Risks and Complications of Orthodontic

Risks and Complications of Orthodontic Miniscrews

Mini screws

By Amal Al- Azebi

Orthodontic department, Faculty Of Dentistry

Suez Canal university
Outlines
Introduction

Reasons For Mini Screw Failure

Risks and Complications of Orthodontic Mini screws

Conclusion

References
Introduction
The risks associated with mini screw placement should be
clearly understood by both the clinician and the patient.

Complications can arise during mini screw placement and after

orthodontic loading that affect stability and patient safety.

A thorough understanding of proper placement technique,

bone density and landscape, peri-implant soft tissue, regional
anatomic structures, and patient home care are essential for
optimal patient safety and mini screw success
Reasons For Mini Screw Failure
• Based on the aforementioned consideration, the hypotheses
about mini screw loss are as follows:
1) deflection of maxillary and mandibular alveolar processes
when mini screw are more cervically placed.
Reasons For Mini Screw Failure
2) mini screw placed too near the periodontal ligament ,with
normal intra-alveolar tooth movement.
Reasons For Mini Screw Failure

3) low bone density , low thickness and low alveolar bone

volume.
Reasons For Mini Screw Failure
• 4) low alveolar cortical bone thickness.

Cortical bone thickness less than 0.5 mm not suitable for

mini screw placement.

Higher success rates have been reported with cortical bone at

least 1.0 mm thick
Reasons For Mini Screw Failure
5) excessive pressure inducing trabecular bone microfracture.
Reasons For Mini Screw Failure

6) sites of higher anatomical weakness in the mandible and the

maxilla.
Reasons For Mini Screw Failure

7) thicker gingival tissue not considered when choosing the

mini screw
Reasons For Mini Screw Failure
8) mini screw loss due to placement in recent extraction site.
Reasons For Mini Screw Failure
9) Mini –implant near the dental root
Reasons For Mini Screw Failure

10) food debris around a mini-implant

Reasons For Mini Screw Failure

11) mini-implant place in free gingiva.

Reasons For Mini Screw Failure

12) mini implant placed in unsuitable alveolar bone.

Reasons For Mini Screw Failure

13) incomplete osseointegration allowing for effective

anchorage with easy insertion and removal of the screw
Reasons For Mini Screw Failure

14) Cigarette Smoking Heavy tobacco consumption is associated

with a significantly higher failure rate.

Therefore, whilst cigarette smoking is not an absolute

contraindication to mini‐implant usage, smokers should be

warned of the risk and advised to stop before mini‐implant

Reasons For Mini Screw Failure
15) Age
adolescent patients have a significantly higher mini‐implant
failure. Except midpalatine suture
A. due to reduced levels of cortical thickness and density of
bone.
B. higher rates of bone remodeling.
C. immature cortical bone is less able to withstand force
applications, especially during the first month after
insertion.
mini‐implants are still successful in adolescents, it is advisable
to be cautious and use light loading forces.
Reasons For Mini Screw Failure
15) Age

Only apply a light initial force, for

instance 50g, during the first four weeks
in adults and six weeks in adolescents,
before applying normal forces, of 150 g.
16) Mini Screw infected
Risks and Complications of Orthodontic Mini screws
Risks And Complications Of Mini Screw In Orthodontics

A) COMPLICATIONS DURING INSERTION

B) COMPLICATIONS UNDER ORTHODONTIC LOADING

C) COMPLICATIONS DURING REMOVAL Mini screw

D) Complications after Removal Mini screw

A) COMPLICATIONS DURING INSERTION
A) COMPLICATIONS DURING INSERTION
1) Pain and Discomfort
2) Trauma to the periodontal ligament or the dental root
3)Mini screw bending, fracture, and torsional stress
4) mini screw Slippage
5) Air subcutaneous emphysema
6) Perforation of Nasal and Maxillary Sinus Floors
7) Damage to Neurovascular Tissues
8) Mini-implant Instability
1) Pain and Discomfort
A) describe the pain as being due to a pressure wave within a
confined space generated by insertion of a rigid fixture into a
confined bone space.

