DENTAL IMPLANTS

Low Insertional Torque and Early

Dental Implant Failure
Brian R. Carr, DMD,R *
,
Haekyung Jeon-Slaughter, PhD,y Timothy W. Neal, DDS,R ,z
Joseph A. Gulko, DDS,R ,x Nicholas C. Kolar, DDS,R ,k and Richard A. Finn, DDS{
Purpose: There is lack of uniformity regarding the ideal insertional torque with which dental implants
need to be placed. The purpose of this retrospective analysis is to compare the incidence of early dental
implant failures with an insertional torque less than 30 N-cm to implants placed with an insertional torque
30 N-cm or greater.
Methods: A retrospective cohort study was conducted to evaluate dental implants placed between 2015
and 2016 at the Veterans Affairs North Texas Health Care System in Dallas. The primary predictor variable
was dental implant insertional torque, measured at the time of implant placement as either greater than or
equal to 30 N-cm or less than 30 N-cm. The primary outcome variable was early implant failure, defined as
implant exfoliation noted by the patient or failure due to implant movement or pain necessitating explan-
tation before prosthesis loading. The study conducted a time-to-event analysis to examine a group differ-
ence in time to implant failure between insertional torque group greater than or equal to 30 N-cm and less
than 30 N-cm using Kaplan-Meir curves and a frailty model. The time to follow-up was censored at
6 months.
Results: One hundred three patients had 214 implants placed, with early failures occurring in 14 im-
plants (6.5%). Implants placed with an insertional torque less than 30 N-cm were nearly 14 times more
likely to have an early failure compared to implants placed with an insertional torque 30 N-cm or greater
(hazard ratio = 13.909; 95% confidence interval, 1.835 to 105.416), which was statistically significant
(P = .0108).
Conclusions: The results of this retrospective cohort study suggest that insertional torque values less
than 30 N-cm are associated with early dental implant failures. Future, prospective studies will be per-
formed to further elucidate the association between insertional torque and early dental implant failure.
! 2022 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 80:1069-1077, 2022

R
US/CA OMS resident.
*Resident, Department of Surgery, Division of Oral and
Maxillofacial Surgery, University of Texas Southwestern Medical
Center, Dallas, TX.
yAssistant Professor, Division of Hematology and Oncology,
Department of Internal Medicine, University of Texas
Southwestern Medical Center, Veterans Affairs North Texas Health
Care System, Dallas, TX.
zResident, Department of Surgery, Division of Oral and
Maxillofacial Surgery, University of Texas Southwestern Medical
Center, Dallas, TX.
xResident, Department of Surgery, Division of Oral and
Maxillofacial Surgery, University of Texas Southwestern Medical
Center, Dallas, TX.
kResident, Department of Surgery, Division of Oral and
Maxillofacial Surgery, University of Texas Southwestern Medical
University of Texas Southwestern Medical Center; Chief, Oral and
Maxillofacial, Surgery, Veterans Affairs North Texas Health Care
System, Dallas, TX.
Conflict of Interest Disclosure: The authors have no conflicts of
interest to disclose or disclaim. There were no grants or drugs
used for this study.
Consent for publication: Not applicable.
Availability of data and materials: The data sets used and analyzed
during this study are available from the corresponding author on
reasonable request.
Address correspondence and reprint requests to Dr Carr: 5613
Belmont Ave Unit 222, Dallas, Texas 75206; e-mail: brian.carr@
utsouthwestern.edu
Received November 4 2021
Accepted February 1 2022
! 2022 American Association of Oral and Maxillofacial Surgeons

Center, Dallas, TX. 0278-2391/22/00096-9

{Professor, Department of Surgery, Division of Oral and https://doi.org/10.1016/j.joms.2022.02.001
Maxillofacial Surgery, Department of Cell Biology-Anatomy,

