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Original Article 1

Miniscrew implants: AIIMS protocol and contemporary


clinical and research studies
Om Prakash Kharbandaa, Vilas D. Samritb

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.

Pre TAD Era


A variety of miniscrew implants in combinations of varying
Very early in the history of fixed orthodontic treatment, length, diameter, and shapes have been designed. More so, these are
orthodontists realized the limitations of using teeth as anchorage commercially available for use by the orthodontists.
and felt the need of stable anchorage system. Efforts for stable Mini implants or miniscrew implants referred as MSIs are different
anchorage were made as early as in 1945, when Gainsforth and from dental implants. They are relatively smaller in size so don’t impose
Highley (1945) used 13 mm long vitallium screw in dogs to move limitations for use in dentate areas. Also they are not meant to remain
the teeth. Though unsuccessful, his efforts led to interest in further for longer period in oral cavity, they are smooth surfaced. The surface
research with implant anchorage. Soon after the introduction of of dental implant is roughened and chemically treated to facilitate
concept of osseointegration by Branemark and his coworkers, osseointegration whereas the MSIs are mechanically retained.
Linkow (1969) used a blade implant in the mandibular 1st molar
region as a partial abutment for a bridge that was restored before Genuine anchorage control benefits
orthodontics and subsequently used for application of class II
elastics to facilitate tooth movement. The MSIs have found multiple clinical applications in orthodontic
The first successful orthodontic treatment with practice. They have been successfully used as stable anchorage for
osseointegrated implant was documented by Creekmore and Eklund complex tooth movements including enmass retraction of anterior
(1983) who used vitallium bone screw in anterior nasal spine to teeth, enmass distalization of maxillary arch and mandibular molar
intrude the upper incisors. But, due to lack of acceptance of surgical protraction. For successful treatment, MSIs must have primary
procedures and fear of complications using implantable materials, stability and be able to withstand orthodontic force levels. The overall
traditional anchoage systems continued to be the main treatment success rate of MSIs has been reported to be 86.5%. (Xu and Xie,
modality. 2016) It is proved that MSIs remain clinically stable under orthodontic
However, in1990s, protocols were developed for simultaneous loading, (Upadhyay et al., 2008; Al-Sibaie and Hajeer, 2014; Monga et
use of implant for restorative as well as orthodontic purpose. The al., 2016) with some histologic osseointegration ranging from 10-58%.
need for orthodontic treatment requiring minimal patient compliance (Cornelis et al, 2007)
has encouraged research into the use of implants as tools to
Development of AIIMS MSI protocol for treatment of bimaxillary
reinforce anchorage. Block and Hoffman (1995) discussed the use
protrusion/ Class II div 1 cases
of onplant coated on one side with hydroxyapatite that was placed
against palatal bone and used for anchorage. Wehrbein et al. (1996) AIIMS MSI protocol (fig. 1) is based on the extensive clinical
developed the palatal implant called Straumann Orthosystem which experience and research work conducted at Department of
was specifically designed for orthodontic anchorage. Orthodontics and Dentofacial Deformities, Centre for Dental Education
TAD Era: Concept of mechanical stability and direct loading
and Research, All India Institute of Medical Sciences (AIIMS), New
Delhi. Before choosing the patient for treatment with MSI implant,
Implants gained widespread attention and acceptance after strict case selection criteria is used (Table 1).
Kanomi (1997) reported use of smaller implant called mini implant
for orthodontic anchorage. He implanted mini-bone screw of 1.2
mm diameter and 6 mm length in the alveolar bone between root
apices of mandibular incisors and reported intrusion of mandibular
incisors by 6 mm in 4 months. But still there was apprehension
regarding its stability and true usefulness. His case paved the way
to clinical and laboratory researches in last two decades and has
evolved successful use of miniscrew implants which have been
advocated for use as absolute anchorage savers in the treatment
of various malocclusions.
a
Department of Orthodontics and Dentofacial Deformities Centre for Dental Education
and Research All India Institute of Medical Sciences, New Delhi-29.
b
Department of Orthodontics and Dentofacial Deformities Centre for Dental Education
and Research All India Institute of Medical Sciences, New Delhi-29.
Om Prakash Kharbanda et al 2

Fig 1. A schematic diagram of AIIMS protocol for MSI anchorage

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

November 2016 Vol 1 Issue 1 Journal of Contemporary Orthodontics


Om Prakash Kharbanda et al 3

Fig 2. Steps in fabrication of AIIMS Universal Connector


A. MSI inserted into the buccal interradicular bone between second premolar and first molar
B. 0.017"x 0.025" stainless steel wire is bent gingivally immediately mesial to the molar auxiliary tube so that the free end passes
distal to MSI head touching it
C. A point is marked on the wire at the level of the MSI slot
D. A bend is given in the wire at the marked point so that now the wire is paralled to the MSI slot
E, F. Now the torque in the horizontal segments of the wire is so adjusted that the wire framework can be passively seated in position

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
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November 2016 Vol 1 Issue 1 Journal of Contemporary Orthodontics

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