ORIGINAL ARTICLE

Correlation between miniscrew stability and

bone mineral density in orthodontic patients
Rodrigo César Santiago,a Fernanda Oliveira de Paula,b Marcelo Reis Fraga,c
Neuza Maria Souza Picorelli Assis,d and Robert Willer Farinazzo Vitrale
Juiz de Fora, Brazil

Introduction: The aims of this study were to correlate the clinical and radiographic stability of titanium mini-
screws when used as orthodontic anchorage for maxillary canine retraction and to assess bone quality.
Methods: Thirty titanium miniscrews were placed in 15 consecutive patients (8 male, 7 female; age range,
12 years 5 months-32 years 11 months) as orthodontic anchorage. Orthodontic loads were applied immedi-
ately after miniscrew placement (T1) with a nickel-titanium closing coil spring. The initial estimated load was
200 g. The bone quality in each region of interest was determined by multi-slice computed tomography.
Results: Bone mineral density (BMD) values ranged from 167 HU to 660.80 HU (mean, 420.63 HU). The
specific regions had a mean close to the maximum value of a previously established scale for the posterior
region of the maxilla (0-500 HU). The paired t test showed a statistically significant difference (P 5 0.450)
when the means of the differences between the right and left sides were compared. Twelve of the 15 subjects
had significantly greater maxillary BMD on the right side. Linear regression also showed a low correlation be-
tween the 2 sides (P 5 0.097). Clinically, the success index was 100%. Although 2 miniscrews were removed
from 1 patient because of severe gingival inflammation with purulent secretion, none of the 28 remaining min-
iscrews showed any mobility after 90 days (T2). Comparisons of the means at T1 and T2 showed no statisti-
cally significant differences in these distances: between nasion and the miniscrew head, between orbitale and
the miniscrew head, and between nasion and orbitale, assessed through cephalometric tracings made on
lateral oblique radiographs (45 ), pointing to the stability of the 28 miniscrews during the 90-day observation
period. BMD values of all subjects were within the normal range of an established scale, and even close to
maximum values. Conclusions: The regions between the maxillary second premolars and first molars, and
mesial to the maxillary second premolars, are safe as far as bone quality is concerned for miniscrew placement
during the first 90 days of canine distalization. A good surgical technique and appropriate planning for minis-
crew placement, inflammation control, and adequate oral hygiene are fundamental to the success of this new
anchorage system during maxillary canine distalization. (Am J Orthod Dentofacial Orthop 2009;136:243-50)

