ORIGINAL ARTICLE

Evaluation of reused orthodontic mini-

implants on stability: An in-vivo study
€
Serkan Ozkan, a
Su€ leyman Kutalmış Bu
€ yu € k,b and Yasin Atakan Benklic
€ k,a Fırat Go
_
Ordu, Kocaeli, and Izmir, Turkey

Introduction: During treatment, some patients may need to change the location of mini-implants (MIs). This
study investigated the stability of MIs relocated to another position in the same patient using the periotest and
torque device. Methods: Twenty-nine MIs were applied randomly to 1 side of the maxillary region, and torque
and periotest values were recorded. The patients were followed-up at 4-week intervals, and periotest
measurements were performed at each session. After recording the torque and periotest values in the fourth
session, the MIs were removed. After applying the appropriate sterilization procedure, the same MIs were
relocated to the contralateral side of the patients’ jaw, and distalization was achieved using a similar
procedure for the group of as-received MIs. Results: Negative correlations were obtained between the torque
meter and periotest data for both MI groups. We observed no significant effect of the MI group on periotest mea-
surements (P .0.05). The effect of the MI group on torque values and the interaction effect of the MI group and
torque values were not statistically significant (P .0.05). Conclusions: It is possible to achieve similar stability
values with as-received and retrieved MIs when appropriate cleaning and sterilization protocols are performed.
(Am J Orthod Dentofacial Orthop 2022;162:689-94)

A
nchorage control has always been an important
factor for successful orthodontic treatment.
Among the variety of skeletal anchorage systems
that have been introduced in orthodontic practice over
the last 2 decades, mini-implants (MIs) have become
popular because of their lower cost, simpler placement
with less traumatic surgery, and less discomfort for pa-
tients compared with other skeletal anchorage systems.1
The success rate of MIs and factors affecting their stabil-
ity have been studied extensively. The use of MIs in or-
thodontics for enhancing anchorage has advanced in
recent years with several applications, including the
retraction of anterior teeth, correction of open bites,
and distalization and intrusion of teeth.2,3
The stability of MIs depends on many factors,
including surface properties of the metal, thread design,
and anatomic structural differences between their loca-
tions. Moreover, MIs can lose their stability because of
changes in their surface properties owing to the tissue
fluids and forces applied during orthodontic treat-
ment.4,5 By contrast, stability is an objective and
measurable value that can be obtained via a variety of
devices and methods, including periotest,6 resonance
frequency analysis,7 insertion and removal torque
values,8 and the pullout strengths of MIs.9
This study investigated the stability of MIs relocated
to another position in the same patient using the periot-
est and torque device. The null hypothesis of the study
was as follows: the stability data obtained from the as-
received mini-implant (AMI) and retrieved mini-
implant (RMI) implanted on the same patient did not
show any statistically significant difference.

