IMPLANT DENTISTRY / VOLUME 20, NUMBER 4 2011 273

Biomechanical Anchorage Evaluation of

Mini-Implants Treated With Sandblasting
and Acid Etching in Orthodontics
Jorge H. Calderón, DDS, MS,* Roberto M. Valencia, DDS,† Adán A. Casasa, DDS,‡ Mauricio A. Sánchez, PhD,§
Roberto Espinosa, DDS,储 and Israel Ceja, MS¶

tarting with Pierre Fauchard in Purpose: The purpose of this loaded, showed up to 1 degree, or less,

S 1728 until today, anchorage con-

trol is basic to achieve orthodon-
tic goals. The literature reports that
study was to assess the stability of
sandblasted and acid-etched minis-
crew implants based on orthodontic
of displacement, while 35% showed
ⱖ2 degrees shift. The mandible mini-
implants resulted in a smaller amount
there have been several techniques and mechanics for space closure after of displacement than the ones located
additives designed to enhance orth- tooth extraction. in the maxilla. The ones located at the
odontic anchorage. However, these in- Materials and Methods: Twenty- anterior maxilla displaced less than
traoral devices, despite all of their four orthodontic mini-implants were the posterior. The best results were
qualities, can cause undesirable effects
placed in 13 patients, for a skeletal obtained with the 8-mm mini-implants,
such as protrusions, intrusions, and
bending of the supported teeth.1– 4
anchorage purpose, all prepared by followed by the 6-mm and 10-mm
An article that was most relevant the manufacturer (3M Unitek— mini-implants.
to this study was written in 1990 by IMTEC Ortho USA) with sandblasting Conclusions: Modifying the mini-
Creekmore and Eklund,5 who de- and acid treatment. Anchorage mea- implant surface with sandblasting and
scribed the use of a rigid endosseous surements were made on occlusal ra- acid treatment offers good bone an-
implant to close the space between 2 diographs, on a monthly basis in a choring for orthodontic purposes.
mandibular molars 10 and 12 mm. Ac- 6-month period. (Implant Dent 2011;20:273–279)
tually, there has been a great effort in Results: All the mini-implants Key Words: mini-implant, anchor-
Europe and Asia to achieve a skeletal were effective for the clinical trial; but age, sandblasting, biocompatibility
or absolute anchorage through a vari- 65% of the mini-implants, after been
ety of small titanium screws (mini or
micro screws), palatal implants, and
plates combined with screws.6 –18 Stability of Mini-Implants damage they may induce to the adja-
Regarding endosseous implants, cent tooth roots.26
Roberts, Nelson, and Block report that So the questions that have arisen
*MD in Orthodontics, Centro de Estudios Superiores de
Ortodoncia, Mexico; Private practice in Palmira, Colombia, these have been designed to meet rigid as to its use have focused on whether
South America.
†Associate Professor, Centro de Estudios Superiores de or absolute anchorage.19,20 These im- mini-implants really provide an ab-
Ortodoncia; Associate Professor, Department of Pediatric
Dentistry and Orthodontics, Universidad Tecnologica de plants are integrated into the surround- solute anchorage and whether the
México, Mexico.
‡Professor and Program Director, Centro de Estudios
ing bone and must remain absolutely displacement affects its anchorage as
Superiores de Ortodoncia, Mexico.
§Affiliate Associate Professor, School of Chemical and Material
secure to receive orthodontic loading reported in some studies.20 –26
Engineering, The University of Oklahoma, Norman, OK.
储Professor, Department of Oral Rehabilitation, Health Science
forces.21–25
and Environmental Center, Universidad de Guadalajara,
Mexico.
Liou et al questioned the stability Factors That Affect
¶Researcher, Exact Science and Engineering Center, of temporary anchorage devices Mini-Implants Success
Universidad de Guadalajara, Mexico.
(TADs) once loaded with forces. They In the conventional prosthetic
Reprint requests and correspondence to Jorge H. believe that although mini-implants uses of dental implants, mobility is
Calderón, DDS, MS, 1212 Arboretum Way, Burlington, are a stable anchorage mechanism, taken into account as a sign of failure
MA 01803, Phone: ⴙ57-317-379-8136, Fax: ⴙ1-781-
273-6603, E-mail: [email protected] they do not remain immobile during due to lack of osseointegration. The
orthodontic treatment; and that al- authors believe that in the case of
ISSN 1056-6163/11/02004-273
Implant Dentistry though radiological and clinical mea- mini-implants for orthodontic anchor-
Volume 20 • Number 4
Copyright © 2011 by Lippincott Williams & Wilkins surements of this phenomenon are age, a small amount of mobility in
DOI: 10.1097/ID.0b013e3182167308 limited, the latent risk is really the TADs when loaded with orthodontic
274 SANDBLASTING AND ACID ETCHING IN ORTHODONTICS • CALDERÓN ET AL