While there are no describe the pain as being due to pain receptors
within the bone tissues.

B) if the pressure dissipates further it will reach the periodontal

tissues of adjacent teeth, and hence stimulate their periodontal
pain receptors.
1) Pain and Discomfort

The majority of patients appear to

experience mild pressure‐related
pain at the time of insertion.
•. 2022 Sep 20;22(1):414.
doi: 10.1186/s12903-022-02460-3.e-based selection of orthodontic their success rate in the mandibular buccal shelf. A randozed,
prospective clinical trial
Joanna Lis , Hyo-Sang Park , Kornelia Rumin 36127718 : PMC9487090 10.1186/s12903-022-02460-3
Michał Sarul 1, 1 2 3

Free PMC article

Results: 91.3% of the SH2018-10 and 75% of the SH1514-08 miniscrews were stable, and this difference was statistically significant (p < .05).
Inflammation of the oral mucosa was noticed around both types of miniscrews and affected 50% of the SH2018-10 and 26.09% of the SH1514-08

Pain lasting longer than 48 h after implantation was related to 60.87% and
group (p < .05).

20.65% of the SH2018-10 and the SH1514-08 miniscrews (p < .05), respectively. Inflammation
associated with larger SH2018-10 miniscrews did not affect their stability (p > .05), contrary
to the SH1514-08 ones (p < .05). When inflammation was present, the overall success rate declined to 64.29%, from 94.74% noted for TADs without
inflammation. According to the log-rank test, smaller TADs failed significantly sooner than the larger ones (p = .002).
Conclusion: Larger SH2018-10 miniscrews are the anchorage of choice for the
mandibular buccal shelf, despite triggering inflammation and long-lasting pain
significantly more often than the smaller ones. Therefore, this issue should be discussed with every patient prior to miniscrew use. Trial
registration ID: ClinicalTrials.gov Identifier: NCT05280678 Date of Registration: 15/03/2022 . Retrospectively

registered.
Keywords: Mandible; Orthodontic anchorage procedures; Orthodontics.
© 2022. The Author(s).
1) Pain and Discomfort
A) Fortunately, reduce the level of pressure discomfort by
diverging the roots of adjacent teeth prior to
insertion This creates more interproximal space and hence a
greater distance between the mini‐implant site and the adjacent
periodontal pain receptors.

B) Pain and Discomfort controlled by simple analgesics (e.g.

paracetamol or ibuprofen)
2) Trauma to the periodontal ligament or the dental root

Interradicular placement of orthodontic mini screws risks

trauma to the periodontal ligament or the dental root.

Potential complications of root injury include

1. loss of tooth vitality,
2. osteosclerosis,
3. and dentoalveolar ankylosis.
2) Trauma to the periodontal ligament or the dental root
2) Trauma to the periodontal ligament or the dental root

Trauma to the outer dental root without pulpal not influence

the tooth’s prognosis.

Dental roots damaged by orthodontic mini screws have

demonstrated complete repair of tooth and periodontium in 12
to 18 weeks after removal of the mini screw
2) Root/Periodontal Damage

Any irreversible effect from mini‐

implant–tooth proximity is on the
mini‐implant: it fails (by becoming
mobile), not the tooth.
 2) Trauma to the periodontal ligament or the dental root
Interradicular placement requires to avoid this problems:
1) proper radiographic ,surgical guide with panoramic and
periapical radiographs to determine the safest site.

2) maxillary buccal greatest amount of interradicular bone

between second premolar and first molar, 5 to 8 mm from
alveolar crest . or from (CEJ) and this better than alveolar crest
mandibular buccal greatest amount of interradicular bone is
either between second premolar and first molar, or between
first molar and second molar, 5 to 8 mm from alveolar crest.
• 2) Trauma to the periodontal ligament or the dental root

in mandibular buccal
The thinnest bone found between first premolar and canine.

If a mini screw has to be implanted

into this region, it should be placed 11 mm below the alveolar
crest
2) Trauma to the periodontal ligament or the dental root

3) During interradicular placement in posterior region, avoid

to change the angle of insertion by inadvertently pulling the
hand-driver toward their body, increasing the risk of root
contact.