1069
1070
Any type of endosseous titanium implant requires a
reasonable amount of stability during the placement
and healing process for overall success. Stability oc-
curs temporally as primary (mechanical engagement
of the implant to bone), and secondary (implant
achieving osseointegration, defined as living bone in
direct contact with the titanium surface without inter-
vening connective tissue).1 Primary stability at the
time of implant placement decreases micromove-
ments between the implant-bone interface, which is
necessary for implant osseointegration and overall suc-
cess. Implants have an increased likelihood of success-
ful osseointegration if the implant-bone gap at the time
of insertion is less than 50 to 150 mm.2 Factors that
affect primary stability include bone quality and quan-
tity, the geometry of the implant (conical vs cylindri-
cal), and the surgical technique used to prepare the
osteotomy site3-6 Bolind et al7 reported that clinically
successful dental implants had a bone to implant con-
tact area of 60 to 99%, but there was no clinical evi-
dence that more bone to implant contact was a
clinically superior finding. Clinical studies addressing
implant placement, healing, and success suggest that
the primary implant stability may be the most crit-
ical element.8
The surgical technique used to prepare an implant
site is a major factor that affects bone viability. When
there is inadequate irrigation during osteotomy prepa-
ration, heat is transferred from the drill to the sur-
rounding bone, which may lead to overheating of
the osteotomy wall.9,10 It has been well-reported that
the temperature threshold for irreversible damage to
bone is 47 ! C for 1 minute, which can be reached
within seconds of drilling without adequate
coolant.9,11,12 This thermal insult can trigger an inflam-
matory response that may induce osteolysis and osteo-
necrosis, leading to bone resorption and micromotion
between the implant and bone, compromising pri-
mary stability.9,11-15
If immediate or early loading protocols are antici-
pated, an accurate assessment of primary implant sta-
bility is critical for clinical decision-making. Long-term
negative sequelae to the implant site may occur if pri-
mary implant stability is low and not appreciated. Pri-
mary implant stability can be determined by
noninvasive methods such as resonance frequency
analysis (RFA) using a vibration to the implant and
structural analyses principle.16 The RFA technique
has gained widespread popularity. Additional methods
to express primary implant stability include detection
of micromotion and is referred to as the implant stabil-
ity quotient (ISQ). Unfortunately, the exact definition
of ISQ is poorly specified in most technical journals.17
The Osstell electronic RFA uses a device called a Smart-
Peg inserted into the implant body to determine micro-
motion. The Osstell measures implant body
LOW INSERTIONAL TORQUE AND IMPLANT FAILURE
movement after the application of 1 N of force and
measures the implant movement in mm/N-cm, and ap-
pears to offer user friendliness and has gained clinical
utility. The periotest applies impact loads to implants
but have been demonstrated to have low sensitivity.17
Reverse torque tests are typically used after some
timeframe of healing to determine a combination of
primary and secondary implant stability.8,18 This test
measures the torque value which breaks the connec-
tion between implant and bone, unfortunately result-
ing in implant failure for those implants with low
insertional torques or compromised bone healing.19
A direct method of measuring primary implant sta-
bility at the time of implant placement is the inser-
tional torque, defined as resistance of the implant to
rotational forces.20,21 The literature is inconclusive
on the appropriate insertional torque needed to resist
these rotational forces and provide adequate primary
stability for successful osseointegration, with some
studies suggesting that an insertional torque of 30 N-
cm or greater is necessary, while others suggest that
low insertional torques less than 30 N-cm are sufficient
for successful osseointegration.22-27 In addition,
studies that have focused on insertional torque and
clinical outcomes such as early implant failure,
defined as failure before prosthesis loading, are
limited.25,26,28
The purpose of this retrospective analysis is to
compare the incidence of early failures in implants
placed with an insertional torque less than 30 N-cm
to implants placed with an insertional torque 30 N-
cm or greater. The null hypothesis is that there is no
difference in early failures between implants placed
with insertional torque less than 30 N-cm and implants
placed with insertional torque 30 N-cm or greater. The
specific aims of our study are to gather data on inser-
tional torque values at implant placement and deter-
mine if different insertional torque values are
associated with early implant failures.
Patients and Methods
STUDY DESIGN AND SAMPLE
The study protocol was approved by the human
studies subcommittee (Institutional Review Board)
and all relevant research and development committees
and subcommittees. To address the study questions,
we designed and conducted a retrospective cohort
study. The study population included subjects who
had presented for evaluation and management of par-
tial or complete edentulism from July 2015 to June
2016 at the Veterans Affairs North Texas Healthcare
System (VANTHCS) in Dallas.
To be considered for the study cohort, the following
inclusion criteria had to have been met: 1) no absolute
contraindications for dental implants according to
CARR ET AL
Table 1. 2014 VHA OFFICE DENTISTRY DENTAL IMPLANT GUIDELINES HIGHLIGHTING ABSOLUTE AND POTENTIAL
CONTRAINDICATIONS TO DENTAL IMPLANT PLACEMENT
Absolute Contraindications
Implant-supported prosthetic dental rehabilitation should
not be considered for patients who exhibit one or more of
the following contraindicating elements
! Patient is unable to give informed consent
! Myocardial infarction/cerebrovascular accident within
the last 6 mo
! Prosthetic heart valve placement within 6 mo
! Significantly elevated international normalized ratio at
the time of surgery in patients taking warfarin
! Cigarette smoking (patient must be free of smoking
habit for a minimum of 6 mo due to significant in-
crease in implant failure)
! Ongoing drug abuse, including alcohol abuse
! Poorly controlled diabetes, due to the complication of
poor tissue healing
! History of radiation therapy to proposed implant site
>45 Gy
! Active cancer therapy with chemotherapy and/or radia-
tion therapy
! History of intravenous bisphosphonate therapy or de-
nosumab
! Active immunocompromise condition which renders
the patient unable to meet elective surgery criteria
either outright or through routine compensatory efforts
