journal of dentistry 38 (2010) 612–620

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Review

The role of primary stability for successful immediate loading

of dental implants. A literature review

Fawad Javed a, George E. Romanos b,*

a
Division of Research, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
b
Eastman Institute for Oral Health, Division of Periodontology, University of Rochester, Rochester, NY, United States

article info abstract

Article history: Objectives: To assess the role of primary stability for successful immediate loading (IL) of
Received 21 December 2009 dental implants.
Received in revised form Data: Original articles studying the role of primary stability for successful immediate
13 March 2010 loading of dental implants were included. The reference lists of potentially relevant review
Accepted 14 May 2010 articles were also sought.
Sources: The MEDLINE-PubMed databases were searched for appropriate articles addressing
the objectives of the present study. Databases were searched from 1979 up to and including
Keywords: April 2010. The search was performed using a variety of keywords in different combinations.
Dental implants Articles published only in English language were included. Letters to the Editor, historical
Immediate loading reviews and unpublished articles were not sought.
Osseointegration Conclusions: There is a significant biological response by the hard and soft tissues to IL of
Primary stability dental implants. Within the limitations of the present literature review, it is evident that the
core issue to observe during IL is the establishment of a good implant primary stability.
There is sufficient evidence to suggest that the degree of achieved primary stability during IL
protocols is dependent on several factors including bone density and quality, implant shape,
design and surface characteristics and surgical technique. Further research is required in
situations, such as poor bone quality and quantity and multiple implants or augmentation
procedures, which may challenge the attainment of primary stability during IL.
Published by Elsevier B.V.

1. Introduction the time of insertion and following loading of the implant. It

The introduction of osseointegrated implants in dentistry
symbolizes a turning point in clinical dental practice.
Immediate loading (IL) of dental implants has recently gained
popularity due to several factors including reduction in
treatment time and trauma as well as aesthetic and
psychological benefits to the patient. A fundamental prereq-
uisite for implant success is substantial primary stability at
may be considered as the unifying principle behind the need
for adequate bone volume and density, longer or wider
implants, and the 3–6-month delay recommended before
implants are placed in function. A poor primary stability is
one of the major causes of implant failure1; other related
causes of implant failure include inflammation, bone loss,
and biomechanical overloading.2,3 An early detection of
problems is essential and every effort should be made to

* Corresponding author. Tel.: +1 585 276 5017.

