ORIGINAL ARTICLE

Midpalatal miniscrew insertion: The

accuracy of digital planning and surgical
placement
Adli M. Q. Al-Gazzawi,a Vanessa Knode,b Bjorn Ludwig,b,c Alaa Othman,a Angelo Salamini,d Nikolaos Pandis,e
and Padhraig S. Flemingf
Amman, Jordan, and Traben-Trarbach and Saar, Germany, and Milan, Italy, and Bern, Switzerland, and Dublin, Ireland

Introduction: The objective of this study was to investigate the accuracy of palatal miniscrew insertion, evalu-
ating the effect of guide fabrication and surgical placement. Methods: Guided insertion of bilateral paramedian
palatal miniscrews was undertaken using Appliance Designer software (3Shape, Copenhagen, Denmark). A
resin surgical guide (P Pro Surgical Guide; Straumann AG, Basel, Switzerland) was used. Superimposition of
the miniscrew position relative to the digital design was undertaken using bespoke software (Inspect 3D module,
OnyxCeph; Image Instruments GmbH, Chemnitz, Germany) to assess surgical inaccuracy. Miniscrew position
relative to the surgical guide was also assessed to isolate the effect of planning inaccuracies. Both horizontal and
vertical discrepancies were evaluated at both implant locations. Results: Twenty-seven patients having bilateral
palatal insertions were examined. Mean discrepancies were \0.5 mm, both in the horizontal and vertical planes.
The mean overall horizontal and vertical discrepancy between the digital design and final miniscrew position on
the left side was 0.32 6 0.15 mm and 0.34 6 0.17 mm, respectively. The maximum horizontal discrepancy
observed was 0.72 mm. No significant differences were observed in relation to the accuracy of mini-implant
positioning on the basis of sidedness, either for horizontal (P 5 0.29) or vertical (P 5 0.86) discrepancy.
Conclusions: High levels of accuracy associated with guided insertion of paramedian palatal implants were re-
corded with mean discrepancies of less than 0.5 mm both in the horizontal and vertical planes. No difference in
accuracy was noted between the left and right sides. Very minor levels of inaccuracy associated both with sur-
gical techniques and surgical guide fabrication were recorded. (Am J Orthod Dentofacial Orthop 2024;166:69-
75)

T
he use of miniscrews in orthodontics has increased planes. The definition of success of a temporary skeletal
in recent years, providing a predictable means of anchorage device (TSAD) is not clear-cut; however, it has
anchorage reinforcement1 while offering versatility been suggested that the presence of a TSAD $6 months
in producing a range of tooth movements in all 3 spatial after placement may represent success.2 Very promising
success rates have been reported for implants placed in
the palate.3,4 However, miniscrews are prone to failure,
a
Private practice, Amman, Jordan. with failure rates of up to 13% being representative.5
b
Private practice, Traben-Trarbach, Germany. A further problem with TSAD placement is inaccuracy,
c
Department of Orthodontics, University of Homburg, Saar, Germany.
d
Henry-Schein Krugg, Milan, Italy. risking contact with key structures, including adjacent
e
Department of Orthodontics and Dentofacial Orthopedics, Medical Faculty, roots and other anatomic boundaries.6,7 Furthermore, ac-
Dental School, University of Bern, Bern, Switzerland. curate placement is important to maximize biomechan-
f
Division of Public and Child Dental Health, Dublin Dental University Hospital,
The University of Dublin, Trinity College Dublin, Dublin, Ireland. ical advantages and, indeed, to offer optimal levels of
All authors have completed and submitted the ICMJE Form for Disclosure of Po- stability and bicortical engagement when required. The
tential Conflicts of Interest, and none were reported. palatal bone depth and cortical bone thickness are more
The datasets used and/or analyzed during the current study are available from
the corresponding author on reasonable request. conducive in the first and second maxillary premolar
Address correspondence to: Padhraig S. Fleming, Division of Public and Child region, with depth reducing laterally.8
Dental Health, Dublin Dental University Hospital, The University of Dublin, Although the popularity of median and paramedian
Trinity College Dublin, Dublin 2, Ireland; e-mail, padhraig.fleming@dental.
tcd.ie. palatal sites for TSAD placement has increased in recent
Submitted, November 2023; revised and accepted, February 2024. years, research concerning the number and nature of
0889-5406/$36.00 complications is limited, with the invasiveness of
Ó 2024 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2024.02.014 procedures inversely related to their acceptance.9 Guided

