J Oral Maxillofac Surg

67:1595-1599, 2009

Factors Associated With the Stability of

Mini-Implants for Orthodontic Anchorage:
A Study of 414 Samples in Taiwan
Tzu-Ying Wu, DDS,* Shou-Hsin Kuang, DDS, DMSc,† and
Cheng-Hsien Wu, DDS‡

Purpose: To evaluate failure rates and factors associated with the stability of mini-implants used for
orthodontic anchorage.
Patients and Methods: We enrolled 166 patients (35 male patients and 131 female patients) who had
consecutively received mini-implants for orthodontic anchorage at the Section of Orthodontics and Pediatric
Dentistry, Taipei Veterans General Hospital (Taipei, Taiwan) from January 2001 to December 2006. A total of
414 mini-implants with diameters ranging from 1.2 to 2.0 mm were evaluated. Clinical variables for analysis
were divided into host-related and implant-related factors. Mini-implants that could be maintained for
orthodontic anchorage for more than 6 months were considered to be successful. Statistical analysis was used
to evaluate the failure rate in our study cohort and to identify possible associated factors.
Results: The overall failure rate was 10.1% (42 of 414 screws) with orthodontic force loading for more
than 6 months. Most failures were due to loosening and occurred within the first 2 weeks. Differences
in overall failure rates for the maxilla and mandible (9.3% and 16.3%, respectively) were not statistically
significant. A lower failure rate was found for the maxilla with implant diameters equal to or less than 1.4
mm (P ⫽ .036). The left side had a lower failure rate than the right (6.7% vs 13.9%, P ⫽ .019). Length
and type of mini-implants, age, and gender were not associated with mini-implant failure.
Conclusions: Use of mini-implants for anchorage is reliable. In our study the overall success rate was
89.9%. Careful diameter selection for different locations is essential. In the maxilla an implant diameter
equal to or less than 1.4 mm is recommended. In the mandible an implant diameter larger than 1.4 mm
is suggested for better orthodontic anchorage. Hygienic care of implantation sites should also be
emphasized for long-term success of mini-implant anchorage.
© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:1595-1599, 2009

Anchorage control is the cornerstone of orthodontic
treatment. Good anchorage control ensures that the teeth
can move predictably. Accordingly, various techniques
have been developed to obtain good anchorage, such as
the multi-bracket appliance, headgear, and chin cap.1
Received from the Department of Stomatology, Taipei Veterans
General Hospital, and School of Dentistry, National Yang-Ming
University, Taipei, Taiwan.
*Attending Physician, Section of Orthodontics and Pediatric Den-
tistry.
†Division Chief, Section of Orthodontics and Pediatric Dentistry.
‡Attending Physician, Section of Oral and Maxillofacial Surgery.
Address correspondence and reprint requests to Dr Wu: Section
of Oral and Maxillofacial Surgery, Department of Stomatology,
Taipei Veterans General Hospital, and School of Dentistry, National
Yang-Ming University, No. 201, Sec. 2, Shipai Road, Beitou District,
Taipei City, 112 17, Taiwan; e-mail: wu_ch@vghtpe.gov.tw
© 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6708-0004$36.00/0
doi:10.1016/j.joms.2009.04.015
The efficacy of these traditional techniques largely de-
pends on patient compliance and the pre-existing dental
condition. The use of mini-implants to obtain absolute
anchorage has recently become very popular in clinical
orthodontic approaches and has had promising re-
sults.2-8 In our department mini-implants for orthodontic
anchorage have been used since 2001. Compared with
miniplates, mini-implants are less expensive, they are
small enough for placement at any surface of the alveo-
lar process, and techniques for manipulation are rela-
tively simple. To obtain desirable anchorage, the stabil-
ity of mini-implants is a prerequisite. The purpose of this
study was to investigate factors relating to the clinical
failure of mini-implants in our patient cohort.
Patients and Methods
STUDY POPULATION
From January 2001 to December 2006, 166 patients
(35 male patients and 131 female patients; mean age,
26.5 ⫾ 8.9 years) who had received mini-implants

