European Journal of Orthodontics 35 (2013) 583589 The Author 2012.

or 2012. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjs066 All rights reserved. For permissions, please email: journals.permissions@oup.com
Advance Access publication 4 October 2012

Effect of the quantity and quality of cortical bone on the failure

force of a miniscrew implant
MasahiroIijima*, MasamitsuTakano**, YoshitakaYasuda***, TakeshiMuguruma*,
SusumuNakagaki*, YasunoriSakakura****, MorioOchi** and ItaruMizoguchi*
*Division of Orthodontics and Dentofacial Orthopedics, Department of Oral Growth and Development, School of
Dentistry, **Division of Fixed Prosthodontics and Oral Implantology, Department of Oral Rehabilitation, Health
Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, ***Yasuda Orthodontic Office, Nishinomiya, Hyogo,
and ****Division of Anatomy, Department of Oral Growth and Development, School of Dentistry, Health Sciences
University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan

Correspondence to: Masahiro Iijima, Division of Orthodontics and Dentofacial Orthopedics, Department of Oral
Growth and Development, School of Dentistry, Health Sciences University of Hokkaido, Kanazawa 1757, Hokkaido
061-0293, Japan. E-mail: iijima@hoku-iryo-u.ac.jp

summary This study examined the influence of the quantity and quality of cortical bone on the failure
force of miniscrew implants. Twenty-six titanium alloy miniscrew implants (AbsoAnchor) 1.4mm in diam-
eter and 5 or 7mm long were placed in cross-sectioned maxillae (n=6) and mandibles (n=20) of human
cadavers. Computed tomography imaging was used to estimate the cortical bone thickness and bone
mineral density [total bone mineral density (TBMD, values obtained from cortical bone plus trabecular
bone); cortical bone mineral density (CBMD, values obtained from only cortical bone)]. Maximum force
at failure was measured in a shear test. Nanoindentation tests were performed to measure the hardness
and elastic modulus of cortical bone around the miniscrew implants. The mean failure force of miniscrew
implants placed in mandibles was significantly greater than that for implants in maxillae, and the bone
hardness of mandibles was significantly greater than that of maxillae. The length of miniscrew implants
did not influence the mean failure force in monocortical placement in the mandible. Cortical bone thick-
ness, TBMD, CBMD, and bone hardness were significantly related to the mean failure force. CBMD was
related to the mechanical properties of cortical bone. In conclusion, the quantity and quality of cortical
bone greatly influenced the failure force of miniscrew implants.

