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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.
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February 2011 Vol 139 Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics