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Incidence of pulp sensibility loss of anterior teeth after paramedian insertion of orthodontic mini-implants in the anterior maxilla

  • Guy's and St Thomas' NHS Foundation Trust and King's College London

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Background The aim of this retrospective investigation was to evaluate the incidence of loss to pulp sensibility testing (PST) of maxillary front teeth after paramedian (3 to 5 mm away from the suture) orthodontic mini-implant (OMI) insertion in the anterior palate. Methods A total of 284 patients (102 males, 182 females; mean age was 14.4 years (±8.8) years at time of OMI-Insertion) with a total of 568 OMIs (1.7 mm diameter, length 8 mm) were retrospectively investigated. A binomial regression analysis was performed to explore covariates, such as age, gender, inclination of upper central incisors, dentition status and insertion position of OMIs that could have contributed to loss of sensibility. Statistical significance was set at p < 0.05. Results Loss of response to PST was encountered during retention in 3 out of 284 patients and the respective OMIs had been placed at height of the second rugae (R-2). Affected teeth were a right canine, a left lateral and a left central incisor. Subsequent root canal treatment was successful. Results of the binomial regression analysis revealed that the covariate insertion position (R-2) of OMIs (p = 0.008) had statistically significant influence on loss of response to PST. Conclusions (1) Although there was no radiographic evidence for direct root injury, the proximity of the implants to the anterior teeth was nevertheless statistically related to loss of PST. (2) In all cases of PST loss OMIs were inserted at the second rugae. Therefore OMIs should be placed either more posteriorly, at the third rugae or in the median plane. (3). Loss of PST was not increased for patients with palatal OMI (0.18%) compared to samples without OMI (0.25%).
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R E S E A R C H Open Access
Incidence of pulp sensibility loss of anterior
teeth after paramedian insertion of
orthodontic mini-implants in the anterior
Jan Hourfar
, Dirk Bister
, Jörg A. Lisson
and Björn Ludwig
Background: The aim of this retrospective investigation was to evaluate the incidence of loss to pulp sensibility
testing (PST) of maxillary front teeth after paramedian (3 to 5 mm away from the suture) orthodontic mini-implant
(OMI) insertion in the anterior palate.
Methods: A total of 284 patients (102 males, 182 females; mean age was 14.4 years (±8.8) years at time of OMI-
Insertion) with a total of 568 OMIs (1.7 mm diameter, length 8 mm) were retrospectively investigated. A binomial
regression analysis was performed to explore covariates, such as age, gender, inclination of upper central incisors,
dentition status and insertion position of OMIs that could have contributed to loss of sensibility. Statistical
significance was set at p< 0.05.
Results: Loss of response to PST was encountered during retention in 3 out of 284 patients and the respective
OMIs had been placed at height of the second rugae (R-2). Affected teeth were a right canine, a left lateral and a
left central incisor. Subsequent root canal treatment was successful. Results of the binomial regression analysis
revealed that the covariate insertion position (R-2) of OMIs (p= 0.008) had statistically significant influence on loss
of response to PST.
Conclusions: (1) Although there was no radiographic evidence for direct root injury, the proximity of the implants
to the anterior teeth was nevertheless statistically related to loss of PST. (2) In all cases of PST loss OMIs were
inserted at the second rugae. Therefore OMIs should be placed either more posteriorly, at the third rugae or in the
median plane. (3). Loss of PST was not increased for patients with palatal OMI (0.18%) compared to samples
without OMI (0.25%).
Keywords: Orthodontic mini-implant, Paramedian insertion, Maxilla, Pulp sensibility loss, Anterior teeth
Sensibility is defined as the ability to respond to a stimu-
lus and testing of the dental pulp, which can be per-
formed using different techniques. In clinical practice
commercially available refrigerant sprays (cold - tests)
are often used for pulp sensibility testing (PST) [1] and
the response is recorded as positive or negative. Various
factors such as previous trauma [2], patient age [3], peri-
odontal attachment loss [4] or medications (sedatives,
tranquilizers, analgesics) [5] are known to have an influ-
ence on the response. It is known that orthodontic tooth
movement can affect PST response temporarily [6], but
sensibility is thought to return to normal after completion
of treatment. The authors state that there is no agreement
in the literature regarding potential long-term sequelae:
reported pulpal responses after orthodontics included cir-
culatory vascular stasis and necrosis [7]. Cases of pulpal
necrosis following orthodontic therapy have been occa-
sionally reported [8, 9], but this is unusual.
* Correspondence:
Department of Orthodontics, University of Saarland, Homburg/Saar,
Private Practice, Am Bahnhof 54, 56841 Traben-Trarbach, Germany
Full list of author information is available at the end of the article
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International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Hourfar et al. Head & Face Medicine (2017) 13:1
DOI 10.1186/s13005-016-0134-9
Adjunctive procedures such as extensive enamel strip-
ping [10] and subtractive Odontoplasty [11, 12] may lead
to a critical rise in intrapulpal temperature [10] with
subsequent pulp necrosis [13]. Clinicians performing
PSTs use the qualitative sensory manifestations to ex-
trapolate the state of the pulp to assess the vitalityof
the tooth [1, 14]. Sensibilityand vitalityare hence
often used interchangeably [1, 5], although it is well
known that PST can produce false positive and false
negative results for vitality.
Orthodontic mini-implants (OMIs) have changed
orthodontic paradigms by broadening the spectrum of
dental movements [15]. Numerous risks and complica-
tions associated with the use of OMIs have been de-
scribed before and specific complications such as
unintentional root damage [16, 17], if severe enough can
lead to loss of sensibility and vitality.
The anterior palate is most suitable [18] as inser-
tion site for OMIs because of high success rates [19]
and ideal anatomical conditions. Palatal bone quality
and quantity for safe insertion of OMIs has been well
documented [2022]. Despite these findings, uninten-
tional root damage of a lateral incisor after parame-
dian OMI-Insertion in the anterior palatal vault has
been reported [23].
