|Year : 2016 | Volume
| Issue : 3 | Page : 112-116
Pain and discomfort experience after miniscrew insertion as an anchorage device in orthodontic patients
AmirHossein Mirhashemi, Mohammad Hashem Hosseini, Hootan Yadalloahi, Yasamin Farajzadeh Jalali
Department of Orthodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
|Date of Web Publication||14-Sep-2016|
Yasamin Farajzadeh Jalali
Department of Orthodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Introduction: The aim of this study was to evaluate the degree of pain and discomfort experienced for 1 week after miniscrew insertion using a questionnaire survey. Materials and Methods: Thirty-nine miniscrews were inserted in the mandible and maxilla of 33 patients with a self-drilling JB head type miniscrew under local anesthesia. Patients were asked to rate the degree of pain and discomfort experienced on a visual analog scale (VAS) after 1 hour, 12 hours, 1 day, and 1 week . Data were analyzed using the Statistical Package for the Social Sciences version 22 software. Repeated measures analysis of variance (ANOVA) with considering the jaw, side of insertion, and length of miniscrew as a between subject factor was used. Results: There was no significant association between the length of miniscrew (P = 0.448), the jaw (P = 0.870), and the side of the insertion (P = 0.346) and causing pain. The maximum degree of pain experience was in 1 hour after insertion that was 48.79 mm in VAS scores, which started to decrease significantly after 12 hours, 1 day, and 1 week as the minimum intensity of the pain was 1 week after the miniscrew insertion that was 2.31 mm in VAS scores. Conclusion: On the basis of the patient responses, it can be concluded that miniscrew could be an acceptable option in orthodontic treatments.
Keywords: Anchorage device, miniscrew, orthodontics, pain
|How to cite this article:|
Mirhashemi A, Hosseini MH, Yadalloahi H, Jalali YF. Pain and discomfort experience after miniscrew insertion as an anchorage device in orthodontic patients. Dent Hypotheses 2016;7:112-6
|How to cite this URL:|
Mirhashemi A, Hosseini MH, Yadalloahi H, Jalali YF. Pain and discomfort experience after miniscrew insertion as an anchorage device in orthodontic patients. Dent Hypotheses [serial online] 2016 [cited 2019 Oct 21];7:112-6. Available from: http://www.dentalhypotheses.com/text.asp?2016/7/3/112/190514
| Introduction|| |
Anchorage preparation is a very important part of the orthodontic treatment. The success of orthodontic treatment generally relies on the anchorage protocol planned for particular cases. Anchorage planning and preparation before tooth movement is essential to prevent inappropriate tooth movements and not to compromise the orthodontic result.  Absolute anchorage is defined as no movements of the anchorag unite as a consequence of the reaction forces applied to move the teeth.  Conventionally, extraoral and intraoral appliances such as headgear, transpalatal arch, and quad-helix are used to reinforce anchorage. The use of extraoral appliances is prevented by poor patient compliance  and potential iatrogenic injuries associated with these appliances.  Intraoral appliances eliminate the need for patient compliance, however, they depend on the relative number of dental anchorage units and periodontal support. In a majority of cases using intraoral anchorage appliances, there are certain degrees of anchorage loss resulting in dental tipping or translation. , In an effort to hamper these complications, skeletal anchorage has been progressively incorporated into orthodontic treatment. Orthodontic skeletal anchorage devices can be divided into miniplates, miniscrews, palatal implants, onplants, and dental implants. Sherwood et al. used buccal plates to improve open bite by molar intrusion,  Park et al. conducted fixation of maxillary molars using buccal miniscrews for treatment of bimaxillary protrusion,  Wehrbein et al. used miniscrews at the median palatine suture to fix maxillary molars for treatment of maxillary protrusion,  Kyung et al. applied mini-implant anchorage to stretch inferior second molars to first molar extraction sites.  Carano et al. used the mini-implants to provide anchorage during incisor intrusion.  Lee et al. suggested that the mid-palatal mini-implants could be effectively used for intrusion of maxillary molars. 