Introduction
Miniscrew implants have been gaining popularity because
their small size allows for more placement sites in the
oral cavity, less discomfort for patients, an easy surgical
procedure, and low cost (Miyawaki etal., 2003; Park etal.,
2006; Kuroda etal., 2007). For the proper application of
miniscrew implants, clinicians expect reliable anchorage
without the need for patient compliance. However, one of
the major concerns regarding miniscrew implants is their
relatively high failure rate. Arecent systematic review article
showed that the failure rate of miniscrew implants ranged
from 13.4 to 20.1 per cent (Schtzle etal., 2009). Many
factors, including implant dimension (Miyawaki etal., 2003;
Morarend etal., 2009), implant length (Lemieux etal., 2011),
insertion orientation (Pickard etal., 2010), insertion torque
(Motoyoshi etal., 2010), cortical bone thickness (Huja etal.,
2005; Motoyoshi etal., 2009), and bone mineral density
(BMD; Santiago etal., 2009; Cha etal., 2010), have been
reported to influence the stability of miniscrew implants.
On the other hand, a recent study showed that cortical bone
thickness decreases during the healing period because of
bone resorption around the miniscrew implant (Salmria
etal., 2008). The immediate application of orthodontic
loading may improve the success rate of miniscrew implants
because cyclic mechanical forces have been shown to
modulate the development and regeneration of bone (Turner
etal., 1994; Robling etal., 2001).
The primary stability of miniscrew implants has been
attributed to mechanical factors (mechanical locking) in
the initial stage. To investigate the mechanical locking of
miniscrew implants and bone, mechanical tests such as a
tension test (pull-out test; Pickard etal., 2010) and shear
test (tangential loading test; Morarend etal., 2009; Lemieux
etal., 2011) have been previously used; some studies have
used human cadavers (Morarend etal., 2009; Pickard etal.,
2010; Lemieux etal., 2011), since the absolute values of
the properties of the bone material of mammals differ con-
siderably (Zioupos etal., 1999). The mechanical locking of
miniscrew implants may be influenced by bone quantity and
bone quality, which have been evaluated using the cortical
bone thickness (Huja etal., 2005; Baumgaertel etal., 2009;
Motoyoshi etal., 2009) or BMD (Santiago etal., 2009; Cha
etal., 2010). Seong etal. (2009) reported that, in human
cadavers, the mechanical properties (hardness and elastic
modulus) of the maxilla and mandible were different. The
bone hardness and elastic modulus are influenced by the
584 M. IIJIMA ET AL.
mineral content and crystal structure, and these may be
associated with the clinical primary stability of a miniscrew
implant. However, little is known about the relationship
between the primary stability of miniscrew implants and the
hardness and elastic modulus of corticalbone.
The purpose of this study was to investigate the influ-
ence of the quantity and quality of cortical bone, such as
the thickness, BMD, hardness, and elastic modulus, on the
force required for failure of miniscrew implants placed in
human cadavers. We hypothesized that the hardness and
elastic modulus of cortical bone do not affect the failure
force of miniscrew implants and that BMD is related to the
mechanical properties of bone.
Materials and methods
Under the permission of domestic law, the human cadav-
ers have been donated to the Health Sciences University of
Hokkaido for dental education and research. Fourteen man-
dibles and four maxillae from 16 cadavers were obtained
for the present study after the cadavers had been used for
anatomical dissection by dental students. Fully dentate and
partially dentate specimens were considered to be accept-
able. The average age of the cadavers was 70.4years (51