The aim of this retrospective investigation was to
evaluate incidence of response loss to PST of maxillary
front teeth after paramedian OMI insertion in the anter-
ior palate.
Patients and treatment protocol
Patients with no history of previous orthodontic treatment
and need for OMI supported orthodontic biomechanics
were included. All patients received treatment by a single
orthodontist (B. L.) in a specialist orthodontic practice
(Traben-Trarbach, Germany), including fixed orthodontic
appliances with OMI placement. As previously described
[2426], two OMIs were inserted symmetrically parasagit-
tal (3 to 5 mm away from the suture) [27] into the anterior
palate for appliance attachment. OMIs were loaded two
weeks after insertion, because of manufacture of the appli-
ances attached to them.
Inclusion criteria:
Unrestored maxillary permanent front teeth without
history of trauma and previous dental treatment
Exclusion criteria:
systemic diseases/disorders
craniofacial malformations
chemo and/or radiotherapy during tooth
accidents/craniofacial trauma
history of previous surgery requiring endotracheal
dental malformations
severe crowding of the upper front teeth
periodontal disease
history of previous orthodontic treatment
tooth agenesis (except for third molars) or tooth loss
enamel stripping or occlusal adjustments to the
upper front teeth
medications such as sedatives, tranquilizer,
Skeletal anchorage
Only one type of mini-implant (1.7 mm diameter, length 8
mm) was used (OrthoEasy®, Forestadent, Pforzheim,
Germany). This implant system has an anodized surface
and features a self-tapping and cutting design and is made
from Titanium-alloy (Ti-6Al-4 V). Following patient con-
sultation and consent, 0.2 ml to 0.5 ml of local infiltration
anaesthesia (Ultracain® D-S, Sanofi-Aventis Deutschland
GmbH, Frankfurt, Germany) was used. The OMIs were
inserted without soft tissue incision or pre-drilling, per-
pendicular to the bone surface, using a motorised dental
handpiece at an insertion speed of 60 RPM. Torque limi-
tation was 30 Ncm. All OMIs were removed at debond.
Bonding and debonding of the fixed appliance
Bonding and removal of the fixed appliances followed a
standardized protocol. Self- ligating steel Brackets (Quick®,
Forestadent, Pforzheim, Germany) were indirectly bonded
applying a light cure bonding material (Transbond® Su-
preme LV, 3 M Unitek, Monrovia, Calif., USA). A halogen
light was used for curing composite material according to
manufacturer instructions.
Bracket removing pliers were used for debonding. The
residual adhesive on each tooth was removed with fluted
tungsten carbide burs and the surface finished using sili-
cone carbide polishers. All clean-up procedures included
Pulp sensibility testing
Thermal PST (cold test) of the maxillary front teeth was
performed just prior to OMI-insertion, at debond of the
fixed appliance/OMI-removal and 24 month post debond.
Endo-Ice® (Coltène/Whaledent Inc., Cuyahoga Falls, Ohio,
USA), producing a temperature of 50 °C was used. The
product was applied to the teeth using a cotton wool pad.
Response was recorded as either positive or negative.
Records included full documentation for the entire
treatment including appropriate radiographs.
Diagnosis of radiographic material
All radiographs were taken with an Orthophos® XG 3
(Sirona, Bensheim, Germany).
Hourfar et al. Head & Face Medicine (2017) 13:1 Page 2 of 7
Panoramic x-rays (OPGs)
OPGs were available pre-treatment (initial diagnostics)
and were used for the diagnosis of bony and dental
anomalies/pathologies prior to OMI-insertion.
Cephalometric analysis
Using the pre-treatment cephalograms (initial diagnostics)
the inclination of upper central incisors (U1/ANS-PNS)
prior to OMI-insertion was measured (Fig. 1), and 108° ±
5° [28] was regarded as a standard mean value.
Assessment of OMIsinsertion positions
Position of the OMIs were assessed using the plaster
working models for the appliances.
Because palatal rugae have been previously described
as stable, clinically visible structures [29], the insertion
positions of the OMIs were classified in relation to the
medial ends of palatal rugae:
1. at second rugae (R-2)
2. between second and third rugae (R-2/3)
3. at third rugae (R-3)
Data collection and statistical analysis
Data was collated using Microsoft Excel® 2007, (Microsoft
Corp., Redmond, Wash., USA). All cephalometric angular
measurements and the assessment of the implant position
were re-measured after three months by the same oper-
ator. Average intra-examiner reliability calculated by the
coefficient of variation (COV) was 0.01 for the former and
using the intraclass correlation coefficient (ICC) was 1.0
for the latter.
A binomial logistic regression analysis was performed
to explore covariates, such as age, gender, Inclination of
upper centrals, dentition status and insertion position of
OMIs that could possibly have contributed to loss of
sensibility. Statistical analysis was performed using SPSS®
for Windows®, version 22.0 (IBM Corp., Armonk, New
York, USA). Statistical significance was set at p< 0.05.
A total of 284 patients (102 males, 182 females) with a
total of 568 OMIs met the inclusion criteria. All patients
were of Caucasian origin. At the time of OMI-insertion
the mean age was 14.4 years ± 8.8 years. 169 patients
were in mixed dentition, and 109 patients were in per-
manent dentition. Average inclination of upper incisors
(U1/ANS-PNS) was 109.81° ± 8.37°; they were hence
slightly proclined. Most OMIs were inserted at the third
rugae (Table 1). In none of the patients root injuries
were diagnosed on the available radiographs.
