ONLINE ONLY

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 definition 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 influencing variables were con-
trolled. The Cochrane Handbook for Systematic Reviews of Interventions was used as the guideline for this
article. Results: Nineteen reports met the inclusion criteria, but definitions of success, duration of force appli-
cation, 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, inflammation, and pain and
discomfort. Only a few articles reported negative outcomes. All proposed correlations between clinical suc-
cess and specific 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 field is still
in its infancy. Interpretation of findings was conditioned by lack of clarity and poor methodology of most stud-
ies. Questions concerning patient acceptability, rate and severity of adverse effects of miniscrews, and vari-
ables that influenced success remain unanswered. This article includes a guideline for future studies of these
issues, based on specific definitions of primary and secondary outcomes correlated with specific operational
variables. (Am J Orthod Dentofacial Orthop 2009;135:564.e1-564.e19)

agreement on the nomenclature.18,19 We used the term

O
sseointegrated implants are considered reliable
sources of anchorage for orthodontists.1-6 How-
ever, the large size of these implants limits their
usage. To overcome this problem, mini-implants were de-
veloped.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 specific time pe-
riods, mostly rely on mechanical retention, and do not
always osseointegrate, other terms such as miniscrews,
miniscrew implants, microscrews, and temporary an-
chorage devices have been used.16,17 There is no general
a
b
Private practice, Milan, Italy.
Research associate, Departments of Radiology, Epidemiology and Biostatis-
tics, Academic Medical Center, University of Amsterdam, Amsterdam, The
Netherlands.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts 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 Ó 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.09.026
‘‘mini-implant’’ in the title, because it is currently the
most frequently used in the orthodontic literature.
Many mini-implants are now available, and ortho-
dontists are trying to incorporate them in various clinical
situations. However, with the introduction of new tech-
niques, questions normally arise. Clinicians desire infor-
mation on actual success rates and possible adverse
effects of mini-implants for orthodontic anchorage.
They also want to identify variables that could influence
success. Although numerous articles on these topics are
available, confusion arises from differences in their find-
ings.20-26 Furthermore, the currently available reviews on
mini-implants either were not systematic or asked differ-
ent 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 influence
success.
564.e1
564.e2 Reynders, Ronchi, and Bipat
CRITERIA FOR CONSIDERING STUDIES
FOR THIS REVIEW
Two categories of selection criteria were estab-
lished. General measures were applied to find studies
on mini-implants and specific selection criteria to im-
prove 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 mini-
mum sample size of 10 miniscrews, with technique ar-
ticles, 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 specific orthodon-
tic indications (eg, interradicular positioning); and (4)
no articles on miniplates, because of their different bio-
mechanical characteristics.
Specific selection criteria for studies on mini-im-
plants included (1) only studies that defined success;
(2) only studies that defined the duration of the applica-
tion of force; (3) no studies that measured implant suc-
cess 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) stud-
ies that measured success either at a predetermined
treatment time or at the completion of orthodontic an-
chorage objectives.
Patients of both sexes without age restrictions and
with a need of absolute anchorage for orthodontic pur-
poses were included.
The outcomes were divided into primary and sec-
ondary 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 ap-
plication 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 fulfill all
necessary orthodontic anchorage objectives.
 Success with mobility (score 1): implants that had
become mobile but could still fulfill all necessary
orthodontic anchorage objectives.
 Success with displacement (score 2): implants that
had become displaced but could still fulfill all neces-
sary orthodontic anchorage objectives.
 Failure (score 3): implants that were lost or had be-
come unusable, including those that had become in-
operative because of excessive tissue proliferation
American Journal of Orthodontics and Dentofacial Orthopedics
May 2009
that could not be reversed by simple excision; im-
plants 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 treat-
ment, or at the removal of the screw.
 Not specified success (score NSS): the type of success
of implants was not specified and included scores 0, 1,
and 2.
Secondary outcomes were divided into 3 categories:
biologic damage, inflammation, and pain and discom-
fort measures.
Biologic damage was analyzed from the day of im-
plant placement until removal. Biologic damage that
occurred or was detected after removal of the implant
was classified 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 dam-
age 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 dam-
age that is not completely reversible with simple den-
tal 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 specified biologic damage (score NSBD): bio-
logic damage was described, but the type was not
identified.
 Postimplant biologic damage (score PIBD):
biologic damage caused by treatment with mini-im-
plants, but it occurred or was found after removal of
the screw.
Inflammation was measured either within the first
month of implant placement or beyond this time limit.
 No inflammation (score 0): No signs of inflammation
during the entire period of treatment with mini-im-
plants.
 Temporary inflammation (score 1): inflammation
confined to the first month.
 Continuing inflammation (score 2): inflammation
lasted longer than the first month.
 Not specified inflammation (score NSI): its duration
was not specified.
Pain and discomfort were measured during the first
2 weeks after placement or beyond.38
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 5
 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 first 2 weeks.
 Severe pain or discomfort (score 2): Severe pain or
discomfort in the first 2 weeks.
 Continuing pain or discomfort (score 3): pain lasting
longer than 2 weeks.
 Not specified pain (score NSP): pain and discomfort
were described, but quality or duration were not
specified.
SELECTION CRITERIA FOR VARIABLES
INFLUENCING SUCCESS OF MINI-IMPLANTS
The second part of this review addressed variables
that might influence the success rates of mini-implants.
These variables were classified under the following 6
headings: implant, patient, location, surgery, orthodon-
tics, and implant-maintenance factors. A correlation be-
tween mini-implant success and these parameters was
tested according to the following criteria: (1) a proposed
association with success was rejected only when the ar-
ticle presented direct proof that at least 1 influencing
variable was not controlled; lack of information about
the control of those factors was insufficient to reject
a correlation; and (2) only factors that had been tested
for statistical significance 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 Evi-
dence Based Medicine Reviews (EBMR), Web of Sci-
ence, 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, minis-
crew, microimplant, screw implant, and temporary
anchorage device. For each search engine, the appropri-
ate characters were used to truncate or explore search
terms. To avoid inappropriate exclusion, noun, adjec-
tive, 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 Jour-
nal of Adult Orthodontics and Orthognathic Surgery.
Reynders, Ronchi, and Bipat 564.e3
In addition, references from each identified article
were manually screened for articles that were missed
by the electronic search engines. Finally, all manual
and electronic searches were solicited for review arti-
cles.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
All abstracts were read, and the full texts of all
relevant articles were collected and reviewed. Ambig-
uous articles were also read to avoid inappropriate
exclusion. All procedures were performed indepen-
dently by 2 authors (R.R. and L.R.). Differences
were resolved by rereading and discussion until con-
sensus was reached.18,35 Studies were also assessed
for eligibility and methodologic quality without con-
sidering the outcomes. For each study, a value was
given based on the quality of the following 4 criteria:
definition 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 classified as clear (3 or 4 points),
partially clear (2 points), or unclear (0 or 1 point). As-
sessment of study validity was not used as a threshold
for inclusion but only as a possible explanation for dif-
ferences in results between studies.35
A decision to perform a meta-analysis was made if
there were sufficient similarities between studies in
the types of participants, interventions, and outcomes.
Although several studies used the same implant system,
the significant 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 flow di-
agram (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 specific 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 qual-
ity 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 random-
ized clinical trial. Another systematic review also did
not find any randomized clinical trials about mini-
implants in the literature.29
564.e4 Reynders, Ronchi, and Bipat American Journal of Orthodontics and Dentofacial Orthopedics
May 2009