85years); 72.9years (5885years) for male and 68.3years as Digital Imaging and Communication in Medicine files,
(5185years) for females. After the mandibles and maxillae
were sectioned, soft tissue was carefully removed.
The region between the second premolar and first molar
was sectioned with a water-cooled diamond-saw (MG4000,
Exakt, Nordsteds, Germany). The samples with missing
teeth (both second premolar and first molar) were excluded
in the present study. For mechanical testing, all samples
were ground with 600 grit sandpaper to a thickness of
approximately 10mm. One or two cross-sectioned speci-
mens of mandible and maxillae were obtained from each
human cadaver. The list of human cadavers used in this
study is shown in Table1.
Twenty-six as-received titanium alloy miniscrew
implants (AbsoAnchor, Dentos, Daegu, Korea) 1.4mm in
diameter and 5 or 7mm long were used. The miniscrew
implants 5mm long were used for both mandibular (n=11)
and maxillary specimens (n=6). To compare miniscrew
implants with different lengths, nine miniscrew implants
7mm long were used for mandibular specimens with com-
paratively thick bucco-lingual diameters to avoid bicortical
support. All miniscrew implants were placed in the buccal
alveolar bone by the same operator (Y.Y.) after an approxi-
mately 2mm deep pilot hole was made with a slow-speed
handpiece and a pilot drill 1.1mm in diameter according to
the manufactures recommendation. All miniscrew implants
were placed perpendicular to the buccal bone surface.
To measure the buccal cortical bone thickness and BMD
of the area that contained miniscrew implants, computed
tomography (CT) images were taken under a 200mm field
of view, 120kV, 130 mA, scanning time of 1.0 seconds/
Table1 List of human cadavers used in this study.
Cadavers Mandible Mandible Maxillae Age
(5mm) (7mm)
1 76
2 67
3 82
4 74
5 74
6 58
7 85
8 58
9 85
10 77
11 53
12 78
13 51
14 67
15 85
16 56
, male; , female.
rotation, and a slice thickness of 1.0mm with a high-
resolution mode before and after the miniscrew implants
were placed (Prospeed FII, GE). The CT data were saved
and 3D reconstructed images of the specimens were made
using SimPlant Pro 12.03 (Materialise, Leuven, Belgium).
The cortical bone thickness was measured by using images
after implantation of the miniscrew implant (Figure1a). The
BMD values per area [total bone mineral density (TBMD,
values obtained from cortical bone plus trabecular bone:
areas of 1.5 5mm or 1.5 7mm); Cortical bone mineral
density (CBMD, values obtained from only cortical bone)]
in Hounsfield units were also determined from images
before the placement of miniscrew implants using the
software (Figure1b).
The maximum force at failure in the shear test (failure
force) for each miniscrew implant was measured with a uni-
versal testing machine (EZtest, Shimadzu, Kyoto, Japan).
Agrip was used to hold the specimens and the position of
the specimen was adjusted so that a knife-edged shearing
blade was secured to the crosshead with the direction of
force parallel to the bone surface (Figure1c). The shear test
was carried out at a crosshead speed of 1mm per minute.
Nanoindentation tests were carried out to measure the
mechanical properties of cortical bone around the minis-
crew implants after shear testing (ENT-1100a, Elionix,
Tokyo, Japan). All of the specimens were ground to be
approximately 5mm thick, using 600 grit sandpaper. All
nanoindentation testing was carried out at 28C with a peak
load of 100 mN using a Berkovich indenter. For each speci-
men, five indentations were placed on the cortical bone
without damage by implant failure and the mean hardness
and elastic modulus were calculated by software provided
with the nanoindentation apparatus (Figure1d).
PRIMARY STABILITY OF AMINISCREW IMPLANT 585

