Original Article

Effects of screw and host factors on insertion torque and pullout strength
Ankit H. Shaha; Rolf G. Behrentsb; Ki Beom Kimc; Hee-Moon Kyungd; Peter H. Buschange

ABSTRACT
Objective: To experimentally study the effects of altering implant length, outer diameter, cortical
bone thickness, and cortical bone density on the primary stability of orthodontic miniscrew implants
(MSIs).
Materials and Methods: Maximum insertion torque (IT) and pullout strength (POS) of 216 MSIs
were measured in synthetic bone with different cortical densities (0.64 g/cc or 0.55 g/cc) and
cortical thicknesses (1 mm or 2 mm). Three MSIs were evaluated: 6-mm long/1.75-mm outer
diameter, 3-mm long/1.75-mm outer diameter, and 3-mm long/2.0-mm outer diameter. To test
POS, a vertical force was applied at the rate of 5 mm/min until failure occurred.
Results: The 6-mm MSIs displayed significantly (P , .001) higher IT and POS than the 3-mm
MSIs did. The 3-mm MSIs with 2.0-mm outer diameters showed significantly higher (P , .001) IT
and POS than the 3-mm MSIs with 1.75-mm outer diameters. The IT and POS were significantly
(P , .001) greater for the MSIs placed in thicker and denser cortical bone.
Conclusion: Both outer diameter and length affect the stability of MSIs. Increases in cortical bone
thickness and cortical bone density increase the primary stability of the MSIs. (Angle Orthod.
2012;82:603–610.)
KEY WORDS: Miniscrew implants; Insertion torque; Pullout strength; Cortex; Density

INTRODUCTION most important factors for maximizing pullout strength

(POS) of orthopedic screws.4,5 Longer orthopedic
Orthodontic miniscrew implants (MSIs) have become
screws demonstrate greater POS than shorter screws
an important tool in the orthodontists’ armamentarium;
do.6 The MSI literature pertaining to the effects of MSI
MSIs provide absolute anchorage, are affordable, can be
length remains controversial.7–9 Previous studies often
quickly placed at various sites, and are easily removed.1–3
compare MSIs that differ in more than one character-
However, MSIs have proven to be less stable than other
istic, which limits their ability to evaluate the effects of
endosseous implants that osseointegrate. Both screw
diameter and length.
and the host factors affect the stability of MSIs.
The host factors are related to the quantity (cortical
The screw factors are related to the screws’ design.
thickness) and quality (cortical density) of the bone.3,10
Implant diameter has been shown to be one of the
Because maximum stress occurs at the cortical level,11 it
has been recommended that cortical bone at MSI
a
Resident, Department of Orthodontics, Orthodontic Depart- insertion sites should be at least 1.0-mm thick.12
ment, St Louis University, St Louis, Mo.
b
Professor and Department Chair, Orthodontic Department, Increased cortical thickness has been associated with
St Louis University, St Louis, Mo. significantly greater MSI success.13 Bone mineral density
c
Assistant Professor, Orthodontic Department, St Louis is also important for ensuring the stability of endosseous
University, St Louis, Mo. implants.14 Bone density has been positively correlated
d
Professor and Department Chair, Orthodontic Department,
with both insertion torque (IT) and POS.15,16
Kyungpook National University, Daegu, Korea.
e
Professor, Department of Orthodontics, Baylor College of Few studies have simultaneously evaluated the IT
Dentistry, Dallas, Tex. and POS of MSIs. Both must be quantified because
Corresponding author: Dr Peter H. Buschang, Department of they provide different information about primary,
Orthodontics, Baylor College of Dentistry, 3302 Gaston Ave, mechanical stability. IT and POS do not respond in
Dallas, TX 75246
(e-mail: PHBuschang@bcd.tamhsc.edu) the same way to experimental effects.15 The ideal MSI
should minimize IT (less potential bone damage) and
Accepted: October 2011. Submitted: July 2011.
Published Online: December 8, 2011
maximize POS (greater holding power).
G 2012 by The EH Angle Education and Research Foundation, The primary aim of this study is to evaluate the
Inc. effects of altering implant length, outer diameter,

DOI: 10.2319/070111-427.1 603 Angle Orthodontist, Vol 82, No 4, 2012

604 SHAH, BEHRENTS, KIM, KYUNG, BUSCHANG

Figure 1. (A) Six-millimeter-long miniscrew implant (MSI) with an outer diameter of 1.75 mm. (B) Three-millimeter-long MSI with an outer
diameter of 1.75 mm. (C) Three-millimeter-long MSI with an outer diameter of 2 mm.