Abstracts retrieved from all search methods

Table I. Characteristics of included studies
N = 3364
Assessment Number Design
Year of of of of
Authors publication validity implants study
Excluded abstracts Freudenthaler et al14 2001 A 12 P
N= 3312 Miyawaki et al12 2003 C 134 R
Reason: * Liou et al21 2004 A 32 P
Motoyoshi et al22 2006 A 124 P
Thiruvenkatachari et al23 2006 B 18 P
Park et al24 2006 C 227 R
Articles retrieved for more detailed analyses Tseng et al25 2006 B 45 R
N= 52 Chen et al26 2006 C 59 R
Berens et al46 2006 C 239 ND
Luzi et al37 2007 B 140 P
Excluded articles Wiechmann et al41 2007 B 133 P
N = 21 Kuroda et al42 2007 B 216 R
Reason: * Motoyoshi et al39 2007 A 169 P
Kuroda et al38 2007 C 116 R
Motoyoshi et al43 2007 B 87 R
Articles retrieved for more detailed analyses Hedayati et al44 2007 B 27 P
N = 31 Chaddad et al45 2008 B 32 P
Moon et al40 2008 A 480 R
Kinzinger et al47 2008 C 16 ND

Excluded articles Assessment of validity: A, clear; B, partially clear; C, unclear.

N= 12
Reason: **
Included articles: N=19
* General selection criteria
** Specific selection criteria
Fig. QUOROM flow diagram.
RESULTS
Primary outcomes, defining success and failure of
mini-implants, are presented in Table II. The definitions
of success varied in the studies. Five articles did not spec-
ify 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 con-
sidered 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 success-
ful. Primary outcomes varied from 0% to 100%. One
article compared 2 protocols but did not define success
in the second protocol.46 Another article gave a success
rate of 86.8%, but our calculations added up to only
Design of study: P, prospective; R, retrospective; ND, not described.
76.7%.41 The time of assessment of success varied
widely (Table II). Six studies analyzed primary out-
comes at specific 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 dam-
age,14,41,46 and Park et al24 recorded 8 broken screws,
with 3 fractured during placement and 5 during re-
moval. Two of 59 screws broke during placement in
another study.26 In both studies, no information was pro-
vided 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.
Inflammation was evaluated in 6 studies and varied
from 0% to 34% (Table II).12,14,23-25,45 Temporary in-
flammation of peri-implant soft tissues was described
in 4 articles.12,14,23,45 Freudenthaler et al14 and Thiru-
venkatachari et al23 reported that inflammation was con-
trolled by improving oral hygiene. However, Tseng
et al25 recorded continuing inflammation in 2 of 45 im-
plants. 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 in-
flammation in 34% of the implants but did not specify
its severity or duration. To control peri-implantitis,
American Journal of Orthodontics and Dentofacial Orthopedics Reynders, Ronchi, and Bipat 564.e5
Volume 135, Number 5

Table II. Analysis of outcomes of studies on mini-implants

Time of success Rate of biologic Rate of Rate of pain
Authors measurement Success rate damage inflammation and discomfort

Freudenthaler ARTT 75% (NSS) 0% (NSBD) 25% (score 1) 37.5% (score 1)

