Georgios E.

Romanos Influence of the implant diameter and

Rafael Arcesio Delgado-Ruiz
Danielle Sacks
bone quality on the primary stability
Jose Luis Calvo-Guirado of porous tantalum trabecular
metal dental implants: an in vitro
biomechanical study

Authors’ affiliations:
Georgios E. Romanos, Department of
Periodontology, School of Dental Medicine, Stony
Brook University, Stony Brook, NY, USA
Rafael Arcesio Delgado-Ruiz, Department of
Prosthodontics and Digital Technology, School of
Dental Medicine, Stony Brook University, Stony
Brook, NY, USA
Danielle Sacks, School of Dental Medicine, Stony
Brook University, Stony Brook, NY, USA
Jose Luis Calvo-Guirado, Department of
International Dentistry Research, Faculty of
Medicine and Dentistry, San Antonio Catholic
University of Murcia (UCAM), Murcia, Spain
Corresponding author:
Georgios E. Romanos, DDS, PhD, Prof. Dr med.
dent.
Department of Periodontology, School of Dental
Medicine, Stony Brook University
106 Rockland Hall, Stony Brook, NY 11794-8700,
USA
Tel.: (631) 632-8755
Fax: (631) 632-8670
e-mail: georgios.romanos@stonybrook.edu
Key words: porous tantalum, primary stability, trabecular metal implants
Abstract
Objectives: The aim of this study was to evaluate the primary, initial stability of Porous Tantalum
Trabecular MetalTM implants (TM) compared with Tapered Screw Ventâ implants (TSV) with
different diameters, inserted in two bone densities.
Methods: A total of 160 implants (80 TM and 80 TSV) with narrow (3.7 mm) and conventional
(4.1 mm) diameters and the same length (10 mm) were placed in artificial bone blocks
representing bone qualities II and IV. The implant stability was evaluated by insertion torque (IT)
and Resonance Frequency Analysis. Statistical analysis was performed with non-parametric Kruskal–
Wallis test with Dunn post-test for the differences between groups.
Results: The results showed higher ISQ values in dense bone compared with soft bone for all the
groups (P < 0.05). Conventional-diameter implants (TSV and TM) showed higher ISQ and IT values
compared with narrow implants (TSV and TM) in dense and soft bone (P < 0.05). Tapered TSV
implants showed higher stability in soft bone compared with TM implants (P < 0.05). In dense bone,
differences were not observed between narrow TSV 3.7 mm and TM 3.7 mm implants (P > 0.05).
Conclusions: Within the limitations of this study, it can be concluded:
• In dense bone blocks, the wider diameter implants are more stable than narrow implants.
• In soft bone blocks, the tapered TSV implants are more stable than TM implants.

