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Original Article

Maximum principal strain as a criterion for prediction of orthodontic
mini-implants failure in subject-specific finite element models
Mhd Hassan Alboghaa; Toru Kitaharab; Mitsugu Todoc; Hiroto Hyakutaked; Ichiro Takahashie

ABSTRACT
Objective: To investigate the most reliable stress or strain parameters in subject-specific finite
element (FE) models to predict success or failure of orthodontic mini-implants (OMIs).
Materials and Methods: Subject-specific FE analysis was applied to 28 OMIs used for
anchorage. Each model was developed using two computed tomography data sets, the first
taken before OMI placement and the second taken immediately after placement. Of the 28
OMIs, 6 failed during the first 5 months, and 22 were successful. The bone compartment was
divided into four zones in the FE models, and peak stress and strain parameters were
calculated for each. Logistic regression of the failure (vs success) of OMIs on the stress and
strain parameters in the models was conducted to verify the ability of these parameters to
predict OMI failure.
Results: Failure was significantly dependent on principal strain parameters rather than stress
parameters. Peak maximum principal strain in the bone 0.5 to 1 mm from the OMI surface was the
best predictor of failure (R2 5 0.8151).
Conclusions: We propose the use of the maximum principal strain as a criterion for predicting
OMI failure in FE models. (Angle Orthod. 2016;86:24–31.)
KEY WORDS: Finite element analysis; Orthodontic mini-implant; Maximum principal strain

INTRODUCTION resorption and formation of fibrous tissue around the
OMI or implant.1 Eventually, OMIs or implants lose
Aseptic failure of orthodontic mini-implants (OMIs)
bone support and fail. Finite element analysis (FEA) is
and dental implants is presumed to be a result of an
a numerical technique that has recently been used to
unfavorable mechanical environment in the surround-
study the mechanical environment around OMIs or
ing bone, which impairs healing and leads to bone dental implants. A common problem in these studies is
that there is no agreement about the stress and strain
a
PhD candidate, Section of Orthodontics and Dentofacial parameters that should be used as criteria to predict
Orthopedics, Faculty of Dental Science, Kyushu University, failure. The majority of previous studies chose criteria
Fukuoka, Japan. based on stress parameters, most commonly the von
b
Associate Professor, Section of Orthodontics and Dentofa-
cial Orthopedics, Faculty of Dental Science, Kyushu University,
Mises yield criterion.2–8
Fukuoka, Japan. Biomedical studies frequently use FEA to predict
c
Associate Professor, Research Institute of Applied Mechan- bone fracture.9–11 Again, there are no validated criteria.
ics, Kyushu University, Kasuga, Japan. Recent studies of bone biomechanics found that bone
d
Professor and Chairman, Department of Mathematics, failure by fracture was driven by deformation, and
National Defense Academy of Japan, Yokosuka, Japan.
strain-based criteria can well predict fracture sites.12–14
e
Professor and Chairman, Section of Orthodontics and
Dentofacial Orthopedics, Faculty of Dental Science, Kyushu These findings may cause us to reconsider the use of
University, Fukuoka, Japan. stress-based criteria in evaluating the mechanical
Corresponding author: Dr Ichiro Takahashi, Section of environment around implants and expose the need in
Orthodontics and Dentofacial Orthopedics, Kyushu University, the dental literature for validated stress and strain
Faculty of Dental Science, 3-1-1, Maidashi, Higashi-ku, Fu-
criteria for predicting OMI or dental implant failure in
kuoka, 812-8582, Japan
(e-mail: takahashi@dent.kyushu-u.ac.jp) finite element (FE) models.
In this study, we used subject-specific FEA of
Accepted; February 2015. Submitted: December 2014.
Published Online: April 1, 2015 clinically successful and failed OMIs to test the
G 2016 by The EH Angle Education and Research Foundation, hypothesis that stress and strain parameters can
Inc. reliably predict the success and failure of OMIs.