et al14
Average: 11 months
Range: 7-20 months
Miyawaki et al12 1 year or ARTT 76.1% (NSS) ND 8.9% (score 1) 15.9% (score 1)
Range: 0%-85%
Liou et al21 9 months 56.25% (score 0) ND ND ND
43.75% (score 2)
Motoyoshi et al22 6 months 85.5% (NSS) ND ND ND
Thiruvenkatachari ARTT 100% (score 0) ND 10% (score 1) ND
et al23
3.5-5.5 months
Park et al24 ARTT 91.6% (scores 0 and 1) 3.5% (NSBD) 34% (NSI) ND
Mean: 15 months Range: 80%-93.6%
SD: 6.16 months
Tseng et al25 ARTT 91.1% (scores 0 and 1) ND 4.4% (score 2) ND
Average: 16 months Range: 80%-100%
Chen et al26 ARTT 84.7% (score 0) 3.4% (NSBD) ND ND
Mean: 19.5 months Range: 72.2%-90.2%
Berens et al46 ARTT Protocol 1: 0% (NSBD) ND ND
Average: 235 days 68.4% (score 0)
Maximum: 733 days 8.3% (score 1)
23.3% (score 3)
Protocol 2:
4.7% (score 3)
Luzi et al37 ARTT 84.3% (score 0) ND ND ND
Minimum:120 days 6.4% (score 1)
Maximum: 37 months
Wiechmann et al41 180 days 76.7% (score 0) 0% (score 2) ND ND
Range: 69.6%-87%
Kuroda et al42 1 year or ARTT 86.4% (NSS) ND ND ND
Range: 35.3%-100%
Motoyoshi et al39 6 months 85.2% (score 0) ND ND ND
Range: 63.8%-97.3%
Kuroda et al38 1 year or ARTT 86.2% (NSS) ND ND Flap group:
Range: 81.1%-88.6% 95%-10%
(scores 1 and 2)
Flapless group:
50%-0% (score 1)
Motoyoshi et al43 ARTT 87.4 (score 0) ND ND ND
6 months or more
Hedayati et al44 ARTT 81.5%(scores 0, 1, and ND ND ND
2)
Average: 5.4 months
Range: 4-6.5 months
Chaddad et al45 150 days 87.5% (score 0) ND 6.25% (score 1) 80% (score 0)
Range: 82.5%-93.5% 6.25% (score 2) 20% (score 1)
Moon et al40 8 months 83.8 (score 0) ND ND ND
Kinzinger et al47 ARTT 100% (score 2) ND ND ND
6.5 months

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, unspecified success (includes
scores 0-2).
Biologic damage scores: 0, no damage; 1, reversible damage; 2, irreversible damage; NSBD, unspecified damage (includes scores 1 and 2).
Inflammation scores: 0, no inflammation; 1, temporary inflammation; 2, continuing inflammation; NSI, unspecified inflammation.
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, unspecified pain and discomfort (includes scores 1-3).
564.e6 Reynders, Ronchi, and Bipat American Journal of Orthodontics and Dentofacial Orthopedics
May 2009

Table III. Variables associated with success rates in studies on mini-implants

Association with Studies proposing Studies rejected
success suggested association with success and reasons for rejection

Implant-related factors
Type: no Miyawaki,12 Park,24 Kuroda,42 Kuroda,38 Chaddad45 Miyawaki12 (a-e), Park24 (a-e), Kuroda42 (a-e),
Kuroda38 (a-e), Chaddad45 (a-e)
Type: yes Miyawaki,12 Wiechmann41 Miyawaki12 (a-e), Wiechmann41 (a-e)
Diameter: yes Miyawaki,12 Wiechmann41 Miyawaki12 (a-e), Wiechmann41 (a-c,e)
Length: no Miyawaki,12 Park,24 Wiechmann,41 Kuroda38 Miyawaki12 (a-e), Park24 (a-e), Wiechmann41
(a-c,e), Kuroda38 (a-e)
Length: yes Chen,26 Tseng25 Chen26 (b,c,e), Tseng25 (b,c,e)
Patient-related factors
Sex: no Motoyoshi,22 Park,24 Kuroda,38 Motoyoshi,43 Motoyoshi22 (b-d), Park24 (a-e), Kuroda38 (a-e),
Moon40 Motoyoshi43 (b-d), Moon40 (c-e)
Age: no Miyawaki,12 Motoyoshi,22 Park,24 Kuroda,38 Moon40 Miyawaki12 (a,c-e), Motoyoshi22 (c,d), Park24
(a,c-e), Kuroda38 (a,c-e), Moon40 (c-e)
Age: yes Motoyoshi39 Motoyoshi39 (c,d)
Physical status VNA
Mandibular plane Kuroda38 Kuroda38 (a-e)
angle: no
Mandibular plane Miyawaki12 Miyawaki12 (a-e)
angle: yes
Temporomandibular symptoms: no Miyawaki,12 Kuroda38 Miyawaki12 (a-e), Kuroda38 (a-e)
Crowding: no Miyawaki12 Miyawaki12 (a-e)
Anteroposterior jaw relationship: no Miyawaki,12 Kuroda38 Miyawaki12 (a-e), Kuroda38 (a-e)
Location-related factors
Peri-implant bone Motoyoshi43 Motoyoshi43 (b,d)
quantity: no
Cortical bone Motoyoshi43 Motoyoshi43 (b,d)
thickness: yes
Keratinized vs oral Chaddad45 Chaddad45 (a-e)
mucosa: no
Exposed vs closed Park24 Park24 (a-e)
mucosa: yes
Same success Miyawaki,12 Motoyoshi,22 Motoyoshi,39 Chaddad,45 Miyawaki12 (a-e), Motoyoshi22 (b-d),
maxilla and mandible Motoyoshi,43 Moon40 Motoyoshi39 (c,d), Chaddad45 (a-e),
Motoyoshi43 (b-d), Moon40 (c-e)
Mandible more Park,24 Wiechmann,41 Kuroda42 Park24 (a-e), Wiechmann41 (a-c,e), Kuroda42
failures than maxilla (a-e)
Lower success Wiechmann41 Wiechmann41 (a-c,e)
lingual mandible
Molar area Moon40 Moon40 (d,e)
lower success than
premolar area in mandible
Molar area Moon40 Moon40 (d,e)
same success as premolar
area in maxilla
Left side Park24 Park24 (a-e)
higher success than
right side
No difference Motoyoshi,22 Motoyoshi,43 Moon40 Motoyoshi22 (b-d), Motoyoshi43 (b-d), Moon40
between left and right sides (c-e)
Root proximity: yes Kuroda42 Kuroda42 (a-e)
Surgery-related factors
Flapless/flap surgery: no Miyawaki,12 Moon40 Miyawaki12 (a-c,e), Moon40 (c,e)
Direction of placement: no Park24 Park24 (a-c,e)
Placement torque: yes Motoyoshi,22 Motoyoshi,39 Chaddad,45 Motoyoshi43 Motoyoshi22 (b,c), Motoyoshi39 (c), Chaddad45
(a-c,e), Motoyoshi43 (b,c)
Self-drilling vs self-tapping VNA
technique
Different surgeons VNA
American Journal of Orthodontics and Dentofacial Orthopedics Reynders, Ronchi, and Bipat 564.e7
Volume 135, Number 5

