56 Orthodontics April 2015

Richard R J Cousley

Mini-Implants in
Contemporary Orthodontics
Part 2: Clinical Applications
and Optimal Biomechanics
Abstract: Since it is well established that orthodontic mini-implants provide stable anchorage in all three dimensions, the focus has
progressed to understanding the related biomechanics. This paper describes the key biomechanical advances for mini-implant treatments,
especially in terms of optimized movement of the target teeth.
Clinical Relevance: An understanding of the optimum insertion sites and biomechanics improves clinical outcomes in orthodontic mini-implant
cases.
Ortho Update 2015; 8: 56–61

When orthodontic mini-implants (OMIs)
became readily available in the early years
of the new millennium they were initially
‘competing’ with existing osseointegrated
fixtures such as restorative (dental) and
orthodontic palatal implants. Therefore,
the initial body of research work and
publications focused on the biological and
clinical factors which appeared to affect OMI
success (stability) rates and whether this
compared favourably with these other bone
fixtures. Subsequently, as both clinicians
and researchers began to see clear evidence
of OMI stability and low morbidity, these
fixtures became more widely utilized for
anchorage reinforcement. These aspects
have been extensively detailed, using the
most recent research evidence, in the first
paper in this series.1 However, in recent
years the focus has broadened to include
new clinical applications, ie how may we
use mini-implant anchorage optimally.2 A
large number of case reports have been
published, often documenting impressive
results of different types of malocclusions
being successfully treated with OMIs.
However, as pointed out by the late Dr
Vince Kokich,3 some of these reports
have strayed into bone anchorage usage
at the expense of other clinical options,
and this has perhaps caused a distraction
from the quality and innovation of the
majority of publications. Fortunately, based
on a combination of these case reports,
and especially from recent systematic
reports (in the form of case series and
randomized controlled trials), we can see
that OMIs provide reliable anchorage.
However, anchorage is only one part of the
clinical picture, and these studies did not
necessarily analyse the nature and range of
biomechanical effects on the dentition.
Over a number of years following
the introduction of OMI, anchorage
orthodontists began to observe clinical side-
effects, such as the development of lateral
openbites (Figure 1), and realized that this
was due to a combination of uncontrolled
canine tipping and an unfavourable vertical
component of the traction (which isn’t
overtly expressed with conventional fixed
appliance mechanics where the traction
runs alongside the archwire). Therefore, it
has become apparent that OMIs provide
the benefits of enhanced anchorage
control, but with the potential for stronger
expression of undesirable tooth movements.
Consequently, the second phase of OMI
clinical innovation and research included a
focus on the reduction of such biomechanical
side-effects. Furthermore, the clinical
observations resulting from customized
OMI biomechanics have crucially altered
our understanding and expectations of
orthodontic tooth movements and treatment
outcomes. This paper aims to highlight these
new biomechanical approaches, perhaps best
exemplified by the addition of powerarms to
the OMI armamentarium.

Richard R J Cousley, BSc, BDS, MSc, FDS RCS, FDS(Orth) RCS, Department of Orthodontics, Peterborough and Stamford Hospitals
NHS Foundation Trust, UK.