Angle Orthodontist, Vol 82, No 4, 2012

EFFECTS OF SCREW AND HOST FACTORS ON STABILITY 605

Figure 2. Synthetic bone cubes used showing (A) cortical and cancellous layers and (B) miniscrew implant.

cortical bone thickness, and cortical bone density on
the primary stability of orthodontic MSIs. Given the
potential root damage that can be caused by MSIs,17,18
it is especially important to determine the stability of
the shorter 3-mm MSIs that have been recently
introduced.19–22 The secondary aim was to determine
if cortical thickness and density interact with MSI
length and diameter.
MATERIALS AND METHODS
Three different MSIs were specifically fabricated by
Dentos (Daegu, Korea). They were either 3-mm or 6-
mm long; the 6-mm MSIs had an outer diameter of
1.75 mm; the 3-mm MSIs had outer diameters of either
1.75 mm or 2 mm. Other than length and outer
diameter, the MSIs were identical in terms of all other
design features (Figure 1); all inner diameters were
1.5 mm, all had 0.5-mm pitch, the apical 1.5 mm of all
MSIs was tapered, all MSIs were self-drilling, and all
were self-tapping. The threaded portions of the 6-mm
and the 3-mm MSIs were 5.5 mm and 2.5 mm,
respectively.
Synthetic Bone
Because of the variability of cadaver and animal
bone,23 synthetic bone has become the standard for
evaluating the primary stability of endosseous implants
and MSIs because of its uniform material properties.5,24
Blocks of synthetic polyurethane bone (Sawbones,
Vashon, WA) were used to test the IT and POS of the
MSIs. The density of the cortical layer was 0.64 g/cc or
0.55 g/cc; the cortical density of the human mandible
has been reported to be 0.64 g/cc.25 Density of the
cancellous layer was 0.48 g/cc for all of the specimens.
The cortical layers were either 1-mm or 2-mm thick.
Testing Groups
The larger bone blocks were cut into 11-mm cubes
for testing purposes (Figure 2). The three MSIs were

Table 1. Groupings of the Three Miniscrew Implants According to Cortical Bone Thickness (CT) and Cortical Bone Density (CD)
Group 1 Group 2 Group 3 Group 4
6 mm/1.75 mm 6 mm/1.75 mm 6 mm/1.75 mm 6 mm/1.75 mm
CT 5 1 mm CT 5 1 mm CT 5 2 mm CT 5 2 mm
CD 5 0.56 g/cc CD 5 0.64 g/cc CD 5 0.56 g/cc CD 5 0.64 g/cc
Group 5 Group 6 Group 7 Group 8
3 mm/1.75 mm 3 mm/1.75 mm 3 mm/1.75 mm 3 mm/1.75 mm
CT 5 1 mm CT 5 1 mm CT 5 2 mm CT 5 2 mm
CD 5 0.56 g/cc CD 5 0.64 g/cc CD 5 0.56 g/cc CD 5 0.64 g/cc
Group 9 Group 10 Group 11 Group 12
3 mm/2 mm 3 mm/2 mm 3 mm/2 mm 3 mm/2 mm
CT 5 1 mm CT 5 1 mm CT 5 2 mm CT 5 2 mm
CD 5 0.56 g/cc CD 5 0.64 g/cc CD 5 0.56 g/cc CD 5 0.64 g/cc

