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Dr. Michael Norton answers your questions

Dec 14, 2022

Dr Michael R. Norton, specialist in Oral Surgery with a practice on London’s Harley Street, is Adj. Professor at the University of Pennsylvania, and Past President of the Academy of Osseointegration (AO), as well as Past President of the Association of Dental Implantology in the UK. He is Associate Editor of the International Journal of Oral & Maxillofacial Implants. Dr Norton’s areas of research include peri-implantitis, primary implant stability and implant design amongst others. He is widely published in the literature.

Questions and answers from the live Q&A

How important to you is the trend in the ISQ values in your clinical decision making?

Dr. Michael Norton: The trend is vital. Using ISQ like torque, i.e. a single measure at time of implant placement is pointless. You neeed to understand what the ISQ trend is, so it is important to take at least one second reading before you restore. If the trend is up then the implant is integrating, if the trend is down then it shows you have a potential problem.

How easy is OsstellConnect to use?

Dr. Michael Norton: Its easy to use, very intuitive.

Is there any clinical evidence of perio-implantitis coming from using too high torque?

Dr. Michael Norton: There is evidence that high torque in the cortical zone causes crestal bone loss. This is a precursor to peri-implantitis.

How do multiunit abutments impact the OSQ value? Is this clinically significant?

Dr. Michael Norton: The choice of abutment or indeed the implant does not affect ISQ. All SmartPegs are calibrated to standardize the ISQ values according to stiffness not according to component.

Hi, thank you for your presentation. For immediate loading we need at least 40ncm primary stabilization torque. But you said best isq value at 25ncm, is it true ?

Dr. Michael Norton: You have been brain-washed to believe you need 40Ncm but this is simply not the case. A torque of 25Ncm can be more than enough.

Do you communicate the recorded ISQ values to your patients along with their healing trends? If so, at what points in the treatment and how?

Dr. Michael Norton: I like to show patients their graphs for ISQ to explain that the implant is integrated or perhaps more to show that implant has not integrated adequately. This then allows me to explain why I will delay loading for example.

How much thinner compared to implant ,should final drill be, in oder to achieve an adequate primary stability and proper ISQ? For example some companies advice fot a 4.2 mm implant to drill at 3.2mm. Is this correct or it may be better to drill closer to implant diameter with minimum torque & speed?

Dr. Michael Norton: There is no set answer to this as it entirely depends on bone density.

Ho much additional time is required to take an ISQ measurement?

Dr. Michael Norton: Less than 1 minute.

What is the implant glue?

Dr. Michael Norton: This is a material under early investigation and more details will be forthcoming in due course.

The glue replaces the bone graft? Greetings from Mexico.

Dr. Michael Norton: Potentially yes the glue replaces the bone graft but this is material has many more years of investigation before it will be a commercial product.

How often do you make decisions to change clinical treatment pathways due to measured ISQ values?

Dr. Michael Norton: Not so often, since most implants integrate successfully. But when ISQ drops unexpectedly then we alter the treatment pathway. The point is you can never know this with a single measurement of torque!

Is there a universal isq device or we need to buy for every system?

Dr. Michael Norton: The device is universal but each implant system has its own SmartPegs which are all sold by Osstell. They provide a compatibility chart so you know which SmartPegs to order.

Do we have any histological studies on the tetranite?

Dr. Michael Norton: Yes. Cochran et al published data in JOMI 2020; 35:39-51 & COIR 2022;33:391-404.

What is the glue material?

Dr. Michael Norton: To learn more about the glue read Norton M et al Int J of Adhesion & Adhesives

Could you pls talk little more about the healing pattern of the bone glue and how it will get transformed into actual bone? And the also about the material like what exactly it is chemically? Thanks.

Dr. Michael Norton: To learn more about the glue read Norton M et al Int J of Adhesion & Adhesives

Any comments on the Versah burs and bone necrosis at high torque?

Dr. Michael Norton: Versah bur compress bone debris into the side of the osteotomy wall to effectively create a stiffer fit. The bone debris will eventually resorb and so stability will be lost for a short time. However the bone debris may protect the osteotomy wall from excessive compressive strain so it may be helpful in that regard.

Can an ISQ VALUE of an implant as low of 37 supplemented by bone graft in the maxillary arch anteriorly at the time of implant insertion , have a chance to increase considerably to the range between 55-85 later on & can we later on gain this implant if the implant is not loaded before 4-6 months?

Dr. Michael Norton: An ISQ of 37 means the implant is materially unstable. If submerged and placed into a protected healing environment then in theory this implant could still osseointegrate and achieve an ISQ of >70.

After progressive loading isq value still didn’t go up then what?

Dr. Michael Norton: If the ISQ does not increase after progressive loading then you may have to consider its removal. I would say if the ISQ is below 65 and it does not increase this implant will be liable to fail at some future time point so it may be better to remove and replace.

What about, all on 4-all on x implants? What is your opinion?

Dr. Michael Norton: This is a treatment concept in which patients are adapted to the prosthetic design. I believe while there is a place for this it is not a panacea for all patients.

If you prepare the implant bed and screwing the implant is becoming difficult, what would you do to avoid increasing loading torque to seat the implant?

Dr. Michael Norton: Remove the implant re-drill using the next widest drill diameter and then re-insert the implant.

Thank you everyone joining us at the Osstell ISQ Symposium. See you again next year!
You can watch the webinar on-demand here.
More information about the symposium can be found on

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