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Features Section |
Orthodontic Department, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK
Address for correspondence: Mr R. Cousley, Orthodontic, Department, Peterborough District Hospital, Thorpe Road, Peterborough, Cambridgeshire, PE3 6DA, UK. Email: Richard.Cousley{at}pbh-tr.nhs.uk
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Abstract |
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 Top Abstract IntroductionTypes of bone anchorageKey design features of...Clinical aspects that influence...ConclusionsReferences |
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Key words: Orthodontic anchorage, orthodontic implants, mini-implants, mini-screws, mini-plates
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Introduction |
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TopAbstractIntroductionTypes of bone anchorageKey design features of...Clinical aspects that influence...ConclusionsReferences |
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In recent years, numerous publications have introduced novel ways of reinforcing anchorage using a variety of devices temporarily anchored in bone. Orthodontic bone anchorage (OBA) is indicated when a large amount of tooth movement (e.g. labial segment retraction or mesial/distal movement of multiple posterior teeth) is required or dental anchorage is insufficient because of absent teeth or periodontal loss. Such devices may also be useful in asymmetric tooth movements, intrusive mechanics, intermaxillary fixation/traction and orthopaedic traction and appear to be rapidly gaining acceptance in routine orthodontic practice. In an effort to improve and distinguish their products, manufacturers have produced systems with innovative design features and differing clinical protocols.
Given that there is no clear consensus on nomenclature, these devices are referred to by a confusing array of names including mini-implants,1
micro-implants,2 microscrew implants,3 miniscrews4 or temporary anchorage devices (TADs).5 Whilst some of these synonyms refer to similar devices, the terminologies used are either vague or inaccurate. For example, the word ‘micro’ is not ideal, since it infers that a device has extremely small dimensions. The term ‘mini-implant’ does not represent all of the systems currently available, and ‘TAD’ is non-specific since all supplementary anchorage devices are temporary and bone anchorage is not clearly denoted. Since the distinguishing feature common to all of these devices is that they provide anchorage through either a mechanical interlocking or biochemical integration with bone, we suggest that they are best referred to as orthodontic bone anchorage devices (BADs).
In view of the rapidly evolving and complex nature of this topic, this paper aims to assist the orthodontist by reviewing the various design features of currently available BADs, and outlining principles of bone anchorage and the clinically relevant factors that influence the choice of a specific BAD.
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Types of bone anchorage |
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TopAbstractIntroductionTypes of bone anchorageKey design features of...Clinical aspects that influence...ConclusionsReferences |
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). Broadly speaking, BADs can either be osseointegrated or mechanically retentive depending on their bone-endosseous surface interface and design features. The latter group can be subdivided according to whether the screw (mini-implant) or plate (mini-plate) components are the principal design elements.
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work on the concept of osseointegration and use of titanium implants to replace missing teeth. These endosseous implants have features to promote both functional and structural integration (osseointegration) at the implant–bone interface, and require an unloaded latency period of up to 6 months.6 In 1984, Roberts et al.7 investigated the tissue response to orthodontic forces applied to restorative implants and concluded that continuously loaded implants remained stable with 100 g force after a 6-week healing period. In a follow-up study on dog mandibles, osseointegration was found in 94% of the implants and it was concluded that less than 10% of endosseous surface area contact with bone was needed to resist forces of up to 300 g for 13 weeks.8 Subsequently, several manufacturers modified restorative implant designs to produce customized orthodontic fixtures. Clinical studies on the use of osseointegrated implants for orthodontic anchorage have reported a success rate of 86–100%.9–13 The retromolar implants,14 OnplantTM, Straumann OrthosystemTM and Mid-plant systemTM are examples of osseointegrated BADs.
