ORIGINAL ARTICLE

Miniscrew stability evaluated with computerized

tomography scanning
Jung-Yul Cha,a Jae-Kyoung Kil,b Tae-Min Yoon,c and Chung-Ju Hwangd
Seoul, Korea

Introduction: In this study, we aimed to determine the effect of bone mineral density (BMD), cortical bone
thickness (CBT), screw position, and screw design on the stability of miniscrews. Methods: Ninety-six mini-
screws of both cylindrical and tapered types were placed in 6 beagle dogs. The BMD and CBT were measured
by computerized tomography and correlated with the placement and removal torque and mobility. A regres-
sion equation to predict the placement torque was calculated based on BMD, CBT, screw type, and screw
position. Results: The placement torque showed a positive correlation in the order of removal torque
(0.66), BMD of the cortical bone (0.58), and CBT (0.48). Placement and removal torque values were signifi-
cantly higher in the mandible compared with the maxilla. Tapered miniscrews had higher placement torque
than did the cylindrical type (P \0.001). However, the removal torque was similar in both groups. Placement
torque was affected by screw position, screw type, and BMD of cortical bone, in that order. Conclusions:
BMD of cortical bone, screw type, and screw position significantly influence the primary stability of mini-
screws. (Am J Orthod Dentofacial Orthop 2010;137:73-9)

