ORIGINAL ARTICLE

Effects of miniscrew orientation on implant

stability and resistance to failure
Michael B. Pickard,
a
Paul Dechow,
b
P. Emile Rossouw,
c
and Peter H. Buschang
d
Moscow, Idaho, and Dallas, Tex
Introduction: The purpose of this study was to determine the effect of miniscrew implant orientation on the
resistance to failure at the implant-bone interface. Methods: Miniscrew implants (IMTEC, Ardmore, Okla)
were placed in 9 human cadaver mandibles, oriented at either 90

or 45

to the bone surface, and tested to

failure in pull-out (tensile) and shear tests. The line of applied force and the orientation of the implants aligned
at 45

were either parallel or perpendicular to the maximum axis of bone stiffness. In the shear tests, the im-
plants aligned at 45

were angled toward and opposing the axis of shear force. Results: The implants aligned
at 90

had the highest force at failure of all the groups (342 680.9 N; P\0.001). In the shear tests, the implants
that were angled in the same direction as the line of force were the most stable and had the highest force at
failure (253 6 74.05 N; P\0.001). The implants angled away from the direction of force were the least stable
and had the lowest force (87 6 27.2 N) at failure. Conclusions: The more closely the long axis of the implant
approximates the line of applied force, the greater the stability of the implant and the greater its resistance to
failure. (Am J Orthod Dentofacial Orthop 2010;137:91-9)
D
espite the serendipitous discovery of the os-
seointegrative properties of titanium and the
subsequent development of titanium dental im-
plants in the 1960s,
1-3
they were not used in orthodon-
tics until the 1980s.
4-9
However, dental implants have
limited anatomic placement options and require a pre-
cise 2-stage protocol and a 3 to 6 month healing pe-
riod.
3,4,6,10,11
Recently introduced miniscrew implants
(MSIs) can be easily placed in almost any intraoral re-
gion, have lower costs, are removed easily, and, conse-
quently, have greater applications for orthodontic
anchorage.
12,13
The success of any implant in providing denitive
anchorage depends on its stability. Most clinical reports
suggest that MSIs are stable with applied forces ranging
from 50 g (0.5 N)
14
to 450 g (4.5 N).
15
However, mini-
screws should not be expected to remain absolutely sta-
tionary during orthodontic loading;
16
MSIs remain
stable as bone remodeling takes place in response to me-
chanical stress.
17-19
This is distinctly different from
movements associated with pathology; these result in
loosened MSIs. Although it seems well established
that MSIs placed with appropriate surgical techniques
can withstand forces in the orthodontic range (1-3 N),
there is only limited information available concerning
the maximum forces that can be applied to them.
Pull-out (tensile) tests are commonly used to evalu-
ate the maximumforces that bone screws can withstand,
and are considered an accurate method of comparing the
relative strength or holding power of surgically placed
bone screws.
20-24
Tests have been conducted with vari-
ous animal bones, including bovine femurs,
20,24,25
por-
cine ribs,
26,27
dog femurs,
20,21
and sheep parietal
bones.
28
There have been only limited pull-out tests on
human mandibles.
23
Importantly, pull-out tests alone
are not adequate for measuring the xation potential of
bone screws, because they do not address shearing
forces.
21,29
Even though pull-out and shear tests produce
forces that substantially exceed those typically used by
orthodontists, these tests provide valuable information
pertaining to primary stability and material characteris-
tics of MSIs.
There are presently no published data on the maxi-
mum pull-out and shear forces that MSIs can withstand,
and there has been only limited pull-out testing of bone
screws in actual anatomic bone sites. Furthermore, there
are no published data on the effect of MSI placement
orientation relative to the bone surface and the axes of
maximum and minimum bone stiffness, despite recent
evidence demonstrating consistent patterns of material
a
Private practice, Moscow, Idaho.
b
Professor and program director, Department of Biomedical Sciences, Baylor
College of Dentistry, Texas A&M University Health Science Center, Dallas.
c
Professor and chairman, Department of Orthodontics, Baylor College of Den-
tistry, Texas A&M University Health Science Center, Dallas.
d
Professor and director of orthodontic research, Department of Orthodontics,
Baylor College of Dentistry, Texas A&M University Health Science Center,
Dallas.
The authors report no commercial, proprietary, or nancial interest in the
products or companies described in this article.
Reprint requests to: Peter H. Buschang, Department of Orthodontics, Baylor
College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246; e-mail,
phbuschang@bcd.tamhsc.edu.
Submitted, September 2007; revised and accepted, December 2007.
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.12.034
91
anisotropy in the cortical bone of various regions of the
human craniofacial skeleton.
30
The purpose of this study was to evaluate the effects
of orthodontic MSI orientation on stability and resis-
tance to failure at the bone-implant interface. The study
was designed to answer the following questions. What is
the maximum amount of force that can be applied to
MSIs in the human mandible? Does loading orientation
affect maximum force? Does the orientation of the long
axis of the miniscrew relative to the surface of the bone
and the direction of the applied force affect the
implants stability and its resistance to failure?
MATERIAL AND METHODS
Nine fresh-frozen, unembalmed, dentate, human ca-
daver mandibles donated for anatomic research pur-
poses were selected for implant placement and testing.
The mandibles came from3 female and 6 male white do-
nors between 48 and 81 years of age. No donors were
known to have suffered from primary bone diseases.
For mounting purposes, impressions were taken of
the test mandibles, and models were poured. Up to 3
custom acrylic (methylmethacrylate) bases were fabri-
cated for each test mandible.
28
To compensate for lin-
gual surface variations, the acrylic base was adapted
to the cortical surface of the entire lingual corpus and in-
ferior ramus. The opposite side of the acrylic base was
ground to a level plane. The acrylic base allowed rigid
xation of the mandible to the test equipment while
maintaining the test site surface orientation perpendicu-
lar to the line of force in the pull-out tests and parallel to
the line of force in the shear tests. Then the custom t to
each lingual surface allowed for uniform distribution of
reaction forces during the application of test loads. It
prevented the development of internal stress/strain in-
duced by exure secondary to xation of the mandible
to the test apparatus. An anterior hole near the mental
foramen and a posterior hole in the inferior ramus
were drilled through the bone sample and the custom
acrylic support base to allow rigid xation of the
mandible to the test equipment.
The tensile and shear testing was completed with
a universal testing machine (model DDL 200RT,
TestResources, Shakopee, Minn), outtted with a 112-
pound calibrated load cell used in tensile mode. Adjust-
able x-axis and y-axis sliding tables (Sherline Products,
Vista, Calif) were mounted to the base of the testing ma-
chine. A 360