by the surgeon
! Documented noncompliance with dentist and/or hy-
giene recommendations. Documented high rate of
failed appointments and cancellations
Carr et al. Low Insertional Torque and Implant Failure. J Oral Maxillofac Surg 2022.
2014 VHA Office Dentistry Dental Implant Guidelines
(Table 1); 2) subjects with a follow-up time of 6 months
since placement; 3) subjects with sufficient dental re-
cords including the insertional torque that was
achieved at the time of implant placement; and 4) sub-
jects with appropriate postoperative documentation
evaluating implant status.
Patients were excluded as study subjects for the
following reasons: 1) if they had inadequate medi-
cal records that made analysis of implant status
over time ambiguous; 2) if they had contraindica-
tions for dental implants according to 2014 VHA Of-
fice Dentistry Dental Implant Guidelines; or 3) if
they had inadequate dental records that did not re-
cord insertional torque at the time of
implant placement.
STUDY VARIABLES
The primary predictor variable is defined as the
insertional torque value used for implant placement.
It was measured using a W&H Implantmed motor
(W&H Group, B€ urmoos, Austria), in increments of
10 N-cm (Fig 1).
1071
Potential Contraindications
Use caution and clinical judgment when planning implant-
supported prosthetic dental rehabilitation for patients
who exhibit one or more of the following relative
contraindications
! Chronic, active parafunctional habits, including
bruxism or clenching
! Poorly controlled medical conditions including but not
limited to advanced cardiac, pulmonary, hepatic or
renal disease, bleeding disorders, and chronic immu-
nosuppressant therapy
! Lack of adequate quantity or quality of bone (verified by
radiographic examination)
! Unrealistic patient expectations
! History of oral bisphosphonate therapy at therapeutic
dose for >3 yr
The primary outcome variable was early implant
failure, defined as implant exfoliation noted by the pa-
tient or failure due to implant movement or pain
necessitating explantation before prosthesis
loading.8,27 The time to follow-up was censored at
6 months. Incidence was defined as early implant fail-
ure in a given time period (6 months). Survival time
was defined as the date of implant failure minus the
date of implant placement in months.
Violation of Albrektsson’s success criteria for dental
implants was used to determine which implants had
an early failure.29 Covariates were defined as age in
years, sex defined as male or female, diabetic status,
immediate implant placement, single versus 2-staged
implant, and implant placement location in the maxilla
or mandible.
SURGICAL TECHNIQUE
Implant placement was performed in the outpatient
clinic or operating room at the VANTHCS in Dallas as
clean-contaminated surgery. Patients were rinsed
with chlorhexidine digluconate for 2 to 3 minutes
before the surgery. A one-time dose of preoperative
1072
FIGURE 1. W&H Implantmed motor showing the value which stopped the implant from inserting all the way (left), as well as the last 10 N-cm
value which did not stop the implant migration (right).
Carr et al. Low Insertional Torque and Implant Failure. J Oral Maxillofac Surg 2022.
antibiotics was used, 2 g of amoxicillin or 600 mg of
clindamycin for those allergic to penicillin. The anti-
biotic prophylaxis was at least 30 minutes before the
surgery began. Subjects were then anesthetized by
local infiltration in the maxilla or inferior alveolar
nerve block in the mandible. Incisions and subperios-
teal flap elevations were then performed conserva-
tively to primarily expose the crestal bone to
preserve the periosteal vascular supply lingually/pala-
tally. The drilling protocols for Zimmer/Biomet cylin-
drical implants (Biomet 3i, Palm Beach Gardens, FL)
were followed. This bone drilling sequence included
a 0.5-mm round crestal perforating burr, 2.3-mm
burr, 2.75-mm next, and finally placement of the 4-
mm cylindrical implant. If the senior author (R.A.F.)
determined that the bone quality was dense or denser
than average bone, type I to II, a 3.2-mm burr was also
used before placing the 4-mm implant.30 The W&H
torque value which stopped the implant from insert-
ing all the way was recorded, as well as the last 10 N-
cm value which did not stop the implant migration,
ie, less than 20 N-cm and less than 30 N-cm (Fig 1).
A cover screw or healing abutment was then placed
and the surgical site closed with resorbable sutures.
Antibiotics and chlorhexidine were prescribed for a
period of 1 week postoperatively. Patients received
follow up care at 2 weeks, 3 months, and 6 months. Af-
ter it was deemed the implants had successfully os-
seointegrated by clinical and radiographic evaluation,
they were referred back to their restorative dentists
for fabrication of their final restorations.
STATISTICAL ANALYSIS
Descriptive statistics, frequencies (n) and percent-
age, were presented for variables of interest. The c2
statistics was conducted to examine a group differ-
ence in study variables.
LOW INSERTIONAL TORQUE AND IMPLANT FAILURE
The study conducted a time-to-event analysis to
examine a group difference in time to implant failure
between insertional torque size group greater than
or equal to 30 N-cm and less than 30 N-cm using
Kaplan-Meir curves.31-33 Kaplan-Meir curves showed
95% confidence bands and number of subjects at
risk. Log-rank test was used to examine a statistical sig-
nificance of a group difference in time to implant fail-
ure. The time to follow-up was censored at 6 months.
Furthermore, the study employed a frailty model (a
random effect Cox model) with a gamma distribution
adjusted for baseline covariates to examine a group dif-
ference in time to implant failure between insertional
torque size group greater than or equal to 30 N-cm and
less than 30 N-cm. Covariates were age, sex, diabetic
status, immediate implant placement, single versus 2-
staged implant, and implant placement location in
the maxilla or mandible. A frailty model allowed
within-subject correlation on implant failure event
when there are multiple implant data within the
same subject. Hazard ratio and 95% confidence inter-
val were reported as results. All statistical analyses
were performed using SAS 9.4 version 9.4 software
(SAS Institute, Cary, NC).
Results
One hundred three patients had 214 implants
placed between July 2015 and August 2016 at the
VANTHCS in Dallas. Of the 214 implants placed, 14
were diagnosed with an early failure (6.5%). Ninety-
eight subjects had 205 implants placed with an inser-
tional torque 30 N-cm or greater, of which 11 had a
diagnosis of early failure, and 5 subjects had 9 implants
placed with an insertional torque less than 30 N-cm, of
which 3 had a diagnosis of early failure. A descriptive
summary of the study population is shown in Table 2.
CARR ET AL 1073