quantity and quality.4,5 The initial stability of minis-

E
asy placement is an advantage of orthodontic
miniscrews. In addition, the tooth can be moved
without the patient’s cooperation; this enhances
treatment efficiency. Some success has been reported
regarding the use of miniscrews as orthodontic anchor-
ages. However, the clinical application of a miniscrew
does not guarantee treatment success, and its stability
is essential before it can be used as orthodontic
anchorage.1-3
It is important to ensure the initial stability of an
orthodontic miniscrew because most failures occur
during the initial stage. Furthermore, stability of the
miniscrew in the initial stage reduces its micromove-
ment, thus allowing for an appropriate environment
that supports the healing process surrounding the bone.
The success of an implant or miniscrew is determined
by the patient’s general condition, the biocompatibility
of the materials, the placement procedure, and bone
a
Assistant professor, Department of Orthodontics, College of Dentistry, Yonsei
University, Seoul, Korea.
b
Private practice, Seoul, Korea.
c
Postgraduate student, Department of Orthodontics, College of Dentistry,
Yonsei University, Seoul, Korea.
d
Professor, Department of Orthodontics, Dental Science Research Institute, The
Institute of Craniofacial Deformities, College of Dentistry, Yonsei University,
Seoul, Korea.
The authors report no commercial, financial, or proprietary interest in the prod-
ucts or companies described in this article.
Reprint requests to: Chung-Ju Hwang, Department of Orthodontics, College of
Dentistry, Yonsei University, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-
752, Korea:; e-mail, hwang@yuhs.ac.
Submitted, August 2007; revised and accepted, March 2008.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.03.024
crews is considered essential in clinical use because of
immediate or early loading in many patients.6
Two factors affect the initial stability of a screw: the
screw factor and the host factor. The screw factor is
related to the characteristics of the screw design, includ-
ing diameter and length.7 Various screw designs have
been introduced to enhance initial stability.8 The goal
is to increase initial fixation by inducing controlled
compressive forces in the cortical bone layer. In the
prosthodontic field, it was reported that a tapered shape
can enhance stability for immediate loading by increas-
ing the mechanical contact between the dental implant
and the surrounding bone.9
The host factor is related to the quantity and quality
of the bone where the screw is placed. Cortical bone
thickness (CBT) (quantity) can affect the initial stability
of a screw.10 Finite element analysis showed that, when
a lateral force is applied to the screw, most of the force is
concentrated on the cortical bone.11,12 For this reason,
the previous studies focused on the anatomic back-
ground related to CBT rather than bone quality, to
improve the stability of the miniscrew.
On the other hand, several studies have used com-
puted tomography (CT) in prosthodontics and orthope-
dics to study factors related to bone density.13-16 It was
reported that bone density differs according to sex, age,
and physical condition. CT was recently suggested to
successfully measure bone mineral density (BMD) in
orthopedics. BMD has been used as a parameter to
establish a treatment plan to ensure the stability of
implants in dentistry.17
73
74 Cha et al
There are 2 methods for measuring BMD. One is
with Hounsfield units (HU), and the other is to measure
BMD indirectly by using a hydroxyapatite block. Since
Hounsfield units can be affected by the loaded voltage
of x-rays and the protocol used, bone density analysis
with a BMD calibration standard (hydroxyapatite
block) has greater advantages for evaluating bone qual-
ity more accurately.18
One assessment method of initial stability is to
measure the torque during placement.9,13,19 Cheng et
al19 proposed that placement torque could be used as
an indicator for initial stability, and, to obtain initial sta-
bility, a certain amount of torque is necessary. Place-
ment torque is the measurement of the resistance at
the screw-bone interface; it reflects the level of bone
deformational strain caused by the miniscrew.
In this study, we hypothesized that BMD values can
be used to predict the mechanical stability of minis-
crews by evaluating placement torque. Our aim was to
determine the effect of BMD, CBT, screw position,
and screw design on the stability of miniscrews.
MATERIAL AND METHODS
For this study, miniscrews were placed in 6 beagle
dogs (age, 1 year; weight, 12 kg). Their purchase,
selection, and management, and the experimental pro-
cedures were carried out according to prescribed condi-
tions of the institutional review board, the Animal
Experiment Committee of Yonsei Hospital, Seoul, Ko-
rea. A nondrilling type of miniscrew, 1.4 mm in diam-
eter and 7 mm in length, was used. Both the cylindrical
type (OAS-1507C) and tapered type (OAS-1507 T,
Biomaterials Korea, Seoul, Korea) were selected; 96
screws were used (Fig 1).
The location of the orthodontic miniscrew place-
ment was determined after evaluating the reconstructed
CT image, taken before placement, to determine
whether there was sufficient interdental space. Sites se-
lected were between the roots of the second, third, and
fourth premolars, and the first molar in the mandible,
between the roots of the second and third premolars,
the first molar, and between the second and third premo-
lars in the maxilla (Fig 2).
The animals were injected subcutaneously with 0.05
mg per kilogram of atropine followed by an intravenous
injection of rompun, 2 mg per kilogram, and ketamine,
10 mg per kilogram, to induce general anesthesia. The
anesthesia was maintained with 2% enflurane, and
each animal’s temperature was maintained with a heat-
ing pad and an electrocardiogram, and monitored.
When placing the mini-implant, 2% hydrochloric acid
lidocaine containing 1:100,000 epinephrine was infil-
American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
trated into the placement area. Before placement,
a 5-to-10 mm gingival incision was made under saline-
solution irrigation, and complete placement of the screw
into the alveolar bone was confirmed.
Screw placement was performed manually with 70
to 90 angulations to gingival surface in consideration
of the buccolingual width of alveolar bone for each
experiment. In all miniscrews, a force of 250 to 300 g
was applied with an elastomeric chain engaged recipro-
cally from a cylindrical miniscrew to a tapered mini-
screw immediately after the placement of miniscrews,
and the elastic chain was exchanged every 3 weeks.
Screw mobility was measured twice on each mini-
screw by using a periotest (Simens AG, Bensheim, Ger-
many) before removing the screw. The sleeve of the
handpiece of the periotest was positioned with 1 to 2
mm from the screw head perpendicularly after an elas-
tomeric chain was removed. The average of 2 measure-