Mini-implants and mini-plate systems
Orthodontic mini-implant and mini-plate systems are derived from maxillofacial fixation techniques and rely on mechanical retention for anchorage (Figure 1
). Since these devices use osseous physical engagement for stability, they are less technique sensitive than osseointegrated implants, amenable to immediate orthodontic loading and are easily removed.15–17 Osseointegration is neither expected nor desired (in terms of screw removal), although animal studies have demonstrated that a limited and variable level (10–58%) of osseointegration can occur.15 In 1983, Creekmore and Eklund18 reported the use of a vitallium screw, resembling a bone-plating screw, placed in the anterior nasal spine region. This was loaded after 10 days for successful intrusion of the adjacent upper incisors. Subsequent modifications to the design of fixation screws have made them more suitable for use in orthodontics and led to the introduction of customized mini-implant kits. In the late 1990s, both Kanomi et al.1 and Costa et al.19 described mini-implants specifically designed for orthodontic use. The AarhusTM, Spider screwTM, Dual TopTM, AbsoanchorTM and IMTECTM are current examples of mini-implant BADs.
Over the same period, alterations to the design of maxillofacial fixation plates have led to the introduction of mini-plate systems. In 1985, Jenner et al.20 reported a clinical case where maxillofacial bone plates were used for orthodontic anchorage. In 1998, Umemori et al.21 used L-shaped LeibingerTM mini-plates in the mandible to intrude molars for anterior open bite correction. They termed this approach the ‘The Skeletal Anchorage System’ (SAS) and suggested that, when compared with osseointegrated implants, these mini-plates provide stable anchorage with immediate loading. Since then other mini-plate design variations have been introduced, e.g. Bollard Mini Plate implantTM and C-tube implantTM (Figure 2). Clinical studies on these non-integrating devices have reported success rates of 86–93% for mini-implants22,23 and 93% for mini-plates.24
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Key design features of BADs |
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TopAbstractIntroductionTypes of bone anchorageKey design features of...Clinical aspects that influence...ConclusionsReferences |
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) and therefore these are described collectively (Table 1). Mini-plate design features however will be described separately.
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Mini-implants on the other hand are manufactured with a smooth endosseous surface or additional surface treatments (e.g. TOMASTM system) to actively discourage osseointegration and therefore simplify their removal.
Dimensions
Orthodontic implants and mini-implants are available in a range of body lengths and diameters. For orthodontic implants both physical stability and osseointegration depend on adequate bone-fixture surface contact, which in turn is a balance between the fixture’s diameter and length.25 If the length is small the diameter must be large and vice versa. In practice, an implant’s primary stability is related to its intra-osseous length, whilst the threads help to dissipate stress within the trabecular bone. Subsequently, the implant’s shape and surface characteristics are important influences on osseointegration, as the load tolerance is proportional to the available osseointegrated surface area. Such orthodontic implants are usually cylindrical in shape (Figure 3) with a relatively short body length (4–7 mm) and large diameter (3–5 mm) as compared with mini-implants. These dimensions provide a large surface area in a limited depth of bone, making them suitable for mid-palatal, retro-molar and edentulous sites.
Conversely, mini-implants have long, narrow conical shapes (Figure 3) and are available in 6–15 mm intra-osseous lengths and in 1.2–2.3 mm diameters. An in vitro laboratory study has compared the mechanical properties of three types of mini-implants (Leone, M.A.S.TM and DentosTM) on a non-biological bone substitute, and the authors concluded that mini-implants should be at least 1.5 mm in diameter in order to resist fracture.26 A clinical study of the factors associated with mini-implant stability assessed fixtures with 1–2.3 mm diameters and 6, 11 and 14 mm body lengths. It was found that implant mobility was associated with 1 mm body diameter, but it was not statistically associated with body length.23 Hence, in terms of a mini-implant’s primary stability, the diameter is more important than body length for mechanical interlocking in bone. If excess resistance is encountered during the placement of a mini-implant, it is preferable to first create a pilot hole using a drill whose diameter is less than the fixture body. For example, insertion of a 1.5 mm diameter mini-implant may warrant the use of a 1.1 mm diameter drill in the maxilla and 1.3 mm in the mandible, due to the differential bone density.
The C-Orthodontic micro-implant developed by Chung et al.27 may be best termed as a hybrid mini-implant, rather than a ‘micro-implant’. Its relatively narrow dimensions (1.8 mm diameter and length up to 10.5 mm) enable interproximal site insertion and loading is recommended after a healing period of 6–8 weeks. The authors claim that its endosseous surface encourages osseointegration even when subjected to early loading (2 weeks), but have not provided clear evidence to support this.
