The Journal of EVIDENCE-BASED DENTAL PRACTICE

REVIEW ARTICLE

COMPARISON OF ANCHORAGE
EFFICIENCY OF ORTHODONTIC
MINI-IMPLANT AND CONVENTIONAL
ANCHORAGE REINFORCEMENT IN
PATIENTS REQUIRING MAXIMUM
ORTHODONTIC ANCHORAGE: A
SYSTEMATIC REVIEW AND META-ANALYSIS

YAN LIU, BDSa,†, ZHEN-JIN YANG, MDSa,†, JING ZHOU, MDSb, PING XIONG, MDSa,
QUAN WANG, MDSa, YAN YANG, MDSa, YU HU, MDSa, AND JIANG-TIAN HU, MDSa
a
The Affiliated Stomatology Hospital of Kunming Medical University, Kunming City, China
b
Department of Stomatology, Kunming Yanan Hospital, Kunming City, China

ABSTRACT CORRESPONDING AUTHOR:

Jing Zhou, Department of
Objective Stomatology, Kunming Yanan
To compare the clinical effectiveness of mini-implants (MIs) and conventional Hospital, Kunming City, 650000,
anchorage appliances used for orthodontic anchorage reinforcement in patients China.
with class I or II malocclusion with bimaxillary protrusion. E-mail: zhoujingjd@163.com
Materials and Methods
Literature search was conducted through PubMed, Embase, and Cochrane from KEYWORDS
inception to July 2018. The following Medical Subject Heading terms were used Orthodontic implant, Traditional
for the search string: “skeletal anchorage”, “temporary anchorage devices”, anchorage, Tooth movement, Anchorage
“miniscrew implant”, “mini-implant”, “micro-implant”. Standardized mean dif- loss, Evidence-based orthodontics
ference (SMD) and 95% confidence interval (CI) of horizontal and vertical move-
ments of teeth from baseline were used for comparison.
†Co-first authors.
Results
Conflict of Interest: The authors declare
A total of 12 studies were included in the final analysis. MI group significantly
that there are no conflicts of interest.
lowered mesial movement of molars compared to conventional anchorage group
(SMD 5 21.48, 95% CI 5 22.25 to 20.72; P 5 .0002). There was significantly Source of funding: This research did
higher retraction of incisors in the MI group than in the conventional group not receive any specific grant from
(SMD 5 20.47 mm, 95% CI 5 20.87 to 20.07; P 5 .02). No significant difference funding agencies in the public,
was seen in vertical movement of molars (SMD 5 20.21 mm, 95% CI 5 20.87 to commercial, or not-for-profit sectors.
0.45; P 5 .52) and incisors (SMD 5 20.30, 95% CI 5 21.18 to 0.58; P 5 .5). Received 1 October 2019; revised 17
December 2019; accepted 17 January
Conclusion 2020
MIs seem to be more effective than the conventional anchorage devices in terms J Evid Base Dent Pract 2020: [101401]
of minimizing unintended mesial movement of molars with maximum retraction 1532-3382/$36.00
of anterior teeth.
ª 2020 Published
by Elsevier Inc.
doi: https://doi.org/10.1016/
j.jebdp.2020.101401