Angle Orthodontist, Vol 82, No 4, 2012

606 SHAH, BEHRENTS, KIM, KYUNG, BUSCHANG

Table 2. Analysis of Variance (ANOVA) of Differences in Insertion Torque (Ncm), Measured at 100% of Insertion, of Miniscrew Implant (MSI)
#1 (6-mm Length, 1.75-mm Outer Diameter), MSI #2 (3-mm Length, 1.75-mm Outer Diameter), and MSI #3 (3-mm Length, 2-mm Outer
Diameter), With Post Hoc Pairwise Comparisons
Post Hoc Probabilities and Relative Differences
MSI #1, MSI #2, MSI #3, ANOVAs,
Density Thickness Mean 6 SD Mean 6 SD Mean 6 SD F Value/Prob MSI # 2 vs 1 MSI # 2 vs 3 MSI # 3 vs 1
0.56 g/cc 1 mm 6.43 6 0.66 4.64 6 0.54 5.44 6 0.72 34.80/,.001 ,.001; Q27.84% .001; Q14.71% ,.001; Q15.4%
0.56 g/cc 2 mm 10.19 6 0.75 7.22 6 0.66 8.24 6 0.88 69.91/,.001 ,.001; Q29.15% .001; Q12.38% ,.001; Q19.14%
0.64 g/cc 1 mm 9.21 6 1.07 6.14 6 0.36 6.46 6 0.66 90.10/,.001 ,.001; Q33.33% .437; Q4.95% ,.001; Q29.86%
0.64 g/cc 2 mm 11.26 6 0.98 8.37 6 0.62 9.18 6 1.3 39.38/,.001 ,.001; Q25.67% .048; Q8.82% ,.001; Q18.47%

inserted into four different types of bone (two densities MSI until failure occurred. Peak load at failure of the
and two cortical thicknesses), resulting in 12 test MSI was recorded in kilograms.
groups. There were a total of 216 MSIs, with 18 MSIs
randomly allocated to each group (Table 1). Statistical Analysis

Insertion Torque MSIs were randomly sorted to test IT and POS.

Each synthetic bone cube was placed in a base that
secured five of its sides. The sixth side was secured
with a jig attached to the base, which also served as a
guide for inserting the MSIs into the center of the bone
cube. The jig was attached to a motor, which rotated
the bone cube and automatically inserted the MSIs at a
constant speed of nine revolutions per minute.
A drill press was modified to secure a Mecmesin
Advanced Force and Torque Indicator (Mecmesin Ltd,
West Sussex, UK), which measured IT. The Torque
Indicator and the MSI were lowered onto the rotating
bone cube with a 3-lb weight attached to the arm of the
drill press. A video camera recorded IT; the video was
used to determine IT at the point of initial engagement
and when 25%, 50%, 75%, and 100% of the MSIs’
threaded portions had been inserted.
Pullout Strength
To evaluate POS, each bone block, along with an
embedded MSI, was placed in a custom metal base of
approximately the same dimensions as the bone
blocks and secured with a lid. Pullout was performed
by attaching an adapter to the miniscrew head; the
adapter was secured to an Instron machine model
1011 (Instron Corp, Canton, MA), which exerted a
vertical force (5 mm/min) parallel to the long axis of the
Skewness and kurtosis statistics showed that the
variables were normally distributed. Because of signif-
icant interactions, separate analyses of variance of
each bone type were performed to compare the three
MSIs, followed by Bonferroni post hoc tests. Separate
analyses of each MSI were also performed for evaluate
the effects of cortical thickness and density.
RESULTS
The IT of the MSIs ranged from 4.6 Ncm to 11.3 Ncm
(Table 2). The 3-mm MSIs had significantly (P , .001)
lower ITs than the 6-mm MSIs; the 3 mm MSIs with
outer diameters of 1.75 mm and 2 mm had ITs that
were 26%–33% and 15%–30% less than the 6-mm
MSIs. Except for the cortical bone that was 1-mm thick
and had a density of 0.64 g/cc, the wider (2 mm) 3-mm
MSIs showed significantly higher IT than the narrower
(1.75 mm) 3-mm MSIs.
Depending on the MSI and material properties of the
bone, POS at failure ranged from 6.7–34.1 kg
(Table 3). POS was significantly (P , .001) lower for
the 3-mm than for the 6-mm MSIs. The POSs of 3-mm
MSIs with an outer diameter of 1.75 mm and 2.0 mm
were 69%–72% and 62%–65% lower, respectively,
than the POS of the 6-mm MSIs. POS was also
significantly lower (13%–21%) for the narrower
(1.75 mm) than wider (2 mm) 3-mm MSIs.