Loss of response to pulp sensibility testing (PST)
Loss of response to PST was encountered in 3 (1.06%)
out of 284 patients or 0.53% per OMI. The percentage
was 0.18% (n= 3) for the 1704 maxillary incisors and ca-
nines and 0.18% (n= 2) for the 1136 maxillary incisors
respectively. PST was found negative in the three af-
fected patients in the second half of two year retention
phase following debond of the fixed appliances. Affected
maxillary teeth were: A right canine, a left lateral and a
left central incisor. Details are in Table 2.
The three affected patients initially presented with
painful teeth and were hence referred to an endodontic
specialist for further clinical and radiographic diagnosis.
All affected teeth received root canal treatment. After
successful treatment the symptoms resolved. Interest-
ingly, no root injury was diagnosed on the intraoral films
during endodontic treatment.
Results of the binomial logistic regression analysis re-
vealed that covariates gender (p=0.996),ageatOMI-
Insertion (p= 0.456), Inclination of upper incisors (U1/
ANS-PNS) (p= 0.289) and dentition status (p=0.587)had
no statistically significant influence on loss of response to
Fig. 1 Inclination of upper central incisors. Measurement of the Inclination of upper central incisor (U1/ANS-PNS) between the palatal plane (ANS-
PNS) and the long axis of U1 (Is-Isa)
Hourfar et al. Head & Face Medicine (2017) 13:1 Page 3 of 7
PST, whereas the insertion position of OMIs (p=0.008)
Loss of response to PST and vitality respectively was en-
countered in 3 out of 284 patients of our sample. The
percentage was 0.18% for the 1704 maxillary incisors
and canines and 0.18% for the 1136 maxillary incisors
respectively. Interestingly, these results are very similar
to those of an investigation by Bauss et al. [30]. They
also found a small percentage of 0.25% (n= 2) for 800
healthy non-traumatized permanent incisors in 200 ran-
domly selected patients who underwent fixed treatment
without OMI placement.
In all affected patients of our sample, symptoms that
led to referral to an endodontic specialist were encoun-
tered during retention. Occurrence of symptoms was
late, considering loss of vitality was only detected long
after OMI removal and debond. However, considerable
variation has been described in the literature [23, 3133]
and loss of vitality can occur up to 2 years after OMI
placement [32] because root injury can remain symp-
tomless over a long period of time. Er et al. [23] reported
a periradicular lesion caused by unintentional root dam-
age after paramedian placement of two OMIs (1.5 mm
diameter, length 10 mm) in the anterior palate for a dis-
talizing appliance in a 22-year-old female, thus requiring
endodontic treatment. Two months after OMI-insertion,
the patient complained of pain and the right maxillary
lateral incisor was endodontically treated.
Root perforations after buccal interradicular insertion
of OMIs have also been reported: two cases of maxillary
first molars [32, 33] and a mandibular right lateral inci-
sior [31]. In the latter additional periapical surgery was
performed for retrograde root canal treatment.
After loss of response to PST, patients were referred to
an endodontic specialist who diagnosed pulp necrosis
and undertook endodontic treatment. Because no root
injury could be diagnosed on the available plain film ra-
diographs and all patients were free of symptoms after
treatment, no additional cone beam computed tomog-
raphy (CBCT) was performed, although this would have
been the modality of choice to diagnose the exact loca-
tion of the possible root injury site [34]. Therefore, we
cannot completely exclude root perforations due to OMI
insertion and this has to be kept in mind when consider-
ing the results of this investigation.
It was well known that OMIs did not remain station-
ary during orthodontics [35] and primary (direct) and
secondary (migration) displacement has been observed.
Primary displacement is due to the elastic characteristics
of the bone whereas the latter occurs under orthodontic
loading over time, caused by remodeling processes of
the bone. In a systematic review by Nienkemper et al.
[36] secondary displacement of OMIs was found 0.23 to
1.08 mm for the head, 0.1 to 0.5 mm for the body and
0.1 to 0.83 mm for the tip. Maximum values ranged
from 1.0 to 4.1 mm for the head, 1.0 to 1.5 mm for the
body and 1.0 to 1.92 mm for the tip. Tipping angles ran-
ging from 1.0 to 2.65° were noted. The mean extrusion
of OMIs ranged from 0.1 to 0.8 mm and intrusion of up
to 0.5 mm was also observed. In our study OMIs were
removed at the time of debond and the tip of displaced
OMIs might have interfered with the tissues supplying
surrounding teeth with innervation and vascularity.
Besides possible complications with the use of OMIs
[16, 17] affecting PST response and pulp vitality, numer-
ous relationships between orthodontics and adjunctive
procedures respectively and the state of the dental pulp
were also described [3739]. Patients requiring adjunctive
procedures to orthodontics on maxillary front teeth such
as approximal enamel reduction [10] and occlusal adjust-
ments [11, 12] were not included, because pulpal
temperature may have risen critically during the proced-
ure [10].
It has been reported that orthodontic tooth move-
ments like intrusion might also influence PST response
[7, 40]. Radiographic examination, albeit limited to two-
dimensional plain film radiographs, did not reveal any
close proximity between the OMIs and the roots of the
teeth. It is therefore unlikely that direct Injury led to loss
of vitality.
However loss of response to PST and vitality might
have been caused by orthodontics itself. This may be
relevant for the canine that required root canal treat-
ment, as direct injury of this tooth during OMI-
Insertion in the anterior palate was unlikely to have
caused this issue and has never before been reported in
literature. Moreover the patient was an adult (37 years)
Table 2 Details of affected patients
Gender Patient 1 Patient 2 Patient 3
female female female
Age (years) 37 11 12
Inclination U1 (degrees) 99.20 98.50 110.50
OMIs insertion positions R-2 R-2 R-2
Affected tooth (FDI-Notation) 13 22 21
R-2, OMIs insertion position at second rugae
Table 1 Distribution of OMIs insertion positionsin relation to
palatal rugae
Insertion position Number Percent
second rugae (R-2) 76 13.4
between second and third rugae (R-2/3) 24 4.2
third rugae (R-3) 468 82.4
Hourfar et al. Head & Face Medicine (2017) 13:1 Page 4 of 7
and older than the other patients affected (11 and 12
years). Hamersky et al. suggested [41] that orthodontic
forces cause biochemical and biologic pulpal tissue changes
and that orthodontic forces may be less safe as the age of
the patient increases. Open apices allow vessels to enter the
pulp and the increased amount of loose connective tissue
in this apical area may help to maintaining pulpal blood
flow during orthodontic force application; this argument
has also been made by other authors [42, 43]. Remarkably
Ingle et al. [44] found that the maxillary canine, which is
generally not affected by dental trauma, appears to be the
tooth most susceptible to pulp hemorrhage and necrosis
when exposed to orthodontic force application, suggesting
ischemic infarction as most likely cause.