June 2020 1
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
INTRODUCTION
M alocclusion, which is due to the disturbed relationship
of the dental arches, is a growing public health
problem because of its high prevalence.1 Malocclusion
caused by dentoalveolar protrusion is difficult to treat, and
the treatment modality often focuses on achieving an
absolute anchorage by restricting the undesirable mesial
movements of posterior teeth which is very critical for
obtaining favorable treatment results.2,3 The successful
treatment of dentoalveolar protrusion requires extraction
of premolars and maximum anchorage for the en-masse
retraction of anterior segment.4 Trans-palatal arches, head-
gears, Nance buttons, and differential moments of multiple
teeth at the anchorage segment are the traditional methods
used for achieving maximum anchorage during the treat-
ment of class I and II malocclusions with dentoalveolar
protrusion.5,6 However, the efficiency of traditional
appliances is challenged by patient compliance,
complicated designs, and elaborate wire bending and
hence is associated with some anchorage loss leading to
different levels of treatment outcomes.7-9
To surpass the shortcomings of traditional methods, ortho-
dontic mini-implants (MIs)10 or mini-plates11 have recently
been used for cases requiring maximum anchorage.
Orthodontic MIs can be placed and removed easily and
have better patient compliance with a reported survival
rate of 80% to 90%.12,13 They are not attached directly to
the teeth, unlike other methods of anchorage
reinforcement.14 Owing to the fact that MIs attain a
proximal contact with bone after their placement and thus
do not permit any unnecessary movements, it is believed
that these anchorage systems are an “absolute” appliance.14
However, owing to increasing evidences in recent times,
there has been certain extent of disagreement about the
precise effects of MIs, with few studies demonstrating sig-
nificant anchorage losses and movements of MIs itself.15-17
Although a number of studies have compared the clinical
effectiveness of MIs and conventional anchorage, a large
gap in knowledge over its efficacy as an anchorage appli-
ance still exists. Studies involving a smaller sample size have
failed to efficiently demonstrate whether or not MIs can
resist undesired tooth movement when compared with
other traditional methods in maximum anchorage–indicated
cases.18,19
Thus, this meta-analysis aimed at comparing the effective-
ness of MIs and conventional anchorage augmentation in
class I or II malocclusion with bimaxillary protrusion where
maximum anchorage is required for successful treatment
outcomes. Primary outcome included the measurement of
mesiodistal movement of maxillary first molars and incisors
while the vertical movement of the molars and incisors were
evaluated as secondary outcomes.
2 Volume 20, Number 2
MATERIALS AND METHODS
This meta-analysis (PROSPERO CRD42018095313) was
conducted in accordance with Cochrane Handbook for
Systematic Reviews of interventions and “Preferred
Reporting Items for Systematic reviews and Meta-analyses
(PRISMA)” guidelines.
Study Selection and Data Extraction
Search of the PubMed, EMBASE, Cochrane Central Reg-
ister of Controlled Trials, and World Health Organization
International Clinical Trials Registry Platform databases
(from inception to July 2018), was performed indepen-
dently by 2 reviewers. The following Medical Subject
Heading terms were used for the search string: “skeletal
anchorage”, “temporary anchorage devices”, “miniscrew
implant”, “mini-implant”, and “micro-implant” published
from inception to July 2018. The search was based on a
well-defined population, intervention, comparator,
outcome research question as follows: (1) enrolled ortho-
dontic patients who were treated with fixed orthodontic
treatment for class I or class II malocclusion with maxillary
or bimaxillary protrusion and those who required maximum
anchorage after the therapeutic extraction of maxillary first
and second premolars during anterior segment retraction;
(2) randomized controlled trials (RCTs), prospective
controlled clinical trials, retrospective controlled cohort
studies that reported the efficiency of buccally inserted
maxillary MIs; (3) RCTs, prospective controlled clinical trials,
retrospective controlled cohort studies that reported the
efficiency of conventional anchorage such as transpalatal
arch, Nance arch and button, lingual arch, and headgear;
(4) measurement of mesiodistal movement of maxillary first
molars and incisors along with the vertical movement of
the molars. All articles published in English language that
reported lateral cephalogram measurements or three-
dimensional digitizer model analysis, regarding the
mesiodistal movement of first molars and incisors, were
also included in this analysis.
Based on the titles and abstracts, full texts of potentially
relevant studies were retrieved and assessed for eligibility
criteria. In addition, the cited references in the included
articles were also manually assessed for their eligibility.
Articles were excluded if (1) studies used anchorage systems
other than MI (Onplant, Orthosystem, mini-plates); (2) suc-
cess rates or application of implant or stability were the
primary focus; (3) microimplant was used either as an
anchorage system for teeth intrusion or for distalization; and
(4) MIs placed in other areas such as the palatal or zygomatic
area. We included the most recent and complete studies
when duplicate data or subgroup analysis of the same study
was found.

