TUGAS METOPEL

Oleh : Nita Hardiana

197160001
Pembimbing :
Prof. Trimurni Abidin, drg., M.Kes., Sp.KG (K)

PPDGS ORTODONSIA
FAKULTAS KEDOKTERAN GIGI
UNIVERSITAS SUMATERA UTARA
2019
INTRODUCTION
Temporary skeletal anchorage devices (TADminiscrew)
do not need osseointegration to obtain clinical success

primary stability

Including:
 Insertion site chracteristics
 Root proximity
 Geometric design of the screw
 Soft-tissue inflamation
 Operator technique
 Magnitude and loading time of the orthodontic force
 Maximum insertion torque
 Cortical density  the most important factor
controlling the primary stability of TAD

maximum stability  tension-compression state

generated Bone- TAD interface

Maximum insertion torque has been suggested

as another parameter in the primary stability of screws
 Value within 5 to 10 Ncm showed the best result of resistance to
movement
A previous experimental study with synthetic bone reported that
the geometric properties of TADthread shape factor, play a
critical role in primary stabilityresistance to extraction

Chapman et al Thread shape factor is calculated :

the mean thread depth and the pitch of the miniscrew
>>(value)  resistance to pullout force becomes better

In orthodontics, pullout force is basically

used to describe the shear strength of
miniscrews placed in bone specimens.
 how screws generate the best stability,
considered:

static components : dynamic component:

• bone quantity and quality insertion phase:
cortical thickness and maximum insertion torque
bone density value
• screw design
The purpose of this in-vitro study was to examine how:
• bone characteristics,
• TAD designs,
• pullout force, and
• maximum insertion torque

are correlated in describing primary stability.

MATERIAL AND METHODS
Four devices were tested in this study:

No Miniscrew Diameter Length

1 Orthoeasy 1,7 mm 10 mm
(Forestadent, Pforzheim, Germany)
2 Orthoscrew 1,65 mm 9 mm
(Leader Ortodonzia, Cinisello Balsamo, Italy)
3 Tomas 1,6 mm 10 mm
(Dentaurum, Ispringen, Germany)
4 ORTHOImplant 1,8 mm 10 mm
(3M Unitek, Monrovia, Calif)
MINISCREWS MEASUREMENT

Each device was examined with a

20.00-kV scanning electron microscope (model S-2500; Hitachi, Tokyo, Japan)
3-dimensional image processing on a
micrometric scale.

Images of the head and the shank of each screw

(Adobe, San Jose, Calif)
were obtained at 20, 80, 100, and 500 times
magnifications and were then converted by using
Photoshop CS3 software

Measurements were obtained in millimeters

of the pitch of the screw and the depth of the
thread; subsequently, the thread shape factor of
each device was calculated
Fig 1. A, Orthoeasy: scanning electron microscope image at 15-times magnification; B,
Orthoscrew: scanning electron microscope image at 15-times magnification; C, Tomas:
scanning electron microscope image at 15-times magnification 15; D, ORTHOimplant:
scanning electron microscope image at 15-times magnification.
BONE SPECIMENS PREPARATION

Fresh pig ribs were collected from the

same animal on the day of the tests

The samples were sliced into 30-mm

sections to obtain 20 specimens

The room temperature was 27C,

The temperature of the bone was
maintained at 37C ± 1C in saline solution
until the test was carried out
BONE MEASUREMENT
the bone specimen characteristics were analyzed (Promax 3D Max; Planmeca Oy,
with CBCT Helsinki, Finland)

For each bone sample, an expert operator (H.T.)

measured the insertion-site imaging software (Romexis,
• Cortical thickness in millimeters Planmeca Oy).
• Cortical and marrow bone density,
expressed in Hounsfield units (HU)

Successively, all TAD were implanted to an

intraosseous thread of 7 mm depth by using a
dedicated thread locker; no predrilling pilot hole
was used

Maximum insertion torque was measured for (model TT50 SD, MHH
Engineering, Bramley, United
each TAD in centi Newton meters with a modified
Kingdom)
torque wrench
PULLOUT TEST

Subsequently, the pullout tests were A universal testing machine. model 8501
performed. plus; Instron, Canton, Mass

with a 10-kN load cell was used for the

pullout tests ;sensibility of the load cell
was 0.0001 kN.

