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Effect of miniscrew angulation on anchorage


resistance
Niles Woodall,a Srinivas C. Tadepalli,b Fang Qian,c Nicole M. Grosland,d Steve D. Marshall,e
and Thomas E. Southardf
Villa Rica, Ga, Seattle, Wash, and Iowa City, Iowa

Introduction: Even though the use of titanium miniscrews to provide orthodontic anchorage has become in-
creasingly popular, there is no universally accepted screw-placement protocol. Variables include the
presence or absence of a pilot hole, placement through attached or unattached soft tissue, and angle of
placement. The purpose of this in-vitro study was to test the hypothesis that screw angulation affects screw-
anchorage resistance. Methods: Three-dimensional finite element models were created to represent screw-
placement orientations of 30 , 60 , and 90 , while the screw was displaced to 0.6 mm at a distance of 2.0
mm from the bone surface. In a parallel cadaver study, 96 titanium alloy screws were placed into 24 hemi-
sected maxillary and 24 hemi-sected mandibular specimens between the first and second premolars. The
specimens were randomly and evenly divided into 3 groups according to screw angulation (relative to the
bone surface): 90 vs 30 screw pairs, 90 vs 60 screw pairs, and 30 vs 60 screw pairs. All screws were
subjected to increasing forces parallel to the occlusal plane, pulling mesially until the miniscrews were
displaced by 0.6 mm. A paired-samples t test was used to assess the significance of differences between 2
samples consisting of matched pairs of subjects, with matched pairs of subjects including 2 measurements
taken on the same subject. One-way analysis of variance (ANOVA) with the post-hoc Tukey studentized
range test was conducted to determine whether there were significant differences, and the order of those
differences, in anchorage resistance values among the 3 screw angulations at maxillary and mandibular
sites. Results: The finite element analysis showed that 90 screw placement provided greater anchorage resis-
tance than 60 and 30 placements. In the cadaver study, although the maximum anchorage resistance provided
by screws placed at 90 to the cadaver bone surface exceeded, on average, the anchorage resistance of the
screws placed at 60 , which likewise exceeded the anchorage resistance of screws placed at 30 , these differ-
ences were not statistically significant. Conclusions: Placing orthodontic miniscrews at angles less than 90 to
the alveolar process bone surface does not offer force anchorage resistance advantages. (Am J Orthod
Dentofacial Orthop 2011;139:e147-e152)

T
he use of titanium miniscrews to provide ortho- was found that 80% had at least 1 active case involving
dontic anchorage has become increasingly popu- miniscrews.1 Compared with traditional endosseous
lar. In a 2008 survey of over 500 orthodontists, it implants, which require time for osseointegration and
a second surgical procedure (trephination) for removal,
a
Private practice, Villa Rica, Ga. miniscrews can be loaded immediately, are smaller, are
b
Senior fellow, Department of Orthopaedics and Sports Medicine, University of
Washington, Seattle. easier to place, can be placed in more varied locations,
c
Associate research scientist, Department of Preventive and Community are more cost effective, and result in less postoperative
Dentistry, University of Iowa, Iowa City.
d
pain.2-5 However, in spite of their wide acceptance and
Associate professor, Department of Biomedical Engineering and Department of
Orthopaedics and Rehabilitation, University of Iowa, Iowa City. ease of use, there is no universally accepted screw-
e
Adjunct associate professor, Department of Orthodontics, University of Iowa, placement protocol, and placement variables can in-
Iowa City. clude the presence or absence of a pilot hole, placement
f
Professor and head, Department of Orthodontics, University of Iowa, Iowa City.
The authors report no commercial, proprietary, or financial interest in the prod- through attached or unattached soft tissue, and angle of
ucts or companies described in this article. placement.
Supported by the Dr George Andreasen Memorial Fund. The primary stability of miniscrews is believed to re-
Reprint request to: Thomas E. Southard, Department of Orthodontics, College of
Dentistry, University of Iowa, Iowa City, IA 52242; e-mail, tom-southard@ sult from mechanical interlock and be determined by
uiowa.edu. factors such as cortical quality and quantity, soft-
Submitted, March 2010; revised and accepted, August 2010. tissue health, operator technique, and screw diameter.6,7
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists. Several authors have suggested placing orthodontic
doi:10.1016/j.ajodo.2010.08.017 mini-implants at an angle to the surface of the cortical
e147
e148 Woodall et al