69
70 Al-Gazzawi et al

Fig 1. A and B, Mini-implant guide fabrication; C, Clinical use; D, TSAD placement.

insertion techniques involving the use of 2-dimensional Germany) and to create an STL file for the maxilla
and 3-dimensional (3D) radiographic imaging coupled including the miniscrew heads (digital design [DD]).
with intraoral (IO) scanning have therefore been harnessed The Easy CT DICOM Viewer module within Blueskye
as a means of improving the accuracy of miniscrew place- software (version 4.8.3, Blueskye plan, Libertyville, IL)
ment. These approaches have shown encouraging levels was used to create an STL file of the maxilla (including
of accuracy coupled with the use of lateral cephalometry bone and teeth) and maxillary teeth (crowns and roots)
and cone-beam computed tomography (CBCT).10,11 within the CBCT image.
Our hypothesis for this study was based on the The virtual dataset for each patient, including IO scan
assumption that the level of accuracy of guided minis- and CBCT-extracted STL files, was imported into Appli-
crew insertion is negligible overall, with little impact ance Designer software (3Shape). CBCT-extracted STL
on both guide fabrication and practical use. Therefore, files were then aligned with the maxillary STL file (IO
we aimed to evaluate the accuracy of guided palatal scan) using the “add align model icon.” STL files,
miniscrew placement, examining both the errors associ- including TSADs (OrthoLox Plus1) of all available diam-
ated with the fabrication of the surgical guide and the eters and lengths, were already saved using the Appli-
surgical procedures. ance Designer software.
The surgical guide was developed from a 3 mm-thick
shell covering palatal mucosa and maxillary teeth.
MATERIAL AND METHODS Appropriately sized TSADs were selected and virtually
Ethical approval was obtained from the Institutional aligned and sited to provide optimal bony support
Review Board in Amman, Jordan (reference no. SOB remote from the roots. TSADs were positioned at a 90
IRB-001). Consecutive patients requiring the indirect angle to the mucosal surface, with the TSAD shoulder
placement of palatal miniscrews were included in the resting on the mucosa. Once the position of the minis-
study (Fig 1, A-D). An IO scan (TRIOS, 3Shape, Copenha- crews was determined, a shell was designed incorpo-
gen, Denmark) and a CBCT image were obtained for each rating the insertion guide, miniscrew heads, and the
patient whose treatment plan included the use of palatal connectors. Three copies of the shell were then created;
miniscrews (OrthoLox plus1; Tiger Dental GmbH, to make the surgical guide, to create a model with the
H€orbranz, Austria) to construct a palatal appliance. Appli- screw heads, and to fabricate the connectors. To finalize
ance designer software from 3Shape was used to create the design of the guide, the “add modify model” icon
stereolithographic (STL) files to fabricate surgical guides was used to remove the miniscrew head and connectors.
for palatal miniscrew insertion (OrthohoLox Plus1, The “create combine model” icon allowed subtraction of
Promedia Medizintechnik Ahnfeldt GmbH, Siegen, the surgical guide from the maxillary STL file. This