forces (⬍200 g) is permissible in ful- critical step in implant retention). Sub-

filling the role as an anchor.27–29 sequently, bone is differentiated with
new osteoblasts to form fibers and la-
Osseointegration mellar bone around the implant, reach-
Osseointegration is a biologic ing a secondary stability.31
phenomenon that occurs in implantol- This process depends on the ma-
ogy and deserves special analysis be- terial of which the implant is made and
cause of its direct relationship with the surface structure treatment to pro-
stability. Slaets et al30 describe that the vide smoothness or roughness on it.32
space between the implant and the Titanium has an outer layer of oxide
bone is filled with blood, forming a surface in which nonfibrillar and
hematoma where proteins, lipids, and amorphous areas of glycoproteins and
other biomolecules attached to the proteoglycans can be attached. This
metal surface are reabsorbed by the provides points for osteoblasts, os-
body itself and a week after osteoblas- teoid, and bone matrix mineralization
tic and osteoclastic activities occur. concluding with the deposition of min-
Berglundh et al consider that the eralized bone matrix on the implant
necrotic bone and hematoma are quickly surface. In addition, new bone grows
replaced by a growing fibrous bone, into the implant surface and spreads to
Fig. 1. Periapical radiograph example for di- the surrounding bone reaching its peak
agnostic purpose. being responsible for the primary
stability. Over the next 4 to 6 weeks, between 3 and 6 weeks after implant
this bone structure is remodeled (a insertion. The authors pointed out that
with mini-implants this process has
not been examined in detail, but it may
occur in a similar manner.
A study by Chung et al shows that
although the retention source of mini-
implants is from a mechanical lock, their
stability depends on the quality and
quantity supporting cortical and alveolar
bone. They also mention that the main
characteristic of the mini-implants used
in their study is the absolute orthodontic
anchorage based on the sandblasting
and acid etching–treated surface to im-
prove osseointegration.33
It is very important to have in
mind the physical qualities of a minis-
crew system and their role in the clin-
ical behavior. A comparison between
current orthodontic miniscrews sys-
tems was described by Lin et al34

MATERIALS AND METHODS

The study sample included 13 in-
dividuals with space closure require-
ments. All were active patients at the
Center for Advanced Studies in Ortho-
dontics, Mexico DF, during the period
of 2009. Twenty-four TAD units (3M
Unitek—IMTEC Ortho, USA) were
clinically placed, in 7 female and 6
male patients.
Before the study, detailed proce-
Fig. 2. SEM images. Left column, temporary anchorage devices (TAD) without sandblasted,
dures were developed, and inclusion
acid etched (SLA) treatment. Right column, TAD with SLA treatment with 25⫻, 100⫻, and criteria were established, such as vol-
1000⫻ magnification, respectively. untarily patient’s acceptance, no sys-
temic compromise, space closure
 IMPLANT DENTISTRY / VOLUME 20, NUMBER 4 2011 275

requirement, patient with leveling and

alignment completed phase, and pa-
tients without infectious foci in the
oral cavity and optimal oral hygiene.
Preoperative periapical x-rays
were evaluated to assess the anatomi-
cal structures, bone density, and root
proximity (Fig 1).
All the 3M Unitek—IMTEC Or-
tho sandblasting and acid etching–
treated surface mini-implants were
Fig. 3. Mini-implant loading. provided exclusively for this research
by the same manufacture (Fig. 2).
The implant lengths were used ac-
cording to anatomical criteria (6, 8,
and 10 mm): 8-mm and 10-mm im-
plants for the upper jaw and 6-mm
implants for the mandible. A periapi-
cal radiograph was taken to verify the
mini-implant’s correct location, and a
unique dose of Ibuprofen (800 mg)
was prescribed only in the presence of
pain after the procedure.
Postoperative instructions were
given to the patient, with especial care
regarding oral hygiene in the surgical
implant location. In addition, a 0.12%
chlorhexidine mouthwash was pre-
scribed once a day after brushing.
Fig. 4. Symetroscope Template angular measurements above the occlusal radiograph. Each patient had a weekly clinical
checkup, and by the fourth week, a
TAD radiograph control was taken. At
the same time, the mini-implant was
loaded up to 150g force with a nickel
titanium closed coil spring (Fig. 3).
The procedures and timeline of
the investigation were the same for
each case; Occlusal Kodak Ultraspeed
radiographs were taken using Corix 70
Plus equipment and 16-in cone head.
The radiographic standardization was
conducted as follows: all the radio-
graphs were previously marked at the
middle, to make it coincide with
the facial midline. The angulation of
the cone for the upper jaw was 65 de-
grees in relation to the occlusal plane;
the lower jaw cone angulation was taken
at 0 degree achieving the beam position
in a perpendicular direction to the plate.
The exposure time was 1.6 seconds as
specified by the manufacturer and then
automatic processed. The radiographs
were taken with an interval of 30-day
period to reach a total of 6.
Fig. 5. Two cone beam computed tomography images of TAD images of the same patient 4 Angular measurements were made
months apart, in space closure treatment for orthodontic purpose. on occlusal radiographs by positioning
on it a Symetroscope millimeter grid
276 SANDBLASTING AND ACID ETCHING IN ORTHODONTICS • CALDERÓN ET AL