Body and thread designs
Orthodontic implants and most mini-implants are commonly described as being self-tapping. Self-tapping body designs often have a special groove in their tip, which cuts or taps the bone during insertion. This feature usually requires a pilot hole to be drilled first and the groove at the tip then creates the thread pattern in bone as the fixture is inserted. Orthodontic implants have broadly similar self-tapping designs to improve the transfer of compressive forces to the adjacent bone, minimize micro-motion and increase the bone-implant surface area. For example, the Straumann Orthosystem relies on the physical shape of its threads to provide primary stability from the time of insertion until osseointegration subsequently occurs.11 Conversely, mini-implants have been manufactured with a wide variety of thread designs and body shapes. As with maxillofacial fixation screws, the first mini-implants were tapped into pre-drilled holes. More recently, we have seen the release of self-drilling mini-implants, which can be screwed directly into bone using a driver at an appropriate torque level.15 This simplifies the insertion stage by avoidance of pre-drilling although some manufacturers indicate that their mini-implants behave in a self-drilling fashion in the maxilla, but may require pre-drilling in the mandible (e.g. IMTEC, Orlus). Kim et al.28 compared the stability of mini-implants in beagle jaws inserted using pre-drilling and drill-free methods. They concluded that both methods showed some evidence of osseointegration under early orthodontic loading and that all of the mini-implants were sufficiently stable for anchorage purposes. However, the drill-free fixtures showed less mobility and more histomorphometric bone-metal contact. This may be because drill-free insertion produces little bone debris and less thermal damage.29
Head designs
Orthodontic implants usually feature two-piece designs with specific healing abutments and intra-oral attachments. A healing cap or cover screw is usually placed during the latency phase and then replaced by specialized fixtures, which enable connection of orthodontic auxiliaries such as a transpalatal arch (TPA) for indirect anchorage.30 The majority of available mini-implants feature various one-piece designs (Table 1). The C-Orthodontic system has a two-piece design, where the head is screwed on to the endosseous base either at insertion or after an apparent osseointegration period of 6–8 weeks.27 The IMTEC mini-implant system also has a detachable head abutment. Mini-implant head designs may have hooks, ball ends or grooves to connect orthodontic traction auxiliaries or rectangular/round slots. These slots have broadly similar dimensions to an orthodontic bracket and can be used to directly engage arch wires. The transmucosal neck is that part of the implant or mini-implant, which emerges through the soft tissue superficial to the cortical plate. A smooth polished transmucosal neck of appropriate height is essential to prevent plaque accumulation and harbouring of micro-organisms, and also provide sufficient clearance for the fixture head.
Mini-plate systems
Orthodontic mini-plate systems are broadly similar to maxillofacial plating systems (Figure 2) in terms of their holed baseplates and fixation screws, but have specifically modified ends to engage orthodontic auxiliaries. They are manufactured from titanium and are supplied in kits containing both mini-plates and fixation screws. The designs may vary in shape and size (Table 1), but are usually available as two- to five-holed mini-plates with transmucosal neck extensions. These plates are about 1.5 mm in thickness and can be bent or trimmed to adapt them to the cortical plate contour at the insertion site. They are secured with mono-cortical fixation screws of 5–7 mm lengths and 1.2–2.3 mm diameters. The intra-oral end is usually a cylindrical tube with holes through which orthodontic wires may be passed. A locking mechanism is integrated into the cylindrical tube, such that it can be tightened to stabilize the orthodontic wire or auxiliary (e.g. Bollard System). The Leibinger SAS kit and C-system contain both self-tapping and self-drilling screws for mini-plate fixation.
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Clinical aspects that influence the choice of a BAD |
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TopAbstractIntroductionTypes of bone anchorageKey design features of...Clinical aspects that influence...ConclusionsReferences |
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and mini-implants,31 but this is difficult to justify in routine clinical practice.
