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The temporary anchorage devices research terrain –

Current perspectives and Future forecasts!

Narayan H. Gandedkar, Koo Chieh Shen, Jitendra

Sharan, Nikhilesh Vaid

www.elsevier.com/locate/bios

PII: S1073-8746(18)30014-8
DOI: https://doi.org/10.1053/j.sodo.2018.01.014
Reference: YSODO529
To appear in: Seminars in Orthodontics
Cite this article as: Narayan H. Gandedkar, Koo Chieh Shen, Jitendra Sharan
and Nikhilesh Vaid, The temporary anchorage devices research terrain –
Current perspectives and Future forecasts! , Seminars in
Orthodontics,doi:10.1053/j.sodo.2018.01.014
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 Title Page

Title: The temporary anchorage devices research terrain – Current perspectives and Future
forecasts!

Author Information:

1) Narayan H. Gandedkar, BDS,MDS,FCFO

Dental Officer Specialist & Clinical Researcher
Cleft and Craniofacial Centre and Dental Service
KK Women’s and Children’s Hospital
100 Bukit Timah Road,
Singapore- 229899

2) Koo Chieh Shen BDS, MClinDent (Orthodontics) (UCL), M Orth RCS (Edinburgh)
Registrar, Dental Service
Cleft and Craniofacial Centre and Dental Service
KK Women’s and Children’s Hospital
100 Bukit Timah Road,
Singapore- 229899

3) Jitendra Sharan BDS, MDS

PhD Scholar,
Department of Orthodontics & Dentofacial Deformities,
CDER,All India Institute of Medical Sciences,
New Delhi,India 110029.

4) Nikhilesh Vaid BDS, MDS

Visiting Professor
European University College,
Building 27, 3rd Floor, DHCC,Dubai, UAE.

Corresponding author:

Narayan H. Gandedkar, BDS,MDS, FCFO

Dental Officer Specialist & Clinical Researcher
Cleft and Craniofacial Centre and Dental Service
KK Women’s and Children’s Hospital
100 Bukit Timah Road,
Singapore- 229899
Phone no: 65 63948151
Email: gandedkar.naru@gmail.com
Title: The temporary anchorage devices research terrain – Current perspectives and Future
forecasts!

Abstract:

Temporary anchorage devices (TADs) have gained profound applications in

contemporary orthodontic protocols to treat almost every genre of malocclusion; be it arising

from dentoalveolar component, from a skeleton component, or a combination of both. The

versatility of TADs has allowed the horizons of orthodontic treatment to be expanded by

utilizing bone as an anchor unit. TAD’s did not enjoy orthodontic mainstay status immediately.

This review dwells into the TAD’s journey through Kuhn’s Paradigm; from its humble beginnings

in the form of animal studies to case reports, randomized control trials and meta-analyses. This

article also weighs-in the potential future of TAD applications in orthodontics and dentofacial

orthopaedics.

Key Words:

Kuhn’s Paradigm, TADs, Mini-screws, Clinical Research, Evolution

 In 1962, Thomas S. Kuhn (1922–1996), an American physicist and epistemologist, in his

‘controversial’ whilst ‘landmark’ textbook on ‘sociology of scientific knowledge’, titled ‘The

Structure of Scientific Revolutions’,1 observed that every single scientific field experiences a

periodic, non-linear, revolutionary accrual of information referred to as ‘paradigm shifts’. He

further elucidates that within each realm of science, often a ‘period of revolution’ exists that

challenges or questions the underlying long-held assumptions of ‘normal science’, leading to

exploration of ‘alternative concepts’. These ‘alternative concepts’ are initially met with

scepticism, as the changes presented by the ‘alternative concepts’ are often counter-intuitive,

at-times theatrical and complex to comprehend. Moreover, these concepts cannot be proven

or disproven by the yardsticks of the ‘old paradigm’. However, subsequently, as more and more

‘favourable evidence’ is gathered, the ‘alternative concepts’ garner widespread ‘peer-group’

consensus and are bestowed due credibility, dismissing the initial contempt.

With every protracted whilst of time, Orthodontics, as a scientific community, has also

experienced Kuhn’s ‘Paradigm Shift/ Revolutionary Period’, for e.g., cephalometry, bonding

agents, pre-adjusted brackets, aligners, 3D diagnostic aids, CAD/CAM applications, and

temporary anchorage devices (TAD’s), to mention a few, that have indispensably led to

‘steadfast advancements’ and ‘greater improvements’ in not only the development of

‘treatment strategies’, but also have played a ‘distinctive role’ in enhancing better ‘outcomes’.