bone not only to help the screw avoid tooth roots but
also to provide increased screw-to-cortical bone con-
tact.8-11 Wilmes et al,8 measuring placement torque as
a sign of primary stability in vitro, measured placement
torque at 7 angles (30 , 40 , 50 , 60 , 70 , 80 , and
90 ) in ilium bone segments of pigs. They concluded
that, to achieve the best primary stability, a placement
angle of 60 to 70 is advisable. In 1 clinical study, it
was suggested that placement of miniscrews at an angle
to the bone surface gave more cortical bone contact and
allowed for longer screws to be placed with no significant
difference in success rates based on angulation.9 This was
supported by another study recommending placement of
miniscrews in the mucogingiva at an angulation of 30 to
45 .10 Deguchi et al,11 using computed tomographic
scanning to measure cortical thickness, concluded that
placing the implant at approximately 30 to the long Fig 1. Miniscrew placement.
axis of the tooth would increase cortical bone contact
by as much as 1.5 times compared with placement at 90 . 1.79 mm thick and was assigned an elastic modulus of
These studies suggest that placement of a miniscrew 13.7 GPa, and the elastic modulus of the trabecular
at an angle to the bone surface increases cortical bone was 200 megapascals (MPa). The bone was as-
bone contact and placement torque, which might have sumed to be homogenous and isotropic with a Poisson’s
a positive effect on miniscrew stability.8-11 However, ratio of 0.3. The contact between the bone and the screw
angulated (as opposed to perpendicular) miniscrew was defined as a frictional interface with a coefficient of
placement can create a different problem. Regardless friction of 0.37.13 The superior, inferior, and lingual
of placement angle, a miniscrew must be placed with nodes of the bony elements were fixed completely,
the head a fixed perpendicular distance from the bone and the screw was displaced to 0.6 mm at a distance
surface so that the miniscrew head is located above the of 2.0 mm from the bone surface.
soft tissues to allow force engagement. Therefore, The maxillae and mandibles of human cadavers were
having a miniscrew exit the bone at an angle other obtained from the Department of Anatomy and Cell
than 90 potentially creates a longer lever arm for the Biology Deeded Body Program at the University of
applied force. The effect of a longer lever arm could Iowa. Vital statistics of the cadavers were not available.
negatively balance, or even outweigh, any positive Fully edentulous or partially dentate specimens with
effect of increased bone contact with an angulated severely atrophic alveolar ridges were excluded. All spec-
screw. Thus, a question still remains: what is the effect imens were hemi-sected, soft tissues were carefully
of miniscrew angulation on anchorage resistance? The removed, and the specimens were stored in 10% buff-
literature does not provide the answer to this question. ered formalin solution.
The purpose of this in-vitro study was to test the hypoth- Twenty-four hemi-maxillae from different cadavers
esis that orthodontic miniscrew angular placement and 24 hemi-mandibles from different cadavers were
impacts screw-anchorage resistance. used. The site for placement of screws was in the area
between the first and second premolars. Periapical radio-
graphs of each specimen were made before and after
MATERIAL AND METHODS placement of the miniscrews to verify that the screws
Three-dimensional finite element models were cre- were not encroaching on the neighboring roots, sinuses,
ated to represent screw placement orientations of 30 , or mental foramina.
60 , and 90 . Each mesh consisted solely of hexahedral A total of 96 commercially available screws were placed
elements modeled by using IA-FEMesh,12 and, in in the 48 hemi-sected maxilla and mandible specimens. All
each model, the screw was represented by a cylinder screws used were 1.5 3 11 mm long (#25-675-11, KLS
with a diameter of 1.5 mm. The screws were modeled Martin, Jacksonville, Fla) and were manufactured from
as a titanium alloy with an elastic modulus of 110 giga- titanium alloy (Ti-6Al-4V). The screws were placed to
pascals (GPa) and Poisson’s ratio of 0.34. A section of a depth of 6 mm. Coronally positioned screws were placed
bone measuring 9.5 mm long, 8.15 mm high, and 4 mm apical to the maximal height of the interproximal
6 mm thick was considered. The cortical layer measured crestal bone. The apically positioned screw was placed

February 2011  Vol 139  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Woodall et al e149

Fig 2. Screw placement groups: A, 90 vs 30 screw pairs; B, 90 vs 60 screw pairs; C, 30 vs 60
screw pairs.

5.5 mm apical to the coronally positioned screw (Fig 1). All


screws were placed by 1 operator (N.W.) with a hand driver
(blade, #25-483-97, and handle, #25-402-99, KLS Mar-
tin) after a pilot hole was drilled with the manufacturer’s
recommended nontapered, 1.1-mm diameter twist drill
for 1.5-mm screws (#25-452-15, KLS Martin).
The cadaver specimens were divided into 4 groups (8
hemi-maxillae and 8 hemi-mandibles per group) accord-
ing to screw placement angulation relative to the bone
surface (Fig 2): 90 vs 30 screw pairs, 90 vs 60 screw
pairs, and 30 vs 60 screw pairs. In the 3 groups, each an-
gle was used apically in half of the specimens and coro-
nally in half of the specimens. As an example, in the first
group, 4 hemi-maxillae had 90 screws placed in the apical
position with 30 screws in the coronal positions, and 4
hemi-maxillae had 30 screws in apical positions with
90 screws in coronal positions. After verification of satis- Fig 3. Bone specimen mounted with tangentially loaded
factory screw placement, the most distal portion of each force parallel to the occlusal plane.
bony specimen was embedded in buff laboratory stone
to a depth of 1.0 in and allowed to harden for 24 hours. fit between the threads of each miniscrew. The grip
Each miniscrew was subjected to tangential force ap- was attached to the force transducer, oriented in a verti-
plication oriented parallel to the occlusal plane (Fig 3) to cal position, and attached to each miniscrew at a distance
mimic orthodontic tangential force to retract the of 2 mm from the screw-bone interface. This distance
anterior teeth. An Instron diametral materials testing was selected to represent space that would be expected
machine (model 1445, Zwick, Ulm, Germany), incorpo- to be occupied by soft tissues in vivo and the screw
rating a force transducer attached to a crosshead and head fixtures.
linked to a computer for recording data, was used to A crosshead speed of 0.05 mm per second, similar to
apply force. A customized X-Y-Z table with a mounting that used in axial pullout studies of miniscrews, was ap-
device was fabricated to rigidly fixate each stone block plied.14 Displacement of the system was measured for
and cadaver specimen during testing. This table allowed 0.60 mm of movement. This amount of displacement
for movement in 3 planes of space to ensure that the was selected to represent the amount of movement
force was parallel to the occlusal plane. A customized that would result in a clinically mobile miniscrew and
grip was designed and machined from stainless steel to potential failure. A paired-samples t test was used to

American Journal of Orthodontics and Dentofacial Orthopedics February 2011  Vol 139  Issue 2
e150 Woodall et al

Fig 4. Force-deflection finite element analysis curves for


screws placed at 30 , 60 , and 90 to the cortical bone.

determine whether there was a significant anchorage re-


sistance difference between 30 and 60 , 30 and 90 , or Fig 5. Von Mises stress diagrams for the cortical bone
60 and 90 screws in the same bone. The same test was with screw placements of 30 (top), 60 (middle), and
also conducted to assess a significant difference in an- 90 (bottom) at 40-N tangential load. As illustrated, the
chorage resistance between the mandibular and maxil- maximum cortical bone stress is less for the 90 screw
placement (134 MPa) than for either the 60 (179 MPa)
lary bones on the same cadaver. If the assumption of
or the 30 (385 MPa) screw placement.
normality was not valid, a nonparametric Wilcoxon
signed rank test, analog of the paired-samples t test,
was conducted. A 2-sample t test was used to determine The maximum anchorage resistance provided by
whether there was a significant difference in anchorage screws placed at 90 to the cadaver bone surface ex-
resistance between apical and coronal positions in the ceeded, on average, the anchorage resistance of screws
maxillary or mandibular bones from different cadavers placed at 60 , which likewise exceeded the anchorage re-
for the 30 , 60 , and 90 screws. sistance of screws placed at 30 (Fig 6). However, statis-
One-way analysis of variance (ANOVA) with the post- tical analysis showed no significant difference in
hoc Tukey studentized range test was used to determine anchorage resistance values when comparing pairs of
whether there were significant differences in anchorage re- 30 to 90 screws, 60 to 90 screws, or 30 to 60
sistance between 30 , 60 , and 90 screws in the maxillary screws in either the maxillary or mandibular bone, since
or mandibular bone. Because of the lack of normality in the deflection ranged from 0.0 to 0.6 mm.
data under some conditions, 1-way ANOVA to the ranked In the mandibular bone samples, further statistical
data followed by the post-hoc Bonferroni multiple com- analysis showed no significant difference in anchorage
parison test, an equivalent test statistic to the nonparamet- resistance between the 30 , 60 , and 90 screws. In the
ric Kruskal-Wallis test, was used as the test statistic. maxillary bone samples when the deflection ranged
All tests had a 0.05 level of statistical significance. from 0.21 to 0.35 mm, results of 1-way ANOVA to the
SAS for Windows (version 9.1, SAS Institute, Cary, NC) ranked data showed a significant effect for screw angu-
was used for the data analysis. lation (P \0.05). The post-hoc Bonferroni test indicated
a significantly greater anchorage resistance force for 90
RESULTS screws than for 30 screws, but no significant differences
The finite element analysis showed maximum an- were found when comparing 60 and 90 screws or 30
chorage resistance forces of 678, 2663, and 3700 N for and 60 screws. In the maxillary bone samples, no other
screws placed at 30 , 60 , and 90 , respectively (Fig 4). statistically significant differences in anchorage resis-
Cortical bone stress was greatest for screws placed at tance were found for the other deflection ranges.
30 , less for screws placed at 60 , and least for screws Overall analysis of the results with 2-way ANOVA
placed at 90 to the cortical bone (Fig 5). procedure indicated no statistical differences in