Miniscrews have been favored in the last decade because they can be inserted easily under local anesthesia by the orthodontist at various locations within the dentoalveolus. The success rates are reported to be 80-90%, which is slightly lower than that of miniplate and palatal implant.  Miniscrews can easily be inserted and removed with a simple procedure, can be loaded immediately, are commercially available in a number of sizes (width and lengths), and are relatively cost-effective. ,,
Although miniscrew insertion is not complicated, patients are still anxious about the procedure. There have been cases wherein the patient's level of pain perception during miniscrew placement was disregarded and which resulted in the patient experiencing discomfort during the procedure. Therefore, it is important to take into consideration the pain experienced by patients during miniscrew insertion.  Pain has previously been defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. , Pain and discomfort are frequently experienced during orthodontic treatment,  including initial archwire placement and separation. It has also been reported that every tenth orthodontic patient fails to complete the treatment because of the pain experienced during the treatment. ,,,, So far, not much is known regarding the pain associated with miniscrews as an orthodontic procedure. We believe studying it can provide a general understanding of its usefulness to help satisfy patients. , The aim of this study was to evaluate the degree of pain and discomfort experienced for 1 week after miniscrew insertion using a questionnaire survey.
| Materials and Methods|| |
A total of 33 patients undergoing orthodontic treatment who required miniscrew placement in the buccal side of dental arches as part of their treatment plan at the Department of Orthodontics, School of Dentistry, at Tehran University of Medical Science were recruited as study participants. All the participants were healthy, with no significant medical findings or special needs. Sample size calculation was conducted using Minitab software (Minitab Inc., PA, U.S), considering the α = 0.05, β = 5 and standard deviation (23.38) from the study by Lee et al.  Information about the treatment and the study was given orally and in writing to all patients and their parents. In addition, written consent was obtained from all the selected patients and their parents. The study was reviewed and approved by the Research Ethics Committee grant number at the Tehran University of Medical Science, Tehran, Iran (IR.TUMS.REC.1394.170).
The miniscrews used in this study were self-tapping, self-drilling, JB head type miniscrew (Dual-Top Anchor System, Jeil Medical Corporation, Seoul, Korea). In the maxilla, 8 mm length 1.6 mm diameter miniscrew was used and 10 mm length ×1.6 mm diameter was used in mandible. Miniscrews were located interdentally between roots in the buccal side of the posterior segment of the maxilla and mandible. The location was determined with the aid of periapical radiography. One operator performed all the procedures for all the patients.
0.12% chlorhexidine (Vi-one, Tehran, Iran) mouth rinse was prescribed prior to the insertion of the miniscrew.  One operator placed all miniscrews under local anesthesia with 2% lidocaine hydrochloride with 1:100,000 epinephrine (Octacaeine, Novocol, Canada). No mucoperiosteal flap was raised, and no pilot hole was required. After administration of local anesthesia, miniscrews were placed manually by screw driver through attached gingival. Patients were requested to notify the operator if any pain or discomfort was experienced during the procedure. After the insertion, periapical radiographs were obtained to check the miniscrew position.
The patient's perception after miniscrew insertion was evaluated using a questionnaire. Topics for patient's response were as follows:
- Degree of pain and discomfort after 1 hour, 12 hours, 1 day, and 1 week
- The time and frequency of taking analgesics after the insertion
- Degree of pain and discomfort caused using analgesics.
The patients were requested to respond to questions by placing a mark along a 10-cm-long visual analog scale (VAS), and to answer question 3 concerning analgesics with a "yes" or "no" response.
The patients were recalled after 1 week for their follow-up visit. Stability of the miniscrews and gingival health around the miniscrew was evaluated. The patients were followed-up until the end of using the miniscrews as part of the treatment and after that they were removed. Gingival health, plaque accumulation, and the stability of the miniscrews was assessed by mobility every 1 month during the orthodontic treatment.
Results were analyzed using the Statistical Package for the Social Sciences version 22 software (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Repeated measures analysis of variance (ANOVA) considering the jaw, side of insertion, and length of miniscrew as a between subject factor was used. The level of statistical significance was considered to be P < 0.05.
| Results|| |
None of the inserted miniscrews were lost during the study period. A total of 33 patients were assessed for eligibility for the study. Their average age was 21.4 years (3.6). All participants completed the questionnaire. In total, 39.3% of them were women and 60.7% were men. From a total of 39 miniscrews, 64.1% were inserted in the maxilla (8 mm × 1.6 mm) and 35.9% in the mandible (10 mm × 1.6 mm). 30.7% of miniscrews were placed bilateral and 69.3% on one side.