Kuhn’s ‘Paradigm shift’ and its relevance to temporary anchorage devices (TAD’s)

The advent of TADs essentially portrays the Kuhn’s philosophy of ‘Paradigm shift/revolutionary

phase’ not just in spirit but in truth as well, as it vehemently transforms itself into providing an

‘immutable fact’ that TADs endow us with ‘absolute anchorage’, which was previously
inconceivable by any other contemporary anchorage modalities. For a better understanding of

this analogy, this article encompasses the journey traversed by TAD’s with an emphasis laid on

the ‘evidence based practise’ of TAD’s, along with the contextual understanding of TAD’s -

current and future research. This article is divided into ‘four phases’ as enumerated in Figures 1

and 2, and discussed below:

Phase I (TADs - Model drift):

As early as 1945, Gainsforth and Higley,2 explored the possibility of applying ‘traction force’ from

vitallium screws placed in the basal bone of a canine breed. Although, at the time, neither the

‘experiment’ nor the ‘thought process per se’ of expending bone as ‘anchorage unit’ via metallic screw

gained wide spread acknowledgment, however, this experiment did ask an important question -

whether the ‘bone screw’ could be used as an ‘absolute anchorage unit’? This led the way, and also,

challenged what was considered the ‘norm’ in science. (Fig 1) The aforementioned question lay dormant

for nearly twenty-five years, and sporadically gained momentum, when Linkow (1969, 1970)3, 4, Sherman

(1978)5, Smith (1979)6, and Gray (1983)7, placed bone screws in experimental animal studies, however, it

was Creekmore and Eklund(1983)8, who successfully placed a vitalliuim alloy screw in the anterior

maxilla for the correction of deep bite. This was the ‘first-human clinical case’ that dealt with possibility

of ‘absolute anchorage’ in the form of placement of surgical screw in the anterior maxilla. The latter

mentioned case report along with the previously stated animal studies successfully steered the phase I

(TAD’s - model drift) to phase II (TAD’s-model crisis).

Phase II (TADs - Model Crisis)

Temporary anchorage devices entered its new phase of ‘model crisis’ and authors furthered their quest

in gathering ‘preliminary data’ to substantiate the ‘alternative concepts appearance’ with studies

primarily focussed on ‘preclinical biomechanical test’, e.g., load bearing, bone healing, maturation, and

adaptation5-7, 9-13
. On the parallel, in the clinical and innovation front, case reports were still relying
heavily on large, bulky implants, e.g., prosthetic fixtures implants and onplants primarily placed in the

non-radicular areas such as the palate, retromolar and edentulous areas or ‘anchor wires’ placed in the

zygomatic bone.9, 14, 15

Up until the late 90’s, most of the ‘bone anchorage devices’ introduced were markedly superior to

the ‘normal science’s’ anchorage conserving modalities, e.g., transpalatal arch, lingual holding arch and

headgears. The main benefits were (1) osseo-integration (2) biocompatibility (3) obviating the need for

significant patient compliance and (4) providing absolute anchorage. Consequently, since the

‘orthodontic implants’ were direct descendants of ‘prosthodontic implants’ and ‘surgical plates’, they

posed inherent shortcomings such as:16

1) Two stage procedure, often requiring periodontal flap surgery

2) Long pre-loading waiting time

3) Large and bulky implants made placement difficult in inter-radicular areas and other vital

structures, e.g., mental foramen in the mandible and greater palatine foramen in the palate

4) Implants were not economically viable in most situations.

5) Requirement of an expert to handle the placement. ( for e.g. Periodontist or an Implantologist)

6) Additional training was deemed essential

7) Point of application of force (orthodontic movements were limited to retraction and intrusion)

8) Owing to the large size, hygiene was also an issue.

