Int. J. Oral Maxillofac. Surg.

2009; 38: 13–18

doi:10.1016/j.ijom.2008.09.006, available online at http://www.sciencedirect.com

Clinical Paper
Surgical Orthodontics

The effect of cortical bone M. Motoyoshi1, M. Inaba2, A. Ono2,

S. Ueno2, N. Shimizu1
1
Department of Orthodontics, Division of

thickness on the stability of

Clinical Research, Dental Research Center,
Nihon University School of Dentistry, Tokyo,
Japan; 2Department of Orthodontics, Nihon
University School of Dentistry, Tokyo, Japan

orthodontic mini-implants and

on the stress distribution in
surrounding bone
M. Motoyoshi, M. Inaba, A. Ono, S. Ueno, N. Shimizu: The effect of cortical bone
thickness on the stability of orthodontic mini-implants and on the stress distribution in
surrounding bone. Int. J. Oral Maxillofac. Surg. 2009; 38: 13–18. # 2008
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. Cortical bone thickness (CBT) was evaluated at mini-implant placement

sites in 65 orthodontic patients and was found to be directly proportional to the
success rate of the mini-implant. The success rate of the mini-implant was
significantly greater at sites with CBT  1.0 mm. To examine the biomechanical
effects of CBT, finite element models were made for CBT from 0.5 to 1.5 mm, at
0.25-mm intervals. Cortical bone models without cancellous bone were constructed
to examine the biomechanical influence on cortical bone after cancellous bone
resorption. CBT influenced the stresses in the cancellous bone, but could not
directly influence the stresses in the cortical bone. For CBT < 1 mm, the cancellous
bone models exhibited von Mises stresses exceeding 6 MPa, and the cortical bone
Keywords: microimplant; mini-screw; tempor-
models without cancellous bone showed von Mises stresses exceeding 28 MPa. ary anchorage devices; finite element method.
Greater CBT values were associated with higher mini-implant success rates. This
morphometric study and mathematical simulation verify that a clinical CBT Accepted for publication 12 September 2008
threshold of 1 mm improves the success rate of mini-implants. Available online 28 October 2008

Titanium mini-implants are used during
orthodontic treatment to strengthen the
orthodontic anchorage and to ensure that
teeth move predictably and without reci-
procal movement1,4,5,9,10,12,18,21,22.
Although mini-implants have been used
to great advantage in orthodontics9,18,
some clinicians have observed mini-
implant loosening during orthodontic
treatment2,20. The stability of the mini-
implant is related to the quality and quan-
tity of cortical bone16, the design and
shape of the screw thread6, the degree
of inflammation accompanying local irri-
tation, the excess orthodontic force14 and
the low maturation of the bone in growing
patients17. The firmness of cortical bone is
one of the principal factors controlling the
stability of mini-implants7,15,16.
Several quantitative studies of cortical
bone thickness (CBT) have been per-

0901-5027/01013 + 06 $30.00/0 # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
14 Motoyoshi et al.

formed in attempts to improve the success

rate of orthodontic mini-implants3,16.
Deguchi et al.3 used computed tomogra-
phy (CT) to investigate CBT in various
locations and concluded that the safest
location for mini-implant placement was
mesial or distal to the first molar. Miya-
waki et al.14 found that a high mandibular
plane angle, which often exists with thin
cortical bone, was associated with tita-
nium screw failure and suggested that
CBT affects the implant success rate. Fig. 1. The placement location was identified by measuring the height (A) from the arch wire
(a). Cortical bone thickness (B) was measured using CT (b).
Motoyoshi et al.16 found a relationship
between the success rate and CBT and
concluded that implants placed in an area to the position of implant placement in the force of approximately 2 N was applied
with CBT  1.0 mm had a better success inter-root gap between the second premo- beginning 1 month after implant place-
rate. The mechanical reciprocity between lar and first molar (Fig. 1). A titanium ment, using a nickel titanium coil spring.
bone quantity and implant stability might mini-implant (diameter, 1.6 mm; length, A mini-implant that endured the orthodon-
be related to this clinical threshold for 8 mm; thread ridge, 0.2 mm high; and tic force for at least 6 months without any
successful implantation of mini-implants thread pitch, 0.6 mm) (ISA orthodontic mobility was considered a success.
with 1.5–2.0 mm diameters. implant; Biodent, Tokyo, Japan) was The CBT and success rate of the mini-
This study used CT to evaluate the CBT placed into the buccal alveolar bone at implants for orthodontic anchorage were
at placement sites in more subjects than the prepared site in the maxilla or mand- analyzed. A x2 test or Fisher’s exact prob-
examined by Motoyoshi et al.16 and inves- ible, without flap surgery. Under local ability test was used to compare the suc-
tigated the relationship between CBT and anesthesia, a pilot hole, 1.3 mm in dia- cess rate of the mini-implant according to
the success rate of mini-implants. The meter and 8 mm long, was created using a CBT, placement location, and gender. The
biomechanical influences in the bone bone drill, and the mini-implant was analyses were performed using SPSS for
around the mini-implant were analyzed placed into the pilot hole. An orthodontic Windows (SPSS Japan, Tokyo, Japan).
using the finite element method, and the
differences in stress distribution were
examined according to differences in the
CBT, to verify the clinical threshold for
successful implantation.