E-mail addresses: fawjav@gmail.com (F. Javed), Georgios_Romanos@urmc.rochester.edu (G.E. Romanos).
0300-5712/$ – see front matter . Published by Elsevier B.V.
doi:10.1016/j.jdent.2010.05.013
 journal of dentistry 38 (2010) 612–620
treat the problem while the damage can still be controlled or
even overturned.
Although establishment of a good primary stability has been
the primary focus during implant placement, there are numer-
ous other factors that may contribute in providing an initial
retention to the implant. Therefore, it is critical to maintain the
integrity of the peri-implant tissues since bone resorption takes
place with or without implant placement in the fresh extraction
socket.4 However, research and understanding in this area is still
unclear and results are sometimes confounding. Specifically, for
immediately loaded implants, the role of the primary implant
stability with the surrounding, mature bone seems to be crucial
for the long-term success.5–8 Hence, in the present literature
review, we aimed to assess and clarify the significance of
primary stability during IL of dental implants.
1.1. The concept of immediate loading
Traditionally, endosseous implants are loaded once bone
healing at the bone–implant interface has occurred. The
complete healing phase may take up to 12 months following
extraction.9,10 However, this post-extraction period may be
accompanied by several problems such as alveolar bone
resorption as well as psychological distress to the patient.
Today immediate loading (IL) of dental implants is an
eminent and acknowledged treatment strategy which is
extensively being used for the rehabilitation of missing teeth
in healthy as well as medically compromised individuals.6,11 IL
may be described as functional loading (with occlusal
contacts) immediately after implantation (or within 3–4 days
after surgery) without waiting for the healing period.4,12,13 IL
has gained popularity due to less tissue trauma, reduced
overall treatment time, decreased patient’s anxiety and
discomfort, high patient acceptance and better function and
aesthetics.14,15 In a clinical retrospective study, dental
implants were loaded immediately after surgery in the area
of the mental symphysis in 226 individuals.16 This study
concluded that the success of immediately loaded implants is
similar to that obtained in the case of delayed loading, once
osseointegration has occurred.16 Studies based on histologic
and histomorphometric evaluation of immediately loaded
implants recovered from humans have also shown a high
degree of bone-to-implant contact percentages.5,17
2. Objectives
The aim of the present literature review was to evaluate the role
of primary stability for successful IL of dental implants. In this
regard, the addressed focused question was: Is there a relation-
ship between primary stability and successful IL of dental
implants? Several factors influence primary stabilization of
dental implants, therefore the pattern of the present review was
customised to mainly summarize the pertinent information.
2.1. Search strategy
As a first step, the authors (FJ and GER) searched the National
Library of Medicine, Bethesda, Maryland (MEDLINE-PubMed) for
appropriate articles addressing the focused question. Databases
613
were searched from 1979 up to and including April 2010 using
the following terms in different combinations: ‘‘immediate
loading’’, ‘‘dental implants’’, ‘‘early loading’’, ‘‘delayed loading’’,
‘‘oral implants’’, ‘‘immediate restoration’’, ‘‘primary stability’’,
‘‘initial stability’’, ‘‘implant shape’’, ‘‘implant design’’, ‘‘bone
mineral density’’, ‘‘surgical technique’’ and ‘‘review’’. This was
supplemented by hand-searching in peer-reviewed journals
and cross-referenced with the articles accessed. Any disagree-
ment between the authors was resolved via discussion.
2.2. Eligibility criteria
The following eligibility criteria were imposed:
 Clinical and animal studies.
 Intervention: immediate loading of dental implants.
 Reference list of potentially relevant research articles.
 Articles published only in English language.
Letters to the Editor, historical reviews and unpublished
articles were not sought.
3. The role of primary implant stability
Osseointegration occurs in two levels: primary and second-
ary.18 Primary osseointegration is associated with the me-
chanical engagement of an implant with the surrounding bone
after implant insertion; whereas bone regeneration and
remodelling offers secondary osseointegration (biological
stability) to the implant.18,19
Primary stability, defined as the biometric stability immedi-
ately after implant insertion, is a critical factor that determines
the long-term success of dental implants.20 In other words,
primary stability is the absence of mobility in the bone bed after
the implant has been placed. The phenomenon behind this is
the same as that applied for reduction of fractured long bones;
that is, there should be utterly no movement between the
fragments when the ends of a fractured long bone are reduced
to endorse fracture healing.21 This is because movements even
at the micrometer range can induce a stress or strain that may
hinder the formation of new cells in the gap. Likewise, during
implant healing a micromotion between 50 and 150 mm may
negatively influence osseointegration and bone remodelling by
