|Year : 2018 | Volume
| Issue : 3 | Page : 103-110
Factors related to the clinical application of orthodontic mini-implants
Panagiota Ntolou, Aikaterini Tagkli, Eudoxie Pepelassi
Department of Periodontology, School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
|Date of Web Publication||14-Jun-2018|
Assoc. Prof. Eudoxie Pepelassi
Department of Periodontology, School of Dentistry, National and Kapodistrian University of Athens, 2 Thivon St., Athens 11527
Source of Support: None, Conflict of Interest: None
Orthodontic mini-implants use has been increased. The purpose of this review was to analyze the factors related to the clinical application of orthodontic mini-implants. For the present study, the electronic databases PubMed, MEDLINE, Cochrane, and Google Scholar were searched for available data. The literature search was performed on the articles published from 2003 up to 2017. International peer-reviewed journal articles related to factors which are associated with the clinical application of orthodontic mini-implants were searched. Successful application of mini-implants depends on proper selection of insertion site, proper selection of mini-implant (length, diameter, tapering), proper insertion (site, predrilling, angle, primary stability, injury, and absence of adjacent anatomic structures), absence of inflammation, and proper orthodontic loading. Insertion site and mini-implant characteristics are selected based mainly on cortical bone thickness, bone density, available bone, adjacent anatomic structures, and soft-tissue thickness. Sites of high cortical bone thickness, high cancellous bone density, sufficient available bone, and thin attached gingiva are ideal for mini-implant insertion. Extremely thick cortical bone requires attention. In thick cortical bone, shorter mini-implants can be selected. For sites of low cortical bone thickness and low cancellous bone density, longer and wider mini-implants are indicated. Very thin cortical bone and very low cancellous bone density negatively affect the prognosis of mini-implants. Very narrow implants entail fracture risk. Predrilling is preferred at high bone quality sites, whereas it is used with caution or even be avoided at low bone quality sites. Angled placement might be considered to increase bone-to-implant contact and reduce root injury risk. Loading time depends on insertion torque. Successful application of mini-implants is based on proper insertion site and mini-implant characteristics selection, proper insertion, absence of inflammation, and proper orthodontic loading. Careful assessment of all the factors that might compromise mini-implant success is important for their clinical application.
Keywords: Bone, orthodontic mini-implants, orthodontics, success, temporary anchorage devices
|How to cite this article:|
Ntolou P, Tagkli A, Pepelassi E. Factors related to the clinical application of orthodontic mini-implants. J Int Oral Health 2018;10:103-10
|How to cite this URL:|
Ntolou P, Tagkli A, Pepelassi E. Factors related to the clinical application of orthodontic mini-implants. J Int Oral Health [serial online] 2018 [cited 2018 Nov 12];10:103-10. Available from: http://www.jioh.org/text.asp?2018/10/3/103/234520
| Introduction|| |
The clinical application of temporary anchorage devices (TADs) and specifically of orthodontic mini-implants has been increased lately. Among orthodontists in Switzerland, maxillary distalization using TADs for Class II cases was selected by 75.1% and mini-screws were the second most frequently used TAD for maxillary distalization. However, a systematic review reported underuse of mini-implants. Specifically, in two previous studies, 56.3 and 40.16% of clinicians did not use them, respectively. For >50% of orthodontists, the limitations to mini-implant use included improper training, risk assessment, improper indications, and insufficient evidence on additional benefits. When properly used, they might be an alternative treatment to conventional molar anchorage  and might reach equivalent  or even superior results in certain cases. The purpose of this review study was to thoroughly analyze the factors related to the clinical application of orthodontic mini-implants.
| Search Strategy|| |
For the present study, the electronic databases PubMed, MEDLINE, Cochrane, and Google Scholar were searched for available data. The literature search was performed on the articles published from 2003 to 2017. International peer-reviewed journal articles related to factors which are associated with the clinical application of orthodontic mini-implants were searched. The following terms were used in the literature search: orthodontics, orthodontic mini-implants, temporary anchorage devices, cortical bone thickness, bone, success, cancellous bone density, mini-implant characteristics, mini-implant selection, mini-implant complications, mini-implant, and success factors. During the search in the above-mentioned databases, the following filters were applied: (1) language: English language, (2) human, animal, in vitro, ex vivo studies, and (3) type of article: randomized controlled trial, clinical trials, systematic reviews, case series, and experimental studies.
| Factors Related to the Clinical Application of Mini-Implants|| |
Mini-implant success is high whereas failure rate is relatively low (13.5%). Most failures occur after orthodontic loading. Failure rate differences between jaws , have limited clinical significance. Their use entails risk of complications, which include inflammation, trauma of anatomic structures, implant loss due to mobility, and implant fracture ,,,,,,, [Table 1] and [Table 2]. Successful application of mini-implants is based on factors concerning the patient, selection of insertion site and mini-implant, insertion procedure, and orthodontic loading.
