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Mini-implants in orthodontics: A systematic review of the literature

Reint Reynders,a Laura Ronchi,a and Shandra Bipatb Milan, Italy, and Amsterdam, The Netherlands Introduction: In this article, we systematically reviewed the literature to quantify success and complications encountered with the use of mini-implants for orthodontic anchorage, and to analyze factors associated with success or failure. Methods: Computerized and manual searches were conducted up to March 31, 2008, for clinical studies that addressed these objectives. The selection criteria required that these studies (1) reported the success rates of mini-implants on samples sizes of 10 implants or more, (2) gave a denition of success, (3) used implants with a diameter smaller than 2.5 mm, and (4) applied forces for a minimum duration of 3 months. Factors associated with implant success were accepted only if potentially inuencing variables were controlled. The Cochrane Handbook for Systematic Reviews of Interventions was used as the guideline for this article. Results: Nineteen reports met the inclusion criteria, but denitions of success, duration of force application, and quality of the methodology of these studies varied widely. Rates of primary outcomes ranged from 0% to 100%, but most articles reported success rates greater than 80% if mobile and displaced implants were included as successful. Adverse effects of miniscrews included biologic damage, inammation, and pain and discomfort. Only a few articles reported negative outcomes. All proposed correlations between clinical success and specic variables such as implant, patient, location, surgery, orthodontic, and implant-maintenance factors were rejected because they did not meet the selection criteria for controlling those variables. Conclusions: Mini-implants can be used as temporary anchorage devices, but research in this eld is still in its infancy. Interpretation of ndings was conditioned by lack of clarity and poor methodology of most studies. Questions concerning patient acceptability, rate and severity of adverse effects of miniscrews, and variables that inuenced success remain unanswered. This article includes a guideline for future studies of these issues, based on specic denitions of primary and secondary outcomes correlated with specic operational variables. (Am J Orthod Dentofacial Orthop 2009;135:564.e1-564.e19)

sseointegrated implants are considered reliable sources of anchorage for orthodontists.1-6 However, the large size of these implants limits their usage. To overcome this problem, mini-implants were developed.7-13 Their advantages, in addition to size, include minimal anatomic limitations, minor surgery, increased patient comfort, immediate loading, and lower costs.11-15 Because these devices are used for specic time periods, mostly rely on mechanical retention, and do not always osseointegrate, other terms such as miniscrews, miniscrew implants, microscrews, and temporary anchorage devices have been used.16,17 There is no general
a

Private practice, Milan, Italy. Research associate, Departments of Radiology, Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Reint Reynders, Via Matteo Bandello 15, 20123, Milan, Italy; e-mail, ortodonzia@fastwebnet.it. Submitted, April 2008; revised and accepted, September 2008. 0889-5406/$36.00 Copyright 2009 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2008.09.026

agreement on the nomenclature.18,19 We used the term mini-implant in the title, because it is currently the most frequently used in the orthodontic literature. Many mini-implants are now available, and orthodontists are trying to incorporate them in various clinical situations. However, with the introduction of new techniques, questions normally arise. Clinicians desire information on actual success rates and possible adverse effects of mini-implants for orthodontic anchorage. They also want to identify variables that could inuence success. Although numerous articles on these topics are available, confusion arises from differences in their ndings.20-26 Furthermore, the currently available reviews on mini-implants either were not systematic or asked different clinical questions.16,17,27-34 Thus, a systematic review of the literature was deemed appropriate. The Cochrane Handbook for Systematic Reviews of Interventions, the CONSORT guidelines, and the QUOROM statement were used as the framework for this article. 35,36 The purposes of this review were to record the actual successes and possible negative effects of mini-implant placement, and to analyze which variables inuence success.
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CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW

Two categories of selection criteria were established. General measures were applied to nd studies on mini-implants and specic selection criteria to improve the quality of the articles. General selection criteria included (1) studies that analyzed the success of mini-implants for orthodontic anchorage; (2) only human clinical studies with a minimum sample size of 10 miniscrews, with technique articles, case reports, opinion articles, reviews, and laboratory, animal, and in-vitro studies excluded; (3) implants with a diameter less than 2.5 mm, because larger implants would not be used for specic orthodontic indications (eg, interradicular positioning); and (4) no articles on miniplates, because of their different biomechanical characteristics. Specic selection criteria for studies on mini-implants included (1) only studies that dened success; (2) only studies that dened the duration of the application of force; (3) no studies that measured implant success at less than 120 days of force application,37 arbitrarily chosen because most orthodontic objectives cannot be completed in less than 3 months; and (4) studies that measured success either at a predetermined treatment time or at the completion of orthodontic anchorage objectives. Patients of both sexes without age restrictions and with a need of absolute anchorage for orthodontic purposes were included. The outcomes were divided into primary and secondary measures. Primary outcomes were the success or failure of mini-implants as anchorage devices during orthodontic tooth movement. Secondary outcomes were possible complications of this treatment. Immobility, mobility, displacement, and failure were used as parameters to classify primary outcomes. These measures were examined from the start of the application of orthodontic forces to 120 days or more37 and were scored as follows.  Success without mobility (score 0): implants with no clinically detectable mobility that could fulll all necessary orthodontic anchorage objectives.  Success with mobility (score 1): implants that had become mobile but could still fulll all necessary orthodontic anchorage objectives.  Success with displacement (score 2): implants that had become displaced but could still fulll all necessary orthodontic anchorage objectives.  Failure (score 3): implants that were lost or had become unusable, including those that had become inoperative because of excessive tissue proliferation

that could not be reversed by simple excision; implants that had caused irreversible biologic damage; implants that could not be used because of the risk of causing irreversible biologic damage; and implants that fractured at placement, during orthodontic treatment, or at the removal of the screw.  Not specied success (score NSS): the type of success of implants was not specied and included scores 0, 1, and 2. Secondary outcomes were divided into 3 categories: biologic damage, inammation, and pain and discomfort measures. Biologic damage was analyzed from the day of implant placement until removal. Biologic damage that occurred or was detected after removal of the implant was classied under a separate heading.  No biologic damage (score 0): no biologic damage and no correcting dental procedures were necessary.  Reversible biologic damage (score 1): biologic damage that is completely reversible with simple dental procedures, including removal of hyperplastic tissue and fractured mini-implants that could be removed without causing irreversible damage.  Irreversible biologic damage (score 2): biologic damage that is not completely reversible with simple dental procedures, including tooth, nerve, sinus, and blood vessel damage; fractured mini-implants that could not be removed; and need for orthognathic surgery caused by uncontrolled biomechanics with mini-implants.  Not specied biologic damage (score NSBD): biologic damage was described, but the type was not identied.  Postimplant biologic damage (score PIBD): biologic damage caused by treatment with mini-implants, but it occurred or was found after removal of the screw. Inammation was measured either within the rst month of implant placement or beyond this time limit.  No inammation (score 0): No signs of inammation during the entire period of treatment with mini-implants.  Temporary inammation (score 1): inammation conned to the rst month.  Continuing inammation (score 2): inammation lasted longer than the rst month.  Not specied inammation (score NSI): its duration was not specied. Pain and discomfort were measured during the rst 2 weeks after placement or beyond.38

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 No pain or discomfort (score 0): no pain or discomfort during the entire treatment period with mini-implants.  Moderate pain or discomfort (score 1): moderate pain or discomfort in the rst 2 weeks.  Severe pain or discomfort (score 2): Severe pain or discomfort in the rst 2 weeks.  Continuing pain or discomfort (score 3): pain lasting longer than 2 weeks.  Not specied pain (score NSP): pain and discomfort were described, but quality or duration were not specied.
SELECTION CRITERIA FOR VARIABLES INFLUENCING SUCCESS OF MINI-IMPLANTS

In addition, references from each identied article were manually screened for articles that were missed by the electronic search engines. Finally, all manual and electronic searches were solicited for review articles.35 References in the review articles were also screened for pertinent studies. This analysis provided a list of studies on mini-implants with their success rates.
METHODS OF THE REVIEW

The second part of this review addressed variables that might inuence the success rates of mini-implants. These variables were classied under the following 6 headings: implant, patient, location, surgery, orthodontics, and implant-maintenance factors. A correlation between mini-implant success and these parameters was tested according to the following criteria: (1) a proposed association with success was rejected only when the article presented direct proof that at least 1 inuencing variable was not controlled; lack of information about the control of those factors was insufcient to reject a correlation; and (2) only factors that had been tested for statistical signicance were included in the analysis of variables. The following electronic data bases were searched through March 31, 2008: Google Scholar Beta, PubMed, Medline, Embase, Science Direct, all 7 Evidence Based Medicine Reviews (EBMR), Web of Science, Ovid, and Bandolier. Librarians specializing in computerized searches of the health sciences at the American Dental Association assisted us. The main subject heading orthodontics was combined with these keywords: implant, screw, mini-implant, miniscrew, microimplant, screw implant, and temporary anchorage device. For each search engine, the appropriate characters were used to truncate or explore search terms. To avoid inappropriate exclusion, noun, adjective, singular, and plural forms of all keywords were used (Appendix Table I). Literature in English, French, German, and Italian was considered. To determine whether the keywords had covered all articles on mini-implants, the following journals were manually screened: The American Journal of Orthodontics & Dentofacial Orthopedics, The Angle Orthodontist, The European Journal of Orthodontics, The Journal of Orthodontics, The Journal of Clinical Orthodontics, Seminars in Orthodontics, and The International Journal of Adult Orthodontics and Orthognathic Surgery.