Table 2. DESCRIPTIVE SUMMARY OF THE STUDY

SAMPLE
Descriptive Summary of the
Study Sample
Implant sample size
Average age at the time of
placement
Implants placed in males
Implants placed in females
Implants placed in the
mandible
Implants placed in the maxilla
Implants placed in diabetic
patients
Implants placed in nondiabetic
patients
Implants placed immediately
Single-staged implant
Two-staged implant
Implants placed with torque
$30 N-cm
Implants placed with torque
<30 N-cm
Early failures
Carr et al. Low Insertional Torque and Implant Failure. J Oral Max-
illofac Surg 2022.
Table 3 compares the study variables with the pre-
dictor variable, insertional torque. Analysis revealed
none of the study variables were associated with low
insertional torque values less than 30 N-cm.
Kaplan-Meir curves (Fig 2) showed a significant
group difference in time to implant failure between
insertional torque size group greater than or equal to
30 N-cm and less than 30 N-cm (log rank P = .0003).
Adjusted frailty model results showed that implant
failure hazard of insertional torque group less than
30 N-cm was 14 times higher than insertional torque
30 N-cm or greater (hazard ratio = 13.91; 95% confi-
dence interval, 1.84 to 105.42); however, none of
covariates included in the model were significant pre-
dictors for implant failure at 6 months. These results
are shown in Tables 4 and 5.
n (%)
Discussion
214 The purpose of the present retrospective cohort
62 analysis is to determine whether there was an associa-
tion between the insertional torque used to place a
190 (89)
dental implant and the occurrence of an early dental
24 (11)
117 (55)
implant failure, defined as exfoliation noted by the pa-
tient or failure due to implant movement or pain
97 (45) necessitating explantation before prosthesis loading.
82 (38) The null hypothesis was that there would be no differ-
ence in early failure rates between implants placed
132 (62) with an insertional torque less than 30 N-cm compared
to those placed with an insertional torque 30 N-cm or
19 (9) greater. None of the covariates were associated with
29 (14) early implant failure in our analysis. A history of
185 (86) implant failure was considered for a covariate but
205 (96)
was not included in the final frailty model due to multi-
9 (4)
collinearity problem. Both Kaplan-Meir curves and
frailty model showed a significant group difference
14 (6.5) in implant failure at 6-month follow-up between inser-
tional torque size group greater than or equal to 30 N-
cm and less than 30 N-cm. Therefore, the null hypoth-
esis can be rejected.
A review of the literature points toward multiple
reasons why insertional torque less than 30 N-cm
could result in higher early failure rates. First, inser-
tional torque values can be considered a proxy for pri-
mary mechanical implant stability at the time of
placement. If an implant is placed with a low inser-
tional torque, it can be inferred that there is less me-
chanical stability, which thereby decreases implant
survival.5 This would make sense why the maxilla
had a higher early failure rate in this study, as maxillary
bone is known to have a higher concentration of type
III to IV bone (based off the system developed by Le-
kholm and Zarb), which is less dense, leading to lower
primary mechanical stability and higher rates of