The possibility of dental trauma before, during and
subsequent to orthodontic treatment plays an import-
ant role when interpreting the results of our study.
Incidence of dental trauma is subject to continuous
investigation [4547] and data from the United States
revealed that 25% of the population from 6 to 50 years of
age may have suffered dental trauma to the anterior teeth
[45]. Surprisingly, some patients are unaware of this and
many choose not to seek dental treatment [45, 48] and
taking a past dental history is likely to be unreliable. Most
dental injuries occur during the first two decades of life;
the most accident-prone time was found from the age 8 to
12 years [46, 48]. Dental trauma is more frequent in boys
than girls however there is considerable variation [47].
Maxillary central incisors, followed by the lateral incisors
are most frequently involved [49]. One investigation eval-
uated pulp vitality in teeth suffering trauma during ortho-
dontic therapy; prevalence of pulp necrosis was 18.6% [30]
and this was much higher than our findings.
We excluded patients who had a past history of gen-
eral anaesthesia; dental trauma during endotracheal in-
tubation anaesthesia is one of the most common
encountered adverse events of general anaesthesia [50].
Maxillary central incisors are affected most frequently
[51]. Incidence of dental trauma reporting was found to
be smaller than 0.2% [52] when assessed by anaesthesiol-
ogists compared to 12.1% [53] when assessed by dentists.
It was suggested that examinations should hence be con-
ducted by dental surgeons [54].
Alomari et al. [6] examined PST response using elec-
tric pulp testing (EPT) during and after orthodontic
treatment. The threshold of response to PST using EPT
was found to vary during but returned to pre-treatment
values towards the end of the retention phase. The au-
thors suggested that responses to electrical pulp testing,
should be interpreted with caution during orthodontics
and that a negative PST response does not always indi-
cate pulpal necrosis.
In daily clinical practice a refrigerant spray (RS) is
often used for practical reasons [55] and in our study
we also used a RS producing a local temperature of -50
°C. There is little evidence which cold delivery method
is most accurate in determining pulp responsiveness.
Jones et al. [56] compared carbon dioxide dry ice sticks
(CO2) with RS and concluded that RS and CO2 were
equivalent in determining pulpal responsiveness, but
was faster.
To distinguish between sensibilityand vitalityad-
vanced techniques such as Laser-Doppler techniques
(Laser Doppler Flowmetry - LDF) to measure intrapulpal
blood flow can be used [1, 5]. LDF was found to be a re-
liable method. However, it is technique-sensitive [57]
and extra-pulpal blood flow, mainly from the periodon-
tal ligament, may contaminate the signal [58]. Moreover
LDF is time-consuming [57, 59] and hence not always
practical for routine clinical use.
Regression analysis showed that only the insertion
position of the OMIs was a statistically significant covar-
iate (p= 0.008) for loss of vitality. In the three patients
affected by a negative response to cold testing the OMIs
were inserted at the second rugae (R-2), and we must as-
sume that a more posterior insertion directed to the
third rugae (R-3) is more likely to preserve vitality. This
is in agreement with a recent investigation by Hourfar
et al. [21] which examined bone availability for OMI in-
sertion in relation to the palatal rugae. Most bone was
found in the vertical dimension at the first and second
rugae for 8 mm long OMIs. Yet they stated that it was
challenging to access the area of the second rugae clinic-
ally: OMIs would have to be inserted vertically to avoid
damage to the incisor roots and perpendicular insertion
to the bone surface might not be suitable for this area.
The inclination of upper incisors (U1/ANS-PNS) was
not a statistically significant covariate (p= 0.289) al-
though a slight tendency towards proclination was noted
within in the sample.
To our knowledge, this study is the first retrospective
study that investigates the relationship between OMI po-
sitioning and loss of PST response and pulp vitality.
Time delay of endodontic complications was accounted
months after debond. We propose further research using
prospective designs to verify the outcome of our
Although there was no radiographic evidence of
OMI induced trauma to the teeth that lost vitality,
the proximity of the implants to the anterior teeth
was positively and related to loss of PST (p= 0.008).
In all cases of PST loss OMIs were inserted at the
second rugae (R-2) and we therefore we recommend
Hourfar et al. Head & Face Medicine (2017) 13:1 Page 5 of 7
that OMIs should be placed either more posteriorly,
at the third rugae (R-3), or in the median plane.
This will decrease risk of trauma to the roots of the
anterior teeth.
PST/vitality loss post OMI-insertion in the anterior
palate was only 0.18%. We conclude that the risk of
palatal OMIs leading to loss of PST/vitality of the
upper front teeth is small.
The authors express their thanks to Mr. J. Hammer for participating in the
collection of data.
Availability of data and materials
For confidentiality issues, the data will only be shared in aggregate form as
presented in the tables.
JH conceived the project, gathered and processed the data, created the
material presented (tables, electronic images, references, et cetera) and
drafted the manuscript. DB translated and critically revised the manuscript.