The primary, initial stability (IS) is a crucial
factor for the establishment of osseointegra-
tion (Friberg et al. 1991, 2002; Esposito et al.
2008; Javed & Romanos 2010) and might be
influenced by factors such as bone quality,
surgical technique and implant macro-design
(Javed & Romanos 2010).
In relation to the bone quality, Schiuma
et al. (2013) evaluated the effect of bone qual-
ity on implant stability. They found a strong
correlation between screw displacement and
bone properties and they concluded that bet-
ter bone quality results in better implant sta-
bility. Anil & Aldosari (2015) demonstrated
that implants placed in dense bone have
higher IS values compared with soft bone,
measured by insertion torque (IT), implant
Date: stability quotients (ISQ) and removal torque
Accepted 24 January 2016
values (RTV). Furthermore, studies by Wang
To cite this article:
Romanos GE, Delgado-Ruiz RA, Calvo-Guirado JL. Influence
et al. (2015) demonstrated that the thickness
of the implant diameter and bone quality on the primary of the cortical bone increased the ISQ values.
stability of porous tantalum trabecular metal dental implants:
an in vitro biomechanical study.
However, differences in the implant design
Clin. Oral Impl. Res. 00, 2016, 1–7 showed dissimilar IT values.
doi: 10.1111/clr.12792
Regarding the surgical technique, it has
been demonstrated that a 10% under prepara-
tion of an implant bed (in length or in diame-
ter) increased the IS of implants inserted in
soft bone and dense bone qualities (Degidi
et al. 2015). In addition, an implant bed
preparation with a modified stepped osteot-
omy (Boustany et al. 2015) and the use of
osteotomes (Shayesteh et al. 2013) have been
shown to improve the IS, which is measured
by Resonance Frequency Analysis (RFA).
However, the IS can be improved through
changes of the implant macro-design as well.
Markovic et al. (2013) performed a clinical
study comparing the IS of self-tapping and
non-self-tapping implants in a randomized
controlled clinical trial. They found that the
self-tapping implants resulted in higher IS val-
ues compared with non-self-tapping implants
after drilling. Sennerby et al. (2015) confirmed
that tapered implants compared with parallel
implants resulted in higher primary stabilities
using different drilling protocols in soft bone.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Romanos et al
Narrow- vs. conventional-diameter implants in vitro
Recently, a new implant design has been
introduced, which consists of a titanium
implant with a middle section of highly por-
ous tantalum material (Kim et al. 2013). This
porous tantalum material has high frictional
characteristics that may facilitate the initial
implant stability within surrounding bone
(Zhang et al. 1999; Levine et al. 2006).
Theoretically, this porous tantalum trabecu-
lar metal (TM)-enhanced titanium dental
implant may serve as a valuable alternative for
patients with soft bone (Types III and IV). The
enlarged surface area that is provided by the
TM shell may result in faster and more robust
osseointegration (Bencharit et al. 2014).
The IS and the bone ingrowth on TM-
enhanced titanium implants were evaluated
in an animal study by Kim et al. (2013). The
authors compared standard-diameter (4.1 mm)
TM-enhanced titanium implants vs. conven-
tional-diameter (4.1 mm) Tapered Screw Vent
(TSV) implants both with the same length
(13 mm) inserted in the healed mandibles of
foxhound dogs. The implant stability was
evaluated by RFA at 0, 2, 4, 8 and 12 weeks.
The authors concluded that the crestal and
apical implant threads and the porous section
of the TM implants provide primary stability
and secondary stability similar to fully
threaded TSV control implants. In addition,
histomorphometric analysis showed bone
ingrowth into the porous region.
More recently, Lee et al. (2015) inserted
TM-enhanced titanium implants in post-
extraction sockets in dogs and compared
their stability values with TSV implants with
the same dimensions (4.1 mm diameter and
13 mm length). The authors found that both
implant designs showed similar stability (ISQ
68/TM implants vs. ISQ 69/TSV implants).
Although these preliminary studies have
shown that the primary stability of conven-
tional-diameter TM titanium implants is sim-
ilar to the IS of conventional-diameter TSV
implants, there is a lack of information regard-
ing the IS of TM titanium implants with nar-
row diameters or when such implants are
inserted in different bone densities.
Therefore, the aim of this study was to
evaluate the IS of Porous Tantalum Trabecu-
lar Metal implants (TM) compared with TSV
implants with different diameters inserted in
different bone densities.
Material and methods
For this in vitro study, a total of 160 osteo-
tomies were created in biomedical test blocks
(size: 13 9 18 9 4 cm) – 80 in solid rigid
2 | Clin. Oral Impl. Res. 0, 2016 / 1–7
polyurethane foam that simulates Type II
(dense) bone and 80 in cellular rigid polyur-
ethane foam blocks that simulates Type IV
(soft) bone (Sawbones; Pacific Research Labo-
ratories Inc., Vashon, WA, USA). The costs of
the artificial bone blocks were relatively low
and the consistency of the material was stan-
dardized and homogenous. The bone densi-
ties of the used blocks were 0.48 and 0.16
g/cm3 respectively. The compressive strength
was 18 and 2.2 MPa and the tensile strength
was 12 and 2.1 MPa respectively.
Two different implant designs: Tapered
Screw Vent implants (TSVâ Zimmer Dental,
Inc., Carlsbad, CA, USA) (Fig. 1) and Trabec-
ular MetalTM Implant (TM) Zimmer Dental,
Inc.) (Fig. 2) with two different diameters,
conventional (4.1 mm) and narrow (3.7 mm),
were placed using the same drill bits, drilling
technique and insertion protocols as
Fig. 1. Tapered implant design (TSV).
Fig. 2. Porous Tantalum Trabecular Metal (TM) implant.
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
described below. Implants tested here were
all 10 mm in length.
Eight experimental groups (with 20 implants
in each group) were created as follows:
Group 1: Narrow-diameter TSV implants
+ type II blocks
Group 2: Conventional-diameter TSV
implants + type II blocks
Group 3: Narrow-diameter TM implants
+ type II blocks
Group 4: Conventional-diameter TM
implants + type II blocks
Group 5: Narrow-diameter TSV implants
+ type IV blocks
Group 6: Conventional-diameter TSV
implants + type IV blocks
Group 7: Narrow-diameter TM implants
+ type IV blocks
Group 8: Conventional-diameter TM
implants + type IV blocks.
Drilling procedures
The blocks were fixed in a metallic platform
to reduce movements during the drilling pro-
cedure and to ensure consistent experimental
conditions. Drilling was performed (by hand)
by one calibrated and experienced clinician
(GR).
During drilling, an in-and-out motion was
performed in bone blocks for 1–2 s without
stopping the handpiece motor. This motion
was repeated until the drill reached the depth
of the reference line (10 mm).
The drilling speed (1500 rpm) was the same
for both implant designs in both bone density
blocks without irrigation. The drills were
replaced after 10 uses, as recommended by
the manufacturer.
Drilling sequence for the TM and TSV narrow-
diameter implants
• Tapered pilot drill (Ref. 0201; Zimmer
Dental, Inc.) with 2.1 mm diameter was
used for the initial perforation inserted up
to 10 mm depth.
• 2.8 mm drill (Ref. SV2.8DN; Zimmer
Dental, Inc.) inserted up to 10 mm depth.
• 3.4 mm drill (Ref. SV3.4DSN; Zimmer Den-
tal, Inc.) inserted up to 10 mm depth.
Drilling sequence for the TM and TSV
conventional-diameter implants
• Tapered pilot drill (Ref. 0201; Zimmer
Dental, Inc.) with 2.1 mm diameter was
used for the initial perforation inserted up
to 10 mm depth.
• 2.8 mm drill (Ref. SV2.8DN; Zimmer
Dental, Inc.) inserted up to 10 mm depth.
• 3.4 mm drill (Ref. SV3.4DN; Zimmer
Dental, Inc.) inserted up to 10 mm depth.
 Romanos et al
Narrow- vs. conventional-diameter implants in vitro