Table 3. COMPARISON OF STUDY VARIABLES WITH INSERTIONAL TORQUE VALUES $30 N-CM AND <30 N-CM

Insertional Torque

Characteristic n $30 N-cm <30 N-cm P Value

Age $62 145 137 8 .166

Male sex 188 179 9 .598
Implant location, maxilla 97 92 5 .529
Diabetes 82 76 6 .074
Prior failure 8 8 0 .548
Placed immediately 29 17 2 .150
Single-staged implant 29 28 1 .827

Carr et al. Low Insertional Torque and Implant Failure. J Oral Maxillofac Surg 2022.
1074 LOW INSERTIONAL TORQUE AND IMPLANT FAILURE

FIGURE 2. Kaplan-Meir curve conducted a time-to-event analysis to examine a group difference in time to implant failure between insertional
torque size groups greater than or equal to 30 N-cm and less than 30 N-cm.
Carr et al. Low Insertional Torque and Implant Failure. J Oral Maxillofac Surg 2022.

implant failures.34-37 The goal of primary stability at
the time of implant placement is to limit the
micromotion at the implant-bone interface.38 Some
studies have postulated that a bone-implant gap less
than 50 to 50 mm is the threshold to avoid micromove-
ments that may compromise bone repair and success-
ful osseointegration.2,39 However, there is no
consistency in the literature as to what insertional tor-
que equates to this micromovement threshold.
A systematic review by de Oliveira et al27 looked at
survival rates of dental implants placed with inser-
tional torques less than 30 N-cm, concluding that
there was not strong enough evidence that an inser-
tion torque of 30 N-cm is enough for implant survival.
They found that 45 N-cm is the most commonly used
threshold. A study by Mal!o et al22 found that implants
placed with insertional torques less than 30 N-cm
have comparable success rates at 1 year compared
to implants placed with insertion torques of 30 N-
cm or greater. Both of these studies, however, looked
at implants that were immediately loaded after place-
ment. Opposing data suggest that in a study of 6,129
dental implants those placed at insertional torque
values of less than 25 N-cm demonstrated statistically

