Miniscrew Implants: The Aarhus Anchorage System

Birte Melsen and Carlalberta Verna

The limitations of orthodontics, as determined by anchorage problems, have become more

obvious as the number of adults seeking treatment increases. Different types of intraoral-
extradental anchorage, such as infrazygomatic crest ligature wires, miniplates, and mini-
screws, have been suggested to overcome the limitations of traditional orthodontic an-
chorage. In the present article, the development of a miniscrew anchorage system is
outlined. Based on the results of monkey experiments and finite element analysis, the
locations for miniscrew placement and loading protocols are discussed. These studies
suggest that immediate loading with known forces increases the bone density surrounding
the miniscrews. Treatment planning, indications for skeletal anchorage, miniscrew biome-
chanics, and possible complications with the Aarhus anchorage® system are discussed.
Semin Orthod 11:24-31 © 2005 Elsevier Inc. All rights reserved.

O ver the past several decades, an increasing number of

adult patients have sought orthodontic treatment, often
referred by periodontists, restorative dentists, or prosth-
odontists. In several of these patients, absence of multiple
teeth, reduction of periodontal support, and inadequate oc-
clusion prevents the use of conventional intraoral anchorage.
These patients often express a desire to maintain what re-
mains of their dentition and to regain the original position of
teeth that have migrated as a result of extractions or tooth
migration caused by marginal bone loss resulting from perio-
dontal disease. The long clinical crowns seen in these patients
are the result of supereruption in addition to marginal bone
loss, resulting in bite deepening, which is worsened by the
absence of posterior teeth with subsequent overloading of
anterior teeth.
The need for orthodontic tooth movement in this type of
patient has been recognized by several authors, who have
suggested the use of removable dentures as anchorage.1,2 The
usefulness of this type of anchorage is limited, however, as
the force systems necessary for the displacement of periodon-
tally involved teeth must be composed of light forces that are
carefully monitored, a requirement that cannot be fulfilled by
a removable appliance.3 As the patients are often in need of
multiple restorations, a natural solution to the anchorage
problem would be to initiate treatment by inserting the an-
ticipated prosthetic implants and using them as anchorage
Department of Orthodontics, Royal Dental College, University of Aarhus,
8000-C Aarhus, Denmark.
Address correspondence Birte Melsen, DDS, DO, University of Aarhus, Depart-
ment of Orthodontics, Royal Dental College, Vennelyst Boulevard 9, Aar-
hus, Denmark 8000-C. Phone: ⫹45 89424037; Fax: ⫹45 86192752;
E-mail: bmelsen@odont.au.dk
for orthodontic tooth movement. Although this solution can
be used in some cases, not all restorations utilize dental im-
plants. Moreover, economic considerations often preclude
the use of implants as part of treatment. Furthermore, the
period required for osseointegration delays the start of ortho-
dontic treatment, which may further deteriorate the situa-
tion. The need for an alternative source of anchorage is obvi-
ous for this type of patient.
The bone quality in the infrazygomatic crest is generally
good and proves sufficient anchorage for the maintenance of
a ligature wire during loading.4 Based on this premise,
Melsen and colleagues5 described the insertion of a surgical
wire through the infrazygomatic arch as an alternative to
implants for the intrusion and retraction of the elongated and
flared upper incisors typical of the aforementioned patients.
This method proved to be an inexpensive and efficient
method of establishing absolute anchorage.
The surgery necessary for the zygoma wire was performed
under local anesthesia. A transmucosal incision, approxi-
mately 1 cm long, was made along the superior aspect of the
infrazygomatic crest, where a horizontal bony canal was
drilled through the zygomatic process approximately 1 cm
lateral to the alveolar process. Then, a double twisted 0.012-
inch stainless steel wire was inserted through the canal, fas-
tened around the anterior aspect of the infrazygomatic crest,
and twisted tightly for 1 to 2 cm. To protect the soft tissues
where the wire penetrated the mucosa, the twisted part of the
wire was covered with a polyethylene tube. The tube was
kept in place extramucosally by a tight orthodontic ligature.
Once the incision was closed, the surgical wire was bent and
adapted so that the ideal point of force application could be
established. A force of 50 g was delivered by a Sentalloy®
closed coil spring extending from the surgical wire to the

