ORIGINAL ARTICLE

Midpalatal miniscrew insertion: The

accuracy of digital planning and surgical
placement
Adli M. Q. Al-Gazzawi,a Vanessa Knode,b Bjorn Ludwig,b,c Alaa Othman,a Angelo Salamini,d Nikolaos Pandis,e
and Padhraig S. Flemingf
Amman, Jordan, and Traben-Trarbach and Saar, Germany, and Milan, Italy, and Bern, Switzerland, and Dublin, Ireland

Introduction: The objective of this study was to investigate the accuracy of palatal miniscrew insertion, evalu-
ating the effect of guide fabrication and surgical placement. Methods: Guided insertion of bilateral paramedian
palatal miniscrews was undertaken using Appliance Designer software (3Shape, Copenhagen, Denmark). A
resin surgical guide (P Pro Surgical Guide; Straumann AG, Basel, Switzerland) was used. Superimposition of
the miniscrew position relative to the digital design was undertaken using bespoke software (Inspect 3D module,
OnyxCeph; Image Instruments GmbH, Chemnitz, Germany) to assess surgical inaccuracy. Miniscrew position
relative to the surgical guide was also assessed to isolate the effect of planning inaccuracies. Both horizontal and
vertical discrepancies were evaluated at both implant locations. Results: Twenty-seven patients having bilateral
palatal insertions were examined. Mean discrepancies were \0.5 mm, both in the horizontal and vertical planes.
The mean overall horizontal and vertical discrepancy between the digital design and final miniscrew position on
the left side was 0.32 6 0.15 mm and 0.34 6 0.17 mm, respectively. The maximum horizontal discrepancy
observed was 0.72 mm. No significant differences were observed in relation to the accuracy of mini-implant
positioning on the basis of sidedness, either for horizontal (P 5 0.29) or vertical (P 5 0.86) discrepancy.
Conclusions: High levels of accuracy associated with guided insertion of paramedian palatal implants were re-
corded with mean discrepancies of less than 0.5 mm both in the horizontal and vertical planes. No difference in
accuracy was noted between the left and right sides. Very minor levels of inaccuracy associated both with sur-
gical techniques and surgical guide fabrication were recorded. (Am J Orthod Dentofacial Orthop 2024;166:69-
75)

T
he use of miniscrews in orthodontics has increased
in recent years, providing a predictable means of
anchorage reinforcement1 while offering versatility
in producing a range of tooth movements in all 3 spatial
a
Private practice, Amman, Jordan.
b
Private practice, Traben-Trarbach, Germany.
c
Department of Orthodontics, University of Homburg, Saar, Germany.
d
Henry-Schein Krugg, Milan, Italy.
e
Department of Orthodontics and Dentofacial Orthopedics, Medical Faculty,
Dental School, University of Bern, Bern, Switzerland.
f
Division of Public and Child Dental Health, Dublin Dental University Hospital,
The University of Dublin, Trinity College Dublin, Dublin, Ireland.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
The datasets used and/or analyzed during the current study are available from
the corresponding author on reasonable request.
Address correspondence to: Padhraig S. Fleming, Division of Public and Child
Dental Health, Dublin Dental University Hospital, The University of Dublin,
Trinity College Dublin, Dublin 2, Ireland; e-mail, padhraig.fleming@dental.
tcd.ie.
Submitted, November 2023; revised and accepted, February 2024.
0889-5406/$36.00
Ó 2024 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2024.02.014
planes. The definition of success of a temporary skeletal
anchorage device (TSAD) is not clear-cut; however, it has
been suggested that the presence of a TSAD $6 months
after placement may represent success.2 Very promising
success rates have been reported for implants placed in
the palate.3,4 However, miniscrews are prone to failure,
with failure rates of up to 13% being representative.5
A further problem with TSAD placement is inaccuracy,
risking contact with key structures, including adjacent
roots and other anatomic boundaries.6,7 Furthermore, ac-
curate placement is important to maximize biomechan-
ical advantages and, indeed, to offer optimal levels of
stability and bicortical engagement when required. The
palatal bone depth and cortical bone thickness are more
conducive in the first and second maxillary premolar
region, with depth reducing laterally.8
Although the popularity of median and paramedian
palatal sites for TSAD placement has increased in recent
years, research concerning the number and nature of
complications is limited, with the invasiveness of
procedures inversely related to their acceptance.9 Guided