Table 3. Analyses of Variance (ANOVAs) Evaluating Differences in Pullout Strength (kg) of Miniscrew Implant (MSI) #1 (6-mm Length,
1.75-mm Outer Diameter), MSI #2 (3-mm Length, 1.75-mm Outer Diameter), and MSI #3 (3-mm Length, 2-mm Outer Diameter) With Post Hoc
Pairwise Comparisons
Post Hoc Probabilities and Relative Differences
MSI #1, MSI #2, MSI #3, ANOVAs,
Density Thickness Mean 6 SD Mean 6 SD Mean 6 SD F Value/Prob MSI # 2 vs 1 MSI # 2 vs 3 MSI # 3 vs 1
0.56 g/cc 1 mm 23.79 6 1.45 6.67 6 0.79 8.47 6 1.07 1234.15/,.001 ,.001; Q71.96% ,.001; Q21.25% ,.001; Q64.40%
0.56 g/cc 2 mm 27.43 6 1.36 8.61 6 0.61 9.94 6 0.86 2017.36/,.001 ,.001; Q68.61% .001; Q13.38% ,.001; Q63.76%
0.64 g/cc 1 mm 26.02 6 1.78 8.15 6 0.76 10.01 6 0.78 1142.05/,.001 ,.001; Q68.68% ,.001; Q18.58% ,.001; Q61.53%
0.64 g/cc 2 mm 34.11 6 0.82 9.78 6 0.61 11.91 6 0.81 5780.34/,.001 ,.001; Q71.33% ,.001; Q17.88% ,.001; Q65.08%