period because of herpetic gingivos-

tomatitis (herpes simplex type I). The
patient showed signs and symptoms
characterized by fever, lymphade-
nopathy, headache, malaise, intense
gingival erythema, and oral vesicles
throughout mouth that led to the loss
of the 4 implants.
All the mini-implants were effec-
tive for the clinical trial; however,
65% of the mini-implants after been
loaded over a 6-month period, showed up
to ⱕ1 degree of angular displacement,
while 35% showed ⱖ2 degrees shift.
The mandible mini-implants re-
sulted within a smaller amount of angu-
lar displacement than the ones
located at the maxilla. The total mini-
implants located at the mandible were in
the posterior area; 60% of the cases did
not show any rotation, while 40% show
up to ⱕ1 degree. The mini-implants
placed at the anterior maxilla region dis-
placed angularly less than the ones at the
posterior. The ones located at the ante-
rior maxilla region 13.3% had an angu-
lar displacement up to 1 degree, and
6.7% of these were ⬎2 degrees. Of the
mini-implants placed at maxillary pos-
terior region, 20% showed ⱕ1 degree
rotation, 13.3% up to 2 degrees, and
26.7% ⬎2 degrees (Tables 1 and 2).
The best results were obtained
with the 8-mm mini-implants size, fol-
Fig. 6. A, Main angulation change effect of mini-implants from the installation time (start) and lowed by the 6-mm and 10-mm mini-
second measurement for the sex, length, and implant position. B, Main angulation change implants; this is simply due to the
effect of mini-implants from the installation time (start) and subsequent measurement for sex,
slenderness effect, thus the danger of
length, and implant position.
misalignment is reduced.
From a nonparametric statistical
(Jhon’s Dental Laboratories, USA; To assess the accuracy of the test (analysis of variance) results, it
1983), and locating in symmetrical po- method, cone beam computed tomog- can be concluded that the measured
sition anatomical structures as the me- raphy was used versus radiograph variables did not show significant dif-
dian palatine suture and nasal spine for technique measure, to quantify the an- ferences in angle changes from the
the upper Jaw and the geni apophysis in gular TAD variation on a 4-month in- first “start” measurement to the last
the mandible. All the images were stan- terval (Fig. 5). The amount of dis- one. However, the noise/error is sig-
dardized and cropped and uprighted to placement error was ⬍1 degree nificantly higher compared with the
the 7 ⫻ 9-cm grid (Fig. 4). The radio- between the two, with a minimum dif- variation values (maybe due to the
graphs were digitally photographed ference between the 2 techniques. sample size, Fig. 6).
before and after to be printed, using The analysis of variance results in
Photoshop, in a uniform way. The Tables 2 and 3 conclude that the length
images of anatomical structures were RESULTS of the mini-implant is statistically signif-
superimposed with a plane line at the Twenty-four orthodontic mini- icant in its standard deviation (variation)
middle palatal suture to match each implants were placed in the total sample as a factor of affectation. Although there
other, and another line was traced group of 13 patients and evaluated dur- are differences between the variables for
through the long center axis of the im- ing a 6 month-period. It is important to all groups of TADs, they remain very
plant. The resulting angle differences mention that 1 case with 4 mini- stable with no marked changes in terms
between the two were taken as the im- implants was excluded from the total of degrees of tilt, when orthodontic
plant stability variation. sample population on the stabilization power loads are placed to the mini-
 IMPLANT DENTISTRY / VOLUME 20, NUMBER 4 2011 277