Material and methods

Morphometric study
The subjects were 65 patients (average age
24.8  7.8 years; range 15.8–36.9 years;
52 females and 13 males) at Nihon Uni-
versity Dental Hospital, who had mini-
implants (209 implants) placed in the pos-
terior alveolar bone as anchors for ortho-
dontic treatment. The usefulness of the
mini-implants for orthodontic anchorage
and the risk of loosening of the mini-
implants during treatment were explained
to the subjects or the subjects’ parents.
This study used only the data for patients
who consented to placement of the mini-
implants and agreed to participate in the
study. This study was approved by the
ethics committee of Nihon University
School of Dentistry.
Before mini-implant placement, CT
images (3D Accuitomo; J. Morita, Kyoto,
Japan) of the maxilla or mandible were
obtained for diagnostic imaging of the
planned implant location. The CBT was
then measured at the prepared site. The
site of implant placement was identified
on tomograms of the prepared site by Fig. 2. Design of the mini-implant used in the study. The screw was 1.6 mm in diameter and
measuring from the height of the arch wire 8 mm long (a). Design of the screw thread (b).
 Stability of orthodontic mini-implants 15

Table 1. Material properties of constituent materials. clinical practice. The equivalent stress
Materials Young’s modulus (MPa) Poisson’s ratio Mass density (g/cm3) (von Mises) was calculated at each node
and the stress distribution on the bone
Titanium 110000 0.3 4.5
Cortical bone 13700 0.3 1.8 elements evaluated using COSMOS/
Cancellous bone 300 0.3 0.8 Works.

Table 2. Success rate of the mini-implant according to location, gender and CBT. Results
Success Failure Total Success rate (%) P-value Morphometric study
Maxilla 102 13 115 88.7 0.549
The statistical analysis showed significant
Mandible 83 11 94 88.3
differences in implant success according
Right 90 14 104 86.5 0.250 to CBT; there were no significant differ-
Left 95 10 105 90.5 ences according to placement location and
Female 143 21 164 87.2 0.192 gender. The success rate of the mini-
Male 42 3 45 93.3 implant was significantly greater for
CBT 3 1.0 mm 140 13 153 91.5 0.027*
CBT  1.0 mm than for CBT < 1 mm
CBT < 1.0 mm 45 11 56 80.4 (Table 2). The relationship between
CBT and the success rate, shown in
CBT: Cortical bone thickness.
* Fig. 4, indicates that greater CBTs were
P < 0.05.
associated with higher mini-implant suc-
Statistical significance was established at assess the stresses and strains surrounding cess rates.
p < 0.05. To evaluate the relationship the mini-implant. Nodes surrounding the
between the CBT and success rate in more bone elements were restricted to three
detail, the subjects were divided into four degrees of freedom. The direction of trac- Finite element analysis
groups according to CBT (0.5–1.0, 1.0– tion in each model was defined with the The von Mises stress distributions in the
1.5, 1.5–2.0, and 2.0+ mm), and the suc- head of the mini-implant parallel to the five models with cancellous bone (models
cess rate was calculated in each group. bone surface. The traction force was fixed a–e) are shown in Fig. 5, where red areas
at 2 N, which is the approximate ortho- denote stress exceeding 6 MPa. Stresses
dontic force applied to a mini-implant in exceeding 6 MPa were distributed in a
Finite element analysis
For the finite element analysis, a 1.6 mm
diameter, 8 mm long commercial mini-
implant was simulated; the height of the
thread ridge was fixed at 0.2 mm with a
thread pitch of 0.6 mm (Fig. 2). CBT was
set from 0.5 to 1.5 mm at 0.25-mm inter-
vals, to examine the biomechanical influ-
ence of CBT and to verify the clinical
threshold. Five models (models a–e) were
constructed using the program Solid-
Works (COSMOS Japan, Tokyo, Japan).
Fig. 3. The finite element model used in the study.
The mini-implant was assumed to be made
of pure titanium. Both the bone and
implant elements were assumed to be
homogeneous, isotropic, and linearly elas-
tic. The material properties of the elements
in the models were based on published
data8,11,19 (Table 1). Each model was
meshed automatically using the program
SolidWorks. Each model consisted of
approximately 240,000 nodes and
180,000 elements (Fig. 3). Five models
(models f–j) consisting of cortical bone
alone were constructed to examine the
biomechanical influence of cortical bone
without cancellous bone; the models with-
out cancellous bone consisted of approxi-
mately 15,000 nodes and 10,000 elements.
The interface between the mini-implant
and the bone elements was fixed, as
osseointegration was assumed. Each bone
element consisted of a cube with 20 mm Fig. 4. Success rate in four groups of different cortical bone thickness: 0.5–1.0, 1.0–1.5, 1.5–
sides. These were sufficiently large to 2.0, and 2.0 mm.
16 Motoyoshi et al.