9) Implant removal was a difficult and cumbersome procedure

10) Lack of proper and established guidelines for successful applications

At the time, the aforementioned limitations not only kept the TADs ‘out of reach’ from regular

orthodontic clinics, but also from conducting human trials. As Eugene Roberts remarked – “The acid-

etched Ti miniscrews developed in his laboratory were never used in patients because the data from

intraoral animals was insufficient to secure a clinical trial approval from the institutional review
board”.17 Hence, the basic premise of the studies and case reports were designed to question the

utilization of ‘prosthodontics implant’ as an orthodontic anchorage modality. Kanomi in 199718 was able

to demonstrate the use of ‘smaller screw (1.2 x 6 mm)’ as a bone anchorage unit and the subsequent

introduction of a ‘series of smaller dimension implants’ was the stepping stone to Phase III (TADs –

Model Revolution). Similarly, the same factors that formed the 2nd phase’s ‘model crisis’ were

responsible for spearheading the pursuit of TADs to more ‘precise and specific’ needs of orthodontic

anchorage. Several questions that arose in Phase II (TAD’s - model crisis) were better addressed in the

3rd phase (TAD’s - model revolution). The factors attributing to the success of TADs classified further, as

enlisted in Table 1.

Phase III (TADs – Model revolution) – the new TAD scientific inquiry

By the turn of the twenty first century, TAD’s had established themselves as an absolute

anchorage modality. Newer scientific enquires began stemming; Roberts et al study was one of

the first studies that conducted a ‘clinical trial’ with the aim to determine the ‘utility of

osseointegrated implant anchorage in the routine clinical practice of orthodontics’, and

demonstrated that osseo-integrated anchorage is a highly reliable clinical procedure. However,

TAD’s ‘secondary stability’ amplified the removal torque value of such implant system which

made it difficult to remove without causing moderate damage to the adjacent hard tissue.

19
Concurrently, several anchorage systems were introduced, which could be broadly classified

into: (Fig. 3)

A. Mini-implants (derived from prosthodontic implants), e.g., Mini-implants (Kanomi, 1997)18,

Aarhus anchorage system (Costa et al, 1998)20, Micro-implant anchorage (Park et al, 2001)21,
 LOMAS (orthodontic mini anchor system) (Lin et al, 2003)22 and Spider screw (Maino et al

,2003)23

B. Skeletal plate system (derived from surgery fixation plates), e.g., Skeletal Anchorage System

(Umemoriet al, 1999)24 and Zygoma Anchor System (De Clerck et al , 2002)25

The factors associated with TAD success, as described in Table 1, were evaluated and researched, and

they are:

1) Patient associated:

Some important patient associated factors, as enumerated above, play a vital role in the

overall success. Considerable amount of published research is available on the ‘overall success

rate’ of TADs from the perspective of ‘patient associated factors’. Studies have shown figures

close to 91.4% in the maxilla and 80% in the mandible respectively. 26-28

Cortical bone thickness and density are the most important determinants of TAD’s

primary and secondary stability.29-32 Temporary anchorage devices’ primary stability solely

depends on mechanical retention and the amount of implant-to-bone (cortical bone) contact.33,
34
Primary stability can be measured by ‘insertion torque’ and ‘pullout force’. This could be

attributed to both mechanical retention as well as bone growth in close proximity and on the

implant surface. Thus removal torque in its true sense does not depict primary stability. Bone

growth rarely occurs on stainless steel or polished titanium implant surfaces hence mechanical

retention of the implant is largely due to its removal torque value.

Subsequently, for secondary stability (osseointegration) to ensue, the peri-implant bone

undergoes several phases of bone healing process such as; (1) inflammatory acceleration (2)

increased osteoclastic activity (bone resorption) (3) a transitional latency period and (4) a

predominant osteogenesis. 35-37 Studies have shown that the failure rate of TADs is higher in the
mandible than the maxilla because of the ‘excessive insertion torque’ generated from the thick

mandibular cortical bone. This is turn causes high levels of peri-implant bone stress, resulting in

secondary microscopic bone necrosis around the TAD’s thread.38-40

Achieving primary stability of temporary anchorage devices in the adolescent group is

notably more challenging. Higher implant failure rates were expected in adolescent age group

as compared to the adult group due to the reduced cortical bone thickness, density and also

owing to the higher bone remodelling levels in adolescents.31, 41, 42

Temporary anchorage devices’ proximity to the root surfaces of adjacent teeth is a

patient-associated factor that requires considerable attention. Histological studies suggest that
43-46
cellular cementum repair ensue consequent to TAD’s associated root trauma. When TADs

are placed near the root (≤ 1mm)46, the anchorage devices are fixated in a bone denuded area