A crosshead speed of 2 mm per minute

was applied in a controlled environment at
27C and 70% humidity

The maximum load and screw

displacement at peak load were measured
Statistical analysis

The nonparametric Kendall rank correlation (tau) was used to

evaluate the strength of dependence among the characteristics
measured

The nonparametric Kruskall-Wallis test was used to evaluate the

differences among the groups

post-hoc comparisons were carried out with the Nemenyi-Damico-

Wolfe-Dunn test.
 RESULTS

For pullout force, maximum insertion torque, and cortical thickness, no

differences were observed among the groups. However, for depth, pitch, and
thread shape factor (P <0.001) as well as for cortical density and marrow
bone density (P = 0.02), differences among the groups were found.
A further significant difference
was found between pitch and
maximum insertion torque
(tau, -0.49). Positive
correlations were also found
between pullout force and
maximum insertion torque
(tau, 0.64), cortical thickness
(tau, 0.36), and marrow bone
density (tau, 0.35)
DISCUSSION
Cortical thickness seems to play a key role in primary stability; a
mechanical interlock between the thread of the screws and high-
density cortical bone permits a high value of interconnection.

in this studyhigher cortical height produced better resistance to

pullout force; this result is in accordance with what was estimated in
a recent animal-based study on the stability of TAD.
• Hounsfield density measurements are useful to estimate the
quality of bone CBCT

• In this study, marrow bone density showed a significant

correlation with pullout force. This result suggests that higher
bone density does not particularly affect the resistance of
insertion of the screws but might result in better stability when
tested with a pullout test.
 In the geometric aspects of the screws, pitch showed a statistically
significant inverted correlation (tau, –0.49) with maximum insertion
torque.

Of the 4 miniscrews  ORTHO implant has the smallest depth and

pitch, and, according to the inverse correlation between pitch and
maximum insertion torque, it showed the highest torque value.
 Several factors were found to affect the primary stability of
orthodontic miniscrews; placement torque and pullout force of
different devices could indirectly describe the state of mechanical
stress generated by the insertion of a screw in the bone

The limitations of this study were related to the invitro setup; so far,
evaluations of soft-tissue health, bone stock, and orthodontic forces
were not considered.
CONCLUSIONS
1. A correlation between the pitch of the miniscrew and
maximum insertion torque values was found.

2. A strong correlation between maximum insertion torque and

pullout force was noted.

3. A direct correlation among cortical thickness, marrow bone

density, and pullout force was observed.

4. Differences in cortical bone thickness were more relevant for

initial stability of the miniscrews than cortical bone quality.
PEMBAHASAN PICO
Problem
Intervention
Comparative
Output
PROBLEM
Temporary skeletal anchorage devices (TADminiscrew)
Tidak memerlukan osseointegration untuk mendapatkan
keberhasilan klinis

Stabilitas primer
termasuk:
 Karakteristik tempat insersi
 Root proximity
 Desain geometrik dari screw
 Inflamasi jaringan lunak
 Teknik operator
 Besar dan waktu pemuatan gaya ortodontik
 Maximum insertion torque
Kepadatan (density) kortikal, dianggap faktor yang paling penting
mengendalikan stabilitas utama perangkat anchorage skeletal
sementara. =Bone quality

• Miniscrews mendapatkan stabilitas maksimumnya secara mekanis

sebagai akibat dari keadaan tension-compresion yang dihasilkan
tulang dengan permukaan Miniscrew. Nilai Maksimum insertion
torque(MIT) telah disarankan sebagai parameter lain dalam stabilitas
utama screw.
• Semakin tinggi nilai MIT Maka kemampuan bertahan/resistance
terhadap gaya perpindahan lebih besar
• Bentuk geometrik dari TAD (thread dan pitch)berperanan dalam
stabilitas primer, dimana chapman et al mnggambarkan pengaruh dari
bentuk ulir dalam kemampuan bertahan “terlepas”/extraction dari screw
tulang kanselous.
• Dengan Meningkatnya nilai desain geometric miniscrew maka kemampuan
bertahan dari gaya tarik/pullout menjadi lebih baik dibawah kondisi
standar

Suatu tes penarikan umumnya digunakan untuk mendapatkan evaluasi

retensi mechanical properti retensi dari bahan atau perangkat ketika
tertanam dalam sesuatu.
 Bagaimana screw menghasilkan stabilitas
terbaiknya:

Komponen statis: Komponen dinamis:

• bone quantity and quality
cortical thickness (CT)
and bone density
(CD&MBD)
• Desain screw(D,P,TSF)
insertion phase:
• maximum insertion
torque value (MIT)
• Gaya tarikan (POF)
 PERTANYAAN PENELITIAN
Apakah ada pengaruh antara karakteristik tulang, desain miniscrew
ortodonti dan stabilitas primer?

