Raghavendra V et al: Safe Zones in Maxilla and Mandible REVIEW ARTICLE

Safe Zones for Miniscrews in Orthodontics: A

Comprehensive Review
V Raghavendra1, Y Muralidhar Reddy2, C Sreekanth3, B VishnuVardhan Reddy4, B.Lakshman
Kumar5, G.Kranthi Praveen Raj6
1- P.G Student, Dept of Orthodontics and Dentofacial Orthopaedics, G.Pulla
Reddy Dental College, Andhra Pradesh, India.
2- Professor and Head, Dept of Orthodontics and Dentofacial Orthopaedics, Correspondence to:
G.Pulla Reddy Dental College, Andhra Pradesh, India. Dr. V Raghavendra,
3- Professor, Dept of Orthodontics and Dentofacial Orthopaedics, G.Pulla P.G Student, Dept of Orthodontics and Dentofacial
Reddy Dental College, Andhra Pradesh, India. Orthopaedics, G.Pulla Reddy Dental College, Andhra Pradesh,
India.
4- Reader, Dept of Orthodontics and Dentofacial Orthopaedics, G.Pulla
Reddy Dental College, Andhra Pradesh, India. Contact Us : [email protected]
5- Associate Professor , Dept of Orthodontics and Dentofacial Orthopaedics, Submit Manuscript : [email protected]
G.Pulla Reddy Dental College, Andhra Pradesh, India. www.ijdmr.com
6- Assistant Professor , Dept of Orthodontics and Dentofacial Orthopaedics,
G.Pulla Reddy Dental College, Andhra Pradesh, India.

ABSTRACT
Miniscrews have been extensively used in orthodontics in the last few years for obtaining absolute orthodontic skeletal
anchorage, which is reflected in escalating number of studies addressing this subject. However, there is still no
consensus in these studies about the factors that influence the success of mini-implants. The success of mini screws
determine various factors like the type of miniscrew, patient characteristics (age & sex), placement site, surgical
technique and orthodontic and miniscrews maintenance factors. The present study focused on only one of the factors –
miniscrew placement site. The most common sites for placing the miniscrews, the palate, the aspect of the maxillary
alveolar process, the retromolar pad in mandible, and the buccal cortical plate in both maxilla and mandible. So the aim
of this article was to provide anatomical map for placement of miniscrews in maxilla and mandible and palatal region,
based on dimensional mapping of the interradicular spaces and cortical bone thickness.
KEYWORDS: Mini Implants, Safe Zones, Interradicular Bone

INTRODUCTION
In recent times, the use of miniscrews usage overview of the safe zones for mini screws
increased in orthodontic practice to obtain absolute placement in both maxilla and mandible and palatal
anchorage. Miniscrews offers many advantages region.
when used as temporary anchorage devices like,
easy placement and removal, immediate loading,
MINI SCREWS & SAFE ZONE
used in a variety of locations, providing absolute Skeletal anchorage has evolved as a mainstream
anchorage, economical and requires less patient orthodontic technique in the past decade. Dental
cooperation. However, concerns about damaging implants,1,2 miniplates3,4 and titanium screws5,6 have
dental roots, allied with the limited inter radicular been used as skeletal anchorage, because these
space; still represent a barrier for the clinical devices can provide absolute anchorage without
application of these miniscrews. Several studies patient cooperation. Titanium screws, especially, are
have been performed to assess the safe locations in currently in vogue because the screws are quite
the interradicular spaces for miniscrew placement, useful for various orthodontic tooth movements with
the so-called ‘‘safe zones.’’ This article provides an minimal anatomic limitation on placement, lower

How to cite this article:

Raghavendra V, Reddy YM, Sreekanth C, Reddy BV, Kumar BL, Raj GKP . Safe Zones for Miniscrews in Orthodontics: A
Comprehensive Review. Int J Dent Med Res 2014;1(4):135-138.

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 Raghavendra V et al: Safe Zones in Maxilla and Mandible REVIEW ARTICLE

medical cost, and simpler placement with less the interradicular space between the maxillary
traumatic surgery.5, 6, 7 second and first molars, 2 to 5 mm from the
alveolar crest.
The major advantages compared with dental  Both on buccal or palatal side, between the first
implants or microplates, miniscrews are small in and second premolar, between 5 and 11 mm
size, allowing placement in many intraoral areas, from the alveolar crest followed by between
low cost and easy implantation and removal. the first premolar and canine, between 5 and 11
However, concerns about damaging dental roots, mm from the alveolar crest.
allied with the limited interradicular space, still  On the buccal side, in the interradicular space
represent a barrier for the clinical application of between the first molar and second premolar,
these miniscrews.8,9 from 5 to 8 mm from the alveolar crest.