ments for a miniscrew was recorded as the mobility
value. During the test period, a chlorhexidine solution
was applied daily to maintain the animals’ oral hygiene
(Fig 3).
The placement torque was the highest (in newtons
per square centimeter) when the miniscrew was placed
completely into the bone. The highest removal torque
was measured during a quarter initial turn by using a tor-
que sensor (MGT50, Mark-10 Co, New York, NY).
To measure the BMD of the implanted area, CT
scanning was done 3 days before placing and removing
the miniscrews. Before scanning, each dog was placed
under intramuscular sedation. The gantry of the CT
device was placed parallel to the occlusal plane, and
the dog’s head was fixed with a strap. The CT scan
was performed with a high-speed advantage CT scanner
(GE Medical System, Milwaukee, Wis) by using
standard CT protocol (high-resolution algorithm,
512 3 512 matrix, 120 Kv, 200 mA) at a table feed of
6 mm per second. The CT data were reconstructed to
1-mm thick transaxial images.
A calibration standard (Dental Phantom, Image
Analysis, Columbia, Ky) was applied to calibrate the
level in Hounsfield units in the dogs during the CT scan-
ning. The calibration standard containing 3 compart-
ments with 0, 75, and 150 mg of hydroxyapatite per
cubic centimeter was attached to the phantom for
BMD calibration. Calibration was performed by mea-
suring the Hounsfield unit values in the 3 compartments
of the dental phantom and relating these values to deter-
mine the BMD with a linear equation. The calibrations
were performed for each dog.
The scanned images were analyzed by V-implant
(CyberMed, Seoul, Korea). The CT data taken before re-
moving the screws were reconstructed to a transaxial
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 1
Fig 1. Features and measurements of the miniscrews tested (mm).
Fig 2. Schematic diagram indicating the approximate
locations of screws. Circles indicate screw heads, and
orthodontic forces were loaded reciprocally between
a cylindrical miniscrew (CS) and a tapered miniscrew
(TS).
image at 1-mm intervals for each occlusal plane of the
maxilla and mandible (Fig 4, A). The vertical location
and inclination of each screw was localized by using a re-
constructed image at the coronal plane from the postop-
erative scans. This information was transferred to the
preoperative images. From the preoperative scanning
data, the average BMD of a cylindrical area (diameter,
2 mm; depth, 5 mm) for each screw site was measured
as the BMD total by Hounsfield unit calibration. The
CBT and average bone mineral density in the cortical
area (BMD cortical) were also calculated (Fig 4, B).
Statistical analysis
To determine the relationship between Hounsfield
units and BMD values, a calibration regression equation
was derived individually for all experimental dogs and
Cha et al 75
was based on a linear relationship: BMD 5 a HU 1
b, where a and b are calibration coefficients.
Pearson correlation analysis was used to determine
the association between placement torque, removal tor-
que, mobility, BMD, and CBT. The categorical vari-
ables (screw type and position) were statistically
evaluated by using independent t tests to determine
any differences in placement torque. The results suggest
that the variables were linearly correlated. Thus, a mul-
tiple regression model was used with placement torque
as the dependent variable, and CBT, BMD, screw type,
and screw position as the independent variables.
RESULTS
A regression equation was obtained by using the av-
erage Hounsfield value (Table I, Fig 5) for the 3 parts in
the standard calibration of each beagle. The parameter
a (inclination) was calculated within the range of
0.813 to 0.935, and the intercept b ranged from 3.80
to 24.47. The correlation coefficient of all regression
equations was .0.98.
A correlation was observed between placement and
removal torque, mobility, screw type, and BMD corti-
cal. The mobility showed a negative correlation with
placement torque (–0.577) and a positive correlation
with BMD cortical (0.575) (Table II).
The values of placement and removal torque, CBT,
and BMD were significantly higher in the mandible
compared with the maxilla (P \0.05). The tapered
screw (14.57 N per square centimeter) had higher place-
ment torque than the cylindrical screw (9.69 N per
square centimeter); this was statistically significant in
the mandible (P \0.001) (Table II). There were no sig-
nificant differences in the removal torque between the
cylindrical and tapered screws. The values of CBT and
BMD were similar in the tapered and cylindrical screw
groups (Table III).
76 Cha et al
Fig 3. Experimental protocol used in this study.
Fig 4. Procedure of BMD measurement in the region of
interest: A, position of calibration phantom and recon-
structed image according to the occlusal plane; B, mea-
surement of Hounsfield units for the region of interest
(red box).
Multiple regression analysis showed that, among all
the variables (CBT, BMD cortical, BMD total, screw
type, screw position), screw position, screw type, and
American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
BMD cortical had significant influences on placement
torque (R2 5 0.801) (Table IV).
DISCUSSION
Recently in orthodontics, the use of miniscrews has
been generalized for the preparation of orthodontic
anchorage in clinical patients. However, studies on the
stability of orthodontic miniscrews are still in their early
stages compared with studies of prosthodontic implants.
Factors that can affect a miniscrew’s stability are
design,20 placement procedures,21,22 and quantity and
quality of the bone related to the host factor.5,23 This
study focused on the assumptions that the quantity
(thickness) and quality (density) of the bone have signif-
icant effects on a miniscrew’s stability.
Information on bone density can be obtained from
the measurement of the Hounsfield units, but there are
issues regarding the reliability of many CT scanners,
since CT values are affected by changes in the effective
energy of the x-ray source, the so-called beam-harden-
ing effect.18 To calibrate Hounsfield unit values, refer-
ence calibration standards for these CT values are
needed for each subject. Calibration coefficients had
a range of 0.813 to 0.935 in this study. The same
1000-HU value for 2 subjects can have a significant
discrepancy of about 120 BMD units. Even though 2
subjects might have the same Hounsfield unit value,
they can have different BMD values, and calibration
coefficients must be used to calculate the BMD values.
We therefore used a hydroxyapatite phantom to provide
accurate calibration.
Regarding the relationship between BMD and
placement torque, there was a positive correlation in
the cortical part of the alveolar bone but no similar
correlation in the total bone. Previous studies15,17
of prosthodontic implants reported high correlation
American Journal of Orthodontics and Dentofacial Orthopedics Cha et al 77
Volume 137, Number 1