rotational table (Sherline Products) was

mounted on top of the sliding tables horizontally for
pull-out tests and vertically for shear tests. A mounting
plate was fabricated from a 0.5 3 3 3 9-in aluminum
bar and attached to the 360

rotational table. Bolts

were used to secure the test mandible and its acrylic
base to the mounting plate.
Acustomimplant holder was attachedto the loadcell
of the testing machine. It was designed to allow for rota-
tional and x-y freedom during attachment of the test im-
plants to the tensile machine. The bottom part of the
implant holder was fabricated from a 6.4-mm diameter
aluminum cylinder with a 2-mm key way cut in its
base to a depth of 4 mm. This space gave the head of
the implant 0.4 mm of horizontal and 0.5 mm of vertical
clearance. A 1.0-mm hole was drilled perpendicular to
the key way at a point 2.0 mm from the base. A 0.028-
in piece of stainless steel orthodontic wire was run
through the implant holder and the hole in the head of
the implant to secure the implant to the implant holder.
MSIs (IMTEC, Ardmore, Okla), 6 mm long and 1.8
mm in diameter, were placed in the buccal cortex of the
mandible, at angles of either 90

or 45

to the buccal sur-

face. They were tested to failure by using pull-out and
shear tests directed along the axes of maximumand min-
imum bone stiffness. The design test matrix consisted of
9 subgroups of 10 implants each (Fig 1). Three sub-
groups were pull-out tests. The remaining 6 were shear
tests. Three shear tests were sheared parallel to the max-
imum axis of bone stiffness, and 3 were sheared parallel
to the minimum axis of bone stiffness, which is perpen-
dicular to the axis of maximum bone stiffness.
The pull-out tests consisted of MSIs in 1 of 3 orien-
tations: placed orthogonally to the buccal surface, an-
gled at 45

along the maximum axis of bone stiffness,

and angled at 45

along the minimum axis of bone stiff-

ness. All 3 implant orientations were tested to failure in
pull-out tests in which the line of force was at 90

to the
bone surface.
In both sets of the shear tests, along the axis of either
maximum or minimum bone stiffness, the MSIs were in
1 of 3 positions: orthogonal to the buccal surface, angled
at 45

toward the same direction as the line of shear

force, and angled at 45

opposite the line of shear force.