• 3.8 mm drill (Ref. SV3.8DN; Zimmer

Dental, Inc.) inserted up to 10 mm depth.
Implant insertion
A total of 160 implants were inserted in a
random scheme (80 TSV and 80 TM, 20 by
group), until they reach the crestal level,
leaving the implant platforms flush with the
block surface.
Insertion torque
Insertion torque values (Ncm) were recorded
during implant insertion by the implant
motor (Frios Unit E, Friadent GmbH, Man-
nheim, Germany). The peak values reached
when the implant platform was at the surface
of the bone block were registered. Each
inserted implant resulted in a single value;
mean values by group were collated and com-
pared.

Primary stability evaluation Implant stability quotient

Fig. 3. Evaluation of the implant stability using the Evaluation of the IS was determined by the Implant stability was evaluated after implant
Resonance Frequency Analysis method. IT and by the ISQ, as follows: placement using RFA with the Osstell

Table 1. (A) Insertion torque (IT) values for porous tantalum trabecular metal (TM) vs. tapered screw vent (TSV) Implants inserted in type IV and type
II synthetic bone blocks. Data expressed as median values, minimum and maximum percentiles. (B) Insertion torque comparison of dental implants of
two different diameters in hard bone Kruskal–Wallis test. (C) Dunn’s multiple comparisons test
(A) Group TSV 3.7a IV TM 3.7b IV TSV 4.1c IV TM 4.1d IV TSV 3.7e II TM 3.7f II TSV 4.1g II TM 4.1h II
Minimum 10.000 10.000 15.000 15.000 25.000 20.000 25.000 25.000
Median 17.500 15.000 20.000*,a,b 20.000*,a,b 30.000*,a,b,c,d 30.000*,a,b,c,d 35.000*a,b,c,d,e,f 30.000*,a,b,c,d
Maximum 20.000 20.000 25.000 25.000 32.000 32.000 40.000 35.000

