meta-analysis of methods used to assess implant stability

Albrektsson et al described a number of factors thatcontribute to the achievement of osseointegra-

tion. Factors such as a suitable host, biocompatiblematerial, careful surgery that follows a specific proto-col, and an appropriate healing time are discussed.1

Primary implant stability is one of these prequisitesfor achievement and maintenance of osseointegra-tion.1 Primary stability depends on the mechanicalengagement of an implant with bone of theosteotomy, but this stability decreases over time asremodeling of the surrounding bone takes place. Sec-ondary implant stability is the result of osseointegra-tion occurring after formation of new bone in thearea adjacent to the implant.

A number of devices and techniques have beendeveloped to assess primary and secondary stability.The Periotest (Medizintechnik Gulden), developed tomeasure the damping characteristics of natural teeth,has been used to evaluate implant stability.2 Theforce used to insert a dental implant is described ascutting torque or insertion torque.2–4 The reversetorque test, a method based on unscrewing (theopposite of cutting torque) the implant from bone,

Meta-analysis of Methods Used toAssess Implant Stability

Murat Cavit Cehreli, DDS, PhD1/Durdu Karasoy, MSc, PhD2/Kivanc Akca, DDS, PhD3/Steven E. Eckert, DDS, MS4

Purpose: To evaluate correlations between Periotest, cutting torque or insertion torque, and/or thereverse torque test with resonance frequency analysis measurements. Materials and Methods: Thecombined search terms dental implant, primary stability, resonance frequency analysis, removal torque,vibration analysis, torque, Periotest, cutting torque, and insertion torque and specific inclusion andexclusion criteria were used to retrieve eligible articles published between 1998 and 2008 (up to April1) from PubMed, EMBASE, OVID, The Cochrane Library databases, and 10 journals by hand-searching.The pooled P value was calculated with the Fisher method. The correlation coefficients (r) were com-bined using fixed and random effect models. Heterogeneity of the studies was tested by performing thehomogeneity test. Results: Fifty articles were identified, but 3 studies were excluded because of limita-tions in study design. Studies that fulfilled the inclusion criteria fell into a variety of categories(11 human cadaver, 16 clinical, 15 animal, and 5 in vitro studies). Assessment of P values revealed thatcorrelation between cutting torque or insertion torque and resonance frequency analysis was significant(6 studies; P = .0022). Correlation between Periotest and cutting torque or insertion torque was signifi-cant (1 study; P = .015), and correlations between resonance frequency analysis and reverse torque testvalues (1 study; P = .319; r = 0.405) and Periotest and resonance frequency analysis (P = .28) wereinsignificant. Nine articles provided r values, and cutting torque or insertion torque and resonance fre-quency analysis showed a statistically significant and direct relationship of 55.4% (P = .000). One studyprovided an r value of –0.149. A statistically significant and direct relationship of 87.6% was foundbetween cutting torque or insertion torque and reverse torque (2 studies; P = .000). Conclusion: Thismeta-analysis of 47 studies showed a statistically significant correlation between cutting torque or inser-tion torque and resonance frequency analysis. INT J ORAL MAXILLOFAC IMPLANTS 2009;24:1015–1032

Key words: cutting-torque, implant stability, insertion torque, meta-analysis, periotest, removal torque,resonance frequency analysis

The International Journal of Oral & Maxillofacial Implants 1015

1Associate Professor, CosmORAL Oral and Dental Health Polyclin-ics, Ankara, Turkey.

2Associate Professor, Department of Statistics, Faculty of Science,Hacettepe University, Ankara, Turkey.

3Associate Professor, Department of Prosthodontics, Faculty ofDentistry, Hacettepe University, Ankara, Turkey.

4Director of Graduate Prosthodontics and Professor of Dentistry,Department of Dental Specialties, Mayo Clinic, Rochester,Minnesota.

Correspondence to: Dr Murat Cehreli, CosmORAL Oral and DentalHealth Polyclinics, Cinnah Cad. 7/5, 06680 Kavaklidere, Ankara,Turkey. Email: [email protected]

1015_Cehreli.qxp 11/20/09 3:25 PM 015

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

had already been developed before the cuttingtorque measurement was introduced. This methodhas been used extensively to quantify the torsionalstrength (critical threshold for torsional failure of theinterface) of bone-implant contact in experimentalanimal studies.5,6

Meredith et al7 introduced resonance frequencyanalysis (RFA), another noninvasive method used pre-viously in construction engineering, to implant den-tistry. RFA, based on continual excitation of theimplant through dynamic vibration analysis, makesuse of a transducer connected to an implant, which isexcited over a range of sound frequencies with sub-sequent measurement of vibratory oscillation of theimplant. This technique causes the implant to vibratewhile, at the same time, analyzing implant motion,and provides information as an implant stability quo-tient (ISQ) on a scale from 1 to 100. ISQ is a numericdescriptive presentation of implant stability deter-mined by a device (Osstell, Integration Diagnostics),but the values obtained are not directly correlatedwith any specific physical parameters.

At present, no gold standard exists for accuratequantification of implant stability at insertion and/orduring function, and the level of correlation betweencurrent methods is also a matter of debate. The pur-pose of this article was to undertake a meta-analysis ofthe current methods used to quantify implant stabilityand to identify correlations among the techniques.

MATERIALS AND METHODS

Search Strategy for the Identification of Pertinent StudiesEligible studies were identified between 1998 and2008 (up to April 1) using the combined terms dentalimplant, primary stability, resonance frequency analysis,removal torque, vibration analysis, torque, Periotest, cut-ting torque, and insertion torque in the following data-bases:

1. PubMed (http://www.ncbi.nlm.nih.gov)2. EMBASE (http://www.embase.com)3. OVID (MEDLINE) (http://ovidsp.tx.ovid.com)4. The Cochrane Library (www.mrw.interscience.

wiley.com)

In addition, the following journals were hand-searched for this review: Clinical Implant Dentistryand Related Research, Clinical Oral Implants Research,Journal of Oral and Maxillofacial Surgery, InternationalJournal of Oral & Maxillofacial Implants, InternationalJournal of Oral and Maxillofacial Surgery, InternationalJournal of Prosthodontics, Journal of Biomedical

Materials Research, Journal of Clinical Periodontology,Journal of Oral and Maxillofacial Surgery, and Journalof Prosthetic Dentistry.

The following inclusion and exclusion criteria wereused to identify eligible studies:

Inclusion Criteria1. The study design (human cadaver study, clinical

study, animal study, and in vitro experiments)should include at least two of the three currentmeasurement techniques: Periotest, cutting torque(or insertion torque) and/or reverse torque test,and resonance frequency analysis.

2. Articles had to be published in journals indexed inthe Science Citation Index (SCI), SCI-Expanded, andIndex Medicus.

3. Articles were published in the English language.

Exclusion Criteria1. Studies that included only one of the measure-

ment techniques were excluded.2. Among articles fullfilling inclusion criterion #1,

those possessing significant flaws in the studydesign or lack of statistical analysis were excludedfrom this meta-analysis.

Study SelectionAt the outset, two independent reviewers weretrained (MC and KA) by calibrating several randomlyselected articles as a practice task. The titles/abstractsof the articles were screened by the independentreviewers (MC and KA) for possible inclusion in themeta-analysis. Any disagreement on candidate arti-cles was resolved by discussion and consultation witha third reviewer (DK). After consensus was reached,full texts of all potentially relevant studies wereobtained. Agreement between the reviewers was cal-culated using the Cohen kappa statistic, whichyielded a kappa score of 0.95. Data were extractedindependently by the two reviewers (MC and KA)using a data extraction form.

Data ExtractionThe studies were divided into four groups: humancadaver studies, clinical studies, animal studies, and invitro studies. According to this classification of thestudies, the first author, year of publication, journal,number in sample, site, type of implants, number oftest sites or implants, method of assessment of pri-mary implant stability, additional assessments, thelevel of significance between parameters, and corre-lation between the measurement techniques (if avail-able) were extracted. In addition, the followinginformation was also extracted from each pertinentstudy:

1016 Volume 24, Number 6, 2009

Cehreli et al

1015_Cehreli.qxp 11/20/09 3:25 PM Page 1016


1. Human cadaver studies: type of surgery.2. Clinical studies: type of surgery, timing of loading,

measurement of marginal bone loss, implant fail-ures, and timing of assessment for implant stabil-ity.

3. Animal studies: duration of the study, type ofsurgery, implant failures, and timing of assessmentfor implant stability.

4. In vitro studies: methodology.

Statistical AnalysisThe analyses were performed using the softwareComprehensive Meta-Analysis, version 2.2 (Biostat),and Excel (Microsoft). Meta-analyses were performedto provide a full and comprehensive summary ofrelated studies, all of which addressed a similar ques-tion.8 A pooled P value was calculated with the Fishermethod. This is distributed as a �2 distribution with2,000 degrees of freedom.9 The correlation coeffi-cients (r) were combined using the fixed and randomeffect models. Heterogeneity of the studies wastested by performing the homogeneity test. Homo-geneity test statistics (Q) are approximately distrib-uted as a �2 distribution with K minus 1 (K-1) degreesof freedom. In the event homogeneity is foundbetween studies, the outcome of a fixed-effect modelis used and if heterogeneity is found, it is appropriateto use the result of a random-effect model.10

RESULTS

Excluded Articles (Criterion No. 2)The studies of Lorenzoni et al11 and Dilek et al12 didnot include any statistical analysis. Therefore, no cor-relation between techniques or with another clinicalparameter was possible. The study of Turkyilmaz etal13 had significant flaws in its design (ie, use of “4-mm-diameter” implants in immediate “fresh” [in fact,formalin-fixed] extraction sockets of “molars,” limita-tions in quantification of cutting torque, increases inISQ values by 3 with no reliable criteria). There isstrong evidence that formalin fixation, to a greatextent, alters the mechanical/biomechanical behaviorof ligaments, spine, and bone (for a comprehensivereview, see Cowin14). Therefore, the results of thisstudy were interpreted as clinically irrelevant and itwas excluded from the analyses.

Included ArticlesA total of 47 articles fullfilled the inclusion criteria. Ofthese, 11 articles were human cadaver studies15–25

(Table 1), 15 articles were clinical studies26–41 (Table2), 15 articles were animal studies42–56 (Table 3), and 5articles were in vitro studies57–61 (Table 4).