|Table 1: Complications of mini-implants,,,,,,,|
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| Factors Concerning the Patient|| |
In terms of general patient factors, healthy individuals deprived from systemic disease or condition or medication compromising osseous healing  are ideal for mini-implants. There is no limit in patient's age although their use in very young individuals was questioned. Daily proper oral hygiene improves prognosis since local inflammation was directly associated with failure , and a relative risk factor for failure when mobility was excluded. Preventing inflammation is imperative for success, whereas factors affecting inflammation are indirectly related to failure, such as improper oral hygiene , and screw emergence at the oral mucosa. Home care is even more important for therapeutically managed periodontitis patients. Dental plaque combined with chronic trauma might aggravate the clinical findings. There is no doubt that periodontal inflammation should be eliminated or at least significantly controlled before mini-implant insertion. Initially, the patient should be educated how to properly remove the dental plaque around the mini-implants, then the patient should be reinforced in the daily effective oral hygiene. Dental cleaning should be performed in regular time intervals.
| Factors Concerning Mini-Implant Location, Characteristics, and Insertion Procedure|| |
Selection of the proper location for mini-implant insertion is based on available bone (cortical bone thickness, bone density, amount), adjacent anatomic structures, soft-tissue thickness, malocclusion, and desired tooth movement , [Table 3] and [Table 4]. The implant in terms of length, diameter, and self-tapping or predrilled is selected based on the site and space available for insertion, supporting bone (cortical bone thickness, bone density), and soft-tissue thickness [Table 5]. Sites with thick cortical bone, dense cancellous bone, plenty available bone, and thin attached gingiva are ideal for mini-implant insertion since they increase the chances for achieving proper primary stability, achieving and maintaining secondary stability, and preventing local inflammation. Furthermore, such sites do not present significant limitations to implant selection.
|Table 3: Factors affecting the selection of the proper mini-implant insertion site,|
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|Table 4: Studies on the factors affecting the selection of proper mini-implants insertion site|
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|Table 5: Factors affecting the selection of the proper mini-implant characteristics|
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Optimal primary stability at insertion, depending on insertion site and mini-implant design characteristics and placement conditions, is essential for success , [Table 6] and [Table 7]. Insertion torque, an indirect measure for primary stability , and bone density, should be considered since excessively high or low torque values result in low stability. There is no evidence that specific maximum insertion torque (MIT) values are associated with higher success rates  though MIT values of 5–10 Ncm have been recommended for most cases., Mean MIT value of 13.28 Ncm (standard deviation [SD] ±0.34) was reported for mandibular tapered self-tapping mini-implants in a systematic review. Insertion torque is positively related to cortical thickness , and implant length,, whereas it is negatively related to predrilling diameter. Significant predictors for higher MIT in vitro included larger implant diameter, higher lead angle of thread, and thicker cortical bone, and their unique contribution to MIT was 12.3%, 10.7%, and 24.7%, respectively. For cortical thickness of about 1 mm, bone density differences did not affect MIT and pull-out strength in vitro.
|Table 7: Studies on the factors affecting primary mini-implant stability|
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Insertion torque remains the most commonly used method to assess primary stability, but other methods are used as well. Primary stability differences might exist among the various methods, which might be important when selecting stability assessment method. A study comparing stability among insertion torque, periotest, and pull-out values showed that they agreed moderately in stability assessment, and periotest was the least reliable method in assessing stability.
In terms of cortical bone thickness, it should be taken into consideration that it is often <1 mm buccally and palatally in the maxilla and buccally in the anterior mandible, whereas it is often thicker than 2 mm buccally and lingually in the posterior mandible, as assessed from human autopsy material at 45° and 90° to the long tooth axis. Maxillary cortical thickness and density significantly increase from the coronal (2 mm) to the apical (8 mm) alveolar bone regions. Cortical bone has greater thickness and density palatally as compared with buccally; this difference becomes greatest anteriorly. In general, bone density is higher in the mandible than in the maxilla. For cortical bone thickness ≤0.5 mm and low cancellous bone density, the prognosis for primary stability is poor. Cortical bone thickness should be >1.0 mm to improve mini-implant success rate. For a 1.2–2.0 mm wide mini-implant, a minimum space of 3–4 mm is required between the mini-implant and the surrounding structures to prevent trauma. Thorough radiologic evaluation including panoramic radiograph, periapical radiographs, and even cone-beam computed tomography (CBCT) in very selected cases might be required for proper mini-implant planning. A surgical stent can be used in cases with high risk of complications during the surgical insertion of mini-implants. However, overuse of CBCT should be avoided for the patient's safety.