All MSI orientations were tested to failure in a shear test
in which the line of shear force was along the bone sur-
face and in a direction parallel to the maximum or min-
imum axis of bone stiffness. The maximum force at
failure in the pull-out and shear tests and the cortical
thickness were recorded for each sample.
Bone-implant test sites were selected on the buccal
cortex of the corpus of the mandibles so that no proxi-
mate defects could adversely affect the test results. A
1.1-mm pilot drill was used to prepare the MSI site;
the pilot holes were drilled only through the cortex. A
guide was fabricated and used with the pilot drill to en-
sure the proper orientation for the MSIs oriented at 45

to the bone surface. After the pilot holes were drilled,

92 Pickard et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
the MSIs were placed according to the manufacturers
specications. Once the MSI was placed, the test man-
dible was set in the custom acrylic base and xed to the
mounting plate anteriorly and posteriorly. The mandible
was then oriented to obtain the correct position of the
test site relative to the actuator, as previously described.
With the mandible secured to the test holder and ap-
propriately positioned, a digital photograph of the im-
plant was taken (DXC-390P digital video, Sony, New
York, NY; macro lens, Konica Minolta, Wayne, NJ;
and imaging software, SCION, Frederick, Md). The
0.028-in stainless steel orthodontic wire was inserted
through the holder and the MSI, and the load screw
was activated to eliminate any play between the MSI
and the load cell. The tensile machine position was
then zeroed, and the test began with the machine mov-
ing at a rate of 2 mm per minute.
24
Data collected dig-
itally included time, load, and position during each
test. At regular intervals during the testing, digital pho-
tographs were recorded and identied with load or posi-
tion information to document the changes of the
implant-bone interface during testing. At failure of the
implant-bone interface, the test was discontinued, the
test data were saved, and a nal digital image of the
postfailure implant-bone interface was recorded. For
each test, maximum force at failure was recorded.
During testing, the mandibles were kept moist. All
tests were conducted with the mandibles at room tem-
perature (22

C). The mandibles were stored by wrap-

ping them in wet paper towels, placing them in
sealable plastic bags, and freezing them at 5

C. Freez-
ing does not adversely affect the elastic properties of
bone measured ultrasonically,
31-33
although it might
have some minor effects on mechanically determined
material properties.
34
Statistical analysis
Preparation of all mandibular specimens, testing,
and data recording were performed by 1 tester
(M.B.P.). Statistical analysis was completed with statis-
tical software (version 14.0, Minitab, State College, Pa).
Fig 1. Test matrix with 9 subgroups.
American Journal of Orthodontics and Dentofacial Orthopedics Pickard et al 93
Volume 137, Number 1
Although the variables distributions were normal, non-
parametric Kruskal-Wallis tests were used for the com-
parisons because of the small sample sizes of the
subgroups. The signicance level of P \0.05 was
used for all tests.
RESULTS
The pull-out tests of the MSIs aligned at 90

to the
cortical surface had a signicantly higher maximum
force at failure (342 6 80.9 N; P \0.001) (mean 6
standard deviation) than all other test groups (Table,
Fig 2). The loading curve for all 3 pull-out test groups
was largely linear until immediately before failure
(Fig 3, A).
At failure, 1 of 2 bone-implant interface congura-
tions was generally seen. In most cases, the bone re-
mained in intimate contact with the MSI at failure.
For MSI failures with intact bone, the 90

MSIs often
had an elliptical surface outline with a conical cross-
sectional shape. Generally, the greatest dimension of
bone was in the direction of maximum bone stiffness
(Fig 4, A). In other cases, the MSI separated from the
bone, with cortical splinters of bone projecting upward
in the direction of the pull-out test.
The pull-out tests of the MSIs aligned at 45

to the
bone surfaceoriented in the direction of either the
minimum or maximum bone stiffnesshad a bone-fail-
ure wedge in the 135

angle between the MSI and the

surface of the bone (Fig 4, B). Similar to the pull-out
tests of the MSIs aligned at 90

to the cortical surface,

the widths of the bone fragments were smaller for the
MSIs oriented along the direction of maximum bone
stiffness than for the MSIs oriented along the direction
of minimum bone stiffness.
The maximum forces at failure in tests of MSIs an-
gled 45

toward the line of shear force in the direction of

maximum bone stiffness (253 674.1 N; P\0.001) and
Table. Descriptive statistics of maximum force at failure
Maximum force at failure
Test type Implant orientation Mean (n) SD (n) Min (n) Max (n)
Pull-out 90