wide area, from the superior margin to

deeper positions, in the models with
CBT values of 0.5 and 0.75 mm (Fig. 5a
and b). In the model with 1.0 mm CBT
(Fig. 5c), the red areas were remarkably
reduced and were seen at the margin. No
red areas were observed in the models
with CBT values of 1.25 and 1.5 mm
(Fig. 5d and e). The maximum von Mises
stresses in the cortical bone for models a–e
(Fig. 6) were constant at approximately
18 MPa, irrespective of CBT. The max-
imum stresses in the cancellous bone
decreased gradually as CBT increased.
The von Mises stress distributions in the
cortical bone for the five models without
cancellous bone (models f–j) are shown in
Fig. 7, where red areas denote stresses
exceeding 28 MPa. In model f, most of
the superior and inferior margins were
red, and in model g, parts of the superior
margin were red. The stresses in models h–j
were reduced compared with the stresses in
models f and g, indicated by the lack of red
areas for these models. Fig. 8 shows the
maximum von Mises stresses in the five
models without cancellous bone. The max-
imum stress decreased markedly as CBT
increased. The stresses in the models with
CBT values of 0.5 and 0.75 mm were
approximately 40 and 28 MPa, respec-
tively, whereas the stresses were less than
25 MPa in the models with CBT > 1.0 mm.

Discussion

Fig. 5. The von Mises stress distribution in cancellous bone with cortical bone thickness of (a) Morphometric outcomes using CT
0.5, (b) 0.75, (c) 1.0, (d) 1.25 and (e) 1.5 mm. Before considering the success rate of the
mini-implants according to CBT, the influ-
ences of placement location and gender on
the success rate were investigated
(Table 2). No significant differences
according to placement location and gender
were observed, in agreement with previous
studies14,15. The success rates in the groups
with CBT  1.0 mm were significantly
higher than those in the groups with
CBT < 1.0 mm. This concurs with the
finding of Motoyoshi et al.16, verifying
1 mm as the clinical threshold for CBT.

The von Mises stress distribution in the

bone elements
Li et al.13 developed a bone remodeling
model that simulates overload bone
resorption and determined the critical
stress curves for overload and underload
resorption. According to their stress
curves, the threshold for overload bone
resorption increases with bone density.
Fig. 6. Plot of the maximum von Mises stress in cortical and cancellous bone versus cortical When the bone density was 1.8 g/cm3,
bone thickness. corresponding to compact bone, overload
 Stability of orthodontic mini-implants 17