The following data were extracted by 2 independent re-
viewers from the included studies on a customized data-
extraction sheet: year of publication, study design, coun-
try, age of the patients at the beginning of treatment, type
of malocclusion, types of appliances used for anchorage
reinforcement, tooth extraction plan of participants, degree
of mesial molar movement and tipping, degree of incisor
retraction and tipping, and treatment duration. Both the
reviewers discussed disagreements until consensus was
reached which was otherwise resolved by a third reviewer.
The records of all the variables were collected through the
superimposition of lateral cephalometric radiograph and
three-dimensional scanning of dental casts. Positive values
represented mesial or extrusion movement of the teeth,
while negative values represented distal and intrusion
movement of the teeth.
Methodological Assessment
The risk of bias was assessed using Cochrane risk of bias
tool for RCTs using the following criteria: random sequence
generation, allocation concealment, blinding of participants
and personnel, blinding of assessors, incomplete outcome
data, selective reporting of outcomes, and other potential
sources of bias. According to the information extracted from
the included primary studies, each domain was rated as
“high risk,” “unclear risk,” or “low risk.” Methodological
assessment of the non-RCTs was carried out using the
modified Newcastle-Ottawa Scale.20 Using this scale,
quality of each selected study was assessed based on the
selection of study groups, the comparability of groups,
and the ascertainment of outcome of interest.
Statistical Analysis
The endpoints analyzed are the absolute movement of the
incisors and molars both vertically and horizontally. As the
endpoints are continuous variables, absolute effect mea-
sures were used for the analysis. Results of the analyses are
presented graphically with forest plots after comparing
study designs, methodologies, participants, and types of
anchorage to judge the clinical heterogeneity of the studies.
The I2 statistics enabled evaluation of statistical heteroge-
neity of the collected data.
In presence of higher heterogeneity (ie, I2 . 50%), random-
effects (RE) meta-analytic models were used to calculate
the weighted overall mean and standard deviation of the
pooled data. Otherwise (I2 # 50%), the analysis was per-
formed using the fixed-effects models. The standardized
mean difference (SMD) with 95% confidence interval (CI)
was used as the absolute treatment effect estimate. Statis-
tical significance was set at P , .05. Subgroup analysis was
performed in terms of participants’ average age at the
beginning of treatment (#18 years old or $18 years old).
Furthermore, funnel plots for the primary outcome were
The Journal of EVIDENCE-BASED DENTAL PRACTICE
used to determine the presence of publication bias. Statis-
tical analysis was performed using the Review Manager
5.3 software.
To evaluate the effect of age on the efficacy of anchorage
devices, a subgroup analysis with patients aged #18 years
and .18 years was also performed.
RESULTS
Study Characteristics
Our search yielded a total of 1819 potentially relevant
studies of which 87 studies were reserved for full-text
reading and further assessment after the initial review. Ac-
cording to the inclusion and exclusion criteria, 12 studies
were included and analyzed in our meta-analysis. The flow
diagram of the study selection is shown in Figure 1. Out of
the 12 studies, 4 were RCTs,21-24 3 were prospective
controlled trials,25-27 and 5 were retrospective studies.28-32
The main characteristics of the included studies are
presented in Table 1.
Methodological Assessment and Publication Bias
Methodological assessment by Cochrane tool revealed a
moderate risk of bias for the 4 RCTs. The common meth-
odological deficiency in all these studies were lack of
blinding of participants and personnel. The results of
applying the Newcastle-Ottawa scale to assess the quality
of the non-RCT studies are shown in Table 2. The scores
ranged from 6 to 8, indicating that all studies were of
relatively high quality. However, all the non-RCTs failed to
report the assessment of outcome with independent blind-
ing, and hence, no star was provided for this parameter.
The publication bias in this meta-analysis was assessed us-
ing funnel plots of the primary outcomes. As shown in
Figure 2, evidence of significant publication bias was found
in mesiodistal movement of molars (Figure 2A) by
inspection of the asymmetrical funnel plots. But, as the
number of studies evaluated in this meta-analysis is rela-
tively less, the observed publication bias might be negli-
gible. Furthermore, as the analysis included studies from
varied geographic location, the skill level of the dentists
would have also contributed to the bias. For the mesiodistal
movement of incisors (Figure 2B), relatively less evidence of
publication bias was observed.
PRIMARY OUTCOMES
Mesiodistal Movement of Molars
All twelve included studies provided the data on mesiodistal
movement of maxillary first molars, wherein 240 patients
were treated with MIs and 254 patients with conventional
anchorage appliances. The random-effects analysis showed
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 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 1. Study flow diagram.
that MIs achieved a maximum reinforcement of orthodontic
anchorage with significantly lesser mesial movement
(I2 5 92.48; SMD 5 21.48 mm, 95% CI 5 22.25 to 20.72,
P 5 .0002) (Figure 3). Subgroup analysis suggested that the
age at the beginning of treatment may be one of the
reasons for different treatment outcomes (.18 years,
SMD 5 21.20 mm, 95% CI 5 22.01 to 20.39,
P 5 .00384; ,18 years old, SMD 5 22.36 mm, 95%
CI 5 24.18 to 20.53, P 5 .0113). The significant
difference in mesiodistal movement of molars in patients
aged .18 years suggested that the advantage provided
by the MIs might be enhanced in adult patients.
Mesiodistal Movement of Incisors
Eleven studies provided data on the mesiodistal movement
of incisors. As the heterogeneity of the included studies
was significantly higher (I2 5 74.90%, P ,.0001), a RE model
4 Volume 20, Number 2
was used for analysis. A total of 213 patients were treated
with MI and 203 patients with conventional anchorage ap-
pliances. The analysis revealed a significant difference be-
tween the MIs and conventional methods
(SMD 5 20.47 mm, 95% CI 5 20.87 to 20.07, P 5 .02)
(Figure 4), with greater retraction of incisors reported in the
MI group. Subgroup analysis revealed a significantly greater
retraction in patients whose treatment was initiated after
18 years (,18 years, SMD 5 20.07 mm, 95% CI 5 20.50
to 0.35, P 5 .73; .18 years old, SMD 5 20.56 mm, 95%
CI 5 21.04 to 20.08, P 5 .02).
SECONDARY OUTCOMES
Vertical Movement of Molars
Six studies reported the assessment of vertical movement of
molars that included 120 patients treated by MI and 112
 Table 1. Characteristics of the included studies.