To avoid this, the clinician may consider using a finger-wrench

or work the hand-driver slightly away from their body with
each turn.
2) Trauma to the periodontal ligament or the dental
root
2) Trauma to the periodontal ligament or the dental root

4) give little anesthesia so, if mini screw begins to

approximate the periodontal ligament, the patient will
experience increased sensation under topical anesthesia.

5) If root contact occurs, mini screw may either stop or begin

to require greater insertion strength. And patient will have
sever pain.

6 ) If trauma is suspected, the clinician should unscrew the

mini screw 2 or 3 turns and evaluate it radiographically
2) Trauma to the periodontal ligament or the dental root

give little
anesthesia
2) Trauma to the periodontal ligament or the dental root
3) Mini screw bending, fracture, and torsional stress

Increased torsional stress during placement can lead to

implant bending or

fracture, that not only affects the mini screw stability but may also
requires surgical intervention.

Mini screw fracture has been reported and caused a sinus tract, and the
fractured tips had to be removed surgically

produce small cracks in the peri-implant bone, that affect mini screw
stability.
3) Mini screw bending, fracture, and torsional stress

Self-tapping method:
Before placing the mini screw, a hole is drilled in the cortical bone and a
mini screw is screwed through this hole with a hand driver. The diameter of
the pilot drill
should be slightly smaller (0.2–0.3 mm) than the inner (or core) diameter of
the mini screw.

Self-drilling method:
Self-drilling is a simpler method than self-tapping.
The mini screw is inserted into the bone without drilling and screwed in
with the hand.
Self-drilling screws better stability, with more bone to
Self-tapping method:
3) Mini screw bending, fracture, and torsional stress

Self-drilling mini screws should be inserted slowly, with

minimal pressure, to assure maximum mini screw-bone
contact.
A purchase point or a pilot hole is recommended in regions of
dense cortical bone, even for self-drilling mini screws.

During mini screw placement in dense cortical bone, the

clinician should consider periodically de-rotating the mini
screw 1 or 2 turns to reduce the stresses on mini screw and
bone
3) Mini screw bending, fracture, and torsional stress

 clinician should stop inserting the mini screw as soon as the

smooth neck of its shaft has reached the periosteum.

Over insertion can add torsional stress to the mini screw neck,
leading to screw loosening and soft-tissue overgrowth.
3) Mini screw bending, fracture, and torsional stress
3) Mini-implant Fracture

This occurs in only a small percentage of cases.

especially when

1. correct planning
2. and technique steps are followed (e.g. predrilling or
perforating sites with dense cortical bone prior to
insertion). I
3) Mini-implant Fracture

Fracture most happens in cervical part of mini screw

because of mechanical stress focusing at this point
3) Mini-implant Fracture
3) Mini-implant Fracture

Mini screws from different manufacturers have different

designs and morphology; outside and internal diameters, the

ratio of these two diameters, and milling in mini screw apical

region were the factors that decide the fracture torque

resistance .
3) Mini-implant Fracture

Stress distribution on the mini screw surfaces and the adjacent

bone in force application was proved to be related to insertion
depth and angulation .

Mini screw inclined insertion with upward traction was

recommended to be the safest option to prevent mini screw
failure and fracture
3) Mini-implant Fracture

This complication could be prevented or limited by choosing the

appropriate placement torque with a suggested range from 5 to
10 N.cm .

In addition, for self-drilling mini screw, a pilot hole should be

applied beforehand to prevent excessive torque
Techniques for avoiding the root damage ,screw fracture and
failure

1. Minimum local anesthesia

2. Placement of a screw into the wider interradicular area
3. Choosing a small and short screw as possible
4. Oblique insertion of mini screw
5. Placing with a self –tapping method
6. Using a screwdriver with a torque limiter range from 5 to 10
N.cm .
4) mini screw Slippage

fully engage cortical bone during placement and inadvertently

slide the mini screw under the mucosal tissue along the
periosteum.