24 1073-8746/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.

doi:10.1053/j.sodo.2004.11.005
Miniscrews 25

teosynthesis screws successfully. However, they did not dis-

cuss the biologic background for the use of nonosseointe-
grated fixtures. The idea of using of nonosseointegrated
screws came from our success with the nonosseointegrated
zygoma ligatures.
It was hypothesized that the wires in the infrazygomatic
crest were loaded such that the pressure concentrated on the
wire generated a local necrosis, leading to resorption and
gradual displacement of the wire through the bone. If this
was true, then osteosynthesis screw retention was initially
purely mechanical and not osseointegrated. To experimen-
tally determine the bony response to immediate orthodontic
force application, miniscrews were placed in the infrazygo-
matic crest and the mandibular symphysis of six Macaque
fascicularis monkeys. The screws were immediately loaded
with either 25 or 50 g of force for 1, 3, and 6 months, after
which the bone-to-screw contact was evaluated histo-
logically.9 The miniscrew did not become loose during treat-
ment; on the contrary, the bone-to-screw contact increased
over the observation period, as did the density of the bone
adjacent to the miniscrew. Studies of the bone turnover ad-
jacent to the screw confirmed the high bone density around
the screws and the accelerated bone turnover found by other
authors.10,11

The Aarhus Anchorage System®

Since the first reports of osteosynthesis screws, several different
designs have been introduced. Costa and colleagues6 described
a miniscrew with a head that imitated a bracket, thereby facili-
tating wire placement between the head of the screw and a
tooth, the tooth then being used as anchorage. The initial mini-
Figure 1 Surgical ligature inserted through a hole in the infrazygo-
matic crest. The ligature is used as anchorage for the intrusion and
screws had an internal Allen wrench-type hole in the head for
retraction of the anterior teeth. (A) Intraoral photo. (B) Radiograph. placement—a design that was common among osseointegrated
implants. This design proved to be problematic, however, as
several miniscrews fractured on removal due to the discrepancy
anterior dental unit, which was comprised of either four or between the bone density generated during miniscrew loading
six anterior teeth ligated together as a unit. The line of action and the decreased strength of the miniscrew collar. This design
of the force was constructed through the center of resistance was replaced by a miniscrew with a bracket-like head. The
based on the type of tooth movement desired (Fig 1).
From 1980 to 2000, 15 patients were treated using the
zygoma wires as anchorage. In three cases, the zygoma wires
became loose before treatment was complete. Due to the
force, the wire “migrated” its way through the cortex before
the end of the orthodontic movement. No complications
were seen in the remaining cases; tooth movement was well
controlled and the results were maintained by the subse-
quent prosthetic restorations. Treatment was usually com-
plete after a 3- to 6-month period and the wires were cut and
removed under local anesthesia. Our zygoma wire experi-
ence led us, despite three failures, to conclude that the
method was an inexpensive and efficient anchorage approach
that could be used where posterior teeth were either not
present or not useful as anchorage.
The replacement of the ligature with a screw seemed a Figure 2 The Aarhus anchorage system with a head that mimics a
logical progression since it offered better stability and made bracket, allowing for the insertion of a full-sized wire. Various
the surgical placement simpler.6 At this point, Creekmore lengths of the transmucosal collar and threaded body are available
and Eklund7 and Fontenelle8 had already clinically used os- for individual anatomies.
26
Figure 3 (A) Micro-CT reconstruction of a miniscrew inserted into a
human mandibular alveolar process. (B) Finite element model of the
actual mandibular configuration (left) and the model used for the
parametric study (right). (C) Distribution of the mesiodistal strain
component in bone around the miniscrew (scale in microstrain,
arrow indicates force direction, compression on left, tension on
right).
screwdriver engaged the entire outer circumference of the mi-
niscrew, which decreased the risk of fracture on removal. The
Aarhus anchorage system® (Fig 2) is available in either 1.5-or
2.0-mm diameters. The length of both the threaded screw and
the transmucosal collar varies to accommodate the thickness of