69
70
Fig 1. A and B, Mini-implant guide fabrication; C, Clinical use; D, TSAD placement.
insertion techniques involving the use of 2-dimensional
and 3-dimensional (3D) radiographic imaging coupled
with intraoral (IO) scanning have therefore been harnessed
as a means of improving the accuracy of miniscrew place-
ment. These approaches have shown encouraging levels
of accuracy coupled with the use of lateral cephalometry
and cone-beam computed tomography (CBCT).10,11
Our hypothesis for this study was based on the
assumption that the level of accuracy of guided minis-
crew insertion is negligible overall, with little impact
on both guide fabrication and practical use. Therefore,
we aimed to evaluate the accuracy of guided palatal
miniscrew placement, examining both the errors associ-
ated with the fabrication of the surgical guide and the
surgical procedures.
MATERIAL AND METHODS
Ethical approval was obtained from the Institutional
Review Board in Amman, Jordan (reference no. SOB
IRB-001). Consecutive patients requiring the indirect
placement of palatal miniscrews were included in the
study (Fig 1, A-D). An IO scan (TRIOS, 3Shape, Copenha-
gen, Denmark) and a CBCT image were obtained for each
patient whose treatment plan included the use of palatal
miniscrews (OrthoLox plus1; Tiger Dental GmbH,
H€orbranz, Austria) to construct a palatal appliance. Appli-
ance designer software from 3Shape was used to create
stereolithographic (STL) files to fabricate surgical guides
for palatal miniscrew insertion (OrthohoLox Plus1,
Promedia Medizintechnik Ahnfeldt GmbH, Siegen,
July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Al-Gazzawi et al
Germany) and to create an STL file for the maxilla
including the miniscrew heads (digital design [DD]).
The Easy CT DICOM Viewer module within Blueskye
software (version 4.8.3, Blueskye plan, Libertyville, IL)
was used to create an STL file of the maxilla (including
bone and teeth) and maxillary teeth (crowns and roots)
within the CBCT image.
The virtual dataset for each patient, including IO scan
and CBCT-extracted STL files, was imported into Appli-
ance Designer software (3Shape). CBCT-extracted STL
files were then aligned with the maxillary STL file (IO
scan) using the “add align model icon.” STL files,
including TSADs (OrthoLox Plus1) of all available diam-
eters and lengths, were already saved using the Appli-
ance Designer software.
The surgical guide was developed from a 3 mm-thick
shell covering palatal mucosa and maxillary teeth.
Appropriately sized TSADs were selected and virtually
aligned and sited to provide optimal bony support
remote from the roots. TSADs were positioned at a 90
angle to the mucosal surface, with the TSAD shoulder
resting on the mucosa. Once the position of the minis-
crews was determined, a shell was designed incorpo-
rating the insertion guide, miniscrew heads, and the
connectors. Three copies of the shell were then created;
to make the surgical guide, to create a model with the
screw heads, and to fabricate the connectors. To finalize
the design of the guide, the “add modify model” icon
was used to remove the miniscrew head and connectors.
The “create combine model” icon allowed subtraction of
the surgical guide from the maxillary STL file. This
Al-Gazzawi et al
deleted any part of the surgical guide that might inter-
fere with the fit of the printed surgical guide. The STL
file of the guide was then exported and printed using
an autoclavable resin material (P Pro Surgical Guide;
Straumann AG, Basel, Switzerland) with the Rapid Shape
3D P 201 printer. An STL file of the miniscrew heads
within the maxillary model (DD) involved the “add
modify model” icon to remove the connectors and the
surgical guide. The “create combine models” icon was
then used to combine the miniscrew head with the
maxillary STL file.
In the in vitro study, maxillary models were created
for 27 patients and used for the insertion of 2 palatal
TSADs using the same surgical template as used clini-
cally. To negate any effect of the hardness of the acrylic
on the accuracy of the miniscrew placement, a hole was
drilled at the miniscrew site. The miniscrews were then
attached to the screwdriver and positioned using the
drilling template. The TSADs were stabilized with self-