High risk regions for mini screw slippage include sloped bony
planes in alveolar mucosa such as the
A. zygomatic buttress
B. retromolar region
C. buccal cortical shelf
A) zygomatic buttress
B) retromolar region
C)buccal cortical shelf
D)maxillary buccal exostosis if present
4) mini screw Slippage

Slippage in retromolar region can lead to the greatest risk

of mini screw moves lingually in the submandibular or lateral
pharyngeal space
near the lingual and inferior alveolar branch nerves.
4) mini screw Slippage

In the retromolar region, serious consideration should be given:

flap exposure for direct visualization and a predrilled pilot hole,

even for self-drilling mini screws.

If alveolar tissue is thin and taut, some clinicians advocate placing

the pilot hole with a transmucosal method, using a slow-speed
bur to perforate both tissue and cortical bone without

making a flap
4) mini screw Slippage

2 retromolar pad mini

screws.
Mini screw on
patient’s right slipped
and entered posterior
submandibular space.
4) mini screw Slippage

Mini screw slippage can occur in dentoalveolar regions of

attached gingiva if the angle of insertion is too steep.

Placement of mini screws less than 30° from the occlusal

plane, typically to avoid root contact in the maxilla or to gain
cortical anchorage in the mandible, can increase the risk of
slippage.
4) mini screw Slippage

To avoid slippage
1) initially engage bone with the minis crew at a more obtuse angle
before reducing the angle of insertion after the second or third turn.
1)
2) Mini screws should engage cortical bone after 1 or 2 turns with the
hand driver.

3) Only minimal force should be used with the hand-driver, regardless

of bone density.

Greater forces increase risk of mini screw slippage.

4) we can use another site for example for Molar up righting
using spring and mini screw in dentoalveolar regions
4) we can use another site for example for Molar up righting Molar
Up righting Using a Lever Arms and mini screw in dentoalveolar
regions
5) Air subcutaneous emphysema

is the condition in which air penetrates the skin or submucosa,

resulting in soft-tissue distention.

Subcutaneous emphysema can occur during routine operative

dental procedures if air from the high-speed or air-water
syringe travels under the gingival tissues.

main symptom of air subcutaneous emphysema is immediate

mucosal swelling with or without crepitus (crackling)
5) Air subcutaneous emphysema

Additional sequelae include cervicofacial swelling, orbital

swelling, otalgia, hearing loss, mild discomfort, airway
obstruction, and possibly interseptal and interproximal alveolar
necrosis.

Clinically visible swelling of the skin and mucosa occurs within

seconds to minutes after air has penetrated the submucosal
space and typically spreads to the neck (in 95% of cases) or the
orbital area ( in 45% of cases).
5) Air subcutaneous emphysema
5) Air subcutaneous emphysema

The clinician should be alert for subcutaneous emphysema

during mini screw placement through the loose alveolar tissue
of the

1) Retromolar region

2) mandibular posterior buccal

3) maxillary zygomatic regions

5) Air subcutaneous emphysema

If pilot hole is to be drilled through the mucosa, should use

slow speed under low rotary pressure.

if a pilot hole or a mucosal punch is placed, an air-water syringe

should never be used. Air from the syringe can enter the
submucosal space through the small tissue opening, even in
attached tissue. Bleeding and saliva should be controlled with
suction, cotton, and gauze, rather than an air-water syringe
5) Air subcutaneous emphysema

In case of subcutaneous emphysema, clinician should

1) immediately discontinue the procedure and take periapical

and panoramic radiographs to determine the extent of the
condition.

2) patient should not be dismissed until swelling begins to

regress and an infection can be ruled out. subside in 3 to 10
days
5) Air subcutaneous emphysema

3) patient should be instructed to apply light pressure with an ice

packs for the first 24 hours .

4) The clinician could prescribe a mild analgesic, an

antibacterial rinse, such as chlorhexidine,
and an antibiotic prophylaxis for a week.

5) In most cases of subcutaneous emphysema, careful observation

for further problems or infection is adequate, and swelling and
6) Perforation of Nasal and Maxillary Sinus Floors

perforation of the nasomaxillary cavities may result in either

infection or creation of a fistula.