Table I. Calibration of BMD by using Hounsfield units (HU) in the 3 compartments of the dental phantom
Calcium hydroxyapatite
3
0 mg/cm 75 mg/cm3 150 mg/cm3

HU HU HU Calibration coefficients

Dog Mean SD Mean SD Mean SD Parameter a Parameter b Correlation coefficient

1 4.2 0.8 81.6 0.7 168.7 1.1 0.868 3.80 0.99

2 6.4 6.2 79.4 2.6 176.9 6.3 0.813 7.24 0.99
3 3.9 1.8 82.3 3.0 178.8 3.4 0.819 4.76 0.99
4 10.8 5.3 74.1 2.1 169.8 4.0 0.827 10.71 0.99
5 7.6 2.0 53.0 4.9 149.8 1.4 0.935 14.16 0.99
6 21.0 5.7 47.8 2.3 160.4 1.4 0.810 24.47 0.98

Table II. Pearson correlation test and independent t test

for placement torque
Variable Correlation coefficient P value

Removal torque .661 0.001

Mobility .577 0.001
CBT .476 0.001
BMD cortical .575 0.001
BMD total .078 0.504

Mean 6 SD

Screw type
Cylindrical 9.69 6 5.32 0.001
Tapered 14.57 6 8.13
Screw
Maxilla 6.06 6 3.03 0.001
position
Mandible 17.84 6 5.03

Pearson correlation test was done between removal torque, mobility,

Fig 5. Graph depicting calibration of BMD values from
Hounsfield units for dog 1. The linear regression equa-
tion is shown on the graph, and the values are listed in
Table I. mg HA/cm3 equal milligrams (0, 75, 150) of
calcium hydroxyapatite per cubic centimeter.
between BMD and placement torque14 and significant
correlation between BMD and pull-out strength.15,22,24
Seebeck et al25 reported that in an axial pullout strength
and cantilever bending test to the implanted screw, the
screw’s stability was mostly related to the CBT and can-
cellous bone density. It is also known that the strength
and stiffness of trabecular bone are in linear proportion
to bone density on the axial and bending loads.26 This
demonstrates that the density of trabecular bone and
cortical bone makes a significant contribution to the sta-
bility of an implant. In a prosthodontic implant, most of
the implant, either in the maxilla or the mandible, is
CBT, and BMD, and the independent t test was performed for screw
type and screw position.
placed near cancellous bone, and the quality of cancel-
lous bone is important in the stability of the implant.27
However, our results indicated a poorer correlation be-
tween total bone density and placement torque com-
pared with cortical bone density.
It was observed that placement torque is related to
screw position. This is due to thicker cortical bone
and better bone quality in the mandible compared
with the maxilla.27 Despite the implant position, the sta-
bility of a prosthodontic implant is more influenced by
its length and diameter in alveolar bone, rather than
the thickness of cortical bone.27 However, the stability
of orthodontics miniscrews, with their relatively smaller
diameter and length, is related to CBT. This study
showed a significant correlation between placement
torque and cortical bone density.
Placement and removal torque also showed a posi-
tive correlation, which supports previously reported
78 Cha et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010