Angle Orthodontist, Vol 86, No 1, 2016 24 DOI: 10.2319/120514-875.1

surface (0. using the same interactive pen display (Wacom Co. and periodontal ligament models. Figure 3A). This function uses a graphy format) for molar. Table 1 lists the element size for each bone and teeth. Japan) at 120 kVp and 150 mA with in-plane resolution of 0. the bone-implant interface immediately after surgery.15 Therefore. Kontich. thus dividing the Finite Element Analysis bone into four zones (zones 1. 3D model at the exact position of OMI at operation time. (INUS Technology. Two computed tomography (CT) images were obtained for each patient using the Aquilion TSX- 101A (Toshiba Medical. and no observer-related errors affected its preoperative CT data set in the segmentation module accuracy. The PDL was traced manually on every slice elements. Seoul. To simulate the condition of nonosseointegration at Ltd. zone 3 (1. they were placed by the same author (TK).4) years. Tokyo.1 (RCCM Inc.214 3 0. The first CT image was obtained before the operation.2 (5. ical properties based on apparent bone density (Papp). Creation of a Three-Dimensional Discretized Model alignment function provided by Rapidform software Three-dimensional (3D) surface models (stereolitho. implant. including Bone elements were given heterogeneous mechan- these bone zones. and an implant that remained stable was determined to be successful (n5 22). The bone was divided into four zones of Kyushu University Faculty of Dental Science according to distance from the implant surface: zone 1 (0.0–1. Japan).0–0. Korea). and the second Figure 1.5 mm. 2. 6 mm long by 1. adjacent teeth. Figure 1 shows all compartments of the final model.3465) 3 0. and 4). No 1. 3. Vol 86. To analyze the relationship between mechanical between each other (bone-PDL. The thresholds were fixed among all component of the model and the rough number of models.5 mm). Inclusion criteria were that OMI should be placed between the maxillary first molar and second premolar and be used for retraction of anterior teeth. and 1.6. PDL-tooth). Korea). applying a CT value threshold-based selection for Japan). we designed models there was no contact between the crowns of three shells based on the distance from the OMI teeth. periodontal ligament.001. the bone segment).9452 3 HU + 1. segment of bone least-mean-squared algorithm to align two surface surrounding these two teeth. and zone 4 (the rest of (registration number 25–279). All included implants were DualTop OMIs (Jeil Medical Corporation.4 mm in diameter. premolar. The final 3D model was discretized with tetrahedral Japan).214 mm and a slice thickness of 0. Seoul. The procedure uses (g/cm3) 5 (0. a The OMI’s geometry was generated by scanning frictionless point-to-point gap contact element was a DualTop OMI with a mCT SkyScan 1072 (Bruker used and solved by penalty formulation. 1 mm. this procedure was completely (PDL) of each tooth were generated using the automated. To incorporate a precise OMI geometry into the final which in turn was derived from the Hounsfield unit (HU. Conversion of HU to apparent density the model was created using a two-step procedure (Papp) is performed using the following formula: Papp explained in detail in Figure 2. 2016 .16 All other microCT.5 mm. The region of interest was selected by elements in Ansys v14 (Ansys Japan KK.CRITERION FOR PREDICTING OMI FAILURE 25 MATERIALS AND METHODS Treatment Procedures and Sample Selection This retrospective study included 28 OMIs in 16 female patients with a mean (SD) age of 21. The exclusion criterion was systemic bone disease. Tokyo. Osaka.5–1. An implant that became loose or dropped out spontane- ously during the first 5 months was defined as a failed implant (n 5 6). of Mechanical Finder (MF) v.0 mm). zone 2 (0. and bone segment This protocol was approved by the ethics committee surrounding these structures. Belgium) with a voxel dimension of materials had shared nodes at the contact surfaces 9 mm. Saitama. The Angle Orthodontist.5 mm). The finite element model consisted of the orthodontic mini- one was obtained immediately after. In all parameters and distance from the OMI.5 mm).