However, the consensus based on dental implant research is

that a soft tissue lining rapidly forms over the end of a
perforating fixture,
and mini‐implant sites heal by bone infill because of the
narrow width of the explanation hole.
6) Perforation of Nasal and Maxillary Sinus Floors

Motoyoshi et al. investigated clinical effects in a retrospective

study where 82 mini‐implants had been inserted mesial and
buccal to the maxillary first molar .

They found perforation of the maxillary sinus in 10% of the sites,

but with no sinusitis symptoms, nor differences in insertion
torque and secondary stability.

In contrast, a study of infra-zygomatic insertions showed that

78% penetrated the maxillary sinus at this site .
6) Perforation of Nasal and Maxillary Sinus Floors

Asymptomatic, mucosal thickening was seen on cone beam

computed tomography (CBCT) in 88% of these sites where the
mini‐implant penetrated by at least 1mm.

it is generally recommended that maxillary alveolar insertion

sites should be within 8mm of the alveolar crest in dentate
areas, and at a more coronal level where maxillary molars are
absent. The nfrazygomatic crest is not recommended for this
reason
6) Perforation of Nasal and Maxillary Sinus Floors
6) Perforation of Nasal and Maxillary Sinus
Floors
7) Damage to Neurovascular Tissues
Nerve injury can occur during placement of mini screws in
1. maxillary palatal slope,
2. mandibular buccal dento-alveolus,
3. retromolar region.

Most minor nerve injuries not involving complete tears are transient,
with full correction in 6 months.

Long-standing sensory aberrations might require

4. pharmacotherapy (corticosteroids),
5. microneuro-surgery,
7) Damage to Neurovascular Tissues

Placement mini screws in maxillary palatal slope risks injury

to greater palatine nerve exiting the greater palatine
foramen.

greater palatine foramen is located laterally to 8 molar or

between 7 and 8 molar.

greater palatine nerve exits the foramen and runs

anteriorly, 5 to 15 mm from gingival border, to incisive
• 7) Damage to Neurovascular Tissues

Mini screws inserted in palatal slope should be placed

medial to the nerve and mesial to the second molar.

Placement of the mini screw above the nerve could increase

the risk of
palatal root contact and reduce biomechanical control.
7)Damage to Neurovascular Tissues

Mini screw in palatal

slope at medial side of
greater palatine nerve

One of My cases
for intrusion
Posterior teeth
One of My cases for
intrusion
Posterior teeth
7) Damage to Neurovascular Tissues

Placement of mini screws in mandibular buccal dentoalveolus

risks injury to inferior alveolar nerve in mandibular canal.

The mandibular canal travels forward in an S-shaped curve

moving from buccal to lingual to buccal.
7) Damage to Neurovascular Tissues
inferior alveolar nerve occupies most buccal position at distal root of
second molar and apex of second premolar, before exiting from
mental foramen.

Mini screws inserted near mandibular second molar and second

premolar are greatest risk for accidental damage to inferior alveolar
nerve.
panoramic radiograph should be taken to determine vertical position of
mandibular canal and the location of the mental foramina.

Greater caution is needed in adult patients who might have a more

occlusal position of the mandibular canal due to resorption of the
7) Damage to Neurovascular Tissues

Placement of mini screws in retromolar pad risks injury to

long buccal nerve and lingual nerve. crosses high on the
retromolar pad supplying the mucosa of the cheek.

To avoid nerve involvement and slippage, we recommend that

1. retromolar mini screws should be no longer than 8 mm

2. and placed in buccal retromolar region below anterior

ramus.
• 8) Mini-implant Instability
Primary stability (mechanically) is effected by
1. bone quality
2. bone quantity
3. surgical technique (Self-drilling screws better stability)
4. Shape of screw (conical shape better for stability than
cylindrical)
5. Angle of insertion

•.
8) Mini-implant Instability
The angle of mini-implant insertion :
had a significant impact on primary stability. The highest insertion
torque values were measured at angles between 60 and 70.

Very oblique insertion angles (30 degree) resulted in reduced

primary stability.