(periodontal ligament space, and tooth root). This bone denuded area and inadequate bone
47
coverage over the TAD thus leads to increased failure rates. In order to avoid failure, the

suggested minimum distance between the TAD’s (1.2 mm in diameter, 6 mm in length) and the

root is 1.5 mm.48 Also due diligence should be exercised during insertion of TADs surrounding

the inter-radicular area, especially in the inter-radicular area of the upper right and lower left

1st permanent molar as they are most susceptible for root damage. 49

Pain and discomfort resulting from the ‘insertion and removal’ of TADs cannot be

underemphasized, as it forms an integral part of the patient’s orthodontic treatment

experience. Studies have shown that a wide range of ‘pain and discomfort’ is experienced; from

undergoing ‘minor uncomfortable’ experience, such as pressure due to pilot drilling, to ‘higher

pain levels’ (comparable to teeth extraction) due to flap surgery.50-54 Researchers have
attempted to quantify the amount of discomfort experienced during TAD placement and

removal. The findings however are subjective, as these studies are confounded by the different

size and types of TAD and unstandardized study designs which may be prone to bias. Ganzer et

al.,55 showed that insertion of TADs led to ‘moderate levels’ of pain and discomfort, which

somewhat helped to fill the ‘knowledge gap’ on the pain outcomes. In order to better manage

pain, topical anaesthesia is generally recommended to achieve gingival and some degree of

periosteal numbness. A full local anaesthetic block of the gingiva-periosteal tissues and cortical

plate is recommended for inter-radicular TAD’s. 55-57

Peri-implant soft-tissue inflammatory hypertrophy due to poor oral hygiene is a

‘secondary risk factor’ for destabilisation and eventual failure of TAD’s (72 % at 1 year).16, 58-60

Failure rate is ascribed to placement of TADs in loose, non-keratinised mucosa. Hence, it is

prudent to place the TAD’s in attached, keratinised mucosa for better long term predictability

and survival rate. A study found TAD’s to be less prone to hygiene issues on the left side as

compared to the right side. This could be due to the right-handed patients brushing more

attentively on the opposite side, whilst neglecting the right side, suggesting that a good oral

hygiene maintenance routine is essential in the long term preservation of the TAD. 26

2) TAD associated:

In the past decade, a plethora of TAD’s have been introduced, some of the notable ones

mentioned earlier. Buschang and Kim noted that an ideal TAD should comprise of two

important characteristics, specifically – (1) minimizing the insertion torque (limit bone damage)

and (2) enhancing the holding power (maximise pullout forces).61

 Researchers have long questioned what the ideal length and diameter of a TAD should

be. This continuing quest has led researchers to experiment with many dimensions, usually

ranging from 3 to 11 mm in length and 1.1 to 3.5 mm in diameter. 22, 62-67 Research (animal and

clinical inclusive) has shown that the diameter of TAD’s play a more important role than its

length, in terms of primary stability. This is due to the fact that an increase in diameter leads to

increased ‘insertion torque’ whereas an increase in length only influences the insertion torque

to a small extent. The additional length of the TAD penetrates into soft cancellous bone, unlike

the increase in diameter with mostly cortical bone involvement. However, the inter-radicular

area is the ‘limiting factor’ for diameter dimension. The recommended dimensions are 6 to 8

mm in length and 1.2 to 1.5 mm in diameter as the TAD is easily accommodated into the inter-

radicular space, providing additional stability with offering qualities as expounded by Buschang

and Kim. 28, 68, 69

There is currently no clear evidence currently available regarding the optimum force

levels tolerated by TADs. It is prudent however, to apply a light initial force of 50 grams during

the first four to six weeks. A retrospective study found no significant differences in implant

stability when forces were increased to 250 grams.70 However, significant TAD displacements

were noted when 400 grams of forces were applied immediately onto the TAD. 65

Huang et al classified the materials used in the manufacture of TAD’s into three categories: 48

 Bioinert: (Titanium, Carbon),

 Biotolerant: Materials surround fibrous layer (Stainless steel, Chromium–cobalt alloy)

 Bioactive (Hydroxyapatite, Ceramic oxidized aluminum).

