ONLINE ONLY

Drift characteristics of miniscrews and molars

for anchorage under orthodontic force:
3-dimensional computed tomography
registration evaluation
Hong Liu,a Tao Lv,a Na-na Wang,b Fang Zhao,b Ke-tao Wang,c and Dong-xu Liud
Jinan, China

Introduction: Although miniscrews have been used as absolute anchorage for a long time, their behavior under
orthodontic loading is still unclear clinically. Therefore, this study was designed to evaluate the behavior of
miniscrews under loading by retrospective 3-dimensional registration. Methods: Sixty adult patients who had
miniscrews as anchorage for en-masse retraction of anterior teeth were studied. Computerized tomography
scans were made before force application and after closure of the extraction spaces, respectively. The
3-dimensional reconstruction and registration of before and after computerized tomography data were
performed to assess the displacement of the miniscrews, first molars, and maxillary central incisors. Results:
The miniscrews and the maxillary first molars drifted mesially 0.23 and 0.91 mm apically, and 0.23 and 0.92
mm coronally; the amounts of maxillary incisor retraction at the edge and the apex were 5.94 and 1.40 mm,
respectively, with 1.84 mm of maxillary central incisor intrusion. Conclusions: Our results indicated that the
miniscrews and the maxillary first molars were mesially displaced under orthodontic loading. A mesial site for
miniscrews might be a better choice for long-term stability. (Am J Orthod Dentofacial Orthop 2011;139:e83-e89)