July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Al-Gazzawi et al 71

deleted any part of the surgical guide that might inter- included (1) miniscrew position relative to the surgical
fere with the fit of the printed surgical guide. The STL guide by comparing the DD and MO scans, (2) in vivo
file of the guide was then exported and printed using evaluation of overall error using the surgical guide by
an autoclavable resin material (P Pro Surgical Guide; comparing the DD and MO scans, and (3) miniscrew
Straumann AG, Basel, Switzerland) with the Rapid Shape insertion inaccuracy associated with surgical guides
3D P 201 printer. An STL file of the miniscrew heads related to in vivo and in vitro factors by comparing the
within the maxillary model (DD) involved the “add DD and MO scans.
modify model” icon to remove the connectors and the Statistical differences between the accuracy of place-
surgical guide. The “create combine models” icon was ment based on left and right sides were evaluated using
then used to combine the miniscrew head with the paired t tests. All analyses were conducted in Stata soft-
maxillary STL file. ware (version 17; StataCorp, College Station, Tex).
In the in vitro study, maxillary models were created
for 27 patients and used for the insertion of 2 palatal RESULTS
TSADs using the same surgical template as used clini- In total, 27 patients having bilateral palatal TSAD
cally. To negate any effect of the hardness of the acrylic insertion (54 TSADs) in paramedian palatal sites using
on the accuracy of the miniscrew placement, a hole was the digitally designed surgical guide were examined
drilled at the miniscrew site. The miniscrews were then in vitro and in vivo.
attached to the screwdriver and positioned using the Some degree of inaccuracy was observed with minis-
drilling template. The TSADs were stabilized with self- crew insertion, with mean discrepancies being \0.5
cured acrylic resin before being removed from the screw- mm both in the horizontal and vertical planes (Fig 2;
drivers and the drilling template. The model with the Table). The mean overall horizontal and vertical discrep-
TSADs was scanned (model [MO] scan) using the TRIOS ancy between the DD and final TSAD position (DD final
3Shape scanner. To investigate the error associated with position IO) on the left side was 0.32 6 0.15 mm and
TSAD insertion clinically, superimposition of the DD with 0.34 6 0.17 mm, respectively. The maximum horizontal
the IO scan was conducted using the “Inspect 3D” mod- discrepancy observed was 0.72 mm. No significant differ-
ule in the OnyxCeph software (Image Instruments ences were identified in relation to the accuracy of min-
GmbH, Chemnitz, Germany). For the in vitro study, su- iscrew positioning on the basis of sidedness either for
perimposition of the DD with the MO scan was per- horizontal (P 5 0.29) or vertical (P 5 0.86) discrepancy
formed in the “Inspect 3D” module. In addition, the (Table).
superimposition of the IO scan with the MO scan was In terms of the source of inaccuracy, little discrepancy
performed to identify significant differences between was noted between the DD and IO scans, with mean hor-
in vivo and in vitro data. The Inspect 3D module allowed izontal differences of 0.22 mm and 0.19 mm on the left
for precise quantification of differences in the 3D data- and right sides, respectively (Fig 3; Table). Similarly, mi-
sets compared with the aligned reference model. The nor amounts of inaccuracy were recorded in relation to
software employed the iterative closest point algorithm the surgical guide (Fig 4; Table) with a mean left-sided
for model registration, using the median palatine raphe horizontal discrepancy of 0.35 6 0.17 mm and vertical
to serve as a stable anatomic reference structure for the inaccuracy of 0.37 6 0.19 mm.
superimposition. Both horizontal and vertical discrep-
ancies were evaluated at both TSADs. The threshold DISCUSSION
values for color changes were set to 0.2 mm to detect
noticeable dimensional deviations. These color changes The increasing recognition of the superiority of para-
enabled the identification of the biggest discrepancies median midpalatal sites for temporary anchorage de-
and helped in understanding positional deviations. The vices has contributed to a range of novel applications,
assessment was carried out using the distance reference including miniscrew-assisted rapid palatal expansion.
as the preferred measurement technique by 1 examiner This increasing versatility has, in turn, been underpinned
(V.K.). The results of the measurements were visually by progress in relation to digital appliance design and
documented and stored for later analysis and evaluation. fabrication. As such, more complex and nuanced,
customized multiimplant designs with associated super-
structures are commonly used. Therefore, there is a pre-
Statistical analysis mium on accurate miniscrew placement both to
Descriptive statistics were calculated and plotted, minimize associated risk and to streamline clinical pro-
highlighting the magnitude of error associated with cedures. Based on the present findings, the mean error
each step of guided miniscrew placement. The analysis associated with paramedian palatal miniscrew

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72 Al-Gazzawi et al

Horizontal Vertical

2
Density

0.0 0.2 0.4 0.6 0.0 0.2 0.4 0.6

Design_IO
Side Left Right

Fig 2. Graphical display of overall inaccuracy of TSAD insertion (IO final position DD), including hor-
izontal and vertical discrepancies for both left and right sides.

