ORIGINAL ARTICLE

Midpalatal miniscrews for orthodontic

anchorage: Factors affecting clinical success
Young Ho Kim,a Seung-Min Yang,b Seonwoo Kim,c Joo Yong Lee,d Kyu Eok Kim,e Anthony A. Gianelly,f
and Seung-Hyun Kyungg
Seoul, Korea, and Boston, Mass

Introduction: The purpose of this study was to investigate the success rate of midpalatal miniscrews used for
orthodontic anchorage and the factors affecting clinical success. Methods: One hundred twenty-eight
consecutive patients (101 female, 27 male; mean age, 23.4 years), who received a total of 210 miniscrews
in the midpalatal suture area, were examined. Success rates were determined according to 10 clinical vari-
ables. Results: The overall success rates were 88.20% for the total number of patients and 90.80% for the
total number of miniscrews. There were no significant associations among success rate and sex, total period
of treatment with miniscrews, diameter of miniscrews, types of tooth movements, and variables that represent
sagittal and vertical skeletal relationships (ANB, FMA, and Sn-GoGn). The operator’s learning curve, patient’s
age, area (midpalatal or parapalatal), and splinting significantly influenced the success rates. After adjusting
for other variables, only 1— splinting—showed a significant effect on the success rate. Conclusions: The join-
ing of 2 miniscrews by splinting, placement of the miniscrew in the midpalatal suture, patient’s age (especially
.15 years), and operator’s skill were factors influencing the clinical success of orthodontic miniscrews in the
palate. (Am J Orthod Dentofacial Orthop 2010;137:66-72)

S
ince the introduction of implants as absolute The midpalatal suture is a highly dense structure with
anchorage in orthodontic treatment, various sufficient bone height up to the cresta nasalis,9,10 and
types of tooth movement without patient com- vertical bone support is somewhat higher (at least 2
pliance have become possible with newly developed mm) than is apparent on cephalograms.7 The midpalatal
miniscrews.1-3 area within 1 mm of the midsagittal suture is composed
Of the possible placement sites for miniscrews, the of the thickest bone available in the whole palate,11 and
midpalatal area has been reported to be appropriate.4-8 the thickness of soft tissues in the midpalatal area is
uniformly 1 mm posterior to the incisive papilla,10
ensuring biomechanical stability of the miniscrews.
a
Associate professor, Department of Orthodontics, Institute of Oral Health & There are no roots, nerves, or blood vessels to compli-
Science, Samsung Medical Center, Sungkyunkwan University School of
Medicine, Seoul, Korea. cate the placement of surgical miniscrews, and there is
b
Associate professor, Department of Periodontics, Institute of Oral Health & no need for additional surgery because of their easy re-
Science, Samsung Medical Center, Sungkyunkwan University School of moval.12 Miniscrews have been placed in the midpalatal
Medicine, Seoul, Korea.
c
Senior statistician, Biostatistics Unit, Samsung Biomedical Research Institute, suture area of adults, and the parapalatal area in adoles-
Samsung Medical Center, Sungkyunkwan University School of Medicine, cents to prevent possible developmental disturbances of
Seoul, Korea.
d
the midpalatal sutures.13 This is because the transverse
Private practice, Seoul, Korea.
e
Resident, Department of Orthodontics, Institute of Oral Health & Science, Sam- growth of the midpalatal suture continues up to the late
sung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. teens14 and is not fused completely even in adults.15,16
f
Professor and chairman emeritus, Department of Orthodontics, Goldman School of Various attempts to use implants as absolute anchor-
Dental Medicine, Boston University, Boston, Mass; now deceased.
g
Associate professor, Department of Orthodontics, Institute of Oral Health & Sci- age in the midpalatal suture area have been made.17-19
ence, Samsung Medical Center, Sungkyunkwan University School of Medicine, Now, midpalatal miniscrews are used for retraction of
Seoul, Korea; visiting professor, Department of Orthodontics, Goldman School maxillary anterior teeth,20,21 intrusion,22-25 distaliza-
of Dental Medicine, Boston University, Boston, Mass.
The authors report no commercial, financial, or proprietary interest in the prod- tion,12 and protraction of maxillary posterior teeth,
ucts or companies described in this article. making it possible to produce movements that were, at
Reprint requests to: Seung-Hyun Kyung, Department of Orthodontics, Institute best, difficult with conventional orthodontic treatment
of Oral Health & Science, Samsung Medical Center, Sungkyunkwan University
School of Medicine, #50, Irwon-dong, Gangnam-Gu, Seoul 135-710, Korea; strategies.
e-mail, shkyung@gmail.com. The purpose of this study was to investigate the
Submitted, August 2007; revised and accepted, November 2007. success rate of midpalatal miniscrews used as orthodon-
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists. tic anchorage for various types of tooth movements and
doi:10.1016/j.ajodo.2007.11.036 factors affecting clinical success.
66
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 67
Volume 137, Number 1

