Clinical use of miniscrew implants as orthodontic anchorage ...

ORIGINAL ARTICLE 

Clinical use of miniscrew implants 

as orthodontic anchorage: Success rates 

and postoperative discomfort 

Shingo Kuroda, a Yasuyo Sugawara, a Toru Deguchi, a Hee-Moon Kyung, b and Teruko Takano-Yamamoto c 

Okayama, Japan, and Daegu, South Korea 

Introduction: In this study, we evaluated the clinical usefulness of miniscrews as orthodontic anchorage. We 

examined their success rates, analyzed factors associated with their stability, and evaluated patients’ 

postoperative pain and discomfort with a retrospective questionnaire. Methods: Seventy-five patients, 116 

titanium screws of 2 types, and 38 miniplates were retrospectively examined. Each patient was given a 

questionnaire that included a visual analog scale to indicate discomfort after implantation. Results: The 

success rate for each type of implant was greater than 80%. The analysis of 79 miniscrews with a 1.3-mm 

diameter showed no significant correlations between success rate and these variables: age, sex, mandibular 

plane angle, anteroposterior jaw-base relationship, control of periodontitis, temporomandibular disorder 

symptoms, loading, and screw length. Most patients receiving titanium screws or miniplates with mucoperiosteal-flap 

surgery reported pain, but half of the patients receiving miniscrews without flap surgery did not 

report feeling pain at any time after placement. In addition, patients with miniscrews reported minimal 

discomfort due to swelling, speech difficulty, and difficulty in chewing. Conclusions: Miniscrews placed 

without flap surgery have high success rates with less pain and discomfort after surgery than miniscrews 

placed with flap surgery or miniplates placed with either procedure. (Am J Orthod Dentofacial Orthop 2007; 

131:9-15) 

Anchorage control in edgewise treatment is an 

important factor affecting treatment results. In 

the traditional approach, appliances such as 

headgear and intraoral elastics are used to reinforce 

anchorage, but it is difficult to obtain stationary anchorage 

even when the patients show excellent cooperation. 

1-4 5-7 

In the past, dental implants, miniplates, and titanium 

screws 8-10 were used as skeletal anchorage. These 

materials can provide stationary anchorage for various 

tooth movements without requiring patient cooperation. 

Dental implants and miniplates have high success 

rates and are strong enough to resist the reciprocal 

1-7 

forces of various orthodontic tooth movements. 

However, implantation of these devices requires com- 

aAssistant professor, Department of Orthodontics and Dentofacial Orthopedics, 

Graduate School of Medicine and Dentistry, Okayama University, Okayama, 

Japan. 

bProfessor, Department of Orthodontics, School of Dentistry, Kyungpook 

National University, Daegu, South Korea. 

cProfessor and chair, Department of Orthodontics and Dentofacial Orthopedics, 

Graduate School of Medicine and Dentistry, Okayama University, Okayama, 

Japan. 

Reprint requests to: Dr Teruko Takano-Yamamoto, Department of Orthodontics 

and Dentofacial Orthopedics, Graduate School of Medicine and Dentistry, 

Okayama University, 2-5-1 Shikata-Cho, Okayama 700-8525, Japan; e-mail, 

t_yamamo@md.okayama-u.ac.jp. 

Submitted, October 2004; revised and accepted, February 2005. 

0889-5406/$32.00 

Copyright © 2007 by the American Association of Orthodontists. 

doi:10.1016/j.ajodo.2005.02.032 

plicated surgery, leading to higher medical costs. In 

contrast, titanium screws have advantages: the ability to 

provide the same rigid anchorage against orthodontic 

loads as dental implants or miniplates, minimal anatomic 

limitations on placement, lower medical costs, 

8-10 

and simpler placements with less traumatic surgery. 

Recently, miniscrews less than 1.5 mm in diameter 

11-13 

have been used for various orthodontic indications. 

However, few human studies have examined factors 

associated with the stability of titanium screws used for 

orthodontic anchorage. 14,15 In addition, there have been 

few human reports about the success rates of miniscrews. 

Fear of pain is a problem because it contributes to 

patients’ avoidance of orthodontic treatment. 

16 Most 

patients report pain and discomfort during orthodontic 

treatment. 17-21 Because of the surgical procedure, many 

patients are also concerned about pain and discomfort 

after implantation. For patients, an appealing feature of 

skeletal anchorage might be the minimal surgical invasion. 

However, there are few reports about postoperative 

pain and discomfort after implantation of orthodontic 

anchorage. 