Brown et al suggested that both stainless steel (SS) and Ti alloys are suitable for immediate
orthodontic loading as they noted no difference in SS and Ti alloys in terms of ‘micro damage burden’

and ‘bone-to-implant’ contact regardless of loading status (Table 2). Thus, both types of screws provided

similar same mechanical stability and histologic responses.71 Orthodontic implant anchor system, BIOS

(bioresorbable implant anchor for orthodontic system), containing biodegradable polylactic acid (PLA)

and polyglycolic acid (PGA) derivatives have been investigated in its use with implants, as early as 1995,

by Glatzmaier et al.72

Kim et al, in a histomorphometry study, noted the drill-free method yielded better results and

success rates, bone implant contact ratio and bone density than drilling method.73 Chen Y et al.,

demonstrated high success rates – 93% (self- drilling) vs. 86% (self-tapping) with high insertion and

removal torque for self-drilling screws in both the maxilla and mandible. The authors noted a greater

percentage bone-to-implant contact values when self-drilling screws were used.43 However, when

placement method was assessed, some of the studies enumerated in Table 2 found the self-tapping

TADs to be on par with self-drilling TADs.

3) Clinician/Operator associated:

The ability to move teeth effectively in all three dimensions with utilization of bone as

an anchorage modality is not only the most ‘revolutionary’ application of TAD, but it has also

pushed the ‘envelope of discrepancy’ of correcting teeth when using orthodontic treatment

alone. Tooth movement in any direction is possible without the adverse effects from Newton’s

third law of motion – ‘for every action there is an equal and opposite reaction’ that had

bewildered the orthodontic fraternity for almost a century.

Fixed functional appliances have been used very routinely as a potential tool in the treatment of

skeletal Class II jaw relationships arising from a mandibular deficiency. These appliances have shown to

produce substantial treatment results. Since they are directly anchored onto the lower archwire or the
canine brackets, proclination of the mandibular anterior teeth is an expected side effect. Hence, to

entirely eliminate the mandibular dental component from the fixed functional appliances, TADs were

used as anchor units. Gandedkar et al were the amongst the first to successfully use TADs as anchoring

units in the lower arch for the comprehensive orthodontic correction of a Class II division 1 case using

fixed functional appliances. 74, 75

Some modalities of Class II and Class III treatment with TAD’s are enumerated below and also in

the table 3, such as;

1) Maxillary molar distalization: Pendulum appliance,76 NiTi coils springs, 77

distal jet and its

modifications.78

2) Enmasse distalization of maxillary arch: NiTi coil spring79-81

3) Enmasse distalization of mandibular arch.82, 83

4) Intermaxillary Class II/III correction: Class II /III elastics traction with TAD’s 84, 85

Complications can ensue at any stage of TAD’s management, and can be classified into various

stages, as described in the table 4, and table 5 showing important systematic review, meta-

analysis, and randomised controlled trials on TAD’s.

Phase IV (TADs - New Paradigm and what’s in-store for the future?)

Comparatively, temporary anchorage devices have come a long way in a short span of time. No

other ‘modality of treatment’ has been pursued so passionately both by clinicians and researchers alike.

Looking from the vantage point of Kuhn’s ‘Paradigm Shift’, TADs have successfully managed to establish

a ‘context of justification’ as far as their application is concerned supported by credible number of

‘empirical evidence’.

Published data on TADS: It’s Demographics and Significance

TAD’s have gained considerable interest as the figure 4 depicts nature of publications related to TAD’s,

from 1991 to 2017, across the world. Since the past decade, the research concerning TAD’s have

specifically focussed on ‘evidence based practice’ with more emphasis on systematic reviews, meta-

analysis, such that a quantitative, statistical approach is used to formally summarise the previously

conducted empirical research.

Today, there’s little doubt, both on the clinical and research terrain, that TADs are a time-tested

modality. From the conception, development, maturation, and acceptance of TAD as a ‘scientific idea’,

TADs exemplify the Paradigm Shift as visualised by Thomas Kuhn. The unanswered questions that still

need deliberation before TADs can be deemed as “Normal Science” is on two terrains-clinical and

material sciences.

Clinical questions:

1) The ‘long term’ results of the studies enumerated in this paper need to be examined further.

2) What is the long-term stability of some of the scenarios that have been treated by TAD’s such

as; posterior teeth intrusion, skeletal open bite cases, en-masse retraction etc.

3) How does the tooth root behave on a long-term basis with the expanded TAD envelope? i.e.,

will there be higher incidences of root resportion?