the bone and mucosa in different locations in the oral cavity,
respectively.12
To evaluate the load transfer from the miniscrew to the sur-
rounding bone, two different three-dimensional finite element
models (FEM) were developed (Fig 3)—1) a geometrically ac-
B. Melsen and C. Verna
Figure 4 Overview of peak strains in bone around the miniscrew
depending on cortical thickness and Young’s modulus of underlying
trabecular bone. As defined by Frost,14 0 to 1700, 1700 to 2900, and
2900 to 14,000 peak strain correspond to adapted, mild overload,
and pathologic overload windows, respectively.
curate model (Fig 3B, left), and 2) a parametric model (Fig 3B,
right)—to evaluate the influence of both the cortical thickness
and the underlying trabecular bone density. In both models, a
mesially directed force of 50 g was applied at the head of the
miniscrew. The primary component of the load transfer takes
place at a single revolution of the miniscrew thread within the
cortex.13 Under the assumed loading condition, the miniscrew is
displaced in a tipping mode, causing tensile stress in the direc-
tion of the force. In general, stress levels were higher in the
cortical bone than in the underlying trabecular bone; the oppo-
site was the case for the strain values. Although a peak value of
2465 microstrain was reached in the trabecular bone, the aver-
age magnitude for bone strain was 10 to 100 microstrain. The
parametric model revealed that the thickness of the cortical bone
determines the overall load transfer from the miniscrew to bone
and that the stiffness (or density) of the trabecular bone plays
only a minor role. When evaluating the peak strains occurring in
Figure 5 Possible orthodontic force lines of action for miniscrews in
the mandible.
Miniscrews
Figure 6 Miniscrew used as direct anchorage. The force is directly
applied from the miniscrew to the active unit for intrusion.
bone relative to the bone strains according to Frost’s mechano-
stat theory (Fig 4),14 it becomes apparent that bone strains can
reach values associated with the pathological overload window
only for thin cortical bone (⬍0.5 mm) with low-density trabec-
ular bone. For medium- and high-density trabecular bone, this
danger is not present, since the bone strains always occur within
the mild overload or adapted windows. Under normal physiologic
loading, the above-mentioned load transfer mechanism may be
altered to some extent. In their FEM analyses of the load transfer
around normal dental implants utilized for orthodontic anchor-
age, Chen an colleagues15,16 demonstrated that bone turnover
around osseointegrated implants is explained by the stress/strain
relationship generated during normal function in the bone ad-
jacent to the implants. Although this finding cannot be directly
extrapolated to the miniscrews, a similar phenomenon is
thought to take place.
Treatment Planning
Before inserting any type of temporary anchorage device (TAD),
it is crucial to define the tooth movement desired with respect to
Figure 7 Miniscrew used as indirect anchorage. The miniscrew is
connected to a double bracket on the premolar. A cantilever is used
from the premolar to intrude the molars. The premolar will not
move since it is connected to the miniscrew.
27
Figure 8 Template made of light-cured acrylic and orthodontic wires
used as a radiographic stent for planning the location of the minis-
crews.
both direction and type. It is advisable to produce a force system
ideally designed for the desired tooth movement (Fig 5). If the
miniscrew can be inserted in a location through which the nec-
essary line of action of the force passes, then the miniscrew can
be used for direct anchorage (Fig 6). If the miniscrew cannot be
placed in the line of action of the force, then the miniscrew must
be used as indirect anchorage. In this case, it should be decided
which teeth will be involved in the reactive unit (Fig 7), as well
as the potential side effects that may occur.
Presurgical Orthodontics
Presurgical orthodontics is seldom required. The mini-
screws can usually be inserted into areas that are not blocked
by roots. Although rare, there may be situations where minor
tooth movement would be necessary to facilitate miniscrew
insertion in the alveolar process. Areas suitable for insertion
were established by analyzing a series of dry skulls. The areas
recommended in the maxilla are the infrazygomatic crest, the
alveolar process, the palate, the infranasal spine, and the
Figure 9 Insertion of the miniscrew directly through mucosa with
the custom screwdriver.
28 B. Melsen and C. Verna