Combined P Values. Among the 47 articles, P val-ues for comparative evaluation of cutting torque orinsertion torque and RFA (or ISQ values) were pro-vided in 6 studies.16,24,26,38,52,55 The P values of thesestudies were combined using the Fisher method toobtain �2 and one P value. The correlation betweencutting torque/insertion torque and RFA was statisti-cally significant (�2 = 30.64 > � 2

2K = � 212 = 21.026; P =

.0022). Among cadaver studies, 2 studies16,24 providedP values and suggested that the correlation betweencutting torque/insertion torque and RFA was statisti-cally insignificant (�2 = 6.73 < �2

2K = �24 = 9.487; P = .15).

Among the clinical studies, P values for compara-tive evaluation of cutting torque/insertion torque andRFA were provided in 2 studies.26,38 The results ofthese studies showed that the correlation betweencutting torque/insertion torque and RFA is statisticallysignificant (�2 = 15.86 > � 2

2K = �24 = 9.487; P = .0032).

Among animal studies, P values for comparison ofcutting torque/insertion torque and RFA were pro-vided in 2 studies.52,55 The results of these studiesshowed a statistically insignificant correlationbetween cutting torque/insertion torque and RFA(�2 = 8.05 < �2

2K = �24 = 9.487; P = .09). One study24 pro-

vided a P value for comparison of cuttingtorque/insertion torque and removal torque valueand found a significant correlation (P = .001). Likewise,the same study24 provided a P value for comparisonof RFA and reverse torque test values and did not finda significant correlation (P = .319; r = 0.405). Onestudy16 provided a P value for comparison of Periotestand cutting torque/insertion torque and Periotestand RFA. A significant correlation was found betweenPeriotest and cutting torque/insertion torque (P =.015), whereas the correlation between Periotest andRFA was insignificant (P = .28).

Combined r Values. Among the 47 articles, 9 ofthem20,24,26,32,34,35,38,41,55 provided r values. Forestplots and funnel plots of these 9 studies are pre-sented in Figs 1 and 2, respectively. Any confidenceinterval that includes a value of 0 implies that no sta-tistically significant correlation was found betweencutting torque/insertion torque and RFA in the study.The confidence intervals of two studies24,55 includedzero. The results of the remaining 7 studies could beinterpreted as showing an individual relationshipbetween cutting torque/insertion torque and RFA.The figure located in the lowest part of each plotshows the pooled estimate and confidence intervalfor the pooled estimate of the outcome of the stud-ies. Because this confidence interval did not include 0,the correlation between cutting torque/insertiontorque and RFA is statistically significant. A plot of thestandard error versus effect size from individual stud-ies should thus be shaped like a funnel (Fig 2) if there


Cehreli et al




Cehreli et al

Tabl

e 1

Fr

esh

Hum

an C

adav

er S

tudi

es

No.

of

No.

of

test

sit

es o

rM

etho

d of

A

ddit

iona

l A

utho

rca

dave

rsS

ite

Sur

gery

Impl

ants

impl

ants

asse

ssm

ent

asse

ssm

ent

Sig

nifi

canc

eC

orre

lati

on

O'S

ulliv

an e

t al15

Nke

nke

et a

l16

Ceh

reli

et a

l17

Akko

caog

lu e

t al1

8

Akca

et a

l19

Akca

et a

l20

Ceh

reli

et a

l21

9 3 2 4 4 1 2

Eden

tulo

us

max

illa

Eden

tulo

us

max

illa

and

man

dibl

e

Ante

rior

max

illa

Den

tate

man

dibl

e

Eden

tulo

us

max

illa

Eden

tulo

us

max

illa

and

man

dibl

e

Max

illar

y

prem

olar

CP

with

out

coun

ters

ink

CP

IP IP CP

CP

IP

1. S

tand

ard

Brå

ne-

mar

k,

2. M

KII

Brå

nem

ark,

3. M

KIV

Brå

nem

ark,

4. T

iO2-

blas

ted

Astr

aTec

h,

5. 3

i Ost

eotit

e

Fria

lit-2

1. 4

.8-m

m IT

I,

2. 4

.1-m

m IT

I

1. IT

I TE,

2. s

olid

scre

w E

sthe

tic P

lus

ITI (

Ø 4

.1 m

m),

3. s

olid

scr

ew

Esth

etic

Plu

s IT

I

(Ø4.

8 m

m)

4.1

�1

2 m

m S

yn-

Oct

a IT

I

1. S

trau

man

n S

LA,

2. T

iO2

-bla

sted

Astr

aTec

h

4.1

�1

2 m

m IT

I

TE

52

48

12

14 16 12

8

1. I

TV (e

lect

roni

c to

rque

forc

e

mea

sure

men

t dev

ice,

Nob

el B

io-

care

, 2. R

FA, 3

. RT

1. I

TV (e

quip

men

t NA)

, 2. P

eri-

otes

t, 3

. RFA

(Oss

tell)

1. I

TV (s

trai

n-ga

uged

cus

tom

-

mad

e to

rque

wre

nch/

data

acq

uisi

-

tion

syst

em),

2. R

FA (O

sste

ll)

1. IT

V (s

trai

n-ga

uged

cus

tom

-mad

e

torq

ue w

renc

h/da

ta a

cqui

sitio

n

syst

em),

2. R

T (s

trai

n-ga

uged

cus

-

tom

-mad

e to

rque

wre

nch/

data

acqu

isiti

on s

yste

m),

3. R

FA (O

sste

ll)

1. I

TV (s

trai

n-ga

uged

cus

tom

-

mad

e to

rque

wre

nch/

data

acq

uisi

-

tion

syst

em),

2. R

T (s

trai

n-ga

uged

cust

om-m

ade

torq

ue w

renc

h/da

ta

acqu

isiti

on s

yste

m),

3. R

FA

(Oss

tell)

1. I

TV (s

trai

n-ga

uged

cus

tom

-

mad

e to

rque

wre

nch/

data

acq

uisi

-

tion

syst

em),

2. R

FA (O

sste

ll)

1. I

TV (s

trai

n-ga

uged

cus

tom

-

mad

e to

rque

wre

nch/

data

acq

uisi

-

tion

syst

em),

2. R

FA (O

sste

ll)

LZ 1.Q

uant

itativ

e C

T,

2. h

isto

mor

phom

etry

Str

ain-

gaug

e an

alys

is

1.M

easu

rem

ent o

f

defe

ct d

epth

, 2. p

eria

pi-

cal r

adio

grap

hy

Str

ain-

gaug

e an

alys

is

Mic

rofo

cus

CT

Str

ain-

gaug

e an

alys

is

• IT

V (M

KIV

-oth

er im

plan

ts e

xcep

t Ast

ra):

P<

.05

• R

T (b

etw

een

impl

ants

): P

> .0

5 (N

S)

• R

FA (B

one

dens

ity: M

KIV

Brå

nem

ark-

Sta

n-

dard

Brå

nem

ark)

: P<

.05

• IT

V (m

andi

ble-

max

illa)

: P<

.00

05

• P

erio

test

(man

dibl

e-m

axill

a): P

< .0

00

5

• R

FA (m

andi

ble-

max

illa)

: P=

.431

• M

icro

stra

ins

betw

een

splin

ted

and

non-

splin

ted

grou

ps: P

> .0

5 (N

S)

• M

icro

stra

in (c

anin

e-la

tera

l inc

isor

s): P

< .0

5

• M

icro

stra

in (c

anin

e-ce

ntra

l inc

isor

): P

< .0

1

• M

icro

stra

in (c

entr

al-la

tera

l inc

isor

): P

> .0

5 (N

S)

• IS

Q (c

anin

e-la

tera

l-cen

tral

inci

sor)

:NA

• IT

V (c

anin

e-la

tera

l-cen

tral

inci

sor)

:NA

• IT

V-IS

Q: P

> .0

5 (N

S)

• R

TV-IS

Q: P

> .0

5 (N

S)

• M

icro

stra

in (A

-P im

plan

ts):

P<

.05

• IT

V-B

V/TV

: P<

.05

• IS

Q--B

V/TV

: P<

.05

• IT

V-IS

Q: P

< .0

5

• M

icro

stra

in (f

irst a

nd s

econ

d pr

emol

ar) (

25

-

100

N):

P<

.05

• M

icro

stra

in (f

irst a

nd s

econ

d pr

emol

ar w

ith

coag

ulum

) (2

5-1

00

N):

P<

.05

No

stat

istic

al a

naly

sis

betw

een

RFA

and

ITV

or R

TV

• P

erio

test

-ITV:

P=

.01

5

• P

erio

test

-RFA

: P=

.280

(NS)

• IT

V-R

FA: =

.19

3 (N

S)

No

stat

istic

al a

naly

sis

betw

een

RFA

and

ITV

ITV-

RTV

: P<

.001

, r =

0.8

38‡‡

No

stat

istic

al a

naly

sis

betw

een

RFA

and

ITV

and

RTV

• IT

V-B

V/TV

: r =

0.8

81‡

‡

• IT

V-R

FA: r

= 0

.79

‡‡

• R

FA-B

V/TV

: r =

0.6

8‡

‡

No

stat

istic

al a

naly

sis

betw

een

RFA

and

ITV




Cehreli et al

Tabl

e 1

Fr

esh

Hum

an C

adav

er S

tudi

es

No.

of

No.

of

test

sit

es o

rM

etho

d of

A

ddit

iona

l A

utho

rca

dave

rsS

ite

Sur

gery

Impl

ants

impl

ants

asse

ssm

ent

asse

ssm

ent

Sig

nifi

canc

eC

orre

lati

on

Akko

caog

lu e

t al2

2

Ceh

reli

et a

l23

Akca

et a

l24

Fanu

scu

et a

l25

A =

impl

ant

in a

nter

ior

loca

tion;

AL

= a

nter

ior

load

ing;

BA

F =

bon

e ar

ea f

ract

ion;

BV

/TV

= p

eri-i

mpl

ant

rela

tive

bone

vol

ume

valu

es; C

BH

= c

ortic

al b

one

heig

ht; C

O =

con

dens

ing

oste

otom

e; C

P =

con

vent

iona

lbo

ne s

ocke

t; C

T =

com

pute

d to

mog

raph

y; D

O =

dril

ling

oste

otom

e; IP

= Im

med

iate

pla

cem

ent

into

ext

ract

ion

sock

et; I

SQ

= im

plan

t st

abili

ty q

uotie

nt; I

TV =

cut

ting

torq

ue o

r in

sert

ion

torq

ue v

alue

; LZ

=Le

khol

m a

nd Z

arb

inde

x (1

985)

; P =

impl

ant

in p

oste

rior

loca

tion;

PL

= p

oste

rior

load

ing;

RFA

=re

sona

nce

freq

uenc

y an

alys

is; R

T =

rem

oval

tor

que

test

; RTV

= r

emov

al t

orqu

e va

lue;

Tb.

th =

tra

becu

lar

thic

knes

s;V

OI =

vol

ume

of in

tere

st.