4) How does the soft-tissue envelope yield itself to such magnitude of teeth movement?

Material Sciences questions:

1) As technology advances; could there be better materials that can be used for enhanced TAD

success?

For e.g., Cell seeding scaffolds, cell-laden hydrogels, electrical cell guiding biomimetic tissue

materials, nano-composites etc.86-89

2) Can 3D Computer aided design and manufacturing modalities (CAD/CAM) and rapid protoyping

make individually customised TAD’s?

 For e.g., 3D Bioprinting, autonomous self-assembly (bottom-up approach), and biodegradable

scaffolds (calcium phosphate, polymethyl methacrylate filaments). 90, 91

Conclusions and Future Forecasts

Temporary Anchorage Devices have provided answers to questions deemed unanswerable a

couple of decades ago. Its incorporation into orthodontic mechanotherapy has probably been

the boldest brush stroke on the orthodontic canvas. The ability to have bone anchored growth

modulation devices has expanded the envelope of growth modulation. The ability to treat even

adult patients conventially indicated for surgery by TAD supported appliance assemblies has

introduced the term “Orthognathic like Orthodontics” into the orthodontic glossary. While long

term effects of therapy and data that can quantify these effects are still around the corner,

there is no looking back on the fact that TADs are orthodontic mainstay today.

There has been an effort on the biomaterial research terrain to develop newer implant

materials that can further augment the already high implant stability rates (quote the number)

by closely studying the implant-tissue interphase. Customized CAD CAM metal printed

appliances today can incorporate TADs as their components easily (designed by software along

with 3D printed templates for precise TAD placement). The widespread application of TADs has

stimulated newer thinking in Orthodontic Biomechanics to simplify mechanics and minimize

untoward reciprocal effects. The application of TAD supported protocols in Lingual and Aligner

mechanics integrates well with the perceived tomorrow of orthodontic appliances.

As we crystal gaze into the future-TADs and customized orthodontic appliances will further

integrate to improve the predictability of mechanotherapy; and a well-defined new “envelope

of orthodontic discrepancy” would have proven indicators & protocols on the evidence terrain!

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 Figures

Figure 1 Kuhn’s ‘paradigm cycle’ explaining the different phases of TAD’s

Figure 2 Four phases of TAD’s with explanation.

Figure 3 Timeline enumerating some of the important ‘breakthroughs and events’ that have

helped shape the ‘TAD’s paradigm’: from TAD’s ‘phase I-model drift’ to ‘phase IV- new

paradigm’

Figure 4 Figure showing the publications of TAD’s since 1991. A search of PubMed with

keywords; orthodontic mini-implant, mini-screw, micro-implant, microimplant,

temporary anchorage device, miniplates, skeletal anchorage system, with over hundred

countries were assessed. Initially, we retrieved more than 90,534 articles, subsequently,

most relevant articles were assessed and the data extracted for statistical analysis with

segregation of number of articles based on countries as shown in the figure. The results

of this ‘data search’ should be interpreted with caution because this is not an exhaustive

data search, as ‘only English language’ literature was searched with access to ‘only one

electronic data base’. The authors have attempted to show the impact of TAD’s across

the world in the recent years.

 Table 1 The factors attributing to the success of TADs

Patient associated: TAD associated Clinician/Operator

associated
Ideal characteristics of  Studies related to
Hard tissue TAD’s pure biomechanics
 Bone behavior (quality,  Dimension  Studies related to
quantity, site) (length, diameter) enmasse
 Dentition( root  Design ( head, distalization, molar
proximity) neck, body, thread protraction, buccal
 Stability (primary and orientation) segment
secondary) and  Insertion type( distalization etc.
mobility self-drilling, self-  Studies related to
 Histocompatibility tapping) and Class II and Class III
Softtissue loading correction
 Mucosa ( type,  Material ( metal,  Studies related to
thickness) resorbable, maxillary expansion
 Presence of treated, non-  Iatrogenic damage,
Inflammation treated, strength ) recovery, and
Age and Sex complications
 Adolescent
 Older age
Oral hygiene
 Peri-implant
inflammation
 Microorganism
 Colonization and
infection
 Pain management
 Habits
 Table 2 Table describing the success rate, length, and area and biomaterials used in the
manufacturing of TAD.