341.85* 81.0 257.0 493.2

45

maximum stiffness 107.9 32.1 71.5 160.1

45

minimum stiffness 141.4 57.0 92.8 250.8

Shear test (direction of maximum bone stiffness) 90

123.8 26.5 85.3 179.3

45

-opposite force 102.3 25.4 74.7 163.0

45

-same as force 253.34* 74.1 152.5 355.6

Shear test (direction of minimum bone stiffness) 90

138.1 34.6 88.5 174.0

45

-opposing force 87.5 27.2 62.2 123.0

45

-same as force 264.16* 21.0 230.2 278.3

*Maximum force at failure was signicantly higher than other tests with P\0.001.
Min, Minimum; Max, Maximum.
Mean Maximum Force at Failure
(with 95% Confidence Interval)
342
108
141
124
102
253
138
88
264
0
50
100
150
200
250
300
350
400
450
PO 90 PO 45
Max
PO 45
Min
SH Max
90
SH Max
45 O
SH Max
45 S
SH Min
90
SH Min
45 O
SH Min
45 S
Test Group
N
e
w
t
o
n
s

(
N
)
Fig 2. Maximum force at failure with 95% CI.
94 Pickard et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
those in the direction of minimum bone stiffness (264 6
21.0 N; P \0.001) were signicantly higher than the
other 4 test groups (Table).
The 45

MSIs opposing the shear line of force most

often failed in a bimodal fashion (Fig 3, B). The loading
curve was initially similar to the other test subgroups
Fig3. Representative loading curves of the 3 modes of implant failure: A, typical pull-out test or shear
of 45

implants angled toward the shear force; B, typical shear test of 45

implants angled away from

the shear force; C, typical shear test of 90

implants.
Fig 4. A, Postfailure bone-implant section of a 90

pull-out test; B, postfailure bone-implant section

of 45

pull-out test; C, buccal surface response when implant contacts lingual cortex.
American Journal of Orthodontics and Dentofacial Orthopedics Pickard et al 95
Volume 137, Number 1
until primary failure, which occurred as the MSI started
to rotate from the original 45

placement. The loading

curve generally attened while the MSI reoriented
to approximately 90

relative to the cortical surface;

as the MSI continued to rotate from 90

to 45

in the
same direction as the applied force, the loading curve
usually increased until nal failure of the MSI-bone
interface.
Shear tests of the MSIs aligned 90

to the cortical
surface also demonstrated a nonlinear loading curve
(Fig 3, C). Similar to the MSIs aligned at 45

and oppos-
ing the shear line of force, the loading curve fell after an
initial linear loading response. The slope of the increas-
ing load response decreased but remained positive until
failure. Unlike the MSIs aligned 45

to the cortical sur-

face and opposing the shear line of force, a single point
of primary failure was not clearly identiable.
DISCUSSION
This study was the rst to demonstrate the effects of
MSI orientation on the stability and resistance to failure
at the bone-implant interface. The stability and resis-
tance to failure of bone screws used for rigid xation,
which are similar to MSIs, are known to depend on
many variables including MSI material,
24,28,35
diame-
ter,
24
length, thread design,
25
surgical placement proto-
col,
36
and the recipient bone qualities.
20
Although the thread length of the MSIs was only
6 mm, the lingual cortex was often reached during
placement. When contact was made, the MSI was not
placed its full length into the bone. Contact with the lin-
gual cortex was based on increased tactile placement
torque and supercial bone layers that volcanoed or
pulled up along the thread of the screw (Fig 4, C).
The rising of the supercial layers suggested axial load-
ing. Some MSIs aligned at 45