‡‡S

pear

man

cor

rela

tion

test

;

4 4 4 3

Fibu

la,

scap

ula,

iliac

cre

st

Post

erio

r

max

illa

Eden

tulo

us

ante

rior

man

dibl

e

Iliac

cre

st

CP

CP

One

-sta

ge

CO

vs

DO

4.1

�10

mm

Str

aum

ann

4.1

�1

2 m

m IT

I

Str

aum

ann

4 �

11

mm

Ast

ra

Tech

24

8 8 12

1. I

TV (s

trai

n-ga

uged

cus

tom

-

mad

e to

rque

wre

nch/

data

acq

uisi

-

tion

syst

em),

2. R

T (s

trai

n-ga

uged

cust

om-m

ade

torq

ue w

renc

h/da

ta

acqu

isiti

on s

yste

m),

3. R

FA

(Oss

tell)

1. I

TV (s

trai

n-ga

uged

cus

tom

-

mad

e to

rque

wre

nch/

data

acq

uisi

-

tion

syst

em),

2. R

FA (O

sste

ll)

1. IT

V (s

trai

n-ga

uged

cus

tom

-mad

e

torq

ue w

renc

h/da

ta a

cqui

sitio

n

syst

em),

2. R

T (s

trai

n-ga

uged

cust

om-m

ade

torq

ue w

renc

h/da

ta

acqu

isiti

on s

yste

m),

3. R

FA (O

sste

ll)

1. I

TV (s

trai

n-ga

uged

cus

tom

-

mad

e to

rque

wre

nch/

data

acq

uisi

-

tion

syst

em),2

. RFA

(Oss

tell)

1. R

adio

grap

hic

mea

-

sure

men

ts, 2

. his

tom

or-

phom

etry

(30

sec

tions

)

1. S

trai

n-ga

uge

anal

y-

sis,

2. r

adio

grap

hic

mea

sure

men

ts

Str

ain-

gaug

e an

alys

is

Mic

rofo

cus

CT

• IS

Q (f

ibul

a-sc

apul

a-ili

ac c

rest

): P

> .0

5 (N

S)

• IT

V an

d R

TV (f

ibul

a-sc

apul

a-ili

ac c

rest

): P

< .0

5

• IT

V an

d R

TV (s

capu

la-il

iac

cres

t): P

> .0

5 (N

S)

• B

AF (i

liac

cres

t-fib

ula-

scap

ula)

: P<

.05

• M

icro

stra

in (1

00

N, A

-P w

ithou

t lift

-A-P

with

lift)

: P<

.05

• M

icro

stra

in (L

ater

al lo

adin

g-ce

ntra

l loa

ding

):

P<

.05

• M

icro

stra

in (s

inus

floo

r-lat

eral

load

ing-

cent

ral

load

ing

with

or w

ithou

t lift

): P

< .0

5

• M

icro

stra

in (2

5 N

-10

0 N

): P

< .0

5

• M

icro

stra

in (A

L-PL

): P

< .0

5

• B

V/TV

(VO

I 1-3

): P

< .0

5

• B

V/TV

(VO

I 4-5

): P

> .0

5 (N

S)

• T

b.th

(CO

-DO

) (VO

I 1-3

): P

< .0

5

• T

b.th

(CO

-DO

) (VO

I 4-5

): P

> .0

5 (N

S)

• IT

V (C

O-D

O):

P>

.05

• IS

Q (C

O-D

O):

P>

.05

• IT

V-R

TV: P

< .0

5‡

‡

• R

FA-IT

V (f

ibul

a): P

< .0

5‡

‡

• R

FA-R

TV(f

ibul

a): P

< .0

5‡

‡

• R

FA-IT

V (il

iac

cres

t and

scap

ula)

: P>

.05

(NS

)‡‡

• R

FA-R

TV (i

liac

cres

t and

scap

ula)

: P>

.05

(NS

)‡‡

• C

BH

(fib

ula-

scap

ula

and

iliac

cre

st):

P<

.05

‡‡

No

stat

istic

al a

naly

sis

betw

een

RFA

and

ITV

• R

FA-IT

V: r

= 0

.52

,

P=

.17

9 (N

S)‡

‡

• R

FA-R

TV: r

= 0

.40

5,

P=

.31

9 (N

S)‡

‡

• IT

V-R

TV: r

= 0

.916

,

P=

.001

‡‡

No

stat

istic

al a

naly

sis

betw

een

RFA

and

ITV




Cehreli et al

Tabl

e 2

C

linic

al S

tudi

es

No.

of

No.

of

Type

of

No.

of

Met

hod

of

Add

itio

nal

Tim

ing

of

Aut

hors

pati

ents

Sit

eim

plan

tsS

urge

ryim

plan

tsLo

adin

gM

BL

Failu

res

test

sit

esas

sess

men

tas

sess

men

tsas

sess

men

tS

igni

fica

nce

Cor

rela

tion

Frib

erg

et a

l26

Payn

e et

al2

7

Frib

erg

et a

l28

da C

unha

et a

l29

O'S

ulliv

an e

t al3

0

9 24

44

(8

drop

-

outs

)

12

13

Eden

tulo

us

max

illa

Eden

tulo

us

man

dibl

e

Tota

l or

bila

tera

l

eden

tulo

us

arch

Spl

it-m

outh

38

impl

ants

in m

axill

a,

4 im

plan

ts

in m

andi

ble

61 48

88

24

42

Two-

stag

e

One

-sta

ge

Two-

stag

e

One

-sta

ge

Two-

stag

e

49

MkI

I sel

f-

tapp

ing

Brå

ne-

mar

k)

ITI S

LA

Ø4

-mm

test

Brå

nem

ark,

Ø4

-mm

sta

n-

dard

Brå

ne-

mar

k

3.7

5 �

13

-mm

stan

dard

Brå

nem

ark,

3.7

5 �

13

-mm

TiU

nite

MkI

II

Brå

nem

ark

Sta

ndar

d an

d

MkI

V B

råne

-

mar

k

6-8

mo

Con

and

early

6-7

mo

Imm

res-

tora

tion

with

out

cont

act

NA

NA

+ + NA

NA

1 M

kII

8

NA

NA

49

ITV

mea

-

sure

men

ts,

47

RFA

(at p

lace

men

t)

48

PTV

, 40

RFA

ITV:

81

im-

plan

ts; R

FA: 8

1

impl

ants

at i

mp-

lant

pla

cem

ent,

seco

nd-s

tage

surg

ery,

and

1 y

24

42

ITV

via

elec

-

tron

ic to

rque

forc

e m

easu

re-

men

t dev

ice,

RFA

Perio

test

, RFA

(Oss

tell)

Elec

tron

ic to

rque

forc

e m

easu

re-

men

t dev

ice

(Oss

eoCa

re),

RFA

(Oss

tell)

ITV

(Oss

eoC

are)

,

RFA

(Oss

tell)

ITV

(Oss

eoC

are)

,

RFA

(Oss

tell)

Clin

ical

and

radi

o-

grap

hic

at

appr

oxi-

mat

ely

20

mo

Clin

ical

and

radi

o-

grap

hic,

LZ Clin

ical

and

radi

o-

grap

hic

- LZ

47

impl

ants

,

RFA

at p

lace

-

men

t;

61 im

plan

ts,

RFA

aft

er 8

mo;

36

impl

ants

,

RFA

aft

er 1

y

Perio

test

, 6-1

2

wk

afte

r ba

se-

line

and

at5

2

wk;

RFA

,

104

wk

ITV

at im

plan

t

plac

emen

t; R

FA

at im

plan

t pla

ce-

men

t,

seco

nd-s

tage

surg

ery,

and

1 y

Impl

ant p

lace

-

men

t

ITV

at p

lace

-

men

t,

RFA

at p

lace

-

men

t and

at

6 m

o

•IT

V (c

ervi

cal a

nd m

iddl

e

leve

l): P

= .0

47

• IT

V (c

ervic

al a

nd th

ird): P

= .0

02

• IT

V (m

iddl

e an

d th

ird):

P=

.131

• R

FA (i

nser

tion-

abut

men

t

conn

ectio

n): P

< .0

01

• R

FA (a

butm

ent c

onne

ctio

n

1 y

): P

< .0

01

• P

TV (c

ontr

ol a

nd te

st, 0

-1 y

):

P>

.05

(NS)

• R

FA (c

ontr

ol a

nd te

st, 2

y):

P>

.05

(NS)

• P

eri-i

mpl

ant p

aram

eter

s

(con

trol

and

test

, 52

and

104

wk)

: P>

.05

(NS)

• R

FA (t

est-c

ontro

l): P

= .0

04

• R

FA (t

est-c

ontr

ol) a

t abu

t-

men

t con

nect

ion

and

1 y:

P>

.03

(NS)

• C

SR (t

est-c

ontro

l): P

= .4

8

• M

BL

(test

-con

trol

): P

> .0

3

(NS)

• IT

V, T

iUni

te (a

t thr

ee p

lace

-

men

t sta

ges)

: P<

.01

• IT

V, s

tand

ard

(at t

hree

pla

ce-

men

t sta

ges)

: P>

.05

(NS)

• IT

V, T

iUni

te-s

tand

ard:

P≤.