a
Department of Orthodontics, Faculty of Dentistry, Ordu University, Ordu, MATERIAL AND METHODS
Turkey.
b
Private practice, Kocaeli, Turkey. The study was performed at Ordu University and
c
Private practice, _Izmir, Turkey approved by the clinical research ethics committee of
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. Ordu University (No. 2015/6). The study included pa-
This work was supported by the Scientific Research Projects Commission of Ordu tients with Class II malocclusion in which orthodontic
University (AR-1528).
€
treatment required maxillary first premolar teeth extrac-
Address correspondence to: Serkan Ozkan, Department of Orthodontics, Faculty
of Dentistry, Ordu University, Ordu 52200, Turkey; e-mail, dtserkanozkan@ tion. The treatment progress was assessed at 4-time in-
gmail.com. tervals (T0-T3). For the possibility that canine retraction
Submitted, January 2021; revised and accepted, June 2021. could not be completed within this period, the
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved. anchorage requirement was planned to be moderate
https://doi.org/10.1016/j.ajodo.2021.06.024 anchorage close to the maximum anchorage. Other
689
690
inclusion criteria were as follows: (1) permanent denti-
tion, (2) Class I skeletal relationship, (3) good oral hy-
giene, (4) no anomaly in the transverse direction, (5)
adequate overjet and overbite relationship to provide
space for anterior incisor retraction, (6) no maxillary
canine with supraposition or excessive rotation, and (7)
no systemic disorder that contraindicated orthodontic
treatment.
For the power analysis, we assumed that the stability
values at different times (T0, T1, T2, and T3) do not
change depending on whether retrieved or as-received
MI is used. Hence, a 2 3 4 mixed model analysis of vari-
ance (ANOVA) was performed. In this analysis, a priori
power analysis was performed to calculate the minimum
sample size required to detect medium-sized effects with
85% power. Power analyses were performed using G*Po-
wer (version 3.1.3; Franz Faul, Christian-Albrechts-
Universitat, Kiel, Germany). The sample size required
to detect a medium-sized effect in the population with
85% power was 26, and approximately 89% power
was calculated using 29 patients included in the study.
Bilateral extractions were not performed simulta-
neously, and extractions on the opposite side were
delayed until the treatment on the first side was
completed. Considering the possibility of space loss, all
extractions were performed 1 week before MI insertion.
One week after tooth extraction, AMIs were randomly
applied to the right or left maxilla of the patients who
met the inclusion criteria until a sample size of 29 pa-
tients was reached (mean age, 15.95 6 1.76 years; 8
males and 21 females). Fifty-eight sectional arches
with reverse closing loop (RCL) bent using 0.016 3
0.022-in stainless steel wire were prepared for the 29 pa-
tients.
One AMI and 2 RMIs failed during the distalization
process because of the patients’ lack of dental hygiene.
Therefore, these patients were excluded from the study,
and 3 new patients were included considering the
abovementioned inclusion criteria.
The periotest instrument uses a percussion rod
controlled by a microcomputer. This rod impacts an ob-
ject 4 times per second for 4 seconds, for 16 percussions.
The more stable the object, the quicker the percussion
rod decelerates and returns to the handpiece. The micro-
computer measures the time the rod requires to come in
contact with the object, and the shortest time indicates a
more stable object.10
MIs (Aarhus Anchorage System, Medicon eG, Tuttlin-
gen, Germany) with a total length of 11.2 mm, a diam-
eter of 1.5 mm, and an endosseous threaded body part
length of 8 mm were used in this study. Before inserting
MIs, the patients were instructed to rinse with a chlor-
hexidine solution. Then, a light local infiltrative
November 2022  Vol 162  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
€
Ozkan et al
anesthesia was applied to retain the sensitivity of the
nerve fibers in the periodontal ligament. MIs were in-
serted in the interdental region between the maxillary
first molar and second premolar region (Fig 1, A) with
an approximate angle of 60 -70 to the bone surface
in the vertical plane, and the primary stability (T0) was
measured 3 times, both horizontally and vertically,
with the periotest at an angle of approximately 15 -
20 to the horizontal plane of the mini-implant (Fig 1,
B). All MIs were inserted by the same surgeon to avoid
inter-surgeon variations.
After the insertion of AMIs, the distalization process
of the canine tooth was initiated using the segmental
RCL canine retractor. Before the RCL retractors were
placed, 45 antitip and 15 -20 antirotation bends
were incorporated into the sectional arch. The retractor
was activated approximately 2 mm to achieve 120-150
g of retraction force (Fig 2, A). At each appointment,
retraction forces were measured with a Correx gauge (Is-
pringen, Germany).
Retractors were reactivated at 4-week intervals, and
retraction was continued until the canines achieved a
Class I relationship.
Patients were followed-up at 4-week intervals, the
retractors were removed, and periotest measurements
of MIs were recorded 3 times horizontally and vertically
at each interval. Then, the same retractors were replaced.
At the end of the distalization process, the last periotest
measurements were made (T3), and MIs were removed
using the torque meter and cleaned and sterilized.
Regarding the cleaning process, MIs were first soaked
in distilled water for 30 minutes in an ultrasonic cleaner
and washed for 5 seconds under the air-water spray to
remove debris. The screw was then placed in 37% phos-
phoric acid for 10 minutes and in sodium hypochlorite
for 30 min, washed with distilled water, dried using
the air water spray, and placed in sterilization packages.
RMIs were then sterilized in an autoclave at 121 C and
18 pounds per square inch pressure for 20 minutes.
Sterilized RMIs were inserted in the contralateral side
of the maxilla with the same previously described
method (Fig 2, B). The distalization process was
continued until the Class I canine relationship was
confirmed using the same method as for AMIs. The
removal torque value was recorded with a torque meter.
Statistical analysis
Statistical analysis was performed using SPSS
(version 20.0; IBM Corp, Armonk, NY). To measure the
reliability of the measurements, 2-tailed Pearson corre-
lation coefficients for the 3 measurements in each period
for AMI and RMI groups were examined separately for
€
Ozkan et al 691