loosening and failure. For indirect anchorage, the miniscrew can

Figure 10 Two miniscrews used as direct anchorage for anterior displace-
ment and intrusion of lower incisors. The left miniscrew has been partly
covered by the mobile mucosa that is stretched by the lip muscles.
be ligated to a tooth or group of teeth via a full-sized rectangular
stainless steel wire. The tooth or group of teeth stabilized with
miniscrew can then be used as absolute anchorage (Fig 7).
The miniscrews are loaded immediately and the force
level is chosen in order to reach a strain value that is
anticipated to generate bone. The force level recom-
mended at the start of treatment is 50 g, chosen from the
results of the previously mentioned FEM analysis.13 With
increasing bone density, the force level can almost cer-
tainly be increased and the miniscrews still able to resist
minor moments. For the first 3 months, however, it is
recommended to keep the forces at a moderate level. Ex-
amples of insertion locations and possible lines of action of
forces are illustrated in Fig 5.

retromolar area. The areas recommended in the mandible are

Removal Procedure
the retromolar area, the alveolar process, and the symphysis. The removal procedure is usually completed uneventfully
A panoramic radiograph, which is normally available from and the miniscrews are often removed with topical anesthe-
pretreatment diagnostic records, is usually sufficient for es-
tablishing the insertion areas outside the alveolar process.
Where a miniscrew is to be inserted into the alveolar process,
a periapical radiograph taken with an acrylic or putty-based
template serves as a guideline for establishing the exact
height and orientation of the miniscrew (Fig 8).

Surgical Placement Procedure

The insertion procedure generally does not involve direct sur-
gery. The latest generation of the Aarhus miniscrew is self-drill-
ing, so the insertion is normally done directly through the mu-
cosa. The mucosa is cleaned with chlorhexidine, then the
miniscrew is placed through the mucosa and inserted directly
into the bone. In the case of thick cortical bone, eg, in the sym-
physis, a 2- to 3-mm incision is made and a pilot hole prepared
with a drill 0.3 mm smaller in diameter than the miniscrew. The
pilot hole is placed with a low speed contra angle handpiece
under saline solution irrigation. The miniscrew is then manually
inserted with a custom screwdriver (Fig 9).
Following insertion, the head of the miniscrew remains
outside the mucosa, with the base of the head resting on, but
not compressing, the mucosa. The drill should be used only
once and replaced with a new sterile drill if another pilot hole
is required. This is done to avoid contamination caused by
bacterial transfer from the oral cavity to the bone.