In cases with insufficient cortical thickness where insertion into cancellous bone is necessary to achieve stability, longer implants are selected., If cortical thickness provides enough stability, shorter implants can be selected. Wider and longer implants may overcome insufficient primary stability in low quality and quantity bone. Longer implants are often selected for the maxilla (8–10 mm) than the mandible (6–8 mm). Mini-implants of 1.4–1.9 mm diameter and 5–8 mm length had the highest success rate (0.87, 95% confidence interval 0.80–0.92) as assessed in a systematic review.
For interdental insertion, narrow implants are selected to prevent root injury. Implant diameter should be carefully selected because in case of narrow implants there is high risk of fracture, whereas for wider implants there is risk of contact with the roots of the adjacent teeth. Insertion in areas with significant bone remodeling such as recent postextraction sites  or in the uncompletely calcified median palatal suture  compromises success.
For insertion into mucosa as compared to attached gingiva, often, surgical incision is required to prevent bur entanglement  and inflammatory response is worse. Elevating a flap for insertion was reported to reduce success. Furthermore, all failed immediate loaded implants had screw emergence at the oral mucosa. In thick attached gingiva (e.g., palate, retromolar area), longer implants might be required and larger moments are generated when forces are applied. The transgingival or submucosal insertion is based on soft-tissue thickness. For transgingival insertion, a site with thin attached gingiva is ideal. In the attempt to prevent inflammation and soft-tissue overgrowth, the implant emerges in the attached gingiva wherever possible.
The selection between the two most commonly used materials, grade 5 titanium alloy or stainless steel, is not important for success since primary stability is similar for both  and osseointegration, which is achieved by titanium alone, is not required for mini-implants. However, it should be mentioned that the superior tensile properties of the stainless steel mini implants provide greater bending, and their higher tactile properties upon insertion help sensing the upcoming fracture.
The selection of predrilled (over self-tapping) mini-implants and predrilling diameter depends on bone quality and gingival thickness. Predrilling is avoided in low bone quality. Small predrill diameters or even no predrilling is selected in the thick gingiva. Larger predrill diameters are preferred in high bone quality and thin gingiva or for submucosal insertion. For predrilling, it has been suggested to choose a drill with implant diameter minus 5 mm, e.g., 1.1 for 1.6 mm mini-implants and 1.5 for 2 mm mini implants; however, this cannot be applied in all cases.
Angled insertion either to the long tooth axis or the occlusal plane has been suggested to increase bone-to-implant contact and reduce anatomic structures injury risk. Angled insertion to the long tooth axis of 30°–40° in the maxilla and 10°–20° in the mandible has been suggested., Changing angle from 90° to 45° increased cortical bone-to-implant contact by 47%. Angulation to the occlusal plane was suggested to be 30°–45° for the posterior maxilla  and mandible , whereas approximately 90° for the anterior maxilla and posterior edentulous maxilla. Steeper angulation (<30°) increases miniscrew slippage risk., Angular (30°–45°) insertion at 4–6 mm from the maxillary alveolar crest significantly increased bone contact,, in most sites, whereas apically inclined insertion increased sinus perforation risk. Insertion at a 90° than 60° angle to the maxillary first molar buccal surface resulted in higher MIT as reported ex vivo for both cylindrical and conical mini-implants.
When selecting between conical and cylindrical mini-implants, it should be taken into account that conicals could provide tighter implant–bone contact at insertion  and require higher insertion torques. However, excessive bone compression might lead to failure. MIT was significantly higher for conicals than cylindricals in vitro.
Injury of the dental root, maxillary sinus (floor or wall), or nerve (mainly of major palatine nerve) might occur with insertion. Depending on the extent of root trauma (contact or perforation), close monitoring alone or endodontic treatment or even tooth extraction might be required. It has been claimed that root injury does not always lead to permanent pulpal and periodontal damage. Concerning a mini-implant inserted too close to a root, bone remodeling might be compromised and occlusal forces might be transmitted to the implant, which might lead even to implant failure. A systematic review based on clinical, animal, and cadaver studies demonstrated that mini-implants with root contact had higher insertion torque than without although no study assessed the diagnostic accuracy of this. In case of sudden significant torque rise during insertion or excessive resistance during insertion, the possibility of root contact cannot be excluded. Therefore, recording torque levels during the entire implant insertion process seems important.