forming fibrous tissues at the bone-to-implant interface
thereby inducing bone resorption.22,23
Several studies4,5,13,24–28 have reported high success rates
with IL of dental implants, which are attributed to high primary
stability. In some clinical studies29–31 an immobilization using
splinting (cross-arch restorations or partial splinting) was
necessary to increase the stability of the implants after surgery.
4. Primary stability for immediate loading in
single-tooth implants
4.1. Immediate loading in healed sites
Clinical studies on IL in healed sites have reported positive
outcomes in terms of implant survival, marginal bone
614 journal of dentistry 38 (2010) 612–620
resorption, soft tissue levels, the incidence of complications of
treatment.32–34 IL in healed sites has been shown to osseoin-
tegrate successfully provided the preoperative planning,
patient selection and surgical guidelines are appropriately
followed.35 Furthermore, a high degree of primary stability and
insertion torque are also a major prerequisite.36,37 Immediate
loading of single-tooth implants was performed in healed
extraction sites in 20 adult patients. The results showed a
satisfactory success rate with positive tissue response. In this
study, the mean change in marginal bone level was 0.01 mm at
12 months interval reflecting the presence of sufficient
primary stability.38 Several studies have reported a success
rate of 100% for IL in healed sites compared to implants
inserted in fresh extraction sites.13,14,39
4.2. Immediate loading at the time of extraction (fresh
extraction sites)
There is adequate data to verify the fact that placing implants
immediately after extraction is an alterative to implant
placement after socket healing.40–43 It is mandatory for such
implants to have an implant stability similar to that when
placed in healed sites. Studies on animal models have also
shown that the dimensions of peri-implant soft tissues remain
within the biological range and are not negatively influenced
by IL.6,7,44 Mijiritsky et al.45 investigated the long-term survival
of single-tooth implants immediately placed in fresh extrac-
tion sites with a 6-year follow-up. In this study, 24 implants
were placed in fresh extraction sites in 16 patients. The results
demonstrated an overall implant survival rate of 95.8%. The
study concluded that successful osseointegration can be
accomplished with IL implants in fresh extraction sites. The
peri-implant conditions were also stable till the sixth year of
follow-up.45 Likewise, Degidi et al.39 evaluated the long-term
survival of 111 immediate implants placed in 111 individuals
with immediate provisionalization (out of occlusion) and
monitored them over a period of 5 years. The parameters for
overall success rate were defined by bone resorption of less
than 1.5 mm after the first year of IL and less than 0.2 mm
subsequently.39 The study reported a success rate of 92.5% for
immediately loaded implants placed immediately after ex-
traction compared to IL at healed sites (success rate: 100%).39
Barone et al.46 placed 18 immediately restored implants placed
in fresh extraction sockets in 18 subjects. During the 1-year
follow-up of individuals participating in this study, 17 of the 18
immediate implants remained successful under function. One
implant was lost due to abscess formation and the overall
implant survival rate was reported to be 94.5%.46 However,
other studies have reported that the success rate of IL of dental
implants in fresh extraction sockets is comparable to IL in
healed sites.26,27 A recent study47 investigated the outcome of
IL in extraction sites affected by periapical infection, such as
fistulas and suppuration. In this study, the test group included
15 patients with periapical lesions or radiolucencies (such as
fistulas or suppuration); whereas the control group included 15
patients without periapical lesions but with root caries or root
fractures. The 2-year follow-up results showed that IL in
extraction sites affected by periapical infection, osseointe-
grated successfully revealing a positive outcome.47 Similarly,
in a prospective clinical study,13 immediate implants were
placed in 13 patients after tooth extraction and 11 patients
received implants after complete socket healing. All implants
were placed in the aesthetic zone and emphasis was
considered on obtaining primary stability by achieving bi-
cortical anchorage and maximum insertion torque of at least
40 Ncm. Within the follow-up period between 1 month and 15
months, all the 24 fixtures showed functional stability. The
success rate for both the immediate implant and implants
placed at healed extraction sites was 100%.13 Lorenzoni et al.48
treated nine patients using an IL protocol. None of implants
failed up to 1 year after insertion, resulting in a survival rate of
100%. Similar results were reported in other studies, where IL
of single-tooth implants placed in fresh extraction sockets was
suggested as a valuable alternative to replace a missing
tooth.36,49
In contrast, a comparative study by Chaushu et al.15
reported data for IL, where 19 implants were installed in fresh
extraction sites and nine implants were placed in healed sites.
After a follow-up period ranging from 6 to 24 months, the