(B) Group Number of points Sum of ranks Mean of ranks

TSV II 4.1 20 641.00 32.050
TM II 4.1 20 738.00 36.900
TSV II 3.7 20 1121.50 56.075
TM II 3.7 20 739.50 36.975

(C) Dunn’s multiple comparisons Mean rank difference P-value

TSV IV 3.7 vs. TM IV 3.7 33.285 ns >0.05
TSV IV 3.7 vs. TSV IV 4.1 20.950 ns >0.05
TSV IV 3.7 vs. TM IV 4.1 18.375 ns >0.05
TM IV 3.7 vs. TSV II 3.7 60.350 ** <0.01
TM IV 3.7 vs. TM II 3.7 45.450 ns >0.05
TSV IV 3.7 vs. TSV II 4.1 101.53 *** <0.001
TSV IV 3.7 vs. TM II 4.1 77.125 *** <0.001
54.775 ** <0.01
15.450 ns >0.05
94.175 *** <0.001
79.275 *** <0.001
135.35 *** <0.001
110.95 *** <0.001
39.325 ns >0.05
39.400 ns >0.05
24.500 ns >0.05
80.575 *** <0.001
56.175 ** <0.01
78.725 *** <0.001
63.825 *** <0.001
119.90 *** <0.001
95.500 *** <0.001
14.900 ns >0.05
41.175 ns >0.05
TSV 3.7 Hard vs. TM 4.1 Hard 16.775 ns >0.05
TM 3.7 Hard vs. TSV 41. Hard 56.075 ** <0.01
TM 3.7 Hard vs. TM 4.1 Hard 31.675 ns >0.05
TSV 41. Hard vs. TM 4.1 Hard 24.400 ns >0.05