Figure1 The series of experiments in the present study. (a and b) Estimation of buccal cortical bone thickness and bone mineral den-
sity using the computed tomography and SimPlant Pro; (c) shear testing of a placed miniscrew implant; and (d) nanoindentation test for
a polished specimen to estimate the bone hardness and elastic modulus.

Statistical analysis
The experimental results were analyzed using IBM SPSS
Statistics software (version 19.0J for Windows, IBM,
Armonk, New York, USA). The data of mean failure force,
buccal bone thickness, TBMD, CBMD, hardness, and
elastic modulus, along with the standard deviation, for
each group was normally distributed (ShapiroWilk test).
However, the values were compared using the Kruskal
Wallis test and the MannWhitney U-test since the number
of samples was different among groups. Significances
were predetermined at P<0.0167 for comparison of the
failure force, buccal bone thickness, TBMD, and CBMD,
and P<0.05 for comparison of the hardness and elastic
modulus. The relationships among the above factors were
investigated with the Pearson correlation coefficient test. Figure2 Failure force in the shear test in the three specimen groups.
Horizontal bars in boxes are medians; 50% of all values are within boxes.
Bottom and top of each box indicate lower and upper quartiles, respec-
Results tively. Vertical lines represent complete range of values.
The results regarding mean failure force, cortical bone
thickness, TBMD, and CBMD are shown in Figures 24; did not find significant differences in cortical bone thick-
the detailed values are summarized in Table2. The Kruskal ness (P=0.181) or TBMD (P=0.149) among the three
Wallis test showed a significant difference in failure force specimen groups. The mean failure forces of both 5 and
(P=0.001) and CBMD (P=0.004) among the three speci- 7mm miniscrew implants in the mandible were signifi-
men groups. On the other hand, the three specimen groups cantly greater than that of 5mm implants in the maxillae,
586 M. IIJIMA ET AL.
Figure3Cortical bone thickness in the three specimen groups.
Horizontal bars in boxes are medians; 50% of all values are within boxes.
Bottom and top of each box indicate lower and upper quartiles, respec-
tively. Vertical lines represent complete range of values.
although there was no significant difference between speci-
mens with different lengths (5 and 7mm) in the mandible.
The mean CBMD of 7mm miniscrew implants in the man-
dible was significantly greater than that of 5mm implants in
the maxillae, although there was no significant difference
between 5mm implants in the mandible and maxillae.
The results regarding mean cortical bone hardness and
elastic modulus are shown in Table3. The mean bone hard-
ness for mandibular specimens was significantly greater
than that for maxillary specimens (P=0.001). Similarly,
the mean bone elastic modulus for mandibular specimens
was significantly greater than that for maxillary specimens
(P=0.003).
Table4 shows the correlations among the mean fail-
ure force, cortical bone thickness, TBMD, CBMD, bone
Figure4 Bone mineral density in Hounsfield units in the three specimen groups. (a) TBMD and (b) CBMD. Horizontal bars in boxes are medians; 50%
of all values are within boxes. Bottom and top of each box indicate lower and upper quartiles, respectively. Vertical lines represent complete range of values.
hardness, and bone elastic modulus in the three specimen
groups. The mean cortical bone thickness (r=0.529),
TBMD (r=0.555), CBMD (r=0.490), and bone hardness
(r=0.400) were significantly related to the failure force in
the shear test. The mean CBMD was significantly related
to the hardness (r=0.446) and elastic modulus (r=0.445).
Discussion
The absolute values of the properties of bone material
in mammals differ considerably (Zioupos etal., 1999).
Therefore, this study used human cadavers to investigate
the failure force of miniscrew implants, which is believed
to be strongly influenced by bone quantity and bone quality.
Age affects the properties of bone in animals and humans
(Zioupos etal., 1999). In general, with age there is an
increase in the mineral content of the bone tissue, which
achieves its best strength and stiffness at maturity (Zioupos
etal., 1999). However, Burstein etal. (1976) measured the
mechanical properties of cortical bone specimens from
human femora and tibiae for a population ranging in age
from 21 to 86years; reported that no significant differences
were found between the mechanical properties of male and
female specimens. Therefore, the results obtained in the
present study are worthwhile, although the age of cadavers
were extremely different from general orthodontic patients.
Lemieux etal. (2011) compared the tensile strength of
miniscrew implants of different lengths (6, 8, and 10mm)
and found that longer miniscrew implants provide greater
anchorage; however, longer miniscrew implants (8 and
10mm) were associated with a greater incidence of sinus
and bicortical perforations (Lemieux etal., 2011). Although
the primary stability of miniscrew implants can be improved
by bicortical placement using longer implants, evaluation
by CT imaging is required to avoid risks such as touching
PRIMARY STABILITY OF AMINISCREW IMPLANT 587