A
nchorage control is an important factor directly
affecting the results of orthodontic treatment,
mainly when maximum anchorage is necessary.1
Although traditional systems, which allow distal move-
ment of the canines in patients with premolar extractions,
a
Postgraduate student, Department of Orthodontics and Pediatrics, Juiz de Fora
Federal University, Juiz de Fora, Brazil.
b
Private practice, Juiz de Fora, Brazil.
c
Professor, Department of Orthodontics and Pediatrics, Juiz de Fora Federal
University, Juiz de Fora, Brazil.
d
Associate professor, Department of Clinical Dentistry, Juiz de Fora Federal
University, Juiz de Fora, Brazil.
e
Associate professor and chair, Department of Orthodontics and Pediatrics, Juiz
de Fora Federal University, Juiz de Fora, Brazil.
The authors report no commercial, proprietary or financial interest in the
products or companies described in this article.
Reprint requests to: Robert Willer Farinazzo Vitral, Av Rio Branco 2595/1603-
1604, Juiz de Fora, MG, Brazil, CEP 36010 907; e-mail, robertvitral@acessa.
com.
Submitted, March 2007; revised and accepted, August 2007.
0889-5406/$36.00
Copyright Ó 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.08.031
have been developed, limitations due to the need for
patient cooperation, operator skill, and precision in
determining the ideal force to perform the movement,
make the control of posterior anchorage a challenge.2-6
Skeletal anchorage models, such as conventional
implants,7-9 onplants,10 palatal implants,11 and mini-
plates,12,13 have been used to provide stationary anchor-
age without requiring patient cooperation and with high
success rates. However, because these devices require
complex surgery and involve high costs, their use is lim-
ited. Miniscrews are temporary skeletal anchorage de-
vices that have several advantages: no need of patient
cooperation, reduction of treatment time,14-16 ability
to withstand a range of orthodontic loads for maximum
anchorage,15 ease of placement and removal, low cost,
and the possibility of immediate activation.17
Although the efficacy and stability of this anchorage
modality in different malocclusion treatments have been
reported in several studies, the clinical behavior of minis-
crews withstanding orthodontic loads is not totally clear
243
244 Santiago et al
Fig 1. Stainless surgical guides (left) and periapical radiographic view (right).
Fig 2. Canine retraction mechanism (left and right, views at T1 and T2).
yet.5,16,18-24 There is the question of whether they remain
absolutely stationary as an intraosseous implant or have
some mobilization as the orthodontic load is applied.16
Factors associated with miniscrew stability and clinical
success, such as age, sex, screw implant characteristics,
placement sites, surgical technique, inflammation,
and bone quantity, have been reported.18,22,24,25 High
failure rates and bone loss have been associated
with dental implants in low-quality bone. Previous
knowledge about bone density is therefore paramount
for correct planning and placement of dental
implants.26-29
Quantitative computed tomography (CT) is an
effective method for bone mineral density (BMD) mea-
surement of specific regions of interest (ROI). A main
advantage is that the resulting image is not influenced
by adjacent structure superimposition.30 Its high sensi-
American Journal of Orthodontics and Dentofacial Orthopedics
August 2009
tivity for tissue differentiation allows for a detection
threshold of 1% or lower in density difference.31
BMD quantitative values in Hounsfield units (HU)
for 4 regions are .850 HU (anterior mandibular re-
gion), 500 to 800 (posterior mandibular and anterior
maxillary regions), and 0 to 500 (posterior maxillary
region).32 Because a positive correlation of the preoper-
atory quantitative-assessed CT mandibular BMD with
torque intensity during implant placement has been
found, CT-measured BMD can be used to estimate
primary implant stability.33-37
Although a few studies have used conventional
radiography6 or CT38-41 for bone quantification before
implant placement for orthodontic anchorage, they are
limited because only bone quantity was assessed.
Bone quality (density) surrounding the implant might
also have an impact on implant stability.39
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 2
Fig 3. Maxillary multi-slice CT images.
In this study, we aimed to correlate the clinical and
radiographic stability of titanium miniscrews used for
orthodontic anchorage during maxillary canine distali-
zation with the bone quality of each ROI determined
with multi-slice CT images.
MATERIAL AND METHODS
The initial sample consisted of 15 consecutive pa-
tients (8 male, 7 female; age range, 12 years 5 months-
32 years 11 months) selected according to the following
criteria: (1) good oral health; (2) indication for maxillary
premolar extraction and canine distalization; (3) no
chronic renal failure and hormonal disorders, particu-
larly thyroid, parathyroid, and adrenal impairment; (4)
no regular use of drugs such as steroids, barbiturates, an-
ticonvulsants, and thyroid hormone replacements; and
(5) no regular tobacco smoking or alcohol drinking.
A total of 30 miniscrews (diameter, 1.8 mm; length,
10.0 mm; SIN-Implant System, São Paulo, Brazil) were
used for orthodontic anchorage. The titanium screws
were placed perpendicular to the maxillary buccal
intraseptal alveolar bone above the mucogingival limit,
between the roots of the second premolars and the first
molars in 12 subjects, and mesial to the roots of the
Santiago et al 245
second molars in 3 subjects. The surgical procedure
consisted of local anesthesia without mucoperiosteal
incision or flap; the screw holes were made with
a 1.0-mm round bur and a twist drill at 500 rpm with
continuous saline solution irrigation. The 1.8-mm
screws were then placed by using a self-tapping method
with continuous irrigation. After the surgery, the pa-
tients were advised to use mouthwash daily (0.12%
chlorhexidine) and brush the placement sites with
a soft toothbrush for 1 week. They were also instructed
to take 50 mg of sodium diclofenac orally for 5 days.
For determination of the minimum height in the in-
terradicular septal region between the maxillary second
premolars and the first molars with sufficient cancellous
bone for miniscrew placement and at least 2 mm of
space between the corticals, periapical radiographs
were obtained (parallelism technique).30 A 0.02-in
stainless steel surgical guide and an acrylic base for op-
timal positioning during miniscrew placement were
manufactured (Fig 1).
The orthodontic load was applied immediately after
miniscrew placement (immediate load), with a 9.0-mm
nickel-titanium closing-coil spring strained between the
head of the screw and the 0.017 3 0.025-in stainless steel
vertical power arm placed in the maxillary canine (Fig 2).
An initial load estimated at 200 g by a dynamometer
(ETM number 8001303, Ormco, Glendora, Calif) was
applied, and the coils were reactivated every 2 weeks.
Fifteen multi-slice CT images (Somaton Spirit, Sie-
mens, Xangai, China) (Fig 3) were obtained from the
maxilla of each of the 15 patients. The subjects were po-
sitioned according to a technique previously reported.30,42
Denta scan software (General Electric Medical
Systems, Milwaukee, Wis) was used for tomogram
reconstruction. For paraxial reconstruction, the following
reference measures were used: length, 16.0 mm; distance,
1.0 mm; thickness, 1.0 mm. Panoramic reconstruction
(Fig 4) allowed identification of the section representing
the interradicular septal region to be studied. Through
paraxial reconstruction (Fig 5), the site for miniscrew
placement was identified, and the largest possible ROI
encompassing buccal cortical and medullary bone was
outlined. BMD per area (cm2), in Hounsfield units, was
calculated by using the software. The values obtained
expressed the mean density of the area under study.
Miniscrew clinical stability was primarily deter-
mined by their permanence in the placement site and ab-
sence of mobility during the first 90 days of orthodontic
load. The success index was calculated as the percentage
of total miniscrews that remained stationary in this pe-
riod. After 30 days, 2 miniscrews from the same subject
led to severe gingival inflammation and had to be re-
moved, thus reducing the sample to 14 patients.
246 Santiago et al
Fig 4. Panoramic reconstruction.
Fig 5. Paraxial reconstruction.
Miniscrew stability was assessed with right and left
lateral oblique radiographs (Fig 6) (Sirona Orthophos 3,
Siemens) obtained soon after miniscrew placement (T1)
and 90 days after activation (T2). The cephalostat was
adjusted for the oblique position according to the man-
ufacturer’s instructions, allowing the x-rays to penetrate
the patient at a 45 angle. The patients were conve-
niently positioned, and the position of the nasal support,
in millimeters, was recorded to permit them to be in ex-
actly the same position at T1 and T2. The following lin-
ear distances were obtained at the left and right sides:
(1) N-mi, distance between nasion (N) and the minis-
crew head (mi); (2) Or-mi, distance between orbitale
(Or) and the miniscrew head (mi); and (3) N-Or, dis-
tance between N and Or (Fig 7).
The study was approved by the Ethics on Research
Committee of Juiz de Fora Federal University, and the
subjects gave their informed consent.
For operator calibration, the error method was used
for BMD determination and assessment of radiographic
American Journal of Orthodontics and Dentofacial Orthopedics
August 2009
stability. For BMD, paraxial reconstructions of 5 CT
scans were used, with 3 bilateral measurements of the
same ROI obtained at 1-week intervals. For radio-
graphic stability, 28 lateral oblique radiographs were
traced twice at 1-week intervals at T1, and 28 lateral
oblique radiographs were traced twice at 1-week inter-
vals, at T2. The Pearson correlation test and analysis
of variance (ANOVA) showed that the operator was
calibrated during BMD determination. For assessment
of radiographic stability, the Student t test for paired
samples showed no statistically significant differences
between the 2 assessments.
The Student paired t test was used for the asessment
of the means obtained for BMD values from the right and
left sides from each subject. Linear regression was used
to assess correlations between the right and left sides.
The Student t test for paired samples was used for
assessment of the radiographic alterations in implant
position, with a 95% confidence interval for the mean
distance of the reference points. Significance at P \
0.05 was established.
RESULTS
Table I shows BMD values for the 15 ROI on the
right and left sides.
Table II shows the Student paired t test results
between the right and left sides (P 5 0.045).
On linear regression, the correlation coefficient
between the right and left sides was 0.44 (P 5 0.097),
as shown in Table III.
The success index for miniscrew clinical stability
for 90 days was 100%, as shown in Table IV.
Table V shows the paired t test values for the assess-
ment of radiographic miniscrew stability between the
right and left sides at T1 and T2.
American Journal of Orthodontics and Dentofacial Orthopedics Santiago et al 247
Volume 136, Number 2