Anatomical site considerations
The most common sites for orthodontic implants are the mid-palatal region,11 para-median area of palate,12 and retromolar edentulous areas.14 For the anterior palate, bone depth can be assessed on a lateral cephalograph such that the antero-posterior location and inclination of the implant are planned to optimize the available bone depth.32 This allows for implants of up to 6 mm lengths to be placed in this region (Figure 4). Implants can also be inserted in para-median positions, i.e. 6–9 mm posterior to the incisive foramen and 3–6 mm laterally.12 This may be a valid option in young patients with a patent mid-palatal suture, although appropriate surgical and radiological planning is essential. If there are any doubts over the degree of obliteration of the mid-palatal suture the implant should be placed just posterior to the first premolars where ossification is usually more complete.33
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), the maxillary sub-nasal spine region, mandibular symphysis, para-median and mid-palate, retro-molar, infra-zygomatic and maxillary tuberosity areas. A volumetric CT study of 20 patients to assess the hard and soft tissue depths required for mini-implant insertion, indicated that 10 mm length screws could be placed in the symphysis and retro-molar regions and 4 mm lengths were preferable in the mid-palate area, incisive and canine fossae.34 In another study Poggio et al.35 assessed the interproximal alveolar sites in terms of the vertical insertion levels for mini-implants using 25 volumetric tomographic images of the maxilla and mandible.35 Mesio-distal and bucco-lingual distances were evaluated 2, 5, 8 and 11 mm from the alveolar crest. The results suggested that in both the maxilla and mandible, insertion in the buccal inter-premolar areas 5–11 mm from the alveolar crest would avoid damage to roots. The mean mesio-distal width of interproximal bone available was 3.5 mm in maxilla and 4.9 mm in mandible in this vertical range. In the maxilla maximum bone width was available on the palatal aspect of the alveolus; however, in the molar region insertion more than 8 mm from the alveolar crest should be avoided because of proximity to the maxillary sinus. In the interproximal sites, the authors suggested that mini-implants should be angled at 30–40° to the vertical axis of teeth to enable insertion of longer ones in the available three-dimensional (3D) bone trough. Although not always necessary, if initial alignment is completed first then there may be more sites available for mini-implant placement through intentional separation of the adjacent roots during this treatment phase.36
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When loaded over a period, these fixtures were displaced by –1 to 1.5 mm in the direction of the applied force. Interestingly, a histological animal study has assessed root repair after injury from mini-implant insertion and found that complete root repair occurred within 12 weeks of fixture removal.38 Finally, in long-term edentulous areas, implant and mini-implant placement should be carefully planned due to likely alveolar resorption and lowering of the maxillary sinus floor.
Recommended sites for the placement of mini-plates are the zygomatic process of the maxilla,39 mandibular body distal to the first molars21 and the maxillary buccal plate above the premolar/molar roots.40 Whilst mini-plates may be placed in bony areas remote from the dental roots and important anatomical structures, their disadvantages include the large scale subperiosteal flap surgery necessary to access these remote sites and the associated patient morbidity. Their transmucosal part is adapted such that it emerges through the soft tissue at an appropriate position and level for orthodontic auxiliaries to be attached. One mini-plate, the C-plate is suitable for subperiosteal placement in the mid-palatal region and has a cross-shaped exposed part for application of forces in multiple directions.
Surgical stents
The insertion techniques for all BADs should attempt to maximize the available bone volume, whilst avoiding adjacent anatomical structures such as dental roots, naso-maxillary cavities and neurovascular tissues. Clinical experience with palatal implants has shown that accurate 3D positioning is a critical factor in this respect.41,32 Several authors have recommended the use of removable stents for orthodontic implants to transfer the pre-surgical prescription to the surgical stage,42–44 but only one stent design provides direct 3D physical guidance for the surgical instruments during insertion (Figure 6a).45
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,46,47 Arguably, such wire markers only provide limited and indirect topographical and angulation information, but no inclination guidance for mini-implant insertion. To overcome this problem, 3D removable stents have been described for mini-implants (Figure 6b).48–50 Although the fabrication of a stent involves additional lab support the advantages of ease and accuracy of mini-implant placement, and reduced chairside time and patient morbidity may outweigh the disadvantages. This is especially true when different clinicians are responsible for planning and placement, or for those inexperienced in insertion techniques.