Table III. Continued

Association with Studies proposing Studies rejected
success suggested association with success and reasons for rejection

Orthodontic-related factors
Magnitude of force: no Kuroda38 Kuroda38 (a-e)
Timing of force Miyawaki12 Miyawaki12 (a-e)
application: no
Timing of force Motoyoshi39 Motoyoshi39 (c,d)
application: yes
Duration of force VNA
Type of force: no Park24 Park24 (a-e)
Type of orthodontic Kuroda38 Kuroda38 (a-e)
movement: yes
Direction of force VNA
Implant-maintenance factors
Antibiotics prescription VNA
Chlorhexidine prescription VNA
Oral hygiene: no Park24 Park24 (a-e)
Control of peri-implant Miyawaki,12 Park24 Miyawaki12 (a-e), Park24 (a-e)
inflammation: yes
Control of mobility: yes Park24 Park24 (a-e)
Total 70 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 ker-
atinized 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 re-
ported minor pain after placement that lasted only 1
day in 3 of 8 patients. Similar findings were reported
by Chaddad et al45 in 2 of 10 patients. Kuroda et al38
analyzed both the quality and the duration of pain dur-
ing the first 2 weeks after placement. One hour after
implantation, 95% of the patients who had screws
placed after raising a mucoperiosteal flap reported
pain, compared with 50% of those who had undergone
a flapless approach. After 2 weeks, the values were
10% and 0% for the respective techniques. Patients in
the flap group described significantly more intense
pain and for a longer period than those in the flapless
group. A similar finding 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 pre-
sented 70 correlations between at least 1 variable and
clinical success; many were contrary associations. All
were rejected because parameters selected as indepen-
dent variables were not controlled and therefore did
not meet the inclusion criteria. Explanations for rejec-
tion are listed in Table III and can be verified in Tables
IV to IX.
DISCUSSION
Nineteen studies were selected from computerized
and manual searches through March 31, 2008, to pro-
vide data regarding the success of mini-implants. Case
reports and technique articles describing the special
merits of a specific miniscrew were those most often ex-
cluded by the general selection criteria. Twelve studies
were excluded because of imprecise methodology. Ran-
domized clinical trials were not available, and the qual-
ity of most included studies was low (Table I). These
findings were surprising, considering the wide interest
in the clinical applications of mini-implants as ortho-
dontic anchorage devices. An analysis of the impact
of the quality of the various studies was superfluous be-
cause all correlations between proposed variables and
success were rejected by the inclusion criteria, and out-
comes from both high- and low-quality articles were
similar (Tables II and III).
For the primary outcomes, most studies found suc-
cess 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 defini-
tions for primary outcomes. Success was analyzed with
various benchmarks including with or without mobility,
564.e8 Reynders, Ronchi, and Bipat American Journal of Orthodontics and Dentofacial Orthopedics
May 2009