A
nchorage control is a fundamental concept in
orthodontic treatment. In the anteroposterior
dimension, 3 anchorage situations are tradition-
ally defined by the ratio of incisor retraction to molar
protraction: maximum anchorage, moderate anchorage,
and minimum anchorage. Miniscrews are considered
absolute anchorage, and the anchorage units remain
completely stationary and prevent molar protraction
into the extraction space.1,2 However, it has been
From Shandong University, Jinan, China.
a
Lecturer, Department of Orthodontics, Shandong Provincial Key Laboratory of
Oral Biomedicine, School of Dentistry.
b
Postgraduate student, Department of Orthodontics, Shandong Provincial Key
Laboratory of Oral Biomedicine.
c
Lecturer, Department of Oral and Maxillofacial Surgery, QILU Hospital.
d
Professor, Department of Orthodontics, Shandong Provincial Key Laboratory of
Oral Biomedicine.
The authors report no commercial, proprietary, or financial interest in the
products of companies described in this article.
Supported by grants from Shandong Science and Technology Planning Project
Contract Research of China (2008GG30002019 and 2008GG30001001) and
Shandong University Dental School Project Research (P2009009 and P2009010).
Reprint requests to: Dong-xu Liu, Department of Orthodontics, Shandong
Provincial Key Laboratory of Oral Biomedicine, School of Dentistry, Shandong
University, Jinan, 250012, China; e-mail, liudongxu@sdu.edu.cn.
Submitted, March 2010; revised and accepted, July 2010.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.07.018
controversial for a long time whether miniscrews and
the molars retain their positions under long-term
orthodontic loading conditions in clinical practice. Zhu
et al,3 Liou et al,4 and Xun et al5 suggested that minis-
crews might move under orthodontic loading. However,
Hsieh et al6 reported movement of endosseous titanium
implants under loading in beagle dogs.
The analysis of the spatial changes of the craniofacial
structures for orthodontic treatment generally relies on
the superimposition of cephalometric tracings at different
times. Although orthodontists can observe the general
growth changes and learn about the effect of treatment
by cephalometric analysis, the 2-dimensional limitations
of radiographic cephalometric tracings such as overlap,
poor visualization of individual structures, errors from
projection, and the inability to identify the true symphysis
cause errors in identification and reduce measurement ac-
curacy.7-10 Therefore, the cephalometric analysis might be
not suitable for evaluating the tiny 3-dimensional (3D)
drift changes of miniscrews and molars.
Compared with 2-dimensional cephalograms, com-
puterized tomography (CT) scanning is a more precise
surveying technique.11-13 The 3D reconstruction and
visualization of CT images can provide further detailed
information on miniscrews and tooth movement. To
e83
e84
Fig 1. Miniscrews were placed in interradicular locations between the first molar and the second pre-
molar at the level of the attached gingiva: A, pretreatment; B, posttreatment.
orthodontists, the visualization of 3D model super-
imposition of pretreatment and posttreatment CT data
is an accurate and reliable method for quantification
of miniscrew movement.14,15 Therefore, the purpose of
this study was to quantitatively evaluate the position
of miniscrews and molars under orthodontic force
(150 g) by using 3D CT registration evaluations.
MATERIAL AND METHODS
Interactive Medical Image Control System (MIMICS,
version 10.01, Materialise, Leuven, Belgium), an interac-
tive tool for the visualization and segmentation of CT
images, and related 3D model soft files, were used in
this study.
Sixty patients (aged 19-27 years) who had bimaxillary
protrusion and miniscrews as anchorage for the en-
masse retraction of anterior teeth were included. All pa-
tients received information on the miniscrew anchorage
methodologies, surgical techniques, and the possibilities
of failure, irritation, and local inflammation during
orthodontic treatment. The miniscrew was 1.6 mm in
diameter and 11 mm in length (Beici Medical, Ningbo,
China). The miniscrew site was the interradicular area
between the maxillary first molar and the second premo-
lar at an oblique angle of 30 to 40 to the long axis of
the teeth and at the level of the attached gingiva.
After the 4 first premolars were extracted, treatment
was done by using preadjusted edgewise appliances,
0.022 3 0.028 oriental preadjusted appliance-KOSAKA
slot bracket (OPA-K, Tomy, Fukushima-ken, Japan).
The appliances for en-masse anterior retraction were
0.019 3 0.025-in stainless steel basal archwires with
incisor lingual root torque and 4 elastic chains for en-
masse retraction. On each side, the lever arm was placed
into the auxiliary tube on the first molar and hooked on
the basal archwire for intrusion of the anterior teeth.
Two elastic chains with a force of 150 g were attached
between the miniscrew and the hook on the basal
archwire between the lateral incisor and the canine.
January 2011  Vol 139  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Liu et al
The patients were interviewed at 1-month intervals.
The process took about 6 months (Fig 1).
The whole-skull CT scans were made 2 weeks after
placement of the miniscrews (T1) and after closure of
extraction space (T2) by 16-flow helical CT (Light Speed
plus, 2004, General Electric, Fairfield, Conn). CT scanning
was done perpendicular to the long axis of the central
incisors on each jaw, and this angle was determined by
setting the gantry angle according to the lateral scano-
gram of the head position (slice thickness, 0.625 mm;
reconstruction interval, 0.3 mm; scan time, 1.0 second;
120 kV; 250 MA). The CT data were saved as DICOM (dig-
ital imaging and communications in medicine) format.
The MIMICS medical imaging density segmentation
software was used for the reconstruction of the primary
3D anthropometric models (alveolar bone, teeth, and
miniscrews).16 The DICOM image files generated in the
CT scan were constituted by pixels with different gray in-
tensities. The different intensity fields correspond to dif-
ferent material densities of the anatomic maxillary
structures. In the MIMICS software, thresholding based
on Hounsfield units (HU) was used to separate bone,
teeth, and miniscrews structures. To include tooth struc-
tures and exclude the alveolar regions, a lower limit of
1500 HU and an upper limit of 3725 HU were defined.
The alveolar bone excluding the teeth was accomplished
with manual editing of the density masks with a lower
limit of 392 HU and an upper limit of 1900 HU, and
the miniscrew masks had a lower limit of 2400 HU and
an upper limit of 3725 HU. For each bone, individual
and separated masks were created. This process allows
posterior generation of independent geometric files
and 3D models. At the same time, the 3D skull model
was reconstructed as the constant reference for the pre-
treatment and posttreatment CT registrations. All 3D
models were exported as standard triangulated language
(STL) points.
Since our research focus was the displacement of
miniscrews and the growth trendency of the adults, we
Liu et al e85

Fig 2. The teeth, miniscrews, and maxilla were registered with the surface points that did not change
after orthodontic treatment: A, pertinent landmark points (black arrows); B, registration of pretreatment
and posttreatment models; C and D, pretreatment and posttreatment models of the teeth after the reg-
istration of the maxilla and the miniscrews at pretreatment (red arrow in C) and posttreatment (black
arrow in C) were matched to those in D.

assumed that the shape of the upper skull in each CT scan
was unchanged. Based on this assumption, we found that
rigid transformation of the upper skull surface would be
adequate for the registration of pretreatment and post-
operative CT scans.
In the MIMICS software, the point registration eas-
ily moved the posttreatment STL points to the certain
locations of pretreatment. This was done by placing 4
sets of landmark points on the 3D STL points. MIMICS
then calculated the transformation matrix that should
be applied to have the best fit between the start and
end points and applied that transformation matrix
on the selected STL points. After point registration,
the STL registration was performed to register the
STL points on the CT masks to improve the accuracy
of registration. All registrations were performed 3
times in 2 weeks, and we selected the best one for
measurement in this study. Repeated registration
and identification of corresponding point landmarks
ensured the accuracy of the registrations, which
were performed carefully; the results are shown in
Figures 2 and 3.
After registration, the 3D position changes of the min-
iscrews and teeth could be evaluated (Fig 3, A and B). The
deviations of the first molar were evaluated at the various
cusp tips and the root apices, and the deviation of the
miniscrews were evaluated at the apex and the head.
In the MIMICS software, the 3D coordinate values were
redefined: the x-axis, y-axis, and z-axis represented the
bucco-palatal, disto-mesial, and vertical positions indi-
vidually. The 3D coordinate values of the same 2 points
were acquired at pretreatment and posttreatment, and
the drift distances in the 3 directions were calculated by
subtraction of the 3D coordinate values (Fig 3, C and D).
The error of the method was calculated for linear
measurements, based on double measurements of 10
randomly selected P patients. It was estimated with the
formula, s 5 O (d)2/2n, where n is the number of
paired measurements and d is the deviation between
the 2 measurements.