Fig 6. Lateral oblique radiographs (left and right sides).

Table I. BMD values

Bone density Bone density
Subject (HU)/right side (HU)/left side

1 507.5 329
2 486.1 319.3
3 480.2 409
4 385 265.7
5 512.1 507.2
6 497.6 354.7
7 448.6 310.1
8 397.8 510.3
9 407.8 317.5
10 498.7 487.2
11 409.5 462
12 369.5 167
13 660.8 563.5
14 346.6 279.6
15 373.3 555.9

ity, proximity to dental roots, waiting time for activa-

Fig 7. Cephalometric tracing.
DISCUSSION
Miniscrews as anchorage auxiliary devices in ortho-
dontic treatment have advantages and efficacy.5,16,18-28
Yet, their stability can be affected by direct placement
in the periodontal ligament, local inflammation, mobil-
tion, amount of load applied, placement site, and bone
density.18,22-24,29-31
Bone quality at the placement site is a possible fac-
tor interfering with miniscrew stability.15,17,19,22 Al-
though CT-assessed BMD is routine for conventional
intraosseous implants, it is not assessed when minis-
crews are used as anchorage devices.
In this sample, BMD values ranged from 167 to
660.8 HU (mean, 420.63 HU). The specific regions be-
tween the maxillary second premolars and first molars
(24 miniscrews) and mesial to the second premolars
(6 miniscrews) had a mean close to the maximum value
of the scale of Norton and Gamble38 for the posterior
248 Santiago et al American Journal of Orthodontics and Dentofacial Orthopedics
August 2009

Table II. Paired Student t test between the right and left Table IV. Analysis of clinical stability
sides
Clinical stability Frequency %
Paired
differences Mean SD t df P Absence 0 0
Presence 28 100
Pair 1 BMD (right side) - 62.87333 110.62207 2.201 14 0.045* Total 28 100
BMD (left side)

*Statistically significant at 0.05.

Table V.Paired t test values for assessment of radio-
Table III. Correlation between paired samples graphic miniscrew stability between the sides at T1
and T2
n Correlation P
T1 T2
Pair 1 BMD (right side) - BMD 15 .444 0.097
(left side) Cephalometric
distance (mm) Mean SD Mean SD P