All abstracts were read, and the full texts of all relevant articles were collected and reviewed. Ambiguous articles were also read to avoid inappropriate exclusion. All procedures were performed independently by 2 authors (R.R. and L.R.). Differences were resolved by rereading and discussion until consensus was reached.18,35 Studies were also assessed for eligibility and methodologic quality without considering the outcomes. For each study, a value was given based on the quality of the following 4 criteria: denition of success, design of the study, description of the methodology, and control of variables. A clear description of each criteria accounted for 1 point. Studies were then classied as clear (3 or 4 points), partially clear (2 points), or unclear (0 or 1 point). Assessment of study validity was not used as a threshold for inclusion but only as a possible explanation for differences in results between studies.35 A decision to perform a meta-analysis was made if there were sufcient similarities between studies in the types of participants, interventions, and outcomes. Although several studies used the same implant system, the signicant heterogeneity within and between studies did not allow for pooling of data and carrying out a meta-analysis.35 The selection procedures are explained in a ow diagram (Fig).36 A total of 3364 abstracts without overlap were found by the search methods and are described in Appendix Table II. Only 52 abstracts met the inclusion criteria or were retrieved because the abstract did not provide enough information to justify exclusion (Fig). Twenty-one articles were excluded according to the general selection criteria, and the specic selection criteria eliminated another 12, leaving 19 studies. The explanations for excluding these articles are given in Appendix Tables III and IV. The assessment of the quality of the 19 studies is given in Table I. Five studies were rated as clear,14,21,22,39,40 8 as partially clear,23,25,37,41-45 and 6 as unclear.12,24,26,38,46,47 No article was a randomized clinical trial. Another systematic review also did not nd any randomized clinical trials about miniimplants in the literature.29

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Abstracts retrieved from all search methods N = 3364

Table I.

Characteristics of included studies

Year of publication 2001 2003 2004 2006 2006 2006 2006 2006 2006 2007 2007 2007 2007 2007 2007 2007 2008 2008 2008 Assessment Number Design of of of validity implants study A C A A B C B C C B B B A C B B B A C 12 134 32 124 18 227 45 59 239 140 133 216 169 116 87 27 32 480 16 P R P P P R R R ND P P R P R R P P R ND

Authors

Excluded abstracts N= 3312 Reason: *

Articles retrieved for more detailed analyses N= 52

Excluded articles N = 21 Reason: *

Articles retrieved for more detailed analyses N = 31

Freudenthaler et al14 Miyawaki et al12 Liou et al21 Motoyoshi et al22 Thiruvenkatachari et al23 Park et al24 Tseng et al25 Chen et al26 Berens et al46 Luzi et al37 Wiechmann et al41 Kuroda et al42 Motoyoshi et al39 Kuroda et al38 Motoyoshi et al43 Hedayati et al44 Chaddad et al45 Moon et al40 Kinzinger et al47

Excluded articles N= 12 Reason: **

Assessment of validity: A, clear; B, partially clear; C, unclear. Design of study: P, prospective; R, retrospective; ND, not described.

Included articles: N=19

* General selection criteria ** Specific selection criteria

Fig. QUOROM ow diagram.

RESULTS

Primary outcomes, dening success and failure of mini-implants, are presented in Table II. The denitions of success varied in the studies. Five articles did not specify the type of primary outcomes.12,14,22,38,42 They gave general descriptions of success without specifying the nature of the stability of the implants. Seven articles considered only immobile screws successful,23,26,39-41,43,45 and 5 accepted mobility.24,25,37,44,46 Displacements of mini-implants were assessed in 3 articles.21,44,47 Most studies found success rates greater than 80% if usable mobile and displaced implants were included as successful. Primary outcomes varied from 0% to 100%. One article compared 2 protocols but did not dene success in the second protocol.46 Another article gave a success rate of 86.8%, but our calculations added up to only

76.7%.41 The time of assessment of success varied widely (Table II). Six studies analyzed primary outcomes at specic time periods: 150 days,45 180 days,41 6 months,22,39 8 months,40 and 9 months.21 In the other studies, success was measured at the completion of the anchorage objectives, varying from 3 to 37 months. Among the secondary outcomes, biologic damage was described in 5 of the 19 articles (Table II).14,24,26,41,46 Three studies found no biologic damage,14,41,46 and Park et al24 recorded 8 broken screws, with 3 fractured during placement and 5 during removal. Two of 59 screws broke during placement in another study.26 In both studies, no information was provided about the outcome of the removal of the fractured implants. Biologic damage that was caused by treatment with mini-implants but occurred after screw removal was not assessed in any study. Inammation was evaluated in 6 studies and varied from 0% to 34% (Table II).12,14,23-25,45 Temporary inammation of peri-implant soft tissues was described in 4 articles.12,14,23,45 Freudenthaler et al14 and Thiruvenkatachari et al23 reported that inammation was controlled by improving oral hygiene. However, Tseng et al25 recorded continuing inammation in 2 of 45 implants. It failed to subside, and the implants were lost or had to be removed. A similar outcome was described in 4 of 32 patients in another study.45 Park et al24 found inammation in 34% of the implants but did not specify its severity or duration. To control peri-implantitis,

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Table II.

Analysis of outcomes of studies on mini-implants

Time of success measurement ARTT Average: 11 months Range: 7-20 months 1 year or ARTT 9 months 6 months ARTT 3.5-5.5 months ARTT Mean: 15 months SD: 6.16 months ARTT Average: 16 months ARTT Mean: 19.5 months ARTT Average: 235 days Maximum: 733 days Success rate 75% (NSS) Rate of biologic damage 0% (NSBD) Rate of inammation 25% (score 1) Rate of pain and discomfort 37.5% (score 1)

Authors Freudenthaler et al14

Miyawaki et al12 Liou et al21 Motoyoshi et al22 Thiruvenkatachari et al23 Park et al24

76.1% (NSS) Range: 0%-85% 56.25% (score 0) 43.75% (score 2) 85.5% (NSS) 100% (score 0)

ND ND ND ND

8.9% (score 1) ND ND 10% (score 1)

15.9% (score 1) ND ND ND

91.6% (scores 0 and 1) Range: 80%-93.6% 91.1% (scores 0 and 1) Range: 80%-100% 84.7% (score 0) Range: 72.2%-90.2% Protocol 1: 68.4% (score 0) 8.3% (score 1) 23.3% (score 3) Protocol 2: 4.7% (score 3) 84.3% (score 0) 6.4% (score 1) 76.7% (score 0) Range: 69.6%-87% 86.4% (NSS) Range: 35.3%-100% 85.2% (score 0) Range: 63.8%-97.3% 86.2% (NSS) Range: 81.1%-88.6%

3.5% (NSBD)

34% (NSI)

ND

Tseng et al25 Chen et al26 Berens et al46

ND 3.4% (NSBD) 0% (NSBD)

4.4% (score 2) ND ND

ND ND ND

Luzi et al37

Wiechmann et al41 Kuroda et al42 Motoyoshi et al39 Kuroda et al38

ARTT Minimum:120 days Maximum: 37 months 180 days 1 year or ARTT 6 months 1 year or ARTT

ND

ND

ND

0% (score 2) ND ND ND

ND ND ND ND

ND ND ND Flap group: 95%-10% (scores 1 and 2) Flapless group: 50%-0% (score 1) ND ND

Motoyoshi et al43 Hedayati et al44

ARTT 6 months or more ARTT Average: 5.4 months Range: 4-6.5 months 150 days 8 months ARTT 6.5 months

87.4 (score 0) 81.5%(scores 0, 1, and 2)

ND ND

ND ND

Chaddad et al45 Moon et al40 Kinzinger et al47

87.5% (score 0) Range: 82.5%-93.5% 83.8 (score 0) 100% (score 2)

ND ND ND

6.25% (score 1) 6.25% (score 2) ND ND

80% (score 0) 20% (score 1) ND ND

ND, Not described; ARTT, anchorage for required treatment time. Success scores: 0, success without mobility; 1, success with mobility; 2, success with displacement; 3, failure; NSS, unspecied success (includes scores 0-2). Biologic damage scores: 0, no damage; 1, reversible damage; 2, irreversible damage; NSBD, unspecied damage (includes scores 1 and 2). Inammation scores: 0, no inammation; 1, temporary inammation; 2, continuing inammation; NSI, unspecied inammation. Pain and discomfort scores: 0, no pain and discomfort; 1, moderate pain and discomfort; 2, severe pain and discomfort; 3, continuing pain and discomfort; NSP, unspecied pain and discomfort (includes scores 1-3).