Table III. Comparison of variables according to screw location and screw type
Screw type Cylindrical Tapered

Variable Position Mean SD Mean SD P value

Removal torque (Ncm) Maxilla 2.29 1.24 1.83 0.81 0.480

Mandible 4.83 2.07 5.89 4.59 0.337
P value 0.001 0.001
Mobility (PTV) Maxilla 3.21 4.41 1.61 3.94 0.203
Mandible 0.12 2.77 2.94 4.03 0.012
P value 0.073 0.014
CBT (mm) Maxilla 1.38 0.6 1.42 0.51 0.510
Mandible 1.98 0.48 2.02 0.33 0.403
P value 0.001 0.001
BMD cortical (mg Maxilla 867.46 242.99 866.46 196.2 0.988
of hydroxyapatite/cm3) Mandible 1030.17 167.81 1049.51 202.3 0.722
P value 0.01 0.004
BMD total (mg Maxilla 579.41 197.73 583.26 172.38 0.945
of hydroxyapatite/cm3) Mandible 697.32 149.34 787.91 191.24 0.076
P value 0.025 0.001

Table IV.Regression equation model to predict place- was found in removal torque. This suggested that the
ment torque with CBT, BMD cortical, BMD total, screw strain generated between the screw and the bone after
type, and screw position placement decreased during healing of the surrounding
bone. Further research involving histologic analysis is
Unstandardized
coefficient Standardized required to confirm this.
coefficient A regression equation between placement torque,
Variable Beta SE Beta t P value BMD, and screw type was derived. Screw type and
CBT 0.053 0.879 0.004 0.060 0.952 position were major variables for the prediction of
BMD cortical 0.005 0.002 0.159 2.781 0.007 placement torque. This results from the difference in
BMD total 0.003 0.002 0.068 1.092 0.278 bone density and structure in the cortical bones of the
Screw type 4.692 0.680 0.326 6.897 0.000 maxilla and the mandible. The maxilla consists of
Screw position 10.428 0.922 0.725 11.310 0.000
more trabecular bone than the mandible, and its cortical
Corrected R2 0.801
bone is relatively thinner. The BMD cortical was also
Dependent value was placement torque (Ncm). chosen as a significant variable, but the impact of the
variables on the regression equation was smaller than
those of screw type and position. These results suggest
studies, and they also had a correlation with the BMD of that it might be difficult to predict the primary stability
cortical bone.28 However, the BMD of the total bone did of a miniscrew solely with BMD values, and screw
not have a major effect on placement and removal torque. design could play a major role in increasing the place-
On the other hand, mobility was associated with the BMD ment torque despite the quantity of bone.
of the total bone and CBT. Therefore, this suggests that Because of the high radiation dose during CT
BMD and CBT could affect a miniscrew’s stability. scanning, there are limitations in using it for clinical
Tapered miniscrews showed 65% higher placement purposes. However, dental CT such as cone-beam CT
torque than the cylindrical type. This coincides with the can be a useful technique for a noninvasive assessment
result from a previous study that used artificial bone.8 of BMD in estimating the stability of a miniscrew at the
As the tapered screw was placed, the torque along with preoperative stage.
the deformation of the surrounding bone increased with
increasing diameter. In this study, a similar bone density
was calculated at the placement area of each screw CONCLUSIONS
type. This meant that screw type affected the initial The BMD of the cortical bone, screw position, and
stability of the miniscrew because it was placed into screw type have a compound influence on the primary
some areas with low bone density or thinner cortical bone. stability of a miniscrew. Cone-beam CT might be a use-
A significant difference in placement torque was ful and noninvasive way to assess the BMD for estimat-
found according to the screw type, but no difference ing the stability of a miniscrew at the preoperative stage.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 1
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