N-mi (right) 76.893 5.0770 77.143 4.6634 0.278

region of the maxilla (0-500 HU), a finding that under- N-mi (left) 78.857 5.6276 79.071 5.5012 0.111
scores its significant quality. The specific regions between Or-mi (right) 37.964 5.4999 38.071 5.4380 0.272
the maxillary second premolars and first molars (24 min- Or-mi (left) 39.429 5.9738 39.536 5.8621 0.487
iscrews) and mesial to the second premolars (6 minis- N-Or (right) 48.679 3.9546 48.750 3.1790 0.903
N-Or (left) 51.250 3.7352 50.643 3.0786 0.105
crews) had a mean close to the maximum value of that
scale, a finding that underscores its significant quality.
The paired t test showed a statistically significant strict oral hygiene practices, and they also received
difference (P 5 0.450) when the means of the differ- oral anti-inflammatory drugs for 5 days after the surgi-
ences between the right and left sides were compared. cal procedure.22-24,29-31
Twelve subjects had significantly greater maxillary In only 1 patient, severe inflammation with purulent
BMD on the right side. Linear regression also showed secretion led to miniscrew removal and repositioning in
a low correlation between the 2 sides (P 5 0.097). another site, although no stability loss was seen. Inflam-
Our subjects were over 12 years old (mean age, mation was ascribed to the miniscrew position, above
21 years 1 month), as advised by the American Food the mucogingival limit, close to the vestibulum floor.
and Drug Administration.43 Variations of bone quality Miniscrews placed in the alveolar mucosa have greater
must be expected in older subjects. Because calcium likelihood to trigger inflammation.20,22,24,46
metabolism declines with age, especially in women, Although no alteration in the initial position of the
the differences might be relevant for miniscrew stabil- miniscrews was observed, they might not remain abso-
ity.44,45 lutely static.18,22 No statistically significant differences
Miniscrew placement in interradicular areas requires were seen between N-mi (P 5 0.278 [right]; P 5 0.111
appropriate radiologic planning, including a surgical [left]), Or-mi (P 5 0.272 [right]; P 5 0.487 [left]), and
guide with periapical radiographs for determination of N-Or (P 5 0.903 [right]; P 5 0.105 [left]) as assessed
a safer placement site.15,25,26 In this study, surgery per- with cephalometric outlines on lateral oblique radio-
formed by the same professional and adequate planning graphs (45 ), pointing to stability of the 28 miniscrews
seemed to be decisive factors for clinical success of the during the 90-day observation period and ascertained by
miniscrew implants, in accordance with methods previ- comparisons of the means at T1 and T2. Variations were
ously used elsewhere. also seen between N and Or at T1 and T2. These varia-
Although a waiting time of 2 weeks is advised be- tions were similar to those between the cephalometric
tween miniscrew placement and load application points and the miniscrews. These nonstatistically signif-
(range, 50-300 gf5,14,16) to allow for tissue cicatrization, icant variations are likely to have been due to distortions
primary mechanical retention allows for immediate de- in the radiographic images.
vice activation.16 In this study, a 200-g load was imme- The most favorable site for miniscrew placement for
diately applied after the placement of 30 miniscrews, canine retraction is between the roots of the maxillary
without apparent interference with stability and clinical second permanent premolars and the first molars.6,27,28
success. In an extensive review, Kravitz and Kusnoto31 observed
Because inflammation control is fundamental for an 11% to 30% variation in the frequency of miniscrew
miniscrew stability, all subjects were advised to use absolute stability loss under orthodontic loads. The
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 2
success index in this study was 100%; none of the 28
miniscrews showed the slightest mobility after 90
days under a 200-g load. BMD values of all subjects
were within the normal range of the Norton and Gam-
ble38 scale, even close to the maximum value, pointing
to the safety of this region between the second premo-
lars and the first molars, and the region mesial to the sec-
ond premolars, for miniscrew placement.
CONCLUSIONS
1. The regions between the maxillary second premo-
lars and the first molars, and mesial to the maxillary
second premolars, are safe as far as bone quality is
concerned for miniscrew placement during the first
90 days of canine distalization, because the BMD
values were within the normal range of an estab-
lished scale.
2. Surgical technique and appropriate planning for
miniscrew insertion, coupled with inflammation
control and adequate oral hygiene, seem fundamen-
tal for the success of this new anchorage system
during maxillary canine distalization.
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