Implantation/explantation
Several studies on endosseous implants have demonstrated that pre-operative prophylactic antibacterial measures reduce post-operative infection and hence early failure rates.51 A single dose of pre-operative antibiotics is generally recommended before placement of orthodontic implants, but the consensus is that this is not required for mini-implants other than for general medical reasons.52 Instead, a chlorhexidine mouthwash or swab may be used immediately pre-operatively to reduce the bacterial load.53
Most BADs can be inserted as a chairside procedure under local anaesthesia, although some patients may prefer general anaesthesia for implant and mini-plate procedures. A generous surgical access flap is clearly required for mini-plate systems and a localized subperiosteal flap is recommended by some mini-implant manufacturers. Conversely, some mini-implants may be screwed directly through the attached mucosa, or a soft tissue punch may be used to prevent mucosal tearing and provide a clean-cut tissue margin around the transmucosal neck. The soft tissue thickness at the insertion site influences the choice of fixture, such that a longer transmucosal neck should be used in areas with thick soft tissues. The pilot hole (if required) should be drilled as per the manufacturer’s recommendations, at a slow speed with adequate cooling using saline irrigation to minimize heat generation (below 47° C) and associated bone necrosis. The fixture may be seated either with digital pressure using a screwdriver (with or without a torque wrench), or a slow speed handpiece depending on operator choice, access and the manufacturer’s recommendations.
The implant placement torque (IPT) is a measure of resistance to fixture insertion and its relationship to mini-implant success rates was studied in 41 patients (124 mini-implants).54 The results showed that the IPT was higher in the mandible than the maxilla, and that the failure rate in the mandible increased when high torque values were encountered during insertion. The authors attributed such failures to excessive stress created in the dense peri-implant bone as indicated by the high IPT values resulting in local ischaemia and bone necrosis. Therefore, it appears that a low IPT may indicate bone deficiency and poor initial stability, whilst a very high torque may be associated with bone degeneration. The authors recommended IPT values within the range of 5–10 Ncm when 1.6 mm diameter mini-implants are used and suggested the use of a relatively larger pilot drill for the mandible than the maxilla. Although the conclusions of this study are limited to pre-drilled mini-implants, it is likely that the general IPT principles also apply to self-drilling ones.
Written and verbal post-operative instructions should include details on oral hygiene measures and analgesia, and will vary depending on the BAD and site selection. Regular chlorhexidine mouthwashes for 1–2 weeks are typically recommended. Clinical studies have shown that inflammation of peri-implant tissue is a contributory risk factor for early failure in both orthodontic implants55 and mini-implants.23,56 Post-operatively, there should be no signs of pain (including tooth sensitivity), peri-implant inflammation or implant mobility, although clinical experience indicates that mini-implants may still be rotated, whilst remaining resistant to translatory movements.
Explantation of orthodontic implants can be done under local anaesthesia using the manufacturer’s specific explanation tools. For example, Orthosystem implants are removed by rotary dissection with an explantation trephine at 750 revolutions per minute. The implant bed is left to granulate and good mucosal coverage occurs within a week.32 Mini-plates require a second episode with full surgical flap access for their removal. Conversely, mini-implants are easily removed by unscrewing them using their screwdriver or handpiece adapter and the consensus is that 90% of such episodes do not even require local anaesthesia.52
Force application on BADs
Straumann recommend that Orthosystem implants are kept unloaded during the initial 12 weeks healing (latency) phase, although there are reports in the literature of this ranging from 2 to 16 weeks.9,10,11,13 In a histomorphometric animal study, osseointegrated implants were subjected to continuous forces of 100–300 g.57 This appeared to favourably influence the turnover and density of peri-implant bone, whilst the degree of osseointegration was independent of the amount of loading within this range. A similar experimental study showed that when a continuous uniform force or a static load (e.g. an orthodontic force) is applied, the marginal peri-implant bone is denser than that around implants loaded with a fluctuating (e.g. masticatory) force.58 Several clinical studies have shown that loaded osseointegrated implants are stable over force levels in the range of 80–600 g.8,11,13