01

• IS

Q-IT

V (u

pon

plac

emen

t):

P≤

.05

• IT

V, ty

pe 4

bon

e-ty

pes

2

and

3): P

= .0

5

• IT

V, ty

pe 2

-type

3: P

> .0

5 (N

S)

• IT

V pe

ak, t

ype

4 bo

ne-ty

pes

2 an

d 3)

: P=

.05

• IT

V pe

ak, t

ype

2-ty

pe 3

:

P>

.05

(NS)

•En

ergy

for i

mpl

ant p

lace

-

men

t MkI

V-ty

pe 4

bon

e: P

= .0

5

• R

FA (a

t pla

cem

ent),

MkI

V-

stan

dard

): P

< .0

5

• R

FA (6

mo)

, MkI

V-st

anda

rd:

P>

.05

(NS)

• IT

V (to

tal)-

RFA

:

r = 0

.62

*

• IT

V (c

ervi

cal l

evel

)-

RFA

: r =

0.8

4, P

= .0

36

• IT

V (c

ervi

cal l

evel

)-

RFA

(ins

ertio

n-ab

ut-

men

t con

nect

ion)

:

r =

–0.7

3; P

= .0

07

No

stat

istic

al a

naly

-

sis

betw

een

PTV

and

RFA

No

stat

istic

al a

naly

-

sis

betw

een

ITV

and

RFA

• IT

V-R

FA (T

iUni

te):

P≤

.01

• IT

V-R

FA (s

tan-

dard

): P

≥.0

1 (N

S)

No

stat

istic

al a

naly

-

sis

betw

een

RFA

and

ITV




Cehreli et al

Tabl

e 2

C

linic

al S

tudi

es

No.

of

No.

of

Type

of

No.

of

Met

hod

of

Add

itio

nal

Tim

ing

of

Aut

hors

pati

ents

Sit

eim

plan

tsS

urge

ryim

plan

tsLo

adin

gM

BL

Failu

res

test

sit

esas

sess

men

tas

sess

men

tsas

sess

men

tS

igni

fica

nce

Cor

rela

tion

Ost

man

et a

l31

Turk

yilm

az3

2

Deg

idi e

t al3

3

Turk

yilm

az e

t al3

4

Turk

yilm

az e

t al3

5

20

30

321

85

108

Eden

tulo

us

Max

illa

Eden

tulo

us

man

dibl

e

Fully

or

part

ially

eden

tulo

us

arch

es

Fully

or

part

ially

eden

tulo

us

arch

es

12

3

60

80

2

158

23

0

CP

or im

m

plac

emen

t

into

fres

h

extr

actio

n

sock

et

One

-sta

ge

One

-sta

ge

or tw

o-

stag

e

One

-sta

ge

or tw

o-

stag

e

One

-sta

ge

or tw

o-

stag

e

MkI

II, M

kIV,

Sel

ect T

aper

ed

(TiU

nite

, Nob

el

Bio

care

)

15

-mm

-long

MkI

II Ti

Uni

te

Brå

nem

ark

58

3 X

ive

Plus

,

164

Fria

lit

Plus

, 55

Xiv

e

tran

sgin

giva

l

MkI

II Ti

Uni

te

Brå

nem

ark

Reg

ular

-pla

t-

form

Brå

ne-

mar

k

Imm

load

-

ing

with

prov

ison

al

fixed

pro

s-

thes

es (n

o

cant

ileve

r)

Early

load

ing

(test

gro

up),

con

load

ing

(con

trol

grou

p)

Imm

res-

tora

tion

with

out

cont

act

and

dela

yed

load

ing

Con

and

early

load

-

ing

NA

+ NA

+ NA

NA

NA

NA

3 NA

NA

12

3

30

(sta

tistic

al

anal

ysis

)

All i

mpl

ants

?

NA

142

impl

ants

RFA

ITV

(Oss

eoC

are)

,

RFA

(Oss

tell)

ITV

up to

50

Ncm

(Oss

eoC

are)

,

RFA

(Oss

tell)

ITV

(NA)

, RFA

ITV

up to

50

Ncm

(Oss

eoC

are)

,

RFA

(Oss

tell)

ITV

up to

50

Ncm

(Oss

eoC

are)

,

RFA

(Oss

tell)

LZ - - Rad

io-

grap

hic

Rad

io-

grap

hic

ITV

at

plac

emen

t; R

FA

at p

lace

men

t

and

6 m

o

Impl

ant

plac

emen

t

Impl

ant

plac

emen

t

Impl

ant

plac

emen

t

Impl

ant

plac

emen

t

• R

FA (0

-6 m

o, te

st a

nd c

on-

trol

: P>

.05

(NS)

- • IS

Q-M

BL:

P<

.004

• Im

plan

t len

gth-

MB

L:

P<

.002

• Im

plan

t typ

e-M

BL:

P<

.046

• B

one

dens

ity (m

axill

a-

man

dibl

e): P

< .0

01

• IT

V (m

axill

a-m

andi

ble)

:

P>

.05

(NS)

• B

one

dens

ity (a

nter

ior-

post

erio

r): P

< .0

01

• B

one

dens

ity (f

emal

e-

mal

e): P

< .0

01

• IT

V (fe

mal

e-m

ale)

: P<

.001

•B

one

dens

ity-IT

V

(you

nger

-old

er):

P<

.001

• B

one

dens

ity (m

axill

a-

man

dibl

e): P

< .0

01

• IT

V (m

axill

a-m

andi

ble)

:

P<

.05

• B

one

dens

ity (a

nter

ior-

post

erio

r): P

< .0

01

• IT

V (a

nter

ior a

nd p

oste

rior

of m

axill

a an

d m

andi

ble)

:

P<

.001

• IT

V (fe

mal

e-m

ale)

: P<

.001

• B

one

dens

ity-IT

V

(you

nger

-old

er):

P<

.05

No

stat

istic

al a

naly

sis

betw

een

RFA

and

ITV

• IT

V-R

FA (f

emal

e):

r = 0

.881

, P

< .0

001

†

• IT

V-R

FA (m

ale)

:

r =

0.9

15

, P<

.00

01†

• IT

V-R

FA (y

oung

er):

r =

0.9

05

, P<

.00

01†

• IT

V-R

FA (o

lder

):

r =

0.8

84

, P<

.00

01†

No

stat

istic

al a

naly

sis

betw

een

ITV

and

RFA

• B

one

dens

ity-IT

V:

P<

.00

01, r

= 0

.67

5,

r2=

0.4

55

‡

• B

one

dens

ity-R

FA:

P<

.00

01, r

2 =

0.2

2‡

• R

FA-IT

V: P

< .0

001

,

r2=

0.2

7‡

• B

one

dens

ity-IT

V:

P<

.00

01, r

= 0

.63

0§

• R

FA-b

one

dens

ity:

P<

.00

01, r

= 0

.65

9§

• R

FA-IT

V: P

< .0

001

,

r =0

.58

3§




Cehreli et al

Tabl

e 2

C

linic

al S

tudi

es

No.

of

No.

of

Type

of

No.

of

Met

hod

of

Add

itio

nal

Tim

ing

of

Aut

hors

pati

ents

Sit

eim

plan

tsS

urge

ryim

plan

tsLo

adin

gM

BL

Failu

res

test

sit

esas

sess

men

tas

sess

men

tsas

sess

men

tS

igni

fica

nce

Cor

rela

tion

Deg

idi e

t al3

6

Can

nizz

aro

et a

l37

Alsa

adi e

t al3

8

Sch

inca

glia

et a

l39

Al-N

awas

et a

l40

Turk

yilm

az e

t al41

Con

= co

nven

tiona

l; A

= im

plan

t in

ante

rior

loca

tion;

CP

= co

nven

tiona

l bon

e so

cket

; CS

R =

cum

ulat

ive

succ

ess

rate

; IP

= im

med

iate

pla

cem

ent i

nto

extr

actio

n so

cket

; IS

Q =

impl

ant s

tabi

lity

quot

ient

; IS

Q-S

TS =

ISQ

val

ues

of 1

46

impl

ants

com

pare

d w

ith ta

ctile

sen

satio

n of

sur

geon

for

cort

ical

bon

e; IS

Q-S

TST

= IS

Q v

alue

s of

14

6 im

plan

ts c

ompa

red

with

tact

ile s

ensa

tion

of s

urge

on fo

r tr

abec

ular

bon

e; L

Z =

Lekh

olm

and

Zar

b in

dex

(19

85

);M

BL

= m

argi

nal b

one

loss

; NS

= n

ot s

igni

fican

t; P

= im

plan

t in

post

erio

r lo

catio

n; P

TV =

Per

iote

st v

alue

; PTV

-STS

= P

TV v

alue

s of

44

impl

ants

com

pare

d w

ith ta

ctile

sen

satio

n of

sur

geon

for

cort

ical

bon

e;ST

S =

tact

ile s

ensa

tion

of s

urge

on; (

T): p

lace

men

t tor

que

mea

sure

men

ts a

nd c

orre

spon

ding

ISQ

val

ues

with

a c

utof

f at 6

0.

*Lin

ear

corr

elat

ion

coef

ficie

nt (r

); †

Spe

arm

an c

orre

latio

n te

st; ‡

regr

essi

on a

naly

sis

test

; §Pe

arso

n co

rrel

atio

n co

effic

ient

; _lin

ear

regr

essi

on o

r an

alys

is o

f var

ianc

e.

14 40

29

8

10 11

8

22

Post

erio

r

max

illa

(gra

fted

vs

nong

raft

ed)

Uln

ar g

raft

with

impl

ants

in a

troph

ic

max

illa

vs

auto

geno

us

graf

t in

max

-

illar

y si

nus

NA

Post

erio

r

man

dibl

e

NA

Post

erio

r

max

illa

80

104

761

42

361

60

One

-sta

ge

and

two-

stag

e

Sin

us li

ft

CP

CP

NA

NA

XiVE

(Den

tspl

y

Fria

dent

)

Zim

mer

Spl

ine

hydr

oxya

patit

e-

coat

ed

MkI

II Ti

Uni

te

Brå

nem

ark

MkI

V Ti

O2-

blas

t-

ed o

r mac

hine

d

Brå

nem

ark

MkI

I

Brå

nem

ark,

Oss

eotit

e

(Bio

met

3i)

Brå

nem

ark

NA

With

or

with

out

sim

ulta

ne-

ous

impl

ant

plac

emen

t:

4-1

1 m

o,

resp

ectiv

ely

NA

Imm

NA

NA

NA

NA

+ +

NA

NA

2,

cont

rol

grou

p

NA

(5 p

a-

tient

s

died

)

2

80

RFA

(Oss

tell)

, 71

patie

nts/

153

impl

ants

; ITV

,

288

patie

nts/

719

impl

ants

;

Perio

test

, 22

patie

nts/

44

impl

ants

; RFA

,

146

impl

ants

RFA

(Oss

tell)

,

42

impl

ants

;

ITV

42 im

plan

ts

Clin

ical

eva

lu-

atio

n, 2

64

impl

ants

; RFA

and

Perio

test

,

90

impl

ants

ITV

(Frio

s U

nit E

,

Den

tspl

y

Fria

dent

),

RFA

(Oss

tell)

Perio

test

,

RFA

(Oss

tell)

STS

, ele

ctro

nic

torq

ue fo

rce

mea

sure

men

t

devi

ce (O

sseo

-

Car

e), R

FA

(Oss

tell

Men

tor)

,

Perio

test

RFA

(Oss

tell)

, ITV

(Oss

eoC

are)

up

to 5

0 N

cm

Perio

test

, RFA

(Oss

tell)

ITV

up to

50

Ncm

(Oss

eoC

are)

, RFA

(Oss

tell)

Rad

io-

grap

hic

Clin

ical

Com

pari-

son

with

LZ Clin

ical

and

radi

o-

grap

hic

Clin

ical

and

radi

o-

grap

hic

(pan

o-

ram

ic)