On the basis of the patient responses, the most amount of the pain was experienced 1 hour after the insertion (48.79 mm in VAS scores ) [Table 1]; after 1 hour, the pain started to decrease significantly after 12 hours, 1 day, and 1 week (P < 0.001) [Table 2].
|Table 2: Repeated measures ANOVA with considering the jaw, side of insertion, and length of miniscrew as a between subject factor|
Click here to view
In addition, no significant relation was detected between the length of miniscrew (P = 0.448), the jaw (P = 0.870), and the side of the insertion (P = 0.346) and causing pain [Table 2].
The number of times the patients took an analgesic after miniscrew insertion is presented in [Table 3].
| Discussion|| |
Orthodontic treatment needs significant patient compliance and is significantly influenced by experiences such as pain. Orthodontic patients often experience pain during treatment.  Pain is a complex sensation that varies from one individual to another, and hence objective quantification of pain is difficult. Limited articles have focused on patients' experience of pain for orthodontic treatment with miniscrews. Therefore, we used a patient questionnaire to survey pain and discomfort for 1 week after miniscrew insertion. The VAS score was chosen for this study. This is one of the most commonly used tools to assess pain intensity and has been shown to be a valid and reliable method of measuring discrete pain as well as being a sensitive, simple, reproducible, and universally accepted method of assessing pain. Other methods are categorical scales such as the VRS and the NRS. The VRS is mostly used to evaluate the quality of pain, and the NRS is preferred when measuring pain intensity. 
The result of this study showed that no significant difference for jaw, length of miniscrew, and side of insertion with respect to causing pain and discomfort, so the analysis was conducted on the whole sample rather than a separated sample. When the degree of pain and discomfort was assessed, the highest score was recorded 1 hour after insertion. It was significantly decreased over the 1-week observation period, which is in accordance with other studies. ,, In addition, no significant relation was detected between the length of miniscrew, the jaw, and the side of the insertion and causing pain. It would have possibly been better to design the study with considering all these factors separately by a randomized clinical trial study.
In comparison with other procedures causing pain and discomfort during orthodontic treatment, Lee et al. found that the postoperative pain of microimplant surgery was significantly less than that of the initial tooth alignment.  Baxmann et al. concluded that significantly lower pain levels are experienced with microimplant insertion than that for tooth extraction. 
In this study, all the miniscrews were placed under local anesthesia by injection of 2% lidocaine hydrochloride with 1:100,000 epinephrine. Although many clinical studies describe placing miniscrews using needle injections of local anesthetic,  some authors have suggested that a topical anesthetic could be used as the sole anesthetic for placing miniscrews. There are several advantages of using a topical anesthetic for placing miniscrews, including patient comfort; simplicity of the procedure for the orthodontist; lack of tissue ballooning, which can obscure the miniscrew placement site; and patient feedback if the miniscrew is placed too close to the root structure. ,, Although Reznick et al. found that a compound topical anesthetic was more effective in controlling pain during miniscrew placement than a single-drug topical anesthetic gel, compound topical anesthetics provided less predictable, often inadequate, and less comfortable local anesthesia than an injection of a local anesthetic for placing miniscrews in buccal sites. 
Self-drilled miniscrews were inserted without flap surgery on buccal sides. Baxmann et al. compare the transgingival placement of a microimplant with the soft tissue-punch technique for gingival-tissue preparation. Punch technique has been described in the literature as a basic method for gingival preparation in implant treatment. These techniques were designed to reduce the risk of peri-implantitis, 38 and to create 39 or preserve 40 the papilla between the teeth and prosthetic implants. Transgingival placement was generally reported to be felt as pressure rather than pain, whereas the feeling of soft-tissue punch was more often described as pain. Evaluation 1 day after the surgical intervention showed a statistically significant preference for the transgingival procedure. The slightly larger wound area and the resulting pain and swelling might have caused this from the soft-tissue punch. There was a statistically significant difference in patient's perception regarding the placement technique. Transgingival placement was clearly favored by the patients. 