Mini-implant fracture risk is low  and becomes even lower at removal. Fracture risk at insertion is positively affected by very thick and dense cortical bone, very narrow implant diameter,, implant overtightening, and insertion of very wide diameter implants into very thick cortical bone, whereas it is negatively affected by predrilling  and implant diameter ≥1.2 mm. Implant length does not affect it. For predrilled implants, if there is excessive resistance during insertion, the implant is unscrewed and the pilot hole widened. For self-tapping implants, excessive pressure during insertion may fracture the screw tip. Insertion stops when the smooth part of the cervical part reaches the periosteum. When fracture occurs, the fragment should be removed. Fracture resistance might be influenced by design differences in mini-implants of similar dimensions.,
Mini-screws are mostly used though mini-plates were reported with significantly lower failure rate than mini-screws. In case a mini-implant has failed, insertion of another one might be considered. Failure rate significantly increases if the previous mini-implant fails, especially if self-tapping stainless steel miniscrews are used. Miniplates and predrilled titanium miniscrews are more reliable for patients with self-tapping stainless steel miniscrew failure. Therefore, miniplates might serve as a backup option when miniscrews repeatedly fail.
Based on a recent systematic review, moderate evidence indicates that mini-implant clinical performance is influenced by implant geometry characteristics and is related to insertion site properties. It should be stressed that in some cases, the site of professional choice is not the most appropriate for mini-implant placement. Then, careful evaluation of all factors will lead to correct decisions.
| Factors Concerning the Orthodontic Loading Period|| |
Mini-implant mobility, which is a common complication,, may occur any time following implant insertion. Primary stability is a prerequisite for orthodontic loading, whereas secondary stability, based on new bone formation, is fundamental for achieving the planned orthodontic movement. Controlling biomechanical forces is important for sustaining secondary stability during the loading time. In the force control attempt, implant angulation plays a role. A loose implant that cannot withstand orthodontic loading has failed. Slight secondary mobility does not necessarily mean failure if the implant can withstand loading. Delayed loading initiation, a few months postinsertion, is usually selected. For immediate loading, high insertion torque is a prerequisite; otherwise, loading should be delayed for at least 6–8 weeks. All implants placed with a minimum torque value of 15 Ncm were reported to survive immediate loading, which was statistically significant.
It has been suggested that loaded mini-implants might present slight displacement although they are stable, which is either primary soon after loading due to tissue elasticity or secondary during loading time due to bone remodeling. A systematic review showed in vitro significant primary displacement (6.4–24.4 μm) with relevant orthodontic forces 0.5–2.5 N and in vivo mean secondary displacement of 0–2.7 mm, with controlled tipping or bodily movement being the most frequent movement type. Although primary displacement was not clinically significant, minor secondary displacement in the force direction might occur. The chance of secondary displacement should be considered for mini-implant insertion close to anatomic structures, especially interdentally. Slightly intentional decentralized insertion, away from force direction, has been suggested.
Median implant survival time is sufficient even for relatively long orthodontic treatments. Special attention is needed at implant removal upon loading completion since fracture risk is not eliminated. Mean maximum removal torque of 10.01 Ncm (SD ± 0.17) was reported for maxillary cylindrical mini-implants in a systematic review. In terms of removal torque, the clinician should remember that removal torque is much lower than insertion torque for both conical and cylindrical mini-implants, that it did not significantly correlate with insertion torque, that it was significantly higher for conicals than cylindricals in vitro, and that, in the maxilla, it was not significantly related to cortical bone thickness and placement period.
| Conclusions|| |
The successful application of mini-implants is based on the proper selection of insertion site; proper selection of mini-implant length, diameter, and tapering; proper insertion in terms of site, predrilling, angle, and primary stability; absence of injury; absence of local inflammation; and proper orthodontic loading. Insertion site and mini-implant characteristics depend on cortical bone thickness, bone density, available amount of bone, adjacent anatomic structures, and soft-tissue thickness. Sites of high cortical bone thickness, high cancellous bone density, sufficient available bone, and thin attached gingiva are ideal for mini-implant insertion. However, extremely thick cortical bone thickness needs special attention when planning mini-implants. Shorter mini-implants can be selected for high cortical bone thickness, whereas longer and wider ones should be selected for low cortical bone thickness and low cancellous bone density. Very thin cortical bone and very low cancellous bone density negatively affect the prognosis of mini-implants. Longer implants are often preferred for the maxilla than the mandible. Very narrow implants entail fracture risk. Predrilling should be preferred at sites of high bone quality, whereas it should be used with caution or even be avoided at sites of low bone quality. Angled mini-implant placement might be considered to increase bone to implant contact and reduce root injury risk. Loading time depends on insertion torque. Careful assessment of all the factors that might compromise mini-implant success is fundamental for their clinical application. Proper planning, proper insertion, achieving primary stability, proper orthodontic loading, as well as absence of inflammation and mobility, for the whole-loading time ensure success.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]