American Journal of Orthodontics and Dentofacial Orthopedics January 2011  Vol 139  Issue 1
e86 Liu et al

Fig 3. The distance between pre- and posttreatment models was measured: A and C, measurement of
the distance at the apex of the root or the miniscrew with the 3D coordinate values of the 2 points; B and
D, measurement of the distance at the head of the miniscrew with the 3D coordinate values of the 2
points.

Statistical analysis significant difference between the 2 measurements

All statistical analyses of drift distances were per-
formed by using the SAS software package (version
9.13, SAS Institute, Cary, NC). For each variable measured
on the 3D models, the mean and standard deviation were
calculated. Differences between displacement of the
miniscrew head and tip were assessed for significance
by using paired t tests, whereas the comparisons of
displacement among 3 roots and 4 crown cusps were
assessed for significance by using 2-way analysis of
variance (ANOVA), respectively.
One examiner (L.H.) measured all parameters of the 30
radiographs twice at a 2-month interval on randomly
selected radiographs. Differences of mean values between
the 2 measurements were assessed by using paired t tests.
RESULTS
The error of the method was negligible for all
measurements (0.04 mm; SD, 0.14 mm). There was no
with paired t tests. After 6 months of orthodontic load-
ing on the miniscrews, the amounts of maxillary incisor
retraction at the edge and the apex were 5.94 6 0.90
mm and 1.40 6 0.23 mm, respectively, with 1.84 6
0.26 mm of maxillary central incisor intrusion. The
amounts of mesial drift of the miniscrews were 0.23 6
0.08 mm (mean 6 SD) at the head and 0.23 6 0.07
mm (mean 6 SD) at the apex (Fig 4). There were slight
drifts of the miniscrews in the buccopalatal and vertical
directions, without statistical significance.
The mean distances of the mesial drift distances of the
roots apices and the 4 cusp tips are shown in Figure 5;
there was no significant difference in the values of the
3 roots and the 4 crown cusps (F 5 0.04 and P 5 0.96
for the root group; F 5 1.35 and P 5 0.28 for the cusp
group). For the first molar, to provide more concise
insight to the position change, measurements at the
3 root apices were averaged to determine the mean
displacement of the roots, and those of the 4 molar