survival rates for immediate implants versus implants placed
after healing were 82.4% and 100% correspondingly. The study
concluded that IL in fresh extraction sites carries a failure risk
of approximately 20% whereas IL in healed sites is a more
promising treatment alternative.15 The success rate of IL in
fresh extraction sites has been reported to range between 79
and 85.7%.50–52 These results are summarized in Fig. 1.
5. Implant design and surface characteristics
in relation to immediate loading
Implant design, a vital parameter for attaining primary stability,
refers to the three-dimensional structure of an implant with all
the components and features that characterize it.6,16,53,54
Implants of varying designs reach various degrees of stability,
which may determine their future clinical performance.55–57
The screw or ‘‘threaded’’ design minimizes the implants’
micromotion during function thereby maintaining the primary
stability.58 Furthermore, a threaded design also increases the
surface area of the implant thereby offering a higher percentage
of bone-to-implant contacts, in comparison to implants with a
cylindrical design. Therefore, threaded type implants are
generally recommended and particularly for IL.4,31,59 The
Vandamme study60 also showed that threaded implants offer
significant bone-to-implant contact during (compared to
cylinder-shaped implants), which may also enhance the
secondary stability. It is accepted that all implants display
some extent of bone loss after osseointegration and through
time of function. It has been claimed that the introduction of
microthreads or ‘‘retention grooves’’ at the neck of the implant
may also assist in reducing distributing stress and reducing the
extent of bone loss following the implant installation.61 Hence,
cylinder-type implants seem to be contraindicated for IL
regimes due to lowering of primary stability and less resistance
to vertical movement and shear stress.62 However, according to
the Chong study,53 if bone quality and quantity are optimal,
then they may compensate for implant design inadequacy.
Tapered implants were initially designed mainly to serve
for IL after tooth extraction. The theory behind the use of
tapered implants is to provide for a degree of compression of
 journal of dentistry 38 (2010) 612–620
Fig. 1 – Studies on immediate loading of single-implant-supported prosthesis in fresh extraction sites.
the cortical bone in a poor bone implant site.63 Cylindrical
wide body implants increase the risk of labial perforation due
to buccal concavities; whereas the decrease in diameter of the
tapered implants toward the apical region accommodates for
the labial concavity.64 In a study, tapered titanium implants
(with lengths and diameters ranging between 3.3 and 5.5 mm
and 13–16 mm respectively) were placed in 16 individuals.
After a mean follow-up duration of 40.7 months, the overall
implant survival rate was reported to be 95.8%.45
Implant surface characteristics have also been shown to
influence osseointegration. Studies have shown that surface
topography and roughness positively influence the healing
process by promoting favourable cellular responses and cell
surface interactions.16,26 Rough surfaces are considered to
enhance primary stability as they present a larger surface area
and allow a firmer mechanical link to the surrounding
tissues.8,65 Studies have reported that the type of loading
contributes to the provision of high torque resistance after
healing in implants placed in the posterior region of the
mandible.7,8,66 A primate study66 demonstrated that implants
treated with sandblasted surface and a progressive thread
design can achieve osseointegration when immediately
loaded. In these studies, the role of the progressive thread
design has been emphasized. In vitro studies67,68 have shown
that sandblasted implant surfaces promote peri-implant
osteogenesis by enhancing the proliferation and metabolic
activity of osteoblasts. In poor bone quality sites, implants
with an acid-etched surfaces can achieve a significantly higher
bone-to-implant contact compared to implants with a
machined surface.69 In a study by Ibañez et al.,70 full arch
restoration was provided to 41 individuals with 343 double
acid-etched surface implants (bruxers and smokers were also
included). The success rate was reported as 99.42% and the
study concluded that a high success rate with IL can be
obtained using double acid-etched surface implants.70 In
another study, 405 implants with micro-textured acid-etched
surface were consecutively installed in 11 completely and 164
partially edentulous individuals. The 3-year follow-up results
615
showed a cumulative success rate of 97.5% for the mandible
and 98.4% for the maxilla.71 IL with hydroxyapatite-coated
implants has also shown constancy in implant stability and
peri-implant tissue conditions when compared to conven-
tional delayed loaded implants.72
6. Immediate loading with reference to bone
density and quality
Variations in bone density can occur in all locations in the oral
cavity. Bone quality is often referred to as the amount of
cortical and cancellous bone in which the recipient socket is
drilled. For example, the densest bone is frequently located in
the anterior mandible, followed by premaxilla and the
posterior mandible. The least dense bone is usually present
