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or 45
were either parallel or perpendicular to the maximum axis of bone stiffness. In the shear tests, the im-
plants aligned at 45
were angled toward and opposing the axis of shear force. Results: The implants aligned
at 90
had the highest force at failure of all the groups (342 680.9 N; P\0.001). In the shear tests, the implants
that were angled in the same direction as the line of force were the most stable and had the highest force at
failure (253 6 74.05 N; P\0.001). The implants angled away from the direction of force were the least stable
and had the lowest force (87 6 27.2 N) at failure. Conclusions: The more closely the long axis of the implant
approximates the line of applied force, the greater the stability of the implant and the greater its resistance to
failure. (Am J Orthod Dentofacial Orthop 2010;137:91-9)
D
espite the serendipitous discovery of the os-
seointegrative properties of titanium and the
subsequent development of titanium dental im-
plants in the 1960s,
1-3
they were not used in orthodon-
tics until the 1980s.
4-9
However, dental implants have
limited anatomic placement options and require a pre-
cise 2-stage protocol and a 3 to 6 month healing pe-
riod.
3,4,6,10,11
Recently introduced miniscrew implants
(MSIs) can be easily placed in almost any intraoral re-
gion, have lower costs, are removed easily, and, conse-
quently, have greater applications for orthodontic
anchorage.
12,13
The success of any implant in providing denitive
anchorage depends on its stability. Most clinical reports
suggest that MSIs are stable with applied forces ranging
from 50 g (0.5 N)
14
to 450 g (4.5 N).
15
However, mini-
screws should not be expected to remain absolutely sta-
tionary during orthodontic loading;
16
MSIs remain
stable as bone remodeling takes place in response to me-
chanical stress.
17-19
This is distinctly different from
movements associated with pathology; these result in
loosened MSIs. Although it seems well established
that MSIs placed with appropriate surgical techniques
can withstand forces in the orthodontic range (1-3 N),
there is only limited information available concerning
the maximum forces that can be applied to them.
Pull-out (tensile) tests are commonly used to evalu-
ate the maximumforces that bone screws can withstand,
and are considered an accurate method of comparing the
relative strength or holding power of surgically placed
bone screws.
20-24
Tests have been conducted with vari-
ous animal bones, including bovine femurs,
20,24,25
por-
cine ribs,
26,27
dog femurs,
20,21
and sheep parietal
bones.
28
There have been only limited pull-out tests on
human mandibles.
23
Importantly, pull-out tests alone
are not adequate for measuring the xation potential of
bone screws, because they do not address shearing
forces.
21,29
Even though pull-out and shear tests produce
forces that substantially exceed those typically used by
orthodontists, these tests provide valuable information
pertaining to primary stability and material characteris-
tics of MSIs.
There are presently no published data on the maxi-
mum pull-out and shear forces that MSIs can withstand,
and there has been only limited pull-out testing of bone
screws in actual anatomic bone sites. Furthermore, there
are no published data on the effect of MSI placement
orientation relative to the bone surface and the axes of
maximum and minimum bone stiffness, despite recent
evidence demonstrating consistent patterns of material
a
Private practice, Moscow, Idaho.
b
Professor and program director, Department of Biomedical Sciences, Baylor
College of Dentistry, Texas A&M University Health Science Center, Dallas.
c
Professor and chairman, Department of Orthodontics, Baylor College of Den-
tistry, Texas A&M University Health Science Center, Dallas.
d
Professor and director of orthodontic research, Department of Orthodontics,
Baylor College of Dentistry, Texas A&M University Health Science Center,
Dallas.
The authors report no commercial, proprietary, or nancial interest in the
products or companies described in this article.
Reprint requests to: Peter H. Buschang, Department of Orthodontics, Baylor
College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246; e-mail,
phbuschang@bcd.tamhsc.edu.
Submitted, September 2007; revised and accepted, December 2007.
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.12.034
91
anisotropy in the cortical bone of various regions of the
human craniofacial skeleton.
30
The purpose of this study was to evaluate the effects
of orthodontic MSI orientation on stability and resis-
tance to failure at the bone-implant interface. The study
was designed to answer the following questions. What is
the maximum amount of force that can be applied to
MSIs in the human mandible? Does loading orientation
affect maximum force? Does the orientation of the long
axis of the miniscrew relative to the surface of the bone
and the direction of the applied force affect the
implants stability and its resistance to failure?