Rad

io-

grap

hic

Impl

ant

plac

emen

t

1. T

est,

prio

r to

rem

oval

of

graf

t; co

ntro

l:

at a

butm

ent

conn

ectio

n;

2. B

oth

grou

ps

at 6

and

12

mo

Tact

ile s

ensa

-

tion

of s

urge

on

at im

plan

t pla

ce-

men

t, R

FA a

nd

Perio

test

at

impl

ant p

lace

-

men

t and

abu

t-

men

t con

nect

ion

At in

sert

ion

Perio

test

and

RFA

dur

ing

fol-

low

-up

Impl

ant

plac

emen

t

• R

FA-im

plan

t dia

met

er: P

= .0

07

• R

FA-im

plan

t len

gth:

P=

.02

• R

FA-la

st b

ur: P

= .0

1

• R

FA-o

ne-s

tage

and

two-

stag

e: P

> .0

5 (N

S)

• P

TV-IS

Q (6

and

12

m):

P>

.05

(NS

)

• P

TV (u

lnar

gra

ft: 0

-6 m

o

and

6-1

2 m

o): P

< .0

01

• P

TV (t

radi

tiona

l gra

ft: 0

-6

mo

and

6-1

2 m

o): P

< .0

01

• IS

Q (u

lnar

gra

ft: 0

-6 m

o): P

= .0

3

• IS

Q (t

radi

tiona

l gra

ft:

0-6

mon

ths)

: P<

.001

• IS

Q (u

lna:

6-1

2 m

o): P

< .0

01

• IS

Q (t

radi

tiona

l gra

ft:

6-1

2 m

o): P

< .0

01

• IT

V-A

and

P: P

< .0

1

• IT

V-LZ

: P

< .0

001

• IS

Q<6

0-IS

Q≥6

0 (T

): P

= .0

5

• IS

Q-L

Z: P

< .0

2

• P

TV-L

Z: P

< .0

2

• IS

Q-S

TS: P

= .0

2

• P

TV-S

TS: P

< .0

001

• IS

Q-S

TST:

P=

.01

• IT

V (c

ontr

ol-te

st):

P=

.76

2

• B

one

loss

(con

trol-t

est):

P=

.22

• R

FA (c

ontr

ol-te

st):

P=

.67

7

• P

TV (M

kII-O

sseo

tite)

:

P=

.48

5 (N

S)

• IS

Q (M

kII-O

sseo

tite)

:

P=

.72

0 (N

S)

• C

ompl

icat

ion

prof

ile

(MkI

I-Oss

eotit

e): P

= .2

94

• IT

V an

d IS

Q (c

ontr

ol1

-test

1):

P<

.05

• IT

V an

d IS

Q (t

est1

-test

2):

P>

.05

(NS

)

• IS

Q (c

ontr

ol2

-test

3):

P<

.05

• IS

Q (t

est3

-test

4): P

> .0

5 (N

S)

ITV-

RFA

: P>

.05

(NS

)_

• P

TV-R

FA (6

and

12

mo)

: P>

.05

(NS

)

ITV-

RFA

(13

6 im

plan

ts):

�=

0.2

, P=

.01

§

No

stat

istic

al

anal

ysis

bet

wee

n

RFA

and

ITV

No

stat

istic

al

anal

ysis

bet

wee

n

RFA

and

PTV

• IT

V-R

FA: P

< .0

5,

r =

0.8

†

• B

one

dens

ity-IT

V:

P<

.05

, r =

0.8

†

• B

one

dens

ity-R

FA:

P<

.001

, r =

0.9

3†




Cehreli et al

Tabl

e 3

A

nim

al S

tudi

es

No.

of

No.

of

test

sit

es

Met

hod

ofTi

min

g of

Add

itio

nal

Aut

hor

anim

als

Sit

eD

urat

ion

Sur

gery

Impl

ants

Failu

res

(or

impl

ants

)ass

essm

ent

asse

ssm

ent

asse

ssm

ent

Sig

nifi

canc

eC

orre

lati

ons

Ras

mus

son

et a

l42

Ras

mus

son

et a

l43

Hal

lgre

n et

al4

4

Sul

et a

l45

10 N

ew

Zeal

and

Whi

te

Rab

bits

9 N

ew

Zeal

and

Whi

te R

ab-

bits

10 N

ew

Zeal

and

w

Whi

te r

ab-

bits

12

New

Zeal

and

Whi

te r

ab-

bits

Prox

imal

tibi

al

met

aphy

ses

Prox

imal

tibi

al

met

aphy

ses

Dis

tal f

emur

,

prox

imal

tibi

a

Tibi

a

Up

to 2

4

wk

Up

to 2

4

wk

12

wk

6 w

k

Onl

ay c

al-

variu

m

graf

t vs

no

graf

t

Onl

ay g

raft

w/

or w

/o

PTFE

mem

-

bran

e

CP

with

tap-

ping

CP

(uni

cor-

tical

)

Brå

nem

ark

Brå

nem

ark

3.7

5�

7 m

m

Brå

nem

ark

sur-

face

pat

tern

ing

(pho

tolit

hogr

a-

phy)

: thr

ee

grou

ps (s

ix s

ec-

tor,

thre

e se

ctor

,

no p

atte

rn)

Cust

om-m

ade

scre

w im

plan

t

with

sur

face

topo

grap

hies

(gro

ups

I-V; A

STM

grad

e 1

cpTi

)

- NA

NA

8?

20

18

60

96

impl

ants

RFA

, RT

RFA

, RT

RFA

, RT

RFA

(Oss

tell)

,

RT

(str

ain-

gaug

ed e

lec-

tron

ic

equi

pmen

t)

RFA

at 4

, 8, 1

6, 2

4

wk;

RT

upon

sac

ri-

fice

RFA

at i

mpl

ant

plac

emen

t and

at

8, 1

6, 2

4 w

k; R

TV

upon

sac

rific

e

RFA

at p

lace

men

t

and

upon

sac

rific

e

(12

wk)

; RT

upon

sacr

ifice

RFA

at i

mpl

ant

plac

emen

t and

upon

sac

rific

e;

RTV

upo

n sa

crifi

ce

His

tolo

gy a

nd

hist

omor

phom

-

etry

Coo

rdin

ate

mea

sure

-

men

ts, h

isto

l-

ogy

and

hist

o-

mor

phom

etry

Auge

r el

ectr

on

spec

tros

copy

,

conf

ocal

lase

r

scan

ning

pro

-

filom

etry

, his

to-

mor

phom

etry

Ram

an s

pec-

tros

copy

, x-ra

y

diff

ract

omet

ry,

hist

omor

phom

-

etry

, enz

yme

hist

oche

mis

try

• R

FA (4

-24

wk)

: P<

.05

• R

TV (t

est-c

ontr

ol):

P<

.05

• R

FA (t

est-c

ontr

ol, 2

4 w

k): P

> .0

5

(NS)

• C

oord

inat

e m

easu

rem

ent (

test

-

cont

rol,

0-24

wk)

: P>

.05

(NS)

• C

oord

inat

e m

easu

rem

ent (

test

-

cont

rol,

8-24

wk)

: P<

.05

• R

TV (t

est-c

ontr

ol):

P>

.05

(NS)

• B

one

graf

t hei

ght m

easu

rem

ent

(test

-con

trol

, 24

wk:

P>

.05

(NS)

• S

cx (t

est-c

ontr

ol):

P=

.003

• R

T (s

ix s

ecto

r-thr

ee s

ecto

r): P

> .0

5

(NS)

• R

FA (0

-12

wk)

(six

sec

tor-f

emur

):

P=

.005

• R

FA (0

-12

wk,

six

sec

tor-t

ibia

):

P=

.02

• R

FA (0

-12

wk,

thre

e se

ctor

-fem

ur):

P=

.11

(NS)

• R

FA (0

-12

wk,

con

trol

-tibi

a):

P=

.06

(NS)

• R

FA (0

-12

wk,

thre

e se

ctor

-tibi

a):

P=

.000

2

• B

VD (c

ontr

ol-p

atte

rned

): P

= .0

5

• R

FA I-

IV: P

> .0

5 (N

S)

• R

TV I-

III: P

= .0

23

• R

TV I-

IV: P

= .0

06

• R

TV I-

V: P

= .0

01

• R

TV II

-III:

P=

.044

• R

TV II

-IV: P

= .0

13

• R

TV II

-V: P

= .0

02

• R

TV I-

II: P

= .9

99

• R

TV II

I-IV,

III-V

, IV-

V: P

> .0

5 (N

S)

• B

IC (t

est-c

ontr

ol):

P>

.05

(NS)

• B

one

area

(tes

t-con

trol

): P

> .0

5

(NS)

• T

otal

new

ly fo

rmed

bon

e (te

st-c

on-

trol

): P

> .0

5 (N

S)

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV




Cehreli et al

Tabl

e 3

A

nim

al S

tudi

es

No.

of

No.

of

test

sit

es

Met

hod

ofTi

min

g of

Add

itio

nal

Aut

hor

anim

als

Sit

eD

urat

ion

Sur

gery

Impl

ants

Failu

res

(or

impl

ants

)ass

essm

ent

asse

ssm

ent

asse

ssm

ent

Sig

nifi

canc

eC

orre

lati

ons

Ste

npor

t et a

l46

Fran

ke S

tenp

ort

et a

l47

Fran

ke S

tenp

ort

and

Joha

nsso

n48

Sul

et a

l49

O’S

ulliv

an e

t al5

0

16 R

ussi

an

rabb

its

6 N

ew

Zeal

and

Whi

te

rabb

its

6 N

ew

Zeal

and

Whi

te

rabb

its

12

New

Zeal

and

Whi

te

rabb

its

9 N

ew

Zeal

and

Whi

te

rabb

its

Prox

imal

tibi

a

Fem

ur

cond

yle

and

tibia

l met

a-

phys

is

Fem

ur

cond

yle

and

tibia

l met

a-

phys

is

Tibi

a

Tibi

al m

eta-

phys

es a

nd

dist

al fe

mor

al

cond

yles

8 w

k

6 w

k

6 w

k

6 w

k

6 w

k

CP

CP

CP

CP

NA

Cus

tom

-mad

e

scre

w c

pTi

impl

ant

Cus

tom

-mad

e

scre

w c

pTi

impl

ant

Cus

tom

-mad

e

scre

w c

pTi

impl

ant

Cus

tom

-mad

e

scre

w im

plan

t

with

five

diff

eren

t

surf

ace

topo

gra-

phie

s (g

roup

s I-V

,

ASTM

gra

de 1

cpTi

)