JAL critically revised the manuscript. BL reviewed the process and critically
revised the manuscript. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethical approval and consent to participate
Ethical approval for this study and for the use of existing radiographic
material respectively was granted (No 224/13, Ärztekammer des Saarlandes,
Saarbrücken, Germany).
Author details
Department of Orthodontics, University of Heidelberg, Heidelberg, Germany.
Department of Orthodontics, Guys and St ThomasNHS Foundation Trust
and Kings College Dental Institute, London, UK.
Department of
Orthodontics, University of Saarland, Homburg/Saar, Germany.
Practice, Am Bahnhof 54, 56841 Traben-Trarbach, Germany.
Received: 6 September 2016 Accepted: 21 December 2016
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Hourfar et al. Head & Face Medicine (2017) 13:1 Page 7 of 7
... Self-drilling titanium orthodontic miniscrews were used in 7 different studies, 15,23,26,[28][29][30]32 whereas non-self-drilling screws were used in 4 studies. 19,24,25,27 The other studies did not specify the type of miniscrew inserted. The miniscrews used among the studies differed in terms of manufacturer and dimensions (such as diameter and length of the miniscrew). ...
... 20,26,29 The adverse events associated with the use of orthodontic miniscrews are summarized in Tables 5 and 6, after dividing them into complications and side effects, and reported separately with the relative information about the insertion site. Seven studies reported root perforation, 18,19,21,23 with an associated periradicular lesion, 16 loss of tooth vitality, 27 pink discoloration of the crown, and transitory loss of vitality. 22 Three studies reported contact of the miniscrew with the root of the adjacent tooth. ...
... The risk-of-bias of the 8 included retrospective studies was assessed using the NOS. [24][25][26][27][28][29][30][31] The scores of the studies ranged from 3 to 5 stars, as reported in Table 7. The interreviewer agreements for study selection, data extraction, and risk-of-bias assessment were suitable, with kappa values of 0.931, 0.988, and 0.943, respectively. ...
Full-text available
Objective: The aim of this systematic review was to evaluate the complications and side effects associated with the clinical use of orthodontic miniscrews by systematically reviewing the best available evidence. Methods: A survey of articles published up to March 2020 investigating the complications associated with miniscrew insertion, in both the maxilla and mandible, was performed using 7 electronic databases. Clinical studies, case reports, and case series reporting complications associated with the use of orthodontic miniscrew implants were included. Two authors independently performed study selection, data extraction, and risk-of-bias assessment. Results: The database survey yielded 24 articles. The risk-of-bias assessment revealed low methodological quality for the included studies. The most frequent adverse event reported was root injury with an associated periradicular lesion, vitality loss, pink discoloration of the tooth, and transitory loss of pulp sensitivity. Chronic inflammation of the soft tissue surrounding the miniscrew with mucosal overgrowth was also reported. The other adverse events reported were lesion of the buccal mucosa at the insertion site, soft-tissue necrosis, and perforation of the floor of the nasal cavity and maxillary sinus. Adverse events were also reported after miniscrew removal and included secondary bleeding, miniscrew fracture, scars, and exostosis. Conclusions: These findings highlight the need for clinicians to preliminarily assess generic and specific insertion site complications and side effects.
... As all studies scored > 70%, they were included in the systematic review (Table S3). Table 1 shows the main characteristics of the included studies; all were published in English (20)(21)(22)(23)(24)(25)(26)(27)(28)(29). There were 327 participants with 736 TADs. ...
... One case report was part of a previously published study; however, a separate analysis was undertaken in the latter (25,27). Authors of a single study were contacted and replied to requests for clarification (28). In 39 subjects, TAD placement was carried out aiming to cause intentional injury of teeth planned for extraction as part of the orthodontic treatment plan (20,21,25,27,29). ...
... In 39 subjects, TAD placement was carried out aiming to cause intentional injury of teeth planned for extraction as part of the orthodontic treatment plan (20,21,25,27,29). There was a single retrospective clinical study that contributed with approximately 86% of the cases (28), and five case reports (22)(23)(24)26,27). Seven patients required treatment as a consequence of TAD-related sequelae. ...
This review, registered in PROSPERO (CRD42018102582), assessed the effect of temporary anchorage device placement on endodontic complications. A search strategy was followed to identify studies where any temporary anchorage devices contacted or were in proximity to tooth roots in humans. Studies with low possibility of bias and published in English or Latin‐character languages were considered for inclusion. Ten studies were identified; five case reports, one clinical study and four studies with intentional injury, totalling 736 temporary anchorage devices in 327 patients. Complications may ensue following temporary anchorage device placement, whether or not root contact occurs. Chronic apical periodontitis developed when there was root injury involving the pulp; necrosis can also occur. When damage was limited to the periodontal ligament, cementum or dentine, repair occurred, normally within 12 weeks. Clinicians should be aware of the potential for endodontic complications during temporary anchorage device placement, as well as during orthodontic treatment.
... • Eindrehmoment [42] • Insertionswinkel [16,42] • Insertionstiefe [82] • unbeabsichtigte Wurzelverletzungen (Verlust der Zahnvitalität, Osteosklerose und dentoalveoläre Ankylose) [31,40,42] • Verletzung von umliegenden Strukturen (Nerven, Blutgefäße) [79] • Emphysembildung [40] • Implantatfraktur [42] • Erfahrenheit des Behandlers [66] • Überhitzung während der Insertion [66] • Abrutschen oder Fehlplatzierung der Miniimplantate [40] • Perforation der Nasennebenhöhlen/Kieferhöhlen [40] ...
... However, in several cases, resolution was successfully achieved through improved oral hygiene [4,48,49]. Whereas adverse effects including root damage, or loss of tooth sensibility have been reported in literature [15,21], none of these complications were reported in the included studies. Also, no failures due to root contact have been reported in the included studies, even though root proximity is considered to be a major risk factor for implant loosening [53]. ...