Table2 Mean failure force, cortical bone thickness, total bone mineral density (TBMD), and cortical bone mineral density (CBMD)
obtained in maxillary and mandibular specimens.

Mandible (5mm) Mandible (7mm) Maxillae P value

Mean Standard Mean Standard Mean Standard

deviation deviation deviation

Failure force (N) 182.47a 51.44 143.95a 30.72 70.30b 26.42 0.001
Cortical bone thickness (mm) 1.90 0.96 2.31 0.78 1.40 0.31 0.181
TBMD (HU; cortical bone plus 1124.47 303.6 1134.63 290.25 831.89 296.89 0.149
trabecular bone)
CBMD (HU; cortical bone) 1541.44a,b 244.07 1771.25a 202.9 1199.39b 375.66 0.004

The values were compared using the KruskalWallis test and the MannWhitney U-test (P<0.0167). Identical letters indicate that mean values were not
significantly different.

Table3 Mean hardness and elastic modulus obtained in

maxillary and mandibular specimens.
Mandible Maxillae
Mean Standard Mean Standard
deviation deviation
Hardness (GPa) 0.64 0.11 0.42 0.10
Elastic modulus 24.41 5.00 18.14 2.94
(GPa)
MannWhitney U-test (P<0.05).
the root and sinus and bicortical perforation of lingual bone
(Morarend etal., 2009). On the other hand, in the present
study, miniscrew implants of two different lengths (5 and
7mm) were compared with regard to the failure force in the
shear test, and there was no significant difference in fail-
ure force between the two lengths of miniscrew implants
when placed in mandibular bone. In addition, CT images
confirmed that none of the specimens showed bicortical
placement. These results may suggest that unless bicortical
placement is used, a long miniscrew implant is unnecessary.
The orientation of a miniscrew implant also influences
its primary stability. Pickard etal. (2010) reported that
the highest concentration of stress could be expected at
an angle of 45 degrees near the cortical surface of bone
in shear tests of miniscrew implants angled at 45 degrees
away (tent-pegged) from the line of force, and this stress
concentration resulted in a reduction in miniscrew implant
stability and resistance to failure. In addition, another
previous study by Morarend etal. (2009) reported that
larger-diameter miniscrew implants provided increased
anchorage force resistance compared with smaller-diameter
monocortical miniscrew implants, although larger diameter
of the miniscrew implants have a higher risk of touching the
root (Kuroda etal., 2007).
The quantity and quality of a cortical bone may influence
the long-term stability of a miniscrew implant. Cha etal.
(2010) reported that the CBMD significantly influenced the
primary stability of miniscrew implants. In the present study,
although there was no significant difference in the buccal
P value
bone thickness or TBMD among the three specimen groups
due to individual variation, the mean buccal bone thickness
(r=0.529), TBMD (r=0.555), and CBMD (r=0.490) in
Pearson correlation coefficient test (two mandibular groups
0.001
0.003 were combined into one group) were significantly related
to the mean failure force, which corresponds to the primary
stability of miniscrew implants. The primary stability of
miniscrew implants may also be influenced by the mechani-
cal properties of bone, such as its hardness and elastic mod-
ulus. Therefore, the present study used the nanoindentation
test to characterize the mechanical properties of bone. With
the nanoindentation technique, it is possible to determine
the hardness and elastic modulus simultaneously (Pharr and
Oliver, 1989; Oliver and Oharr, 1992; Iijima etal., 2011).
The nanoindentation tests have allowed the measurement
of mechanical properties for extremely small volumes of
materials where the contact radius is less than 100nm and
the indentation in the present study were placed carefully
on the cortical bone without cracking to avoid the effects of
bone damage by implant failure.
The results of the nanoindentation test showed that there
was a significant correlation between the mean failure force
in the shear test and bone hardness. However, the elastic
modulus of bone was not significantly correlated with
the failure force. In addition, the mean bone hardness of
mandibular specimens was significantly greater than that of
maxillary specimens, which agrees with a previous finding
(Zioupos etal., 1999); and thus mandibular bone is more
resistant to deformation and can bear more load under
clinical conditions. In the present study, the failure force in
shear testing determined for the mandible was significantly
greater than that for maxillae. However, previous studies
have reported a lower clinical success rate with miniscrew
implants in the mandible (Park etal., 2006; Wu etal.,
2009). The reasons for the lower clinical success rate in
the mandible may be that the inflammation of peri-implant
588 M. IIJIMA ET AL.

Table4 Pearsons correlation coefficient (r) among failure force, cortical bone thickness, bone mineral density (BMD), hardness, and
elastic modulus.

Failure force Cortical bone TBMD (cortical bone CBMD (cortical Hardness Elastic modulus
thickness plus trabecular bone) bone)

Failure force 1
Cortical bone 0.529** 1
thickness
TBMD (cortical bone 0.555** 0.769*** 1
plus trabecular bone)
CBMD (cortical bone) 0.490 *
0.664 ***
0.672*** 1
Hardness 0.400* 0.426* 0.326 0.446* 1
Elastic modulus 0.311 0.246 0.126 0.445* 0.430* 1

CBMD, cortical bone mineral density; TBMD, total bone mineral density.
*
P<0.05, **P<0.01, ***P<0.001.

tissue (Miyawaki etal., 2003), proximity of miniscrew References

implants to the adjacent tooth (Kuroda etal., 2007), or
microdamage to the cortical bone (Lee and Baek, 2010) due
to less ductile characteristic in the mandibularbone.
The failure force of miniscrew implants is affected not
only by the cortical bone thickness but also by TBMD,
CBMD, and the cortical bone hardness; CBMD was associ-
ated with the mechanical properties of bone. Although con-
ventional CT scan is useful method to estimate the BMD
values in an experiment, it is not clinically justified due to
high radiation exposure of patients.
Conclusions
Under the conditions of this in vitro study, the following
conclusions can be drawn:
1. The failure force of miniscrew implants placed in the
mandible was significantly greater than that of the
implant in the maxillae and the bone hardness of the man-
dible was significantly greater than that of the maxillae.
2. The length of miniscrew implants did not influence the
failure force in monocortical placement in the mandible.
3. The cortical bone thickness, BMD (TBMD and CBMD),
and bone hardness were factors that influenced the fail-
ure force.
4. CBMD was associated with the mechanical properties
of cortical bone.
Funding
This study was partially supported by the Research Project
of the Research Institute of Personalized Health Sciences,
Health Sciences University of Hokkaido.
Acknowledgements
The authors thank Hirohito Ikeda and Eiji Nakayama for
kindly taking CT images and for their expert technical
assistance.
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