Conclusions: To achieve the best primary stability, an insertion angle

ranging from 60 to 70 is advisable. If the available space between
two adjacent roots is small, a more oblique direction of insertion
seems to be favorable to minimize the risk of root contact.
8) Mini-implant Instability
The angle of mini-implant insertion
• B) COMPLICATIONS UNDER ORTHODONTIC LOADING
B) COMPLICATIONS UNDER ORTHODONTIC LOADING
1)Stationary anchorage failure
2) Mini screw migration
3) Irritation from auxiliary spring
4) Aphthous ulceration
5) Soft-tissue coverage of the mini screw head and
auxiliary
6) Interference with tooth movement
7) Mini screw loosening
1)Stationary anchorage failure

• According to the literature, the rates of stationary anchorage failure of

mini screws under orthodontic loading vary between 11% and 30%.
• If a mini screw loosens, it will not regain stability and will probably need
to be removed and replaced.

• Stability of the orthodontic mini screw throughout treatment depends on

 bone density
 peri-implant soft tissues
 mini screw design
 surgical technique
 force load
1)Stationary anchorage failure

• The key determinant for stationary anchorage is bone density.

• Stationary anchorage failure is often a result of low bone

density due to inadequate cortical thickness.

• Bone density is classified into 4 groups (D1, D2, D3, and D4)
based on Hounsfield units (HU)—an x-ray attenuation unit used
in computed tomography
1) Stationary anchorage failure

D1 (>1250 HU) is dense cortical bone primarily found in

anterior mandible and maxillary midpalatal area.
D2 (850-1250 HU) is thick (2 mm), porous cortical bone with
coarse trabeculae primarily found in anterior maxilla and
posterior mandible.
 D3 (350–850 HU) is thin (1 mm), porous cortical bone with
fine trabeculae primarily found in posterior maxilla with some
in posterior mandible.
 D4 (150–350 HU) is fine trabecular bone primarily found in
posterior maxilla and tuberosity region
1) Stationary anchorage failure
1) Stationary anchorage failure
1) Stationary anchorage failure

 Sevimay et al 47 reported that osseointegrated dental

implants placed in D1 and D2 bone showed lower stresses at
the implant-bone interface.
Placement of mini screws in D1 and D2 bone might provide
greater stationary anchorage under orthodontic loading.
D1 -D3 bone are optimal for self-drilling mini screws.
D4 bone is not recommended due to the reported high failure
rate.
• 1) Stationary anchorage failure

maxillary tuberosity is not suitable because of the

minimal bone thickness in the area
Alternative site than maxillary tuberosity for distalization
1) Stationary anchorage failure

53-55% stationary anchorage failure is greater

in maxilla due to

A) greater trabeculae
B)lower bone density
with the exception of the midpalatal region
• 1) Stationary anchorage failure
• By contrast, others have stated that mini screws placed in
maxilla show higher success rate than mandible Due to:
A) Occlusal stress
B) food impaction force may be factors causing mobility
and failure of mini screws in Mandible.
C) because greater amounts of cortical thickness and density
cause excessive insertion torque, which reflects high levels of
peri‐implant bone stress.
localized stress results in microscopic bone necrosis around the
threads and hence secondary mini‐implant failure
1) Stationary anchorage failure

midpalatal suture most favorable placement site for mini screws Duo
to :
1) high density of cortical bone
2) thin keratinized soft tissue ensures the biomechanical stability of the
miniscrews
3) higher success rate (90%) thanparapalatal suture region (84%) .

However, the parapalatal area is the most

suitable region for mini screw
placement in adolescents for preventing developmental disturbances of the
midpalatal suture,
as the transverse growth of the midpalatal suture continues up until the late teens.
Loss of midpalat mini screws is likely a result of tongue pressure
1) Stationary anchorage failure

• Peri-implant soft-tissue
Type
 health
 thickness
can affect stationary anchorage of the mini screw.
 1) Stationary anchorage failure
nonkeratinized alveolar tissues and movabale have greater
failure rates than attached tissues.
The movable, nonkeratinized is easily irritated; soft-tissue
inflammation around the mini screw is directly associated with
increased mobility.

thick keratinized tissue, such as palatal slope, are less likely to

obtain adequate bony stability.