3 0.4 100. This process finally transforms the mCT-obtained OMI into the coordinates of the preoperative CT data set.2–0.000 Periodontal ligament 6. Then. Properties of Materials and Descriptions of Mesh in Finite Element Models Elastic Modulus Poisson Ratio Mesh Size E (GPa) n mm No. TODO.1 4000 Zone 4 0.1 240. TAKAHASHI Figure 2. which CT image voxel to the corresponding element.05–0.05–0.000 Zone 2 0.3 0.0 90.18 densities (Figure 3B).5–1. In the first step.19 The Table 1. with the OMI model attached to the postoperative bone geometry.05–0.. is performed defining the preoperative bone as the reference. Vol 86.000 Implant 114 0. This step transforms the mCT-obtained OMI to the coordinates of the postoperative CT data set. KITAHARA.3 0.1 7000 Zone 3 0. and both resulting geometries (OMI and bone) are imported into the final finite element model in the Mechanical Finder. calculate Young’s modulus using the nonlinear equa. the first time using the preinsertion CT data set and the second time using the postoperative data set.34 0.3 0. the surface model of the orthodontic mini-implant (OMI) obtained from the microcomputed tomography (mCT) data set was aligned with the rough surface model of the OMI obtained from the postoperative computed tomography (CT) data set.000 Bone Zone 1 0. No 1. Once the final coordinates of the OMI model are obtained. The ratio between the ash density and contained five rods of hydroxyapatite with specific apparent density was considered to be equal to 0. In the second step. of Elements Teeth 20.000 Angle Orthodontist.3 0.0 120.000e{5:19e (g/cm3).7 0. mesh alignment between the two bone geometries (preoperative and postoperative). the OMI model is saved with the new position. HYAKUTAKE. Ltd) that density.89 3 1025 0. 2016 . Apparent density was used to The previous formulae were incorporated into MF.05–0. the geometry of the corresponding half of the maxilla was generated two times.1 120.45 0. which followed an algorithm to assign the HU from the {2:30Pash tion E (MPa) 5 20.26 ALBOGHA.5–1. formula was developed by calibrating the CT scan of was proposed by Cong et al. Kyoto Kagaku Co. the preoperative hemimaxilla is trimmed to the volume of interest.17 where Pash is the ash a phantom (B-MAS200.6.

3 for all One parameter was calculated in the OMI model. the main Angle Orthodontist. adopting linear-elasticity theory. Bone properties were derived from the preoperative computed tomography image. elements. and OMIs) representing the maximum displacement (MaxD) at were assumed to be homogeneous and were assigned the bone-implant contact interface (Table 2). Statistical Analysis.20 Other materials (PDL. (A) Mesiodistal section of the finite element model showing the heterogeneous distribution of bone properties. Poisson value applied to bone was 0. Fine mesh size Peak values of 20 parameters related to stress and was applied only to zones 1 through 3. and a prediction from the head of the OMI. Tokyo. 2016 . We values as shown in Table 1. a phantom with five different densities was scanned and calibrated.24 All models were solved using the sparse using JMP Pro 11 (SAS Institute Japan Inc.23 Constraints were assigned regression models for predicting OMI failure was to all cutting faces (Figure 4) that were sufficiently far proposed as a predictive criterion. Japan).CRITERION FOR PREDICTING OMI FAILURE 27 Figure 3. Vol 86. No 1. (B) To develop a formula that converts Hounsfield units to bone densities. Convergence of the parameters listed in Table 2 Parameters. ensure that the distribution of stress and strain is Figure 5). and strain parameters in zone 4 are reported. matrix solver in MF. Although stress strain were calculated for each bone zone (Table 2).22 performed logistic regression analysis of failure (vs A load of 2.6. The necessary to achieve clinically effective retraction of parameter that exhibited the best fit (R2) in logistic six upper anterior teeth.21. This is important in FEA to formula was introduced and plotted (Table 3.0 N was applied to the head of the OMI success) on these 21 parameters to determine which in the mesial direction to simulate what would be could be used as a predictive criterion for failure. teeth. All statistical calculations were performed accurate. and was tested by solving a series of models (five Convergence Test iterations) with coarser mesh size.