1595
1596
(total number, 414) for orthodontic anchorage at the
Section of Orthodontics and Pediatric Dentistry, Tai-
pei Veterans General Hospital (Taipei, Taiwan) were
enrolled in this study. Among these patients, 4 types
of mini-implants were used: type A (MIA, Absoanchor;
Detos Co, Daegu, South Korea) (n ⫽ 339; diameter of
1.1, 1.2, 1.3, 1.4, 1.5, or 1.7 mm; length of 7, 8, or 10
mm); type B (Lomas; Mondel Medical System GmbH,
Tuttlingen, Germany) (n ⫽ 36; diameter of 1.5 or 2.0
mm; length of 11 or 13 mm); type C (A1; Bio-ray,
Syntec Scientific Co, Chang Hua, Taiwan) (n ⫽ 20;
diameter of 1.5 or 2.0 mm; length of 10 or 12 mm);
and type D microimplants (microscrew; Mondel Med-
ical System GmbH) (n ⫽ 19; diameter of 1.2, 1.4, 1.5,
or 2.0 mm; length of 12 or 13 mm). Type A, B, and C
mini-implants all possess a special screwhead design
for hooking orthodontic appliances, whereas the type
D microimplants, which were originally designed for
orthopedic purposes in the maxillofacial region,
lacked this special attachment (Fig 1). Therefore type
D mini-implants were discontinued for orthodontic
anchorage starting in 2004.
SURGICAL TECHNIQUE
Informed consent was obtained from patients be-
fore surgery. All surgical procedures were performed
by the senior oral surgeon. After local anesthesia, a
small vertical mucoperiosteal stab incision (3-4 mm)
was made on the attached gingivae to expose the
underlying cortical bone. The mini-implant was
tapped into the cortical bone directly with a handheld
screwdriver. In the placement of type A and D mini-
implants, additional pilot hole preparation, by drilling
through the cortical bone with a twist drill at 1,000
rpm under continuous normal saline solution irriga-
FIGURE 1. Four types of mini-implants were used in this study: type
A (Absoanchor) (diameter, 1.4 mm; length, 10 mm); type B (Mon-
deal) (diameter, 2.0 mm; length, 13 mm); type C (Bio-ray) (diam-
eter, 2.0 mm; length, 10 mm); and type D (microscrew; Mondeal)
(diameter, 1.5 mm; length, 13 mm).
Wu, Kuang, and Wu. Mini-Implant Stability. J Oral Maxillofac
Surg 2009.
MINI-IMPLANT STABILITY
tion, was usually necessary because of their smaller
diameters and higher titanium alloy content. Initial
stability was checked, and a form used to record
screw types was filled out by the surgeon. The pa-
tients were given instructions for postoperative care,
and antibiotics were prescribed (500 mg amoxicillin 4
times daily for 3 days). Orthodontic loading was applied
1 to 2 weeks later.
CLINICAL VARIABLES
To assess possible factors that could affect the clin-
ical success of mini-implants, 8 clinical variables were
collected for analysis. The variables in this study were
divided into 2 categories: host-related factors and im-
plant-related factors. Host-related factors were age,
gender, and anatomic details such as the recipient jaw
(maxilla or mandible), side, and sites of implant place-
ment. Implant-related factors included type, length,
and diameter of the mini-implants. To assess the in-
fluence of bone density and thickness of cortical bone
on success, the recipient sites were divided into 4
groups: 1) interdental area (buccal alveolar bone be-
tween teeth), 2) palatal area, 3) edentulous area, and
4) retromolar area (Fig 2).
Mini-implants that were maintained in the bone for
more than 6 months without obvious mobility and that
were capable of sustaining the function of anchorage
were considered successes. If the mini-implants loos-
ened during treatment within 6 months or fractured
during insertion, they were considered failures.
STATISTICAL ANALYSIS
The overall success rate and the success rates for
different clinical variables were calculated. To deter-
mine contributions of continuous data (implant diam-
eter and length) to the level of success, a Student t test
was used. To evaluate clinical success stratified by
different categorical variables, either the ␹2 or Fisher
exact test was performed. The differences between
values were considered significant when a 2-tailed
P value was less than .05. Statistical analysis was
performed with SPSS software, version 15.0 (SPSS,
Chicago, IL).
Results
The overall failure rate was 10.1% for mini-implants
(42 of 414 screws) with orthodontic force loading for
more than 6 months. The main reason for implant
failure was screw loosening that had usually occurred
within the first 2 weeks (data not shown).
The failure rate was not significantly affected by age
or gender, although the failure rate for younger ages
was higher (Table 1). Regarding anatomic factors, the
left side had a significantly lower failure rate than the
right side (6.7% vs 13.9%, P ⫽ .019) but no difference
WU, KUANG, AND WU
FIGURE 2. Sites of screw implant placement (arrows). A, Interdental area between mandibular second premolar and first molar. B, Maxillary
palatal alveolar bone. C, Edentulous ridge of first molar. D, Retromolar area distobuccal to second molar.
Wu, Kuang, and Wu. Mini-Implant Stability. J Oral Maxillofac Surg 2009.
was found for the sites of mini-implant placement
(Table 1). Diameter and length did not appear to
contribute to mini-implant failure (P ⫽ .707 and P ⫽
.356, respectively) (Table 2). However, the difference
in failure rate between the maxilla and mandible was
significant when the implant diameter was equal to or
less than 1.4 mm (8.4% and 16.3%, respectively; P ⫽
.036) (Table 3). Although the opposite result was
found for an implant diameter larger than 1.4 mm,
this finding was not statistically significant (13.2% for
maxilla vs 2.7% for mandible, P ⫽ .085).
The failure rates for each type of mini-implant were
as follows: 10.6% for type A, 2.8% for type B, 20.0%
for type C, and 5.3% for type D. Although type C
mini-implants had a higher failure rate than the other
types, the differences were not statistically significant
(Table 1).
Mini-implants for orthodontic anchorage have been
used in our department since 2001. We also evaluated
experience-related factors by analyzing the failure
rate in terms of yearly trends. The initial failure rate
was as high as 25% in the first few years but progres-
sively declined to 7.9% in 2006 (Fig 3).
Discussion
Anchorage control is important in orthodontic
treatment. A reliable anchorage source eliminates
unwanted tooth movement. The use of mini-implants
to obtain absolute anchorage has gained attention
among contemporary orthodontic practitioners be-
1597
cause of its efficiency and simplicity. In our study the
total failure rate was 10.1%, which was quite similar
to other studies showing the high reliability of mini-
implants for orthodontic anchorage.9-11
In this study we found that diameter and length
were not factors associated with mini-implant failure.
However, the impact of diameter on mini-implant
failure was relevant when considering the jaw in
which the implant was inserted. The data showed a
lower failure rate in the maxilla when the implant
diameters were equal to or less than 1.4 mm. The
different biological adaptation mechanisms of jaw
bone during or after mini-implant insertion may be
responsible. A predrilling process was performed rou-
tinely for these smaller-diameter mini-implants. Heat
is always generated during the drilling process, which
may lead to osteonecrosis.12-14 When the factor of
drilling speed is controlled for, a greater drilling time
will produce higher bone temperature, which is det-
rimental to bone healing.14,15 This might happen
when performing pilot hole preparation over the
mandible because a greater drilling time is needed
because of its cortical bone, which is thicker on
average.15,16 When one takes basic physiology into
consideration, the process of drilling and implant
placement may create stress and heat on the bone,
with microcrack formation,17 and microdamage can
stimulate bone modeling or remodeling in the bone
that supports the implant.18 In the maxilla bone re-
sponds to increased strain through processes result-
ing in modeling, which increased bone volume.19
1598 MINI-IMPLANT STABILITY