Anchorage Method of Space closure

Author, year Age Sex methods Malocclusion Tooth extraction measurement duration (months)

RCTs

Upadhyay MI, 17.6 y; T, 17.3 y M/F: 0/18 (T); Headgear Angle’s class I with All the 4 first Cephalometric MI: 8.61 6 2.2,
et al., 200821 0/18 (MI) and TPA bialveolar protrusion premolars analysis T: 9.94 6 2.44

Al-Sibaie MI, 23.02 6 6.23 y; M/F: 12/16 (MI); TPA Angles class II Bilateral maxillary Lateral MI: 12.90, T: 16.97
and Hajeer, T, 20.46 6 4.8 y 9/19 (T) division I first premolars cephalometric
201322 analysis

Liu et al., MI: 21.65 6 4.4 y; M/F: 3/14 (MI); TPA Bialveolar protrusion All the 4 first Lateral MI: 25.6 6 5.06
200924 T: 19.71 6 3.06 y 3/14 (T) with Angles class I premolars cephalometric T: 26.88 6 6.54
or Angles class II analysis
division I

Sandler MI, 14.15 y Headgear Orthodontic Different extraction 3D study model MI: 26.83, T: 27.72
et al., 201423 T, 14.26 y and Nance patients requiring patterns followed analysis
Button maximum according to require
anchorage of space in each
patient

Non-RCTs (retrospective studies)

Park et al., MI, 18.8 6 4.7 y; M/F: 4/8 (MI); TPA or headgear Angles class II Maxillary first 3D model analysis MI: 8.6 6 0.8,
201232 T, 25.4 6 8.3 y 1/11 (T) division I premolars and T: 9.8 6 1.4

The Journal of EVIDENCE-BASED DENTAL PRACTICE

mandibular second
premolars

Koyama MI, 25 6 5.1 y; M/F: 1/13 (MI); Headgear and Angle’s class I with All the 4 first Lateral Unclear
et al., 201129 T, 24.8 6 5.1 y 2/12 (T) others bimaxillary premolars cephalometric
protrusion analysis

Lee and Kim, MI, 24.64 6 7.85 y; M/F: 0/20 TPA and headgear Angles class I with All the 4 first Lateral Unclear
201130 T, 22.16 6 3.11 y (MI & T) dentoalveolar premolars cephalometric
protrusion analysis

Yao et al., MI, 24.72 6 4.15; M/F: 2/23 (MI); Headgear Angle’s class I or Bilateral maxillary Lateral MI: 29.81, T: 32.29
200828 T, 22.32 6 3.92 2/20 (T) class II with first premolars cephalometric
bimaxillary analysis
June 2020

protrusion

(continued )
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The Journal of EVIDENCE-BASED DENTAL PRACTICE