Table 1. Angular Measurement and Statistics for Implant Motion in the Posterior that implant osseointegration failure pos-
Zone of the Maxillary Arch sibility is due to microtrauma. It is consid-
ered useful to give this period of time
Patient
(healing) to suppress mild pain and pres-
Measurement A B C D E F sure on adjacent teeth reported by patients.
An anchorage system is compro-
Start 61 51 67 67 69.5 55
mised when systemic disease is in-
Progress 1 56 50 72 72 63 60
Progress 2 60 53 75 75 66
volved.27 One of the patients of this
Progress 3 70 70 study who received 4 TADs lost them
Average 59.00 51.33 71.00 71.00 66.17 57.50 in the first 4 weeks of healing because
SD 2.65 1.53 3.37 3.37 3.25 3.54 of signs and symptoms consistent with
Minimum 56.00 50.00 67.00 67.00 63.00 55.00 herpetic gingivostomatitis, with multiple
Maximum 61.00 53.00 75.00 75.00 69.50 60.00 ulcerations in the mouth, leading to fail-
ure because of an increased mobility. It
Table 2. Analysis of Variance for Change From “Start” is not possible to control a viral incubat-
ing process, but we have to be sure that
Source DF SS MS Var Comp Total SD
the failure is not due to the mini-implant
Sex 1 34.1020 34.1020 0.00 0.00 0.00 but the systemic condition of the patient.
Length 3 170.0844 56.6948 2.534 32.00 1.592 The mini-implant removal has
Position 6 62.3434 10.3906 0.519 6.55 0.720 been evaluated in animal and human
Error 109 530.6181 4.8681 4.868 61.46 2.206 models. Findings indicated no difficul-
Total 119 797.1479 7.921 2.814
ties on the removal, no matter bone in-
DF, degrees of freedom from each source; SS, sum of squares; MS, mean squares; Var Comp, variance components; SD, standard deviation.
tegration. Studies showed mini-implants
osseointegration when analyzed micro-
Table 3. Analysis of Variance From “Start” Versus Sex, Length, and Position scopically regardless of immediate or
Source DF SS MS Var Comp Total SD delayed loading. Furthermore, all TADs
Sex 1 4.3566 4.3566 0.054 0.71 0.233 could be easily removed.44 A study by
Length 3 5.8799 1.9600 0.044 0.58 0.209 Seong et al45 found a 100% success rate
Position 6 5.6212 0.9369 ⫺0.617 0.00 0.000 for implants placed without loading and
Error 109 818.5903 7.5100 7.510 98.71 2.740 any fractures or distortion after removal
Total 119 834.4479 7.608 2.758 but requiring higher removal torque at
DF, degrees of freedom from each source; SS, sum of squares; MS, mean squares; Var Comp, variance components; SD, standard deviation. the end of the treatment. Therefore, to
prevent complications they suggested
implants. The mini-implants were re- Permanency is not an expected leaving them without any load for no
moved at the end of the orthodontic property on mini-implants whose role more than 6 months.
mechanical movements to be examined is temporary but provides a strong ba- The debate over whether fibroin-
by SEM (Fig. 7). sis enabling them to achieve the ther- tegration and osseointegration occurs
Bone fragments were found em- apeutic goals.36 In this order of ideas, a is still open, and the authors believe
bedded in the treated surface, creating follow-up question is whether it is further histological studies must be
new bone fibers and lamellar bone possible to use implants as orthodontic done to define this feature.
around the implant, with secondary sta- anchorage, by doing surface treatment This study demonstrated that
bility. To compare the treated and non- to improve bone integration, with a sandblasting and acid etching the
treated surfaces, SEM mini-implant lower risk of failure under dynamic surface of a mini-implant makes an
study photograph was done by Ferrer et loading and achieving greater stabil- interesting alternative in absolute
al. This unpublished work, done for a ity. Literature reports that sandblasting but temporary anchorage. 45 Simi-
Master Degree Thesis (2009),35 (as seen and acid etching an implant provides a larly, conclusion shared with authors
in Fig. 8) shows that this secondary an- structure surface that allows it to inte- such as Chung et al.33 Based on tis-
chorage can be thought as a “maximum,” grate more efficiently.37– 42 sue reaction, implant mobility, or
which can be added to the mechanical Another major controversy arises angular displacement, there was
anchorage given by the screw threads. from the pursuit of stability in mini- also an effortless removal of TADs
implants and immediate or delayed by requiring just a little more torque
DISCUSSION loading. Raghavendra et al stated that than the ones without surface
Since 1983, mini-implants have there is a period of healing in prosthetic treatment.
been one of the most efficient anchor- implants critical to its success, and in Their anchorage efficiency in space
ing devices for orthodontics.5–11 The this period, the mechanical stability is closure after extraction was excellent
actual risk for angular displacement replaced by a biological stability. Their with an average rate of 1 mm/mo. It
could be the root implant contact to results concluded that the healing time would be useful information to search in
the adjacent root teeth.26 for an implant is 4 weeks43 and suggest further clinical investigation the effec-
278 SANDBLASTING AND ACID ETCHING IN ORTHODONTICS • CALDERÓN ET AL

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