Our aim in this study was to evaluate the clinical 

usefulness of miniscrews as orthodontic anchorage. We 

examined their success rates, analyzed the factors 

9

10 Kuroda et al 

Fig 1. Implants used as orthodontic anchorage. A, Type A titanium screws, 2.0-mm in diameter and 

7-mm in length, and 2.3-mm in diameter and 11-mm in length; B, type B titanium screw, 1.3-mm in 

diameter and 8-mm in length; C, miniplate with screws, 2 mm in diameter and 5 mm in length; 

D, clinical use of type B screw. 

associated with their stability, and evaluated patients’ 

postoperative pain and discomfort caused by implantation 

with a retrospective questionnaire. 

MATERIAL AND METHODS 

Our subjects were 75 patients with malocclusions 

(12 male, 63 female; mean age, 21.8 years; SD, 8.2 

years) who had surgery at Okayama University Hospital 

to place a skeletal anchorage for edgewise treatment 

between November 2000 and March 2004. Before 

implantation, the advantages and disadvantages were 

explained to each patient and his or her parents when an 

implant anchor was considered desirable for orthodontic 

treatment. Two kinds of titanium screws with 

different diameters and lengths were used: type A 

(Inter-maxillary fixation screw, Keisei Medical Industrial, 

Tokyo, Japan): diameter, 2.0 or 2.3 mm; length, 7 

or 11 mm; screw head, 3 mm; and type B (AbsoAnchor, 

American Journal of Orthodontics and Dentofacial Orthopedics 

January 2007 

Dentos, Daegu, Korea): diameter, 1.3 mm; length, 6, 7, 

8, 10, and 12 mm; screw head, 3 mm. Miniplates with 

2 or 3 screws (SAS system [Dentsply-Sankin, Tokyo, 

Japan]; diameter, 2.0 mm; length, 5 mm) were also 

used for skeletal anchorage (Fig 1). 

The miniplates were placed under local anesthesia 

by senior oral surgeons at the Department of Oral and 

Maxillofacial Surgery, Okayama University Hospital in 

Japan. First, a mucoperiosteal incision was made at 

the site where emergence of the anchor was desirable. 

The mucoperiosteal flap was then reflected to 

expose the cortical bone. The miniplate was adjusted 

to fit the contour of the bone surface, and screw holes 

were made by using a 1.5-mm twist drill with continuous 

normal saline-solution irrigation. The plates were 

then fixed by 2 or 3 monocortical miniscrews by using 

a self-tapping method. The head of miniplate was 

exposed to the oral cavity through the incision. The


Volume 131, Number 1 

mucoperiosteal incision was sutured with 3-0 silk. The 

sutures were removed 7 to 10 days after surgery. 

Type A screws were placed by the same senior oral 

surgeons in the same manner as miniplates. Under local 

anesthesia, the mucoperiosteal flap was reflected to 

expose the cortical bone. The screw holes were made 

by using a 1.6-mm twist drill with continuous normal 

saline-solution irrigation. The screw head was adjusted 

at least 2 mm above the mucosa and exposed to the oral 

cavity through the incision. The mucoperiosteal incision 

was sutured, and the sutures were removed 7 to 10 

days after surgery. 

Type B screws were placed under local anesthesia 

by an orthodontist (S.K.). No mucoperiosteal incision 

or flap was made, and the screw holes were made by a 

1.0-mm round bar and twist drill at 500 rpm with 

continuous normal saline-solution irrigation. The 

1.3-mm screws were then placed through the attached 

gingiva by using a self-tapping method with continuous 

irrigation. The screw was inserted 5 or 6 mm into the 

alveolar bone, and the screw head was adjusted at least 

2 mm above the mucosa. (Fig 1D). After the placement 

surgery, the positions of the screws were checked with 

dental radiographs. 

The orthodontic appliances were not adjusted at the 

implantation appointment. Loading of the miniplates 

and the type A screws began 4 to 12 weeks after 

placement surgery, whereas that of the type B screws 

began 0 to 12 weeks after surgery. The orthodontic load 

was applied by elastic chain or nickel-titanium closing 

coil springs, estimated between 50 and 200 g. If the 

orthodontic force could be applied to the skeletal 

anchorage for 1 year (or until completion of the 

orthodontic treatment), we recorded the skeletal anchorage 

as a success. 

Each patient received a retrospective questionnaire 

with a 100-point visual analog scale (VAS) concerning 

discomfort caused by the implant surgery, not by the 

adjustment of the orthodontic appliances. They were 

asked whether they experienced any of the following 

forms of discomfort after implantation: pain (time 

course and intensity), swelling, difficulty in chewing, 

speech difficulty, and difficulty in toothbrushing. The 

VAS was a 100-mm line with anchors at each end of 

the line that read “no pain (or discomfort)” (0 mm) and 

“pain (or discomfort) as much as it could be” (100 

mm). Those who experienced pain were asked when it 

occurred: immediately after implantation, after 1 hour, 

at 12 hours, and from 1 to 14 days. 