Thin, keratinized tissue, seen in dentoalveolar or midpalatal

region, is ideal for mini screw placement
1) Stationary anchorage failure
1) Stationary anchorage failure

• mini screw placement. Mini screw geometry and surgical

technique directly influence the stress distribution of peri-
implant bone.

• Most mini screw losses occur as a result of excessive stress at

the screw-bone interface.

• Self-drilling mini screws can have greater screw-bone contacts

(mechanical grip) and holding strengths compared with self-
tapping screws.
1) Stationary anchorage failure

• It is still not clear the maximum force-load a mini screw can

withstand in regard to stationary anchorage.

• Dalstra et al reported that mini screws inserted into thin cortical

bone and fine trabeculae should be limited to 50 g of immediate
loaded force.

• Buchter et al reported that mini screws placed in dense

mandibular bone remained clinically stable with up to 900 g of
force. Many articles reported mini screw stability with loading
1) Stationary anchorage failure

Orthodontic mini screws can remain clinically stable but not

absolutely stationary under orthodontic loading.
2) Mini screw migration(Displacement)
2) Mini screw migration(Displacement)

• patient’s may only be noticed if it interferes with oral hygiene

and gingival hyperplasia occurs.

• Migratory movements do not cause pain perse.

• However, mini‐ implant displacement is more likely to occur in

areas with thin cortical bone and occasionally warrants mini‐
implant replacement.
3) Irritation from auxiliary spring
To avoids this problems use Powerarm
Or use crimpable hooks distal to canine
 Or the retraction
direct from canine
One of My cases
Or use long
crimpable hooks
4) Aphthous ulceration

• Minor aphthous ulcerations, or canker sores,

can develop around mini screw shaft or adjacent buccal

mucosa in contact with the mini screw head.

• Aphthi are characterized as mildly painful ulcers affecting

nonkeratinized mucosa.
4)Aphthous ulceration

Minor aphthous ulcerations caused by

soft-tissue trauma
but might occur as a result of genetic predisposition,
 bacterial infection,
allergy,
 hormonal imbalance,
vitamin imbalance,
 and immunologic and psychologic factors.
4)Aphthous ulceration

Minor aphthous ulcerations are self-limiting and resolve within 7

to 10 days without scarring.

Placement of a healing abutment

a wax pellet, or followable composite around the head or
 large elastic separator over mini screw head,
use of chlorhexidine (0.12%, 10 mL),
typically prevents ulceration and improves patient comfort.
aphthous ulceration not direct risk factor for mini screw stability,
but its presence might forewarn of greater soft tissue inflammation
4)Aphthous ulceration

Labial ulceration
caused by this
mandibular mini-
implant’s insertion at
the mucogingival
junction and by the
active movement of
the adjacent labial
sulcus
5) Soft-tissue coverage of the miniscrew head and auxiliary

Mini screws placed in alveolar mucosa, particularly in the

mandible, might become covered by soft tissue.

The bunching and rubbing of loose alveolar tissue can lead to

coverage of both the mini screw head and its attachments (ie,
coil spring, elastic chain) within a day after placement.
Soft-tissue coverage might be a risk factor for mini screw
stability.
5) Soft-tissue coverage of the miniscrew head and auxiliary

• Soft-tissue overgrowth can be minimized by placement of

1. healing abutment cap, or
2. wax pellet, or
3. elastic separator In addition to
4. antibacterial
5. chlorhexidine.
6. partial insertion with a longer mini screw (10 mm) in
regions of loose alveolar mucosa, leaving 2 or 3 threads of
the shaft exposed to minimize the possibility of soft-tissue
5) Soft-tissue coverage of the mini screw head and auxiliary

(a) Overgrowth of the labial sulcular tissues

5) Soft tissue inflammation, infection, and periimplantitis

Inflammation of periimplant soft tissue has been associated with

a 30% increase in failure rate.

Peri-implantitis is inflammation clinically and radiographically

evident
1. loss of bony support,
2. bleeding on probing,
3. suppuration,
4. epithelia infiltrations, and
 5) Soft tissue inflammation, infection, and periimplantitis
• The clinician should be forewarned of soft-tissue irritation if
the soft tissues begin twisting around the mini screw shaft
during placement.