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April 2015
Powerarms (elongated hooks)
are now regarded as a key component in
OMI treatments since they have enabled
direct traction to be applied much more
parallel to the occlusal plane during both
incisor retraction and molar protraction
treatments (Figure 2). This has eliminated the
use of oblique vectors of traction and hence
reduced any vertical intrusive side-effects.
It has also, perhaps inadvertently, paved
the way for the next advance in OMI direct
anchorage techniques. This centres on the
‘receiving end’ of the traction and possibilities
for enhanced control of the target teeth.
This review paper will describe current
biomechanical approaches based on this
latest awareness and the shift from maximum
anchorage-focused goals to include
maximized treatment effects on the target
teeth. Since it is now possible to control
anchorage, and hence tooth movements, in
all three dimensions (3D), OMI applications
are best discussed in each of the three planes
of space: antero-posterior, transverse and
vertical. Furthermore, OMI treatments may
be subdivided within these 3D categories
according to the principal treatment
objective for the most common orthodontic
treatment plans (Table 1). This paper will
describe these subgroup topics within the
context of these 3D clinical applications.
Clinical applications in 3D
Antero-posterior anchorage
Bodily incisor retraction and torque control
Orthodontists will be
most familiar with the classical use of
orthodontic anchorage reinforcement to
prevent mesial movement (anchorage
loss) of the maxillary molar teeth. Such
reliable anchorage is readily accomplished
with OMIs, using either direct or indirect
anchorage. Indirect anchorage involves
using OMI(s) to stabilize the anchor tooth/
teeth, such as when the maxillary first
molar is anchored by a wire connection to
mid-palatal OMI(s) (Figure 3). Orthodontic
Dimension
Antero-posterior Anterior tooth retraction and
torque
Transverse Centreline correction
Vertical Incisor intrusion
Table 1. Clinical applications according to their dimension of OMI traction.
Orthodontics 57
traction, eg a closing coil spring, is then a
attached between the molar hook (on the
anchor unit) and the anterior (target) teeth
or archwire hook. However, there is a risk
of anchorage loss due to wire distortion or
failure of the molar attachment. Indirect
anchorage also relies on conventional fixed
appliance traction mechanics and therefore
entails its limitations, such as the risk of
incisor retroclination (controlled tipping), b
rather than providing scope for true bodily
incisor retraction. This is only feasible
with direct traction between an OMI and
powerarm.
Direct anchorage for incisor
movements is typically achieved using an
OMI inserted transmucosally on the buccal
side of the alveolus, between the first
Figure 1. Oblique traction was applied in this
molar and second premolar roots. Direct
hypodontia case to protract the upper molars (a).
anchorage provides both stable anchorage
It resulted in a unit of mesial movement but also
(the avoidance of mesial movement of the
‘rollercoaster’ bowing of the archwire and a lateral
adjacent molars since no traction is applied
openbite (b).
to these teeth) and enhanced control of
incisor teeth movements. Interestingly, this
additional torque control is classically more
anchorage demanding than conventional
traction, which tends to retrocline and tip
teeth. The improved biomechanical control
occurs because the powerarm’s long length
applies the traction closer to the centre of
resistance of the target teeth (than with a
conventional short hook). Powerarms are
Figure 2. Traction applied to a ‘shepherd’s crook’
usually crimped onto a rigid (eg 0.019” x
type of powerarm in this Class II division 1 case.
0.025”) stainless steel archwire (Figure 2), This makes the force vector almost parallel to the
but they may also be bonded directly onto occlusal plane and applied closer to the centre of
either the labial or palatal surface of an resistance of the anterior teeth (than a standard
individual target tooth (Figure 4). Several archwire hook).
designs of crimpable powerarms are
currently available: the original ‘shepherd’s
crook’ (Figure 2) and the more recently
introduced sigmoid version (Figure 5).
The author has found that the latter one
is more adaptable in terms of the level of
traction and the ease with which it may be
contoured between the lip and gingival
soft tissue zones. Both of these powerarm
designs provides better torque control as Figure 3. Indirect anchorage of the maxillary
the incisors are less prone to retroclination first molars, involving a rigid transpalatal arch
between the molars and a mid-palatal implant.
Clinical applications
Molar distalization Molar protraction
Occlusal plane levelling Bone anchored palatal
expansion
Molar intrusion Tooth extrusion
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 58 Orthodontics
a a
b important to confirm the anterior palatal
b
c palatal cortical plate.
c
d because the force is applied at some
d adjacent fully erupted second molar crown,
e the anterior teeth, unless they have been
Figure 4. A single-tooth powerarm, bonded to
the upper left canine crown. Direct traction was
used to distalize the canine in a bodily manner f
(a, b) prior to alignment of the adjacent lateral
incisor tooth (c, d).
Figure 5. Traction applied to a sigmoid-shaped
powerarm later during treatment in the patient
shown in Figure 2. This powerarm has been more
easily contoured in a neutral zone between the
adjacent mucosa and lip tissue. Its increased
length also made the force vector parallel to
the occlusal plane and closer to the centre of
resistance of the anterior teeth.
April 2015
(lingual tipping of their crowns) during
their retraction.4-7 In turn, this ensures that
the combination of the planned antero-
posterior tooth movements and an optimal
aesthetic result may be achieved, even
in adult ‘camouflage’ patients (Figure 6).
However, given the amount of palatal
movement of the upper incisor roots which
may now be achieved, it’s particularly
alveolar width on a lateral cephalogram
prior to treatment. If this is limited, eg
where the anterior palate has been
moulded by a digit habit, then the planned
amount of incisor root retraction should be
reduced to avoid an increased risk of incisor
root resorption, due to contact with the
Bodily molar movements
Conventional fixed appliance
biomechanics for molar distalization is
typically applied at the coronal level.
However, this tends to tip the molar teeth
distance coronal to the molar’s centre of
resistance (furcation point). This tipping
effect on the first molar is exacerbated if
it is not counteracted by contact with an
although in turn the second molar then
tends to tip distally.8 All of the so-called
‘non-compliance’ distalizers also inevitably
suffer anchorage loss, both during molar
distalization and then during retraction of
bone anchored.9,10 Fortunately, the use of
mini-implants now provides the required
combination of effective anchorage and
better control of bodily tooth movements
when molar teeth are being distalized or
protracted (mesialized).
Figure 6. An adult patient with a Class II division 2 malocclusion featuring increased upper incisor/
gingival display (a) and lower premolar hypodontia (b). The arches have been aligned prior to placement
of maxillary OMIs and powerarms (c). The upper incisors have been intruded and retracted, as well as
lower incisors proclined (d, e). Cephalometric superimposition (f) of the alignment and traction phases
demonstrates upper incisor intrusion and torque, plus mild upper molar intrusion.
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 April 2015 Orthodontics 59