Statistical analysis 

The chi-square or the Fisher exact probability test 

was used to examine the correlation between the 

Table I. Success rates, sizes of titanium screws, numbers 

of subjects and implants 

Clinical variable Type A Type B Miniplate with screws 

Success rate (%) 81.1 88.6 86.8 

Size of screws (mm) 

Diameter 2.0 or 2.3 1.3 2.0 

Length 7 or 11 6-12 5 

Subjects (n) 18 40 22 

Implants (n) 37 79 38 

success rates and types of implant anchor for the 154 

implant anchors. Those tests were also used to examine 

the correlations between the distribution of patients 

reporting pain and the types of implant anchor. Analysis 

of variance and the Fisher protected least-significant 

difference were used to compare the discomfort of 

each implant anchor in the 75 subjects with 154 implant 

anchors. A nonparametric correlation analysis between 

the variables of discomfort was made by using the 

Spearman rank correlation methods. The chi-square or 

the Fisher exact probability test was used to examine 

the correlation between the success rates and the 

classifications of each variable for the 79 implants of 

screw B. Any probability of P .05 was considered 

insignificant. These analyses were made with statistical 

analysis software (StatView, SPSS, Chicago, Ill). 

RESULTS 

Kuroda et al 11 

There was no significant difference in the success 

rates between types A and B screws or between 

miniplates and type A or B screws. Each type of 

implant had a high success rate over 80% (Table I). 

Contacts between screws and roots were not observed 

in radiographs. 

In the analysis of the 79 type B screws, there were 

no correlations between the success rate and any of the 

following variables: age, sex, mandibular plane angle, 

anteroposterior jaw-based relationship, control of periodontitis, 

temporomandibular disorder symptoms, start 

of loading, amount of loading, and screw length. 

However, the type B screws for intrusion had a significantly 

lower success rate than that for other orthodontic 

indications (Tables II and III). In addition, use in the 

molar area had a significantly lower success rate than in 

the premolar area when the type B screws were placed 

buccally. 

Type A screws and miniplates showed similar time 

course distributions in patients reporting pain (Fig 2). 

Most patients reported pain 1 hour after placement 

surgery, approximately 95% of type A screws and 

100% of miniplates, and most patients required pain 

medication. However, 1 hour after surgery, only half of


Table II. Success rates and numbers of screws according 

to clinical variables of subjects treated with 79 

type B screws 

Clinical variable 

Success rate 

(%) 

Number of 

screws 

Mandibular plane angle 

High 88.9 36 

Average 87.5 32 

Low 90.9 11 

Skeletal pattern 

Class I 78.6 28 

Class II 92.5 40 

Class III 100.0 11 

Age (y) 

20 92.5 40 

20-30 82.4 34 

30 100.0 5 

Sex 

Male 85.7 7 

Female 88.9 72 

Periodontitis 

No 87.8 74 

Yes 100.0 5 

Temporomandibular disorder symptoms 

No 96.0 25 

Yes 85.2 54 

the patients with type B screws reported pain, and the 

frequency dropped to 10% at day 1. At day 5, more than 

half of patients with type A screws or miniplates 

continued to report pain. After day 7, no patent with a 

type B screws reported pain, whereas approximately 

10% of the patients with type A screws or miniplates 

still reported pain more than 14 days after surgery. 

Significant differences in the numbers of patients reporting 

pain were observed between type A and type B 

screws on day 0 to day 9, and miniplates on day 0 to 

day 14 (P .05). Half of the patients with type B 

screws did not feel pain and used no pain medication at 

any time after surgery. 

The intensity of pain reported by the patients 

showed a similar time course as the distribution of 

patients reporting pain (Fig 3). The VAS assessments 

peaked 1 hour after surgery when the average pain 

intensity reached 65.7 for type A screws, 66.4 for 

miniplates, and 19.5 for type B screws. There was a 

significant difference in the mean scores, with VAS 

assessments of type B screws significantly lower than 

those of miniplates and type A screws. The difference 

in scores between miniplates or types A and B screws 

immediately after surgery to 7 days after surgery was 

statistically significant (P .05). 

