ONLINE ONLY

Effect of miniscrew angulation on anchorage

resistance
Niles Woodall,a Srinivas C. Tadepalli,b Fang Qian,c Nicole M. Grosland,d Steve D. Marshall,e
and Thomas E. Southardf
Villa Rica, Ga, Seattle, Wash, and Iowa City, Iowa

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-
dontic anchorage has become increasingly popu-
lar. In a 2008 survey of over 500 orthodontists, it
a
Private practice, Villa Rica, Ga.
b
Senior fellow, Department of Orthopaedics and Sports Medicine, University of
Washington, Seattle.
c
Associate research scientist, Department of Preventive and Community
Dentistry, University of Iowa, Iowa City.
d
Associate professor, Department of Biomedical Engineering and Department of
Orthopaedics and Rehabilitation, University of Iowa, Iowa City.
e
Adjunct associate professor, Department of Orthodontics, University of Iowa,
Iowa City.
f
Professor and head, Department of Orthodontics, University of Iowa, Iowa City.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Supported by the Dr George Andreasen Memorial Fund.
Reprint request to: Thomas E. Southard, Department of Orthodontics, College of
Dentistry, University of Iowa, Iowa City, IA 52242; e-mail, tom-southard@
uiowa.edu.
Submitted, March 2010; revised and accepted, August 2010.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.08.017
was found that 80% had at least 1 active case involving
miniscrews.1 Compared with traditional endosseous
implants, which require time for osseointegration and
a second surgical procedure (trephination) for removal,
miniscrews can be loaded immediately, are smaller, are
easier to place, can be placed in more varied locations,
are more cost effective, and result in less postoperative
pain.2-5 However, in spite of their wide acceptance and
ease of use, there is no universally accepted screw-
placement protocol, and placement variables can in-
clude the presence or absence of a pilot hole, placement
through attached or unattached soft tissue, and angle of
placement.
The primary stability of miniscrews is believed to re-
sult from mechanical interlock and be determined by
factors such as cortical quality and quantity, soft-
tissue health, operator technique, and screw diameter.6,7
Several authors have suggested placing orthodontic
mini-implants at an angle to the surface of the cortical
e147
e148
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
axis of the tooth would increase cortical bone contact
by as much as 1.5 times compared with placement at 90 .
These studies suggest that placement of a miniscrew
at an angle to the bone surface increases cortical
bone contact and placement torque, which might have
a positive effect on miniscrew stability.8-11 However,
angulated (as opposed to perpendicular) miniscrew
placement can create a different problem. Regardless
of placement angle, a miniscrew must be placed with
the head a fixed perpendicular distance from the bone
surface so that the miniscrew head is located above the
soft tissues to allow force engagement. Therefore,
having a miniscrew exit the bone at an angle other
than 90 potentially creates a longer lever arm for the
applied force. The effect of a longer lever arm could
negatively balance, or even outweigh, any positive
effect of increased bone contact with an angulated
screw. Thus, a question still remains: what is the effect
of miniscrew angulation on anchorage resistance? The
literature does not provide the answer to this question.
The purpose of this in-vitro study was to test the hypoth-
esis that orthodontic miniscrew angular placement
impacts screw-anchorage resistance.
MATERIAL AND METHODS
Three-dimensional finite element models were cre-
ated to represent screw placement orientations of 30 ,
60 , and 90 . Each mesh consisted solely of hexahedral
elements modeled by using IA-FEMesh,12 and, in
each model, the screw was represented by a cylinder
with a diameter of 1.5 mm. The screws were modeled
as a titanium alloy with an elastic modulus of 110 giga-
pascals (GPa) and Poisson’s ratio of 0.34. A section of
bone measuring 9.5 mm long, 8.15 mm high, and
6 mm thick was considered. The cortical layer measured
February 2011  Vol 139  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Woodall et al
Fig 1. Miniscrew placement.
1.79 mm thick and was assigned an elastic modulus of
13.7 GPa, and the elastic modulus of the trabecular
bone was 200 megapascals (MPa). The bone was as-
sumed to be homogenous and isotropic with a Poisson’s
ratio of 0.3. The contact between the bone and the screw
was defined as a frictional interface with a coefficient of
friction of 0.37.13 The superior, inferior, and lingual
nodes of the bony elements were fixed completely,
and the screw was displaced to 0.6 mm at a distance
of 2.0 mm from the bone surface.
The maxillae and mandibles of human cadavers were
obtained from the Department of Anatomy and Cell
Biology Deeded Body Program at the University of
Iowa. Vital statistics of the cadavers were not available.
Fully edentulous or partially dentate specimens with
severely atrophic alveolar ridges were excluded. All spec-
imens were hemi-sected, soft tissues were carefully
removed, and the specimens were stored in 10% buff-
ered formalin solution.
Twenty-four hemi-maxillae from different cadavers
and 24 hemi-mandibles from different cadavers were
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
placement of the miniscrews to verify that the screws
were not encroaching on the neighboring roots, sinuses,
or mental foramina.
A total of 96 commercially available screws were placed
in the 48 hemi-sected maxilla and mandible specimens. All
screws used were 1.5 3 11 mm long (#25-675-11, KLS
Martin, Jacksonville, Fla) and were manufactured from
titanium alloy (Ti-6Al-4V). The screws were placed to
a depth of 6 mm. Coronally positioned screws were placed
4 mm apical to the maximal height of the interproximal
crestal bone. The apically positioned screw was placed
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.