cured acrylic resin before being removed from the screw-
drivers and the drilling template. The model with the
TSADs was scanned (model [MO] scan) using the TRIOS
3Shape scanner. To investigate the error associated with
TSAD insertion clinically, superimposition of the DD with
the IO scan was conducted using the “Inspect 3D” mod-
ule in the OnyxCeph software (Image Instruments
GmbH, Chemnitz, Germany). For the in vitro study, su-
perimposition of the DD with the MO scan was per-
formed in the “Inspect 3D” module. In addition, the
superimposition of the IO scan with the MO scan was
performed to identify significant differences between
in vivo and in vitro data. The Inspect 3D module allowed
for precise quantification of differences in the 3D data-
sets compared with the aligned reference model. The
software employed the iterative closest point algorithm
for model registration, using the median palatine raphe
to serve as a stable anatomic reference structure for the
superimposition. Both horizontal and vertical discrep-
ancies were evaluated at both TSADs. The threshold
values for color changes were set to 0.2 mm to detect
noticeable dimensional deviations. These color changes
enabled the identification of the biggest discrepancies
and helped in understanding positional deviations. The
assessment was carried out using the distance reference
as the preferred measurement technique by 1 examiner
(V.K.). The results of the measurements were visually
documented and stored for later analysis and evaluation.
Statistical analysis
Descriptive statistics were calculated and plotted,
highlighting the magnitude of error associated with
each step of guided miniscrew placement. The analysis
American Journal of Orthodontics and Dentofacial Orthopedics
71
included (1) miniscrew position relative to the surgical
guide by comparing the DD and MO scans, (2) in vivo
evaluation of overall error using the surgical guide by
comparing the DD and MO scans, and (3) miniscrew
insertion inaccuracy associated with surgical guides
related to in vivo and in vitro factors by comparing the
DD and MO scans.
Statistical differences between the accuracy of place-
ment based on left and right sides were evaluated using
paired t tests. All analyses were conducted in Stata soft-
ware (version 17; StataCorp, College Station, Tex).
RESULTS
In total, 27 patients having bilateral palatal TSAD
insertion (54 TSADs) in paramedian palatal sites using
the digitally designed surgical guide were examined
in vitro and in vivo.
Some degree of inaccuracy was observed with minis-
crew insertion, with mean discrepancies being \0.5
mm both in the horizontal and vertical planes (Fig 2;
Table). The mean overall horizontal and vertical discrep-
ancy between the DD and final TSAD position (DD final
position IO) on the left side was 0.32 6 0.15 mm and
0.34 6 0.17 mm, respectively. The maximum horizontal
discrepancy observed was 0.72 mm. No significant differ-
ences were identified in relation to the accuracy of min-
iscrew positioning on the basis of sidedness either for
horizontal (P 5 0.29) or vertical (P 5 0.86) discrepancy
(Table).
In terms of the source of inaccuracy, little discrepancy
was noted between the DD and IO scans, with mean hor-
izontal differences of 0.22 mm and 0.19 mm on the left
and right sides, respectively (Fig 3; Table). Similarly, mi-
nor amounts of inaccuracy were recorded in relation to
the surgical guide (Fig 4; Table) with a mean left-sided
horizontal discrepancy of 0.35 6 0.17 mm and vertical
inaccuracy of 0.37 6 0.19 mm.
DISCUSSION
The increasing recognition of the superiority of para-
median midpalatal sites for temporary anchorage de-
vices has contributed to a range of novel applications,
including miniscrew-assisted rapid palatal expansion.
This increasing versatility has, in turn, been underpinned
by progress in relation to digital appliance design and
fabrication. As such, more complex and nuanced,
customized multiimplant designs with associated super-
structures are commonly used. Therefore, there is a pre-
mium on accurate miniscrew placement both to
minimize associated risk and to streamline clinical pro-
cedures. Based on the present findings, the mean error
associated with paramedian palatal miniscrew
July 2024  Vol 166  Issue 1
72 Al-Gazzawi et al

