQ) and outcome of the normality tests (Kol-
                                                                                     mogorov-Smirnov, Lilliefors, Shapiro-Wilk) at time T0 (a),
                                                                                     T1 (b), and T2 (c). See “Materials and Methods” section for
                                                                                     details.
                    C
                                             o               ni
                                         izi
                          Ed




                   Table 2. Descriptive statistics of implant stability values (ISQ) at time T0, T1, and T2. The ISQ values (mean and median)
                   progressively increase over time (see also diagram f).
               C
    CI
©




                   Diagram e. Outcome of the Friedman ANOVA test indicating the overall significance of the time effect.

                   Annali di Stomatologia 2013; IV (2): 196-203                                                                             201
5-Falisi_- 21/06/13 10:42 Pagina 202




                   G. Falisi et al.


                                                                                  and Prof. Claudio Rastelli and Dr. Massimo Vullo for par-
                                                                                  ticipating to the interventions.


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    CI




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©




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                   Annali di Stomatologia 2013; IV (2): 196-203                                                                                              203