Table 4. ANALYSIS OF STUDY VARIABLES AGAINST THE PRIMARY OUTCOME VARIABLE, EARLY DENTAL IMPLANT
FAILURE

Analysis of Maximum Likelihood Estimates

Parameter DF Parameter Estimate Standard Error c2 P Value Hazard Ratio

Age 1 !0.02503 0.02894 0.7482 .3870 0.975

Male gender 1 !0.91095 0.85567 1.1334 .2871 0.402
Diabetic status 1 !0.42426 0.80896 0.2750 .6000 0.654
Maxillary vs mandibular 1 9.73415 80.61390 0.0146 .9039 16,884.55
location
Single vs 2-staged 1 0.65793 0.80014 0.6761 .4109 1.931
Immediate vs delayed 1 !0.64635 1.25009 0.2673 .6051 0.524
placement
Carr et al. Low Insertional Torque and Implant Failure. J Oral Maxillofac Surg 2022.
CARR ET AL
Table 5. HAZARD RATIOS FOR INSERTIONAL TORQUE <30 N-CM VERSUS $30 N-CM
Hazard Ratios for Insertional Torque
Characteristic Point Estimate
Insertional Torque <30 N-cm vs 13.909
$30 N-cm
Carr et al. Low Insertional Torque and Implant Failure. J Oral Maxillofac Surg 2022.
significant less failures than those placed at 25 N-cm
or greater.40
A study by Verrastro Neto et al41 looked at the
various peri-implant angiogenic and bone-related
markers in implants placed with insertional torques
less than 30 N-cm and greater than or equal to 30 N-
cm over a period of 3 months, and found that pro-
osteogenesis markers, vascular endothelial growth
factor, and osteoprotegerin, were higher in the low
insertional torque group during the first 30 days.
Interestingly, they found that tartrate-resistant acid
phosphatase, a marker of osteoclastogenesis, was up-
regulated in implants placed with torques 30 N-cm or
greater. However, they also found multiple pro-
osteogenesis markers were elevated in the 30 N-cm
or greater group after 3 months, including bone-
morphogenic protein-9 and periostin. They
concluded that each group had markers that were
both beneficial and detrimental to early peri-
implant repair.
Kotsu et al42 histologically evaluated healing at im-
plants placed with different insertion torques in a
canine model. They found that implants placed with
an insertion torque of 30 and 50 N-cm resulted in
higher bone-implant contact compared to implants
placed with lower torques of 10 N-cm after 8 weeks
of healing, with the former providing adequate pri-
mary stability and limiting micromotions that could
lead to integration failure.
There have been studies that have cautioned the use
of excessively high insertional torques for dental
implant placement, claiming that insertion torques
greater than 40 to 45 N-cm can compress the sur-
rounding bone and disturb the local microcirculation,
leading to necrosis of osteocytes in the peri-implant
bone, resulting in bone resorption.43 A multicenter
study by Grandi et al21 looked at implants placed
with high insertion torques compared to implants
placed with insertion torques of 45 N-cm or less, and
found that implants placed with insertion torques be-
tween 30 and 45 N-cm had similar outcomes to im-
plants placed with insertion torques between 50 and
80 N-cm, with no evidence of bone resorption or os-
seointegration failure in either group up to 12 months
after implant placement.20
1075
95% Wald Confidence
Limits P Value
1.835 105.416 .0108
The geometry of the implant (conical vs cylindrical)
is also a factor that affects primary stability. A study by
Joshi et al48 found that conical implants have greater
primary stability than cylindrical implants due to bet-
ter contact with bone.44 A study by George et al45
postulated that the reason for this is that the thread ge-
ometry of conical implants leads to a larger surface
area in contact with bone, resulting in greater primary
stability. In their study of 20 implants (10 conical and
10 cylindrical), they found a mean insertional torque
value of 38.50 ! 4.74 N-cm for conical implants versus
26.0 ! 5.16 N-cm for cylindrical implants. In the pre-
sent study, all implants that were placed had a cylindri-
cal geometry. Future studies looking at implant
geometry should be conducted to further elucidate
the effects this variable has on primary stability and
implant failure, and if the lower insertional torque
associated with cylindrical implant geometry is a risk
factor for early implant failure.
Although insertional torque is one way to measure
primary implant stability, there are other methods to
assess implant stability via detecting implant micro-
motion and is referred to as ISQ. Recently, ISQ has
been gaining popularity and has been purported to
be a more accurate assessment of implant stability,
but its validity for clinical use continues to be ques-
tioned, and its exact definition remains poorly
defined.17,46 In addition, a literature review by Huang
et al47 found that the majority of published literature
on ISQ is from experimental (preclinical) studies,
while prospective randomized controlled trial publi-