Success Rate, Length and Area Biomaterials

First author Diameter/length Area and First Biomaterial Study highlight

(Year) And type (self- percentage author name and
drilling, self- success (Year) composition
tapping, torque
etc)
Cheng S J, 2.0mm/ 5- 91.4%, Junker Calcium  Thin calcium
16
2004 15mm Posterior R, 2009 phosphate phosphate
86
Pure Ti jaws coating (CaP) coating
Self-tapping improves bone-
implant
integration
 Paucity of
human studies
comparing
thinly coated
CaP and
roughened
implants
Park H-S, 1.2mm/ 5- 91.6%, Pan C Y, Ti-6Al-4V alloy  Ti alloy
67
2006 10mm Inter- 2012 87 mini-implants preferred over
Ti alloy radicular (2 x 10-12mm) Ti due to its
2.0mm/ 10- area and 316L superior
15mm stainless steel strength
Ti mini-implants (2  Both types of
Self-tapping x 10-12mm) mini-implants
were
mechanically
stable when
measured with
resonance
frequency
Motoyoshi 1.6mm/ 8mm 85.5%, Agarwal FN7-10-coated  FN7-10-coated
M, 2007 39 Ti Posterior R, 2015 stainless steel screws showed
88
Self-tapping jaws mini-screws up to 45% more
fixation
compared with
uncoated
 screws at the 3
month period
Wiechmann 1.1mm/ 10mm 86.8%,
D, 200789 Ti alloy Inter-
1.6mm/ 6-8mm radicular
Ti area
Self-tapping

Table 3 Table showing various forms of teeth movement possible by TAD’s along with
some important studies on iatrogenic damage and histocompatibility.

Pure biomechanics of teeth movement

First author Pure biomechanics of Point of application of force
(Year) teeth movement
Yao C C, 2004 Intrusion of posterior  Force application of 150-250g on the buccal mini-
90
buccal segments plate and palatal mini-screw
 Maxillary 1st and 2nd molars were intruded 3mm
with slight distal tipping of the 2nd molar
Rachala M R, Anterior open bite  Ti mini-screws (1.3 x 9mm) were placed in the
201091 maxilla and intrusive forces were applied with NiTi
closed coil springs over 8 months
 Maxillary molars were intruded about 4mm each
Enmasse distalization, buccal segment distalization, expansion
First author Enmasse distalization, Study highlight
(Year) buccal segment
distalization,
expansion
Gelgor IE, Distalization of buccal  Maxillary first molars were distalized 3.9-4.3mm
200492 segments per side over a period of 4.6 months
 Distal molars tipped 8.76° on average
Upadhyay M, En masse retraction  Mini-implants placed in the maxillary and
200893 of maxillary and mandibular inter-radicular bone provided absolute
mandibular anterior anchorage for retraction of anterior teeth
teeth  In the group with mini-implants, the molars were
also distalized and intruded
MacGinnis M, Micro-implant-  MARPE is beneficial in patients with fused sutures
201494 assisted rapid palatal  Less tipping of the teeth with more translation of
expansion (MARPE) the complex occurred compared to conventional
RPE
Wilmes B, Hybrid Hyrax with 2  The first molar region experience a mean
201040 mini-implants and expansion of 5.0 ± 1.5mm
facemask  Expansion was achieved after 4 to 14 days
  All mini-implants were stable at time of insertion
and removal
Iatrogenic Damage And Histocompatibility
First author Iatrogenic damage Study highlight
(Year) and
Histocompatibility
Fabbroni G, Iatrogenic damage  Of the 232 screws inserted in the prospective
2004 95 study, 26 screws had major contact and 37 minor
contact with adjacent teeth
Rinaldi J C , Iatrogenic damage  Repair occurred at the mini-implant surface
2010 96 through cementoblastic activity.
 In addition, the periodontal ligament space was
well preserved in all specimens, and
 No microankylotic spots were detected
Ahmed VK, Iatrogenic damage  Damaged root surfaces showed significant repair
2014 44 at 1 month, with 70% exhibiting excellent repair at
3 months
 Damaged teeth remained vital and showed no
additional mobility
Deguchi T, Histocompatibility  Increased labelling incidence, higher woven-to-
2003 97 lamellar-bone ratio and
 Increased osseous contact was found in the
healing group fixated with small titanium screws
Wehrbein H, Histocompatibility  High (>70%) direct bone contact in foxhounds
200898  Identified mineralized bone, bone marrow and
small areas of suture tissue
 Table 4 Table describing the complications and causes associated with TAD’S along with
potential resolutions.