to the bone surface also

appeared to contact the lingual cortex. Because of the
consistency of the results, the potentially confounding
effect of contact with the lingual cortex was limited.
A clinical implication is that, when placing an MSI in
the mandible, even the short 6-mm thread length is po-
tentially adequate to achieve bicortical achorage and is
more than adequate for monocortical placement. Saka
23
concluded that it was unnecessary to have a bone screw
more than 7 mm in length and 2 mm in diameter for
monocortical applications in the mandible.
MSIs loaded along their long axes showed the great-
est stability and resistance to failure. This nding can be
explained by the fact that the screws that were oriented
parallel to the line of force had threads that were perpen-
dicular to the load and thus in an optimum position to
resist the load. Since this principle applies regardless
of the force levels, the effects of orientation on MSI sta-
bility and resistance to failure identied in this study
might apply to the clinical success of MSIs.
Although the physiologic thresholds of bone strain
for the mandible have not been determined,
37
it is rea-
sonable to suggest that, at levels above physiologic
strain limits, microdamage leading to bone resorption
can occur.
18,19,38
Strain is related to and proportional
to stress or force applied over an area. MSIs have
a smaller area and, therefore, higher stress and strain as-
sociated with an applied load than the larger dental im-
plants. Clearly, the larger the area over which an
orthodontic load is applied, the greater the force that
can be applied without exceeding physiologic strain
limits. As this study conrms, the more closely the
line of force and the long axis of the MSI are coincident,
the greater the area of distributed load and the greater
the MSIs stability and resistance to failure.
Another consideration is that any discrepancy be-
tween the MSI orientation and the line of applied force
tends to decrease the uniformity of load distribution on
the screwthreads, resulting in disproportionate load dis-
tribution at the implant-bone interface.
37,39
The greater
the proportion of the force that is not along the long axis
of the MSI, the greater the amount of torque on the
bone-implant interface.
39
As the angle between the
long axis of the MSI and the line of force increases,
stress concentrations increase in unfavorable areas
such as the acute angles of the bone-implant interface.
In shear tests of the MSIs angled at 45

away (tent-
pegged) from the line of force, the highest stress con-
centration would be expected at the 45

degree angle of
bone near the cortical surface (Fig 5). These stress con-
centrations resulted in reductions in MSI stability and
resistance to failure.
The maximum pull-out force of the MSIs aligned at
90

to the bone surface in this study compares well

with the uniaxial pull-out tests of several miniscrew de-
signs 1.5 to 2.0 mm in diameter and 5 to 7 mm long.
23
Fig 5. Stress concentrations of 45

implants opposing
the line of shear force.
96 Pickard et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
Differences could be due to differences in screw de-
sign, length, diameter, and placement location. Huja
et al,
40
for example, showed signicantly smaller max-
imum pull-out forces for 6-mm MSIs placed in the an-
terior (134.5 N) rather than in the posterior (388.3 N)
mandible. Unfortunately, there are no comparable stud-
ies in any bone that report pull-out test results of in-
clined MSIs or bone screws. Shear tests have been
performed on bio-absorbable implants loaded with
50 N, but they were not tested to failure.
29
Because
orthodontic MSIs are primarily loaded in shear, more
studies are needed to explore the variables affecting
MSI stability and resistance to failure when loaded
obliquely or in shear.
A uniform load distribution in the peri-MSI bone
might explain the observed stability and high force at
failure of the uniaxially loaded orthogonal MSIs in
pull-out tests. In this situation, the line of force and
the long axis of the MSI are colinear, and the force is
distributed to the surrounding bone uniformly.
37,39,41
In most pull-out tests, failure did not occur at the
bone-implant interface. Rather, it occurred in the sur-
rounding bone. This suggests that the mechanical reten-
tion of the implant-bone interface was greater than the
cohesive strength of the surrounding bone matrix.
MSIs that have lost their primary stability and be-
come displaced can still support an applied load. This
supports ndings of studies in which mobile MSIs could
still resist orthodontic loading.
16,42
In the shear tests, the
MSIs aligned at 45

to the cortical surface and away

from the direction of loading (tent-peg orientation)
lost stability and were displaced from their initial place-
ment orientation, but they continued to support a signif-
icant applied load. This produced a bimodal loading
curve with 2 regions (points) of failure and 3 distinct
phases of loading-failure behavior (Fig 3, B). During
the rst phase, the implant-bone interface appears stable
and resists the applied load with a linear load response
similar to the other pull-out tests (Fig 3, A). However,
the MSI then goes through an identiable primary fail-
ure in which the implant-bone interface fails, but only
partially, as indicated by a small decrease in the loading
curve. During the second phase of loading, the MSI ro-
tates from its initial placement position angled away
from the direction of loading to about 90