MATERIAL AND METHODS

The subjects were 128 patients (101 female, 27
male; age range, 8.1-56.2 years; mean age, 23.4 6 8.0
years), who received miniscrews for orthodontic
anchorage in the midpalatal area. All miniscrews were
placed by 1 doctor (S.H.K.) at the Department of Ortho-
dontics, Samsung Medical Center, Seoul, Korea,
between 1999 and 2005. The patients were informed
about the possibilities of inflammation around and
loosening of the miniscrews.
A total of 210 miniscrews were placed without flap el-
evation under local anesthesia. They were placed in the
midpalatal sutures and, sagittally, between the mesial
and distal aspects of the maxillary first molar. In adoles-
cents, miniscrews were placed in the parapalatal area in-
stead of the midpalatal areas to prevent possible damage
to the developing sutures. An orthodontic force was ap-
Fig 1. Two types of miniscrews used in the study: left,
plied immediately with elastomeric modules (power
cylindrical type (diameter, 1.5 mm; length, 5.0 mm;
chain), and they were replaced every 3 weeks. head diameter, 3.0 mm); right, tapered type (diameter,
Two types of self-drilled miniscrews of the same 2.0 mm; length, 5.0 mm; head diameter, 4.0 mm).
length but different diameters were used (Fig 1). One
was a surgical miniscrew (diameter, 1.5 mm; length, Figure 2 shows the orthodontic mechanics for some
5.0 mm; KLS-Martin, Jacksonville, Fla) that oral sur- types of tooth movements by single or splinted minis-
geons usually use for fixation of bone fragments. The crews with or without an extension arm: distalization
other was especially designed (diameter, 2.0 mm; of maxillary molars, mesialization of maxillary molars,
length, 5.0 mm; Orthoplant, Biomaterials Korea, Seoul, intrusion of maxillary molars, and retraction of anterior
Korea) and developed for orthodontic anchorage at the teeth.
midpalatal area. Its head diameter was larger (4.0 mm) The procedure was regarded as a clinical success
so that it provided a wide contact area between when a miniscrew remained without loosening until it
its head and a screw-supported bonded sheath had accomplished its purpose. To examine the factors
(S-sheath), generating higher bonding strength suffi- affecting the clinical success of midpalatal miniscrews
cient to resist heavy orthodontic forces. The sheath for orthodontic anchorage, 10 clinical variables were
was custom-made with a normal lingual sheath welded investigated: operator’s learning curve (determined by
onto metal mesh.25 calculating the success rate of miniscrews placed by
Although some patients were treated with 1 mini- the operator over 4 time periods of 18 months each),
screw as orthodontic anchorage, most patients, espe- sex, age, area (midpalatal or parapalatal), total treat-
cially adolescents and young adults, were treated with ment period with miniscrews, splinting (single screw
2 miniscrews splinted together to ensure stability. The vs joined screws), diameter of miniscrew (1.5 vs 2.0
S-sheath was used because a heavy orthodontic force mm), types of tooth movements (distalization, mesiali-
was needed to control several maxillary posterior teeth zation, intrusion, retraction of anterior teeth, and combi-
simultaneously. Splinting was done by simply bonding nations), and variables representing sagittal and vertical
the S-sheath on the top of 2 miniscrews with flowable skeletal relationships (ANB, FMA, and Sn-GoGn). In
composite resin. After placing the miniscrews, 500 to previous studies, there was no evaluation of the clini-
800 g of force was applied initially for various types cian’s skill as a factor influencing success rates. There-
of tooth movement: distalization, mesialization, intru- fore, this study included an evaluation over time of
sion, or retraction of anterior teeth, either singly or in whether the operator’s increasing experience with the
combination. Elastomeric chains generally lose 50% procedure was a factor that affected the stability of
to 70% of their initial force during the first day of miniscrews.
load application and, at 3 weeks, retain only 30% to
40% of the original force.26-28 Therefore, we believed Statistical analysis
that 250 to 400 g might be loaded over 3 to 7 teeth after Success rates related to the numbers of subjects and
force degradation of the elastomers. miniscrews were calculated. The success rate was also
68 Kim et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010