in the posterior maxilla as well as mandible. In this context,
the clinicians should confirm their assumptions regarding
bone density at the time of osteotomy development, since
bone density at an implant site is a significant feature with
respect to surgical protocol and osseointegration. According to
Romanos et al.7 implant stability in the long-term after IL
seems to be increased due to the significant increase of the
peri-implant bone density at the implant–bone interface.
A poor bone quantity and quality have been indicated as
the main risk factors for implant failure as it may be associated
with excessive bone resorption and impairment in the healing
process compared with higher density bone.7,73 According to
Misch,74 most of the immediately loaded implants are placed
in anatomical sites with dense and good quality bone. The
mandible (particularly in the interforaminal region) has a
better bone quality compared to the maxilla and this is
probably the reason why reports are available regarding IL in
the anterior part of the mandible with high survival rates.5,11 A
histological study7 based on animal models, reported compa-
rable bone quality values around implants placed in the
posterior regions of mandible, following delayed as well as IL
protocols. In a human split mouth designed study24 it has been
616 journal of dentistry 38 (2010) 612–620
Fig. 2 – Success of immediately-loaded implants in the maxilla (modified from Rocci et al., 2003).52 Numbers of implants
inserted in the maxillary regions are shown in parenthesis.
concluded a high success rate (100%) of immediately loaded
implants in a similar way like delayed loaded implants. In
general, the use of IL in the anterior region of the mandible
seems to play a significant role in the overall success since this
region has the best bone quality.4 Clinical studies75,76 have
reported dental implants in the mandible to have higher
survival rates compared to those in the maxilla, especially for
the posterior maxilla. In another study, immediately loaded
implants in the anterior maxilla showed successful osseoin-
tegration (96%) with stable peri-implant conditions till at
least the sixth year of follow-up.45 Cross-arch restorations on
immediately loaded implants placed in the maxilla presented
high success rates (96.66% after 6 years of loading), when the
implants have a design allowing high implant primary
stability.23 Results by Rocci et al.52 have reported a successful
IL in the posterior maxilla (Fig. 2).
7. Impact of surgical technique on the primary
stability
Besides the quantity and quality of bone and morphology of
the implant, the surgical technique adopted also influences
primary stability during IL. Surgical principles used to obtain a
successful IL focus on two primary factors, atraumatic surgery
and establishing rigid, initial stability. An atraumatic surgical
technique is essential to maintain cellular viability thereby
preventing the formation of an epithelial connective tissue
layer along the bone–implant interface and promote heal-
ing.77,78 Thus, if proper surgical techniques are applied, then
the clinical outcomes of IL can be superior to those for
conventional delayed loading protocols.79 Likewise, IL with
flapless surgery technique has also been shown to reduce the
treatment period and enhance implant stability compared to
the conventional flap surgery protocol.80,81 According to Oh
et al.,82 a flapless implant surgery provides esthetic soft tissue
results in single-tooth implants either immediately or delayed
loaded. Some studies have also preferred insertion torque as a
determinant of implant stability and torque values of 32, 35,
40 N cm and higher have been chosen as thresholds for IL.13,48
The use of computed tomography for a three-dimensional
evaluation of bone implant sites is an interactive method for
treatment planning and the fabrication of stereolithographic
models as custom surgical templates. It has been documented
that the use of stereolithographic appliances in accordance
with flapless surgery assists in the IL of implants.83
The bone condensing technique has also been suggested to
enhance the primary stability of dental implants by increasing
the bone density. Experimental studies have shown that bone
condensing increases the bone-to-implant contact in early
phases of implant placement.84,85 However, on clinical
grounds, controversial results have been observed concerning
the efficacy of this surgical method. Several studies30,86–88
have suggested against tapping and/or using osteotome
techniques on recipient sites with poor quality bone. Gulsahi
et al.89 placed single-tooth dental implants by both conven-
tional and bone condensing techniques in 14 patients with
bilateral missing teeth. The results showed no significant
difference in bone mineral density and bone mineral content
between the two implant placement techniques. Interestingly,
the success rate of the conventional technique (92.9%) was
greater than the bone-condensing technique (71.5%).89 Exper-
imental studies90,91 have shown that bone condensing can
lead to fractured spongiosal trabeculae. In another study, 22
implants were inserted using the bone condensing technique
and the labial cortical plate fractured in three patients during
the procedure.92 On the contrary, some clinical studies93,94