Table IV. Implant-related factors in studies on mini-implants

Number of Diameter (D)
Authors implants Implant type and length (L) Success rate*
14
Freudenthaler et al 12 Leibinger D 2 mm 75%
L 13 mm
Miyawaki et al12 10 Photo but not described D 1.0 mm 0%
L 6 mm
Miyawaki et al12 101 Photo but not described D 1.5 mm 83.9%
L 11 mm
Miyawaki et al12 23 Photo but not described D 2.3 mm 85%
L 14 mm
Liou et al21 32 Leibinger D 2 mm 100%
L 17 mm
Motoyoshi et al22 124 Biodent D 1.6 mm 85.5%
L 8 mm
Thiruvenkatachari et al23 18 Not described D 1.3 mm 100%
L 9 mm
Park et al24 19 Leibinger D 1.2 mm 84.2%
L 5 mm
Park et al24 157 Osteomed D 1.2 mm 93.6%
L 6, 8,10 mm
Park et al24 46 Absoanchor D 1.2 mm 89.1%
L 4, 6, 7, 8, 10 mm
Tseng et al25 15 Leibinger D 2 mm 80%
L 8 mm
Tseng et al25 10 Leibinger D 2 mm 90%
L 10 mm
Tseng et al25 12 Leibinger D 2 mm 100%
L 12 mm
Chen et al26 18 Abosanchor D 1.2 mm 72.2%
L 6 mm
Chen et al26 41 Absoanchor D 1.2 mm 90.2%
L 8 mm
Berens et al,46 protocol 1 133 Absoanchor D 1.3-2 mm 76.7%
Dual Top L not described
Berens et al,46 protocol 2 106 Absoanchor D 1.3-2 mm 95.3%
Dual Top L not described
Luzi et al37 140 Aarhus D 1.5, 2 mm 90.7%
L 9.6, 11.6 mm
Wiechmann et al41 79 Absoanchor D 1.1 mm 69.6%
L 5, 6, 7, 8, 10 mm
Wiechmann et al41 54 Dual Top D 1.6 mm 87%
L 5, 6, 7, 8, 10 mm
Kuroda et al42 195 Absoanchor D 1.3 mm Maxilla, 77.1%-95.8%
L 6, 7, 8, 10, 12 mm Mandible, 35.3%-83.9%
Kuroda et al42 21 Martin D 1.5 mm Maxilla
L 9 mm 50%-100%
Motoyoshi et al,39 early 47 Biodent D 1.6 mm 63.8%
load adolescent group L 8 mm
Motoyoshi et al,39 late 36 Biodent D 1.6 mm 97.2%
load adolescent group L 8 mm
Motoyoshi et al,39 early load 86 Biodent D 1.6 mm 91.9%
adult group L 8 mm
Kuroda et al38 37 Keisei D 2.0, 2.3 mm 81.1%
L 7, 11 mm
Kuroda et al38 79 Absoanchor D 1.3 mm 88.6%
L 6, 7, 8, 10, 12 mm
Motoyoshi et al43 87 Biodent D 1.6 mm 87.4%
L 8 mm
Hedayati et al44 27 O&M Medical D 2.0 mm 81.5%
L 9, 11 mm
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 5
Table IV. Continued
Number of
Authors implants Implant type
45
Chaddad et al 17 Dual Top
Chaddad et al45 15 C-Implant
Moon et al40 480 Dual Top
Kinzinger et al47 16 T.I.T.A.N. Pin-System
Dual Top
*Definition of success as established by the authors of the respective studies.
with or without displacement, or not specified (Table II).
Second, the timing of assessment of the primary out-
comes differred among the studies—from 3 to 27
months after the application of orthodontic forces. An
implant lost after 4 months could then be defined either
as a failure or a success depending on the time of its as-
sessment. Some articles measured primary outcomes
from the day of placement, not from the start of applied
orthodontic forces.23,26 Third, the interpretation of pri-
mary outcomes was hampered by differences in study
design and methodology. Fourth, variables were fre-
quently not controlled and could have easily skewed
the findings. 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 re-
sult 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 biome-
chanics are applied. Displacements of apparently stable
mini-implants were recorded in 3 studies,21,44,47 and
this finding was confirmed in the literature.52 To avoid
trauma to adjacent structures, a safety clearance of 2
mm was recommended in interdental areas.21,52 How-
ever, 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 in-
trusion 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,
Reynders, Ronchi, and Bipat 564.e9
Diameter (D)
and length (L) Success rate*
D 1.4, 1.6, 2.0 mm 82.5%
L 6, 8, 10 mm
D 1.8 mm 93.5%
L 8.5 mm
D 1.6 mm 83.8%
L 8 mm
D 1.6 mm 100%
L 8-9 mm
and other forms of trauma, can appear later. Long-
term screening was not part of the protocol in any of
the 19 studies.
Information about the character and the duration of
inflammation 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 influencing 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 vari-
ables involved. Tables IV through IX show the many un-
controlled variables. Rejection measures were relatively
lenient, because proposed associations were rejected
only when the article presented direct proof that a poten-
tial influencing 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 influence success; they are dis-
cussed below. To facilitate this discussion, these vari-
ables were divided into 6 categories: implant, patient,
location, surgery, orthodontic, and implant-mainte-
nance 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 specified.12,23,46 Eight studies did not control
for implant type, diameter, and or length when com-
paring outcomes.12,24,38,41,42,45-47 Both confirming
and refuting associations were found between implant
type and primary outcomes (Table IV). However, the
564.e10 Reynders, Ronchi, and Bipat American Journal of Orthodontics and Dentofacial Orthopedics
May 2009

Table V. Patient-related factors in studies on mini-implants

Authors Sex and number of implants Age (y) Physical status Dental status

Freudenthaler et al14 4 females: NIND 22.1 (mean) ND D

4 males: NIND Range: 13-46
Miyawaki et al12 42 females: NIND 21.8 (mean) ND D
9 males: NIND SD: 7.8
Liou et al21 16 females: 32 implants Range: 22-29 ND ND
Motoyoshi et al22 37 females: 114 implants 24.9 (average) ND ND
4 males:10 implants SD: 6.5
Range: 13.3-42.8
Thiruvenkatachari et al23 7 females: 12 implants 19.6 (mean) D D
3 males: 6 implants Range: 16-21
Park et al24 52 females: 138 implants 15.5 (mean) ND ND
35 males: 89 implants SD: 8.3
Tseng et al25 14 females: NIND 29.9 (mean) ND ND
11 males: NIND Range: 22-44
Chen et al26 20 females: NIND 29.8 (mean) ND ND
9 males: NIND Range: 19-57
Berens et al46 61 females: NIND 28 (mean) ND ND
24 males: NIND Range: 31-51
Luzi et al37 60 females: NIND 34.3 (mean) ND D
38 males: NIND Range: 13-64
Wiechmann et al41 36 females: NIND 26.9 (mean) ND ND
13 males: NIND SD: 8.9
Range: 13.5-46.2
Kuroda et al42 92 females: NIND 22.5 (mean) ND ND
18 males: NIND SD: 8.1
Motoyoshi et al,39 adolescent group 24 females: NIND 15.9 (mean) ND ND
6 males: NIND SD: 1.9
Range: 11.7-18.9
Motoyoshi et al,39 adult group 24 females: NIND 26.2 (mean) ND ND
3 males: NIND SD: 5.6
Range: 20.4-36.1
Kuroda et al38 63 females: NIND 21.8 (mean) ND ND
12 males: NIND SD: 8.2
Motoyoshi et al43 28 females: 76 implants 24.4 (average) ND D
4 males: 11 implants SD: 6.5
Range:14.6-42.8
Hedayati et al44 ND 17.4 (mean) ND D
Range 15.5-19
Chaddad et al45 ND Range: 13-65 D ND
Moon et al40 131 females: 323 implants Young: 14.4 (mean) Range: 10-18 ND ND
78 males: 157 implants Adult: 26.2 (mean)
Range: 19-64
Kinzinger et al47 6 females: 12 implants 12.2 (average) ND ND
2 males: 4 implants