Unlike the maxilla, the mandible dissipates the strain Table 2. IMPACT OF DIAMETER AND LENGTH ON
more readily because of its thick cortical bone. Hence CLINICAL SUCCESS OF MINI-IMPLANTS
a remodeling response is evoked instead of a model-
ing response in the mandible. This remodeling re- Clinical Failure No. of
Variable Rate (%) Failure/Total No. P Value
sponse may increase bone porosity and decrease the
strength of the supporting bone.20 This could possi- Diameter .707 (NS)
bly lead to the ultimate failure of the mini-implants in 1.1 mm 5.5 3/55
the mandible. From a clinical view, the increased 1.2 mm 13.9 22/158
1.3 mm 8.8 8/91
cortical bone thickness may cause fracture of mini- 1.4 mm 11.1 1/9
implants with a small diameter. We also noted that 1.5 mm 0 0/17
there was a trend toward more mini-implant failures 1.7 mm 8.7 2/23
in the maxilla when diameters were larger than 1.4 2.0 mm 9.8 6/61
mm. A possible explanation is that mini-implants with Length .356 (NS)
7.0 mm 0 0/2
diameters larger than 1.4 mm were usually placed at a 8.0 mm 13.2 5/38
higher level without keratinized tissue rather than in 10.0 mm 10.5 32/304
the inter-radicular area. According to a recent study, 11.0 mm 0 0/18
nonkeratinized mucosa was a risk factor for mini- 12.0 mm 18.2 4/22
implant failure10; a mini-implant placed in an area of 13.0 mm 3.8 1/26
14.0 mm 0 0/2
movable mucosa might have a higher risk of food 15.0 mm 0 0/2
impaction, which could result in inflammation and
loosening of the mini-implant. On the basis of our For univariate analysis of continuous variables, the Stu-
dent t test was used.
study, implant diameters equal to or less than 1.4 mm Abbreviation: NS, not significant (P ⬎ .05).
are recommended for orthodontic anchorage in the
Wu, Kuang, and Wu. Mini-Implant Stability. J Oral Maxillofac
Surg 2009.