a a

b d

Figure 7. A palatal distalizer in an adult patient, c

anchored on two paramedian OMIs and where the
pushcoil pressure is applied to the molar furcation
levels (a). Spaces have been opened in the buccal
segments, and the pushcoil recompressed with
composite stops, prior to bonding of a fixed
appliance (b).

e
Alveolar insertion sites provide
limited scope for such antero-posterior
molar movements, especially when molar
distalization needs to be followed by a
second phase of premolar and anterior
tooth retraction. Therefore, maxillary molar
distalization, especially involving half a
unit or more of molar movement, is best
achieved with OMIs inserted in the mid-
palate area, since there is no potential root
interference (Figure 7). This also facilitates
application of the distalizing force at the
furcation level and hence better bodily
molar movement.2,11 Whilst this indirect
anchorage is more technically demanding,
in terms of distalizer appliance design,
f g
fabrication and insertion, such distalizers
tend to be easy to re-activate during
molar distalization. This typically involves
re-compression of the pushcoil (active
component) to ensure continuous force
application.
Similarly, mid-palatal anchorage
may be used for molar protraction, where
the posterior teeth need to be moved
mesially to close spaces due to either
hypodontia or premature tooth losses. Figure 8. Pre-treatment panoramic radiograph showing ectopic lower canines and impacted lower
This involves a similar combination of mid- second molars (a). OMIs could only be sited in the canine regions, then traction applied via powerarms to
palatal anchorage and a U-shaped base protract the molars (b). Sufficient mesial movement of the buccal segments has been achieved, although
wire, but with traction applied from the lower incisor proclination has also occurred. The OMIs were then removed and standard space closure
frame to the molar(s). Alternatively, direct undertaken (c-e) to achieve a Class I incisor relationship (f, g).

