Kaohsiung Journal of Medical Sciences (2014) 30, 111e115

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REVIEW ARTICLE

Miniscrew implant applications in contemporary

orthodontics
Hong-Po Chang a,b, Yu-Chuan Tseng a,c,*

a
Faculty of Dentistry, Kaohsiung Medical University, Kaohsiung, Taiwan
b
Department of Dentistry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
c
Department of Orthodontics, Dental Clinics, Kaohsiung Medical University Hospital,
Kaohsiung, Taiwan

Received 2 May 2013; accepted 31 May 2013

Available online 8 December 2013

KEYWORDS Abstract The need for orthodontic treatment modalities that provide maximal anchorage
Miniscrew implants; control but with minimal patient compliance requirements has led to the development of
Orthodontic implant-assisted orthodontics and dentofacial orthopedics. Skeletal anchorage with miniscrew
anchorage; implants has no patient compliance requirements and has been widely incorporated in ortho-
Risk factors dontic practice. Miniscrew implants are now routinely used as anchorage devices in orthodon-
tic treatment. This review summarizes recent data regarding the interpretation of bone data
(i.e., bone quantity and quality) obtained by preoperative diagnostic computed tomography
(CT) or by cone-beam computed tomography (CBCT) prior to miniscrew implant placement.
Such data are essential when selecting appropriate sites for miniscrew implant placement.
Bone characteristics that are indications and contraindications for treatment with miniscrew
implants are discussed. Additionally, bicortical orthodontic skeletal anchorage, risks associ-
ated with miniscrew implant failure, and miniscrew implants for nonsurgical correction of
occlusal cant or vertical excess are reviewed. Finally, implant stability is compared between
titanium alloy and stainless steel miniscrew implants.
Copyright 2013, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights
reserved.

Conflicts of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this
paper.
* Corresponding author. Department of Orthodontics, Kaohsiung Medical University Hospital, Number 100, Tzyou 1st Road, Kaohsiung
80756, Taiwan.
E-mail address: [email protected] (Y.-C. Tseng).

1607-551X/$36 Copyright 2013, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.kjms.2013.11.002
112 H.-P. Chang, Y.-C. Tseng