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 archi-
tecture of implants on success.57-60 Furthermore, the
implant material has an impact on the placement tech-
nique. Compared with pure titanium, titanium alloys
are stronger, and drilling a pilot hole is frequently un-
necessary.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 sufficiently controlled for
a correlation with failure.12 Studies on porcine iliac
bone segments confirmed an association between im-
plant diameter and success.61,62 Implants with a smaller
diameter are easier to place between the roots, but
a small decrease in this dimension significantly in-
creases 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
American Journal of Orthodontics and Dentofacial Orthopedics Reynders, Ronchi, and Bipat 564.e11
Volume 135, Number 5

Table VI. Location-related factors in studies on mini-implants

Bone Keratinized or Exposed
Authors Implant site condition nonkeratinized mucosa or closed

Freudenthaler et al14 Buccally in mandible D ND ND

Miyawaki et al12 Posterior buccal alveolar bone in maxilla and mandible D Keratinized ND
Liou et al21 Zygomatic buttresses of maxilla D Nonkeratinized Exposed
Motoyoshi et al22 Posterior buccal alveolar bone in maxilla and mandible ND ND ND
Thiruvenkatachari et al23 Buccal alveolar bone in maxilla and mandible ND ND ND
Park et al24 Various locations in maxilla and mandible D Both Both
Tseng et al25 Various locations in maxilla and mandible D ND ND
Chen et al26 Various locations in maxilla and mandible ND ND ND
Berens et al46 Various locations in maxilla and mandible ND Both ND
Luzi et al37 Various locations in maxilla and mandible D Both Exposed
Wiechmann et al41 Various locations in maxilla and mandible ND Keratinized ND
Kuroda et al42 Various locations in maxilla and mandible ND Keratinized ND
Motoyoshi et al39 Posterior buccal alveolar bone in maxilla and mandible D Keratinized ND
Kuroda et al38 Various locations in maxilla and mandible D Both Exposed
Motoyoshi et al43 Posterior buccal alveolar bone in maxilla and mandible D ND ND
Hedayati et al44 Palate and posterior buccal alveolar bone in mandible ND ND ND
Chaddad et al45 Posterior buccal alveolar bone in maxilla and mandible ND Both ND
Moon et al40 Posterior buccal alveolar bone in maxilla and mandible D Keratinized ND
Kinzinger et al47 Anterior palate D Keratinized Exposed

D, Described; ND, not described.

Table VII. Surgery-related factors in studies on mini-implants

Authors Flap or flapless surgery Placement technique Direction of placement
14
Freudenthaler et al Flap ST and same-size pilot hole Perpendicular to bone
Miyawaki et al12 Both ND ND
Liou et al21 Flap ST and smaller pilot hole ND
Motoyoshi et al22 Flapless ST and smaller pilot hole ND
Thiruvenkatachari et al23 ND ND ND
Park et al24 Flap ST and smaller pilot hole Various angulations
Tseng et al25 Flapless SD and smaller pilot hole in cortex ND
Chen et al26 Flapless SD and smaller pilot hole in cortex ND
Berens et al46 Flapless SD and smaller pilot hole in cortex ND
Luzi et al37 Flapless SD and no pilot hole ND
Wiechmann et al41 Flapless SD and smaller pilot hole in cortex ND
Kuroda et al42 Flapless ST and smaller pilot hole 20 -40 to long axis of tooth
Motoyoshi et al39 Flapless ST and smaller pilot hole 30 to long axis of tooth
Kuroda et al38 Both ST and smaller pilot hole ND
Motoyoshi et al43 Flapless ST and smaller pilot hole ND
Hedayati et al44 Flapless ST and same-size pilot hole 30 to midsagittal plane
Chaddad et al45 Flapless SD and pilot hole in cortex only (size ND) ND
Moon et al40 Both SD and no pilot hole 70 -80 to long axis of tooth
Kinzinger et al47 Flapless SD and ST, no pilot hole ND

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 pal-
atal mucosa, can easily become dislodged.25,67,68 Lon-
ger 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 stud-
ies found a disproportionate division of the sexes with
an excess of females (Table V). Ten studies did not de-
fine the numbers of implants for each sex, and 2 articles
564.e12 Reynders, Ronchi, and Bipat American Journal of Orthodontics and Dentofacial Orthopedics
May 2009

Table VIII. Orthodontics-related factors in studies on mini-implants

Type of orthodontic Timing of force Force Duration of force Direction
Authors movement application magnitude Type of force application of force

Freudenthaler Mandibular molar Immediate (at time of 150 g Continuous and Average: 11 months D
et al14 protraction surgery) intermittent
Range: 7-20 months
Miyawaki et al12 Various movements Immediate (\1 month) \200 g Continuous 1 year or ARTT ND
in both jaws
Miyawaki et al12 Various movements Delayed (1-3 months) \200 g Continuous 1 year or ARTT ND
in both jaws
Miyawaki et al12 Various movements Delayed (.3 months) \200 g Continuous 1 year or ARTT ND
in both jaws
Liou et al21 En-masse retraction of Immediate (after 2 400 g Continuous 9 months D
maxillary anteriors weeks)
Motoyoshi et al22 Retraction of anterior Immediate (at time of \200 g ND 6 months ND
teeth in both jaws surgery)
Thiruvenkatachari Retraction of canines Immediate (after 15 100 g Continuous 3.5-5.5 months or D
et al23 in both jaws days) ARTT
Park et al24 Various movements Immediate and delayed \200 g Continuous and Mean: 15 months or ND
in both jaws (no time definition) Intermittent ARTT
SD: 6.16 months
Tseng et al25 Various movements Immediate (after 2 100-200 g Continuous and Average:16 months ND
in both jaws weeks) intermittent
ARTT
Chen et al26 Various movements Immediate (after 2 100-200 g Continuous and Mean: 19.5 months ND
in both jaws weeks) intermittent
ARTT
Berens et al46 Various movements Immediate (at time of Maximum Intermittent Average: 235 days ND
in both jaws surgery) of 150 g
Maximum: 733
days
ARTT
Luzi et al37 Various movements Immediate (at time of 50 g Continuous Minimum:120 days D
in both jaws surgery) or ARTT
Maximum: 37
months
Wiechmann et al41 Various movements Immediate (at time of 100-200 g Continuous and 180 days D
in both jaws surgery) intermittent
Kuroda et al42 ND Immediate and delayed 50-200 g Continuous and 1 year or ARTT ND
(after 0-12 weeks) intermittent
Motoyoshi et al39 Retraction of anterior Immediate (after 2-4 Approximately Continuous 6 months ND
teeth in both jaws weeks) and delayed 200 g
(more than 3
months)
Kuroda et al38 Various movements Immediate and delayed 50-200 g Continuous and 1 year or ARTT ND
in both jaws (0-12 weeks) intermittent
Motoyoshi et al43 Retraction of anterior Immediate (at surgery) ND ND 6 months or more ND
teeth in both jaws
Hedayati et al44 Canine retraction in Immediate (after 7-11 180 g Continuous Average: 5.4 ND
both jaws days) months
Range: 4-6.5
months
Chaddad et al45 Various movements Immediate (at surgery) 50-250 g Continuous and 150 days ND
in both jaws intermittent
Moon et al40 ND Immediate (after 2-3 \200 g Continuous and 8 months ND
weeks) intermittent
Kinzinger et al47 Distalization of Immediate (after 1 200-240 g Continuous Average: 6.5 D
maxillary molars week) months or ARTT