1346). Our statistical model yielded values of is expected to fail with a probability greater than 95%. peak values of principal (minimum and maximum) Considering the nature of the load applied on an strain in all bone zones were significantly related OMI. . The finite element model after meshing.9–11 Most studies that evaluated OMIs using (red dots) are assigned to bone cutting surfaces. the OMI dental implants. Only we found that peak values of MaxPN in bone had the minimum principal strain diverged in all zones. when the strain in this area is less than 3793 mstrain. it is expected to be stable with a probability greater than 95%.25 postulating that exceeding this amount would interfere with healing.2–8 Recent studies26 showed that von Mises stress does not reliably predict the yielding behavior of bone and that the principal strain criterion correctly purpose for adding this zone was to ensure that identified the risk of failure.29 failure (P . Our value of Angle Orthodontist. plotted in Figure 5) shows resorption occurred in 50% of the bone surface along that when strain is greater than 5785 mstrain. DISCUSSION Primary stability is an important factor in the success of OMIs and dental implants. Equivalent stress (von Mises stress) is a mechanical criterion widely used in conventional mechanics to predict failures of materials and is advocated in many studies to be applicable to bone catastrophic failure Figure 4. . Previous studies postu- lated a 50–200 mm threshold for immediate postoper- ative micromotion at the bone-implant interface. In contrast. The constraints prediction.16. KITAHARA. well below the postulated thresholds. Frost28 suggested explained most of the variability (R2 5 0. stress. These findings may suggest that primary stability was not the immediate cause of the failure of OMIs analyzed in this study.1706).05). The found that when the strain was greater than 6700 mstrain. prediction formula (Table 3. MaxPN close to those previously published.8151. and it explained RESULTS only a small amount of the variation in stability Most of the parameters converged at the mesh observed in the sample (R2 5 0. It also chronic overload rather than catastrophic failure of showed that equivalent (von Mises) and principal bone. Melsen and Lang31 mend for predicting failure with good reliability.13. MaxD showed a significant correlation with tion of bone strength. the probability of failure ranges between 5 and 95%. In addition. it did not have good reliability to predict failure. highest correlation to stability among all stress and Logistic regression analysis (Table 2) showed that strain parameters.28 ALBOGHA.05).27 Consistent with these boundaries were far from OMI. making this parameter the one we recom. and a mesial load of 2 N (red arrow) is applied to the head of the implant in the FEA have assessed their results using equivalent mesial direction. but it explained the small amount of Yeh and Keaveny30 showed that microdamage may the variability (R25 0. 2016 . failure of OMI is likely to be a result of fatigue and to failure or success of the OMIs (P . No 1. . element size used in the study (Table 2). occur in cancellous bone at relatively low strains of The maximum principal strain (MaxPN) in zone 2 approximately 0. causing in the development of fibrous scar tissue around the implant instead of the bone apposition. studies we found equivalent stress to be significantly correlated to stability only in zone 2. Vol 86. TAKAHASHI On the other hand. The FE models in the present study expected values for the displacement at bone-implant interface (MaxD) not exceeding 7. causing the OMIs to loosen. TODO. Although MaxD presented significant correlation to stability (P .2% (2000 mstrain).05).5 mm. Between these two values. HYAKUTAKE. Fatigue causes irreparable bone microdamages to stresses in most bone areas were not related to failure accumulate with subsequent bone resorption and reduc- or success.28. that microdamages start to accumulate when strain Table 2). exceeds 3000 mstrain.