• Some clinicians advocate a 2-week soft-tissue healing period

for mini screws placed in the alveolar mucosa before
orthodontic loading
• C) COMPLICATIONS DURING REMOVAL Mini screw
C) COMPLICATIONS DURING REMOVAL Mini screw

• 1) fracture

• 2) Partial osseointegration
• 1) fracture
• The mini screw head could fracture from the neck of the shaft
during removal.
• The authors recommend a minimum diameter of 1.6 mm for
self-drilling mini screws that are 8 mm or longer placed in
interradicular bone.

• The proper placement technique can minimize the risk of

mini screw fracture during its removal.
• If the mini screw fractures flush with the bone, the shaft might
need to be removed with a trephine.
• 2) Partial osseointegration

• Although orthodontic mini screws achieve stationary

anchorage primarily through mechanical retention, they can
achieve partial osseointegration after 3 weeks, increasing the
difficulty of their removal.

• The mini screw typically can be removed without complications

a few days after the first attempt of removal.
• D) Complications after Removal
D) Complications after Removal

• 1) Soft Tissue Scarring

• 2) Bone and Root Resorption

• 3) Alveolar Bone Exostoses

• 1) Soft Tissue Scarring
After orthodontic mini screw removal, detectable soft tissue
scarring may develop at a fairly high rate .Even though this
scarring was only located at the site of placement and was not
considered serious.

it might give negative esthetic problems .The scar tissues were

excised successfully under local anesthesia, but further studies
should be investigated for soft tissue healing improvement and
visible scarring prevention
• 1) Soft Tissue Scarring
1) Soft Tissue Scarring

Flat gingiva and buccal interdental gingival insertion are more

likely to have scar formation.

Proper mini screw placement torque may limit the negative

tissue responses such as
scar tissue formation.
• 2) Bone and Root Resorption
 Excess microdamage during mini screw insertion may cause
bone resorption .

In addition, based on the presently available evidence,

mini screw-assisted intrusion is a risk factor for induced
inflammatory root resorption;
(insertion site, intrusion site, duration, and magnitude of
intrusive force) may have influence on the outcome .

The magnitude of intrusive force was associated directly with

the root resorption .
2) Bone and Root Resorption

• Nevertheless, due to methodological inconsistencies, it was

challenging to quantitatively assess the results .

• During this process, the application of photobiomodulation

might have a possibility to lower the progression of root
resorption, but it may also slightly lower intrusion distance
and speed
• 3) Alveolar Bone Exostoses

• An alveolar bone exostosis is bone overgrowth .

• Alveolar bone exostoses have been reported once in the
literature as a complication of orthodontic mini screw

• Normally, the treatment will not be operated unless its size

affects the periodontal tissue or causes pain and discomfort

for patients. In this case, resective osseous surgery was
performed, and orthodontic treatment was continued after one
month without recurrence
Conclusion

This seminar has highlighted the potential risks and

complications of mini screw placement with the hope of
educating both clinician and patient. Bone density and soft
tissue health directly affect implant stability.
Proper mini screw home care by the patient is as important as
proper placement by the orthodontist. Above all, maximum
effort should be made to simplify the surgery and then modify
the mechanics.
Mini screws valuable tool , should use with precautions and
used at the appropriate time .
 References
• The Orthodontic Mini-Implant Clinical Handbook

• D. M. Ramirez-Ossa, N. Escobar-Correa, M. A. RamirezBustamante, and A.

A. Agudelo-Suarez, 2020,The Journal of Evidence-Based Dental Practice

• N. D. Kravitz and B. Kusnoto, “Risks and complications of orthodontic

miniscrews,” American Journal of Orthodontics and Dentofacial Orthopedics,
2007
• Van Mai Truong , 1 Soyeon Kim , 1 Jaeheon Kim , 1 Joo Won Lee , 1 and
Young-Seok Park 1,2,(2022),Revisiting the Complications of Orthodontic Minis
crew
Thank you