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 60 Orthodontics
a anchorage may be utilized when premolar
b orthodontic space closure. However, in
c intrusion of the anterior teeth, although
d the unilateral absence of teeth or an
e
f
Figure 9. An adult patient with absent upper left
second premolar and first molar teeth, requiring
movement of the upper centreline to the right
side as well as left molar protraction (a). OMI-
powerarm traction was used on the right side
and conventional traction (anchorage loss) on
the left side (b, c), to achieve the desired tooth
movements (d–f), which would normally be
mutually exclusive.
April 2015
a
mesialization is not required in the maxillary
arch and for any form of molar protraction
in the mandibular arch. This involves the
application of traction from an OMI, ideally
inserted mesial or distal to the first premolar,
to a molar powerarm (Figure 8). Such molar
protraction can obviate the need for long-
term restorative pontic provision and it
should be considered as a treatment option
b
where there is sufficient alveolar bone for
12
the author’s experience, the greater the
alveolar deficiency then the greater the
potential for side-effects such as mesial
tipping of the molar and subsequent
binding of the archwire in the molar tube.
This leads to mesial shunting of the entire
arch and manifests as advancement and c
these side-effects can be counteracted with
the use of conventional intra-arch traction
(Figure 8).
Transverse anchorage
Some patients present with
a large asymmetrical displacement of
the dental centreline, due to either d
underlying transverse skeletal asymmetry.
Correction of this centreline discrepancy
requires anchorage reinforcement on
the contralateral side to the centreline
displacement. Unfortunately, conventional
anchorage, such as a transpalatal arch
or headgear, connects the anchor teeth
on both sides of the arch even when this
e
anchorage on the side of the centreline
shift is at best unwarranted and may even
be contra-indicated for tooth movements
on this side (such as molar protraction).
In contrast, OMIs provide the benefit of
effective unilateral anchorage specifically
applied to the target side (Figure 9).
Unilateral anchorage is also beneficial for
correction of vertical asymmetry where
the patient has an occlusal plane cant,
ie the occlusal plane is tilted (relative to
the face) with one side at a lower vertical f
level than the other side. Fortunately, it is
now possible to correct both centreline
displacements and many vertical occlusal
plane cants using mini-implant anchorage.
Such vertical anchorage is best exemplified
in the context of molar intrusion, as
described in the next section.
Vertical anchorage g
It is now recognized that
skeletal anchorage has caused a paradigm
shift in the management of patients with
excessive vertical growth discrepancies,
especially those with anterior open-
bite (AOB).13,14 This is especially the
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 April 2015
h more ‘effort’ for the orthodontist, from the
Figure 10. An adult patient with a Class II division I
malocclusion, on a skeletal II base with increased
vertical proportions and increased upper incisor
display (a–c). Expansion and intrusion of the
maxillary molars has resulted in anterior bite
closure and premature canine contacts, prior to
bonding of upper fixed brackets (d, e). The AOB
has been corrected with improvements in the
smile aesthetics and Class II profile at debond
(f, g). The occlusal corrections were stable 15
months later despite poor retainer compliance (h).
Figure 11. Buttons have been bonded to the
palatal aspect of the maxillary second molars to
enable direct intrusion/torque of these teeth,
using elastomeric traction.
case for patients with Class I and Class
II malocclusions, where closure of the
AOB is typically accompanied by Class II
improvements such as an overjet reduction
(Figure 10).13 Conversely, this may worsen
the antero-posterior and facial profile
discrepancies in patients with Class III and
bimaxillary incisor proclination features. These
cases are best treated using conventional
options, involving either premolar extractions
(with subsequent incisor teeth retraction
during space closure), or orthognathic
surgery (typically a maxillary osteotomy with
vertical impaction and possibly advancement
movements). Patients with a significant
anterior vertical facial excess, presenting as a
‘gummy smile’, and gross lip incompetence,
are also still more appropriately treated with
a maxillary impaction osteotomy since the
surgical approach is currently more effective
at achieving a large reduction in the anterior
mid-facial length.
Whilst OMI-assisted intrusion
of the maxillary molars may represent
patient’s perspective it’s a minimally invasive
treatment compared to dental extractions
and orthognathic surgery. Although some
authors advocate OMI placement on the
buccal side of the maxillary alveolus14 or in
mid-palatal sites, this author has found that
palatal alveolar sites are ideal for posterior
vertical anchorage purposes. In particular,
the posterior palatal alveolus offers sufficient
interproximal root clearance, a suitable soft
tissue environment, reliable cortical bone
support, and adequate distance between the
OMI and intruding teeth.13 In addition, the
insertion of OMIs distal (rather than mesial)
to the upper first molar teeth enables direct
intrusion of the first molars and makes it
simple to apply direct traction to the second
molar teeth. The latter is beneficial when
the terminal molars require additional
intrusion (especially of the palatal cusps)
or torque control (Figure 11). The potential
negative side-effect is that palatal traction
risks causing arch constriction because the
anchorage point is medial to the molar
crown and its fulcrum point. However, this
is readily countered by a customized rigid
TPA or quadhelix expander (Figure 10).2,13
These are all technique findings based on
clinical observations. More formal research
findings are becoming available, initially
in the form of retrospective research. For
example, a recent study of 31 maxillary molar
intrusion cases has indicated that adolescent
patients have greater scope for favourable
mandibular skeletal improvements following
molar intrusion than adults,15 but ideally
this requires a prospective study as future
evidence. In addition, there is still a need
for long-term research results, since AOB
correction is classically one of the most prone
malocclusion traits to relapse.
Conclusions
Orthodontic mini-implants
provide several advantages over and
above those available with conventional
anchorage reinforcement. On the one
hand the resultant anchorage is reliable,
minimally invasive, largely independent of
patient compliance, and feasible in all three
dimensions, while at the same time, it’s
now possible to produce more consistent
bodily movements of the target teeth than
with conventional biomechanics, because
correct biomechanical designs mean that
the forces are applied close to the centres
of resistance of the target teeth. This
is achieved with the use of powerarms
in direct anchorage scenarios, and the
positioning of palatal appliances near the
level of the molar furcations in indirect
anchorage cases.
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Orthodontics 61
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