Table 1. CLINICAL VARIABLES RELATED TO FAILURE

RATE OF MINI-IMPLANTS
maxilla whereas the choice of diameter should be
Failure No. of Failures/ P larger than 1.4 mm in the mandible.
Clinical Variables Rate (%) Total No. Value Although there was not a significant difference in
failure rates between sites of implantation, the failure
Gender .67
Male 8.9 7/79 rate appeared to be higher in the mandible (12.6%
Female 10.4 35/335 [17/135]) than in the maxilla (9.3% [25/268]). Corre-
Age .48 spondingly, a recent study by Park et al11 on 227
⬍20 yr 13.5 17/126 screw implants showed a higher failure rate in the
20-25 yr 9.7 11/113
mandible (13.6% for the mandible and 4% for the
25-30 yr 8.2 7/85
⬎30 yr 7.8 7/90 maxilla). However, a similar study by Miyawaki et al9
Side of placement .019* did not show a significant difference between the
Right 13.9 79/209 maxilla (15.9%) and mandible (16.4%). The different
Left 6.7 13/194 outcomes of these studies might be because of di-
Site of placement .133
verse diameter selection and different placement pro-
Interdental 9.7 38/393
Palatal 0 0/11 cedures.
Edentulous 30.8 4/13
Retromolar 0 0/1
Type of screw .194
A (MIA) 10.6 36/339 Table 3. FAILURE RATE OF MINI-IMPLANTS AS A
B (Lomas) 2.8 1/36 FUNCTION OF SITE AND DIAMETER
C (A1) 20 4/20
D (Mondeal) 5.3 1/19 Failure Rate P
Recipient jaw (excluding Maxilla Mandible Value
palate) .311
Maxilla 9.3 25/268 Diameter ⱕ1.4
Mandible 12.6 17/135 mm (n ⫽ 313) 8.4% (18/215) 16.3% (16/98) .036*
Diameter ⬎1.4
For univariate analysis of categorical variables, either the mm (n ⫽ 90) 13.2% (7/53) 2.7% (1/37) .085
Fisher exact test or ␹2 test was used.
*Statistically significant (P ⬍ .05). *Statistically significant (P ⬍ .05).
Wu, Kuang, and Wu. Mini-Implant Stability. J Oral Maxillofac Wu, Kuang, and Wu. Mini-Implant Stability. J Oral Maxillofac
Surg 2009. Surg 2009.
WU, KUANG, AND WU
FIGURE 3. Yearly trends in failure rate for mini-implant anchorage
from 2002 to 2006.
Wu, Kuang, and Wu. Mini-Implant Stability. J Oral Maxillofac
Surg 2009.
Interestingly, our data showed that the side of implant
placement affects outcome: the left side had a lower
failure rate. A similar finding was reported by Park et
al.11 Because our surgeons were all right-handed, a pos-
sible explanation is that there is better hygiene mainte-
nance on the left side in right-handed patients, who
account for most of the population.11,21,22
Regarding implant factors, there was no statistically
significant difference in failure rates among the types,
diameters, or lengths selected. However, for dental
implantation, the shorter and smaller-diameter im-
plants had lower survival rates than their counter-
parts.23,24 The difference in failure rates of screw
implants and dental implants might be because of
different stabilization mechanisms. For dental im-
plants, osseointegration is the key to success, which
is highly related to the contact surface of implant and
bone. Thus a greater diameter and length would pro-
vide more contact surface. On the other hand, the
stability of mini-implants was established by mechan-
ical locking between screw thread and cortical
bone.25 Therefore diameter and length might not play
an important role in the success of mini-implants.
The benefit of mini-implants for orthodontic prac-
tice reduces the complexity and expands the possi-
bility of treatment in the field. To gain appreciably
more anchorage, we recommend the selection of an
implant with a diameter equal to or less than 1.4 mm
in the maxilla and larger than 1.4 mm in the mandible.
Different bone adaptation mechanisms may be re-
sponsible for this phenomenon. Furthermore, hy-
gienic care of peri-implant tissue is important to the
long-term success of mini-implants.
References
1. Favero L, Brollo P, Bressan E: Orthodontic anchorage with
specific fixtures: Related study analysis. Am J Orthod Dentofa-
cial Orthop 122:84, 2002