2 e

xper

imen

tal

(EXP

) im

plan

ts

with

1-d

eg a

nd

2-d

eg ta

per;

Brå

nem

ark

impl

ant (

cont

rol)

NA

1 r

abbi

t

NA

8 NA

32

impl

ants

36

impl

ants

36

impl

ants

48

impl

ants

36

impl

ants

RFA

, RT

RFA

, RT

RFA

, RT

(for

tibia

l im

plan

ts,

six

rabb

its)

RFA

(Oss

tell)

,

RT

(str

ain-

gaug

ed

elec

tron

ic

equi

pmen

t)

RFA

, ITV

(Nob

el

Bio

care

), R

T

RFA

at 0

, 2, 4

, 6,

8 w

k; R

T up

on

sacr

ifice

RFA

(14

impl

ants

)

at 0

, 6 w

k;

RT

upon

sac

rific

e

(18

impl

ants

)

RFA

at 0

, 6 w

k;

RT

upon

sac

rific

e

RFA

at i

mpl

ant

plac

emen

t and

upon

sac

rific

e;

RTV

upo

n sa

crifi

ce

RFA

at i

mpl

ant

plac

emen

t and

upon

sac

rific

e;

ITV

at im

plan

t

plac

emen

t;

RT

upon

sac

rific

e

Dua

l-ene

rgy

x-ra

y an

alys

is

(DEX

A), h

isto

-

mor

phom

etry

,

IGF-

1 le

vel

mea

sure

men

t

Opt

ical

inte

rfer

-

omet

ry, s

hear

stre

ngth

cal

cu-

latio

n, h

isto

-

mor

phom

etry

His

tom

orph

om-

etry

, she

ar

stre

ngth

cal

cu-

latio

n

- -

• R

FA (G

H g

roup

-con

trol

, 2 w

k):

P=

.01

• R

FA (G

H g

roup

-con

trol

, 8 w

k):

P=

.08

• R

FA (G

H g

roup

, 2, 4

, 8 w

k): P

= .0

5

• R

TV (G

H g

roup

-con

trol

): P

= .6

63

(NS)

• B

IC (G

H g

roup

-con

trol

): P

= .5

98

(NS)

• D

EXA

(GH

gro

up-c

ontr

ol):

P=

.599

• IG

F-1

leve

l (G

H g

roup

-con

trol

,

1 w

k): P

= .0

008

• R

FA (F

GF-

cont

rol):

P=

.26

(NS)

• R

TV (F

GF-

cont

rol):

P=

.26

(NS)

• S

hear

str

engt

h (F

GF-

cont

rol):

P=

.24

(NS)

• B

one

area

api

cal (

FGF-

cont

rol):

P=

.02

• R

FA (E

MD

+PG

A-tr

eate

d-co

ntro

l,

6 w

k): P

= .1

8

• R

FA (E

MA+

PGA-

trea

ted-

cont

rol,

0-6

wk)

: P=

.35

• R

TV (c

ontr

ol-E

MA+

PGA-

trea

ted)

:

P=

.03

• R

FA I-

IV: P

>.05

(NS)

• R

TV I-

III: P

= .0

23

• R

TV I-

IV: P

= .0

06

• R

TV I-

V: P

= .0

01

• R

TV II

-III:

P=

.044

• R

TV II

-IV: P

= .0

13

• R

TV II

-V: P

= .0

02

• R

TV I-

II: P

= 0.

999

• R

TV II

I-IV,

III-V

, IV-

V: P

> .0

5 (N

S)

• R

FA (E

XP-c

ontr

ol):

P=

.05

• R

FA (E

XP1-

cont

rol):

P>

.05

(NS)

• R

FA (E

XP2-

cont

rol):

P=

.032

• IT

V (E

XP-c

ontr

ol):

P>

.05

(NS)

• IT

V (E

XP2-

cont

rol-f

emur

): P

= .0

005

• IT

V (E

XP1-

cont

rol-t

ibia

): P

= .0

512

(NS)

• R

T (N

S)

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

No

stat

istic

al

anal

ysis

betw

een

RFA

and

ITV

or R

TV

1015_Cehreli.qxp 11/20/09 3:25 PM 24



Cehreli et al

Tabl

e 3

A

nim

al S

tudi

es

No.

of

No.

of

test

sit

es

Met

hod

ofTi

min

g of

Add

itio

nal

Aut

hor

anim

als

Sit

eD

urat

ion

Sur

gery

Impl

ants

Failu

res

(or

impl

ants

)ass

essm

ent

asse

ssm

ent

asse

ssm

ent

Sig

nifi

canc

eC

orre

lati

ons

Bal

atso

uka

et a

l51

Nke

nke

et a

l52

Buc

hter

et a

l53

Al-N

awas

et a

l54

16 N

ew

Zeal

and

Whi

te

rabb

its

12 G

öttin

gen

min

ipig

s

6 G

ottin

gen

min

ipig

s

16 b

eagl

e

dogs

Dis

tal f

emor

al

cond

yle

and

prox

imal

tibi

a

Max

illa

Cra

nial

and

caud

al p

art o

f

tibia

con

dyle

Max

illar

y

prem

olar

,

man

dibu

lar

prem

olar

8 w

k of

nico

tine

or s

alin

e

expo

sure

6 m

o

7 d

and

28

d

3 m

o

CP

CP

vs

oste

otom

e

CP

vs

oste

otom

e

CP

Expe

rimen

tal

3.5

�6

-mm

TiO

2-b

last

ed

Astr

aTec

h

3.8

�1

3-m

m

Xive

Fria

dent

4.1

�10

mm

ITI

SLA

MkI

II B

råne

mar

k

turn

ed, M

kIII

Brå

nem

ark

TiU

-

nite

, MkI

V B

råne

-

mar

k Ti

Uni

te,

Str

aum

ann

SLA

,

Str

aum

ann

TPS

NA

3 a

ni-

mal

s

NA

11

32

impl

ants

108

impl

ants

56

impl

ants

160

impl

ants

ITV

(dig

ital

torq

ue g

auge

DTS

-48

5-0

-0,

Cra

ne E

lec-

tron

ics)

, RFA

,

RT(

digi

tal

torq

ue g

auge

DTS

-48

5-0

-0,

Cra

ne E

lec-

tron

ics)

ITV,

RFA

(Oss

tell)

RFA

(Oss

tell)

,

RT

RFA

(Oss

tell)

,

ITV

(Nob

el

Bio

care

DEC

60

0,

max

imum

50

Ncm

torq

ue)

ITV

at p

lace

men

t;

RFA

at p

lace

men

t

and

8 w

k; R

T at

2

and

4 w

k (im

plan

ts

at d

ista

l tib

ia)

ITV

at p

lace

men

t;

RFA

at p

lace

men

t

and

seco

nd-s

tage

surg

ery

RFA

at p

lace

men

t

and

upon

sacr

ifice

; RT

upon

sacr

ifice

RFA

at i

mpl

ant

plac

emen

t, st

art o

f

load

ing,

end

of

load

ing

(3 m

o)

His

tolo

gy,

hist

omor

-

phom

etry

- His

tolo

gy,

scan

ning

elec

tron

mic

rosc

opy

-

• R

FA (t

est-c

ontr

ol, 2

and

4 w

k): P

> .0

5

(NS)

• R

TV (t

est-c

ontr

ol, 2

and

4 w

k): P

> .0

5

(NS)

• B

IC (t

est-c

ontr

ol, 2

and

4 w

k): P

> .0

5

(NS)

• B

D-i

(test

-con

trol

, 2 a

nd 4

wk)

: P>

.05

(NS)

• L

M (t

est-c

ontr

ol, 2

and

4 w

k): P

> .0

5

(NS)

• R

FA in

itial

-sur

gica

l tec

hniq

ue: P

= .4

2

(NS)

*

• R

FA s

econ

d-st

age

surg

ery-

surg

ical

tech

niqu

e: P

= .3

2 (N

S)*

• R

FA in

itial

-hea

ling

time:

P=

.007

*

• R

FA 6

mo-

surg

ical

tech

niqu

e: P

= .0

7*

• R

FA 6

mo-

heal

ing

time:

P=

.15

(NS)

*

• R

ate

of im

plan

t fai

lure

-hea

ling

time:

P<.

001

• R

T (7

and

28

d, C

P): P

= .0

01

• R

T (7

and

28

d, o

steo

tom

e): P

= .0

04

• In

terf

acia

l stif

fnes

s (7

d,

oste

otom

e-CP

): P

= .0

42

• In

terf

acia

l stif

fnes

s (2

8 d,

oste

otom

e-CP

): P

= .2

49 (N

S)

• R

FA (o

steo

tom

e-CP

): P

> .0

5 (N

S)

• IS

Q-IL

-STR

: P>

.05

(NS)

• IS

Q-L

L: P

< .0

01

• IS

Q-A

L: P

> .0

5 (N

S)

• IT

V-R

OC:

0.4

3, P

= .5

47 (N

S)

• IS

Q-R

OC:

0.8

6, P

= .0

3

• IS

QB

-RO

C: 0

.86

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

and

ITV

• R

FA in

itial

-

ITV:

P<

.001

*

• R

FA 6

mo-

ITV:

P=

.12

(NS

)*

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV

No

stat

istic

al

anal

ysis

betw

een

ITV

and

RFA




Cehreli et al

Tabl

e 3

A

nim

al S

tudi

es

No.

of

No.

of

test

sit

es

Met

hod

ofTi

min

g of

Add

itio

nal

Aut

hor

anim

als

Sit

eD

urat

ion

Sur

gery

Impl

ants

Failu

res

(or

impl

ants

)ass

essm

ent

asse

ssm

ent

asse

ssm

ent

Sig

nifi

canc

eC

orre

lati

ons

Sch

lieph

ake

et a

l55

Buc

hter

et a

l56

BD

-i =

Bon

e de

nsity

with

in t

he im

plan

t th

read

s; B

IC =

bon

e-im

plan

t-co

ntac

t; B

VD

= v

olum

e de

nsity

of

new

ly f

orm

ed b

one;

EM

D =

Em

doga

in; G

H =

gro

wth

hor

mon

e; F

GF

= r

ecom

bina

nt h

uman

fib

robl

ast

grow

th f

acto

r-4/a

ltelo

colla

gen;

IGF-

1 =

insu

linlik

e gr

owth

fac

tor

1; IL

I = n

ewly

dev

elop

ed p

arab

olic

scr

ew t

ype

impl

ant:

ISQ

-AL

= c

ompa

rison

of

ISQ

aft

er lo

adin

g fo

r m

ediu

m-r

ough

, sm

ooth

, and

ver

y ro

ugh

impl

ants

; IS

QB

-RO

C =

com

paris

on o

f IS

Q v

alue

s at

the

beg

inni

ng o

f lo

adin

g be

twee

n su

cces

sful

and

fai

led

impl

ants

; IS

Q-IL

-STR

= c

ompa

rison

of

ISQ

val

ues

at im

plan

t pl

acem

ent

and

befo

re lo

adin

g;IS

Q-L

L =

com

paris

on o

f IS

Q v

alue

s be

fore

load

ing

and

end

of lo

adin

g fo

r se

lf-ta

ppin

g an

d no

nsel

f-ta

ppin

g im

plan

ts; I

SQ

-RO

C =

com

paris

on o

f IS

Q b

etw

een

succ

essf

ul a

nd f

aile

d im

plan

ts;

ITV-

RO

C =

com

paris

on o

f IT

V b

etw

een

succ

essf

ul a

nd f

aile

d im

plan

ts; L

M =

line

ar m

easu

rem

ents

; NS

= n

ot s

igni

fican

t; P

GA

= p

ropy

lene

gly

col a

lgin

ate;

RO

C =

rec

eive

r op

erat

ing

char

acte

ristic

cur

ve a

naly

sis;

Scx

= t

he a

vera

ged

mea

n sp

acin

g of

pro

file

heig

hts

in t

he x

-dire

ctio

n (h

oriz

onta

l) in

mm

. *A

naly

sis

of v

aria

nce;

†P

ears

on c

orre

latio

n co

effic

ient

.

10 fo

xhou

nd

dogs

8 G

ottin

gen

min

ipig

s

Man

dibl

e

Cra

nial

and

caud

al p

art o

f

tibia

con

dyle

1 m

o an

d

3 m

o

7 d

and

28

d

CP

CP

Expe

rimen

tal

impl

ants

with

diff

eren

t sur

face

text

ures

and

com

posi

tions

Com

mer

cial

ly

pure

tita

nium

(ILI)

1 NA

80

(40

1 m

o

eval

uatio

n

and

40

3 m

o

eval

uatio

n)

40

impl

ants

Elec

tron

ic

torq

ue fo

rce

mea

sure

men

t

devi

ce

(Oss

eoC

are)

,

RFA

(Oss

tell)

RFA

(Oss

tell)

,

RT

ITV

and

RFA

at

impl

ant p

lace

-

men

t; R

T an

d R

FA

at te

rmin

atio

n

( 1 m

o an

d 3

mo)

RFA

at i

mpl

ant

plac

emen

t and

upon

sac

rific

e;

RTV

upo

n sa

crifi

ce

His

tom

or-

phom

etry

SEM

, his

to-

mor

phom

etry

• IT

V (d

iffer

ent i

mpl

ant l

ocat

ion)

: P>

.05

(NS)

• IS

Q 0

-1 m

o: P

= .0

01

• IS

Q 0

-3 m

o: P

< .0

01

• B

IC 0

-3 m

o: P

< .0

01

• B

VD 0

-3 m

o: P

< .0

01

• R

TV 7

-28

d: P

= .3

51(N

S)

• R

FA 0

-7 d

: P=

.291

(NS)

• R

FA 0

-28

d: P

= .4

35 (N

S)

• IT

V-R

FA (a

t

inse

rtio

n):

�=

-0.1

49,

P=

.149

(NS)

†

• B

IC-R

FA:

�=

0.1

28

,

P=

.26

4 (N

S)†

• B

VD-R

FA:

�=

0.2

06

P =

.07

2 (N

S)†

No

stat

istic

al

anal

ysis

betw

een

RFA

and

RTV




Cehreli et al

Tabl

e 4

In

Vit

ro S

tudi

es

No.

of

No.

of t

est

test

sit

esM

etho

d of

Add

itio

nal

Aut

hor

mod

els

Sit

eM

etho

dIm

plan

tsor

impl

ants

asse

ssm

ent

asse

ssm

ent

Sig

nifi

canc

eC

orre

lati

on

Ceh

reli

et a

l57

Lach

man

n et

al5

8

Lach

man

n et

al5

9

Sak

oh e

t al6

0

Kim

et a

l61

C =

Con

ical

; CH

= c

ylin

dric

-hyb

rid; C

P =

conv

entio

nal b

one

sock

et; C

YN =

cyl

indr

ic; I

TV =

inse

rtio

n to

rque

val

ue; P

OT

= Pu

sh-o

ut te

st; P

TV =

Per

iote

st v

alue

; RFA

= re

sona

nce

freq

uenc

y an

alys

is;

UP

= un

derd

imen

sion

ed s

ite p

repa

ratio

n.

*One

-taile

d pa

ired

t tes

t; †

linea

r re

gres

sion

; ‡Pe

arso

n co

rrel

atio

n co

effic

ient

.

1 2 NA

5 1. I

n

vitr

o,

2. b

eagl

e

dogs

Expe

rimen

tal

met

al b

lock

Blo

cks

of

bovi

ne b

one

Expe

rimen

tal

acry

lic b

lock

Porc

ine

iliac

bone

blo

ck

1. In

vitr

o sa

w-

bone

,

2. b

ucca

l sid

e

of m

axill

a an

d

man

dibl

e

Dyn

amic

fatig

ue te

st

up to

50

0,0

00

cyc

les

1. M

anua

l vs

torq

ue-

cont

rolle

d at

tach

men

t,

2. l

oose

ning

and

retig

hten

ing

of a

ttac

h-

men

t scr

ew 3

. com

pari-

son

of im

plan

t sta

bilit

y,

4. r

educ

tion

of p

eri-

impl

ant b

one

heig

ht

Red

uctio

n of

per

i-

impl

ant b

one

heig

ht

CP

and

unde

rdim

en-

sion

ed s

ite p

repa

ratio

n

ITV

and

RTV

of C

and

CYN

in v

itro

saw

bone

mod

el

synO

cta

ITI

Fria

lit-2

Mac

hine

d B

råne

-

mar

k, F

rialit

-2

C a

nd C

H C

amlo

g

self-

tapp

ing

1.6

�6-

mm

Ti-6

Al-4

V du

al-to

p

orth

odon

tic

min

i-im

plan

t

(C a

nd C

YN)

16 8

NA

NA

20

impl

ants

(tor

que

test

), 3

2 im

plan

ts

(RFA

and

his

tom

or-

phom

etry

)

1. P

erio

test

(at e

ach

105

load

cyc

le);

2. R

T (s

trai

n-

gaug

ed c

usto

m-m

ade

torq

ue w

renc

h/da

ta

acqu

isiti

on s

yste

m) a

t

5 �

105

load

cyc

les

Perio

test

, RFA

(Oss

tell)

Perio

test

, RFA

(Oss

tell)

Elec

tron

ic to

rque

forc

e

mea

sure

men

t dev

ice

(Oss

eoC

are

DEC

601

), R

FA

(Oss

tell)

1. I

TV (E

lcom

ed S

A20

0C

,

W&

H),

2. R

TV, 3

. RFA

with

inte

rmed

iate

jig

Insp

ectio

n

unde

r 10

�

mag

nific

atio

n

- - – Rad

iogr

aphi

c

bone

den

sity

,

push

-out

test

His

tolo

gy a

nd

hist

omor

phom

-

etry

• P

TV-s

ynO

cta

abut

men

t at 5

�10

5

load

cyc

les:

P=

.015

• P

TV-s

olid

abu

tmen

t at 5

�10

5 lo

ad

cycl

es: P

= .0

29

• M

anua

l vs

torq

ue c

ontr

olle

d at

tach

-

men

t-ISQ

: sof

t bon

e: t

= 2.

5, P

= .0

45;

hard

bon

e: t

= 3.

5, P

= .0

2*

• B

one

com

posi

tion-

RFA

: P<.

000

1*

• B

one

com

posi

tion-

PTV:

P<

.000

8*

• B

one

loss

-impl

ant s

tabi

lity:

P<

.000

1

• P

eri-i

mpl

ant b

one

loss

-Per

iote

st a

nd

Oss

tell:

P<

.000

1

• IT

V (C

P:C-

CH):

P<

.001

• IT

V (C

and

CH

:UP-

CP):

P<

.05

• P

TV (C

H-C

): P

< .0

5

• P

TV (C

:CP-

UP)

: P<

.05

• IS

Q (C

P-U

P): P

> .0

5 (N

S)

• IS

Q (C

-CH

): P

> .0

5 (N

S)

• P

OT

(C-C

H):

P<

.01

• P

OT

(CH

:UP-

CP):

P<

.05

• IT

V (C

-CYN

): P

< .0

01

• R

TV (C

-CYN

): P

< .0

01

• IS

Q (C

-CYN

): P

> .0

5 (N

S)

No

stat

istic

al

anal

ysis

bet

wee

n

PTV

and

RTV

• P

TV-R

FA†:

r2 =

0.8

, P<

.000

1†

• P

TV-R

FA: r

2 =

0.9,

P<

.000

1†

• N

o st

atis

tical

anal

ysis

bet

wee

n

PTV,

RFA

, and

ITV.

• P

OT-

PTV:

P<

.05‡

• P

OT-

ITV:

P<

.05‡

• P

OT-

RFA

: P>

.05

(NS)

‡

No

stat

istic

al a

naly

-

sis

betw

een

RFA

and

ITV

and

RTV



is no publication bias. If the chance of publication isgreater for studies with positive statistically signifi-cant results, larger effect size estimates, or some otherless defined mechanism, the shape of the funnel plotmay become skewed.10 The plot of the nine studieshas a funnel image and therefore there is no publica-tion bias. In addition, possible publication bias wasassessed by the rank correlation test and yielded P =.21, which reveals that there was no publication biasat the 95% confidence level. In addition, the Begg test(P = .92, with continuity correction) and the Eggertest (P = .78) also revealed no publication bias at the95% confidence level.

It has already been suggested that perhaps thebest way of dealing with the quality of studies in ameta-analysis is through the use of sensitivity analysis.In such a way, the robustness of the results of a meta-analysis can be assessed through changing the stud-ies that are included. A simple but informative

sensitivity assessment can be performed by repeatingthe meta-analysis systematically and excluding eachindividual study in turn. Perhaps the most effectiveway of displaying the results of such an assessment isto create a plot that shows each pooled result, with astudy excluded, compared to the pooled result includ-ing all studies.62 In the present analysis, the point esti-mate and confidence interval did not changematerially with the exclusion of any individual study(Fig 3). Methodologic quality was assessed using achecklist given by Downs and Black.62 Answers werescored for the included articles. The total maximumscore was 31. This scoring was carried out by onereviewer and checked by a second reviewer. The qual-ity scores of the studies and the ranking of the studiesusing the quality scores are summarized in Table 5.Studies were stratified into high-quality and low-qual-ity studies using the quality score. The median qualityscore was calculated. Studies with scores higher than


Cehreli et al

Fig 1 Forest plot of nine studies that included r values (pointestimate and 95% confidence intervals).