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Table III.

Variables associated with success rates in studies on mini-implants

Studies proposing association with success Miyawaki,12 Park,24 Kuroda,42 Kuroda,38 Chaddad45 Miyawaki,12 Wiechmann41 Miyawaki,12 Wiechmann41 Miyawaki,12 Park,24 Wiechmann,41 Kuroda38 Chen,26 Tseng25 Motoyoshi,22 Park,24 Kuroda,38 Motoyoshi,43 Moon40 Miyawaki,12 Motoyoshi,22 Park,24 Kuroda,38 Moon40 Motoyoshi39 VNA Kuroda38 Miyawaki12 Miyawaki,12 Kuroda38 Miyawaki12 Miyawaki,12 Kuroda38 Motoyoshi43 Motoyoshi43 Chaddad45 Park24 Miyawaki,12 Motoyoshi,22 Motoyoshi,39 Chaddad,45 Motoyoshi,43 Moon40 Park,24 Wiechmann,41 Kuroda42 Wiechmann41 Moon40 Studies rejected and reasons for rejection Miyawaki12 (a-e), Park24 (a-e), Kuroda42 (a-e), Kuroda38 (a-e), Chaddad45 (a-e) Miyawaki12 (a-e), Wiechmann41 (a-e) Miyawaki12 (a-e), Wiechmann41 (a-c,e) Miyawaki12 (a-e), Park24 (a-e), Wiechmann41 (a-c,e), Kuroda38 (a-e) Chen26 (b,c,e), Tseng25 (b,c,e) Motoyoshi22 (b-d), Park24 (a-e), Kuroda38 (a-e), Motoyoshi43 (b-d), Moon40 (c-e) Miyawaki12 (a,c-e), Motoyoshi22 (c,d), Park24 (a,c-e), Kuroda38 (a,c-e), Moon40 (c-e) Motoyoshi39 (c,d) Kuroda38 (a-e) Miyawaki12 (a-e) Miyawaki12 (a-e), Kuroda38 (a-e) Miyawaki12 (a-e) Miyawaki12 (a-e), Kuroda38 (a-e) Motoyoshi43 (b,d) Motoyoshi43 (b,d) Chaddad45 (a-e) Park24 (a-e) Miyawaki12 (a-e), Motoyoshi22 (b-d), Motoyoshi39 (c,d), Chaddad45 (a-e), Motoyoshi43 (b-d), Moon40 (c-e) Park24 (a-e), Wiechmann41 (a-c,e), Kuroda42 (a-e) Wiechmann41 (a-c,e) Moon40 (d,e)

Association with success suggested Implant-related factors Type: no Type: yes Diameter: yes Length: no Length: yes Patient-related factors Sex: no Age: no Age: yes Physical status Mandibular plane angle: no Mandibular plane angle: yes Temporomandibular symptoms: no Crowding: no Anteroposterior jaw relationship: no Location-related factors Peri-implant bone quantity: no Cortical bone thickness: yes Keratinized vs oral mucosa: no Exposed vs closed mucosa: yes Same success maxilla and mandible Mandible more failures than maxilla Lower success lingual mandible Molar area lower success than premolar area in mandible Molar area same success as premolar area in maxilla Left side higher success than right side No difference between left and right sides Root proximity: yes Surgery-related factors Flapless/ap surgery: no Direction of placement: no Placement torque: yes Self-drilling vs self-tapping technique Different surgeons

Moon40

Moon40 (d,e)

Park24

Park24 (a-e)

Motoyoshi,22 Motoyoshi,43 Moon40 Kuroda42 Miyawaki,12 Moon40 Park24 Motoyoshi,22 Motoyoshi,39 Chaddad,45 Motoyoshi43 VNA VNA

Motoyoshi22 (b-d), Motoyoshi43 (b-d), Moon40 (c-e) Kuroda42 (a-e) Miyawaki12 (a-c,e), Moon40 (c,e) Park24 (a-c,e) Motoyoshi22 (b,c), Motoyoshi39 (c), Chaddad45 (a-c,e), Motoyoshi43 (b,c)

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Table III.

Continued
Studies proposing association with success Kuroda38 Miyawaki12 Motoyoshi39 VNA Park24 Kuroda38 VNA VNA VNA Park24 Miyawaki,12 Park24 Park24 70 Studies rejected and reasons for rejection Kuroda38 (a-e) Miyawaki12 (a-e) Motoyoshi39 (c,d)

Association with success suggested Orthodontic-related factors Magnitude of force: no Timing of force application: no Timing of force application: yes Duration of force Type of force: no Type of orthodontic movement: yes Direction of force Implant-maintenance factors Antibiotics prescription Chlorhexidine prescription Oral hygiene: no Control of peri-implant inammation: yes Control of mobility: yes Total

Park24 (a-e) Kuroda38 (a-e)

Park24 (a-e) Miyawaki12 (a-e), Park24 (a-e) Park24 (a-e) 70

Reasons for rejection: a, implant-related factors were not controlled; b, patient-related factors were not controlled; c, location-related factors were not controlled; d, surgery-related factors were not controlled; e, orthodontics-related factors were not controlled; f, implant maintenance-related factors were not controlled. VNA, Variable was not analyzed.

these authors recommended placing implants in the keratinized gingiva or to cover the screws by soft tissue, and to improve oral hygiene. Pain and discomfort were recorded in 4 of the 19 studies (Table II).12,14,38,45 Freudenthaler et al14 reported minor pain after placement that lasted only 1 day in 3 of 8 patients. Similar ndings were reported by Chaddad et al45 in 2 of 10 patients. Kuroda et al38 analyzed both the quality and the duration of pain during the rst 2 weeks after placement. One hour after implantation, 95% of the patients who had screws placed after raising a mucoperiosteal ap reported pain, compared with 50% of those who had undergone a apless approach. After 2 weeks, the values were 10% and 0% for the respective techniques. Patients in the ap group described signicantly more intense pain and for a longer period than those in the apless group. A similar nding was recorded by Miyawaki et al12 in 7 of 44 patients within a week after implant placement. Variables proposed as having possible associations with success are given in Table III. The studies presented 70 correlations between at least 1 variable and clinical success; many were contrary associations. All were rejected because parameters selected as independent variables were not controlled and therefore did not meet the inclusion criteria. Explanations for rejec-

tion are listed in Table III and can be veried in Tables IV to IX.
DISCUSSION

Nineteen studies were selected from computerized and manual searches through March 31, 2008, to provide data regarding the success of mini-implants. Case reports and technique articles describing the special merits of a specic miniscrew were those most often excluded by the general selection criteria. Twelve studies were excluded because of imprecise methodology. Randomized clinical trials were not available, and the quality of most included studies was low (Table I). These ndings were surprising, considering the wide interest in the clinical applications of mini-implants as orthodontic anchorage devices. An analysis of the impact of the quality of the various studies was superuous because all correlations between proposed variables and success were rejected by the inclusion criteria, and outcomes from both high- and low-quality articles were similar (Tables II and III). For the primary outcomes, most studies found success rates greater than 80%, with a range of 0% to100%. Five factors are possible explanations for this variation. First, the studies used a wide range of denitions for primary outcomes. Success was analyzed with various benchmarks including with or without mobility,

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Table IV.

Implant-related factors in studies on mini-implants

Number of implants
14

Authors Freudenthaler et al Miyawaki et al12 Miyawaki et al12 Miyawaki et al12 Liou et al21 Motoyoshi et al22 Thiruvenkatachari et al23 Park et al24 Park et al24 Park et al24 Tseng et al25 Tseng et al25 Tseng et al25 Chen et al26 Chen et al26 Berens et al,46 protocol 1 Berens et al,46 protocol 2 Luzi et al37 Wiechmann et al41 Wiechmann et al41 Kuroda et al42 Kuroda et al42 Motoyoshi et al,39 early load adolescent group Motoyoshi et al,39 late load adolescent group Motoyoshi et al,39 early load adult group Kuroda et al38 Kuroda et al38 Motoyoshi et al43 Hedayati et al44

Implant type Leibinger Photo but not described Photo but not described Photo but not described Leibinger Biodent Not described Leibinger Osteomed Absoanchor Leibinger Leibinger Leibinger Abosanchor Absoanchor Absoanchor Dual Top Absoanchor Dual Top Aarhus Absoanchor Dual Top Absoanchor Martin Biodent Biodent Biodent Keisei Absoanchor Biodent O&M Medical