cations are still insufficient to justify it as a means to
measure implant stability. Future prospective studies
that correlate ISQ with insertional torque values
would be helpful in elucidating ISQ effectiveness in
measuring implant stability and determining out-
comes such as implant failure.
Although our data suggest an interesting clinical as-
sociation between low insertional torque and early
implant failure, there are study limitations that need
to be mentioned. First, this is a retrospective chart re-
view, which has its own inherent limitations such as
reliance on past medical and dental records. Second,
this study was conducted at an academic training cen-
ter. Third, the unbalanced and small sample size for
1076
the less than 30 N-cm group (n = 9) raises a concern
regarding generalizability of the study findings.
Future studies with larger sample sizes are warranted.
In conclusion, the preliminary results from this
retrospective cohort analysis suggest that a low inser-
tional torque value less than 30 N-cm is associated
with early implant failure. Future, prospective studies
with larger cohorts will be performed to further eluci-
date the association between insertional torque and
early dental implant failure.
References
1. Br!
anemark PI: Osseointegration and its experimental back-
ground. J Prosthet Dent 50:399, 1983
2. Szmukler-Moncler S, Salama S, Reingewirtz Y, Dubruille JH:
Timing of loading and effect of micromotion on bone implant
interface: A review of experimental literature. J Biomed Mater
Res 43:192, 1998
3. Beer A, Gahleitner A, Holm A, et al: Correlation of insertion tor-
ques with bone mineral density from dental quantitative CT in
the mandible. Clin Oral Implants Res 14:616, 2003
4. Lachmann S, Laval JY, Axmann D, Weber H: Influence of implant
geometry on primary insertion stability and simulated peri-
implant bone loss: An in vitro study using resonance frequency
analysis and damping capacity assessment. Int J Oral Maxillofac
Implants 26:347, 2011
5. Freitas AC Jr, Bonfante EA, Giro G, et al: The effect of implant
design on insertion torque and immediate micromotion. Clin
Oral Implant Res 23:113, 2012
6. Trisi P, Perfetti G, Baldoni E, et al: Implant micromotion is related
to peak insertion torque and bone density. Clin Oral Implants
Res 20:467, 2009
7. Bolind P, Johansson CB, Balshi TJ, et al: A study of 275 retrieved
Br!
anemark oral implants. Int J Periodontics Restorative Dent 25:
425, 2005
8. Kittur, Oak N, Dekate R, et al: Dental implant stability and its
measurements to improve osseointegration at the bone-
implant interface: A review. Mater Today Proc 43:1064, 2021
9. Al-Sabbagh M, Bhavsar I: Key local and surgical factors related to
implant failure. Dent Clin North Am 59:1, 2015
10. Esposito M, Thomsen P, Ericson LE, Lekholm U: Histopathologic
observations on early oral implant failures. Int J Oral Maxillofac
Implants 14:798, 1999
11. Eriksson A, Albrektsson T, Grane B, McQueen D: Thermal injury
to bone: A vital-microscopic description of heat effects. Int J
Oral Surg 11:115, 1982
12. Yacker MJ, Klein M: The effect of irrigation on osteotomy depth
and bur diam- eter. Int J Oral Maxillofac Implants 11:634, 1996
13. Yeniyol S, Jimbo R, Marin C, et al: The effect of drilling speed on
early bone healing to oral implants. Oral Surg Oral Med Oral
Pathol Oral Radiol 116:550, 2013
14. Marzook HAM, Yousef EA, Denewar M, Farahat MRL: In-vitro
assessment of bone viability with different implant drill speeds.
Br J Oral Maxillofac Surg 58:e301, 2020
15. Witek L, Parra M, Tovar N, et al: Effect of surgical Instru-
mentation variables on the osseointegration of Narrow-
and Wide-Diameter Short implants. J Oral Maxillofac Surg
79:346, 2021
16. Monje A, Ortega-Oller I, Galindo-Moreno P, et al: Sensitivity of
resonance frequency analysis for detecting early implant failure:
A case-control study. Int J Oral Maxillofac Implants 29:456, 2014
17. Mucha JN: Orthodontic finishing: Ten steps to success. APOS
Trends Orthod 8:184, 2018
18. Swami V, Vijayaraghavan V, Swami V: Current trends to measure
implant stability. J Indian Prosthodont Soc 16:124, 2016
19. Zeynep OK, Ender K: An Overview of implant stability Measure-
ment. Mod App Dent Oral Health 2, 2018
LOW INSERTIONAL TORQUE AND IMPLANT FAILURE
20. Ottoni JM, Oliveira ZF, Mansini R, Cabral AM: Correlation be-
tween placement torque and survival of single-tooth implants.
Int J Oral Maxillofac Implants 20:769, 2005
21. Grandi T, Guazzi P, Samarani R, Grandi G: Clinical outcome and
bone healing of implants placed with high insertion torque: 12-
month results from a multicenter controlled cohort study. Int J
Oral Maxillofac Surg 42:516, 2013
22. Mal" o P, Lopes A, de Ara" ujo Nobre M, Ferro A: Immediate
function dental implants inserted with less than 30N$cm