Introduction (CBCT) imaging should ideally be performed in all ortho-

dontic patients who are candidates for miniscrew implants.
Ensuring adequate anchorage is often challenging in or- Routine panoramic, lateral, and frontal cephalometric ra-
thodontics and dentofacial orthopedics [1], especially diographs may not provide all information needed to opti-
because many of the various methods developed for rein- mize the location of a miniscrew placement. However,
forcing anchorage depend on patient compliance. A major lateral cephalometric radiographs enable accurate and
advance in orthodontic treatment in recent years is the reliable preoperative evaluations of bone quantity in the
introduction of skeletal anchorage with miniscrew im- paramedian palate and palatal region [14,15]. The bone
plants, which is widely used in orthodontic treatments for quality in these regions tends to be relatively high [16].
expanding the boundary of tooth movement and has no
patient compliance requirements [2]. Miniscrew implants Sites for miniscrew implant placement
are now well-established auxiliary anchorage devices and
are routinely used in orthodontic practice. Miniscrew implants are available in varying lengths and di-
ameters to accommodate placement at different sites in
Orthodontic miniscrew implants both jaws. Most miniscrew implants have a thread diameter
ranging from 1.2 mm to 2.0 mm and a length ranging from
The need for orthodontic treatment modalities that maxi- 6.0 mm to 12.0 mm. Potential sites for miniscrew implant
mize anchorage control and minimize patient compliance placement in the maxilla include the area below the anterior
requirements has led to the development of implant- nasal spine, the palate (either on the midpalate or the par-
assisted orthodontics. Although osseo-integrated dental amedian palate), the infrazygomatic crest, the maxillary
implants provide reliable anchorage for managing maloc- tuberosities, and the alveolar process (both buccally and
clusions [3], their applications are limited by their large palatally between the roots of the teeth). Possible sites for
size. The miniplate has greater stability compared to the miniscrew implant placement in the mandible include the
miniscrew, but the flap surgery required for insertion and symphysis or parasymphysis, the alveolar process (between
removal results in swelling and discomfort [4]. Miniscrew the roots of the teeth), and the retromolar area [17,18].
implants are now the most common temporary anchorage
devices because of their many advantages, including their Indications and contraindications for
low cost and simple surgical placement and removal. The
treatment with miniscrew implants
small and convenient size of the miniscrew implant also
enables their use in many anatomical regions, including the
interdental area [5]. The most common indication for treatment with miniscrew
implants is molar protraction followed by indirect
anchorage for space closure, intrusion of supraerupted
Bone quantity and quality teeth, intrusion of anterior open bite, anterior en-masse
retraction, molar uprighting, intrusion of maxillary cant,
Cortical bone thickness is an important factor in the success molar distalization, traction on impacted canine, and
of a miniscrew implant. Insufficient cortical bone thickness attachment of protraction facemask. Other indications
often causes inadequate primary stability. If primary stabil- occur in a clear minority of cases [19].
ity is not achieved upon insertion, the miniscrew implant may Contraindications for using miniscrew implants include
loosen during orthodontic treatment [6]. A cortical bone problematic healing, compromised immune defense,
thickness of less than 1 mm has a higher likelihood of minis- bleeding disorders, pathological bone quality, or inade-
crew implant failure compared to a thickness of 1 mm or quate oral hygiene [4,20]. Miniscrew implants may also be
more [7,8]. Numerical analyses using finite element models contraindicated in children with deciduous or early mixed
(FEMs) have shown that deflection of miniscrew implants dentition [20]. Heavy smoking detrimentally affects the
decreases as cortical bone thickness increases [9] and that success rates of orthodontic miniscrews [21]. The contrib-
cortical bone with thickness less than 1 mm is vulnerable to uting role of temporary smoking cessation in the success of
stresses that can cause bone resorption in this region [10]. dental implants [22] should be considered in the prognosis
Two key determinants of primary stability are bone of orthodontic miniscrew placements but requires further
quality and quantity [11]. Cortical bone quantity and investigation.
quality affect the long-term stability of a miniscrew
implant. Stationary anchorage failure often results from
low bone density due to inadequate cortical thickness [12].
Bicortical orthodontic skeletal anchorage
The primary implant stability of a miniscrew implant can be
estimated by computed tomography (CT) measurements of Compared to monocortical miniscrew placement, bicortical
cortical bone thickness [13]. placement provides higher force resistance and stability
but lower cortical bone stress [23]. Because the miniscrew
implant is inserted across the full width of the alveolus,
Use of CT or CBCT for preoperative evaluation most of the critical orthodontic anchorage is provided by
of miniscrew implant placement the buccal/labial layer and lingual cortical bone layer [24].
The clinically relevant dimensions of bone available for a
Because they provide clinicians with potentially important palatal miniscrew implant anchorage include both cortical
information, CT or cone-beam computed tomography layers, i.e., the outer cortical layer of the nasal floor and
Miniscrew implant applications in orthodontics 113

the outer cortical layer of the oral hard palate [15]. Clini- potential soft-tissue irritation or inflammation; firm attached
cians should consider bicortical skeletal anchorage when gingiva is usually preferable to movable mucosa [29].
increased orthodontic loading or diminished cortical bone
thickness is expected.
Relative stability of titanium alloy and stainless
steel miniscrew implants