Fig 2. Midpalatal miniscrew placements: A, distalization of maxillary molars; B, mesialization of max-

illary molars; C, intrusion of maxillary molars; D, retraction of anterior teeth.

presented for each category of clinical variable. A cally significant difference in the success rates between
continuous clinical variable was categorized to provide the sexes (OR 5 0.70; P 5 0.4517).
the success rate. Logistic regression analysis was used The total period of treatment with miniscrews varied
to examine the influence of each of 10 clinical variables according to the purpose of orthodontic treatment.
(categorical variables and continuous variables without Although some patients were treated for less than
categorization) on success. Multiple logistic regression 6 months with miniscrews, other treatments lasted
analysis was also used to investigate the influence of more than 18 months. When a miniscrew failed before
each variable when the effects of other variables were it achieved its purpose, it was replaced. In these cases,
controlled. The odds ratio (OR) for each factor was the total period of treatment with miniscrews was calcu-
also calculated. lated by the sum of the periods during which the 2 min-
iscrews were loaded. In the group of patients with
relatively short treatments (\6 months), 3 of 11 minis-
crews failed, for a success rate of 72.7%. In the group
RESULTS with longer treatments (.18 months), some patients
Fifteen of the 128 patients had at least 1 miniscrew needed more than 1 miniscrew because of the early
failure, for a success rate of 88.20%. Eighteen of the 197 loss of the first miniscrew, and 11 of 111 miniscrews
miniscrews failed, for a success rate of 90.80%. The failed, for a success rate of 90.1%. Even though the dif-
average time after placement for miniscrew failure ference in success rates between the groups with shorter
was 3.5 months. and longer treatment periods (72.7% and 90.1%-95.1%,
Logistic regression analysis showed no significant respectively) was high, there was no statistical signifi-
association between the success rate and each of follow- cance between the treatment period and the success
ing variables: sex, total period of treatment with minis- rate (OR 5 0.93; P 5 0.2386).
crews, diameter of miniscrew, types of tooth movement, Similarly, the success rate for miniscrews with
and variables representing sagittal and vertical skeletal a 2.0-mm diameter (91.9%) was slightly higher than
relationships (ANB, FMA, and Sn-GoGn). for those with a 1.5-mm diameter (89.0%), but the diam-
Six of 51 miniscrews placed in 27 male patients eter of the miniscrews was not a significant factor.
were recorded as failures, for a success rate of 88.2%. With the midpalatal miniscrews, various kinds of
In 101 female patients, 12 of 146 miniscrews failed, rep- tooth movements could be made: distalization, mesiali-
resenting a success rate of 91.8%. There was no statisti- zation, intrusion, retraction of anterior teeth, and
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 69
Volume 137, Number 1