Diameter (D) and length (L) D 2 mm L 13 mm D 1.0 mm L 6 mm D 1.5 mm L 11 mm D 2.3 mm L 14 mm D 2 mm L 17 mm D 1.6 mm L 8 mm D 1.3 mm L 9 mm D 1.2 mm L 5 mm D 1.2 mm L 6, 8,10 mm D 1.2 mm L 4, 6, 7, 8, 10 mm D 2 mm L 8 mm D 2 mm L 10 mm D 2 mm L 12 mm D 1.2 mm L 6 mm D 1.2 mm L 8 mm D 1.3-2 mm L not described D 1.3-2 mm L not described D 1.5, 2 mm L 9.6, 11.6 mm D 1.1 mm L 5, 6, 7, 8, 10 mm D 1.6 mm L 5, 6, 7, 8, 10 mm D 1.3 mm L 6, 7, 8, 10, 12 mm D 1.5 mm L 9 mm D 1.6 mm L 8 mm D 1.6 mm L 8 mm D 1.6 mm L 8 mm D 2.0, 2.3 mm L 7, 11 mm D 1.3 mm L 6, 7, 8, 10, 12 mm D 1.6 mm L 8 mm D 2.0 mm L 9, 11 mm 75% 0% 83.9% 85% 100% 85.5% 100% 84.2% 93.6% 89.1% 80% 90% 100% 72.2% 90.2% 76.7% 95.3% 90.7% 69.6% 87%

Success rate*

12 10 101 23 32 124 18 19 157 46 15 10 12 18 41 133 106 140 79 54 195 21 47 36 86 37 79 87 27

Maxilla, 77.1%-95.8% Mandible, 35.3%-83.9% Maxilla 50%-100% 63.8% 97.2% 91.9% 81.1% 88.6% 87.4% 81.5%

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Table IV.

Continued
Number of implants
45

Authors Chaddad et al

Implant type Dual Top C-Implant Dual Top T.I.T.A.N. Pin-System Dual Top

Diameter (D) and length (L) D 1.4, 1.6, 2.0 mm L 6, 8, 10 mm D 1.8 mm L 8.5 mm D 1.6 mm L 8 mm D 1.6 mm L 8-9 mm 82.5% 93.5% 83.8% 100%

Success rate*

17 15 480 16

Chaddad et al45 Moon et al40 Kinzinger et al47

*Denition of success as established by the authors of the respective studies.

with or without displacement, or not specied (Table II). Second, the timing of assessment of the primary outcomes differred among the studiesfrom 3 to 27 months after the application of orthodontic forces. An implant lost after 4 months could then be dened either as a failure or a success depending on the time of its assessment. Some articles measured primary outcomes from the day of placement, not from the start of applied orthodontic forces.23,26 Third, the interpretation of primary outcomes was hampered by differences in study design and methodology. Fourth, variables were frequently not controlled and could have easily skewed the ndings. Fifth, removal and replacement of implants in the same patient could have introduced underreporting. Secondary outcomes caused by the placement of miniscrews were only sporadically mentioned in the studies (Table II). Studies showing an intervention to be effective are more likely to be published and may result in overestimate of effectiveness due to publication bias.35,48-50 Various forms of biologic damage have been presented in the orthodontic literature including: root trauma, soft-tissue irritation, nerve injury, trauma to blood vessels, and sinus perforation.13,21,25,27,51 Furthermore, mini-implants have been proposed as an alternative for certain orthognathic surgical procedures, but could also be its cause when uncontrolled biomechanics are applied. Displacements of apparently stable mini-implants were recorded in 3 studies,21,44,47 and this nding was conrmed in the literature.52 To avoid trauma to adjacent structures, a safety clearance of 2 mm was recommended in interdental areas.21,52 However, root damage caused by screws was shown to heal in animal studies53,54 and in a report of 2 patients.55 Daimaruya et al56 reported no harm to the nerve after intrusion of molars into the neurovascular bundle of dogs. Information on damage caused by miniscrews should be collected up to a year after their removal, because consequences of fractured implants, and root, nerve,

and other forms of trauma, can appear later. Longterm screening was not part of the protocol in any of the 19 studies. Information about the character and the duration of inammation of the peri-implant tissues was rarely given; these parameters require further investigation. Similar conclusions can be drawn with regard to pain and discomfort. The assessment of variables inuencing the success of mini-implants was complicated because of the small number of failures, the lack of clarity of the selected studies, the wide variety in designs, and the many variables involved. Tables IV through IX show the many uncontrolled variables. Rejection measures were relatively lenient, because proposed associations were rejected only when the article presented direct proof that a potential inuencing factor was not controlled. Elimination of correlations would have been instant if not describing controllable variables had been an exclusion criterion. Notwithstanding these tolerant measures, all proposed associations were rejected (Table III). The large number of contrary correlations were probably the testimony of the poor control of variables. The proposed associations should therefore be interpreted as strictly hypothetical variables that could inuence success; they are discussed below. To facilitate this discussion, these variables were divided into 6 categories: implant, patient, location, surgery, orthodontic, and implant-maintenance factors. Implant-related factors are summarized in Table IV. Implants are made of various materials and differ in design and surface treatment. Implant types varied between and within the 19 studies (Table III) or were not specied.12,23,46 Eight studies did not control for implant type, diameter, and or length when comparing outcomes.12,24,38,41,42,45-47 Both conrming and refuting associations were found between implant type and primary outcomes (Table IV). However, the

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Table V. Authors

Patient-related factors in studies on mini-implants

Sex and number of implants 4 females: NIND 4 males: NIND 42 females: NIND 9 males: NIND 16 females: 32 implants 37 females: 114 implants 4 males:10 implants 7 females: 12 implants 3 males: 6 implants 52 females: 138 implants 35 males: 89 implants 14 females: NIND 11 males: NIND 20 females: NIND 9 males: NIND 61 females: NIND 24 males: NIND 60 females: NIND 38 males: NIND 36 females: NIND 13 males: NIND 92 females: NIND 18 males: NIND 24 females: NIND 6 males: NIND 24 females: NIND 3 males: NIND 63 females: NIND 12 males: NIND 28 females: 76 implants 4 males: 11 implants ND ND 131 females: 323 implants 78 males: 157 implants 6 females: 12 implants 2 males: 4 implants Age (y) 22.1 (mean) Range: 13-46 21.8 (mean) SD: 7.8 Range: 22-29 24.9 (average) SD: 6.5 Range: 13.3-42.8 19.6 (mean) Range: 16-21 15.5 (mean) SD: 8.3 29.9 (mean) Range: 22-44 29.8 (mean) Range: 19-57 28 (mean) Range: 31-51 34.3 (mean) Range: 13-64 26.9 (mean) SD: 8.9 Range: 13.5-46.2 22.5 (mean) SD: 8.1 15.9 (mean) SD: 1.9 Range: 11.7-18.9 26.2 (mean) SD: 5.6 Range: 20.4-36.1 21.8 (mean) SD: 8.2 24.4 (average) SD: 6.5 Range:14.6-42.8 17.4 (mean) Range 15.5-19 Range: 13-65 Young: 14.4 (mean) Range: 10-18 Adult: 26.2 (mean) Range: 19-64 12.2 (average) Physical status ND ND ND ND Dental status D D ND ND

Freudenthaler et al14 Miyawaki et al12 Liou et al21 Motoyoshi et al22

Thiruvenkatachari et al23 Park et al24 Tseng et al25 Chen et al26 Berens et al46 Luzi et al37 Wiechmann et al41

D ND ND ND ND ND ND

D ND ND ND ND D ND

Kuroda et al42 Motoyoshi et al,39 adolescent group

ND ND

ND ND

Motoyoshi et al,39 adult group

ND

ND

Kuroda et al38 Motoyoshi et al43

ND ND

ND D

Hedayati et al44 Chaddad et al45 Moon et al40

ND D ND

D ND ND

Kinzinger et al47

ND

ND

D, Described; ND, not described; NIND, number of implants by sex not described.

orthopedic literature as well as laboratory and animal studies have demonstrated the importance of the architecture of implants on success.57-60 Furthermore, the implant material has an impact on the placement technique. Compared with pure titanium, titanium alloys are stronger, and drilling a pilot hole is frequently unnecessary.28 Implant diameters ranged from 1.0 to 2.3 mm, with success rates varying from 0% to 100% (Table IV). All 10 mini-implants with a diameter of 1.0 mm were lost in 1 study, but variables were not sufciently controlled for

a correlation with failure.12 Studies on porcine iliac bone segments conrmed an association between implant diameter and success.61,62 Implants with a smaller diameter are easier to place between the roots, but a small decrease in this dimension signicantly increases the torsional strength and therefore the risk of fracture.7,26,63-65 It has been suggested that implants smaller than 1.3 mm should be avoided, especially in the thick cortical bone of the mandible.7,64 Fractures were also reported in 2 studies with implants of these dimensions.24,26

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Table VI.