Notes for (A): One letter was assigned to each group (a, b, c, d, e, f, g or h). The letter indicates median differences found with the Dunn’s multiple compar-
ison test. Significant P-values were *P < 0.05.
c
TSV 4.1/Type IV was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV.
d
TM 4.1/Type IV was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV.
e
TSV 3.7/Type II was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV, cTSV 4.1/Type IV.
d
TM 4.1/Type IV.
f
TM 4.1/Type II was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV, cTSV 4.1/Type IV.
d
TM 4.1/Type IV.
g
TSV 4.1/Type II was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV, cTSV 4.1/Type IV.
d
TM 4.1/Type IV, eTSV 3.7/Type II, fTM 3.7/Type II.
h
TSV 3.7/Type II was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV, cTSV 4.1/Type IV, dTM 4.1/Type IV.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 3 | Clin. Oral Impl. Res. 0, 2016 / 1–7
Romanos et al
Narrow- vs. conventional-diameter implants in vitro
Mentorâ device (Osstell Integration Diagnos-
tics, Savadaled, Sweden) (Fig. 3). Specific
transducers were used, and replaced after 10
uses to reduce the effects of the wearing of
the smart peg threads on the ISQ values.
Measurements were taken as follows: the
transducer was screwed into the inserted
implant. The probe was laterally oriented in
relation to the transducer and measure-
ments were taken. Each measurement was
repeated twice and mean values were
recorded. All measurements were performed
by independent, unbiased examiner (DS).
Data were expressed as a range of ISQ
values (1–100). Mean values were collated
by group and compared.
Statistical analysis
The statistical analyses were performed with
SPSS version 13.0 software (SPSS, Chicago,
IL, USA). Non-parametric Kruskal–Wallis test
was used to evaluate differences within
groups. Median values, minimum and maxi-
mum values were included. Multiple compar-
isons of the median values were performed
with the Dunn’s post-test. Significance was
set as P < 0.05.
Results
Insertion torque values
Higher stability values were observed in dense
bone compared with soft bone for all groups
(P < 0.05). In soft bone, the IS values measured
by IT ranged from 17.25 to 21.25 Ncm, being
higher for wider diameter implants. In dense
Fig. 4. Comparison of the primary stability of TM vs. TSV implants of different diameters in soft and hard bone
measured by insertion torque. Bars indicate mean values; horizontal bars show median, minimum and maximum
values. Narrow- and conventional-diameter implants of both groups (TM and TSV) placed in soft bones resulted in
lower median values compared with implants inserted in dense bone. Porous Tantalum Trabecular Metal implants
(TM), Tapered Screw Vent implants (TSV), Newton 9 centimetres (Ncm).
4 | Clin. Oral Impl. Res. 0, 2016 / 1–7
bone, wider diameter TSV (32.25  4.43 Ncm)
and TM (29.25  3.82 Ncm) implants showed
the highest stability values (P < 0.05) com-
pared with narrow TSV (29.05  2.50 Ncm)
and TM (27.65  4.17 Ncm) implants
(Table 1 and Fig. 4).
Implant stability quotients
Similar trends of stability pattern were
observed with the RFA analysis. The bone
density affected the stability values. The ISQ
values were higher in dense bone (mean ISQ
values ranged from 59.42  1.45 to
65.16  0.66) compared with soft bone (mean
ISQ values ranged from 49.85  2.53 to
57.02  1.19). In soft bone, the TSV implants
showed higher stability values (P < 0.05)
compared with TM implants. In dense bone,
differences were not observed (P > 0.05)
between narrow TSV 3.7 and TM 3.7 mm.
However, wider diameter TSV implants
showed higher stability (P < 0.05) compared
with wider TM implants (Table 2 and Fig. 5).
Discussion
The aim of this study was to evaluate the
primary stability (IS) of Porous Tantalum
Trabecular Metal implants (TM) compared
with Tapered Screw Vent implants (TSV)
with different diameters inserted in different
bone densities.
For this in vitro study, well-tested polyur-
ethane blocks were used (American Society
for Testing Materials, 2013). The synthetic
polyurethane blocks were selected over bio-
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
logical samples (i.e. cow ribs) because these
blocks have mechanical properties similar to
cortical and cancellous bone; therefore, fac-
tors inherent to anatomical or structural dif-
ferences of biological samples were excluded.
During the drilling procedures, cooling was
not used because the purpose was to evaluate
stability and not thermal variations. Instead,
at the end of the drilling procedure com-
pressed air was applied to remove the debris
that might be trapped in the implant bed.
The results of the present study showed
that conventional-diameter implants of
4.1 mm had greater IS compared with nar-
rower diameter implants of 3.7 mm diameter
in dense bone. This could be explained by
the increased bone–implant contacts provided
by wider implants, which might have influ-
enced the results.
There is a general opinion in implant den-
tistry that implants with a diameter of 4 mm
or greater should be used to replace missing
teeth (Lazzara 1994). However, for narrow
alveolar ridge segments with relatively low
magnitude of loading forces, narrower diame-
ter implants can be used as a valid solution
to avoid ridge augmentations (Zinsli et al.
2004; Sohn et al. 2011; Petropoulou et al.
2013; Maiorana et al. 2015).
In the posterior part of the jaws, conven-
tional-diameter implants have demonstrated
higher survival rates compared with narrow
implants due to the risk of complications
under occlusal loading that might affect the
narrow implant integrity (Winkler et al.
2000). In contrast to this, other authors have
shown successful use of narrow-diameter
implants (i.e. 3.5 mm) for the replacement of
a single molar and presented small numbers
of complications only in bruxers (Romanos &
Nentwig 2000). Without doubt, narrow-dia-
meter implants have to be chosen after a
comprehensive treatment plan, including
loading evaluation, to avoid complications,
such as fractures, as has been recently
reported (Karl et al. 2014).
In the present work, tapered TSV implants
showed higher IS compared with TM in soft
bone qualities. This might be explained by
the presence of threads along the entire sur-
face of TSV implants compared with the TM
implants, which only have threads at the
coronal and apical portions. Thus, the lack of
threads could impact the primary implant
stability. Previous studies performed by
Bayarchimeg et al. (2013) showed similar ISQ
values in solid polyurethane artificial blocks
with mono-cortical layer. In the present
study, we used solid blocks with homoge-
nous consistency to evaluate better the
 Romanos et al
Narrow- vs. conventional-diameter implants in vitro