combinations of these. Although these movements depended on the achievement of purpose, not on the
require heavy forces of over 500 g, the success rates amount of time that the miniscrews lasted as anchorage.
varied from 88.7% to 96.0%; there were no statistically According to this criterion, 5 miniscrews were recorded
significant differences. as successes, although they lasted less than 6 months.
The success rate according to the ANB difference On the other hand, 4 miniscrews were regarded as fail-
representing sagittal skeletal relationships varied from ures even though they lasted more than 1 year because
89.1% (Class I) to 97.1% (Class III), but there was no they did not complete their missions.
significant association between the ANB value and the Most previous studies reported success rates on the
success rate (OR 5 1.05). In patients whose FMA and basis of the total number of miniscrews; however, the
Sn-GoGn represented vertical skeletal relationships, success rate based on the total number of patients is
those with high angles had high success rates of also meaningful. In this study, the success rates were
97.4% (FMA) and 97.1% (Sn-GoGn), but there were 88.20% for the total number of patients and 90.80%
also no significant associations (OR 5 1.03 [FMA)]; for the total number of miniscrews; these rates are
1.02 [Sn-GoGn]). similar to those reported for buccal miniscrews.29-33
There were significant associations between the suc- The applied force was initially 500 to 800 g per mini-
cess rate and the following variables: operator’s learn- screw, although a miniscrew placed in the buccal bone
ing curve, age, area, and splinting. The operator’s can withstand 200 to 250 g. Therefore, considering
learning curve, which indicated his skill or experience the amount of applied force and the success rates in
over time, had a significant association with the success this study, we recommend the midpalatal area as an
rate; the longer his learning experience, the higher the appropriate site to obtain a strong orthodontic anchor-
success rate (OR 5 1.60; P 5 0.0132). During the first age for group movements of maxillary teeth.
18 months, when the operator was not accustomed to the Many studies have reported the success rates for
procedure for placing miniscrews in the palate, 9 of 36 miniscrews placed during several years without consid-
miniscrews failed, a success rate of 75%. This was much ering improvements of the operator’s skills. When the
lower than the rates of later periods (91.2%-97.9%); the operator in this study (S.H.K.) was a novice in placing
success rate increased to more than 95% after the third the midpalatal miniscrews, his success rate for the first
period of 18 months. 18 months was 75%. Thereafter, his success rate
Age was also associated with the success rate, and increased to over 90% and remained over 90% until
the logistic regression analysis showed that older the last period of 18 months. This result indicates that
patients had higher success rates (OR 5 1.01; P 5 the operator’s skill or experience is critical to the suc-
0.0249). Notably, in the group of patients less than 15 cess rate, and this finding might also be true for labial
years of age, 9 of 31 miniscrews failed, for a success miniscrew applications.
rate of 71.0%, which was much lower than rates for Many studies have found no significant differences
the older groups (92.9%-100%). between success rate and age, but, in this study, younger
In the parapalatal area, 5 of 24 miniscrews failed, patients, especially those less than 15 years of age, had
whereas in the midpalatal area, only 13 of 173 failed. a higher failure rate than did older age groups.29-32 This
Thus, the miniscrews in the parapalatal area showed might be attributed to a difference in bone density
a significantly lower success rate (79.2%) than those because calcification of bone is not completed in adoles-
in the midpalatal area (92.5%) (OR 5 2.77; cents, or a difference in area because miniscrews were
P 5 0.0426). usually placed in the parapalatal area in adolescents.
Splinting the 2 miniscrews produced a higher suc- The midpalatal area has sufficient bone height for the
cess rate (95.9%) than use of 1 miniscrew (82.4%) placement of miniscrews, although, even in adults, there
(OR 5 0.23; P 5 0.0033), and splinting was also the is low bony obliteration or fusion of the midpalatal
only clinical variable that showed a significant associa- suture.15,16 However, in growing children and adoles-
tion with the success rate (OR 5 0.09; P 5 0.013) after cents, the parapalatal area is recognized as an alterna-
controlling for the effects of the other variables (Table). tive.34,35 Miniscrews placed in the parapalatal area
had a significantly higher failure rate, and there were
3 failures in 1 adolescent patient. Thus, although cau-
DISCUSSION tion is required in the placement of miniscrews in the
The criterion used to define the success rates for parapalatal area in adolescents, this procedure is not
miniscrews in previous studies was how long they lasted contraindicated in patients younger than 15 years old.
under loading—eg, 6 months,29 10 to 12 months,30 and The most important factor contributing to the
1 year.31,32 However, the criterion in this study success rate of miniscrews in the midpalatal area was
70 Kim et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010

Table. Success rates and number of loosened miniscrews according to 10 clinical variables
Logistic regression Multiple logistic regression

Clinical variable Miniscrews (n) Loosened miniscrews (n) Success rate (%) OR P value OR P value