Orthodontic Mechanics
The mechanics used in relation to the application of TADs de-
pends on whether the miniscrew is being used as direct or indi-
rect anchorage. For direct anchorage, the line of action of the
force has to pass through the miniscrew (Fig 6). If the line of
action of the force does not pass through the miniscrew, as
would be the case for a power arm, a force away from the mi-
niscrew long axis would be generated, thereby creating a mo-
ment that results in a shearing force. Since these miniscrews are
not osseointegrated, a shearing force would likely lead to screw
Figure 11 (A) Miniscrew placed through alveolar mucosa and max-
illary basal bone. The mucosa was allowed to cover the miniscrew,
leaving a ligature passing through the mucosa. Note the power arm
from the molar which ensures that the line of action of the force is
apically displaced. (B) The transverse and rotational side effects are
controlled from the lingual with a transpalatal arch activated for
mesial displacement with one-point contact on the left side only.
Miniscrews
Figure 12 (A) Patient with atrophy of the lower alveolar process following extraction of a premolar and
two molars. (B) A transcortical miniscrew was inserted. (C) A power arm of 0.016 ⫻ 0.022 TMA® was
tied to the miniscrew, which was buried under the mucosa. (D) Occlusal view and (E) radiograph
revealing that the distal displacement of the premolar generated enough bone for subsequent implant
placement.
sia, or at most, local anesthesia. The custom screwdriver is
used to unscrew the miniscrew. In the rare cases where the
miniscrew is so tight that it is difficult to unscrew, just the act
of attempting to unscrew the miniscrew usually causes local
microfractures or bone remodeling sufficient to loosen the
miniscrew after 3 to 7 days.
Complications
Complications related to the use of miniscrews are rare and
can be classified into three groups.
Complications During Insertion
1. Initial lack of stability due to inadequate thickness of
the cortical bone. If this occurs, a different location
must be determined.
2. Miniscrew insertion in the periodontal ligament or
tooth root. If this occurs, the miniscrew should be re-
moved and inserted in a different location. The damage
to the root will most likely not influence the tooth’s
prognosis as long as there is no resulting pulp damage.
Complications During the Loading Period
1. The miniscrew may become loose. If a miniscrew loos-
ens, it cannot be expected to regain its stability and
should be removed and relocated. The loosening may
be caused by either local inflammation or local bone
remodeling. The maintenance of immaculate oral hy-
giene around the miniscrew should be stressed with the
patient. Dental floss dipped in 2% chlorhexidine works
well for maintaining inflammation-free soft tissues
around the miniscrew. Local bone remodeling can oc-
cur around a deciduous tooth undergoing resorption
and exfoliation. It follows that a miniscrew can loosen
even after having been initially fixed if an adjacent de-
ciduous tooth is exfoliating.
2. Hypertrophy of the mucosa adjacent to a miniscrew
may develop (Fig 10). The clinical appearance is not
29
proportional to patient discomfort, and the hypertro-
phy is dependent primarily on patient resistance and
oral hygiene. Mucosal irritation is minimized if the mi-
niscrew is inserted into attached gingival. If, for ana-
tomical reasons, the miniscrew must be inserted
through alveolar mucosa, the clinician could allow the
miniscrew to be covered by mucosa and only have the
wire or attachment pass through the mucosa (Fig 11).
Complications at Removal
1. The miniscrew cannot be removed. This problem usu-
ally resolves a few days after an attempt has been made
to loosen the miniscrew. If this does not occur, then the
miniscrew can be removed with a trephine. This, how-
ever, has not been necessary in our experience.
2. The miniscrew could fracture on removal. This oc-
curred in a number of cases initially, when the minis-
crew neck was weakened due to its internal Allen
wrench socket. In these cases, the head fractured from
the miniscrew by the movement applied to loosen the
miniscrew.
Summary
Although many authors have suggested the use of TADs for
absolute anchorage in extraction cases, the Aarhus anchorage
system® was not developed for this purpose, as those types of
cases can be treated by other means.17 Based on our animal
experiments and clinical experience, the Aarhus anchorage
system® is indicated in the following two groups of patients:
1) adult patients with insufficient teeth for the establishment
of conventional anchorage, and 2) any patient where reactive
forces are anticipated to cause adverse effects.
Desirable tooth movement in the first group of patients
includes intrusion and retraction of maxillary anterior teeth,
intrusion of supererupted molars, and distal movement of
premolars into regions of pronounced alveolar atrophy fol-
lowing long periods of molar edentulism (Fig 12). Desirable
30 B. Melsen and C. Verna

Figure 13 Patient with agenesis of six premolars in which the spaces were to be closed by displacing the molars mesially
with two miniscrews placed in the alveolar process. (A) Pretreatment right buccal. (B) Pretreatment left buccal. (C)
Posttreatment right buccal. (D) Posttreatment left buccal.

Figure 14 (A) Adult female with deep mentolabial sulcus. (B) Intraoral photograph showing large overjet and deep
overbite. (C) Lower occlusal photograph showing crowding with missing lower left canine. (D) Two miniscrews were
utilized as anchorage for the mesial displacement of the lower arch. (E) Posttreatment profile showing improvement of
soft tissue profile. (F) Intraoral photograph showing reduction of overjet by mesial displacement of the lower anterior
teeth. (G) Lower occlusal photograph showing replacement of the missing canine with an implant.
Miniscrews
tooth movement in the second group of patients includes
protraction of molars in cases of premolar agenesis (Fig 13),
anterior modeling of the lower alveolar process without any
forces generated on the posterior teeth (Fig 14), space closure
with TADs and an inadequate number of teeth in the reactive
unit.
In the first group of patients, there has been no solution
with conventional orthodontics. In the second group of pa-
tients, miniscrews offer an alternative to prosthetic and/or
surgical solutions. Regardless of the reason for use, it is cru-
cial that the orthodontist completely understand the force
system that is being used.
References
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