Fig 2 Funnel plot of nine studies including r values.

–0.2 0 0.2 0.4 0.6 0.8 1.0Point estimate

0.700.60

0.50

0.40

0.300.20

0.10

0

Sta

ndar

d er

ror

Fig 3 Point estimate and confidence interval with study removedof nine studies including r values.

Table 5 Quality Scores and Ranking of Studies

Study Quality score Ranking of study

Akca et al20 5 9Akca et al24 8 4 (tie)Friberg et al26 9 2 (tie)Turkyilmaz32 8 4 (tie)Turkyilmaz et al34 7 7 (tie)Turkyilmaz et al35 9 2 (tie)Alsaadi et al38 12 1Turkyilmaz et al41 8 4 (tie)Schliephake et al55 7 7 (tie)

Akca et al20

Akca et al24

Friberg et al26

Turkyilmaz32

Turkyilmaz et al34

Turkyilmaz et al35

Alsaadi et al38

Turkyilmaz et al41

Schliephake et al55

–0.50 0.00 0.50 1.00

Akca et al20

Akca et al24

Friberg et al26

Turkyilmaz32

Turkyilmaz et al34

Turkyilmaz et al35

Alsaadi et al38

Turkyilmaz et al41

Schliephake et al55

–0.50 0.00 0.50 1.00



the median (8) were classified as high-quality studies,while studies with the median quality score or lowerwere classified as low-quality studies. Pooled esti-mates were calculated for the high- and low-qualitystudies. Pooled estimates were 0.541 (95% confi-dence interval [CI], 0.183 to 0.899; P = .00) and 0.564(95% CI, 0.247 to 0.882; P = .00) for high-quality andlow-quality studies, respectively. A cumulative meta-analysis based on a quality score can be conducted.In such an analysis, trials are combined, starting withthe highest-quality study and adding in studies oneby one in descending order of their quality score. Apooled estimate is calculated after each additionalstudy. Inspection of this graph can provide an oppor-tunity to discern the effect of quality on outcome (Fig4).10 Because the quality of studies that included rvalues was low and the differences betwen groupswere not remarkable, the pooled estimate valueswere similar.

Since a fixed-effect model r of 0.577 (standarderror [SE] 0.03; P = .000), a random-effect model r of0.554 (SE 0.109; P = .000), and a Q value of 94.57 (P =.000) were found, the studies had heterogeneity.Because the random-effect model led to an r value of0.554, cutting torque/insertion torque and RFAshowed a direct relationship of 55.4%, which was sta-tistically significant (P = .000). When the cadaver stud-ies were excluded from this analysis and the outcomewas re-evaluated, the studies had heterogeneity: thefixed-effect model r was 0.629 (SE 0.032; P = .000), therandom-effect model r was 0.637 (SE 0.099; P = .000),and the Q value was 48.44 (P = .000). The random-effect model, with r = 0.637, showed that the clinicalstudies detected a direct relationship of 63.7%between cutting torque/insertion torque and RFA,which was statistically significant (P = .000). When theanalysis was undertaken for the cadaver studies,homogeneity was detected: the fixed-effect model rwas 0.726 (SE 0.029; P = .000), the random-effectmodel r was 0.726 (SE 0.029; P = .000), and the Q valuewas 0.457 (P = .499). The fixed-effect model yieldedan r of 0.726, showing a direct relationship of 72.6%between cutting torque/insertion torque and RFA,which was statistically significant (P = .000). Amonganimal studies, only one55 provided an r value(–0.149).

For comparison of cutting torque/insertion torqueand reverse torque test values, r values were providedin two studies.18,24 The studies had homogeneity: thefixed-effect model r was 0.876 (SE 0.114; P = .000), therandom-effect model r was 0.876 (SE 0.114; P = .000),and the Q value was 0.117 (P = .732). These studiesrevealed a direct relationship of 87.6% between cut-ting torque/insertion torque and reverse torque testvalues, which was statistically significant (P = .000).

DISCUSSION

The reason for carrying out this meta-analysis for arti-cles after 1998 was that, according to the presentsearch, RFA was introduced in 1996 and studies oncutting torque (insertion torque) measurementsappear after 1999; therefore, comparative studiesbetween these techniques were not present before1998.The present meta-analyses showed that most ofthe studies involved had focused on exploring possi-ble correlations between cutting torque/insertiontorque and RFA. This is caused by the duration of useof the Periotest device, which is no longer commer-cially available. Today, RFA is more common. Con-trolled torque application in a stepwise manner is notavailable in some commercially available devices,which makes exploration of the correlation betweensome parameters (cutting torque/insertion torqueand RFA) irrelevant. In the present meta-analysis,comparisons of cutting torque/insertion torque withreverse torque test values and of Periotest with cut-ting torque/insertion torque or RFA were performedin a limited number of studies and, therefore, it seemsthat a reliable conclusion cannot be drawn from sucha small pool of evidence. Among in vitro studies,two58,59 provided r values for comparison of Periotestand RFA. Because the number of test sites was notprovided in the latter study,59 the r values could notbe combined. If this had been possible, the relation-ship between Periotest and RFA would have been sta-tistically significant.


Cehreli et al

Fig 4 Cumulative meta-analysis based on a quality score (pooledestimate and 95% confidence intervals).

Alsaadi et al38

Friberg et al26

Turkyilmaz et al35

Akca et al24

Turkyilmaz32

Turkyilmaz et al41

Turkyilmaz et al34

Schliephake et al55

Akca et al20

–0.50 0.00 0.50 1.00



The use of P values of available studies and r val-ues with or without involvement of cadaver and ani-mal studies showed that the correlation betweencutting torque/insertion torque and RFA was statisti-cally significant. Of these studies, the largest samplesize was found in the study by Alsaadi et al,38 inwhich both cutting torque/insertion torque and RFAmeasurements were undertaken on 142 implants andhad an r of 0.583. Using the same implant system,Alsaadi et al38 measured cutting torque/insertiontorque and RFA of 136 implants. Although the samplesize in these two studies is similar, the correlationcoefficient between these two variables was r = 0.20(SE = 0.08) in the latter study. The r value of this studyis the lowest among all the r values used in the pre-sent meta-analysis. When r approaches 1 (100%), thecorrelation between the two parameters increases,indicating a strong relationship. In the study of Turky-ilmaz et al,35 however, the authors calculated a corre-lation of 20% between cutting torque/insertiontorque and ISQ, which was found to be statisticallysignificant (P = .01).

Among the studies dedicated to quantification ofcutting torque/insertion torque (n = 15 for both eval-uation of P and r values), the OsseoCare unit (NobelBiocare) was used in seven studies,26,32,34,35,38,41,55 acustom-made strain-gauged torque wrench con-nected to a data acquisition system was used in twostudies,20,24 and the measuring device was not identi-fied in two studies.16,52 The OsseoCare unit can applyonly a limited amount of torque (20, 30, 40, or 50 Ncmin the surgical mode and 10, 20, 32, or 45 Ncm in theprosthetic mode), and it has function measures thatcan only be used during low-velocity surgery andprosthetic modes. In all the studies that involved theuse of the OsseoCare unit, no attempt to calibrate thedevice was undertaken, such as the methods used byO’Sullivan et al30,50; therefore, the accuracy of the cut-ting torque/insertion torque measurements isunknown. Likewise, the studies by Nkenke et al16,52

did not include calibration experiments. The custom-made strain-gauged torque wrench used in two stud-ies20,24 had two strain gauges bonded on two sides.The strain-gauge data from the custom-made wrenchwere simultaneously digitized by a data acquisitionsystem during insertion of the implant and weredisplayed in a computer by the software at a highsample rate. The findings from calibration experi-ments of this torque wrench were published inanother article63 and revealed that the highest stan-dard deviation in strains occurred for 67 Ncm of torqueand was 0.84 µ�. The linear regression to data pointsyielded the calibration constant as 0.126 Ncm/m�with R2 = 0.99997.

Another important parameter of the studies thatincluded cutting torque/insertion torque measure-ments may be the implant system used in the experi-ments. Six studies26,32,34,35,38,41 used Brånemarkimplants, two studies16,52 used Frialit implants, twostudies used Straumann implants,20,24 one study usedan Astra Tech implant,20 and one study55 used experi-mental implants. Implant design might be an impor-tant factor leading to the significant correlationfound between cutting torque/insertion torque andRFA in the present meta-analysis. The study by daCunha et al29 (Table 2) found a significant correlationbetween cutting torque/insertion torque and RFA forBrånemark TiUnite implants but not for Brånemarkstandard implants. This study was not included in themeta-analyses because exact P and r values were notprovided. With Frialit-2 implants, Nkenke et al16 couldnot find a correlation between cutting torque/inser-tion torque and RFA. Using experimental implants,Schliephake et al55 could not detect a statistically sig-nificant correlation between cutting torque/insertiontorque and RFA. Likewise, a cadaver study22 using ITIimplants ( Table 1) and a clinical study36 of Xiveimplants ( Table 2) could not find correlationsbetween cutting torque/insertion torque and RFA.

When data gathered in one research project arepartially reported as if they represent a single study, aproblem of statistical significance can arise, particularlyfor future meta-analyses. In scientific publishing, theleast publishable unit is the smallest amount of infor-mation that can produce a publication in a journal.Thisapproach, which is known as salami publication orsalami slicing,64 can lead to a distortion of the scientificliterature, as it may cause the same data to be countedseveral times as apparently independent results in col-lective studies. Inevitably, unsuspecting readersassume that data presented in each “salami slice” (eacharticle) is derived from a different subject sample. Inthe present meta-analysis, four articles32,34,35,41 wereundertaken predominantly on the same patient popu-lation, in which the number of assigned implants orthe patients differed between the publications. Never-theless, the inclusion of these studies did not changethe outcome of this meta-analysis.

CONCLUSIONS

This meta-analysis showed that there is a strong cor-relation between cutting torque/insertion torquemeasurements and resonance frequency analysis.Reliable conclusions cannot be drawn from publica-tions relating to comparison of other asessment tech-niques because of the very limited evidence.


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meta-analysis of methods used to assess implant stability

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