Risk factors associated with failure of Despite their many differences, both titanium alloy and
miniscrew implants stainless steel meet the mechanical requirements for stable
miniscrew implants. The primary stability of a miniscrew
A recent meta-analysis reported that miniscrew implants implant depends on insertion depth rather than on the
have a failure rate of 0.123 (87.7% success rate) [25]. This implant material [37]. Selecting the appropriate depth is
figure is slightly higher than the 83.6% success rate reported extremely important for primary stability of the miniscrew
in a previous meta-analysis of uncontrolled studies [26]. implant and is critical for treatment success. Although
Compared to other treatments, miniscrew implants have a titanium-alloy miniscrews achieve stationary anchorage
relatively low and clinical acceptable failure rate, which mainly through mechanical retention, they can achieve
explains their widespread use in clinical practice. The partial osseointegration after 3 weeks. The partial osseoin-
clinical success rate of miniscrew implants currently used in tegration of titanium-alloy miniscrew implants is a distinct
implant-assisted orthodontics exceeds 80%, which is a advantage in orthodontic applications because it provides
considerable improvement compared to previous miniscrew effective anchorage with easy insertion and removal [1].
implants but still unsatisfactory, especially in comparison However, partial osseointegration can also complicate the
with the success rate for dental implants (>90%) [27,28]. removal of titanium-alloy miniscrew implants by increasing
The failure rate of the miniscrew implants does not the torque values required for removal. Again, further
significantly differ by sex, insertion site, or insertion side studies are needed to compare the long-term stability be-
(left vs. right) [7,29]. However, failure risks tend to be tween orthodontic miniscrew implants composed of titanium
higher in younger (<20 years old) patients compared to alloy and those composed of stainless steel.
older (>20 years old) patients [4,7], probably due to the
active bone metabolism and low maturation of the maxil- Miniscrew implant for nonsurgical correction
lofacial bone in growing children [7]. of occlusal cant or vertical excess
The failure rates of miniscrew implants inserted in the
mandible tend to be higher than those inserted in the
The mechanics of using miniscrew implants follow general
maxilla. The difference is attributable to: (1) the higher
biomechanical principles. However, compared with con-
bone density of the mandible, which requires a higher
ventional orthodontic principles, miniscrew implants have
insertion torque that decreases the survivability of the
several characteristic features that not only make treat-
miniscrew implant [30] and overheats the mandible during
ment with conventional orthodontic mechanotherapy
the placement procedure [4]; and (2) the smaller amount of
easier and more efficient, but also enable treatment in
cortical bone formation at the head of the miniscrew im-
which conventional anchorage would be impossible.
plants inserted in the mandible [31].
Clinical applications of miniscrew implants have been
Insertion torque is positively associated with miniscrew
expanded to include correction of occlusal cant and correc-
implant failure rates, and insertion torque values higher
tion of vertical excess that would otherwise require orthog-
than 10 Ncm are associated with a higher failure rate
nathic surgery. The authors have used miniscrew implant
compared to values lower than 10 Ncm [7,32]. A miniscrew
anchorages for vertical control of both left and right side
implant failure may result from excess stress at the initial
molars in such patients for horizontal and/or vertical
boneeimplant interface resulting in microdamage, local
improvement in the occlusal cant or vertical skeletal
ischemia, and delayed healing in the adjacent bone [32].
discrepancies.
The proximity of a miniscrew implant to the adjacent
In adult patients with moderate-to-severe facial asym-
tooth root is a major cause of failure, particularly in the
metry or hyperdivergency, a combined treatment of
mandible [33]. Another contributing factor in miniscrew
orthognathic surgery and orthodontic therapy can improve
implant failure is root contact during insertion [33,34].
facial esthetics, and morphological and functional occlu-
However, root injuries are usually treatable. Removal of the
sions. In some patients with facial asymmetry or hyper-
mobile screws that cause inflammation can prevent further
divergency, miniscrew implant anchorages are a potential
root resorption of the adjacent tooth [34,35]. Finite element
alternative to surgery for improving dental and skeletal
analysis (FEM) is useful for simulating stress distribution in
disharmony in transverse and/or vertical dimensions [38,39]
orthodontic biomechanics. Numerical analyses using FEMs
(Fig. 1).
have shown that root contact increases stresses that can
cause irreversible loss of miniscrew implant stability [10,36].
Attached gingiva is not always necessary for miniscrew Future directions
implant maintenance but is more favorable compared with
the oral mucosa [2]. However, irritation of the miniscrew The use of orthodontic miniscrew implants expands the
installation site by oral mucosa may cause unfavorable con- envelope of discrepancies that are potentially correctable
ditions, including compromised stability. Therefore, the by orthodontic and dentofacial orthopedic treatment.
insertion site must be carefully selected to minimize However, the relative effectiveness and efficiency of
114 H.-P. Chang, Y.-C. Tseng

Figure 1. An adult Class III malocclusion with lateral deviation of the mandible (B) resulted in facial asymmetry (A). The
posteroanterior cephalometric radiograph detected no cant of the maxilla. However, an occlusal cant (C) and a chin point deviation
to the right side from the facial midline (A) were noted. The buccally inclined right maxillary posterior teeth were corrected with
elastomeric chains from an orthodontic miniscrew inserted in the midpalate (D). The maxilla was treated without surgery. Modified
intraoral vertical ramus osteotomy was performed to correct a lateral deviation in the prognathic mandible after the presurgical
orthodontic treatment (E, F).

miniscrew implants used for various clinical problems need Cooperation Project, S101012) and Kaohsiung Medical
further evaluation in prospective controlled studies. University Hospital, Kaohsiung, Taiwan (KMUH96-6R05).
Of the many hypothesized factors in the failure rates of
orthodontic miniscrew implants, most need further evi-
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