Fig 1. Measurement of MI stability with (A) torque meter and (B) periotest.

Fig 2. Clinical photographs of (A) AMI and (B) RMI with a canine retraction device.

the horizontal and vertical periotest measurements. Cor-

Table I. Minimum correlation values of 3 consecutive
relation between the torque meter and periotest was also
measurements performed by periotest in horizontal
evaluated using Pearson’s correlation coefficients for
and vertical directions for as-received MIs and
both AMI and RMIs. Repeated measures (2 3 4) ANOVA
retrieved mini-implants at 4 different times (T0, T1,
was performed to evaluate the interaction between the 2
T2, and T3)
MI groups and time. Statistical significance was defined
at P \0.05. Time AMI-horizontal RMI-horizontal AMI-vertical RMI-vertical
T0 0.982* 0.978* 0.990* 0.990*
RESULTS T1 0.927* 0.998* 0.980* 0.991*
T2 0.992* 0.993* 0.995* 0.864*
Correlation analysis between the 3 measurements T3 0.994* 0.993* 0.987* 0.991*
taken vertically and horizontally for both AMI and
*P \0.001, 2-tailed.
RMIs showed a strong and significant correlation
between the 2 measurements performed at the same
period for each group (rmin 5 0.864) (Table I). Negative
Table II. Correlations between periotest and torque
correlations were observed between the torque meter
and periotest data for both AMI and RMI groups meter values
(rmin 5 0.126), excluding the measurements during AMI RMI
removal for the AMI group (rmin 5 0.036) (Table II).
Correlations Horizontal Vertical Horizontal Vertical
ANOVA analysis for both horizontal and vertical peri-
Ti-Pi 0.625** 0.137* 0.326* 0.282*
otest measurements revealed no significant effect of Tr-Pr 0.042* 0.036* 0.126* 0.227*
MI group on periotest measurements (horizontal:
Pi, periotest, MI insertion value; Pr, periotest, MI removal value; Ti,
F [1, 28] 5 1.73, P .0.05, hp2 5 0.058; vertical: torque meter, MI insertion value; Tr, torque meter, MI removal value.
F [1, 28] 5 2.75, P .0.05, hp2 5 0.089), whereas differ- *P .0.05, 2-tailed; **P \0.01, 2-tailed.
ence in the main effect of time was statistically signifi-
cant (horizontal: F [2.37, 66.43] 5 135.66, P \0.001,
hp2 5 0.829; vertical: F [2.09, 58.56] 5 56.18, (horizontal: F [3, 84] 5 1.43, P .0.05, hp2 5 0.048; ver-
P \0.001, hp2 5 0.667). The interaction effect of MI tical: F [2.15, 60.23] 5 1.61, P .0.05, hp2 5 0.054)
group and time variables was not statistically significant (Table III). Moreover, the effect of MI group on torque

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Ozkan et al

Table III. Effect of MI group (as-received MIs and retrieved MIs) and measurement time intervals on the periotest and
torque meter values
ANOVA Pairwise Comparisons