to the cortical
surface. During the third phase, the MSI continues its
rotation toward the line of force until additional load re-
sults in ultimate failure. The increase of load observed is
surprising, since the rotating MSI has left a trailing bone
trough in which reduced mechanical retention might be
expected. This bimodal pattern might be due to the
screws apex being forced into the lingual cortex, at
which point it functions as a fulcrum or hinge point, re-
stricting the apex from swinging free and pulling the
threaded MSI into the bone on the same side as the ap-
plied force. This effectively distributes the load into the
leading edge of the resisting bone. When the MSI rea-
ches about 45

or less toward the line of force, the

apex and the entire MSI can pull out, leading to com-
plete and ultimate implant-bone failure. Moreover, the
destructivenes of the failure process results in only par-
tial resistance of the screwthreads in direct pull-out, and
the force at failure is much less than that in screws that
were originally angled at 45

in the direction of the load.

In many cases, the ultimate load at failure slightly ex-
ceeds that which occurred during primary failure, dem-
onstrating the resistive effect of the apex wedging into
the lingual cortex during the rotation of the MSI. This
wedging effect of the apex is supported by the observa-
tion that some MSIs showed bending in their tapered
apical portions.
It is likely that the apex of the MSI contacted the lin-
gual cortex after it began rotating. The MSI acts as
a Class II lever arm (load is between the fulcrum point
and the applied force). The apex acts as a fulcrum point
as it wedges into the inner surface of the lingual cortex,
the buccal cortex acts as the resisting load, and the ap-
plied load is the shear force at the head of the MSI.
This effectively magnies the effective load delivered
to the bones buccal cortex. The ratio of the distance be-
tween the hole in the head of the MSI to the apex of the
MSI (about 9.5 mm) and the distance between the loca-
tion of the buccal cortex to the apex of the MSI (about
4-5 mm) suggests that the effective load on the bone
can be increased by a factor of about 2. The geometry
of the MSI relative to the buccal cortex and the inner
portion of the lingual cortex is the likely explanation
of the magnitude and mode of implant-bone failure. In
these tests, the remaining self-tapping section of the
screw is predominantly in medullary bone, which pro-
vides little primary mechanical retention.
43
The primary
retention of the MSI is in the buccal cortex. The combi-
nation of the mechanical lever arm effect and the geo-
metric stress concentrations previously discussed
results in decreased stability and lower resistance to fail-
ure in MSIs oriented at 45

opposing the line of shear

force, and enables signicant movement of the MSI
and increased cortical bone damage before ultimate
failure.
Similar to the MSIs aligned at 45

to the cortical sur-

face and opposing the shear line of force, the MSIs
aligned at 90

to the cortical surface and loaded in shear

had a nonlinear loading curve (Fig 3, C), but without
a clearly identiable point of primary failure. Their
loading curve response, reduced stability, and lower re-
sistance to failure appear to be due to the same
American Journal of Orthodontics and Dentofacial Orthopedics Pickard et al 97
Volume 137, Number 1
mechanical disadvantage as the MSIs aligned at 45

to
the cortical surface and opposing the shear line of force.
CONCLUSIONS
1. MSIs loaded along their long axis have the greatest
stability and resistance to failure. The more closely
the long axis of the MSI approximates the line of
applied force, the greater the stability of the MSI
and the greater its resistance to failure. Thus, it
might be important when placing orthodontic
MSIs to avoid loading them in a direct shear mode.
2. MSIs angled in the same direction as the applied
load have greater stability and resistance to failure
than MSIs that are tent-pegged or oriented
away from the applied load. The mechanical and
geometric disadvantages of the latter orientation
reduce MSI stability and resistance to failure.
3. MSIs originally loaded in shear that have lost their
primary stability and become displaced can still
support an applied load, especially if the apex of
the MSI is initially in contact with the deep surface
of the lingual cortex. However, failure in this mode
results in greater damage to peri-implant bone than
failure of MSIs loaded along their long axis.
4. MSI stability and resistance to failure is indepen-
dent of MSI orientation along directions of maxi-
mum and minimum bone stiffness. However,
patterns of anisotropy in cortical bone do affect
the structure of the bone-MSI failure site.
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