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Micro-implants for Orthodontic Anchorage: A review

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REVIEW
Micro-implants for Orthodontic Anchorage: A review
J Kannaperuman,1 Gowri Natarajarathinam,2 Adith Venugopal,3
ABSTRACT
Orthodontic treatment has become increasingly popular in all
ages and the demand is expected to grow in the future.
Anchorage is a critical factor that determines the success of
orthodontic treatment. In the past decades, micro implants have
been used in orthodontics for anchorage and has been
documented to have promising results. Micro implants provide
absolute anchorage which results in the desired tooth movement
and minimize undesirable effects. The purpose of this article is to
review and update current concepts of using dental implants for
orthodontic anchorage.
Key words: Micro-implants, Orthodontic Anchorage, Tooth
Movement
Introduction
Anchorage has always been a challenge in orthodontics.
Orthodontic treatment has become increasingly
popular in all ages and the demand is expected to grow
in the future. However, not everybody will have
adequate dentition for anchorage. This becomes even
more difficult in partially edentulous patients and in
patients with dentofacial deformities. In most cases
other alternative anchorage aids have to be used.
Branemark introduced the concept of Osseointegration
with titanium implants in 19641. Decades after that,
implants were used in orthodontics to reinforce
anchorage. Orthodontic anchorage is defined as
“resistance to unwanted tooth movement.” Dentists
use appliances to produce desired movements of teeth
in the dental arch. According to Newton’s third law of
motion, every action has an equal and opposite
reaction; this means that, inevitably, other teeth move
if the appliance engages them. Anchorage is the
resistance to the force provided by other teeth or
devices2,3. In orthodontic treatment, reciprocal effects
must be evaluated and controlled. The goal is to
maximize desired tooth movement and minimize
undesirable effects. The purpose of this article is to
review and update current concepts of using dental
implants for orthodontic anchorage.
IJCD • APRIL, 2013 • 4(1) reactions and no neoplasm formation), it is
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© 2013 Int. Journal of Contemporary Dentistry
Indications:
Anchorage plays a major role in orthodontic treatment
success. Micro implants are indicated in the following
situations.
Intrude/Extrude Molars – Intrusion and extrusion are
two relatively complicated movements to be achieved.
Micro-implants will be a great aid in these movements.
Although, they might cause some degree of facial
movement also. Micro implants are placed between the
roots or apical to the roots to achieve this type of
movement.
Close edentulous space – Orthodontic treatment
becomes more challenging for people with
malocclusion and congenitally missing teeth. In those
situations implants have been used in the retro molar
area to close the space. This is a better modality that to
prepare the adjacent tooth for a bridge which will pose
many complications later on. (Figure 1,2,3)
Pre-restorative tooth Movement – Correction of tilted
abutment teeth are also done by micro implants. They
facilitate the uprighting the tilted tooth at the end of a
long edentulous span. (Figure 4)
Providing orthopedic anchorage – Provide orthopedic
anchorage. Palatal implants can be used to elicit palatal
expansion. This applies to partially edentulous patients
or children with congenital diseases that result in facial
developmental defects or missing teeth. Implants in
congenital anomalies can promote orthodontic and
orthopedic therapy and accelerate jaw movement by
sutural distraction.
Implant Selection Criteria:
A. Implant materials – The material should be
biocompatible and nontoxic. It should also
possess excellent mechanical properties like
resistance to stress, strain and should not leach
any corrosion products. Because of titanium’s
characteristics (no allergic and immunological
considered an ideal material and is widely used.