1599
2. Lee JS, Park HS, Kyung HM: Micro-implant anchorage for lin-
gual treatment of a skeletal Class II malocclusion. J Clin Orthod
35:643
3. Park HS, Bae SM, Kyung HM, et al: Micro-implant anchorage for
treatment of skeletal Class I bialveolar protrusion. J Clin Orthod
35:417, 2001
4. Bae SM, Park HS, Kyung HM, et al: Clinical application of
micro-implant anchorage. J Clin Orthod 36:298, 2002
5. Kyung HM, Park HS, Bae SM, et al: The lingual plain-wire
system with micro-implant anchorage. J Clin Orthod 38:388,
2004
6. Park HS, Kwon OW, Sung JH: Micro-implant anchorage for
forced eruption of impacted canines. J Clin Orthod 38:297,
2004
7. Carano A, Lonardo P, Velo S, et al: Mechanical properties of
three different commercially available miniscrews for skeletal
anchorage. Prog Orthod 6:82, 2005
8. Park HS, Jang BK, Kyung HM: Maxillary molar intrusion with
micro-implant anchorage (MIA). Aust Orthod J 21:129, 2005
9. Miyawaki S, Koyama I, Inoue M, et al: Factors associated with
the stability of titanium screws placed in the posterior region
for orthodontic anchorage. Am J Orthod Dentofacial Orthop
124:373, 2003
10. Cheng SJ, Tseng IY, Lee JJ, et al: A prospective study of the risk
factors associated with failure of mini-implants used for ortho-
dontic anchorage. Int J Oral Maxillofac Implants 19:100, 2004
11. Park HS, Jeong SH, Kwon OW: Factors affecting the clinical
success of screw implants used as orthodontic anchorage. Am J
Orthod Dentofacial Orthop 130:18, 2006
12. Eriksson A, Albrektsson T, Grane B, et al: Thermal injury to
bone. A vital-microscopic description of heat effects. Int J Oral
Surg 11:115, 1982
13. Eriksson AR, Albrektsson T: Temperature threshold levels for
heat-induced bone tissue injury: A vital-microscopic study in
the rabbit. J Prosthet Dent 50:101, 1983
14. Reingewirtz Y, Szmukler-Moncler S, Senger B: Influence of
different parameters on bone heating and drilling time in im-
plantology. Clin Oral Implants Res 8:189, 1997
15. Sharawy M, Misch CE, Weller N, et al: Heat generation during
implant drilling: The significance of motor speed. J Oral Max-
illofac Surg 60:1160, 2002
16. Brisman DL: The effect of speed, pressure, and time on bone
temperature during the drilling of implant sites. Int J Oral
Maxillofac Implants 11:35, 1996
17. Hoshaw SJ, Watson JT, Schaffler MB, et al: Microdamage at
bone-implant interface affects bone remodeling activity. Trans
Orthop Res Soc 20:188, 1995
18. Garetto LP, Tricker ND: Remodeling of bone surrounding at
the implant interface, in Garetto LP, Turner CH, Duncan RL, et
al (eds): Bridging the Gap Between Dental and Orthopedic
Implants. Indianapolis, School of Dentistry, Indiana University,
2002, pp 89-99
19. Huja SS: Mechanisms of bone adaptation to miniscrew im-
plants, in Cope JB (ed): OrthoTADs: The Clinical Guide and
Atlas. Dallas, TX, Under Dog Media, 2007, pp 23-33
20. Hoshaw SJ, Brunski JB, Cochran GVB: Mechanical loading of
Brånemark implants affects interfacial bone modeling and re-
modeling. Int J Oral Maxillofac Implants 9:345, 1994
21. Tezel A, Orbak R, Canakci V: The effect of right or left-hand-
edness on oral hygiene. Int J Neurosci 109:1, 2001
22. Addy M, Dummer PM, Hunter ML, et al: The effect of tooth-
brushing frequency, toothbrushing hand, sex and social class
on the incidence of plaque, gingivitis and pocketing in adoles-
cents: A longitudinal cohort study. Community Dent Health
7:237, 1990
23. Winkler S, Morris HF, Ochi S: Implant survival to 36 months as
related to length and diameter. Ann Periodontol 5:22, 2000
24. Weng D, Jacobson Z, Tarnow D, et al: A prospective multi-
center clinical trial of 3i machined-surface implants: Results
after 6 years of follow-up. Int J Oral Maxillofac Implants 18:417,
2003
25. Costa A, Raffainl M, Melsen B: Miniscrews as orthodontic an-
chorage: A preliminary report. Int J Adult Orthodon Orthog-
nath Surg 13:201, 1998