Miyawaki et al. reported that patients having buccal miniscrews inserted without flap surgery experienced almost no swelling or pain.  Kuroda et al., Kawaguchi et al., and Tseng also compared pain levels from insertion of miniplates and miniscrews. They found that miniplates resulted in significantly stronger pain than miniscrews without incision, but that no significant difference was observed between miniplates and miniscrews with incision. From these results, a major factor causing pain in orthodontic skeletal anchorage device insertion is suggested to be surgical stress due to incision, periosteal detachment, and suturing. On the other hand, the volume of the parts of miniplates that was exposed in the oral cavity was large and the plates were inserted within the range of motion of the buccal mucosa. Therefore, discomfort caused by the movement of the buccal mucosa occurred continuously. However, most parts of the miniscrews, including the screw heads, were inserted into the attached gingiva such that their surrounding soft tissues were not traumatized by the movement of alveolar mucosa. ,,
| Conclusion|| |
The result of this study showed that the pain experience after miniscrew insertion is significantly low. The peak of the pain and discomfort level was recorded 12 h following insertion, and after that started to decrease. On the basis of the patient responses, it can be concluded that miniscrew was accepted option in orthodontic treatments.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zawawi KH. Acceptance of orthodontic miniscrews as temporary anchorage devices. Patient Prefer Adherence 2014;8:933-7.
Nanda R. Esthetics and biomechanics in orthodontics. St. Louis, Missouri: Saunders, Elsevier Inc.; 2015.
Nanda RS, Kierl MJ. Prediction of cooperation in orthodontic treatment. Am J Orthod Dentofacial Orthop 1992;102:15-21.
Samuels RH. A review of orthodontic face-bow injuries and safety equipment. Am J Orthod Dentofacial Orthop 1996;110:269-72.
Feldmann I, Bondemark L. Anchorage capacity of osseointegrated and conventional anchorage systems: A randomized controlled trial. Am J Orthod Dentofacial Orthop 2008;133:e19-28.
Geron S, Shpack N, Kandos S, Davidovitch M, Vardimon AD. Anchorage loss-A multi- factorial response. Angle Orthod 2003;73:730-7.
Sherwood K, Burch J, Thompson W. Closing anterior open bites by intruding molars with titanium miniplate anchorage. Am J Orthod Dentofacial Orthop 2002;122:593-600.
Park H, Bae S, Kyung H, Sung J. Micro-implant anchorage for treatment of skeletal class I bialveolar protrusion. J Clin Orthod 2001;35:417-22.
Wehrbein H, Feifel H, Diedrich P. Palatal implant anchorage reinforcement of posterior teeth: A prospective study. Am J Orthod Dentofacial Orthop 1999;116:678-86.
Kyung SH, Choi JH, Park YC. Miniscrew anchorage used to protract lower second molars into first molar extraction sites. J Clin Orthod 2003;37:575 -
Carano A, Velo S, Leone P, Siciliani G. Clinical applications of the Miniscrew Anchorage System. J Clin Orthod 2005;39:9-24.
Lee JS, Kim DH, Park YC, Kyung SH, Kim TK. The efficient use of midpalatal miniscrew implants. Angle Orthod 2004;74:711-4.
Tsui WK, Chua HD, Cheung LK. Bone anchor systems for orthodontic application: A systematic review. Int J Oral Maxillofac Surg 2012;41:1427-38.
Cope J. Temporary anchorage devices in orthodontics: A paradigm shift. Semin Orthod 2005;11:3-9.
Jasoria G, Shamim W, Rathore S, Kalra A, Manchanda M, Jaggi N. Miniscrew implants as temporary anchorage devices in orthodontics: A comprehensive review. J Contemp Dent Pract 2013;14:993-9.
Fritz U, Ehmer A, Diedrich P. Clinical suitability of titanium micro-screws for orthodontic anchorage-Preliminary experiences. J Orofac Orthop 2004;65:410-8.