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Background/aim Retraction of the upper incisors/canines requires maximum anchorage. The aim of the present study was to analyze the efficacy of mini implants in comparison to conventional devices in patients with need for en masse retraction of the front teeth in the upper jaw. Material and methods An electronic search of PubMed, Web of Science, and EMBASE and hand searching were performed. Relevant articles were assessed, and data were extracted for statistical analysis. A random effects model, weighted mean differences (WMD), and 95% confidence intervals (CI) were computed for horizontal and vertical anchorage loss at the first molars in the analyzed patient treatments. Results A total of seven RCTs employing direct anchorage through implants in the alveolar ridge were finally considered for qualitative and quantitative analysis, and further five publications were considered for the qualitative analysis only (three studies: indirect anchorage through implant in the mid-palate, two studies: direct/indirect anchorage in the alveolar ridge). In the control groups, anchorage was achieved through transpalatal arches, headgear, Nance buttons, intrusion arches, and differential moments. WMD [95% CI, p] in anchorage loss between test and control groups amounted to − 2.79 mm [− 3.56 to − 2.03 mm, p < 0.001] in the horizontal and − 1.76 mm [− 2.56 to − 0.97, p < 0.001] favoring skeletal anchorage over control measures. The qualitative analysis revealed that minor anchorage loss can be associated with indirect anchorage, whereas anchorage gain was commonly associated with direct anchorage. Implant failures were comparable for both anchorage modalities (direct 9.9%, indirect 8.6%). Conclusion Within its limitations, the meta-analysis revealed that maximum anchorage en masse retraction can be achieved by orthodontic mini implants and direct anchorage; however, the ideal implant location (palate versus alveolar ridge) and the beneficial effect of direct over indirect anchorage needs to be further evaluated. Electronic supplementary material The online version of this article (10.1186/s40729-018-0144-4) contains supplementary material, which is available to authorized users.
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Orthodontic miniscrews (OM) are widely used in modern orthodontic clinical practice to improve skeletal anchorage and have a high safety profile. A complication at the time of OM insertion is tooth root perforation or periodontal ligament trauma. Rarely, OM injury can cause permanent damage, such as ankylosis, osteosclerosis, and loss of tooth vitality. The aim of this work was to analyze potential risks and dental complications associated with the use of OMs. A search of the PubMed, Cochrane, Web of Science, and Scopus databases was conducted without a time limit using the keywords “orthodontic mini-screw” and “dental damage”, resulting in 99 studies. After screening and eligibility, including articles obtained through a citation search, 13 articles were selected. Four studies revealed accidental injuries caused by OM. Most of the damage was localized at the root level and resolved spontaneously with restorative cement formation after prompt removal of the OM, while the pain disappeared. In some cases, irreversible nerve damage, extensive lesions to the dentin–pulp complex, and refractory periapical periodontitis occurred, requiring endodontic and/or surgical treatment. The choice of insertion site was the most important element to be evaluated during the application of OMs.
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This case report describes the treatment of two children, in whom the rapid maxillary expansion and distalization of the maxillary permanent first molar were simultaneously achieved with the use of an appliance supported by skeletal anchorage. In both cases, there was extensive unilateral mesialization of the maxillary permanent first molar, probably due to premature loss of the deciduous second molar, causing a Class II subdivision and insufficient space for eruption of the second premolar. Unilateral posterior crossbite was also present in both cases. Two mini-implants were placed in the anterior region of the palate and a diversified intraoral appliance was designed to concomitantly perform the expansion and distalization. In addition to successfully obtaining the two movements, a molar Class I relationship, space to allow eruption of the second premolar, and correction of the crossbite were achieved. This case report showed that the appliance made it possible to achieve the above-mentioned movements without producing the side effects usually associated with them.
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Aim The aim of this study was to measure the transfer accuracy of computer-aided design/computer-aided manufacturing (CAD/CAM) insertion guides using mini-implants. The target value is the virtual planned position (100%). It is also clinically mandatory to use sterilised surgical guides (autoclaved at 137°C). The results obtained using sterilised and non-sterilised insertion guides were compared. In addition, the actual position of the mini-implants, as implemented, was compared with the digitally planned positions. Materials and Methods Following CAD/CAM planning and production of 60 insertion guides made from synthetic resins that had been previously tested for suitability, 120 mini-implants were inserted in pairs and in blocks of the bone of the substitute material. Half of the insertion guides were sterilised, while the other half were non-sterilised. Compared with the position of the mini-implants in the digital plans, deviations in the apical and coronal distances between the mini-implants and insertion depth, as well as the included angle of the mini-implants to one another and to the surface of the bone substitute material, were determined. Results In post-sterilisation, the dimensional and material changes were observed. When compared, the deviations to the virtual planned position were achieved when the performed insertion using sterilised insertion guides were lower than those achieved when using non-sterilised insertion guides. The heat treatment during the sterilisation process improved the accuracy of the insertion guides. When comparing sterile insertion guides to the digital planned position (100%), the mean coronal deviation was 0.057 mm (0.81%), the apical deviation was 0.428 mm (6.11%), and insertion depth mean deviation at the right side was 0.15 mm (2.15%), while that on the left was 0.073 mm (1.04%). Conclusion The CAD/CAM TAD insertion guide could not achieve 100% accuracy in translating the digitally planned position into the real anatomic location. Deviations to the ideal position between 0.81 and 6.11% were observed. Clinically, for appliances that fit post-mini-implant insertion, the coronal distance of the mid-mini-implant head is the most important. At this point, the mean deviation to the planned positions is 0.81%, which is clinically acceptable and most likely reproducible by using CAD/CAM insertion guides.