There were significant differences in the discomfort 

of swelling, speech difficulty, and difficulty in chewing 


January 2007 

Table III. Success rates and numbers of screws according 

to clinical variables of 79 type B screws 

Clinical variable Success rate (%) Number of screws 

Location of implant 

Maxillary premolar 95.6 45 

Maxillary molar 66.7* 6 

Palatal molar 90.0 10 

Mandibular premolar 88.9 9 

Mandibular molar 66.7* 9 

Start of loading 

Immediate 89.8 59 

1 month 85.7 14 

1 month 83.3 6 

Initial loading (g) 

50 80.0 5 

100 89.1 55 

150 75.0 8 

200 100.0 11 

Screw length (mm) 

6 69.2 13 

7 83.3 6 

8 93.3 45 

10 91.7 12 

12 100.0 3 

Orthodontic indication 

Retraction 95.0 60 

Protraction 80.0 5 

Intrusion 64.3** 14 

*P .05 vs premolar; **P .05 vs retraction. 

after placement surgery between types A and B screws, 

and between miniplates and type B screws (P .001) 

(Fig 4). Difficulty in speech and chewing were correlated 

with intensity of swelling (P .001). However, 

there was no significant difference in difficulty in 

toothbrushing between types A and B screws, or 

between miniplates and type A or B screws. 

DISCUSSION 

Miniplates and titanium screws of more than 1.5 mm 

5-10,14,15 

in diameter were used as orthodontic anchorages. 

In this study, the success rates of miniplates and type A 

screws were more than 80%. We previously reported 

success rates of 96.4% for miniplates, 83.9% for 

14 

1.5-mm screws, and 85.0% for 2.3-mm screws. 

Cheng et al 

15 reported an 89% success rate with 140 

screws measuring 2.0 mm in diameter. Recently, miniscrews 

less than 1.5 mm in diameter have been used 

11-13 

for various methods of tooth movement. We used 

79 small titanium screws measuring 1.3 mm in diameter 

(type B), and our success rate was 88.6%. Therefore, 

it is suggested that miniscrews are as stable as 

miniplates or long, large-diameter screws. 

Type B screws showed no correlations between the 

success rate and several clinical variables: age, sex,



Fig 2. Distribution of patients reporting pain after implantation 

of orthodontic anchorage. Significant differences 

between type B screw and type A screw or 

miniplate indicated by **(P .05), and between type B 

screw and miniplate indicated by *(P .01) (h, hours; 

d, days). 

Fig 3. Mean intensity of pain after implantation of 

orthodontic anchorage. Significant differences between 

type B screw and type A screw or miniplate indicated by 

*(P .05) (h, hours; d, days). 

mandibular plane angle, and anteroposterior jaw-based 

relationship. The screw length of type B had no 

correlation to the success rate. We selected the screw 

length according to the thickness of the oral mucosa 

and allowed 5 to 6 mm of bone support. For instance, 


Fig 4. Discomfort after implantation. Significant differences 

between type B screw and type A screw or 

miniplate indicated by *(P .001). 

we used a 10-mm screw if the palatal mucosa was 4 

mm thick. Therefore, the screw lengths in this study 

might not be related to the success rate, because they 

did not correspond to the length implanted into the 

bone. Type B screws could resist a load of 200 g for 

en-masse tooth movement even if they were inserted 

only 5 mm into the bone. Miniscrews, which have short 

lengths and small diameters, are considered unlikely to 

touch the root if they are placed in a tooth-bearing area, 

and unlikely to invade the maxillary sinus. In addition, 

miniscrews are also considered to be less surgically 

invasive than long, large-diameter screws. Therefore, 

miniscrews are more useful than miniplates or long, 

large-diameter screws in clinical applications. 

Our histological study indicated that small titanium 

screws can function as rigid osseous anchorage against 

22,23 

orthodontic loads with a minimal healing period. In 

this study, the timing of loading was not related to the 

14 

success rate as we had shown in our previous report. 

Type B screws with immediate loading had a high 

success rate of 89.8%. In addition, Romanos et al 

showed that immediate loading increased the ossification 

of the alveolar bone around the implant. Therefore, 

immediate loading might have contributed to the good 

prognosis of miniscrew implants. 

The use of type B screws for intrusion at the 

posterior maxilla and mandible showed a significantly 

lower success rate than that for other orthodontic 

indications. In the maxilla, it might be difficult to obtain 

sufficient mechanical interdigitation between the screws 

and the alveolar bone, because cortical bone is thinner 

than the mandible. Our previous study showed that 

22



January 2007 

maxillary implants had less bone-implant contact than 

23 

those of mandibular in dogs. In addition, oral hygiene 

control is sometimes poor in the posterior maxilla, and 

the risk of peri-implant inflammation is higher than that 

in the anterior region. For intrusion of the maxillary 

molars, we recommend placing the screws outside the 

buccal alveolar area. Titanium screws placed in the 

zygomatic process are useful to intrude maxillary 

molars. 8 In addition, the palate is a suitable area to 

place miniscrews for intruding maxillary molars, because 

the palate has sufficient cortical bone and attached 

gingiva. In our study, type B screws in the 

palatal molar area had a higher success rate than those 

in the buccal molar area. 