MATERIAL AND METHODS
Nine fresh-frozen, unembalmed, dentate, human ca-
daver mandibles donated for anatomic research pur-
poses were selected for implant placement and testing.
The mandibles came from3 female and 6 male white do-
nors between 48 and 81 years of age. No donors were
known to have suffered from primary bone diseases.
For mounting purposes, impressions were taken of
the test mandibles, and models were poured. Up to 3
custom acrylic (methylmethacrylate) bases were fabri-
cated for each test mandible.
28
To compensate for lin-
gual surface variations, the acrylic base was adapted
to the cortical surface of the entire lingual corpus and in-
ferior ramus. The opposite side of the acrylic base was
ground to a level plane. The acrylic base allowed rigid
xation of the mandible to the test equipment while
maintaining the test site surface orientation perpendicu-
lar to the line of force in the pull-out tests and parallel to
the line of force in the shear tests. Then the custom t to
each lingual surface allowed for uniform distribution of
reaction forces during the application of test loads. It
prevented the development of internal stress/strain in-
duced by exure secondary to xation of the mandible
to the test apparatus. An anterior hole near the mental
foramen and a posterior hole in the inferior ramus
were drilled through the bone sample and the custom
acrylic support base to allow rigid xation of the
mandible to the test equipment.
The tensile and shear testing was completed with
a universal testing machine (model DDL 200RT,
TestResources, Shakopee, Minn), outtted with a 112-
pound calibrated load cell used in tensile mode. Adjust-
able x-axis and y-axis sliding tables (Sherline Products,
Vista, Calif) were mounted to the base of the testing ma-
chine. A 360
or 45
to the
bone surface.
In both sets of the shear tests, along the axis of either
maximum or minimum bone stiffness, the MSIs were in
1 of 3 positions: orthogonal to the buccal surface, angled
at 45
C. Freez-
ing does not adversely affect the elastic properties of
bone measured ultrasonically,
31-33
although it might
have some minor effects on mechanically determined
material properties.
34
Statistical analysis
Preparation of all mandibular specimens, testing,
and data recording were performed by 1 tester
(M.B.P.). Statistical analysis was completed with statis-
tical software (version 14.0, Minitab, State College, Pa).
Fig 1. Test matrix with 9 subgroups.
American Journal of Orthodontics and Dentofacial Orthopedics Pickard et al 93
Volume 137, Number 1
Although the variables distributions were normal, non-
parametric Kruskal-Wallis tests were used for the com-
parisons because of the small sample sizes of the
subgroups. The signicance level of P \0.05 was
used for all tests.
RESULTS
The pull-out tests of the MSIs aligned at 90
to the
cortical surface had a signicantly higher maximum
force at failure (342 6 80.9 N; P \0.001) (mean 6
standard deviation) than all other test groups (Table,
Fig 2). The loading curve for all 3 pull-out test groups
was largely linear until immediately before failure
(Fig 3, A).
At failure, 1 of 2 bone-implant interface congura-
tions was generally seen. In most cases, the bone re-
mained in intimate contact with the MSI at failure.
For MSI failures with intact bone, the 90
MSIs often
had an elliptical surface outline with a conical cross-
sectional shape. Generally, the greatest dimension of
bone was in the direction of maximum bone stiffness
(Fig 4, A). In other cases, the MSI separated from the
bone, with cortical splinters of bone projecting upward
in the direction of the pull-out test.
The pull-out tests of the MSIs aligned at 45
to the
bone surfaceoriented in the direction of either the
minimum or maximum bone stiffnesshad a bone-fail-
ure wedge in the 135
implants.
Fig 4. A, Postfailure bone-implant section of a 90
pull-out test; C, buccal surface response when implant contacts lingual cortex.
American Journal of Orthodontics and Dentofacial Orthopedics Pickard et al 95
Volume 137, Number 1
until primary failure, which occurred as the MSI started
to rotate from the original 45
to 45
in the
same direction as the applied force, the loading curve
usually increased until nal failure of the MSI-bone
interface.
Shear tests of the MSIs aligned 90
to the cortical
surface also demonstrated a nonlinear loading curve
(Fig 3, C). Similar to the MSIs aligned at 45
and oppos-
ing the shear line of force, the loading curve fell after an
initial linear loading response. The slope of the increas-
ing load response decreased but remained positive until
failure. Unlike the MSIs aligned 45
away (tent-
pegged) from the line of force, the highest stress con-
centration would be expected at the 45
degree angle of
bone near the cortical surface (Fig 5). These stress con-
centrations resulted in reductions in MSI stability and
resistance to failure.
The maximum pull-out force of the MSIs aligned at
90
implants opposing
the line of shear force.
96 Pickard et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
Differences could be due to differences in screw de-
sign, length, diameter, and placement location. Huja
et al,
40
for example, showed signicantly smaller max-
imum pull-out forces for 6-mm MSIs placed in the an-
terior (134.5 N) rather than in the posterior (388.3 N)
mandible. Unfortunately, there are no comparable stud-
ies in any bone that report pull-out test results of in-
clined MSIs or bone screws. Shear tests have been
performed on bio-absorbable implants loaded with
50 N, but they were not tested to failure.
29
Because
orthodontic MSIs are primarily loaded in shear, more
studies are needed to explore the variables affecting
MSI stability and resistance to failure when loaded
obliquely or in shear.
A uniform load distribution in the peri-MSI bone
might explain the observed stability and high force at
failure of the uniaxially loaded orthogonal MSIs in
pull-out tests. In this situation, the line of force and
the long axis of the MSI are colinear, and the force is
distributed to the surrounding bone uniformly.
37,39,41
In most pull-out tests, failure did not occur at the
bone-implant interface. Rather, it occurred in the sur-
rounding bone. This suggests that the mechanical reten-
tion of the implant-bone interface was greater than the
cohesive strength of the surrounding bone matrix.
MSIs that have lost their primary stability and be-
come displaced can still support an applied load. This
supports ndings of studies in which mobile MSIs could
still resist orthodontic loading.
16,42
In the shear tests, the
MSIs aligned at 45
to the cortical
surface. During the third phase, the MSI continues its
rotation toward the line of force until additional load re-
sults in ultimate failure. The increase of load observed is
surprising, since the rotating MSI has left a trailing bone
trough in which reduced mechanical retention might be
expected. This bimodal pattern might be due to the
screws apex being forced into the lingual cortex, at
which point it functions as a fulcrum or hinge point, re-
stricting the apex from swinging free and pulling the
threaded MSI into the bone on the same side as the ap-
plied force. This effectively distributes the load into the
leading edge of the resisting bone. When the MSI rea-
ches about 45
to
the cortical surface and opposing the shear line of force.
CONCLUSIONS
1. MSIs loaded along their long axis have the greatest
stability and resistance to failure. The more closely
the long axis of the MSI approximates the line of
applied force, the greater the stability of the MSI
and the greater its resistance to failure. Thus, it
might be important when placing orthodontic
MSIs to avoid loading them in a direct shear mode.
2. MSIs angled in the same direction as the applied
load have greater stability and resistance to failure
than MSIs that are tent-pegged or oriented
away from the applied load. The mechanical and
geometric disadvantages of the latter orientation
reduce MSI stability and resistance to failure.
3. MSIs originally loaded in shear that have lost their
primary stability and become displaced can still
support an applied load, especially if the apex of
the MSI is initially in contact with the deep surface
of the lingual cortex. However, failure in this mode
results in greater damage to peri-implant bone than
failure of MSIs loaded along their long axis.
4. MSI stability and resistance to failure is indepen-
dent of MSI orientation along directions of maxi-
mum and minimum bone stiffness. However,
patterns of anisotropy in cortical bone do affect
the structure of the bone-MSI failure site.
REFERENCES
1. Branemark PI, Aspegren K, Breine U. Microcirculatory studies in
man by high resolution vital microscopy. Angiology 1964;15:
329-32.
2. Branemark PI, Adell R, Breine U, Hansson BO, Lindstrom J,
Ohlsson A. Intra-osseous anchorage of dental prostheses. I. exper-
imental studies. Scand J Plast Reconstr Surg 1969;3:81-100.
3. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study
of osseointegrated implants in the treatment of the edentulous jaw.
Int J Oral Surg 1981;10:387-416.
4. Roberts WE, Smith RK, Zilbernam Y, Mozsary PG, Smith RS.
Osseous adaption to continuous loading of rigid endosseous im-
plants. Am J Orthod 1984;86:95-111.
5. Roberts WE, Helm FR, Marshall KJ, Gonglof RK. Rigid endo-
sseous implants for orthodontic and orthopedic anchorage. Angle
Orthod 1989;59:247-56.
6. Turley PK, Kean C, Schur J, Stefanac J, Gray J, Hennos J, et al.
Orthodontic force application to titaniumendosseus implants. An-
gle Orthod 1988;58:151-62.
7. Douglass JB, Killiany DM. Dental implants used as orthodontic
anchorage. J Oral Implantol 1987;13:28-38.
8. Odman J, Lekholm U, Jemt T, Branemark PI, Thilander B. Os-
seointegrated titanium implants: a new approach in orthodontic
treatment. Eur J Orthod 1988;10:98-105.
9. Higuchi KW, Slack JM. The use of titanium xtures for intraoral
anchorage to facilitate orthodontic tooth movement. Int J Oral
Maxillofac Implants 1991;6:338-44.
10. Smalley WM, Shapiro PA, Hohl TH. Osseointegrated titanium
implants for maxillofacial protraction in monkeys. Am J Orthod
Dentofacial Orthop 1988;94:285-95.
11. Southard TE, Buckley MJ, Spivey JD, Krizan KE, Casko JS. In-
trusion anchorage potential of teeth versus rigid endosseous im-
plants: a clinical and radiographic evaluation. Am J Orthod
Dentofacial Orthop 1995;107:115-20.
12. Kanomi R. Mini-implant for orthodontic anchorage. J Clin Orthod
1997;31:763-7.
13. Costa A, Raffaini M, Melsen B. Miniscrews as orthodontic an-
chorage: a preliminary report. Int J Adult Orthod Orthognath
Surg 1998;13:201-9.
14. Park HS, Bae SM, Kyung HM, Sung JH. Micro-implant anchor-
age for treatment of skeletal Class I bialveolar protrusion. J Clin
Orthod 2001;35:417-22.
15. Kyung SH, Hong SG, Park YC. Distalization of maxillary molars
with a midpalatal miniscrew. J Clin Orthod 2003;37:22-6.
16. Liou EJW, Pai BCJ, Lin JCY. Do miniscrews remain stationary
under orthodontic forces? Am J Orthod Dentofacial Orthop
2004;126:42-7.
17. Gedrange T, Bourauel C, Kobel C, Harzer W. Three-dimensional
analysis of endosseous palatal implants and bones after vertical, hor-
izontal, anddiagonal force application. Eur J Orthod2003;25:109-15.
18. Frost HM. Wolffs law and bones structural adaptations to me-
chanical usage: an overview for clinicians. Angle Orthod 1994;
64:175-88.
19. Frost HM. A 2003 update of bone physiology and Wolffs law for
clinicians. Angle Orthod 2004;74:3-15.
20. Koranyi E, Bowman CE, Knecht CD, Janssen M. Holding power
of orthopedic screws in bone. Clin Orthop 1970;72:283-6.
21. Foley WL, Frost DE, Paulin WB, Tucker MR. Uniaxial pull-out
evaluation of internal screw xation. J Oral Maxillofac Surg
1989;47:277-80.
22. Ellis JA, Laskin DM. Analysis of seating and fracturing torque of
bicortical screws. J Oral Maxillofac Surg 1994;52:483-6.
23. Saka B. Mechanical and biomechanical measurements of ve cur-
rently available osteosynthesis systems of self-tapping screws. Br
J Oral Maxillofac Surg 2000;38:70-5.
24. Cheung LK, Zhang Q, Wong MCM, Wong LLS. Stability consid-
erations for internal maxillary distractors. J Cranio Maxillofac
Surg 2003;31:142-8.