5% MaxPN4 (mstrain) 9110 9221 2249 1709 1 11.96 12. b Numbers in the first column (1 to 4) refer to bone zones according to their distance from the orthodontic mini-implant as follows: zone 1 5 0.00288 1. the odds ratio Dividing bone into different zones was useful in (Table 3) indicates that for every increase of 1000 mstrain overcoming this problem by investigating strain in in MaxPN in zone 2.004** 0.0013 . the parameter diverged.7 1 0.87 0.33 12.0029 . Probability formula for failure: Prob[F] 51 / (1 + Exp[2Lin(F)]).5408 .78 0.77 0.205 0.5% ES2 (MPa) 7.0552 . MaxPN. rather than to propose specific thresholds. equivalent (von Mises) stress.0099 .6068 .5% MaxPS3 (MPa) 1. Predictive Formula of Failure Probability by Maximum Principle Strain in Zone 2 (MaxPN2)a Term Estimate SE x P Value Odds Ratio Lower 95% Upper 95% Intercept 213.5581 .8151 . It is the only parameter in this table measured for OMI.0855 .7032972 8.01 0.51 1 1.72 15. Angle Orthodontist.095 0.9153 .86 1 1.00061 1.00881 a Estimated linear intermediate formula: Lin[F] 5 213.487 0.0 mm.31 0.. Table 3.7266 .05.89 1 3.46 1.5 mm from the OMI surface. Peak Values of Stress and Strain Parameters With Their Correlations to Success and Failurea Descriptive Data Convergence Failed (n 5 6) Successful (n 5 22) Logistic Regression Test Stress and Strain Probability Measurementsb Mean SD Mean SD df x2 .84 0.0957 — MaxPN1 (mstrain) 21.5341 . degrees of freedom.10% MinPS2 (MPa) 24.28 14.4 1 4.026* 0. All other parameters are measured for bone.83 2.9648 .542 19.76 1 2.88 0.57 .7032972 + 0.048* 0.10% MinPS3 (MPa) 21.5–1.0166 . ES.5 mm.75 0.002877514 * MaxPN2.4374 Div MinPN3 (mstrain) 25927 5635 2883 567 1 15. Div.042* 0.5 mm.5 3.2224 .3869 — MinPN1 (mstrain) 229. c MaxD is the maximum displacement measured for the bone-implant interface.33 0.29 0.001*** 0. a SD indicates standard deviation.. minimum principal stress.691 0.10% MinPS4 (MPa) 22.011* 0.5 mm. df.042 .001*** 0.31 In general.5% ES4 (MPa) 4.938 22.7171 . we cannot claim that the values of 0.13 1.0–0..501 29.001871271 2.1223 — MaxPS1 (MPa) 17.1632 — MinPS1 (MPa) 217.1475 .5% ES1 (MPa) 17.182 9195 8744 1 4.1425 Div MaxPN2 (mstrain) 13..5% MaxPS4 (MPa) 5.27 1.001*** 0.23 21. zone 3 5 1.029* 0.14 0. 2016 .10% MaxPS2 (MPa) 8.059 0.66 1. zone 2 5 0.15 8.591 0.7833 . and in light of the limitations of increased strain that extends to areas more than the current study.2 6.69 1 0.3051 .269 0. the failure of OMIs within 5 months is As the FE modeling depends on many assumptions likely caused by bone resorption induced by the and simplifications.99 0.56 1 4. stronger than that in zone 1.48 1.3 1 0.1583 . .725 8388 2177 1251 1 23.41 11.843 0.001*** 0.57 1.4056 . 5785 mstrain (failure risk 95%) is slightly lower than that the differences between failed and successful cases. MaxPS.91 1 0.3382 .002877514 0. . ** P .280 22103 1718 1 12.1346 .001.21 9.526 Div MinPN4 (mstrain) 23871 2358 21580 1292 1 7.0393 . maximum principal strain. *** P .04 6.2194 Div MinPN2 (mstrain) 214.33 1 0.006** 0. No 1.2866 . .67 15. MinPS.5% ES3 (MPa) 1.78 21.42 220. minimum principal strain.2 18. difference percentage at the mesh element size used in the 28 models.1087 — — — MaxPN2 0.1241 1. and zone 4 5 larger than 1.2887 .99 23. maximum principal stress.42 10.7485 .72 1.2588 .37 2.87 1 8..0054 . MinPN.01. x2 R2 Dif % c MaxD (mm) 3. reported by Melsen and Lang.37 2.543410568 2.3823 . MaxPN presented correlation in zone 2 that was unless they are validated by clinical measurements. parameters reported in the current study are universal. As the MaxPN diverged clinical outcome we had in the present study (failed or in this zone. Vol 86.36 . the singularity problem may have covered successful) was adequate to achieve our objective.65 1 3. the formed by the threads of OMI. zones not affected by singularity.746 28691 7586 1 6.1706 . Dif%. the risk of failure increases by 288%.CRITERION FOR PREDICTING OMI FAILURE 29 Table 2. This finding may be Because the main objective of this study was to attributed to the singularity problem in zone 1 that determine the most suitable parameter for predicting results from the presence of helical fissure in bone failure.65 2.4827 .001*** 0.5% MaxPN3 (mstrain) 7508 4316 1425 1146 1 15. Taken together.2545 — * P .0–1.

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