Location-related factors in studies on mini-implants

Implant site Buccally in mandible Posterior buccal alveolar bone in maxilla and mandible Zygomatic buttresses of maxilla Posterior buccal alveolar bone in maxilla and mandible Buccal alveolar bone in maxilla and mandible Various locations in maxilla and mandible Various locations in maxilla and mandible Various locations in maxilla and mandible Various locations in maxilla and mandible Various locations in maxilla and mandible Various locations in maxilla and mandible Various locations in maxilla and mandible Posterior buccal alveolar bone in maxilla and mandible Various locations in maxilla and mandible Posterior buccal alveolar bone in maxilla and mandible Palate and posterior buccal alveolar bone in mandible Posterior buccal alveolar bone in maxilla and mandible Posterior buccal alveolar bone in maxilla and mandible Anterior palate Bone condition D D D ND ND D D ND ND D ND ND D D D ND ND D D Keratinized or nonkeratinized mucosa ND Keratinized Nonkeratinized ND ND Both ND ND Both Both Keratinized Keratinized Keratinized Both ND ND Both Keratinized Keratinized Exposed or closed ND ND Exposed ND ND Both ND ND ND Exposed ND ND ND Exposed ND ND ND ND Exposed

Authors Freudenthaler et al14 Miyawaki et al12 Liou et al21 Motoyoshi et al22 Thiruvenkatachari et al23 Park et al24 Tseng et al25 Chen et al26 Berens et al46 Luzi et al37 Wiechmann et al41 Kuroda et al42 Motoyoshi et al39 Kuroda et al38 Motoyoshi et al43 Hedayati et al44 Chaddad et al45 Moon et al40 Kinzinger et al47

D, Described; ND, not described.

Table VII. Authors

Surgery-related factors in studies on mini-implants

Flap or apless surgery
14

Placement technique ST and same-size pilot hole ND ST and smaller pilot hole ST and smaller pilot hole ND ST and smaller pilot hole SD and smaller pilot hole in cortex SD and smaller pilot hole in cortex SD and smaller pilot hole in cortex SD and no pilot hole SD and smaller pilot hole in cortex ST and smaller pilot hole ST and smaller pilot hole ST and smaller pilot hole ST and smaller pilot hole ST and same-size pilot hole SD and pilot hole in cortex only (size ND) SD and no pilot hole SD and ST, no pilot hole

Direction of placement Perpendicular to bone ND ND ND ND Various angulations ND ND ND ND ND 20 -40 to long axis of tooth 30 to long axis of tooth ND ND 30 to midsagittal plane ND 70 -80 to long axis of tooth ND

Freudenthaler et al Miyawaki et al12 Liou et al21 Motoyoshi et al22 Thiruvenkatachari et al23 Park et al24 Tseng et al25 Chen et al26 Berens et al46 Luzi et al37 Wiechmann et al41 Kuroda et al42 Motoyoshi et al39 Kuroda et al38 Motoyoshi et al43 Hedayati et al44 Chaddad et al45 Moon et al40 Kinzinger et al47

Flap Both Flap Flapless ND Flap Flapless Flapless Flapless Flapless Flapless Flapless Flapless Both Flapless Flapless Flapless Both Flapless

ND, Not described; SD, self-drilling screw; ST, self-tapping screw.

The length of a mini-implant is determined by depth and quality of the bone, screw angulation, transmucosal thickness, and adjacent vital structures.25,38,63,66 Short screws in regions with thick soft tissues, such as the palatal mucosa, can easily become dislodged.25,67,68 Longer screws are recommended in these sites.46,68 The minimal depth of placement of a mini-implant is at least 5 to 6 mm.13,25,38 but deeper placements have

been recommended when bone quality is low.45,46 Screw length was correlated with success in 2 studies, but this association did not pass the inclusion criteria and requires further analysis (Table III).25,26 Of the patient-related factors (Table V), most studies found a disproportionate division of the sexes with an excess of females (Table V). Ten studies did not dene the numbers of implants for each sex, and 2 articles

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Table VIII.

Orthodontics-related factors in studies on mini-implants

Type of orthodontic movement Mandibular molar protraction Various movements in both jaws Various movements in both jaws Various movements in both jaws En-masse retraction of maxillary anteriors Retraction of anterior teeth in both jaws Retraction of canines in both jaws Various movements in both jaws Various movements in both jaws Various movements in both jaws Various movements in both jaws Timing of force application Immediate (at time of surgery) Immediate (\1 month) Delayed (1-3 months) Delayed (.3 months) Force magnitude 150 g Type of force Continuous and intermittent Continuous Continuous Continuous Continuous ND Continuous Continuous and Intermittent Continuous and intermittent Continuous and intermittent Intermittent Duration of force application Average: 11 months Range: 7-20 months 1 year or ARTT 1 year or ARTT 1 year or ARTT 9 months 6 months 3.5-5.5 months or ARTT Mean: 15 months or ARTT SD: 6.16 months Average:16 months ARTT Mean: 19.5 months ARTT Average: 235 days Maximum: 733 days ARTT Minimum:120 days or ARTT Maximum: 37 months 180 days 1 year or ARTT 6 months Direction of force D

Authors Freudenthaler et al14 Miyawaki et al12 Miyawaki et al12 Miyawaki et al12 Liou et al21 Motoyoshi et al22 Thiruvenkatachari et al23 Park et al24

\200 g \200 g \200 g

ND ND ND D ND D ND

Immediate (after 2 400 g weeks) Immediate (at time of \200 g surgery) Immediate (after 15 100 g days) Immediate and delayed \200 g (no time denition) Immediate (after 2 weeks) Immediate (after 2 weeks) Immediate (at time of surgery) 100-200 g

Tseng et al25

ND

Chen et al26

100-200 g

ND

Berens et al46

Maximum of 150 g

ND

Luzi et al37

Various movements in both jaws

Immediate (at time of surgery)

50 g

Continuous

Wiechmann et al41 Kuroda et al42 Motoyoshi et al39

Various movements in both jaws ND Retraction of anterior teeth in both jaws

Kuroda et al38 Motoyoshi et al43 Hedayati et al44

Various movements in both jaws Retraction of anterior teeth in both jaws Canine retraction in both jaws

Immediate (at time of surgery) Immediate and delayed (after 0-12 weeks) Immediate (after 2-4 weeks) and delayed (more than 3 months) Immediate and delayed (0-12 weeks) Immediate (at surgery) Immediate (after 7-11 days)

100-200 g 50-200 g Approximately 200 g

Continuous and intermittent Continuous and intermittent Continuous

D ND ND

50-200 g ND 180 g

Continuous and intermittent ND Continuous

1 year or ARTT 6 months or more Average: 5.4 months Range: 4-6.5 months 150 days 8 months Average: 6.5 months or ARTT

ND ND ND

Chaddad et al45 Moon et al40 Kinzinger et al47

Various movements in both jaws ND Distalization of maxillary molars

Immediate (at surgery) Immediate (after 2-3 weeks) Immediate (after 1 week)

50-250 g \200 g 200-240 g

Continuous and intermittent Continuous and intermittent Continuous

ND ND D

ND, Not described; D, described; ARTT, anchorage for required treatment time.

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Table IX. Authors

Implant maintenance-related factors in studies on mini-implants

Antibiotic protocol Chlorhexidine protocol Oral-hygiene protocol Peri-implantitis protocol ND 3 days PI 1 week PI 3 days PI ND ND ND ND ND ND ND ND 3 days PI ND 3 days PI 1 hour before placement ND ND ND ND ND 1 week PI ND ND ND ND ND ND 1 week PI ND ND ND ND ND 1 week PI 1 week PI ND ND ND ND OH instruction ND ND OH instruction OH instruction ND ND OH instruction OH instruction ND ND ND ND ND ND ND ND Mobility protocol

Freudenthaler et al14 Miyawaki et al12 Liou et al21 Motoyoshi et al22 Thiruvenkatachari et al23 Park et al24 Tseng et al25 Chen et al26 Berens et al46 Luzi et al37 Wiechmann et al41 Kuroda et al42 Motoyoshi et al39 Kuroda et al38 Motoyoshi et al43 Hedayati et al44 Chaddad et al45 Moon et al40 Kinzinger et al47

OH reinforcement ND ND ND ND ND ND ND OH reinforcement ND OH reinforcement Monitor force levels Local cleaning ND and antibiotics ND ND ND ND OH reinforcement ND Analgesics and antibiotics ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

ND, Not described; PI, postimplant placement; OH, oral hygiene.

