SELF-TAPPING MINI-SCREWS INSERTION USING TWO

DIFFERENT TECHNIQUES AND ITS EFFECT ON

INSERTION TORQUE: A SPLIT MOUTH SINGLE
BLINDED RANDOMIZED CLINICAL TRAIL










A Proposal
Submitted for Partial Fulfillment of the
PhD in (Orthodontics)
















By

MESHARI ALRESHIDI

B.D.S., MUST University 2009
Postgraduated from DIJON University 2014

Orthodontics Department
Hail university
KSA




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-Introduction:

Anchorage is one of the key factors in controlling tooth movement and attaining
successful orthodontic treatment. Therefore, the use of mini-screws has become
an integral part of orthodontic treatment to achieve a secure and reliable
anchorage preparation. One of the means that can be used to determine the
success of mini-screws is to measure their insertion torque. The insertion torque
usually correlated with the primary stability of mini-screws which can be.
a deciding factor for the success or failure of the mini-screw.

According to the technique of insertion mini-screws can be inserted with two

ways. The first method is the self-tapping method in which the mini-screw is
introduced after insertion of a pilot drill inside the bone, using a low speed high
torque hand piece under irrigation with saline. The second method is the
self-drilling technique in which the mini-screw is introduced directly without
drilling using its sharp tip.

Piezosurgery, is an advanced surgical technique that was developed from the

desire to discover a safer and precise method to do bone surgery. Piezosurgery
was found to have the ability for production of clean, accurate and smooth wall
osteotomy and it also can control hemorrhage. The concept of this device
depends on the use of electric current to cause oscillation of the piezotome tip
which cause selective destruction of bone without causing heat which may lead
to osteonecrosis or soft-tissue damage.

-Review of Literature:

Grewal et al. (2019) found that mini-screws has many advantages of over
other methods of anchorage which include an increase in the quality and
efficiency of treatment, ease of placement, lower costs and marked reduction in
the need for patient’s cooperation 1.

Ntolou et al., (2018) pointed out the importance of primary stability as

a main component in the mini-screws success, which apparently based on
thickness, quality of bone, length, diameter and design of mini-screws. It was also
found that method of placement, penetration depth and the number of cortical
plates involved were also important factors in primary stability 2.

Di Leonardo et al., (2018) investigated the effect of inserion torque on

mini-screws and considered it as one of the success keys of mini-screws which
appraise the primary stability. He found that the recommended insertion torque
for mini-screws in the paramedian region of the palate should not exceed 10 Ncm
otherwise it will negatively affect the success rate 3.

Wilmes and Drescher, (2009) investigated the factors that affect the
insertion torque values and found that insertion torque can be increased by using
mini-screws with a larger diameter, deeper penetration and placement in regions
with thicker cortical plates. Another method to increase the insertion torque is the
oblique placement of mini-screws which increases the bone-screw contact area,
but this method may lead to earlier contact of the collar with mucosa in one side
which reduce the penetration depth potential. Oblique placement of mini-screws
can also make the oral hygiene difficult to maintain and increase the chance of
food debris and accumulation of microbial plaques and inflammation of soft
tissue. These factors may contribute to negative effects on the long-term success
of mini-screws 4.

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Motoyoshi et al. (2006) performed a study to determine the ideal insertion
torque of mini-screws and found that the recommended insertion torque of mini-
screws should lie within the range of 5-10 N cm when 1.6 mm diameter mini-
screws were utilized 5.

Chen et al., (2008) performed a study on dogs to investigate the insertion

torque of self-drilling versus self-tapping mini-screws. The results of the study
showed that self-drilling mini-screws showed a very high insertion torque
especially in the mandible which caused high percentage of breakage in mini-
screws 6.

A systematic review by Chen et al., (2009) investigated the critical factors

for the success of mini-screws and found that to achieve a successful self-tapping
technique with optimal insertion torque, the mini-screw length and diameter
should be larger than the osteotomy by 0.2 to 0.5 mm 7.

Jean and Marie Curie (1880) was the first to describe the piezoelectric
effect 8. After that Vercellotti in 1988 pioneered the usage of piezoelectric
surgery. By this method he was able to make surgical orthodontics much more
simple, easy and without producing heat that can adversely affect the success of
implant 9.

Eriksson et al. (1984) found that heating of bone during drilling for the
purpose of implant insertion with a high temperature was associated with high
risk of failure 10.

Gomez et al., (2018) found that cortical piezo-puncture was able to

produce accurate and precise drilling without heat generation and was also able
to reach optimal insertion torque 11.

Aim of the study:

This study aims at investigating the effect of self-tapping method utilizing

piezotome versus self-tapping using conventional pilot drill on insertion torque
and success rate of mini-screw in patients requiring maximum anchorage.