5.5 mm apical to the coronally positioned screw (Fig 1). All

screws were placed by 1 operator (N.W.) with a hand driver
(blade, #25-483-97, and handle, #25-402-99, KLS Mar-
tin) after a pilot hole was drilled with the manufacturer’s
recommended nontapered, 1.1-mm diameter twist drill
for 1.5-mm screws (#25-452-15, KLS Martin).
The cadaver specimens were divided into 4 groups (8
hemi-maxillae and 8 hemi-mandibles per group) accord-
ing to screw placement angulation relative to the bone
surface (Fig 2): 90 vs 30 screw pairs, 90 vs 60 screw
pairs, and 30 vs 60 screw pairs. In the 3 groups, each an-
gle was used apically in half of the specimens and coro-
nally in half of the specimens. As an example, in the first
group, 4 hemi-maxillae had 90 screws placed in the apical
position with 30 screws in the coronal positions, and 4
hemi-maxillae had 30 screws in apical positions with
90 screws in coronal positions. After verification of satis- Fig 3. Bone specimen mounted with tangentially loaded
factory screw placement, the most distal portion of each force parallel to the occlusal plane.
bony specimen was embedded in buff laboratory stone
to a depth of 1.0 in and allowed to harden for 24 hours. fit between the threads of each miniscrew. The grip
Each miniscrew was subjected to tangential force ap- was attached to the force transducer, oriented in a verti-
plication oriented parallel to the occlusal plane (Fig 3) to cal position, and attached to each miniscrew at a distance
mimic orthodontic tangential force to retract the of 2 mm from the screw-bone interface. This distance
anterior teeth. An Instron diametral materials testing was selected to represent space that would be expected
machine (model 1445, Zwick, Ulm, Germany), incorpo- to be occupied by soft tissues in vivo and the screw
rating a force transducer attached to a crosshead and head fixtures.
linked to a computer for recording data, was used to A crosshead speed of 0.05 mm per second, similar to
apply force. A customized X-Y-Z table with a mounting that used in axial pullout studies of miniscrews, was ap-
device was fabricated to rigidly fixate each stone block plied.14 Displacement of the system was measured for
and cadaver specimen during testing. This table allowed 0.60 mm of movement. This amount of displacement
for movement in 3 planes of space to ensure that the was selected to represent the amount of movement
force was parallel to the occlusal plane. A customized that would result in a clinically mobile miniscrew and
grip was designed and machined from stainless steel to potential failure. A paired-samples t test was used to