failed to show how the sexes were divided in their subjects.44,45 Sex and success were not correlated according to 5 articles,22,24,38,40,43 but a study that used computed tomography measured thinner cortical bone thickness in females in the attached gingiva mesial to the maxillary rst molar.69 Most studies had a wide range of the age variable. Immediate loading of miniimplants showed signicantly higher success rates in adults compared with adolescents in a study by Motoyoshi et al.39 This nding probably indicates that the bone density of adolescents is insufcient to support immediate loading with orthodontic forces. However, soft tissue and bone thickness around the rst molars vary signicantly in the vertical and horizontal dimensions and could have skewed this proposed association.69,70 Physical and dental statuses were described in only 2 and 6 of the 19 articles, respectively, and their impact on success rates needs additional clarication (Table V). Osteoporosis, uncontrolled diabetes, periodontal disease, smoking, and pharmacologic prescriptions such as bisphosphonates are considered risk factors for classic dental implants.24,71-74 It is probably wise to avoid the use of mini-implants in these patients or to monitor them carefully, allowing longer healing periods and applying specic loading protocols.71,72 Location-related factors (Table VI) include hard-tissue parameters. Animal studies showed that the holding power of mini-implants is determined by the quality and quantity of the bone into which they are placed.61,62,75 Initial stability after placement was facilitated by

greater cortical bone thickness.62 However, several reports warned about the risk of overheating during implant placement in areas with a dense cortex.20,24 One study found higher success rates when the cortical bone was at least 1.0 mm thick.43 In that article, peri-implant bone quantity was not correlated with success and seemed therefore a less important factor for implant stability than cortical bone thickness. However, the wide range in the age variable could have distorted these proposed associations (Table V). A relationship between success and the character of the soft tissues has been proposed.20,24,45 It was recommended to position implants in keratinized gingiva rather than nonkeratinized mucosa.19,20,63 Keratinized gingiva is thought to reduce the development of hypertrophic tissues and inammation.66,76 To avoid these secondary outcomes, it also was suggested to cover implant heads with mucosa.24,76 Proper implant site selection was proposed as a key factor for the success of mini-implants.7,13,20,37,41,46,77 Therefore, any correlation with success was rejected when the position of the implant was not precisely indicated (Table III). Primary outcomes varied between placement sites.24,40-43 Differences in success were recorded between the premolar and molar areas in the mandible,40 and a study noted that root proximity was a major risk factor for screw failure.42 This latter nding was conrmed in an animal study.54 Furthermore, growing third molars, exfoliating tooth buds, periodontal diseases, and edentulous areas are thought to change bone

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quality.44,76,78 To obtain better insight into these parameters, controlled studies are necessary and might lead to site-specic protocols for implant placement. Surgery-related factors (Table VII) include experience of the surgeon, sterilization, ap or apless surgery, self-tapping or self-drilling technique, pilot hole preparation in the cortex only or for the entire screw depth, diameter of the pilot hole, cooling technique, drill speed and pressure, direction of placement, steady or wiggling placement procedures, monocortical vs bicortical anchorage, and placement torque.9,12,19,22,24,37,39,40,43,45,63,76,77 Studies of dental implants indicate that gentle surgical placement is a key element for success.72 Excessive surgical trauma and thermal injury can lead to osteonecrosis and brous encapsulation of the implant.79-81 Failure rates can probably be reduced with increasing clinical experience.15,37,40 In most studies, screw implants were placed according to a specic protocol (Table VII). Similar success rates were found for both ap and apless procedures, but the inuence of cortical pilot hole preparation or self-tapping or self-drilling techniques was not analyzed in any study.12,40 Four studies correlated the amount of placement torque with success (Table III).22,39,43,45 Because of the suggestion that excessively high seating forces could cause necrosis and local ischemia,82 specic torque levels were recommended for the maxilla and the mandible.22,39 One study analyzed the impact of placement direction on success.24 Various angulations were chosen to avoid biologic damage and to increase contact with cortical bone.24,39 However, no surgery-related factor met the selection criterion for variables (Table III). Orthodontics-related factors were divided in 6 categories: timing, magnitude, type, duration, and direction of force, and type of orthodontic movement. Each is discussed separately, but there are probably delicate relationships between them. There is controversy about the proper timing of orthodontic force application.9,12,24,38,39,71,77,83 Comparison of outcomes was complicated because of the wide interpretation of immediate, varying from the time of surgery to 4 weeks later (Table VIII). Immediate loading might promote the mechanical stability of screws,83 especially in sites with poor bone quality,84 but the opposite also was reported.71 Research on dental implants showed that placement into soft, spongy bone with poor initial stability often risks the formation of connective tissue encapsulation, similar to pseudoarthrosis.85-87 Animal studies reported that immediate loading of mini-implants can be successful,88,89 but stresses generated by functional and orthodontic forces should not be neglected.90 Motoyoshi et al39

found signicantly lower failure rates for immediate compared with delayed loading in adolescents, but not for the early load group in adults (Table IV). This could indicate that immediate loading is possible if bone is denser and more mature. Force levels varied from 50 to 400 g, but most studies used forces of 200 g or less. Because excessive strain levels might lead to screw loosening in areas with thin cortical bone and low-density trabecular bone,76,91 it was recommended to start with forces of 50 g and increase them after initial healing.45,76 Liou et al21 found signicant screw displacements after applying immediate forces of 400 g. However, a study using the same protocol correlated screw displacement to the duration and not to the direction or magnitude of forces of 200 to 425 g.52 These latter authors suggested, however, that loading beyond this force range could cause different outcomes and required further investigation. Regardless, displacements were also seen at lower force levels.44,47 Both light continuous and the more extreme initial forces of intermittent loading have been used for orthodontic tooth movement. However, the type of force and its relationship to implant stability were analyzed in only 1 study.24 Four methods of force application were compared, but no correlation was found with primary outcomes. The duration of force application varied widely, from 3 to 37 months (Table VIII). Little is known about the long-term stability of miniscrews. Implant displacement was found in 3 studies after 9, 5.4, and 6.5 months, respectively.21,44,47 Wang and Liou52 found a correlation between the duration of force application and the amount of displacement, but they suggested that the relatively high forces could have inuenced this association. A potential relationship between implant success and the direction of force application has been hypothesized.13,14,20,63,66 Costa et al13 suggested that miniscrews could loosen when a moment was generated in the unscrewing direction. Cheng et al20 recommended avoiding lateral, torsional, and extrusive forces, and Freudenthaler et al14 suggested that the placement site of the mini-implant should be the same as the center of resistance of the teeth. Mini-implants were prescribed for a wide variety of orthodontic indications (Table VIII). The inuence of the type of orthodontic movement on primary outcomes was analyzed in only 1 study.38 Signicantly higher failure rates were found for intrusive movements compared with retraction and protraction of teeth, but this correlation was rejected by the inclusion criteria for variables (Table III).

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Implant maintenance-related factors (Table IX) included control of peri-implantitis. Prophylactic antibiotics, chlorhexidine rinses, oral-hygiene instructions, and reinforcements are important factors of implant maintenance.39,43,63,66,76,92 The possible relationship between success and antibiotics or chlorhexidine was not analyzed in any study (Table IIII). Park et al24 associated control of peri-implantitis with success but found no correlation between oral-hygiene measures and primary outcomes (Table III). They also reported higher success rates on the left side of the mouth; this nding was considered a consequence of better oral hygiene by right-handed patients.93 Research on dental implants has demonstrated that micro-movements of more than 100 mm are sufcient to jeopardize healing and can cause brous encapsulation.87,94 Park et al24 recommended monitoring implant mobility and orthodontic forces regularly and reported that mobile screws could be successful if the forces were less than 200 g. Beyond orthodontic-force factors, other force variables including occlusion and tongue jiggling might also inuence outcomes.19,37,90 Monitoring these factors should become a part of the implantmaintenance protocol. Future research should apply a standardized methodology to analyze primary and secondary outcomes of using mini-implants in orthodontic treatment protocols. Our denitions of outcome measures are proposed as initial guidelines for this purpose. Furthermore, our classication system of the variables that could inuence success rates is suggested as a starting framework for research on mini-implants. Studies should focus on implant systems for specic orthodontic indications by testing 1 hypothesis at a time. Further randomized clinical trials are needed to analyze the differences in outcomes between mini-implants and other forms of anchorage. Because this research is generally costly, implant manufacturers should be solicited to fund high-quality independently conducted trials.29

3.

4.

5.

Adverse effects of mini-implants included biologic damage, inammation, and pain and discomfort. Few articles reported on these outcomes. Variables suggested as having an association with the success of mini-implants were divided into 6 categories: implant, patient, location, surgery, orthodontic, and implant-maintenance factors. All proposed correlations were rejected by the selection criteria for this review, because the parameters selected as independent variables were not controlled. This systematic review has shown that clinical studies on mini-implant placement are still in their infancy. A proposal for a standardized methodology for future studies was presented with our classication system for variables and specic denitions of primary and secondary outcomes.

We thank Charles Greene, University of Illinois, and Louis Keith, Northwestern University, for reviewing this manuscript; Mary Kreinbring, American Dental Association library, for assistance with the computerized searches; and Rossella Bassi, Elisabetta Bello, and Alice Marino for preparing the tables.

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CONCLUSIONS

1.

2.

The analysis of success rates was complicated because of various denitions of primary outcomes, different timings of success assessment, poor methodologies, and lack of clarity in most studies. Rates of primary outcomes of mini-implants with diameters of 1.0 to 2.3 mm ranged from 0% to 100%. Most studies reported success rates greater than 80% if mobile and displaced implants were included as successful.