Tseng YC, Chen CM, Wang HC, Wang CH, Lee HE, Lee KT. Pain perception during miniplate-assisted orthodontic therapy. Kaohsiung J Med Sci 2010;26:603-8.
Baxmann M, McDonald F, Bourauel C, Jäger A. Expectations, acceptance, and preferences regarding microimplant treatment in orthodontic patients: A randomized controlled trial. Am J Orthod Dentofacial Orthop 2010;138:250-e1.
Patel V. Non-completion of orthodontic treatment: A study of patient and parental factors contributing to discontinuation in the hospital service and specialist practice [thesis]. Heath Park. United Kingdom: University of Wales; 1989.
Bergius M, Kiliaridis S, Berggren U. Pain in orthodontics. A review and discussion of the literature. J Orofac Orthop 2000;61:125-37.
Giannopoulou C, Dudic A, Kiliaridis S. Pain discomfort and cervicular fluid changes induced by orthodontic elastic separators in children. J Pain 2006;7:367-76.
Bondemark L, Fredriksson K, Ilros S. Separation effect and perception of pain and discomfort from two types of orthodontic separators. World J Orthod 2004;5:172-6.
Jones ML. An investigation into the initial discomfort caused by placement of an archwire. Eur J Orthod 1984;6:48-54.
Erdinc AM, Dincer B, Yao YL, Feng XP, Jing XZ. Perception of pain during orthodontic treatment with fixed appliances. Eur J Orthod 2004;26:79-85.
Williams OL, Bishara SE. Patient discomfort levels at the time of debonding: A pilot study. Am J Orthod Dentofacial Orthop 1992;101:313-7.
Casarett D, Karlawish J, Sankar P, Hirschman KB, Asch DA. Obtaining informed consent for clinical pain research: Patients′ concerns and information needs. Pain 2001;92:71-9.
Justens E, De Bruyn H. Clinical Outcome of Mini-Screws Used as Orthodontic Anchorage. Clin Implant Dent Relat Res 2008;10:174-80.
Lee TC, McGrath CP, Wong RW, Rabie AB. Patients′ perceptions regarding microimplant as anchorage in orthodontics. Angle Orthod 2008;78:228-33.
Kuroda S, Sugawara Y, Deguchi T, Kyung HM, Takano- Yamamoto T. Clinical use of miniscrew implants as orthodontic anchorage: Success rates and postoperative discomfort. Am J Orthod Dentofacial Orthop 2007;131:9-15.29.
Scheurer PA, Firestone AR, Bürgin WB. Perception of pain as a result of orthodontic treatment with fixed appliances. Eur J Orthod 1996;18:349-57.
Arcuri C, Muzzi F, Santini F, Barlattani A, Giancotti A. Five years of experience using palatal mini-implants for orthodontic anchorage. J Oral Maxillofac Surg 2007;65:2492-7.
Kravitz ND, Kusnoto B. Placement of mini-implants with topical anesthetic. J Clin Orthod 2006;40:602-4.
Graham JW. Profound, needle-free anesthesia in orthodontics. J Clin Orthod 2006;40:723-4.
Baumgaertel S. Compound topical anesthetics in orthodontics: Putting the facts into perspective. Am J Orthod Dentofacial Orthop 2009;135:556-7.
Lamberton JA, Oesterle LJ, Shellhart WC, Newman SM, Harrell RE, Tilliss T, et al
. Comparison of pain perception during miniscrew placement in orthodontic patients with a visual analog scale survey between compound topical and needle-injected anesthetics: A crossover, prospective, randomized clinical trial. Am J Orthod Dentofacial Orthop 2016;149:15-23.
Miyazawa K, Kawaguchi M, Tabuchi M, Goto S. Accurate pre-surgical determination for self-drilling miniscrew implant placement using surgical guides and cone-beam computed tomography. Eur J Orthod 2010;32:735-40.
Kawaguchi M, Miyazawa K, Tabuchi M, Fuyamada M, Goto S. Questionnaire survey on pain and discomfort after insertion of orthodontic buccal miniscrews, palatal miniscrews and, orthodontic miniplates. Orthod Waves 2014;73:1-7.
[Table 1], [Table 2], [Table 3]