25. You ZH, Bell WH, Schneiderman ED, Ashman RB. Biomechan-
ical properties of small bone screws. J Oral Maxillofac Surg 1994;
52:1293-302.
26. Boyle JM, Frost DE, Foley WL, Grady JJ. Torque and pullout
analysis of six currently available self-tapping and emergency
screws. J Oral Maxillofac Surg 1993;51:45-50.
27. Boyle JM, Frost DE, Foley WL, Grady JJ. Comparison between
uniaxial pull-out tests andtorque measurement of 2.0-mmself-tap-
ping screws. Int J Adult Orthod Orthognath Surg 1993;8:129-33.
28. Gosain AK, Song L, Carrao MA, Pintar FA. Biomechanical eval-
uation of titanium, biodegradable plate and screw, and cyanoacry-
late glue xation systems in craniofacial surgery. Plast Reconstr
Surg 1998;101:582-91.
29. Glatzmaier J, Wehrbein H, Diedrich P. Biodegradable implants for
orthodontic anchorage. A preliminary biomechanical study. Eur J
Orthod 1996;18:465-9.
30. Schwartz-Dabney CL, Dechow PC. Variations in cortical material
properties throughout the human dentate mandible. Am J Phys
Anthropol 2003;120:252-77.
98 Pickard et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
31. Evans FG. Preservation effects. In: Evans FG, editor. Mechanical
properties of bone. Springeld, Ill: Charles C. Thomas; 1973. p.
56-60.
32. Dechow PC, Huynh T. Elastic properties and biomechanics of the
baboon mandible [abstract]. Am J Phys Anthropol 1994;22:94-5.
33. Zioupos P, Smith CW, An YH. Factors affecting mechanical proper-
ties of bone. In: An RA, Draughn RA, editors. Mechanical testing of
bone and the bone-implant interface. New York: CRC Press; 2000.
34. Martin RB, Sharkey NA. Mechanical effects of postmortem
changes, preservation, and allograft bone treatments. In: Corwin
SC, editor. Bone mechanics handbook. 2nd ed. Boca Raton, FL:
CRC Press; 2001. p. 1-24.
35. Tengvall P, Skoglund B, Askendal A, Aspenberg P. Surface immo-
bilized bisphosphonate improves stainless-steel screw xation in
rats. Biomaterials 2004;25:2133-8.
36. Gantous A, Philips JH. The effects of varying pilot hole size on the
holding power of miniscrews and microscrews. Plast Reconstr
Surg 1995;95:1165-9.
37. Cehreli M, Duyck J, De Cooman M, Puers R, Naert I. Implant de-
sign and interface force transfer. A photoelastic and strain-gauge
analysis. Clin Oral Implants Res 2004;15:249-57.
38. Duyck J, Ronold HJ, Oosterwyck HV, Naert I, Sloten JV,
Ellingsen JE. The inuence of static and dynamic loading on mar-
ginal bone reactions around osseointegrated implants: an animal
experimental study. Clin Oral Implants Res 2001;12:207-18.
39. Watanabe F, Hata Y, Komatsu S, Ramos TC, Fukuda H. Finite el-
ement analysis of the inuence of implant inclination, loading po-
sition, and load direction on stress distribution. Odontology 2003;
91:31-6.
40. Huja SS, Litsky AS, Beck FM, Johnson KA, Larsen PE. Pull-out
strength of monocortical screws placed in the maxillae and mandi-
bles of dogs. Am J Orthod Dentofacial Orthop 2005;127:307-13.
41. Ueda C, Markarian RA, Sendyk CL, Lagana DC. Photoelastic
analysis of stress distribution on parallel and angled implants af-
ter installation of xed prostheses. Braz Oral Res 2004;18:
45-52.
42. Melsen B, Costa A. Immediate loading of implants used for ortho-
dontic anchorage. Clin Orthod Res 2000;3:23-8.
43. Freudenthaler JW, Haas R, Bantleon HP. Bicortical titanium
screws for critical orthodontic anchorage in the mandible: a pre-
liminary report on clinical applications. Clin Oral Implants Res
2001;12:358-63.
American Journal of Orthodontics and Dentofacial Orthopedics Pickard et al 99
Volume 137, Number 1