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13.

14.

15.

16.

17.

18.

19. 20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

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31. Arcuri C, Muzzi F, Santini F, Barlattani A, Giancotti A. Five years of experience using palatal mini-implants for orthodontic anchorage. J Oral Maxillofac Surg 2007;65:2492-7. 32. Prabhu J, Cousley RRJ. Current products and practice. Bone anchorage devices in orthodontics. J Orthod 2006;33:288-307. 33. Ohashi E, Pecho OE, Moron M, Lagravere MO. Implant vs screw loading protocols in orthodontics. Angle Orthod 2006;76:721-7. 34. Huan LH, Shotwell JL, Wang HL. Dental implants for orthodontic anchorage. Am J Orthod Dentofacial Orthop 2005;127:713-22. 35. Higgins JPT, Green S, editiors. Cochrane Handbook for Systematic Reviews of Interventions 5.0.0. (updated February 2008). The Cochrane Collaboration, 2008. Available at: www.cochranehandbook.org. 36. Turpin DL. CONSORT and QUORUM guidelines for reporting randomized clinical trials and systematic reviews. Am J Orthod Dentofacial Orthop 2005;128:681-5. 37. Luzi C, Verna C, Melsen B. A prospective clinical investigation of the failure rate of immediately loaded mini-implants used for orthodontic anchorage. Prog Orthod 2007;8:192-201. 38. Kuroda S, Sugawara Y, Deguchi T, Kyung HM, TakanoYamamoto T. Clinical use of miniscrew implants as orthodontic anchorage: success rates and postoperative discomfort. Am J Orthod Dentofacial Orthop 2007;131:9-15. 39. Motoyoshi M, Matsuoka M, Shimizu N. Application of orthodontic mini-implants in adolescents. Int J Oral Maxillofac Surg 2007; 36:695-9. 40. Moon CH, Lee DG, Lee HS, Im JS, Baek SH. Factors associated with the success rate of orthodontic miniscrews placed in the upper and lower posterior buccal region. Angle Orthod 2008;78: 101-6. 41. Wiechmann D, Meyer U, Bu chter A. Success rate of mini- and micro-implants used for orthodontic anchorage: a prospective clinical study. Clin Oral Implants Res 2007;18:263-7. 42. Kuroda S, Yamada K, Deguchi T, Hashimoto T, Kyung HM, Takano-Yamamoto T. Root proximity is a major factor for screw failure in orthodontic anchorage. Am J Orthod Dentofacial Orthop 2007;131(4 Suppl):S68-73. 43. Motoyoshi M, Yoshida T, Ono A, Shimizu N. Effect of cortical bone thickness and implant placement torque on stability of orthodontic mini-implants. Int J Oral Maxillofac Implants 2007;22: 779-84. 44. Hedayati Z, Hashemi SM, Zamiri B, Fattahi HR. Anchorage value of surgical titanium screws in orthodontic tooth movement. Int J Oral Maxillofac Surg 2007;36:588-92. 45. Chaddad K, Ferreira AF, Geurs N, Reddy MS. Inuence of surface characteristics on survival rates of mini-implants. Angle Orthod 2008;78:107-13. 46. Berens A, Wiechmann D, Dempf R. Mini- and micro-screws for temporary skeletal anchorage in orthodontic therapy. J Orofac Orthop 2006;67:450-8. 47. Kinzinger G, Gulden N, Yildizhan F, Hermanns-Sachweh B, Diedrich P. Anchorage efcacy of palatally-inserted miniscrews in molar distalization with a periodontally/miniscrew-anchored distal jet. J Orofac Orthop 2008;69:110-20. 48. Easterbrook PJ, Berlin JA, Gopalan R, Matthews DR. Publication bias in clinical research. Lancet 1991;337:867-72. 49. Song F, Eastwood AJ, Gilbody S, Duley L, Sutton AJ. Publication and related biases. Health Technol Assess 2000;4(10):1-115. 50. Ledford H. Weighing up the evidence. Nature 2007;447:512-3. 51. Kravitz ND, Kusnoto B. Risks and complications of orthodontic miniscrews. Am J Orthod Dentofacial Orthop 2007;131(4 Suppl):S43-51.

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52. Wang YC, Liou EJ. Comparison of the loading behavior of selfdrilling and predrilled miniscrews throughout orthodontic loading. Am J Orthod Dentofacial Orthop 2008;133:38-43. 53. Asscherickx K, Vannet BV, Wehrbein H, Sabzevar MM. Root repair after injury from mini-screw. Clin Oral Implants Res 2005; 16:575-8. 54. Chen YH, Chang HH, Chen YJ, Lee D, Chiang HH, Yao CC. Root contact during insertion of miniscrews for orthodontic anchorage increases the failure rate: an animal study. Clin Oral Implants Res 2008;19:99-106. 55. Maino BG, Weiland F, Attanasi A, Zachrisson BU, Buyukyilmaz T. Root damage and repair after contact with miniscrews. J Clin Orthod 2007;41:762-6. 56. Daimaruya T, Nagasaka H, Umemori M, Sugawara J, Mitani H. The inuences of molar intrusion on the inferior alveolar neurovascular bundle and root using the skeletal anchorage system in dogs. Angle Orthod 2001;71:60-70. 57. Yano S, Motoyoshi M, Uemura M, Ono A, Shimizu N. Tapered orthodontic miniscrews induce bone-screw cohesion following immediate loading. Eur J Orthod 2006;28:541-6. 58. Motoyoshi M, Yano S, Tsuruoka T, Shimizu N. Biomechanical effect of abutment on stability of orthodontic mini-implant. A nite element analysis. Clin Oral Implants Res 2005;16:480-5. 59. Song YY, Cha JY, Hwang CJ. Mechanical characteristics of various orthodontic mini-screws in relation to articial cortical bone thickness. Angle Orthod 2007;77:979-85. 60. Gausepohl T, Mo hring R, Pennig D, Koebke J. Fine thread versus coarse thread. A comparison of the maximum holding power. Injury 2001;32(Suppl 4):SD1-7. 61. Wilmes B, Ottenstreuer S, Su YY, Drescher D. Impact of implant design on primary stability of orthodontic mini-implants. J Orofac Orthop 2008;69:42-50. 62. Wilmes B, Rademacher C, Olthoff G, Drescher D. Parameters affecting primary stability of orthodontic mini-implants. J Orofac Orthop 2006;67:162-74. 63. Melsen B. Mini-implants: where are we? J Clin Orthod 2005;39: 539-47. 64. Carano A, Lonardo P, Velo S, Incorvati C. Mechanical properties of three different commercially available miniscrews for skeletal anchorage. Prog Orthod 2005;6:82-97. 65. Carano A, Velo S, Incorvati C, Poggio P. Clinical applications of the mini-screw-anchorage system (M.A.S.) in the maxillary alveolar bone. Prog Orthod 2004;5:212-35. 66. Maino BG, Mura P, Bednar J. Miniscrew implants: the spider screw anchorage system. Semin Orthod 2005;11:40-6. 67. Hong RK, Heo JM, Ha YK. Lever-arm and mini-implant system for anterior torque control during retraction in lingual orthodontic treatment. Angle Orthod 2005;75:129-41. 68. Park YC, Lee SY, Kim DH, Jee SH. Intrusion of posterior teeth using mini-screw implants. Am J Orthod Dentofacial Orthop 2003;123:690-4. 69. Ono A, Motoyoshi M, Shimizu N. Cortical bone thickness in the buccal posterior region for orthodontic mini-implants. Int J Oral Maxillofac Surg 2008;37:334-40. 70. Kim HJ, Yun HS, Park HD, Kim DH, Park YC. Soft-tissue and cortical-bone thickness at orthodontic implant sites. Am J Orthod Dentofacial Orthop 2006;130:177-82. 71. Chung KR, Kim SH, Kook YA. The C-orthodontic micro-implant. J Clin Orthod 2004;38:478-86. 72. Gapski R, Wang HL, Mascarenhas P, Lang NP. Critical review of immediate implant loading. Clin Oral Implants Res 2003;14:515-27.