have shown that bone condensing yields an improved
histologic bone-to-implant contact.
IL using cross-arch fixed restorations has been shown to
enhance implant primary stability. In a study by Romanos and
Nentwig,24 implants were connected with their abutments
and splinted immediately after surgery using cross-arch fixed
temporary restorations. After a mean loading period of
approximately 3 years, good implant stability without bone
loss was observed. The results demonstrated a long-term
success (98.6%) of IL implants placed in occlusal function using
fixed cross-arch implant-supported restorations.24
 journal of dentistry 38 (2010) 612–620
8. Methods of evaluation of the primary
stability of the immediately loaded dental
implants
Stabilization of IL implants in the surrounding lamellar bone
has been standardized using a variety of techniques including
the periotest, resonance frequency analysis (RFA) and cutting
torque resistance analysis.
8.1. Periotest
The periotest has been supported as a reliable method to
gauge primary stability.24,95 It is composed of a metallic
tapping rod in a handpiece, which is electromagnetically
driven and electronically controlled. Signals produced by
tapping are converted to unique values called ‘‘periotest
values’’. Periotest has been shown to be helpful in determining
the implant stability not only in conventional implants but
also in IL of dental implants.6,66 According to Dilek et al.96 IL
can only occur if their periotest values in between the range of
8 to +9. Results by Abboud et al.38 also reported that periotest
values of ‘‘ 4’’ are indicative of a successful IL protocol.
However, other studies have given even a narrower range for
periotest values, that is 4 to 2 and 4 to +2.97
8.2. Resonance frequency analysis (RFA)
RFA can be used to monitor the changes in stiffness and
stability at the implant–tissue interface and to discriminate
between successful implants and clinical failures4,98,99; which
was replaced by the ‘‘implant stability quotient (ISQ)’’
introduced by Ostell (Integration diagnostics).5,40,99 However,
it is tricky to characterize a general standardized range of ISQ
readings for a successful implant osseointegration for differ-
ent implant systems.100
In a recent study, Zix et al.98 compared two non-invasive
methods used to measure dental implant stability, such as
Periotest and RFA (Osstell). The results showed that both
measurement techniques had a significant association to the
implant diameter; however, the RFA technique appeared to be
more precise compared to the periotest.98 In another study,
Sjöström et al.99 compared implants placed in grafted and
normal non-grafted maxilla by means of RFA. In this study, the
RFA for failed implants showed lower values compared to
successful implants. Experimental studies100,101 have also
investigated the hypothesis that measurements of implant
stability using RFA correlates with histomorphometric data of
bone anchorage. However, the results could not verify the
hypothesis since that RFA values at the time of implant
placement did not correlate with the torque required to tap the
bone for implant placement. The study concluded that validity
of the individual measurement of implant stability using RFA
should be considered with caution.101 The results of the
clinical studies should be evaluated with caution, because the
boundary height, width, and density factors can influence the
resonance frequency of dental implants.102
However, there is no clinical study today, which proves the
RFA level for implants, which survived in a long-term and the
necessary minimum RFA threshold we need for the success of
IL implants.
617
8.3. Cutting torque resistance analysis
In the cutting torque resistance analysis (CRA), the energy
required for an electric motor to cut bone during implant
surgery is measured. This energy was shown to be significant-
ly associated with bone density which influences primary
stability.103 CRA may be used to determine bone hardness and
also to locate areas of low bone density. A torque gauge
incorporated within the drill is used to determine the insertion
torque. According to O’Sullivan et al.,104 there is a significant
difference in CRA between type-1 and type-4 bone types. Major
limitation of this technique is that it does not provide any
information regarding bone quality until an osteotomy is
performed.
9. Conclusion
There is a significant biological response by the hard and soft
tissues to IL of dental implants. Within the limitations of the
present literature review, it is evident that the core issue to
observe during IL is the establishment of a good implant
primary stability. There is sufficient evidence to suggest that
the degree of achieved primary stability during IL protocols is
dependent on several factors including bone density and
quality, implant shape, design and surface characteristics and
surgical technique. Further research is required in situations,
such as poor bone quality and quantity and multiple implants
or augmentation procedures, which may challenge the
attainment of primary stability during IL.
Conflicts of interest
The authors declare that they have no conflicts of interest and
there was no external source of funding for the present study.
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