Studies were considered eligible if their objective was to investigate adverse effects in soft and hard tissues associated with orthodontic minscrews used in the treatment of dental malocclusions in the maxilla or the mandible of healthy individuals. Studies were excluded if the following were present; other types of temporary anchorage devices, patients with syndromes, and having had orthognathic surgery. The study designs included were randomized controlled trials, prospective clinical trials, retrospective longitudinal studies, case series, and preliminary data (of retrospective study). Key Study Factor : Orthodontic miniscrews inserted in the maxilla and/or the mandible. Main Outcome Measures : The main outcome was any complications associated with the use of orthodontic miniscrews in treatment of dental malocclusions in male and female patients. Main Results : Initially, 1980 studies were identified as potentially eligible for inclusion. After removal of duplicates and screening the titles and abstracts, the full text of 63 studies was assessed for eligibility. Finally, 24 studies including 11 case reports, eight retrospective longitudinal studies, three prospective controlled trials, one case series, and one preliminary data of a retrospective study were included. The tooth adjacent to the miniscrew was the most commonly affected structure. The most commonly reported complication was root perforation reported in four studies while, three studies reported associated peri-radicular lesion, loss of tooth vitality, pink discoloration of the crown, and temporary loss of vitality. Three studies reported perforation of the maxillary sinus while only one study reported perforation of the nasal cavity. Complications that occurred immediately at the removal of a miniscrew included fracture of the minscrew reported in three studies, secondary bleeding reported in one study, and loss of bone tissue around the insertion site reported in one study. Delayed complications included scars reported in two studies, exostosis reported in one study, inflammatory lesions reported in four studies, necrosis of the buccal or palatal mucosa at the insertion site reported in one study, and traumatic sores on the soft tissues in direct contact with the miniscrew reported in two studies. Pain, during and after the insertion of a miniscrew, was reported in two studies. Conclusions : This systematic review found that the most common complication with the insertion of orthodontic miniscrews' is the occurrence of lesions at the root during interradicular insertion. Other reported complications were pain, soft tissue and hard tissue inflammation, hypertrophy of the gingival tissues surrounding the miniscrew, and perforation of the maxillary sinus and nasal cavity. Well-designed and executed randomized clinical trials would address the gap in knowledge for clinicians regarding complications of orthodontic miniscrews insertion.
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Introduction In the current era, the major indication for septoplasty is nasal obstruction due to deviated nasal septum (DNS). Even though septoplasty is a commonly performed surgery, its effectiveness in relieving nasal obstruction in DNS has not been proven. Objective The present study involved the measurement of both objective (nasal patency) and subjective (quality of life measures) outcome measures for the evaluation of the efficacy of septoplasty as compared with medical management. Methods Patients with DNS presenting with nasal obstruction were included and randomized into a septoplasty group or into a nonsurgical management group, with 70 patients in each group. The improvement in nasal obstruction was assessed subjectively by the visual analogue scale (VAS), and the sino-nasal outcome test-22 (SNOT-22) and the nasal obstruction symptom evaluation (NOSE) questionnaires and was measured objectively by assessment of nasal patency by peak nasal inspiratory flow (PNIF) at 0, 1, 3, and 6 months of treatment in both groups. Results The average VAS, SNOT-22 and NOSE scores for the septoplasty versus the nonsurgical group before treatment were 6.28 versus 6.0, 19.5 versus 15, and 14 versus 12, respectively, and at 6 months post-treatment, the scores were 2.9 versus 5.26, 10 versus 12, and 8 versus 10 (p = 0.001), respectively. The average PNIF scores at 0 and 6 months were 60/50 l/min and 70/60 l/min, respectively, in the septoplasty group (p = 0.001); the scores at 0 and 6 months in the nonsurgical management group were 60/60 l/min and 70/70 l/min, respectively (p = 0.001). Conclusion Surgical correction of DNS by septoplasty improves nasal obstruction better than nonsurgical management at 6 months postsurgery.
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Endotracheal intubation is a procedure performed during general anaesthesia with the use of an endotracheal tube in order to maintain a patent airway. This routinely used procedure is connected with a risk of complications within the region of the masticatory system. Trauma of teeth, their surrounding structures and the soft tissue of the oral cavity is observed in app. 1.38 per 1000 procedures. The main causes of this damage are the surgical skills and experience of the surgeon, the anatomical conditions present and the mode of conducting the procedure. In order to reduce the risk of postoperative complications, patients with a high risk of sustaining an injury during endotracheal intubation should be equipped with elastic mouthguards, which reduces the possibility of damage. The scoring in a scale of endotracheal intubation difficulty should be used for qualification for the use of such mouthguards.
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This study aimed to compare the accuracy of conventional intraoral (CI) radiography, photostimulable phosphor (PSP) radiography, cone beam computed tomography (CBCT) and multidetector computed tomography (MDCT) for detection of strip and root perforations in endodontically treated teeth. Mesial and distal roots of 72 recently extracted molar were endodontically prepared. Perforations were created in 0.2, 0.3, or 0.4 mm diameter around the furcation of 48 roots (strip perforation) and at the external surface of 48 roots (root perforation); 48 roots were not perforated (control group). After root obturation, intraoral radiography, CBCT and MDCT were taken. Discontinuity in the root structure was interpreted as perforation. Two observers examined the images. Data were analyzed using Stata software and Chi-square test. The sensitivity and specificity of CI, PSP, CBCT and MDCT in detection of strip perforations were 81.25% and 93.75%, 85.42% and 91.67%, 97.92% and 85.42%, and 72.92% and 87.50%, respectively. For diagnosis of root perforation, the sensitivity and specificity were 87.50% and 93.75%, 89.58% and 91.67%, 97.92% and 85.42%, and 81.25% and 87.50%, respectively. For detection of strip perforation, the difference between CBCT and all other methods including CI, PSP and MDCT was significant (p < 0.05). For detection of root perforation, only the difference between CBCT and MDCT was significant, and for all the other methods no statistically significant difference was observed. If it is not possible to diagnose the root perforations by periapical radiographs, CBCT is the best radiographic technique while MDCT is not recommended.