Variables df F hp2 P value T0-T1 T0-T2 T0-T3 T1-T2 T1-T3 T2-T3

Horizontal Periotest
MI 1 1.737 0.058 0.198 0.000* 0.000* 0.000* 1 0.813 1
Time 3 135.664 0.829 0.000*
MI 3 time 3 1.427 0.048 0.241
Vertical Periotest
MI 1 2.745 0.089 0.109 0.000* 0.000* 0.000* 0.96 0.54 1
Time 3 56.178 0.667 0.000*
MI 3 time 3 1.610 0.054 0.207
Torque meter
MI 1 0.014 0.000 0.908
Time 1 207.629 0.881 0.000*
MI 3 time 1 0.895 0.031 0.352
Df, degrees of freedom.
*P \0.001.

values and the interaction effect of MI group and torque
values were not statistically significant (F [1, 28] 5 0.14,
P .0.05, hp2 \0.001; F [1, 28] 5 0.90, P .0.05,
hp2 5 0.054 respectively), whereas difference in
the main effect of time was statistically significant
(F [1, 28] 5 207.63, P \0.001, hp2 5 0.881) (Table III).
DISCUSSION
The widespread use of MIs has effectively prevented
anchorage loss in patients in which anchorage is of crit-
ical importance. As mentioned previously, it may be
necessary to change the location of MI in some patients
during treatment. The possibility of reusing MIs reduces
treatment costs and increases the number of applica-
tions of the miniscrews quantity per treatment.11
Mothobela et al12 showed that the failure rate and
high cost of MIs are deterrent factors.
Currently, the results of sterilizing and reusing some
medical devices have been investigated in several
studies, particularly in the medical field.13-16 Schwartz
et al15 investigated the results of sterilizing and reusing
implant heads on a different patient and reported no
clinical difference, although there were changes in the
surface properties. Kirkpatrick et al13 and Selvaraj
et al16 reported that reusing pacemakers and defibrilla-
tors are safe and feasible, particularly in low-middle-
income countries, when adhering to certain sterilization
procedures.
A review of the literature records 2 successful
methods to remove microorganisms, body fluids, and re-
sidual surface debris from possible partial osseointegra-
tion after the original use of miniscrews and subsequent
reinsertion of MIs. The first method is autoclave
sterilization. During the sterilization phase, microorgan-
isms, including bacteria, spores, and fungi, are elimi-
nated, their growth is prevented, and protein residues
are denatured to reduce allergenic risk.11 Methods that
can be used for sterilization include autoclaving, gamma
irradiation, oxygen plasma therapy, and ultraviolet radi-
ation. Autoclave sterilization is a method that is
routinely performed in orthodontic applications and
provides acceptable histologic results for MI reimplanta-
tion.17 The second method was defined by Noorollahian
et al,11 and it involves placing MIs in 37% phosphoric
acid for 10 minutes and subsequently in a sodium hypo-
chlorite solution for 30 minutes. They stated that low pH
phosphoric acid (2.25-3.05) could remove the mineral
component of residual bone debris,18 whereas sodium
hypochlorite can dissolve organic components.19 Their
study also showed that this method does not cause
any side effects that affect mechanical properties, such
as insertion and removal torque, fracture resistance,
and the residual residue amount. Therefore, our study
used this protocol after mechanical ultrasonic cleaning
was applied.
One of the unfortunate reasons for MI failure is an MI
fracture during insertion or removal. Mattos et al20
found a statistically significant decrease in the fracture
torque values of RMIs and did not recommend reusing
MIs, although the fracture torque values were greater
than the insertion torque values specified by Motoyoshi
et al.21 By contrast, Noorollahian et al11 and Estelita
et al22 found no difference between AMI and RMIs. In
parallel, Hergel et al,23 who conducted their study on
artificial bones, stated that despite the wear and atrophy
observed on RMIs, no significant change was found in
overall primary stability and fracture torque resistance