A minimal clearance of 1 mm of alveolar bone The optimal site for mini-implant placement in the
around the screw has been recommended to preserve anterior region is between the central and lateral
the periodontal health.10 Therefore, when the incisors in the maxilla at the 6-mm level from the
diameter of the miniscrew and the minimum CEJ. So, in the maxilla, the more anterior and the
clearance of alveolar bone are considered, more apical, the safer the location becomes.14
interradicular space larger than 3 mm is needed for Table-1: The order of safer sites , available in the inter-
safe miniscrew placement.10,11 Several studies have radicular spaces in maxillary arch
site Inter -radicular space Distance from the
been performed to assess the safe locations in the alveolar creast
interradicular spaces for miniscrew placement, the Palatal 1st molar and 2nd 2-8mm
so-called ‘‘safe zones”. premolar
Palatal 1st molar and 2nd molar 2-5mm
Palatal and 1st premolar and 2nd 5-11mm
10
Poggio et al evaluated tomographic images of buccal premolar
mandible and maxilla to define ‘‘safe zones’’ for Palatal and 1st premolar and canine 5-11mm
buccal
placing miniscrews. In the maxilla, they Buccal 1st molar and 2nd 5-8mm
recommended on palatal side interradicular spaces premolar
between the canine and the 2nd molar, (except Buccal Central and lateral 6mm
incisor
greater palatine area) and on the buccal side
In the palatal area safer zones for placement of
between the canine and the first molar. In the
miniscrews determined based on bone density.
mandible, they suggested interradicular spaces
Bone density is classified into 4 types D1, D2, D3
between the canine and the second molar.
and D4. D1, D2, D3 are optimal for self-drilling
miniscrews and Implant placement in D4 not
Assessment of interradicular area is a critical factor
recommended.13 (Table 2)
for placement of miniscrews in either maxillary or
Table 2: Bone Type and Bone Density
mandibular arch. For assessing the interradicular
area periapical radiographs are used which is at
fixed magnification. Interradicular area measured Bone type Bone density
(Houns field units)
between the lamina dura of adjacent tooth roots was D1 >1250
calculated using the reference landmarks at the
D2 850-1250
alveolar crest. For example 3,6,9 mm from alveolar
D3 350-850
creast.12
D4 150-350

The order of the safer sites available in the Based on bone density mid palatal suture (D1&D2) in
interradicular spaces of the maxilla is as follows10; the hard palate considered as safer zone in palate. D3
bone density seen in paltal slopes at region of 1st,
 On the palatal side, the interradicular space
2nd and 1st molar area. D4 bone density is seen at the
between the maxillary first molar and second
most posterior palate.
premolar, 2 to 8 mm from the alveolar crest,

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 Raghavendra V et al: Safe Zones in Maxilla and Mandible REVIEW ARTICLE

Based on Soft tissue considerations, Thin and a significantly thicker lingual cortex at the 2-mm
keratinized mucosa is the preferred area for implant level from the CEJ.15
placement. (Table 3)
Different dentoskeletal patterns influence the
Amount of Mucosal site Prognosis
keratinisation availability of interradicular spaces for miniscrew
Non-keratinized Alveolar mucosa Greater Failure rates implant placement .13 Subjects with Class II skeletal
mucosa patterns have significantly greater interradicular
Gingiva (thin Dentoalveolar Ideal
keratinized) (or) distances and larger areas in the maxilla when
mid paltal region compared with the subjects with skeletal Class III
Thick keratinized Paltal slope Are less likely to obtain patterns. In contrast, in the mandible, the
mucosa adequate bony stability.
interradicular distances and areas in the subjects
Table -3: Comparision of Mucosal Site And Prognosis with skeletal Class III patterns are greater than those
The following is the order of the safer sites available in the subjects with skeletal Class II patterns. A
in the interradicular spaces of the mandible: probable explanation for this is the difference in
dentoalveolar compensation observed between these
Interradicular spaces between 2nd and 1st molar, 2nd groups. Subjects with skeletal Class II patterns
and 1st premolar, 1st molar and 2nd premolar at 11 presents with retrognathic mandibles and more
mm from alveolar crest and Interradicular spaces upright maxillary incisors than did the subjects with
between the 1st premolar and canine at 11 mm from skeletal Class III patterns; as a result, the subjects
the alveolar crest.10 with skeletal Class II patterns presented with greater
amounts of interradicular space in the maxillary
The optimal site for mini-implant placement in the arch. In contrast, subjects with skeletal Class III
anterior region is between the lateral incisor and the patterns presents with prognathic mandibles
canine in the mandible at the 6-mm level from the combined with excessively retroclined mandibular
CEJ.14 Many factors could play a key role for the incisors; therefore, greater amounts of mandibular
mini implant success, such as age, sex, the type and interradicular space are observed in these subjects
direction of the applied force, the loading period, than in the subjects with skeletal Class II patterns.
bone quality, and quantity of the insertion site. The availability of interradicular space was mainly
influenced by the axial inclination of teeth due to
Sex and age affects the anatomic measurements in dentoalveolar compensatory changes for variations
certain areas in the maxilla and the mandible. The in sagittal skeletal discrepancies.13,14
males and the age group older than 18 years had a
significantly higher buccolingual, palatal, and The features of the ideal titanium miniscrew for
buccal cortical thickness at specific levels and sites orthodontic skeletal anchorage in the interradicular
in the maxilla and the mandible .15 spaces should be 1.2 to 1.5 mm maximum diameter,
with 6–8 mm cutting thread and a conic shape. If the
In the Maxilla, anteriorly the group older than 18 screw is inserted perpendicular to the dental axis,
years significantly has thicker palatal cortex at the then it obtains less bone support than when inserted
2-mm level from the CEJ and higher buccal and at an oblique angle. A miniscrew insertion at 30–40°
palatal cortical thicknesses at 6 mm. Posteriorly, the to the dental axis allows the insertion of a longer
group aged 19–27 years had a significantly higher screw in the available bone depth. Because of the
mesiodistal palatal distance at the 2-mm level at the reduced tip diameter, a conic screw insertion has a
CEJ and a thicker buccal and palatal cortex with a lower risk of damaging roots.14
highly significant difference at the 4-mm and 6-mm
level from the CEJ. In the Mandible, anteriorly there CONCLUSION
was no significant difference amongst different age
groups. Posteriorly, the group aged 19– 27 years had The safe zone for mini-implant placement in the
anterior region is between the central and lateral

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 Raghavendra V et al: Safe Zones in Maxilla and Mandible REVIEW ARTICLE

incisors in the maxilla and between the lateral is a major factor for screw failure in orthodontic
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