February 2011  Vol 139  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Woodall et al e151

Our finding of no statistically significant difference in


anchorage force between apical and coronal screw
placements supports the in-vitro findings of Brettin
et al.16 If this holds to be true in vivo, it supports the
choice to place a miniscrew toward the alveolar crest
(assuming adequate labiolingual alveolar thickness)
where there is a better chance that it can be placed in at-
tached gingiva. This position reduces the chances of
peri-implant inflammation and possibly decreases the
likelihood of screw mobility and failure.3,6
The limitations of this in-vitro study are evident.
Biologic changes after osseous loading could not be
examined. However, the fact that mechanical retention
is thought to provide the primary stability of tempo-
rary anchorage devices allows in-vitro studies to be
Fig 6. Average force-deflection curves for screws placed of more value than if miniscrews relied on tissue heal-
at 30 , 60 , and 90 to the cadaver cortical bone. ing or osseointegration. This study provides an indica-
tion of force anchorage resistance for immediate
loading after screw placement. Additionally, the age,
anchorage force resistance between screws placed systemic health, and bone density of each subject
apically and coronally for the 30 , 60 , or 90 screws was unknown. However, it was assumed that random
in the mandibular and maxillary bone samples. pairing of coronal and apical screws at 30 , 60 , and
90 angulations would minimize the impact of these
DISCUSSION factors.
The principal finding of this in-vitro study was that The results of this study conflict with the suggestion
placing orthodontic miniscrews at angles less than 90 made by several authors who advise placing orthodontic
to the alveolar process bone surface does not offer force miniscrews at an angle to the alveolar process bone.8-11
anchorage resistance advantages. Finite element analy- Except when this makes sense to avoid tooth roots or
sis showed that bone stress actually increased dramati- other anatomy, the concept that placement at an
cally, and anchorage resistance diminished by a factor angle increases anchorage resistance is not supported
of up to 5 times, as the screw-to-bone angle diminished. by this study. Based on our results, we recommend
These results appear to support the clinical finding of placement of miniscrews at 90 to the bone surface
Miyawaki et al6 that miniscrew placement angulation when possible and acute-angle placement as a second
was not a factor in miniscrew anchorage success or choice.
failure. Our findings do not support the notion that in-
creased cortical bone contact resulting from angulated CONCLUSIONS
placement of miniscrews improves their anchorage
resistance. 1. In a cadaver model, anchorage resistance offered by
Screw-to-cortical-bone area contact increases as screws placed at 90 to the alveolar process bone
the screw-to-bone angle diminishes. At first glance, it was, on average, greater than the anchorage resis-
would seem that anchorage resistance should likewise tance of screws at 60 or 30 . However, the differ-
increase as the screw-to-bone angle diminishes. How- ences were not statistically significant.
ever, any load applied to the screw must be applied 2. In a finite element model, the anchorage resistance
at a set distance from the bony surface to account of screws placed at 90 to the alveolar process bone
for soft-tissue thickness. The net outcome is that, as was dramatically greater than that of screws placed
the screw-to-bone angle diminishes, the screw-to- at either 60 or 30 . The cortical bone stress created
cortical-bone area contact increases, but the cantilever by loading screws placed at 90 was less than the
load arm concomitantly lengthens. For the 90 and 30 bone stress created by loading screws at either 60
screws, this resulted in 2 and 4 mm lever arms, respec- or 30 .
tively. Butcher et al15 found that screw failure was 3. Based on the results of this study, the placement of
greater if the load was applied 3 mm from the bone temporary anchorage devices at angles less than 90
surface than if it was applied 1 mm from the bone to the alveolar process bone surface does not offer
surface. force anchorage resistance advantages.

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e152 Woodall et al

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