Stage Complication Causes Resolution

During 1. Periodontal 1. Improper selection 1. Assessment of cortical bone
TAD ligament injury of TAD thickens with radiographs
Insertion 2. Tooth root injury 2. Inadequate 2. Assessment of inter-radicular
3. Neurovascular cortical bone space
bundles injury thickness 3. Judicious use of TAD
4. Necrosis and local 3. Excess TAD placement splints/guides
ischemia insertion torque 4. TAD placement in keratinised
5. Maxillary sinus 4. Wrong TAD gingival area.
perforation insertion 5. Insertion torque not
6. TAD fracture angulation exceeding 10 Ncm.
5. Abrupt Increased 6. Selection of proper TAD
insertion torque dimension
During 1. Inflammation and 1. Poor oral hygiene 1. Re-enforcement of oral
treatment infection 2. Excessive hygiene instructions
2. Poor bone orthodontic 2. prophylactic oral anti-
remodelling treatment force inflammatory drugs
application 3. Use of minimal orthodontic
force (≤ 250 g).
During 1. Fracture of TAD 1. Torque control while removal
TAD 2. Micro-fracture of 1. Excessive 2. 3-7 days wait period allow
removal bone force/torque screw to loosen after initial
application during attempt.
removal 3. Selection of quality material
2. Poor TAD material TAD ( e.g., Ti-Al-V)
quality
 Table 5 Table showing important systematic review, meta-analysis, and
randomised controlled trials on TAD’s.

First author Year Study Purpose of study

Type
Cunha AC 99 2017 SR* & How do geometry-related parameters influence the clinical
ǂ
MA performance of orthodontic mini-implants?
de Guzmán- 2017 SR & MA Effectiveness class III malocclusions treatment with skeletal
Barrera JR 100 anchorage
Yi J (2016)101 2016 SR & MA Comparison of the success rate between self-drilling and
self-tapping miniscrews
Antoszewska- 2016 SR & MA Effectiveness of orthodontic miniscrew implants in
Smith J 102 anchorage reinforcement during en-masse retraction: A
systematic review and meta-analysis
†
Lamberton JA 2016 RCT Comparison of pain perception during miniscrew
103
placement
Alsafadi AS 104 2016 SR Effect of molar intrusion with temporary anchorage devices
in patients with anterior open bite
Hong S 105 2016 MA Prognostic factors associated with the success rates of
posterior orthodontic miniscrew implants
Nienkemper 2014 SR Systematic review of mini-implant displacement under
M 106 orthodontic loading
Jambi S 107 2014 Cochrane Effect of surgical anchorage techniques compared to
DSR§ conventional anchorage
Dalessandri D 2013 MA Determination of success rates of TAD’s
108

da Costa G 109 2013 MA Intraoral distalizer effects with conventional and skeletal
anchorage
Alves J M110 2012 SR Root repair after contact with mini-implants
Major MP111 2012 SR & MA Skeletal anchored maxillary protraction for midface
deficiency in children and early adolescents with Class III
malocclusion
Tsui WK112 2012 SR Bone anchor systems for orthodontic application
Feng X 113 2012 SR Effectiveness of TAD-anchored maxillary protraction in late
mixed dentition
Papageorgiou 2012 MA Failure rates and associated risk factors of
SN 114 orthodontic miniscrew implants
Papadopoulos 2011 MA Clinical effectiveness of orthodontic miniscrew implants
MA 115
Li F 116 2011 SR Comparison of anchorage capacity between implant and
headgear during anterior segment retraction
Lehnen S51 2011 RCT Patient expectations, acceptance and preferences in
 treatment with orthodontic mini-implants.
117
Fudalej P 2011 SR Are orthodontic distalizers reinforced with the temporary
skeletal anchorage devices effective?
Schätzle M118 2009 SR Survival and failure rates of TAD’s
Chen Y119 2009 SR Critical factors for the success of orthodontic mini-implants
Reynders R50 2008 SR Mini-implants in orthodontics
69
Crismani AG 2007 SR Miniscrews in orthodontic treatment

*SR, systematic review; ǂ MA, meta-analysis; †RCT, randomised controlled trial; §DSR,
Database of Systematic Reviews.