American Journal of Orthodontics and Dentofacial Orthopedics February 2011  Vol 139  Issue 2
e150
Fig 4. Force-deflection finite element analysis curves for
screws placed at 30 , 60 , and 90 to the cortical bone.
determine whether there was a significant anchorage re-
sistance difference between 30 and 60 , 30 and 90 , or
60 and 90 screws in the same bone. The same test was
also conducted to assess a significant difference in an-
chorage resistance between the mandibular and maxil-
lary bones on the same cadaver. If the assumption of
normality was not valid, a nonparametric Wilcoxon
signed rank test, analog of the paired-samples t test,
was conducted. A 2-sample t test was used to determine
whether there was a significant difference in anchorage
resistance between apical and coronal positions in the
maxillary or mandibular bones from different cadavers
for the 30 , 60 , and 90 screws.
One-way analysis of variance (ANOVA) with the post-
hoc Tukey studentized range test was used to determine
whether there were significant differences in anchorage re-
sistance between 30 , 60 , and 90 screws in the maxillary
or mandibular bone. Because of the lack of normality in the
data under some conditions, 1-way ANOVA to the ranked
data followed by the post-hoc Bonferroni multiple com-
parison test, an equivalent test statistic to the nonparamet-
ric Kruskal-Wallis test, was used as the test statistic.
All tests had a 0.05 level of statistical significance.
SAS for Windows (version 9.1, SAS Institute, Cary, NC)
was used for the data analysis.
RESULTS
The finite element analysis showed maximum an-
chorage resistance forces of 678, 2663, and 3700 N for
screws placed at 30 , 60 , and 90 , respectively (Fig 4).
Cortical bone stress was greatest for screws placed at
30 , less for screws placed at 60 , and least for screws
placed at 90 to the cortical bone (Fig 5).
February 2011  Vol 139  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Woodall et al
Fig 5. Von Mises stress diagrams for the cortical bone
with screw placements of 30 (top), 60 (middle), and
90 (bottom) at 40-N tangential load. As illustrated, the
maximum cortical bone stress is less for the 90 screw
placement (134 MPa) than for either the 60 (179 MPa)
or the 30 (385 MPa) screw placement.
The maximum anchorage resistance provided by
screws placed at 90 to the cadaver bone surface ex-
ceeded, on average, the anchorage resistance of screws
placed at 60 , which likewise exceeded the anchorage re-
sistance of screws placed at 30 (Fig 6). However, statis-
tical analysis showed no significant difference in
anchorage resistance values when comparing pairs of
30 to 90 screws, 60 to 90 screws, or 30 to 60
screws in either the maxillary or mandibular bone, since
deflection ranged from 0.0 to 0.6 mm.
In the mandibular bone samples, further statistical
analysis showed no significant difference in anchorage
resistance between the 30 , 60 , and 90 screws. In the
maxillary bone samples when the deflection ranged
from 0.21 to 0.35 mm, results of 1-way ANOVA to the
ranked data showed a significant effect for screw angu-
lation (P \0.05). The post-hoc Bonferroni test indicated
a significantly greater anchorage resistance force for 90
screws than for 30 screws, but no significant differences
were found when comparing 60 and 90 screws or 30
and 60 screws. In the maxillary bone samples, no other
statistically significant differences in anchorage resis-
tance were found for the other deflection ranges.
Overall analysis of the results with 2-way ANOVA
procedure indicated no statistical differences in
Woodall et al
Fig 6. Average force-deflection curves for screws placed
at 30 , 60 , and 90 to the cadaver cortical bone.
anchorage force resistance between screws placed
apically and coronally for the 30 , 60 , or 90 screws
in the mandibular and maxillary bone samples.
DISCUSSION
The principal finding of this in-vitro study was that
placing orthodontic miniscrews at angles less than 90
to the alveolar process bone surface does not offer force
anchorage resistance advantages. Finite element analy-
sis showed that bone stress actually increased dramati-
cally, and anchorage resistance diminished by a factor
of up to 5 times, as the screw-to-bone angle diminished.
These results appear to support the clinical finding of
Miyawaki et al6 that miniscrew placement angulation
was not a factor in miniscrew anchorage success or
failure. Our findings do not support the notion that in-
creased cortical bone contact resulting from angulated
placement of miniscrews improves their anchorage
resistance.
Screw-to-cortical-bone area contact increases as
the screw-to-bone angle diminishes. At first glance, it
would seem that anchorage resistance should likewise
increase as the screw-to-bone angle diminishes. How-
ever, any load applied to the screw must be applied
at a set distance from the bony surface to account
for soft-tissue thickness. The net outcome is that, as
the screw-to-bone angle diminishes, the screw-to-
cortical-bone area contact increases, but the cantilever
load arm concomitantly lengthens. For the 90 and 30
screws, this resulted in 2 and 4 mm lever arms, respec-
tively. Butcher et al15 found that screw failure was
greater if the load was applied 3 mm from the bone
surface than if it was applied 1 mm from the bone
surface.
American Journal of Orthodontics and Dentofacial Orthopedics
e151
Our finding of no statistically significant difference in
anchorage force between apical and coronal screw
placements supports the in-vitro findings of Brettin
et al.16 If this holds to be true in vivo, it supports the
choice to place a miniscrew toward the alveolar crest
(assuming adequate labiolingual alveolar thickness)
where there is a better chance that it can be placed in at-
tached gingiva. This position reduces the chances of
peri-implant inflammation and possibly decreases the
likelihood of screw mobility and failure.3,6
The limitations of this in-vitro study are evident.
Biologic changes after osseous loading could not be
examined. However, the fact that mechanical retention
is thought to provide the primary stability of tempo-
rary anchorage devices allows in-vitro studies to be
of more value than if miniscrews relied on tissue heal-
ing or osseointegration. This study provides an indica-
tion of force anchorage resistance for immediate
loading after screw placement. Additionally, the age,
systemic health, and bone density of each subject
was unknown. However, it was assumed that random
pairing of coronal and apical screws at 30 , 60 , and
90 angulations would minimize the impact of these
factors.
The results of this study conflict with the suggestion
made by several authors who advise placing orthodontic
miniscrews at an angle to the alveolar process bone.8-11
Except when this makes sense to avoid tooth roots or
other anatomy, the concept that placement at an
angle increases anchorage resistance is not supported
by this study. Based on our results, we recommend
placement of miniscrews at 90 to the bone surface
when possible and acute-angle placement as a second
choice.
CONCLUSIONS
1. In a cadaver model, anchorage resistance offered by
screws placed at 90 to the alveolar process bone
was, on average, greater than the anchorage resis-
tance of screws at 60 or 30 . However, the differ-
ences were not statistically significant.
2. In a finite element model, the anchorage resistance
of screws placed at 90 to the alveolar process bone
was dramatically greater than that of screws placed
at either 60 or 30 . The cortical bone stress created
by loading screws placed at 90 was less than the
bone stress created by loading screws at either 60
or 30 .
3. Based on the results of this study, the placement of
temporary anchorage devices at angles less than 90
to the alveolar process bone surface does not offer
force anchorage resistance advantages.
February 2011  Vol 139  Issue 2
e152 Woodall et al

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