Operator’s learning 1.60 0.0132 1.33 0.2911

curve (mo)
First 18 36 9 75.0
Second 18 68 6 91.2
Third 18 47 1 97.9
Fourth 18 46 2 95.7
Sex 0.4517 0.7164
Male 51 6 88.2 0.70 0.71
Female 146 12 91.8 1.00 1.00
Age (y) 1.01 0.0249 3.23 0.1269
\15 31 9 71.0
\20 32 0 100.0
\30 112 8 92.9
.30 22 1 95.5
Area 0.0426 0.2716
Midpalatal 173 13 92.5 2.77 3.23
Parapalatal 24 5 79.2 1.00 1.00
Total treatment period 0.93 0.2386 0.94 0.4569
using miniscrews (mo)
\6 11 3 72.7
6-12 41 2 95.1
12-18 34 2 94.1
.18 111 11 90.1
Splinting 0.23 0.0033 0.09 0.013
Single 74 13 82.4
Splint 123 5 95.9
Miniscrew diameter (mm) 0.74 0.4975 0.33 0.2674
1.5 73 8 89.0
2.0 124 10 91.9
Tooth movements 0.7875 0.6193
Distalization 55 4 92.7 0.55 0.56
Mesialization 10 1 90.0 0.40 0.28
Intrusion 36 4 88.9 0.36 0.39
Retraction of anterior 71 8 88.7 0.36 0.57
teeth
Combination 25 1 96.0 1.00 1.00
Sagittal skeletal
relationship
ANB ( ) (mean) 1.05 0.5302 1.16 0.2195
Class I (3.28) 128 14 89.1
Class II (7.42) 35 3 91.4
Class III (–1.91) 34 1 97.1
Vertical skeletal
relationship
FMA ( ) (mean) 1.03 0.3814 1.08 0.4444
Low angle (20.16) 36 4 88.9
Middle angle (29.5) 122 13 89.3
High angle (39.8) 39 1 97.4
Sn-GoGn ( ) (mean) 1.02 0.5129 1.02 0.8381
Low angle (28.3) 30 3 90.0
Middle angle (38.0) 138 14 89.9
High angle (48.4) 34 1 97.1
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 71
Volume 137, Number 1

splinting. In the multiple regression analysis, splinting There have been reports that the mandibular plane
was the only clinical variable that showed a significant angle may be related31 or not related32 to the success
difference in the success rate, and this result strongly rates of miniscrews. In this study, sagittal and vertical
suggests that the stability of midpalatal miniscrews skeletal variables also did not show significant differ-
can be further enhanced by splinting 2 miniscrews. ences in the success rate, supporting the midpalatal
Although in some patients 1 of the 2 splinted minis- approach for miniscrews used as absolute anchorage,
crews loosened, no patient had both splinted miniscrews regardless of a patient’s sagittal and vertical skeletal
loosen simultaneously. It was difficult to detect loosen- pattern.
ing of the splinted screws because the 2 miniscrews
were splinted firmly with composite resin and an
S-sheath. The only sign indicating loosening was the CONCLUSIONS
continuous growth of inflammatory tissue around the The overall success rates of midpalatal miniscrews
S-sheath. We found that, unlike inflammation from were 88.20% for the total number of patients and
poor oral hygiene, inflammation caused by loose minis- 90.80% for the total number of miniscrews under an
crews was not controlled with improved oral hygiene. initial load of 500 to 800 g per miniscrew. The midpala-
Therefore, we believe that inflammation or swelling tal area is appropriate for miniscrews, and midpalatal
around a miniscrew might be a result of its loosening miniscrews can serve as absolute orthodontic anchorage
rather than a cause. for various types of tooth movements with high success
When screws were placed in the midpalatal area, rates. Factors that influenced the clinical success
there was no significant association between success of miniscrews in the palate were splinting 2 miniscrews,
rate and sex; this agrees with previous reports.29-32 placement of the miniscrews in the midpalatal suture,
The stability of a miniscrew increases as its diameter the patient’s age (especially .15 years), and the opera-
increases; theoretically, this is because the applied force tor’s skill.
can be distributed over more bone area, resulting in
decreased pressure. Petrie and Williams36 emphasized
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