Table 2. (A) Implant stability quotients (ISQ) for porous tantalum trabecular metal (TM) vs. tapered screw vent (TSV) Implants inserted in type IV and
type II synthetic bone blocks. Data expressed as median values, minimum and maximum percentiles. (B) Insertion torque comparison of Zimmer den-
tal implants of two different diameters in hard bone Kruskal–Wallis test. (C) Dunn’s multiple comparisons test
(A) Group TSV 3.7a IV TM 3.7b IV TSV 4.1c IV TM 4.1d IV TSV 3.7e II TM 3.7f II TSV 4.1g II TM 4.1h II
Minimum 52.600 44.000 54.000 47.000 59.400 56.000 64.000 59.000
Median 54.500*,b 51.000 57.000*,a,b,d 53.000 60.400*,a,b,d 59.500 65.250*,a,b,c,d,e,f 62.650*,a,b,c,d,f
Maximum 57.500 52.500 58.900 55.700 62.700 61.600 66.300 64.200

(B) Group Number of points Sum of ranks Mean of ranks

TSV II 4.1 20 641.00 32.050
TM II 4.1 20 738.00 36.900
TSV II 3.7 20 1121.50 56.075
TM II 3.7 20 739.50 36.975

(C) Dunn’s multiple comparisons Mean rank difference P-value

TSV IV 3.7 vs. TM IV 3.7 33.285 ns >0.05
TSV IV 3.7 vs. TSV IV 4.1 20.950 ns >0.05
TSV IV 3.7 vs. TM IV 4.1 18.375 ns >0.05
TM IV 3.7 vs. TSV II 3.7 60.350 ** <0.01
TM IV 3.7 vs. TM II 3.7 45.450 ns >0.05
TSV IV 3.7 vs. TSV II 4.1 101.53 *** <0.001
TSV IV 3.7 vs. TM II 4.1 77.125 *** <0.001
54.775 ** <0.01
15.450 ns >0.05
94.175 *** <0.001
79.275 *** <0.001
135.35 *** <0.001
110.95 *** <0.001
39.325 ns >0.05
39.400 ns >0.05
24.500 ns >0.05
80.575 *** <0.001
56.175 ** <0.01
78.725 *** <0.001
63.825 *** <0.001
119.90 *** <0.001
95.500 *** <0.001
14.900 ns >0.05
41.175 ns >0.05
TSV 3.7 Hard vs. TM 4.1 Hard 16.775 ns >0.05
TM 3.7 Hard vs. TSV 41. Hard 56.075 ** <0.01
TM 3.7 Hard vs. TM 4.1 Hard 31.675 ns >0.05
TSV 41. Hard vs. TM 4.1 Hard 24.400 ns >0.05

Notes for (A): Letters indicates median differences found with the Dunn’s multiple comparison test. Significant P-values were *P < 0.05.
a
TSV 3.7/Type IV was significantly higher than bTM 3.7/Type IV.
c
TSV 4.1/Type IV was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV, dTM 4.1/Type IV.
e
TSV 3.7/Type II was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV, dTM 4.1/Type IV.
f
TM 4.1/Type II was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV, cTSV 4.1/Type IV.
d
TM 4.1/Type IV, fTM 3.7/Type II.
g
TSV 4.1/Type II was significantly higher than aTSV 3.70/Type IV, bTM 3.7/Type IV, cTSV 4.1/Type IV.
d
TM 4.1/Type IV, eTSV 3.7/Type II, fTM 3.7/Type II.