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EFFECTS OF SCREW AND HOST FACTORS ON STABILITY
Table 4. Analyses of Variance Evaluating the Effects of Cortical Bone Thickness (1 vs 2 mm) and Density (0.56 vs 0.64 g/cc) on Insertion
Torque for Each Miniscrew Implant (MSI)
Effect F Value
MSI #1 (6-mm length, 1.75-mm outer diameter)
Thickness 158.54
Density 69.39
MSI #2 (3-mm length, 1.75-mm outer diameter)
Thickness 330.01
Density 100.37
MSI #3 (3-mm length, 2-mm outer diameter)
Thickness 163.64
Density 20.60
Bone Characteristics
IT and POS were significantly (P , .001) greater for
MSIs placed in 2-mm- than in 1-mm-thick cortical bone
(Table 4). Reducing cortical thickness by 50% (from
2 mm to 1 mm) decreased IT by 27.1%–31.7%.
Reducing density by 14% (from 0.64 g/cc to 0.56 g/cc)
decreased IT by 12.5%–18.8%.
IT increased in a curvilinear fashion as the MSIs
were inserted, with the greatest increases generally
occurring during the last 25% of MSI insertion
(Figure 2). The effects of cortical thickness and density
(q IT with q thickness and q density) were well
established after the MSI had been inserted 50% of its
length and increased thereafter.
POS was also significantly (P , .001) greater when
MSIs were placed in thicker, more dense, cortical bone
(Table 5). The POS of MSIs placed into the 1-mm-
thick cortex were 1.7–5.9 kg or 15.4%–19.1% less
than when placed into 2-mm-thick cortical bone.
Compared with more dense cortical bone, the POS
was reduced 1.8–4.5 kg or 14.8%–16.1% when placed
in less dense bone.
Intercorrelations
IT and POS were significantly and positively
correlated for the 6-mm MSIs (r 5 .73; P , .001),
the 3-mm long 1.75-mm wide MSIs (r 5 .81; P , .001),
Table 5. Analyses of Variance Evaluating the Effects of Cortical Bone Thickness (1 vs 2 mm) and Density (0.56 vs 0.64 g/cc) on Pullout
Strength for Each Miniscrew Implant (MSI)
Effect F Value
MSI #1 (6-mm length, 1.75-mm outer diameter)
Thickness 190.23
Density 109.82
MSI #2 (3-mm length, 1.75-mm outer diameter)
Thickness 117.15
Density 64.76
MSI #3 (3-mm length, 2-mm outer diameter)
Thickness 65.08
Density 70.78
607
Prob Differences in Ncm at 100% of Insertion
,.001 1 mm was 2.91 Ncm (Q27.10%) less than 2 mm
,.001 0.56 g/cc was 1.92 Ncm (Q18.78%) less 0.64 g/cc
,.001 1 mm was 2.40 Ncm (Q30.82%) less than 2 mm
,.001 0.56 g/cc was 1.33 Ncm (Q18.32%) less than 0.64 g/cc
,.001 1 mm was 2.76 Ncm (Q31.73%) less than 2 mm
,.001 0.56 g/cc was 0.98 Ncm (Q12.53%) less than 0.64 g/cc
and the 3-mm long 2.0-mm wide MSIs (r 5 .65;
P , .001). After controlling for cortical thickness and
density, none of the MSIs showed statistically signif-
icant correlations between IT and POS.
DISCUSSION
While the 3-mm MSIs showed less IT and POS than
the 6-mm MSIs did, the values were consistently
above limits previously recommended for stability. IT in
the present study was consistently greater than the
4 Ncm needed to provide sufficient anchorage for
MSIs.26 More importantly, the pullout forces of the
3-mm MSIs, especially those 2-mm wide, were also all
substantially above the ranges of orthodontic forces
typically applied for tooth movements (0.03–0.40 kg)
and skeletal changes (0.5–1 kg).27,28 Importantly, MSIs
are not typically subjected to axial loads such as those
used in the present experiment to standardize testing
techniques; MSIs might be expected to fail at even
lower loads when forces are delivered from other
directions. Even after reducing POS by 34%, as
suggested to more closely approximate the POSs of
the same screws tested in the tangential (cantilever)
mode,29 the stability of the 3-mm MSIs is still more than
sufficient to withstand orthodontic loads (Figure 3).
There have been in vivo studies that support the
clinical use of the 3-mm MSIs. Mortensen et al.19
Prob Differences in kg
,.001 1 mm was 5.87 kg (Q19.07%) less than 2 mm
,.001 0.56 g/cc was 4.46 kg (Q14.82%) less than 0.64 g/cc
,.001 1 mm was 1.78 kg (Q19.40%) less than 2 mm
,.001 0.56 g/cc was 1.33 kg (Q14.83%) less than 0.64 g/cc
,.001 1 mm was 1.69 kg (Q15.43%) less than 2 mm
,.001 0.56 g/cc was 1.76 kg (Q16.06%) less than 0.64 g/cc
Angle Orthodontist, Vol 82, No 4, 2012
608 SHAH, BEHRENTS, KIM, KYUNG, BUSCHANG

Figure 3. Temporal changes in insertion torque from the initial engagement through 25%, 50%, 75%, and 100% of engagement for
(A) 6-mm-long, 1.75-mm-wide miniscrew implants (MSIs); (B) 3-mm-long, 1.75-mm-wide MSIs; and (C) 3-mm-long, 2.0-mm-wide MSIs.