ND, Not described; D, described; ARTT, anchorage for required treatment time.
American Journal of Orthodontics and Dentofacial Orthopedics Reynders, Ronchi, and Bipat 564.e13
Volume 135, Number 5

Table IX. Implant maintenance-related factors in studies on mini-implants

Authors Antibiotic protocol Chlorhexidine protocol Oral-hygiene protocol Peri-implantitis protocol Mobility protocol

Freudenthaler et al14 ND ND ND OH reinforcement ND

Miyawaki et al12 3 days PI ND ND ND ND
Liou et al21 1 week PI 1 week PI OH instruction ND ND
Motoyoshi et al22 3 days PI ND ND ND ND
Thiruvenkatachari et al23 ND ND ND OH reinforcement ND
Park et al24 ND ND OH instruction OH reinforcement Monitor force levels
Tseng et al25 ND ND OH instruction Local cleaning ND
and antibiotics
Chen et al26 ND ND ND ND ND
Berens et al46 ND ND ND ND ND
Luzi et al37 ND 1 week PI OH instruction OH reinforcement ND
Wiechmann et al41 ND ND OH instruction Analgesics and antibiotics ND
Kuroda et al42 ND ND ND ND ND
Motoyoshi et al39 3 days PI ND ND ND ND
Kuroda et al38 ND ND ND ND ND
Motoyoshi et al43 3 days PI ND ND ND ND
Hedayati et al44 1 hour 1 week PI ND ND ND
before placement
Chaddad et al45 ND 1 week PI ND ND ND
Moon et al40 ND ND ND ND ND
Kinzinger et al47 ND ND ND ND ND

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

failed to show how the sexes were divided in their sub-
jects.44,45 Sex and success were not correlated accord-
ing 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 first molar.69 Most studies had a wide
range of the age variable. Immediate loading of mini-
implants showed significantly higher success rates in
adults compared with adolescents in a study by Mo-
toyoshi et al.39 This finding probably indicates that the
bone density of adolescents is insufficient to support im-
mediate loading with orthodontic forces. However, soft
tissue and bone thickness around the first molars vary
significantly 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 clarification (Table V).
Osteoporosis, uncontrolled diabetes, periodontal dis-
ease, smoking, and pharmacologic prescriptions such
as bisphosphonates are considered risk factors for clas-
sic 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 specific loading protocols.71,72
Location-related factors (Table VI) include hard-tis-
sue 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 re-
ports warned about the risk of overheating during im-
plant 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-im-
plant bone quantity was not correlated with success and
seemed therefore a less important factor for implant sta-
bility than cortical bone thickness. However, the wide
range in the age variable could have distorted these pro-
posed associations (Table V).
A relationship between success and the character of
the soft tissues has been proposed.20,24,45 It was recom-
mended to position implants in keratinized gingiva
rather than nonkeratinized mucosa.19,20,63 Keratinized
gingiva is thought to reduce the development of hyper-
trophic tissues and inflammation.66,76 To avoid these
secondary outcomes, it also was suggested to cover im-
plant 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 indi-
cated (Table III). Primary outcomes varied between
placement sites.24,40-43 Differences in success were re-
corded 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 finding
was confirmed in an animal study.54 Furthermore, grow-
ing third molars, exfoliating tooth buds, periodontal dis-
eases, and edentulous areas are thought to change bone
564.e14 Reynders, Ronchi, and Bipat
quality.44,76,78 To obtain better insight into these param-
eters, controlled studies are necessary and might lead to
site-specific protocols for implant placement.
Surgery-related factors (Table VII) include experi-
ence of the surgeon, sterilization, flap or flapless sur-
gery, 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 tech-
nique, drill speed and pressure, direction of placement,
steady or wiggling placement procedures, monocorti-
cal vs bicortical anchorage, and placement tor-
que.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 fi-
brous encapsulation of the implant.79-81 Failure rates
can probably be reduced with increasing clinical expe-
rience.15,37,40 In most studies, screw implants were
placed according to a specific protocol (Table VII).
Similar success rates were found for both flap and flap-
less procedures, but the influence of cortical pilot hole
preparation or self-tapping or self-drilling techniques
was not analyzed in any study.12,40 Four studies corre-
lated 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 specific 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 cate-
gories: 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 or-
thodontic force application.9,12,24,38,39,71,77,83 Compari-
son 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 den-
tal implants showed that placement into soft, spongy
bone with poor initial stability often risks the formation
of connective tissue encapsulation, similar to pseu-
doarthrosis.85-87 Animal studies reported that immedi-
ate 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
American Journal of Orthodontics and Dentofacial Orthopedics
May 2009
found significantly 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 stud-
ies 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 in-
crease them after initial healing.45,76 Liou et al21 found
significant screw displacements after applying immedi-
ate 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 differ-
ent outcomes and required further investigation. Re-
gardless, 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 ortho-
dontic 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 pri-
mary 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 displace-
ment 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 influenced this
association.
A potential relationship between implant success
and the direction of force application has been hypoth-
esized.13,14,20,63,66 Costa et al13 suggested that minis-
crews 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 influence of
the type of orthodontic movement on primary outcomes
was analyzed in only 1 study.38 Significantly higher fail-
ure rates were found for intrusive movements compared
with retraction and protraction of teeth, but this correla-
tion was rejected by the inclusion criteria for variables
(Table III).
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 5
Implant maintenance-related factors (Table IX) in-
cluded control of peri-implantitis. Prophylactic antibi-
otics, 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 asso-
ciated control of peri-implantitis with success but found
no correlation between oral-hygiene measures and pri-
mary outcomes (Table III). They also reported higher
success rates on the left side of the mouth; this finding
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 sufficient
to jeopardize healing and can cause fibrous encapsula-
tion.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 influence outcomes.19,37,90 Monitor-
ing these factors should become a part of the implant-
maintenance protocol.
Future research should apply a standardized meth-
odology to analyze primary and secondary outcomes
of using mini-implants in orthodontic treatment
protocols. Our definitions of outcome measures are
proposed as initial guidelines for this purpose. Fur-
thermore, our classification system of the variables
that could influence success rates is suggested as
a starting framework for research on mini-implants.
Studies should focus on implant systems for specific
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 manufac-
turers should be solicited to fund high-quality inde-
pendently conducted trials.29
CONCLUSIONS
1. The analysis of success rates was complicated be-
cause of various definitions of primary outcomes,
different timings of success assessment, poor meth-
odologies, and lack of clarity in most studies.
2. 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.
Reynders, Ronchi, and Bipat 564.e15
3. Adverse effects of mini-implants included biologic
damage, inflammation, and pain and discomfort.
Few articles reported on these outcomes.
4. 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 se-
lected as independent variables were not controlled.
5. This systematic review has shown that clinical stud-
ies on mini-implant placement are still in their in-
fancy. A proposal for a standardized methodology
for future studies was presented with our classifica-
tion system for variables and specific definitions 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 As-
sociation library, for assistance with the computerized
searches; and Rossella Bassi, Elisabetta Bello, and
Alice Marino for preparing the tables.
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May 2009