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Summary AIM : The aim of this retrospective investigation was to measure vertical bone thickness on the hard palate, determine areas with adequate bone for the insertion of orthodontic mini-implants (MIs), and provide clinical guidelines for identification of those areas. Pre-treatment records of 1007 patients were reviewed by a single examiner. A total of 125 records fulfilled the inclusion criteria and were further investigated. Bone measurements were performed on cone-beam computed tomography scans, at a 90° angle to the bone surface, on 28 predetermined and standardized points on the hard palate. Bone thickness at various areas was associated to clinically identifiable areas on the hard palate by means of pre-treatment plaster models. Bone thickness ranged between 1.51 and 13.86mm (total thickness) and 0.33 and 1.65mm (cortical bone thickness), respectively. Bone thickness was highest in the anterior palate and decreased significantly towards more posterior areas. Plaster model analysis revealed that bone thickness was highest at the level of the third palatal ruga. The areas on the anterior palate with adequate bone thickness for successful insertion of orthodontic MI correspond to the region of the third palatal ruga. These results provide stable and clinically identifiable landmarks for the insertion of palatal MIs. © The Author 2015. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email:
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Perioperative dental damage is one of the most common anesthesia-related adverse events and is responsible for the greatest number of malpractice claims against anesthesiologists; therefore, several dental considerations are warranted. A thorough evaluation may necessitate a dentist's help, requires that anesthesiologists receive more formal training regarding oral and dental anatomy, and enables performing the treatments necessary to minimize the risks of dental injuries. Nevertheless, this preanesthetic assessment is frequently overlooked by surgeons and anesthesiologists. The present study aimed to investigate, for both dentists and anesthesiologists, how often and under what circumstances dental trauma occurs during general anesthesia as well as isolate possible anatomical, dental, and anesthesiological risk factors, based on which suggestions for preventive measures could be made. Anesthesiologists must perform a thorough preoperative oral evaluation to help identify the dentition at risk; the evaluation should include the patient's dental history, oral/dental examination, and a specific discussion with the patient about any existing dentures or crowns. The dental examination should especially include an assessment of the patient's upper incisors-the teeth most likely to be injured during the perioperative period-for pre-existing damage. Preoperative notes should record any damages or missing teeth. In addition, anesthesiologists must take adequate intraprocedure precautions to prevent/minimize iatrogenic dental injury.
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Miniscrew anchorage has greatly expanded the limit of clinical orthodontics. Even without patient compliance, miniscrews can provide stationary anchorages for various tooth movements and even make it possible to move the tooth in directions which have been impossible with traditional orthodontic mechanics. On the other hand, the clinical use of miniscrew anchorage includes some risks. Screw fracture might be one of the most undesirable side effects in clinical use of miniscrew anchorage, which occurs in not only the placement but also the removal. A lot of factors are suggested to relate with screw failure, but screw-root proximity and the mandible are considered as two common factors. Damages of soft tissues are temporary in most cases, but damages of hard tissues are irreversible and should be avoided. We have to understand these risks and complications of miniscrew anchorage, and pay attention for their safety-conscious use.
Miniscrews have been used in recent years for anchorage in orthodontic treatment. However, it is not clear whether the miniscrews are absolutely stationary or move when force is applied. Sixteen adult patients with miniscrews (diameter = 2 mm, length = 17 mm) as the maxillary anchorage were included in this study. Miniscrews were inserted on the maxillary zygomatic buttress as a direct anchorage for en masse anterior retraction. Nickel-titanium closed-coil springs were placed for the retraction 2 weeks after insertion of the miniscrews. Cephalometric radiographs were taken immediately before force application (T1) and 9 months later (T2). The cephalometric tracings at T1 and T2 were superimposed for the overall best fit on the structures of the maxilla, cranial base, and cranial vault to determine any movement of the miniscrews. The miniscrews were also evaluated clinically for their mobility (0: no movement, 1: less than or equal to0.5 mm, 2: 0.5-1.0 mm, 3: >1.0 mm). The mobility of all miniscrews was 0 at T1 and T2. On average, the miniscrews tipped forward significantly, by 0.4 mm at the screw head. The miniscrews were extruded and tipped forward (-1.0 to 1.5 mm) in 7 of the 16 patients. Miniscrews are a stable anchorage but do not remain absolutely stationary throughout orthodontic loading. They might move according to the orthodontic loading in some patients. To prevent miniscrews hitting any vital organs because of displacement, it is recommended that they be placed in a non-tooth-bearing area that has no foramen, major nerves, or blood vessel pathways, or in a tooth-bearing area allowing 2 mm of safety clearance between the miniscrew and dental root.
Objective: To evaluate the stability and bone availability of the most distal (third) palatal ruga, as an anatomical region for safe insertion of orthodontic mini-implants (OMIs) in the anterior palate. Study design: Orthodontic records of 35 patients were analysed. Initial (T1) and final (T2) study models were bisected and the outline of the palatal contour was marked on the surface. Models were scanned and the palatal contours were superimposed on the palatal structures on the respective initial and final cephalometric images. Cephalometric measurements were used to assess vertical (3rdRug-PP, 2ndRug-PP, and 1stRug-PP), and oblique bone levels (3rdRug-U1, 2ndRug-U1, 1stRug-U1, and 3rdRug-U1(o)). Paired Student's t-test was used to compare measurements between T1 and T2. Results: The position of the third palatal ruga remained stable during orthodontic treatment (Δ2ndRug-3rdRug P = 0.1mm; P = 0.61 and Δ1stRug-3rdRug P = 0.2mm; P = 0.39). Bone availability also remained adequate (3rdRug-U1T2 (o) = 9.9mm). Conclusion: The third palatal ruga is a reliable clinical landmark to evaluate bone availability for the placement of OMIs in the anterior palate.