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EFFECTS OF SCREW AND HOST FACTORS ON STABILITY
Figure 4. Pullout strengths (means 6 2 standard deviations) of
6-mm and 3-mm miniscrew implants.
recently reported success rates of 60% for 3-mm long,
1.75-mm wide, mandibular MSIs loaded with 900 or
600 g of force in dogs. After they eliminated the screws
whose tips had sheared off during insertion and all the
MSIs from one unusually active dog that regularly
chewed its bowl and cage bars, the net success rates
increased to 95.2%. In a series of experiments using
rabbits, Liu et al. loaded 170 MSIs that were 3-mm
long, 1.75-mm wide with continuous forces of up 200 g
and had an overall success rate of 91.1%.20–22
The 3-mm MSIs with 2-mm outer diameters provid-
ed greater primary stability than those with a 1.75-mm
outer diameter. When inserted into bone with a cortical
density of 0.56 g/cc, the 0.25-mm difference in width
resulted in a 12.4%–14.7% difference in IT. The positive
effects that the outer diameter has on primary stability of
MSIs have been previously emphasized.5,30,31 Because
the wider outer diameter displaces more bone during
insertion, it produces greater friction at the bone-screw
interface, leading to greater IT. Interestingly, the same
screws showed much smaller (5%–8.8%) differences in
IT when they were inserted into denser cortical bone.
This indicates that increases in purchase power
associated with increases in the outer diameter of MSIs
have less of an effect on denser bone.
Importantly, differences in POS related to MSI
diameter were greater than the differences in IT
(Figure 4). This indicates that the positive effects of
the wider MSIs (ie, greater resistance to pullout)
outweigh the potentially negative effects (ie, increased
IT). These differences emphasize the importance of
measuring both insertion torque and pullout in exper-
iments performed to optimize MSI designs.
The results of this study indicate that the wider 3-mm
MSIs provide a feasible alternative to the longer MSIs
typically used by orthodontists. The drawbacks of
longer screws pertain to the surrounding anatomic
limitations.32,33 When MSIs are inserted into the
periosteum or teeth, abnormal or no healing often
takes place; it is not uncommon to find a lack of
periodontal ligament or lack of bone regeneration,
609
bone degeneration in the furcation area, ankylosis, or a
total lack of healing associated with inflammatory
infiltrate or pulpal invasion.17,18 The small increase in
the outer diameter of a 3-mm MSI substantially
compensates for the reduction in its length, providing
an alternative that potentially avoids damage to the
teeth and surrounding structures.
Significant increases of IT and POS occurred when
MSIs were inserted into thicker cortical thickness.
Decreasing cortical thickness by 50% (2 mm vs 1 mm)
reduced IT and POS by 27%–32% and 15%–19%,
respectively. Motoyoshi et al.13 and Huja et al.3 previously
showed decreases in IT and POS with decreases in
cortical thickness. Because the effects of cortical
thickness were relatively greater on IT than POS, care
must be taken when MSIs are placed in excessively thick
cortical bone. For example, the cortical bone in the
mandibular posterior region can be up to 3-mm thick33–35;
thicker bone might be expected to increase strains and
microfractures during insertion, which could affect
healing and compromise secondary stability.
The IT of MSIs placed in high-density cortical bone
was 13%–19% greater than IT of screws placed in
low-density cortical bone; POS was 15%–16% greater.
Increases in IT with greater bone density are well
established in the prosthodontic and orthodontic litera-
ture.15,16,36,37 Greater bone density implies greater bone
quantity, which requires higher torsional forces to
advance the MSIs during insertion.24 Greater amounts
of bone also increase the amount of bone-to-implant
contact and greater engagement of bone by MSI threads,
both of which contribute to increases in the POS.36
CONCLUSIONS
N The shorter 3-mm MSIs had ITs and POSs that were
26%–33% and 69%–72% lower, respectively, than 6-
mm MSIs.
N Increasing the outer diameter by 0.25 mm signif-
icantly increased the primary stability; the 3 mm
MSIs that were 1.75-mm wide had ITs and POSs
that were 12%–14% and 13%–21% lower, respec-
tively, than the 2.0-mm-wide MSIs.
N Decreasing cortical thickness by 50% produced IT
values that were 27%–32% lower and POS values
that were 15%–19% lower.
N Decreasing cortical density from 0.64 g/cc to 0.56 g/cc
(12.5%) decreased IT and POS by 12%–19% and 5%–
16%, respectively.
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