resorption was observed in areas with von

Mises stresses exceeding 28 MPa. When
the bone density was 0.8 g/cm3, corre-
sponding cancellous bone adjacent to cor-
tical bone, overload resorption was
observed in areas with von Mises stresses
exceeding 6 MPa. Areas with stresses
exceeding 6 and 28 MPa according to
the authors’ cancellous and pure cortical
bone models, respectively, are plotted in
red and represent areas of probable degen-
eration (i.e. bone resorption).
The plots for the cancellous bone mod-
els reveal that thinner cortical bone tends
to be associated with greater von Mises
stress in the superior marginal position
(Fig. 5). Areas of bone resorption were
observed around the screw thread in the
models with CBTs of 0.5 and 0.75 mm. In
the model with 1.0 mm CBT, bone resorp-
tion might occur at part of the superior
margin. Bone resorption would not occur
in the cancellous bone in the models with
CBT > 1 mm (Fig. 5d and e). The max-
imum von Mises stress in the cancellous
bone decreased linearly as CBT increased
(Fig. 6), whereas the maximum von Mises
stress in the cortical bone remained con-
stant and below the threshold for bone
resorption. Unexpectedly, CBT influenced
stress in the cancellous bone but did not
directly influence stress in the cortical
bone. Bone resorption is anticipated in
cancellous bone with a CBT < 1 mm,
and cancellous bone support might be lost
in these cases. Cancellous bone is less
Fig. 7. The von Mises stress distribution in the cortical bone models without cancellous bone, dense in the deeper part of the implant
with cortical bone thickness of (f) 0.5, (g) 0.75, (h) 1.0, (i) 1.25 and (j) 1.5 mm. site than in the superior position, adjacent
to the cortical bone8, and thus the thresh-
old for cancellous bone resorption might
be lower in the deeper areas, which
showed low stress levels in the models.
Cancellous bone in the deeper position
surrounding a mini-implant might be
resorbed in cases with a CBT < 1 mm.
The biomechanical responses in cortical
bone following cancellous bone resorption
were simulated with cortical bone models
without cancellous bone. The cortical bone
models with a CBT < 1 mm (Fig. 7f and g)
showed areas of bone resorption, with von
Mises stresses exceeding 28 MPa, whereas
the maximum von Mises stress was less
than 25 MPa in the models with a CBT of
1 mm (Fig. 8). Based on these findings for
cancellous and cortical bone models, the
CBT threshold enabling a mini-implant to
endure orthodontic forces appears to be
1 mm, which was supported by the present
morphometric study as well as by a pre-
vious study16, which concluded that the
CBT at the prepared site should be
Fig. 8. Plot of the maximum von Mises stress in the cortical bone models without cancellous 1.0 mm to improve the success rate of
bone versus cortical bone thickness. mini-implants.
18 Motoyoshi et al.
Fig. 9. CT images of a mobile mini-implant. The white broken line (a) indicates the location of
the tomographic slice (b). Bone resorption is observed surrounding the mini-implant, just below
the cortical bone (b, white arrows).
Based on the above findings, the process
leading to mini-implant failure begins
with bone resorption occurring from a
superior to an inferior position in cancel-
lous bone, resulting in the loss of cancel-
lous bone support. Consequently, bone
resorption occurs at the superior and infer-
ior margins of the cortical bone. Even-
tually, the mini-implant can no longer
resist the orthodontic force, and it loosens.
This cascade might be verified in future
animal experiments.
The nonlinear relationship between
CBT and the success rate (Fig. 4) contrasts
with the relationship between CBT and the
von Mises stress in cortical bone (Fig. 8).
For a CBT < 1 mm, the maximum von
Mises stress in bone increased markedly,
whereas the success rate of the mini-
implant decreased.
On a CT image of a mini-implant that
became mobile 1 month after orthodontic
force application (Fig. 9), bone resorption
was observed surrounding the mini-
implant, confirming the results of the
mathematical simulation based on the
finite element method.
Acknowledgments. The authors thank the
staff of the Department of Radiology,
Nihon University School of Dentistry,
for their assistance with the CT. This study
was supported by grants from Nihon Uni-
versity Individual Research Grant 2007
and Grant-in-Aid for Scientific Research
(C) 2007.
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Address:
Mitsuru Motoyoshi
Department of Orthodontics
Division of Clinical Research
Dental Research Center
Nihon University School of Dentistry
1-8-13, Kanda-Surugadai,
Chiyoda-ku
Tokyo 101-8310
Japan
Tel: +81 3 3219 8105
Fax: +81 3 3219 8312.
E-mail: motoyoshi@dent.nihon-u.ac.jp