-Materials and Methods:

15 subjects who require maxillary first premolar extractions and canine distalization
will be recruited in this study. Thirty mini-screws (1.6 mm in diameter and 8 mm in
length) will be randomly allocated using table of random numbers with allocation ratio
of 1:1 and will be inserted mesial to the maxillary molars following a randomized split
mouth single blinded study design as the patients will not know which type of
miniscrew is placed at which location. Retraction will be carried out utilizing nickel-
titanium spring ligated directly to anterior hooks in the archwire and the TADs to
produce force of 90 to 100 gram .
The sample will be divided as follows:

Group 1 (experimental): 15 mini-screws inserted after using

the piezoelectric method with a piezotome tip having a diameter of 1.1 mm. A pilot
hole less than the length of mini-screw thread part by 0.5 mm as recommended by Chen
et al 7 will be done.

Group 2 (control): 15 mini-screws inserted after using a pilot drill with the same
diameter and taper as the piezotome tip. A pilot hole will be drilled utilizing.
a handpiece adjusted at a speed of 500 rpm and intermittent drilling to same depth of
in group 1. Irrigation with saline will be done to prevent heat generation and to lubricate
the drill.
To evaluate the primary stability of a miniscrew, the maximum insertion torque will be
measured utilizing torque sensor (Mark-10, MGT 12, Copiague, NY, USA). Periotest
value will be measured by Periotest system (Siemens, Bensheim, Germany)
immediately after insertion and after 6 months 12.
Miniscrews Success will be evaluated by absence of mobility (less than 1 mm) and
capacity to sustain the anchorage function throughout the orthodontic treatment 13.
Statistical Analysis

The collected data will be tabulated and statistically analyzed utilizing IBM SPSS®
version 21 software package (IBM Corp., Armonk, NY). An unpaired t test will also
be used for comparison between the two groups. The p-value (P < 0.05) will be taken
as statistically significant.

PICOTS Framework
P: population: patients requiring maximum anchorage
I: Interventions: self-tapping method of miniscrew utilizing piezotome
C: Control: self-tapping method of miniscrew utilizing pilot drill
O: Outcome: the maximum insertion torque
T: Time: 6 months

S: Study Design: RCT Split Mouth

-References:

1. Grewal M, Mago J, Jhamb M, Singh M. Implants in Orthodontics: A Review.

Research & Reviews: A Journal of Dentistry 2019;8:5-8.
2. Ntolou P, Tagkli A, Pepelassi E. Factors related to the clinical application of
orthodontic mini-implants. Journal of International Oral Health 2018;10:103.
3. Di Leonardo B, Ludwig B, Lisson JA, Contardo L, Mura R, Hourfar J. Insertion
torque values and success rates for paramedian insertion of orthodontic mini-implants.
Journal of Orofacial Orthopedics/Fortschritte der Kieferorthopädie 2018;79:109-115.
4. Wilmes B, Drescher D. Impact of insertion depth and predrilling diameter on primary
stability of orthodontic mini-implants. The Angle Orthodontist 2009;79:609-614.
5. Motoyoshi M, Hirabayashi M, Uemura M, Shimizu N. Recommended placement
torque when tightening an orthodontic mini-implant. Clinical oral implants research
2006;17:109-114.
6. Chen Y, Shin H-I, Kyung H-M. Biomechanical and histological comparison of self-
drilling and self-tapping orthodontic microimplants in dogs. American Journal of
Orthodontics and Dentofacial Orthopedics 2008;133:44-50.
7. Chen Y, Kyung HM, Zhao WT, Yu WJ. Critical factors for the success of orthodontic
mini-implants: a systematic review. American Journal of Orthodontics and Dentofacial
Orthopedics 2009;135:284-291.
8. Labanca M, Azzola F, Vinci R, Rodella LF. Piezoelectric surgery: twenty years of
use. British Journal of Oral and Maxillofacial Surgery 2008;46:265-269.
9. Vercellotti T. Technological characteristics and clinical indications of piezoelectric
bone surgery. Minerva stomatologica 2004;53:207-214.
10. Eriksson AR, Albrektsson T, Albrektsson B. Heat caused by drilling cortical bone:
temperature measured in vivo in patients and animals. Acta Orthopaedica Scandinavica
1984;55:629-631.
11. Gomez J, Giraldo L, Montoya D, Urrea M. Cortical piezo-puncture as a minimally
invasive method for reducing miniscrew implant insertion torque: A preliminary in vitro
Study. APOS Trends in Orthodontics 2018;8:124-124.
12. Park H-J, Choi S-H, Choi YJ, Park Y-B, Kim K-M, Yu H-S. A prospective, split-
mouth, clinical study of orthodontic titanium miniscrews with machined and acid-etched
surfaces. The Angle Orthodontist 2018;89:411-417.
13. Choi S-H, Jang S-H, Cha J-Y, Hwang C-J. Evaluation of the surface characteristics
of anodic oxidized miniscrews and their impact on biomechanical stability:
An experimental study in beagle dogs. American Journal of Orthodontics and
Dentofacial Orthopedics 2016;149:31-38.