effects of the implant design and diameter on
the IS. Furthermore, the bone densities of the
used blocks were similar in the present study
to other published papers (Tabassum et al.
2009; Bayarchimeg et al. 2013).
This statement is supported by the studies
of Mesa et al. (2008), who studied the factors
influencing the IS of dental implants. In a
retrospective 10-year study, the authors
found that the length of the implants, the
presence of threads, the anatomical location
and the gender influence the primary
stability.
Furthermore, studies by Kan et al. (2015)
take into account that discrepancies
between implant diameter and final drill
diameter might explain the increased IS of
tapered implants.
How do the TM implants obtain their pri-
mary implant stability? We may hypothesize
that there are two major areas of interlock-
ing (the apical and the coronal threaded por-
tions), but the middle porous region must
have impact on the primary stability. Dur-
ing placement under manual compression,
some broken particles of the adjacent
implant bone bed could be trapped inside
the porous area together with debris pro-
duced during the implant insertion. This
may contribute to the additional IS of the
TM implants at the porous middle portion
of the implant.
From the clinical standpoint, implants
placed in weak (soft) or grafted bone present
better mechanical stability if they have a
narrow diameter and tapered macro-design.
In general, implants with different thread
designs and surfaces present higher
stability when they have tapered macro-
design (O’Sullivan et al. 2000; Romanos et al.
2014). This should be considered in clinical
practice today for alveolar ridges with defi-
ciencies in bone quality and quantity. For
this reason, almost every implant company
has introduced tapered-design implant macro-
designs. Such macro-designs present signifi-
cant advantages in clinical scenarios where
initial implant stability is important, such as

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 5 | Clin. Oral Impl. Res. 0, 2016 / 1–7
Romanos et al
Narrow- vs. conventional-diameter implants in vitro
Fig. 5. Comparison of the primary stability of TM vs. TSV implants of different diameters in soft and hard bone
measured by Resonance Frequency Analysis. Bars indicate mean values; horizontal bars show median, minimum
and maximum values. Lower ISQs were obtained for the TM implants compared with TSV in both bone densities
and diameters. Implant Stability Quotient (ISQ), Porous Tantalum Trabecular Metal implants (TM), Tapered Screw
Vent implants (TSV).
immediate loading protocols, implant place-
ment in fresh extraction sockets and
implants placed in compromised bone quali-
ties. Other options to increase IS would be
preparation of undersized osteotomies. The
placement of etched implants using an
undersized preparation technique resulted in
enhanced primary implant stability. How-
ever, besides the mechanical aspects, the
biological effect of undersized drilling, i.e.
the bone response on the extra IT forces,
should also be elucidated (Tabassum et al.
2009).
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6 | Clin. Oral Impl. Res. 0, 2016 / 1–7
In addition, there is a conflict in the cur-
rent literature on how reliable the evaluation
of the ISQ values is at the time of the
implant placement (Atieh et al. 2014).
Others suggested previously that the ISQ
values (RFA) are a better and more reliable
method for evaluation of the implant stabil-
ity and seem to be influenced more by corti-
cal bone thickness than by implant length
(Miyamoto et al. 2005). Therefore, in the
present study, we were able to present data
for both IT and ISQ values compared with
the previous studies.
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© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
On the other hand, the implant surface
plays an important role in narrow-diameter
orthodontic implants without showing differ-
ences between the loaded and unloaded con-
ditions in the rabbit tibia. Surface roughness,
especially the SLA surface, increased the
RTVs at 4 weeks (Chang et al. 2009).
This is the first report describing the stabil-
ity of the macro-design of TM implants of
different diameters inserted in different bone
densities. More studies are required to under-
stand how the primary stability of this new
implant design might be improved for imme-
diate loading protocols.
This slightly tapered implant macro-design
used in this in vitro study presents additional
benefits for the clinician due to the increased
biological stability over time explained by
the bone formation within the trabecular
mesh compared with conventional TSV
implants (Lee et al. 2015).
The additional biological stability achieved
by this implant design may be a significant
benefit for the long-term success of this
implant system in clinical practice.
Conclusions
Within the limitations of this in vitro study,
it can be concluded that:
• In dense bone blocks, the wider diameter
implants are more stable than narrow
implants.
• In soft bone blocks, the tapered TSV
implants are more stable than TM
implants.
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