Cheng et al 

15 also reported that screws in the 

posterior mandible had a lower success rate. In our 

animal study, all implant failures occurred in the 

mandible. 24 The reason remains unclear; however, 

several possibilities are speculated. We placed the 

screws between the roots of the first and second molars 

through the attached gingiva when intrusion of molars 

was required, but this was a narrow site, and the 

surgical procedure was technically difficult. In addition, 

the posterior mandible has less attached gingiva and a 

narrow oral vestibule; therefore, oral hygiene around 

the screws tends to be worse, and the screws are more 

susceptible to infection. Thus, the reason for the lower 

success rate in the mandible might be related to the 

surgical difficulty caused by the anatomical structure of 

the mandible. 

Pain during orthodontic treatment is a patient’s 

major concern. Half of the patients with type B screws 

did not complain of pain and did not need pain 

medication at any time after surgery. In our previous 

study, most patients receiving 1.5-mm screws without 

14 

flap surgery reported neither swelling nor pain. We 

believe that flap reflection is closely related to pain 

caused by the surgical procedure. In a previous study, 

50% of the patients who received periodontal-flap 

surgery reported severe or moderate pain after the 

surgical prodedurse. 25 Curtis et al 

26 showed that mucogingival 

surgery was significantly related to pain and 

was 3.5 times more likely to cause pain than osseous 

surgery and 6 times more likely than plastic soft-tissue 

surgery. A clinical trial to evaluate the influence of the 

incision and the reflection of a flap on pain after 

removal of the mandibular third molars indicated that 

the nonsurgical approach was effective in reducing pain 

and discomfort after extractions. 

27 duration of pain after surgery, and flap surgery should 

be avoided to reduce the patient’s pain after the 

placement procedure. 

In most orthodontic treatments, pain generally increases 

with time, according to measurements at 4 and 

24 hours, and then decreases to normal levels of 

17-21 

sensation 7 days after treatment. A pain assessment 

of 40 to 50 on the 100-point VAS scale was shown 1 

day after orthodontic treatment. 

In addition, the 

flapless surgical technique to place the dental implant 

28 

causes less pain and discomfort for patients. Therefore, 

the placement of screws without an incision or 

flap surgery could reduce both the intensity and the 

17 In this study, we 

asked patients to report the pain caused by the implants, 

and VAS assessments for the type B screws peaked 

1 hour after surgery when the average pain intensity 

reached 19.5. It is suggested that pain caused by the 

type B screw might be less than that caused by 

orthodontic tooth movement. In addition, when the 

orthodontic treatment is finished, miniscrews can be 

removed under topical anesthesia only and do not 

require sutures or postremoval medications. Therefore, 

miniscrews placed without flap surgery are more comfortable 

for the patient because of the minimal surgical 

invasion, and they provide suitable orthodontic anchorage. 

There were significant differences in the discomfort 

of swelling, speech difficulty, and chewing difficulty 

after placement surgery between types A and B screws, 

and between miniplates and type B screws. Type B 

screws are more comfortable than type A screws or 

miniplates for patients during orthodontic treatment. 

Speech and chewing difficulties might be correlated 

with the intensity of swelling. Miniplates and long 

screws placed through movable soft tissue sometimes 

cause swelling adjacent to the implantation site after 

flap surgery or infection during treatment. In contrast, 

type B screws placed at the attached gingiva without 

incision are less likely to develop infection and inflammation. 

Patents with type B screws might report slight 

swelling during treatment. In addition, no bleeding was 

observed immediately after surgery when type B 

screws were placed at the attached gingiva. Therefore, 

we believe that miniscrews placed without flap surgery 

are more comfortable for patients. 

CONCLUSIONS 

Miniscrews had a high success rate of approximately 

90%—the same as miniplates and large titanium 

screws, and they provided sufficient anchorage immediately 

after placement surgery for any orthodontic 

tooth movement. In addition, miniscrews placed without 

a mucoperiosteal incision or flap surgery significantly 

reduced the patient’s pain and discomfort after 

implantation. Miniscrews have suitable characteristics 

as orthodontic anchorage.



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