allergic and immunological reactions and no
neoplasm formation), it is considered an ideal
material and is widely used.
B. Implant Sizes – Implants must achieve primary
stability and should withstand mechanical forces.
The maximum load is proportional to the bone-
implant contact area. There are many factors that
affect the surface area like shape, diameter, length,
pitch frequency etc4,5. The ideal size for anchorage
remains to be determined. Therefore, the
dimension of implants should be congruent with the
bone available at the surgical site and the treatment
plan.
C. Implant Shape – Implant shape should minimize
trauma and achieve good primary stability. The
shape also determines the area for stress transfer.
Studies have shown that the degree of surface
roughness is related to the degree of
osseointegration. Most implants used for
orthodontic anchorage are similar to conventional
designs6,7.
Biomechanics:
Ability to withstand stress and strain as important as
primary stability in case of orthodontic implants.
Biomechanics is a critical aspect in anchorage because
orthodontic forces are very different from occlusal
forces. Orthodontic loads are continuous, horizontal,
and usually 20 to 300 g. Occlusal loads are
discontinuous, vertical, and sometimes up to several
kilograms. Studies have reported with reference to
anatomical site, duration and amount of force, titanium
alloy implants seem to provide excellent biomechanical
properties.
Clinical Applications:
The application of miniscrew implants has been
expanded to include a wide array of cases,including the
correction of deep over bites 8 closure of extraction
spaces, correction of a canted occlusal plane, alignment
of dental midlines, extrusion of impacted canines,
extrusion and uprighting of impacted molars, molar
intrusion, maxillary molar distalization, distalization of
mandibular teeth, en-masse retraction of anterior
teeth, molar mesialization, upper third molar alignment,
intermaxillary anchorage for the correction of sagittal
discrepancies, and correction of vertical skeletal
discrepancies that would otherwise require an
orthognathic surgical procedure9-12.
Selection of microimplants:
1) Depending on the length -The length of screw
portion is ranging from 5mm to 12 mm. 6mm of screw
IJCD • APRIL, 2013 • 4(1)
© 2013 Int. Journal of Contemporary Dentistry
REVIEW
depth is enough for maxillary bone, and 5mm is enough
for the mandible. However, always we should consider
the depth of soft tissue when choosing proper length of
microimplants. Especially palatal mucosa may be very
thick in many. So, if soft tissue is 6mm thick, in order to
place 6mm of screw portion into the bone, at least
12mm length of microimplant should be chosen. The
standard protocol requires that the soft tissue thickness
as well as the bone quality must be evaluated at the
location of placement. Also, in choosing the proper
length of a microimplant, the path of insertion of the
microimplant must be considered. A microimplant can
be placed either in a diagonal direction or a
perpendicular direction relative to the cortical bone
surface. It is better and easier to place microimplant in a
perpendicular direction, but, there are many situations
in which the microimplant should be placed in a
diagonal direction so as to avoid injury to an adjacent
tooth root. When the microimplant is placed in a
diagonal direction rather than perpendicular direction,
it is better to use a slightly longer microimplant.
2) Depending on the diameter – There are various
diameters of microimplants which are ranging from 1.2
mm to 2.7 mm, so they can be placed anywhere in the
mouth. Depending on the inter-radicular distance,
quality of bone and site of placement, we can choose
different diameters of microimplants. Thicker the
microimplant, the greater becomes mechanical
retention, but also the greater possibility for root
contact. It can be recorded from the review that thicker
microimplants do not always guarantee higher success
rate, even there is a report that microimplant of smaller
diameter showed higher success rate than thicker ones
(Kuroda et al,2007-a). Also thicker microimplants may
be hard to remove due to osseointegration,
authorprefer microimplants of smaller diameter as
possible. When we place the microimplants between
root, if we choose bigger ones, we can have more
chance to touch the roots. If microimplant is touched
the root, the failure rate will be increased significantly
(Kuroda et al, 2007-b)
3. Depending on the inserting sites
Buccal & labial areas of maxilla : Cortical bone in these
areas is not that thick, so use tapered microimplant
neck of 1.3-1.4mm and tip of 1.2-1.3mm thick.
Microimplants made by titanium alloys of this thickness
can be inserted safely without pre-drilling on maxillary
buccal areas.
Palatal areas of maxilla: Soft tissue is thick, so usually
micro implants
of longer than 10mm is needed, but the longer, the
higher possibility of breakage, so use a little thicker
ones ( 1.5-1.6 mm of neck ) than buccal areas. The
distance between roots is greater in palatal areas than
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 REVIEW

Fig 1. Implant anchorage to move maxillary canine Fig 2. Implant anchorage to move maxillary canine

Fig 3. Uprighting tilted molars Fig 4. Types of micro implants

Fig 5. Micro implants to minimize edentulous space Fig 6. Approximate size of a micro implant

IJCD • APRIL, 2013 • 4(1)

63 © 2013 Int. Journal of Contemporary Dentistry

buccal area, there is lower possibility of root contact
even when using thicker microimplants.
Midpalatal suture : There is no worries for root contact,
and also this is sutured area, so thicker ones are used.
Micro implants of diameter larger than 1.7mm is
recommended. Even 2.7mm thick one can be used for
younger cases.
Buccal & labial areas of mandible : Cortical bone of
mandible is harder than maxilla, so, a little thicker ones
(1.4-1.6mm) are better to prevent breakage especially
for self-drilling (drill-free) method.
Surgical Procedure:
The surgical protocol is similar to standard implant
surgery. Placement must be aseptic, atraumatic, and
precise to ensure success. Literature does not provide a
justifiable answer to the time to wait before loading
these implants18,19. But it has been clearly proved that
direct orthodontic forces generate less stress on
implants due to limited force imposed (< 3N, about 300
g). With good bone quality and primary stability,
immediate loading is a possibility. Complete
osseointegration is not necessary but it is not very
feasible to apply full load during the healing period. So,
loading time should be a clinical decision based on the
individual case.
Loading and Anchorage Considerations:
In contrast to dental implants, orthodontic miniscrews
are loaded immediately, and most authors suggest the
use of light forces early on.44 Only a few studies, mostly
on animals, have dealt with the investigation of tissue
reaction to immediate loading of miniscrew
implants.45-47. In a study using finite element analysis,
it was found that immediate loading should be limited
to 50 cN of force in a 2 mm diameter miniscrew
implant. In fact, Liou et al.48 found that miniscrew
implants might move according to orthodontic loading
in some patients, and it is therefore advised to allow 2
mm of safety clearance between the miniscrew implant
and dental roots of the adjacent teeth.
Implant Maintenance:
After surgery, the surrounding soft tissues must be
maintained to ensure longevity of the implant. Plaque
accumulation near the gingival margin can cause
perimucositis and later peri-implantitis. Without proper
management implant failure is even a possibility.
Therefore, patients must be instructed to follow daily
plaque control at home and have periodic professional
care, similar to regular periodontal maintenance.
IJCD • APRIL, 2013 • 4(1)
© 2013 Int. Journal of Contemporary Dentistry
REVIEW
Limitations:
Limitations of micro implants include longer treatment
time, financial concerns, and anatomical limitations.
However, the benefit from superior anchorage and time
saved by using implant anchorage often exceeds the
healing time after surgery. Implant surgery does cost
more than other treatments. In addition, implant
anchorage reduces the risk of jeopardizing existing
dentition. Application of implants might be limited by
the amount and quality of bone20,21. Therefore,
thorough evaluation is critical before treatment.
Conclusions
Currently, micro implants have become predictable and
reliable adjuncts for orthodontic anchorage.
Osseointegration can be used to provide rigid
orthodontic or orthopedic anchorage. Although initial
results are encouraging, the risks and benefits must be
thoroughly evaluated. Further investigations are
needed to standardize the treatment protocol.
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About the Authors
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kportho@rediffmail.com
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