Mini-implants are usually described as being loaded immediately15 or after a healing period of 2 weeks.37 They apparently withstand forces ranging between 50–250 g19,22,23 and are stable when horizontal or vertical forces are applied provided that these forces cause minimal rotational moments.19 A study of factors associated with the stability of mini-implants, concluded that the main risk factors for premature loosening were a small diameter, peri-implant inflammation and patients with high mandibular plane angles (who appeared to have thinner buccal cortical bone), but not force levels.23
In terms of orthodontic mechanics, either direct or indirect traction may be applied to BADs. For instance, palatal implants usually provide indirect anchorage via a TPA connected to anchor teeth (Figure 4). The TPA can be either soldered to the implant cap or secured with a clamping cap or resin bonding (e.g. Mid-plant system, Straumann Orthosystem). It is important to plan the fabrication of the TPA with the implant position and dental attachments (molar bands or bonding bases) in mind so that a conflict in the paths of insertion is avoided.32 One should also allow for possible deformation of the TPA, as occurred in a prospective study of Orthosystem palatal implants.30 This resulted in 0.9 mm of anchorage loss and consequently a stiffer 1.2 mm2 rectangular TPA was recommended.59
Conversely, mini-implants usually provide direct anchorage whereby traction is applied to the fixture’s head (Figure 5a). Occasionally, a mini-implant can be reinforced by combining it with an abutment via a rigid rectangular wire, e.g. to a bracket on the tooth that forms the anchorage unit. A FEM study of mini-implants has shown that the use of an abutment may significantly reduce the stress concentrated in the peri-implant bone.60 Clinically, this could increase the anchorage value and flexibility of applying forces in different vectors. In some scenarios, it is possible to apply a combination of force applications depending on the type of tooth movement required, e.g. simultaneous intrusion and retraction of anteriors, distalization of buccal segments with vertical control, uprighting of terminal molars with cantilever attachments. Recent clinical reports also describe the innovative use of BADs in atypical fixed appliance situations, e.g. with the Pendulum appliance and Distal jet for molar distalization,61 alignment of ectopic canines,3 unilateral molar intrusion62 and inter-maxillary traction.63,64
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Conclusions |
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TopAbstractIntroductionTypes of bone anchorageKey design features of...Clinical aspects that influence...ConclusionsReferences |
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,10,13,30 However, they have disadvantages of relatively high costs, invasive placement and removal, elaborate planning and laboratory support, a limited range of anatomical sites for insertion and the requirement for a latency period before clinical loading. Although, mini-plates can be placed in remote sites independent of the alveolar ridge, this means that surgical access can prove difficult. This is their main disadvantage along with the associated increase in patient morbidity, the degree of invasiveness and relatively high costs. However, they do have advantages of being amenable to immediate loading and versatility in terms of the application of forces in different vectors.
Arguably, mini-implants will be more widely used than the other two BAD groups because of their ease of insertion and removal, wide range of insertion sites, low cost, lower patient morbidity and discomfort, and early/immediate loading. They are also considered more clinician-friendly, since orthodontists can easily insert them as a routine procedure. Although, mini-implants have been shown to displace under loading,37 they can be safely placed in most interproximal areas. Their main limitations are dependence on adequate bone quality/depth for stability, adjacent soft tissue inflammation and a small risk of fracture during insertion or removal. On balance, it appears that as techniques evolve further, mini-implants may be the BAD of choice in most clinical scenarios requiring maximum anchorage reinforcement, whereas implants and mini-plates may be reserved for those cases requiring the use of remote anchorage sites due to over-riding anatomical considerations.
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Notes |
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References |
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TopAbstractIntroductionTypes of bone anchorageKey design features of...Clinical aspects that influence...ConclusionsReferences |
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2 Kyung HM, Park HS, Bae SM, Sung JH, Kim IB. Development of orthodontic micro-implants for intraoral anchorage. J Clin Orthod 2003; 37: 321–28.[Medline]
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32 Cousley R. Critical aspects in the use of orthodontic palatal implants. Am J Orthod Dentofacial Orthop 2005; 127: 723–29.[CrossRef][Medline]
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