Table 1. (continued)

Anchorage Method of Space closure

Author, year Age Sex methods Malocclusion Tooth extraction measurement duration (months)

Lai et al., MI, 24.6 y; T, 21.7 y M/F: 3/21 (MI); Headgear Angle’s class I or Bilateral maxillary 3D model analysis Unclear
200831 0/16 (T) class II with first premolars
bimaxillary
protrusion

Non-RCTs (prospective studies)

Chen MI, 26.53 6 3.54 y; M/F: 6/9 (MI); Headgear Bimaxillary All the 4 first Lateral MI: 21.93, T: 23.88
et al., 201525 T, 25.25 6 3.19 y 7/9 (T) protrusion premolars cephalometric
analysis

Upadhyay Average age: 17.2 M/F: 5/10 (MI); Nance arch Angles class I or Bilateral maxillary Lateral MI: 9.2, T: 10.6
et al., 200827 (14.5-22.3) y 4/11 (T) and others class II division I with first premolars cephalometric
bialveolar protrusion analysis

Chopra MI, 15.12 6 1.42 y; M/F: 12/13 Nance Button; Bimaxillary All the 4 first Lateral MI: 21.16, T: 21.76
et al., 201726 T, 15.08 6 1.53 (MI & T) lingual arch protrusion premolars cephalometric
analysis

M/F, male/female; MI, mini-implant; RCT, randomized controlled trial; T, traditional anchorage; TPA, transpalatal arch.
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Table 2. Quality of the nonrandomized controlled trial studies.

Park et al., Koyama Lee and Kim, Upadhyay Chopra Chen et al., Lia et al., Yao et al.,
Quality evaluation 201232 et al., 201129 201130 et al., 200821 et al., 201726 201525 200831 200828

Representativeness of the * * * * * * * *
mini-implant group

Selection of the * * * * * * * *
conventional anchorage
group

Ascertainment of the * * * * * * * *
mini-implant treatment
group

Demonstration that * * * * * * * *
outcome of interest was
not present at the start
of the study

Comparability of ** * ** ** * * ** **
participants in mini-implant
and conventional anchorage
groups

Assessment of outcome – – – – – – – –
with independent blinding

Adequacy of follow-up * * * * * * * *
for outcomes to occur

Lost to follow-up – – – * – – – –
acceptable

Total quality (score) High (7) High (6) High (7) High (8) High (6) High (6) High (7) High (7)

Each study was scored based on all the parameters mentioned and studies were assigned 1 or 2 stars based on the Newcastle-Ottawa scale description.

patients treated with conventional appliances. As the het-
erogeneity among the studies was significantly higher, a
random-effects model was used for analysis (I2 5 83.27,
P , .0001) (Figure 5). Although there were no significant
differences between the groups, a negative SMD was
demonstrated (SMD 5 20.21 mm, 95% CI 5 20.87 to
0.45, P 5 .52) indicating the intrusion of maxillary molars
to be higher in MIs group than in the conventional
anchorage group.
Vertical Movement of Incisors
Seven studies reported the assessment of vertical move-
ment of incisors which included 117 patients treated by MIs
and 110 patients with conventional appliances. A RE model
was used for the analysis as the heterogeneity was signifi-
cantly higher (I2 5 89.76%, P , .0001). There was no sig-
nificant difference observed between the MIs and
conventional groups; however, a negative SMD indicated
better intrusion in the MI group than in the conventional
group (SMD 5 20.30, 95% CI 5 -1.18 to 0.58; P 5 .5)
(Figure 6).
DISCUSSION
Although there are several anchorage reinforcing appli-
ances, achieving an absolute anchorage control while
treating bimaxillary protrusion poses a therapeutic chal-
lenge to clinicians.7 The availability of multiple treatment
modalities further complicates the selection of optimal
treatment choice. Currently, MIs have been widely used
as orthodontic anchorage reinforcement as they provide
an absolute anchorage with an ideal movement of only
the targeted teeth.33,34 Furthermore, as they are directly
attached to the bony appendages, they were
considered to be effective. Several studies have
reported that traditional anchorage reinforcement is

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 The Journal of EVIDENCE-BASED DENTAL PRACTICE

conventional appliances in terms of dental variants.