January 2011  Vol 139  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Liu et al
Fig 4. Drift distance of the miniscrew heads and tips
(n 5 60; P .0.05).
cusp tips were averaged to determine the mean displace-
ment of the crown. The drift distances in the buccopala-
tal and vertical directions were minimal and had no
significant change. The average mesial drift distances
of the crown and the roots were 0.92 6 0.19 mm and
0.91 6 0.22 mm, respectively, as shown in Figure 5.
Differences of the displacement between the crown
and the roots had no statistical significance.
DISCUSSION
Anchorage, defined as resistance to unwanted tooth
movement,17 is a prerequisite for the orthodontic
treatment of dental and skeletal malocclusions.18,19
Orthodontists could not obtain absolute anchorage to
prevent undesirable tooth movements until the appea-
rance of miniscrews. Absolute or infinite anchorage is
defined as no movement of the anchorage unit (zero
anchorage loss) as a consequence of the reaction forces
applied to move teeth.17 In recent years, titanium screws
have gained enormous popularity in the orthodontic
community and are considered absolute sources of
orthodontic anchorage.18-20 However, based on our
results by longitudinal evaluation in this study, we found
that miniscrews were displaced in the direction of
force application, and they could not prevent mesial
displacement of the molars.
In this retrospective study, we selected miniscrews
placed in interradicular areas for our research and
excluded any loosened samples. Compared with the
mandible, the posterior area of the maxilla is more of-
ten used for miniscrew placement, and the density and
cortex thickness are also different. Therefore, in this
study, we focused on miniscrew in the maxilla. After
American Journal of Orthodontics and Dentofacial Orthopedics
e87
the 3D registration of the pretreatment and posttreat-
ment 3D models and the redefinition of 3D coordi-
nates, the 3D displacements of teeth (incisors, molars)
and miniscrews were measured. The results showed
that the miniscrews were displaced in the direction of
force application, and the displacements of the minis-
crews in the buccopalatal and vertical directions were
tiny and negligible. Hence, we concentrated on the
disto-mesial displacement of miniscrews, molars, and
incisors.
Before the extraction of the premolars and orthodon-
tic treatment, all teeth remain stationary under balanced
functional loadings. The teeth are in the midst of power-
ful opposing muscular forces of lips, cheeks, and tongue
(lip-cheek-tongue system). In balance, equal forces
against the teeth are normally maintained in the neutral
space. Proximal surfaces of the teeth are also subject to
various forces. Proximal contact between adjacent teeth
helps maintain the teeth in normal alignment. The bal-
ance was broken when the first premolars were extracted
and retraction forces were applied with miniscrews. The
incisors, molars, and miniscrews showed different dis-
placement behaviors: the incisors were retracted 5.94
mm on average, the molars drifted mesially 0.91 mm
on average, and the miniscrews moved 0.23 mm on
average.
Orthodontic tooth movement has been studied for
100 years.21-23 It occurs as a result of site-specific
resorption and the formation of the alveolar bone.
The remodeling processes of the alveolar-support
structures are triggered by alterations in the stress-
strain distribution in the periodontium caused by the
intra-alveolar displacement of the roots in the intra-
alveolar space.23,24 The periodontal ligament plays an
important role in orthodontic tooth movement.25 The
incisors were retracted under orthodontic loads. Why
did the molars move mesially without orthodontic force
application? As we know, all teeth are aligned in their
arches with varying degrees of inclination in both the
mesiodistal and faciolingual directions, and the occlusal
force and occlusal contact appear to result in mesial
drifting of the teeth toward the midline.26 When the
first premolars were extracted, the occlusal force caused
the molars’ mesial movement into the extraction
spaces.27,28
However, miniscrews were placed in the maxilla with
osseointegration at the bone-screw interface,29 and the
displacement behavior of miniscrews cannot be explained
with the conventional periodontal pressure-tension
concept. The Frost mechanostat theory is a practical
means for conveying the complex concepts of bone
biomechanics.30-32 Bone remodeling-modeling activity
is controlled by the peak strain of dynamic loading,
January 2011  Vol 139  Issue 1
e88 Liu et al

Fig 5. The mean distances of the mesial drift distance of A, the 3 root apices and mean movement of the
roots and B, the 4 cusp tips and mean displacement of the crown. MBR, mesiobuccal root; DBR, distobuc-
cal root; PR, palatal root; root, mean displcement of the roots; MLC, mediolingual cusp; DLC, distolingual
cusp; MBC, mesiobuccal cusp; DBC, distbuccal cusp; crown, mean displacement of crown. The F and
P values were 0.04 and 0.96 for the 3 root groups and 1.35 and 0.28 for the 4 crown cusps, respectively.

which can be explained by the behavior of miniscrew
displacement. According to Newton’s third law of mo-
tion, every action has an equal and opposite reaction;
this means that, inevitably, the miniscrew’s anchorage
undertakes the force from the elastic chain for retrac-
tion of the anterior incisors. The bone remodeling
processes at the bone-screw interface and the screw mo-
bilization mechanisms are strictly correlated with the
stress-strain field in the surrounding bone developing
with the force.33,34 Many computational methods,
such as finite element analysis, have been used to
investigate the stress and strain distribution developed
in the surrounding bone; these provide significant
information to predict how bone remodels and its
consequences.34
In this study, we observed that both the molars and
the miniscrews drifted mesially but not at the same
pace. Our results implied that the miniscrews might
contract the roots after treatment. According to a previ-
ous report, maxillary interradicular distances ranged
from 1.6 to 3.46 mm with miniscrews were 1.6 mm in
diameter; the space between the root and miniscrew
was limited; and the different mesial-drift ratio of the
molars and the miniscrews might be a critical factor
for miniscrew looseness.13 When miniscrews are placed
clinically, a mesial placement site might be a better
choice for long-term stability.
In this limited study, we evaluated the displacement of
miniscrews placed in interradicular areas of the maxilla.
Several factors were related to miniscrew displacement:
loading period, cortical thickness, miniscrew characteris-
tics, force magnitude, and force direction.35-40 Therefore,
further studies of long-term stability of miniscrews need
to be developed.
CONCLUSIONS
Our results indicated that the miniscrews and maxil-
lary first molars were mesially displaced under orthodon-
tic loading, suggesting that a mesial site for miniscrews
could be a better choice for long-term stability.
We thank Professor Guang-chun Wang for his
assistance.
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