APPENDIX: SELECTION PROCEDURES Appendix Table III. Articles excluded by general selec-
Appendix Table I. Keywords for the search engines tion criteria (n 5 21)

Keywords Abbreviations used* Year of Reasons

Authors publication for exclusion
Orthodontics Orthodon, Orthodontics, Orthodontic
Wehrbein et al1 1998 1D
Implants Implant, Implants
Wehrbein et al2 1999 1D
Screw Screw, Screws
Bernhart et al3 2001 1D
Mini-implant Mini-implant, Mini-implants
Lee et al4 2004 1B (case)
Miniscrew Mini-screw, Mini-screws, Miniscrew,
Philippart and 2004 1B (technique)
Miniscrews
Philippart-Rochaix5
Microimplant Micro-impant, Micro-implants,
Sung et al6 2004 1B (case)
Microimplant, Microimplants
Park et al7 2004 1B (case)
Screw implant Screw implant, Screw
Travess et al8 2004 1B (review)
implants
Yao et al9 2005 1E
Temporary anchorage Temporary anchorage device,
Park et al10 2005 1B (technique)
device Temporary anchorage
Melsen and Verna11 2005 1B (technique)
devices
Herman and Cope12 2005 1B (technique)
*For each search engine, the appropriate characters (*, $, and so on) Crismani et al13 2005 1D
were used to truncate or explore search terms. Maino et al14 2005 1B (technique)
Maino et al15 2005 1 B (technique)
Chen et al16 2006 1A
Appendix Table II. Abstracts retrieved by electronic,
Cho17 2006 1B (case)
hand, and reference searching Kyung18 2006 1B (review)
Arcuri et al19 2007 1D
Number of abstracts Wang and Liou20 2008 1A
Search method without overlap Lim et al21 2008 1B (laboratory)
Google Scholar 3309 General exclusion criteria: 1A, study did not analyze success of mini-
PubMed (AA) 0 implants; 1B, not a clinical study on humans but a technique article,
Embase (AA) 16 case report, opinion article, review article, or laboratory, animal,
Science direct (AA) 24 or in-vitro study; 1C, sample size smaller than 10 mini-implants;
Other search 0 1D, implant diameter .2.5 mm; 1E, miniplates.
engines (AA)
Hand searching (AA) 1
References review 12
Appendix Table IV. Articles excluded by specific selec-
articles (AA)
References selected 2 tion criteria (n 5 12)
articles (AA)
Year of Reasons
Total 3364
Authors publication for exclusion
AA, Additional abstracts that were not retrieved by any other search
method. Costa et al22 1998 2A, 2B
Google Scholar was used as the basis, because it had the largest num- Fritz et al23 2004 2A, 2C
ber of abstracts and therefore the most overlap. Cheng et al24 2004 2B
Gelgor et al25 2004 2A
Park et al26 2005 2C
Berens et al27 2005 2A,2C
Kircelli et al28 2006 2A
Herman et al29 2006 2C
Wu et al30 2006 2A, 2B
Xun et al31 2007 2A
Chen et al32 2007 2B
Gelgor et al33 2007 2A

Specific exclusion criteria: 2A, no definition of success; 2B, no dura-

tion of force application; 2C, duration of force application\3 months.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 5
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