Figure 2. Publication bias. (A) Mesiodistal movement Also, the unintended movement of teeth was less in
of molars. (B) Mesiodistal movement of incisors. MIs.

Primary Outcomes
Restricting the mesial movement of the molars while
closing extraction spaces is very crucial during en-masse
retraction and is the key factor for retaining an absolute
anchorage.3,31 The results of our study demonstrated a
significantly minimal, undesirable mesial molar
movement with MIs in comparison to conventional
appliances (SMD 5 21.48 mm, P 5 .0002), indicating
an absolute anchorage that is achievable with MIs. The
major causes of anchorage loss in conventional methods
are biomechanical deficiencies and the patients’
discomfort of wearing headgear for 12 hours per day.13
In clinical practice, a decrease in mesial movement of
2 mm on each side can achieve better treatment
outcomes in some patients. In addition, patients’ age
seemed to play an important role in the mesiodistal
movement of molars and incisors. The mesial movement
of the molars was lower and the distal movement of the
incisors was greater in patients aged $18 years than
those in patients aged #18 years. This may be due to
the significantly higher cortical thickness at specific sites
in adult patients that provide more stability to MIs than
younger patients.37

Our results showed slightly higher values than the previous

associated with anchorage loss along with poor patient meta-analysis reported by Papadopoulos et al.38 and Xu
compliance and injuries.8,35,36 From our analysis, it and Xie7 wherein they reported a mean difference
was evident that MIs achieved better anchorage than of 22.4 mm (95% CI 5 22.9 to 21.8 mm, P 5 0)

Figure 3. Mesiodistal movement of molars. CI, confidence interval; RE, random-effects; SMD, standardized mean
difference.

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 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Figure 4. Mesiodistal movement of incisors. CI, confidence interval; RE, random-effects; SMD, standardized mean
difference.

and 22.01 mm (95% CI 5 22.45 to 21.58 mm),
respectively, between the MIs and the conventional
anchorage groups. In the present study, we analyzed the
SMD, whereas in the previous analysis, the mean
difference between the groups was evaluated. SMD was
used in assessing the effectiveness of MIs and a
conventional anchorage system to account for any kind of
reporting bias from the included articles. This method
ensured uniform units of all parameters considered for the
analysis.

Figure 5. Vertical movement of molars. CI, confidence interval; RE, random-effects; SMD, standardized mean
difference.

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 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 6. Vertical movement of incisors. CI, confidence interval; RE, random-effects; SMD, standardized mean
difference.
In our meta-analysis, greater incisor retraction of 20.47 mm
was seen in the MI group than in the conventional group.
The amount of incisor movement is reciprocally related to
mesiodistal movement of the molars; lesser mesial move-
ment of molars makes more space for incisor retraction.
According to Horiuchi et al., palatal cortical bone and width
of alveolar bone are the possible limiting factors during
incisor retraction.39 The movement of anterior teeth using
conventional anchorage appliances mostly depends on
the forces applied on the posterior teeth and patient
compliance and hence is less compared to MIs.
The subgroup analysis also revealed a greater advantage in
patients aged .18 years in terms of minimizing unintended
mesial movement with maximum anterior retraction. The
probable reasons for the same could be the stable bony
appendages in the adult population; this requires further
confirmatory studies. Other factors could not be accounted
for in this analysis because of lack of data stratified based on
the other demographic parameters in the included studies.
Nevertheless, the influence of other parameters might be
interdependent on each other which may not be possible to
account for.
Secondary Outcomes
From our study, it was evident that MIs could provide more
intrusive effect on molars than the conventional method.
Molar extrusion with resultant clockwise rotation of the
mandible can lead to an increase in the open bite, which is
one of the common adverse effects of the conventional
method. Yao et al.40 reported molar intrusion followed by
counter clockwise rotation of mandible, thereby improving
10 Volume 20, Number 2
the class II malocclusion only in the MI group. The
intrusion of molars is particularly beneficial for patients
with anterior open bite resulting in clockwise rotation of
maxillary dentition.41 Even minor changes in the vertical
dimension of posterior teeth can produce significant
changes in the anterior dimension, with about 1 mm of
posterior teeth intrusion producing 3 to 4 mm of upward
and forward movement of the chin.21
However, there was no significant difference in the vertical
movement of incisors (P 5 .96). The placement of anterior
hooks and the occlusogingival positioning of the MIs in the
jaws play an important role in the intrusion effect of molars
and incisors.42 However, the thickness of bone and the
overlying mucosa and the proximity to the roots are some
of the confounding factors that limit altering the vertical
position of the implant.21 Patients with gummy smile or
deep bite can benefit from the intrusive effects of incisors
exhibited by MIs.
It is also noteworthy to mention that the observed outcomes
(either anchorage loss or gain) in the included studies may
also be influenced by friction. It has been suggested that
there may be distal and intrusive forces resulting from the
direction of the retraction forces which may cause increased
friction of the archwire to the brackets or tubes.43 However,
as suggested by Upadhyay et al., it is unclear if this effect
will be more pronounced when a coil spring is left in
place for a couple of months after front retraction,44 and
the same has not been analyzed so far. Thus, the
underlying biomechanical causes need to be further
explored. In our analysis, studies describing implants