of torque in full-arch maxillary rehabilitations using the
all-on-4 concept: Retrospective study. Int J Oral Maxillofac
Surg 47:1079, 2018
23. Walker LR, Morris GA, Novotny PJ: Implant insertional torque
values predict outcomes. J Oral Maxillofac Surg 69:
1344, 2011
24. Verardi S, Swoboda J, Rebaudi F, Rebaudi A: Osteointegration of
tissue-level implants with very low insertion torque in soft
bone: A clinical study on SLA surface treatment. Implant Dent
27:5, 2018
25. Norton MR: The influence of low insertion torque on primary
stability, implant survival, and maintenance of marginal bone
levels: A closed-cohort prospective study. Int J Oral Maxillofac
Implants 32:849, 2017
26. Lemos CAA, Verri FR, de Oliveira Neto OB, et al: Clinical effect of
the high insertion torque on dental implants: A systematic re-
view and meta-analysis. J Prosthet Dent 126:490, 2021
27. Douglas de Oliveira DW, Lages FS, Lanza LA, et al: Dental
implants with immediate loading using insertion torque of
30 Ncm: A systematic review. Implant Dent 25:675, 2016
28. Olmedo-Gaya MV, Manzano-Moreno FJ, Ca~ naveral-Cavero E, et al:
Risk factors associated with early implant failure: A 5-year retro-
spective clinical study. J Prosthet Dent 115:150, 2016
29. Albrektsson T, Zarb G, Worthington P, Eriksson AR: The long-
term efficacy of currently used dental implants: A review and
proposed criteria of success. Int J Oral Maxillofac Implants 1:
11, 1986
30. Lekholm U, Zarb G: Patient Selection and Preparation. Br! ane-
mark P.I.Zarb G.Albrektsson T.Tissue-Integrated Prostheses. Chi-
cago, Quintessence, 1985, pp 199–211
31. Kaplan EL, Meier P: Nonparametric estimation from incomplete
observations. J Am Stat Assoc 53:457, 1958
32. Hosmer DW Jr, Stanley L: Applied survival analysis: Regression
modelling of time to event data. Eur Orthod Soc 561, 1999
Data. New York. John Wiley & Sons, Inc. 308-317
33. Rich JT, Neely JG, Paniello RC, et al: A practical guide to under-
standing Kaplan-Meier curves. Otolaryngol Head Neck Surg 143:
331, 2010
34. Block MS, Christensen BJ: Porous bone Increases the risk of Pos-
terior Mandibular implant failure. J Oral Maxillofac Surg 79:
1459, 2021 Jul
35. Truhlar RS, Orenstein IH, Morris HF, Ochi S: Distribution of bone
quality in patients receiving endosseous dental implants. J Oral
Maxillofac Surg 55(12 Suppl 5):38, 1997
36. Chugh T, Jain AK, Jaiswal RK, et al: Bone density and its impor-
tance in orthodontics. J Oral Biol Craniofac Res 3:92, 2013
37. Lekholm U, Zarb GA: Patient selection and preparation, in Bra
nemark P-I, Zarb GA, Albrektsson T (eds): Tissue- integrated
Prostheses: Osseointegration in clinical Dentistry. Chicago,
Quintessence, 1985, pp 199–209
38. De Santis D, Cucchi A, Rigoni G, et al: Relationship between pri-
mary stability and crestal bone loss of implants placed with high
insertion torque: A 3-year prospective study. Int J Oral Maxillofac
Implants 31:1126, 2016
39. Szmukler-Moncler S, Piatelli A, Favero GA, Dubruille JH: Consid-
erations preliminary to the application of early and immediate
loading protocols in dental implantology. Clin Oral Implants
Res 11:12, 2000
40. Hickin MP, Shariff JA, Jennette PJ, et al: Incidence and Determi-
nants of dental implant failure: A review of electronic Health re-
cords in a U.S. Dental School. J Dent Educ 81:1233, 2017
41. Verrastro Neto A, Andrade R, Corr^ea MG, et al: The impact of
different torques for the insertion of immediately loaded
CARR ET AL
implants on the peri-implant levels of angiogenesis- and
bone-related markers. Int J Oral Maxillofac Surg 47:
651, 2018
42. Kotsu M, Urbizo Velez J, Bengazi F, et al: Healing at implants
installed from ! 70- to < 10-Ncm insertion torques: An experi-
mental study in dogs. Oral Maxillofac Surg 25:55, 2021
43. O’Sullivan D, Sennerby L, Meredith N: Measurements comparing
the initial stability of five designs of dental implants: A human
cadaver study. Clin Implant Dent Relat Res 2:85, 2000
44. Goswami MM, Kumar M, Vats A, Bansal AS: Evaluation of dental
implant insertion torque using a manual ratchet. Med J Armed
Forces India 71(Suppl 2):S327, 2015
1077
45. George A, Khalil A, Hassan H: Comparison between cylinder and
tapered implants in delayed immediate placement. Alexandria
Dent J 40:221, 2015
46. Aparicio C, Lang NP, Rangert B: Validity and clinical significance
of biomechanical testing of implant/bone interface. Clin Oral
Implants Res 17(Suppl 2):2, 2006
47. H H, W G, H E: The clinical significance of implant stability quo-
tient (ISQ) measurements: A literature review. J Oral Biol Cranio-
fac Res 10:629, 2020
48. Joshi S, Dhatrak P, Nimbalkar S: An effect of various parameters
on insertion torque to improve the success rate of dental implan-
tation: a review. Mater Today. Proc 43:928, 2021