73. Piesold JU, Al-Nawas B, Grotz KA. Osteonecrosis of the jaws by long-term therapy with bisphosphonates. Mund Kiefer Gesichtschir 2006;10:287-300. 74. Mengel R, Behle M, Flores-de-Jacoby L. Osseointegrated implants in subjects treated for generalized aggressive periodontitis: 10-year results of a prospective, long-term cohort study. J Periodontol 2007;78:2229-37. 75. Struckhoff JA, Huja SS, Beck FM, Litsky AS. Pull-out strength of monocortical screws at 6 weeks postinsertion [abstract]. Am J Orthod Dentofacial Orthop 2006;129:82-3. 76. Melsen B, Verna C. Miniscrew implants: the Aarhus anchorage system. Semin Orthod 2005;11:24-31. 77. Lin JC, Liou EJ. A new bone screw for orthodontic anchorage. J Clin Orthod 2003;37:676-81. 78. Costa A, Pasta G, Bergamaschi G. Intraoral hard and soft tissue depths for temporary anchorage devices. Semin Orthod 2005; 11:10-5. 79. Satomi K, Akagawa Y, Nikai H, Tsuru H. Bone-implant interface structures after nontapping and tapping insertion of screw-type titanium alloy endosseous implants. J Prosthet Dent 1988;59:339-42. 80. Eriksson RA, Albrektsson T. The effect of heat on bone generation: an experimental study in the rabbit using the bone growth chamber. J Oral Maxillofac Surg 1984;42:705-11. 81. Eriksson RA, Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury: a vital microscopic study in the rabbit. J Prosthet Dent 1983;50:101-7. 82. Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont 1998;11:491-501. 83. Giancotti A, Arcuri C, Barlattani A. Treatment of ectopic mandibular second molar with titanium miniscrews. Am J Orthod Dentofacial Orthop 2004;126:113-7. 84. Maino BG, Maino G, Mura P. Spider screw: skeletal anchorage system. Prog Orthod 2005;6:70-81. 85. Brunski JB, Moccia AF Jr Pollack SR, Korostoff E, Trachtenberg DI. The inuence of functional use of endosseous dental implants on the tissue-implant interface. I. Histological aspects. J Dent Res 1979;58:1953-69. 86. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone, connective tissue, and eptithelium to endosteal implants with titanium-sprayed surfaces. J Maxillofac Surg 1981;9:15-25. 87. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH. Timing of loading and effect of micromotion on bone-dental implant interface: review of experimental literature. J Biomed Mater Res 1998;43:192-203. 88. Kim JW, Ahn SJ, Chang YI. Histomorphometric and mechanical analyses of the drill-free screw as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2005;128:190-4. 89. Deguchi T, Takano-Yamamoto T, Kanomi R, Hartseld JK Jr., Roberts WE, Garetto LP. The use of small titanium screws for orthodontic anchorage. J Dent Res 2003;82:377-81. 90. Cattaneo PM, Dalstra M, Melsen B. Analysis of stress and strain around orthodontically loaded implants: an animal study. Int J Oral Maxillofac Implants 2007;22:213-25. 91. Dalstra M, Cattaneo PM, Melsen B. Load transfer of miniscrews for orthodontic anchorage. Orthodontics 2004;1:53-62. 92. Herman R, Cope JB. Miniscrew implants: IMTEC mini ortho implants. Semin Orthod 2005;11:32-9. 93. Tezel A, Orbak R, Canakci V. The effect of right or left-handedness on oral hygiene. Int J Neurosci 2001;109:1-9. 94. Brunski JB. Avoid pitfalls of overloading and micromotion of intraosseous implants. Dent Implantol Update 1993;4:77-81.

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APPENDIX: SELECTION PROCEDURES

Appendix Table I. Keywords Orthodontics Implants Screw Mini-implant Miniscrew

Appendix Table III.

Keywords for the search engines

Abbreviations used*

Articles excluded by general selection criteria (n 5 21)

Year of publication 1998 1999 2001 2004 2004 2004 2004 2004 2005 2005 2005 2005 2005 2005 2005 2006 2006 2006 2007 2008 2008 Reasons for exclusion 1D 1D 1D 1B (case) 1B (technique) 1B (case) 1B (case) 1B (review) 1E 1B (technique) 1B (technique) 1B (technique) 1D 1B (technique) 1 B (technique) 1A 1B (case) 1B (review) 1D 1A 1B (laboratory)

Authors Wehrbein et al1 Wehrbein et al2 Bernhart et al3 Lee et al4 Philippart and Philippart-Rochaix5 Sung et al6 Park et al7 Travess et al8 Yao et al9 Park et al10 Melsen and Verna11 Herman and Cope12 Crismani et al13 Maino et al14 Maino et al15 Chen et al16 Cho17 Kyung18 Arcuri et al19 Wang and Liou20 Lim et al21

Orthodon, Orthodontics, Orthodontic Implant, Implants Screw, Screws Mini-implant, Mini-implants Mini-screw, Mini-screws, Miniscrew, Miniscrews Microimplant Micro-impant, Micro-implants, Microimplant, Microimplants Screw implant Screw implant, Screw implants Temporary anchorage Temporary anchorage device, device Temporary anchorage devices *For each search engine, the appropriate characters (*, $, and so on) were used to truncate or explore search terms. Appendix Table II. Abstracts retrieved by electronic, hand, and reference searching Number of abstracts without overlap 3309 0 16 24 0 1 12 2 3364

Search method Google Scholar PubMed (AA) Embase (AA) Science direct (AA) Other search engines (AA) Hand searching (AA) References review articles (AA) References selected articles (AA) Total

General exclusion criteria: 1A, study did not analyze success of miniimplants; 1B, not a clinical study on humans but a technique article, case report, opinion article, review article, or laboratory, animal, or in-vitro study; 1C, sample size smaller than 10 mini-implants; 1D, implant diameter .2.5 mm; 1E, miniplates.

Appendix Table IV. Articles excluded by specic selection criteria (n 5 12) Year of publication 1998 2004 2004 2004 2005 2005 2006 2006 2006 2007 2007 2007 Reasons for exclusion 2A, 2B 2A, 2C 2B 2A 2C 2A,2C 2A 2C 2A, 2B 2A 2B 2A

Authors Costa et al22 Fritz et al23 Cheng et al24 Gelgor et al25 Park et al26 Berens et al27 Kircelli et al28 Herman et al29 Wu et al30 Xun et al31 Chen et al32 Gelgor et al33

AA, Additional abstracts that were not retrieved by any other search method. Google Scholar was used as the basis, because it had the largest number of abstracts and therefore the most overlap.

Specic exclusion criteria: 2A, no denition of success; 2B, no duration of force application; 2C, duration of force application \3 months.

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18. Kyung HM. The use of microimplants in lingual orthodontic treatment. Semin Orthod 2006;12:186-90. 19. Arcuri C, Muzzi F, Santini F, Barlattani A, Giancotti A. Five years of experience using palatal mini-implants for orthodntic anchorage. J Oral Maxillofac Surg 2007;65:2492-7. 20. Wang YC, Liou EJ. Comparison of the loading behavior of selfdrilling and predrilled miniscrews throughout orthodontic loading. Am J Orthod Dentofacial Orthop 2008;133:38-43. 21. Lim SA, Cha JY, Hwang CJ. Insertion torque of orthodontic miniscrews according to changes in shape, diameter, and length. Angle Orthod 2008;78:234-40. 22. Costa A, Raffaini M, Melsen B. Miniscrews as orthodontic anchorage: a preliminary report. Int J Adult Orthod Orthognath Surg 1998;13:201-9. 23. Fritz U, Ehmer A, Diedrich P. Clinical suitability of titanium microscrews for orthodontic anchoragepreliminary experiences. J Orofac Orthop 2004;65:410-8. 24. Cheng SJ, Tseng IY, Lee JJ, Kok SH. A prospective study of the risk factors associated with failure of mini-implants used for orthodontic anchorage. Int J Oral Maxillofac Implants 2004;19: 100-6.  Dolanmaz D, 25. Gelgo r IE, Bu yu kyilmaz T, Karaman AIY, Kalayci A. Intraosseous screw-supported upper molar distalization. Angle Orthod 2004;74:838-50. 26. Park HS, Lee SK, Kwon OW. Group distal movement of teeth using microscrew implant anchorage. Angle Orthod 2005;75:602-9. 27. Berens A, Wiechmann D, Rudiger J. Lancrage intra-osseux en or` laide de mini-et de microvis. Int Orthod 2005;3: thodontie a 235-43. , Kircelli C. Maxillary molar distalization 28. Kircelli BH, Pektas ZO with a bone-anchored pendulum appliance. Angle Orthod 2006; 76:650-9. 29. Herman RJ, Currier F, Miyake A. Mini-implant anchorage for maxillary canine retraction: a pilot study. Am J Orthod Dentofacial Orthop 2006;130:228-35. 30. Wu JC, Huang JN, Zhao SF, Xu XJ, Xie ZJ. Radiographic and surgical template for placement of orthodontic microimplants in interradicular areas: a technical note. Int J Oral Maxillofac Implants 2006;21:629-34. 31. Xun C, Zeng X, Wang X. Microscrew anchorage in skeletal anterior open-bite treatment. Angle Orthod 2007;77:47-56. 32. Chen YJ, Chang HH, Huang CY, Hung HC, Lai HH, Yao CC. A retrospective analysis of the failure rate of three different orthodontic skeletal anchorage systems. Clin Oral Implants Res 2007;18:768-75. 33. Gelgor IE, Karaman AI, Buyukyilmaz T. Comparison of 2 distalizing systems supported by intraosseous screws. Am J Orthod Dentofacial Orthop 2007;131:161.e1-8.