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Ozkan et al
after the second insertion. In this study, the insertion
torque values (15.09 6 1.04 Ncm) were well below the
fracture torque values (36.82 6 7.41 Ncm) specified by
Mattos et al,20 and no MI was fractured during the inser-
tion.
Primary stability is mainly affected by the MI design,
cortical bone thickness, and placement angle.24 Studies
have used periotest, resonance frequency analysis, inser-
tion and removal torque measurements, and tensile
strength tests to evaluate primary stability.6-9 Insertion
and removal torque and tensile strength tests are the
most common methods for evaluating primary
stability.24,25 Good quality and thickness of cortical
bone and torque values within the optimal range in-
crease MI stability.8,21 In a study by Watanabe et al,26
the periotest was proposed to assess the suitability of
the cortical bone thickness. This alternative would
reduce or eliminate the exposure to radiation associated
with cone-beam computed tomography. In addition, a
significant correlation was found between these 2
variables and the periotest in the same study. When
cone-beam computed tomography results were absent,
periotest values were an important index in predicting
the prognosis of MI insertion. In addition to measuring
the torque values, pullout testing25 could not be used
in our current study as it can only be applied to labora-
tory studies.
In this study, in addition to the differences between
AMI and RMIs in terms of stability, the consistency of 2
different stability evaluation methods, torque meters
and periotest, was compared. In this context, the con-
sistency and measurement error of periotest was
examined with repeated periotest measurements taken
from AMI and RMIs in both horizontal and vertical di-
rections. Manz et al27 made 3 measurements from
each sample in their in vitro study in which they inves-
tigated the reliability of the periotest device and eval-
uated the consistency among the measured values.
They stated that the periotest system is highly repro-
ducible for both intra-researcher and inter-
researchers. Crum et al28 investigated the reliability
of wired and wireless periotest devices in vitro; they
measured 3 times for each sample and stated that
both wired and wireless periotest devices gave reliable
and meaningful results while evaluating the bone-
implant surface. In our study, the correlation of the
3 periotest measurements taken vertically and hori-
zontally was examined, and a high degree of correla-
tion was observed (rmin 5 0.927).
In the present study, the correlation between the
vertical and horizontal measurements of the periotest
device and insertion and removal torque values was
evaluated separately. Çehreli et al29 found a negative
American Journal of Orthodontics and Dentofacial Orthopedics
693
correlation between insertion torque and periotest
values in their study. The negative correlation between
the insertion torque and periotest values could be ex-
plained by the fact that low periotest values indicate
high implant stability.26 Although the correlation be-
tween the insertion torque and periotest values was
examined in these studies, the correlation of the vertical
and horizontal measurements of both insertion and
removal torque values was also investigated in the pre-
sent study. Considering the insertion torque values in
our study, horizontal periotest measurements had a sig-
nificant negative correlation with AMIs, supporting the
previous studies, whereas they showed a marginally sig-
nificant (values between 0.05 and 0.1 can be considered
marginally significant) negative correlation with RMIs
(r 5 0.33, P 5 0.085). Although there was a negative
correlation in vertical measurements, no statistical sig-
nificance was found.
CONCLUSIONS
1. Because there was no statistically significant differ-
ence between the 2 MI groups, the null hypothesis
was accepted.
2. Similar stability values with AMIs and RMIs can be
achieved when appropriate cleaning and steriliza-
tion protocols are applied.
3. It is clinically possible to achieve a similar perfor-
mance between AMIs and MIs applied for the
second time on the same patient.
AUTHOR CREDIT STATEMENT
€
Serkan Ozkan contributed to methodology and orig-
inal draft preparation, S€ uleyman Kutalmış B€ uy€uk
contributed to data curation and conceptualization,
Fırat G€ok contributed to investigation and resources,
and Yasin Atakan Benkli contributed to formal analysis.
ACKNOWLEDGMENTS
This work was supported by the Scientific Research
Projects Commission of Ordu University (AR-1528). We
thank Bircan Bektaş for her valuable contributions in
the sterilization stage of mini-implants.
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