placed between the first and second premolars were
included. During the space closure, the force produced by
the elastomeric chain or coil spring between the MIs and
hooks has a vertical and horizontal components to intrude
and retract the anterior segment, thereby resulting in the
intrusive effect of these teeth.45 In cases where bodily
retractions are indicated, forces should pass near the
center of resistance.46
The analysis was carefully designed and performed to
minimize the possible bias. Not only the study design but
also the participants, intervention, and outcomes were
screened. Nonetheless, the effect estimate reported in the
current analysis may be lower because of the inclusion of
retrospective studies. In participant selection, maximum
anchorage reinforcement was required in the treatment
plan, which means all the patients needed a maximum
retraction of incisors and minimum of the extraction space
for molar mesial movement. In the experimental group, we
selected participants with MIs inserted buccally between the
roots of posterior teeth. In outcome evaluation, more vari-
ables were detected to evaluate the efficiency of anchorage
than the previous study. However, it was hard to avoid all the
biases in this meta-analysis, such as lack of original high-
quality studies and the heterogeneity in the included study.
Although there are many benefits achievable with MIs,
studies have reported that MIs were not capable of
achieving absolute anchorage in comparison to mini-
plates;47 however, it was clinically better than conventional
anchorage appliances in cases requiring maximum
anchorage. However, orthodontists must be careful of the
vertical effect, taking biomechanics into consideration. No
adverse events were reported in the included studies.
With the increasing number of techniques that have the po-
tential to reduce patient discomfort and improve quality-of-
life outcomes, there is a concurrent increase in determining
the dental patient-reported outcome measures (PROMs) to
determine the outcome of treatment from the patient’s
perspective.48,49 In the current analysis, no PROMs have been
reported in patients with conventional and micro-implant
anchorage. Thus, the patient-perceived benefit is not clear.
However, it could be plausible that as many of the traditional
appliances such as headgears are extraoral, it would be un-
comfortable for patients wearing the device, thereby leading
to less than desired levels of compliance.26
We acknowledge certain limitations within our analysis.
Although a detailed and thorough search strategy was used,
only English articles were included, resulting in a possible
publication bias. The number of RCTs included in our
analysis was limited based on the placement of the im-
plants, and thus, retrospective studies were included. Also,
the patients included in these studies would have under-
gone treatment, using different techniques such as torque,
The Journal of EVIDENCE-BASED DENTAL PRACTICE
tip back bend arch, or elastic traction, thereby affecting the
treatment outcomes so as to conceal the true results of the
meta-analysis. Furthermore, as the number of studies
reporting efficiency of MI after the therapeutic extraction of
maxillary first and second premolars during anterior
segment retraction is limited, we have included studies
reporting variations in extraction pattern. Hence, the results
should be interpreted with caution.
CONCLUSION
It was seen from the current analysis that the use of MIs
facilitates better anchorage preservation than conventional
methods as suggested by the absolute measures of teeth
movement in different planes in patients requiring
maximum anchorage. We conclude that the use of MIs can
significantly reduce the anchorage loss by minimizing the
mesial movement of maxillary molars and increasing the
degree of maxillary anterior segment retraction in compar-
ison to conventional anchorage devices.
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