JContempOrthod 1 1 1 4
JContempOrthod 1 1 1 4
JContempOrthod 1 1 1 4
Miniscrew implants (MSIs) have appeared to be the boon to orthodontists with wide range of applications in management of complex
malocclusions. However, MSI failures remains the most common problem affecting their successful utilization. Researches are oriented
towards improving the stability and minimizing their failure rate. This article presents the brief review of MSI development, their use in
anchorage management and update on development of protocol and current status of research at AIIMS, New Delhi. This knowledge
will be helpful in exploring possible research approaches in bone and soft tissue adaptation to MSIs and possible modification of current
design of MSI for improving its success rate.
There must be a definite indication for use of MSI and should cases because of varied level of the mucogingival junction and
have low risk-benefit ratio. Enthusiastic use of an invasive and differences in bone height, thereby leading to canting of occlusal
costly procedure like MSI anchorage in all patients is not plane. In such cases, indirect loading can serve the purpose. It has
recommended. been proved that anchorage control with indirect loading is
A fully bonded 022" preadjusted appliance is used. Upper comparable with direct loading method and it is suggested that in
molars receive triple buccal tubes and lower double buccal tube. If clinical situations when directly loaded MSIs are not preferable,
there is no crowding in the arches, extraction of premolars (both indirectly loaded MSIs can be considered as a robust option.
upper and lower premolars in bimaxillary protrusion cases and upper (Monga et al., 2016)
premolars only in Class II div 1 cases) is deferred till alignment is According to recent FEM studies, direct loading can overload
completed. A sequence of wires is used for levelling and alignment the MSIs and the peri implant bone, sometimes, leading to MSI
until a 0.019"x0.025" stainless steel wire is passively engaged. failure. (Holberg et al., 2013, 2014) Indirect loading technique allows
Extractions of premolars is performed as needed. The most common the clinician to vary the position of MSI at preferable site. At the
site for MSI placement is buccal interradicular space between same time, good biomechanical control of the teeth can be obtained
second premolar and first molar in attached gingiva 4-5 mm apical by applying standard orthodontic mechanics.
to the alveolar crest. MSIs are placed in identified locations in the
mouth under local infiltration and anti-inflammatory drugs for next MSI failure and biological basis
three days and strict oral hygiene programme is prescribed.
MSI failure can be attributed to number of factors including
A time lapse of 3 weeks is suggested so that the inflammation
biological, implant related or technique related factors. (Kharbanda
around the MSI subside. Before loading the MSIs, an auxiliary wire
et al., 2013) Biological factors include age and gender of the patient,
framework AIIMS universal connector (Kharbanda et al., 2013)) is
bone quantity and quality, nature of soft tissue, periodontal
fabricated in 0.017"x0.025" stainless steel wire which connects the
condition and oral hygiene maintenance. Dimensions and shape of
molar at its auxiliary slot and the bracket head of the MSI so that
the MSI, type (predrilled or self-drilling) constitute the factors
the MSIs are indirectly loaded during retraction of the anterior
related to the MSI. Angulation of the MSI, proximity to dental
teeth. (fig. 2) The connector is so fabricated that it is passively
roots, loading protocol and amount of load applied also affect the
fitted in slots on the MSI or the connected molar without exerting
stability of the MSI. They have been extensively researched to
any force at both the ends. The enmass retraction of the anterior
identify their role in MSI failure.
teeth is carried out using conventional mechanics. (fig. 3) The
Bone quality is considered to be an important factor affecting
patient is followed every 6-8 weeks. Once the extraction spaces are
MSI stability and greater failure is reported in low density bone
closed, the MSIs along with connector is removed and finishing is
(Chen et al., 2008). In addition to bone availability in interradicualar
carried out in the usual manner.
region between second premolar and first molar, this site has good
Direct vs indirect loading bone quality for MSI insertion. (Poggio et al., 2006; Samrit et al,
2012). Local inflammation i.e., peri implantitis is also identified to
In clinical practice and most of the research studies, the MSIs be one of the major factor contributing to MSI failure accounting
are directly loaded. However, in cases where enmass retraction is for about 30% of MSI failures. (Miyawaki et al., 2003; Park et al.,
carried out by direct loading, MSIs on both sides of the jaw should be 2006; Samrit et al., 2012)
placed at the same height or location. This may not be possible in all
Fig 3. Enmass retraction of anterior teeth using indirect anchorage and conventional sliding mechanics
The focus of research now shifted towards minimizing the control and improved treatment outcome.
peri implant inflammation. Human study was conducted at AIIMS They have also helped in management of complex tooth
to explore the inflammatory response and found that there is movements. While mechanical and design related factors have been
significant rise in level of inflammatory marker during MSI insertion a major research interest, lately, focus has shifted towards
and on loading. (Monga et al., 2014) These levels gradually ‘biological’ studies. AIIMS protocol of use of MSI supported
decrease towards baseline over the period after loading. This led indirect anchorage and cooling period of three weeks before loading
to the conclusion that at least 3 weeks of cooling period is necessary is based on sound biological basis. Further research is in progress
after MSI insertion for the inflammation to subside. Another to induce implant- soft tissue interface to minimize peri-implantitis.
research at AIIMS on surface characterization of retrieved MSIs
References
has led to the new area for exploration which would help in reduction
of peri implantitis and thereby reduction in failure rate. (Patil et al., 1. Al-Sibaie S and Hajeer MY, 2014. Randomized controlled trial assessment of
2015). changes following en-masse retraction with mini-implants anchorage compared to two-
step retraction with conventional anchorage in patients with Class II Division 1
malocclusion: a randomized controlled trial. European Journal of Orthodontics, 36:275–
Summary 283.