Horizontal Vertical

2
Density

0.0 0.2 0.4 0.6 0.0 0.2 0.4 0.6

Design_IO
Side Left Right

Fig 2. Graphical display of overall inaccuracy of TSAD insertion (IO final position DD), including hor-
izontal and vertical discrepancies for both left and right sides.

Table. Horizontal and vertical discrepancy associated with bilateral miniscrew placement in vitro and in vivo
Horizontal Vertical

Dimension Left Right P value* Left Right P value*

design_io 0.32 6 0.15 0.12-0.72 0.35 6 0.16 0.12-0.6 0.43 0.34 6 0.17 0.08-0.62 0.31 6 0.17 0.03-0.68 0.39
design_mi 0.22 6 0.12 0.04-0.43 0.19 6 0.12 0.02-0.41 0.19 0.21 0.13 0.21 6 0.14 0.03-0.55 1.00
Io_mi 0.35 6 0.17 0.12-0.71 0.39 6 0.20 0.06-0.87 0.29 0.37 0.19 0.36 6 0.19 0.05-0.76 0.86

Note. Values are presented as mean 6 standard deviation values with corresponding ranges.
*Paired t test P values.

placement was low, with the maximal error in the hori-
zontal plane not exceeding 1 mm. As such, it appears
that guided insertion of palatal miniscrews can be un-
dertaken predictably and with a high degree of accuracy.
Moreover, low levels of error were observed in both clin-
ical and laboratory procedures. The results mirror those
obtained from allied research studies primarily on the
basis of CBCT-based guided insertion.10,11
The level of discrepancy observed in this study was
consistently low, with no statistical difference between
the left and right sides, and there were very similar levels
of accuracy in the horizontal and vertical planes. In a
similar study, based on guided palatal insertion
involving conventional and 3D-printed surgical guides,
comparable discrepancies were observed with slightly
greater levels of error found with the 3D-printed (Im-
primo LC Splint; Scheu-Dental, Iserlohn, Germany) and
a conventional guide (Memosil 2; Kulzer, Hanau,
Germany) relative to 2 other conventional guides.12,13
The surgical stents in this study were 3D-printed and
included a shoulder to control the depth of insertion.
Similar techniques have been deployed in the infrazygo-
matic crest region; however, mean reported levels of
displacement of the miniscrew tip were as high as 3.3
mm.13 The displacement of the miniscrew head in isola-
tion was assessed in this study, with displacement at the
tip likely to be amplified relative to this; however, Su
et al13 noted mesiodistal inaccuracy of up to 2.38 mm
using a guided technique. These larger discrepancies
may relate to anatomic differences at the infrazygomatic
region allied to differences in stent design.
The surgical guides used in the present study were 3D-
printed and relatively rigid, spanning the arch bilaterally.
This design is likely to minimize the risk of distortion and

July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Al-Gazzawi et al 73

Horizontal Vertical

2
Density

0.0 0.1 0.2 0.3 0.4 0.5 0.0 0.1 0.2 0.3 0.4 0.5
Design_MI
Side Left Right

Fig 3. Graphical display of inaccuracy of TSAD insertion (DD-MO scan), including horizontal and ver-
tical discrepancies for both left and right sides.

Horizontal Vertical

2.5

2.0

1.5
Density

1.0

0.5

0.0

0.25 0.50 0.75 0.25 0.50 0.75

IO_MI
Side Left Right

Fig 4. Graphical display of inaccuracy (IO final position MO Scan), including horizontal and vertical
discrepancies for both left and right sides.

inaccurate localization. Alternative designs, including Notwithstanding this, the use of silicone, soft-tissue-
semicircular unilateral guides, may be prone to flexure borne guides has shown similar levels of accuracy to
and inaccurate placement, risking inaccuracy.13 3D-printed rigid tooth-borne guides.14 Nevertheless,

American Journal of Orthodontics and Dentofacial Orthopedics July 2024  Vol 166  Issue 1
74
the use of surgical guides introduces an additional step,
with the use of augmented reality being piloted to facil-
itate miniscrew placement and prove superior to freehand
approaches.15 However, there is no evidence to suggest
that augmented reality leads to superior accuracy relative
to the use of physical guides.
Overall, guided approaches have been shown to
reduce the risk of complications associated with minis-
crew placement, including root perforation and
encroachment on the nasal and maxillary sinus.16 In
this study, a lateral cephalogram was used for the assess-
ment of bone density and height in the hard palate. This
approach has been validated on the basis of CBCT im-
ages14,17; however, bone density on the lateral cephalo-
gram may reflect minimum bone heights in the midline.
The use of bicortical anchorage has been recommended
to enhance the stability of maxillary skeletal expander
appliances,18 potentially increasing the degree of basal
bone separation, although longer implants do not
appear to increase the predictability of sutural separa-
tion.19 Notwithstanding, this approach places a greater
premium on surgical accuracy and planning, underlining
the need for in-depth planning and guided techniques.
This study was limited to a single practice involving 2
experienced operators. As such, the generalizability of
the findings is open to debate. Nevertheless, it is impor-
tant to note that the use of guided approaches may
attenuate the impact of surgical skills and experience,
offering more predictability relative to freehand ap-
proaches.13 Thus, it seems reasonable to conclude that
surgical errors of \1 mm in both vertical and horizontal
planes are achievable with guided insertion of parame-
dian palatal miniscrews.
CONCLUSIONS
1. High levels of accuracy associated with guided
insertion of paramedian palatal implants were
observed with mean discrepancies of \0.5 mm
both in the horizontal and vertical planes.
2. No difference in accuracy was noted between the
left and right sides.
3. Very minor levels of inaccuracy related to both sur-
gical techniques and surgical guide fabrication were
recorded.
AUTHOR CREDIT STATEMENT
Adli Al-Gazzawi contributed to conceptualization,
methodology, and formal analysis; Vanessa Knode
contributed to methodology and formal analysis; Bjorn
Ludwig contributed to conceptualization, methodology,
and formal analysis; Alaa Othman contributed to
July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Al-Gazzawi et al
conceptualization and methodology; Angelo Salamini
contributed to conceptualization and methodology; Ni-
kolaos Pandis contributed to methodology and formal
analysis; and Padhraig Fleming contributed to methodol-
ogy and formal analysis and drafted the original manu-
script.
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