Table. Horizontal and vertical discrepancy associated with bilateral miniscrew placement in vitro and in vivo
Horizontal Vertical

Dimension Left Right P value* Left Right P value*

design_io 0.32 6 0.15 0.12-0.72 0.35 6 0.16 0.12-0.6 0.43 0.34 6 0.17 0.08-0.62 0.31 6 0.17 0.03-0.68 0.39
design_mi 0.22 6 0.12 0.04-0.43 0.19 6 0.12 0.02-0.41 0.19 0.21 0.13 0.21 6 0.14 0.03-0.55 1.00
Io_mi 0.35 6 0.17 0.12-0.71 0.39 6 0.20 0.06-0.87 0.29 0.37 0.19 0.36 6 0.19 0.05-0.76 0.86

Note. Values are presented as mean 6 standard deviation values with corresponding ranges.
*Paired t test P values.

placement was low, with the maximal error in the hori- a conventional guide (Memosil 2; Kulzer, Hanau,
zontal plane not exceeding 1 mm. As such, it appears Germany) relative to 2 other conventional guides.12,13
that guided insertion of palatal miniscrews can be un- The surgical stents in this study were 3D-printed and
dertaken predictably and with a high degree of accuracy. included a shoulder to control the depth of insertion.
Moreover, low levels of error were observed in both clin- Similar techniques have been deployed in the infrazygo-
ical and laboratory procedures. The results mirror those matic crest region; however, mean reported levels of
obtained from allied research studies primarily on the displacement of the miniscrew tip were as high as 3.3
basis of CBCT-based guided insertion.10,11 mm.13 The displacement of the miniscrew head in isola-
The level of discrepancy observed in this study was tion was assessed in this study, with displacement at the
consistently low, with no statistical difference between tip likely to be amplified relative to this; however, Su
the left and right sides, and there were very similar levels et al13 noted mesiodistal inaccuracy of up to 2.38 mm
of accuracy in the horizontal and vertical planes. In a using a guided technique. These larger discrepancies
similar study, based on guided palatal insertion may relate to anatomic differences at the infrazygomatic
involving conventional and 3D-printed surgical guides, region allied to differences in stent design.
comparable discrepancies were observed with slightly The surgical guides used in the present study were 3D-
greater levels of error found with the 3D-printed (Im- printed and relatively rigid, spanning the arch bilaterally.
primo LC Splint; Scheu-Dental, Iserlohn, Germany) and This design is likely to minimize the risk of distortion and

July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Al-Gazzawi et al 73

Horizontal Vertical

2
Density

0.0 0.1 0.2 0.3 0.4 0.5 0.0 0.1 0.2 0.3 0.4 0.5
Design_MI
Side Left Right

Fig 3. Graphical display of inaccuracy of TSAD insertion (DD-MO scan), including horizontal and ver-
tical discrepancies for both left and right sides.

Horizontal Vertical

2.5

2.0

1.5
Density

1.0

0.5

0.0

0.25 0.50 0.75 0.25 0.50 0.75

IO_MI
Side Left Right

Fig 4. Graphical display of inaccuracy (IO final position MO Scan), including horizontal and vertical
discrepancies for both left and right sides.

inaccurate localization. Alternative designs, including Notwithstanding this, the use of silicone, soft-tissue-
semicircular unilateral guides, may be prone to flexure borne guides has shown similar levels of accuracy to
and inaccurate placement, risking inaccuracy.13 3D-printed rigid tooth-borne guides.14 Nevertheless,

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74 Al-Gazzawi et al

the use of surgical guides introduces an additional step, conceptualization and methodology; Angelo Salamini
with the use of augmented reality being piloted to facil- contributed to conceptualization and methodology; Ni-
itate miniscrew placement and prove superior to freehand kolaos Pandis contributed to methodology and formal
approaches.15 However, there is no evidence to suggest analysis; and Padhraig Fleming contributed to methodol-
that augmented reality leads to superior accuracy relative ogy and formal analysis and drafted the original manu-
to the use of physical guides. script.
Overall, guided approaches have been shown to
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American Journal of Orthodontics and Dentofacial Orthopedics July 2024  Vol 166  Issue 1