The MSIs are useful addition to orthodontic armamentarium. When 2. Block MS and Hoffman DR, 1995. A new device for absolute anchorage for orthodontics.
used judiciously, these can certainly add to effective anchorage American Journal of Orthodontics and Dentofacial Orthopedics, 107:251-258.
3. Chen YJ, Chang HH, Lin HY, et al., 2008. Stability of miniplates and miniscrews 13. Monga N, Chaurasia S, Kharbanda OP, et al., 2014. A study of interleukin 1â levels
used for orthodontic anchorage: experience with 492 temporary anchorage devices. in peri-MSI crevicular fluid (PMCF). Progress in Orthodontics, 15:30.
Clinical Oral Implants Research, 19: 1188-1196. 14. Monga N, Kharbanda OP and Samrit V, 2016. Quantitative and qualitative
4. Cornelis MA, Scheffler NR, De Clerck HJ, et al., 2007. Systematic review of the assessment of anchorage loss during en-masse retraction with indirectly loaded MSIs in
experimental use of temporary skeletal anchorage devices in orthodontics. American patients with bimaxillary protrusion. American Journal of Orthodontics and Dentofacial
Journal of Orthodontics and Dentofacial Orthopedics, 131(4 Suppl):S52-58. Orthopedics, 150:274-282.
5. Creekmore TD and Eklund MK, 1983. The possibility of skeletal anchorage. Journal 15. Park HS, Jeong SH and Kwon OW, 2006. Factors affecting the clinical success of
of Clinical Orthodontics, 17:266-269. screw implants used as orthodontic anchorage. American Journal of Orthodontics and
Dentofacial Orthopedics, 130:18-25.
6. Gainsforth BL and Higley LB, 1945. A study of orthodontic anchorage possibilities
in basal bone. American Journal of Orthodontics and Oral Surgery, 31:406-416. 16. Patil P, Kharbanda OP, Duggal R, et al., 2015. Surface deterioration and elemental
composition of retrieved orthodontic MSIs. American Journal of Orthodontics and
7. Holberg C, Winterhalder P, Holberg N, et al., 2013. Direct versus indirect loading
Dentofacial Orthopedics, 147:S88-100.
of orthodontic MSI implants—an FEM analysis. Clinical Oral Investigations, 17:1821-
1827. 17. Poggio PM, Incorvati C, Velo S, et al., 2006. “Safe zones”: a guide for MSI
positioning in the maxillary and mandibular arch. Angle Orthodontist, 76:191-197.
8. Holberg C, Winterhalder P, Holberg N, et al., 2014. Indirect MSI anchorage:
biomechanical loading of the dental anchorage during mandibular molar protraction— 18. Samrit V, Kharbanda OP, Duggal R, et al., 2012. Bone density and MSI stability
an FEM analysis. Journal of Orofacial Orthopedics, 75:16-24. in orthodontic patients. Australian Orthodontic Journal, 28:204-212.
9. Kanomi R, 1997. Mini-implant for orthodontic anchorage. Journal of Clinical 19. Upadhyay M, Yadav S, Nagaraj K, et al., 2008. Treatment effects of mini implants
Orthodontics, 31:763-767. for en masse retraction of anterior teeth in bialveolar dental protrusion patients: a
randomized controlled trial. American Journal of Orthodontics and Dentofacial
10. Kharbanda OP, Samrit V and Hari P, 2013. Temporary anchorage devices. In:
Orthopedics,134:18– 29.
Kharbanda OP, ed. Orthodontics. Diagnosis and management of malocclusion and
dentofacial deformities. Elsevier, New Delhi, India. 20. Wehrbein H, Glatzmaier J, Mundwiller U, et al., 1996. The Orthosystem—a new
implant system for orthodontic anchorage in the palate. Journal of Orofacial Orthopedics,
11. Linkow LI, 1969. The endosseous blade implant and its use in orthodontics.
57:142-153.
International Journal of Orthodontics, 7:149-154.
21. Xu Y, and Xie J, 2016. Comparison of the effects of mini implant and traditional
12. Miyawaki S, Koyama I, Inoue M, et al., 2003. Factors associated with the stability
anchorage on patients with maxillary dentoalveolar protrusion: A systematic review.
of titanium screws placed in the posterior region for orthodontic anchorage. American
Angle Orthodontist, Sep 29. [Epub ahead of print]
Journal of Orthodontics and Dentofacial Orthopedics, 124:373–378.