TUJUAN PENELITIAN
Untuk mengetahui bagaimana karakteristik tulang, desain miniscrew,
pullout force dan maximum insertion torque di korelasikan dengan
stabilitas primer
INTERVENTION
Variabel :
• Variabel independent (bebas) : 4 mcm miniscrew
No Miniscrew Diameter Length
1 Orthoeasy 1,7 mm 10 mm
(Forestadent, Pforzheim, Germany)
2 Orthoscrew 1,65 mm 9 mm
(Leader Ortodonzia, Cinisello Balsamo, Italy)
3 Tomas 1,6 mm 10 mm
(Dentaurum, Ispringen, Germany)
4 ORTHOImplant 1,8 mm 10 mm
(3M Unitek, Monrovia, Calif)

Keempat merk miniscrew tersebut kemudian masing-masing di ukur :

• Depth=D kedalaman ulir
• Pitch=P  Puncak screw
• TSF=Thread shape factor  faktor bentuk ulir
• Variabel dependen:
• POF=Pullout force  gaya tarik
• MIT=Maximum insertion torque  Tork insersi maksimum
• CT=cortical thickness ketebalan kortikal
• CD=cortical density  kepadatan kortikal
• MBD=marrow bone densitykepadatan tulang marrow

• Variabel terkendali : spesimen tulang

 COMPARATIVE
No Variabel Definisi Operasional Alat Cara mengukur Hasil Skala
Ukur Ukur Ukur
1 Orthoeasy Miniscrew diproduksi Scanning elektron mm Rasio
(D, P, TSF) oleh Forestadent, microscope img. Kemudian
Pforzheim, Germany convert menggunakan
Photoshop CS3
2 Orthoscrew Miniscrew diproduksi Scanning elektron mm Rasio
(D, P, TSF) oleh Leader microscope img. Kemudian
Ortodonzia, Cinisello convert menggunakan
Balsamo, Italy Photoshop CS3

3 Tomas Miniscrew diproduksi Scanning elektron mm Rasio

(D, P, TSF) oleh Dentaurum, microscope img. Kemudian
Ispringen,Germany convert menggunakan
Photoshop CS3
4 ORTHOImpla Miniscrew diproduksi Scanning elektron mm Rasio
nt oleh 3M Unitek, microscope img. Kemudian
(D, P, TSF) Monrovia, Calif convert menggunakan
Photoshop CS3
No Variabel Definisi Operasional Alat Ukur Cara Hasil Skala
mengukur Ukur Ukur
5 D=Depth of the thread Kedalaman ulir mm Rasio
minisckrew
6 P=pitch of the screw Jarak antar puncak mm Rasio
mini screw
7 TSF=thread shape faktor bentuk ulir D/P Rasio
factor dari masing2 merk
No Variabel Definisi Operasional Alat Ukur Cara Hasil Skala
mengukur Ukur Ukur

8 POF = pullout force Gaya tarik yang universal kN Rasio

diberikan ke testing
miniscrew machine
9 MIT = maximum Torsi insersi Modified Ncm Rasio
insertion torque maksimum torque
wrench
10 CT = cortical thickness Ketebalan tulang CBCT mm Rasio
kortikal
11 CD = cortical density Kepadatan tulang CBCT HU interval
kortikal
12 MBD = marrow bone Kepadatan tulang CBCT HU interval
density marrow
 ANALISIS DATA:
 Nonparametric Kendall rank correlation (tau) digunakan untuk
mengevaluasi kekuatan di antara pengukuran karakteristik
 Pengukuran nonparametric Kruskall-Wallis test digunakan untuk
mengevaluasi perbedaan antara group tersebut.
 perbandingan post-hoc dilakukan dengan uji Nemenyi-Damico-
Wolfe-Dunn.
 Output
1. Ada korelasi antara pitch (P) miniscrew dan nilai torsi insersi
maksimum (MIT)
2. Ada korelasi yg kuat antara torsi insersi maksimum (MIT) dan gaya
penarikan (POF)
3. Ada korelasi langsung antara ketebalan kortikal (CT), kepadatan
tulang marrow (MBD) dan gaya penarikan (POF)
4. Perbedaan ketebalan tulang kortikal (CT) lebih relevan utk satabilitas
inisial/awal dari miniscrew daripada kualitas tulang kortikal (CD)